One thing should be made clear at the outset. A comprehensive and progressive program for further development means an expenditure of money. If the state hospitals are to fulfill their obligations to the community which they serve they must have more physicians. Provisions must be made for directors of clinical psychiatry, pathologists, internists, surgeons, dentists, and specialists of various kinds. Experts in hydrotherapy, massage and electrical treatments are necessary, as well as dietitians, industrial instructors, occupational teachers, specialists in reeducational work, psychologists, social workers, etc. Furthermore, they must be provided in sufficient numbers if anything is to be accomplished. As a matter of fact, no very great outlay of funds would be required in making a tremendous increase in efficiency. Although the institutional expenditures have increased enormously of late years, largely as a result of war conditions, increased costs, higher wages, etc., the amount actually invested in this humanitarian movement by the various states is not commensurate in any way with the results which are to be obtained. If we leave out of consideration everything except the saving in dollars and cents to be effected by methods which will in many instances render a protracted hospital residence unnecessary, the outlay involved would be well warranted. It should be brought to the attention of the public that very few states are expending as much as one dollar per day for the maintenance of the individual patient. Modern hospital treatment of the highest type, under these circumstances, is manifestly impossible. The time has come when we should no longer be satisfied with the purely custodial care of mental cases.
CHAPTER V
THE HOSPITAL TREATMENT OF MENTAL DISEASES
The responsibility of the hospital for the future of the patient begins with his arrival at the institution and the ultimate outcome of the case often depends entirely upon the developments of the first few weeks of his residence in the wards. A complete understanding of the patient's mental condition, the prospects of an ultimate recovery and the line of treatment to be followed can only be determined by a thorough and accurate examination on admission. This constitutes the basis for all further procedure. If satisfactory results are to be obtained this task should be delegated to a medical officer who has had an extended psychiatric experience. For purposes of completeness, as well as uniformity, a definite plan should be followed. The form used in writing the initial history and in recording the results of the routine mental and physical examinations at the Boston State Hospital are described in full in the "Medical Staff Manual" which is furnished to all assistant physicians entering the service. This has been found to be of great assistance in the training of new men along proper lines and insures a uniformity of hospital records which is indispensable. In a general way the form of examination employed by Meyer and Kirby [31] for some years has been followed. As this scheme is fairly representative of the method of procedure used by hospitals for mental diseases throughout the country it has been thought worth while to reproduce it in full.
HISTORY
Name of Physician: Date:
Name of Informant, Address, Relation to Patient:
It is often desirable to make a note on the intelligence and apparent reliability of the informant.
Residence and Citizenship of Patient:
Birthplace? Date of birth? Time in Massachusetts? If foreign born, date of arrival in U. S.? Naturalized or alien?
Family History:
It is not sufficient to ask simply the general question: Has any member of the family been insane or nervous? A great many persons will answer in the negative, whereas a detailed inquiry will often bring out a number of instances of nervous or mental troubles.
Specific inquiry must be made concerning the persons of the direct ancestral lines as follows:
(a) Paternal grandparents—nervous or mental disease?
(b) Maternal grandparents—nervous or mental disease?
(c) Father: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?
(d) Mother: Age, nervous or mental disease, alcoholism? If dead, age at death and cause of death?
(e) Number of children in family (brothers and sisters of patient). Nervous or mental trouble in any of these besides patient? Psychopathic personality, alcoholism, criminality, etc.?
(f) Collateral branches: mention any known cases of insanity or nervous diseases in uncles, aunts or cousins.
PERSONAL HISTORY OF PATIENT
1. Early Development:
Birthplace and age, unusual incidents attending birth, retardation in talking or walking, infantile convulsions, night terrors, fits of temper, etc.—Severe illness or infectious diseases in infancy or childhood—Sequella? Frights, shocks or injuries?
2. Education, Intellectual and Moral Development:
Educational opportunities, time spent in school, interest in studies, progress, marks, behavior, truancy, etc.?
As an adult, regarded as bright, intelligent or dullminded? Well informed or ignorant? Reading, memory, judgment?
Moral responsibility, reliability, religious interests? Church affiliations?
Criminal traits, tramp life, police record?
3. Sexual Life:
Precocious interests in childhood, masturbation, abnormal practices, assaults or seduction?
Love affairs and disappointments? Age at marriage or reasons for single life. Moderate or excessive sexual desires, irregularities or prostitution.
Miscarriages, number of children, date of birth of youngest? If barren, what explanation; what effect on patient?
Frigidity, loss of power, refusal of partner, infidelity, measures to prevent conception. Treatment of partner, abuse, separation, divorce.
Perversions, abnormal methods of gratification with same or opposite sex.
In women, unusual symptoms at menstrual periods; age at menopause, nervous symptoms accompanying climacterium?
4. Diseases and Injuries:
Any previous nervous affection or symptoms, such as headaches, nervous prostration, chorea, epilepsy, hysterical attacks, etc.?
Mention severe infections diseases and sequella, if any. Inquire concerning tuberculosis, rheumatism, heart disease, nephritis, etc.
Venereal disease, syphilis and gonorrhea, full account, if possible, of how acquired, age, treatment and after affects.
Severe injuries, particularly head traumata, should be described as regards their immediate and subsequent effects.
5. Occupation:
Kinds of work undertaken, ambition, efficiency, wages, etc. Length of time in different positions, reasons for change, etc.
6. Alcoholism and Other Toxic Influences:
Intemperate, moderate or total abstainer? If intemperate, age at which drinking began, apparent cause of same, kind of beverage consumed and approximate amounts. Periodic or steady drinker? Usual reaction to alcohol?
