THE MEDICAL SERVICE OF STATE HOSPITALS FOR

THE INSANE.*

BY WILLIAM L. RUSSELL, M. D.,

Medical Inspector for the State Commission in Lunacy, New York.

In the development of institutional care of the insane, one of the chief problems has been to provide for the individual the attention needed to bring about cure, and at the same time to furnish for the large and rapidly increasing numbers a shelter or asylum from neglect and brutality. This problem has not yet been fully solved, and the more urgent need of the many seems at times to dominate every other consideration. The care and treatment of insane persons in properly organized medical institutions was, until after the middle of the nineteenth century, not carried out very extensively in this country. Of the present State hospitals only twenty were established previous to 1850. After that, progress was more rapid, and on December 31, 1903, the United States census tabulations showed that there were, in all, 328 institutions for the insane throughout the states and territories. Of these 226 were public and 102 private. The number of State hospitals was 148, and, during the five years that have since passed, this number has no doubt been increased. State care and State supervision are gradually taking the place of local provision for the insane, and wherever this has been accomplished, greater attention to the medical needs of the cases has invariably followed. The unenlightened and merely custodial methods of the past, and the great expense and difficulties which attend such a rapid development as has occurred, continue, however, to influence the present standards and rate of progress. In fact, the public has not yet grasped the facts clearly enough to have learned to demand for the insane much more than protection from abuse and gross

*Read at the Fourteenth Illinois State Conference of Charities and Correction, October 11, 1909.

privation. Only a comparatively few persons have given sufficient attention to the subject to have gained an intelligent insight into the conditions from which the inmates of the institutions really suffer and as to what should be done to bring about cure, amelioration, and prevention. The consequence is that the representations made to legislatures and administrative boards in regard to the value and needs of the medical features of the work too frequently fail to prove sufficiently clear and convincing to overcome the ignorance and indifference which prevail so generally. The lack of knowledge and skill concerning mental disorders which the public tolerates in general physicians and nurses, and the consequent neglect of so many cases in the early stages; the almost total lack of provision for the temporary care of insane persons previous to their commitment or for their safe return to ordinary life after their discharge; the delays and injurious irritations which result from legal methods based on groundless fears for the liberties of persons of sound mind; the inadequate return which people are willing to pay well for at the inferior grades of private institutions; the neglect of preventive measures; and the enormous aggregations of insane persons which are being accumulated in single institutions without sufficient regard to the effect on individuals, all furnish evidence that the public has not yet clearly grasped the known facts relating to mental disease or to the best methods of dealing with it. So much progress has, however, been made, that, were it not for the obvious need of further improvements, it would be easier to speak only words of congratulation and praise.

PROGRESS OF MEDICAL ADMINISTRATION.

The history of institutional development shows that, in spite of all difficulties and obstacles, recognition of the medical character of the disorders of insane persons and of their needs has, for a hundred years, been shaping the internal administration of the institutions towards better and better medical attention to the individual cases. One of the most distinctive features of State care is that it brings the cases into institutions which are under medical management. Medical administration of the whole institution is the method which is found to be most satisfactory throughout the world. And this can be readily understood, for mental disease

affects the whole personality and for its proper management the physician must be able to control the whole environment. Under medical administration, the institutions have been gradually assuming the features of a medical organization. Although hindered often by imperfect structural arrangements, overcrowding, and inability to divide the patients into small enough groups, efforts have been made to classify them in accordance with various specific needs. In recent years, more tangible provision for classification may be seen in special buildings for the study of the new cases and for the treatment of the more acute conditions, which have been added at many institutions, in special wards or buildings for general hospital purposes equipped for the treatment of those suffering from acute physical illnesses and surgical conditions, and in infirmaries for the extremely feeble and bed-fast. Special examination and treatment features such as suitably equipped examination rooms attached to the wards, surgical operating rooms, medical bath rooms, laboratories and other features needed for medical ends have now become recognized essentials of every well-equipped State hospital. For the better personal care and nursing of the patients, training schools for nurses have been established at the institutions, and there is good reason to believe that ere long systematic training of every attendant employed will be an established custom.* The employment and amusement of the patients, which have heretofore been developed largely with a view to utilitarian institutional ends or to sociability are now being applied more definitely as a treatment measure for the individual case. A good start has been made in this in some places. Even in the management of the dietary and in the administration of medicine, changes have been made from the traditional asylum methods to others more adapted to supply the medical needs of the individual case.

