Mental diseases: a public health problem. James Vance May
We may, therefore, reasonably conclude that there was an average number of at least 19.36 per 100,000 (from 1906 to 1910 this amounted to 32.1) in which the primary cause of death was associated with mental diseases, an exceedingly conservative estimate. This does not take into consideration the deaths due to senility (15.5) or suicide (12.8), conditions which might very logically be included for obvious reasons. It is, of course, well known that the psychoses rarely, if ever, appear in the death certificates as a primary cause of death. As a matter of fact, they are not always shown in the secondary causes. Information on this subject is still less satisfactory from a statistical point of view. During the year 1917 (contributory causes have not been reported since that year) there was a total of 1,066,711 primary causes of death shown in the registration area and only 372,291 contributory causes. Of this number the following may be classified as having been associated with psychoses:
| Disease | Primary Cause | Contributory Cause |
|---|---|---|
| Encephalitis | 620 | 904 |
| Meningitis (total) | 6,673 | 6,815 |
| Softening of the brain | 888 | 722 |
| General paralysis of the insane | 5,248 | 648 |
| Other forms of mental alienation | 1,651 | 3,895 |
| ——— | ——— | |
| Total | 15,080 | 12,987 |
The contributory causes definitely showing mental diseases constitute only 3.4 per cent of the whole number, and the death rate for 1917, including both primary and contributory causes suggestive of probable psychoses, was 37.2 per 100,000. This would indicate that the number of deaths from mental diseases shown in the primary causes represents only about fifty-three per cent of all mental cases which are actual factors in determining the death rate of the community. A comparison of these figures with the number of cases dying in hospitals shows that they cannot be looked upon as determining the percentage of the general population showing psychoses. Of the 1,952 persons dying in the institutions for mental diseases in Massachusetts in 1919, approximately nineteen per cent showed the psychoses in the primary causes of death. This percentage would probably be fairly constant throughout the country. It is, of course, a well recognized fact that the death certificate at best is not beyond suspicion and does not furnish information regarding the cause of death which can be accepted without question.
Dr. Richard C. Cabot[1] has made an elaborate study of errors in diagnosis as shown by autopsies. His work shows the following percentage of diagnostic accuracy:
| Per cent. | |
|---|---|
| Diabetes mellitus | 95 |
| Typhoid fever | 92 |
| Aortic regurgitation | 84 |
| Lobar pneumonia | 74 |
| Cerebral tumor | 72.8 |
| Tubercular meningitis | 72 |
| Gastric cancer | 72 |
| Mitral stenosis | 69 |
| Brain hemorrhage | 67 |
| Aortic stenosis | 61 |
| Phthisis, active | 59 |
| Miliary tuberculosis | 52 |
| Chronic interstitial nephritis | 50 |
| Hepatic cirrhosis | 39 |
| Acute endocarditis | 39 |
| Bronchopneumonia | 33 |
| Acute nephritis | 16 |
It must be admitted that Cabot's findings are discouraging. They are not so bad as they would seem, however, at first thought. Death certificates, unfortunately, do not have the significance which they should have. Physicians are well known to be entirely too careless in their preparation and inclined to look upon them merely as legal formalities which cannot readily be avoided. It is furthermore difficult, as every doctor knows, to point to one immediate primary cause of death in every instance. Very often there is a combination of factors concerned and it is possible at practically every autopsy to find lesions not represented in any way whatever in the death certificate. It is unquestionably true that statistics of any kind must be based on information some of which we know to be inaccurate. This should not be used as an argument for discontinuing, absolutely, our search for knowledge. It is merely a reason why our clinical standards should be improved.
An exceedingly important contribution to our rather limited fund of accurate information regarding the general health of the country was the publication recently issued by the Metropolitan Life Insurance Company[2] on the mortality statistics of wage earners and their families. This covers a period of six years (1911 to 1916) and represents a study of 635,449 deaths. The cases reported came from every state in the union with the following exceptions: Mississippi, North Dakota, South Dakota, Wyoming, Colorado, Texas, Nevada, Arizona and New Mexico. Canada and many other localities outside of the "Registration Area" of the United States Census Bureau were included. The facts presented in this report are unique in that they render available for the first time a careful and detailed consideration of the diseases which may be looked upon as representative of the industrial population of the country. The various occupations shown in the order of their numerical importance were as follows:—Laborers, teamsters, drivers and chauffeurs, machinists, textile mill operatives, clerks, office assistants, etc. It covers a study of ten million policy holders and nearly fifty-four million years of life in the aggregate. The age groups studied range from one year to seventy-five in ratios not very different from those exhibited in the general population. The death rate for all persons exposed was 11.81 per 1,000 as compared with a rate of over thirteen per 1,000 (white) of the general population of the registration area during the same period of time. The death rate per 100,000 from 1911 to 1916 of some of the more important general diseases was as follows:
| Typhoid fever | 16.8 |
| Diphtheria and croup | 24.3 |
| Scarlet fever | 8.6 |
| Acute articular rheumatism | 6.3 |
| Diabetes | 14.4 |
| Cancer and other malignant tumors | 70.0 |
| Bronchopneumonia | 30.2 |
| Diarrhea and enteritis (over two years old) | 13.9 |
| Cirrhosis of the liver | 15.0 |
| Puerperal septicemia |
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