*

It would, perhaps, not be advisable to attempt to predict in regard to the further development of the distinctly medical features of the public institutions for the insane. The large accumulation of chronic and incurable cases will continue to make the most ardent worker pessimistic at times and to furnish an argument for the economist. The so-called custodial needs can never be en

*It is already in Illinois and in New York.

tirely subordinated, as a certain number of the patients will always be fairly able bodied and yet incurable. Even these cases present surprises, however, and in many instances those considered incurable have, after years, recovered and been discharged to useful living, and my own experience with a few apparently incurable cases, and the testimony of others in regard to many, have convinced me that other similar cases would also recover if they could be given the close personal study and attention which have been given to a few. It should not be assumed that because a condition is protracted, it must necessarily be incurable. Of those discharged recovered, 25 per cent have been under treatment for a year. In New York, during five years, 47 per cent of the cases admitted to the State hospitals were restored to their homes recovered or improved sufficiently to be considered suitable to be at large. Thus nearly half the cases responded to remedial measures, enough surely to justify the efforts which have been made to emphasize and develop the medical features of the institutions. The principal needs of a large proportion of the remainder are also clearly medical. Many of them are, in every sense of the word, sick. They are affected with organic diseases of the nervous system, of the blood vessels, or of the internal organs, or they are in the last stages of senile decay. A large number are brought to the institutions merely to receive the medical and nursing attention given to the incurably sick and dying. Forty per cent of the deaths at the institutions occur during the first year of residence, and so prevalent are conditions requiring bed treatment, that in thirteen New York State hospitals the average daily number of patients in bed, because of illness, is nearly 200 for each hospital. The need of active medical attention to the condition and treatment of the patients is the predominant characteristic of the institutions, and the views of those who, since Pinel first entered the Bicêtre, have been striving to shape the administration and work of the institutions so as to provide for it, have proven to be perfectly sound. The principle has received general recognition in the change of title from asylum to hospital of nearly every institution for the insane in the country, and present indications are that it will continue to prevail in the future.

THE CLINICAL WORK.

The clinical work of the hospital is that which relates directly to the medical study and treatment of the individual patients. Upon its character depends the efficiency for remedial purposes of the institution as a whole. Its purpose is to determine the abnormal conditions presented by the patients and to apply to their treatment the resources of the institution. Unless it is properly provided for and attended to, the institution must fail to carry out the purposes of a hospital however well it may serve as a comfortable home or aslyum. The clinical work should not, however, be looked upon as distinct from the rest of the work. By some, even physicians, the clinical work is looked upon as a means of contributing to the physical comfort and safety of patients under custodial care, rather than as an indispensable essential of respectable medical administration. To realize its highest usefulness it must harmonize with the various features and requirements of the hospital organization and administration, of which it should be the center. Without it, the knowledge of the individual patients essential to the accomplishment of the true purpose of the hospital will be lacking. As all State hospitals for the insane have grown to a size which precludes the superintendent from attending personally to the examination and treatment of the individual cases, it is necessary to delegate these to assistant physicians and to organize the work so that each may attend to his own part. The organization and methods will vary to a considerable extent, according to the size of the hospital, the number of patients received on original commitment, the structural features, and the personal views of the superintendent. It seems unfortunate that there is such a wide divergence of opinion in regard to the proper maximum size of institutions for the insane, but in the present stage of institutional development this seems to be inevitable. Dr. Tucker, an Australian, who some years ago visited all the principal institutions in the world, learned from the superintendent of each that it was of exactly the right size. It is certainly unusual to hear a superintendent complain of defects which he attributes to the size of his institution, and some have even been heard to boast of the enormous number of patients under their care. In a report presented to the National Conference of Charities two or three years ago by