Inquire about attacks of neuritis, delirium, hallucinatory episodes, suspicions, ideas of jealousy.
Other toxic influences: Drug habits, occupational poisons, lead, arsenic, phosphorus, mercury, etc. Illuminating gas poisoning, nicotine intoxication.
7. Mental Make-up or Type of Personality:
Very important because certain of the non-organic psychoses appear to be a further development of mental traits or tendencies early recognized as personal peculiarities or deviations from the normal. In addition to the points already covered under the preceding headings, the following important types should always be borne in mind and appropriate inquiries made:
Manic make-up: Lively, active, sociable, pushing, talkative, cheerful, optimistic; may be domineering, irritable and inclined to cruelty; sometimes not very efficient, may be noted as changeable, lacking in persistence, concentration and application. May show transient blue spells or lowering of spirits.
Depressive make-up: Gloomy, worrisome, blue natures who feel continuously inhibited or restrained and unable to make decisions; easily discouraged.
Cyclothymic make-up: Emotionally unstable, either up or down, have blue spells or are unduly cheerful and care-free.
Shut-in make-up: Shy, retiring, self-conscious, bashful, quiet, secretive, seclusive and unsociable. Lack of interest in opposite sex or definite aversion; often prudish and over-particular. Unusual religious interest frequent. Inclined to day-dreaming, show fondness for the abstract and mystical. Odd habits, hobbies or cranky pursuits are common.
Paranoid make-up: Mistrustful, suspicious, tend to misunderstand; unduly sensitive, feel discriminated against and have feelings of self-importance. (These traits may be related to shut-in tendencies.)
Other types of make-up include the psychasthenic, neurasthenic and hysterical; also the mentally retarded or undeveloped (feebleminded).
8. Previous Attacks of Mental Disorder:
Obtain dates, places where treated, apparent cause, duration of attacks and general character of symptoms.
9. Precipitating Cause of Present Psychosis:
Try to determine what occurrence or situation appeared to bring about the mental breakdown. Emotional strains, excitement, quarrels, worries, griefs, disappointments, sexual episodes, separation, deaths, childbirth, etc., financial loss, overwork, physical disease, etc.
10. Onset and Symptoms of the Psychosis:
Take as far as possible a spontaneous account beginning with date when first symptoms were noticed in the patient. In this connection particular attention should be given to changes in behavior, in mood, in manner of speech, in attitude towards others and towards work.
Appearance of suspicious, unusual interests, peculiar ideas and delusions?
Hallucinations in various fields and reaction to them?
Obtain as much as possible regarding trend of patient's ideas, topics of conversation and content of hallucinations. What did voices say? What was seen in visions?
Forgetfulness, impairment of memory, loss of orientation and clouding of sensorium.
Always inquire regarding suicidal inclinations or attempts, threats of violence, assaults or homicidal tendencies.
Compare informant's statement with those given in the commitment certificate.
What treatment was given at home? Name of physician in attendance?
Date on which patient was taken to hospital.
PHYSICAL EXAMINATION
I. GENERAL TYPE, APPEARANCE AND CONDITION:
1. Weight (with or without clothes).
2. Height and general frame.
3. Malformations (wherever possible state the origin); asymmetries of skull, face, body, spine, thorax; form of palate (low, high, asymmetrical, saddle or V-shaped, longitudinal torus).
Ears (adherent lobules, prominent anthelix, satyr-points, large, angle, asymmetry, length, etc.).
Abnormalities of hands, feet, sexual organs.
4. Color of the skin.
Color and quantity of the hair.
Color of the eyes.
General complexion.
5. General nutrition (panniculus and muscles).
6. Condition of the skin and mucous membranes; anemia, jaundice, dropsy, pallor, flushing and cyanosis; eruptions (describe in detail). Trophic disorders.
7. Scars, bruises and moles (size, location, color and origin).
8. Evidence of syphilis: scars, including those of the penis, back of tongue (patches devoid of villi and fissures) and palate; tibial crests; glands of elbow, groins and neck.
9. Signs of gout and rheumatism, goitre or nodes of the thyroid, etc.
10. Temperature, general, and various parts of the body (both sides if indicated as in hemiplegia).
II. NERVOUS SYSTEM:
1. General and subjective sensations and facial expression:
General feeling of well-being or exhaustion, general complaints, weakness, etc.
Vertigo: (constant, occasional, or occurring when the patient walks, or in the dark).
Headache: Whole head or limited space; frontal, vertical, occipital, unilateral, bilateral, deep or superficial; constant or periodic, aggravated at night or by some special cause, as with heat, with or without tenderness of head or spine to touch or pressure. Backache (general or localized).
Ovarian, infra-mammary, lumbar and vertex pains (in hysteria).
Neuralgic pains: (fifth nerve, intercostal nerves, sciatic nerve, with pain points, etc.) and muscular pains.
General or wandering pains: Pains in bones (legs) afternoon or night. Girdle pains. Precordial pains (with or without anxiety).
Zones of hyperesthesia: See below.
2. Eyes:
Expression: lids: obliquity, mongol type, lagophthalmus, protrusion of eyeballs (with or without the Graefe symptom), ptosis; spasm of palpebral muscles.
Movement of eyes, nystagmus, strabismus (divergent or convergent); position and extent of movement of the eyes; double vision (in what direction does the second object move and incline?).
Weakness of the internal rectus (in close focussing).
Conjunctiva, lachrymal canal. Scars of cornea. Arcus senilis. Reflectory iridoplegia.
Size and form of pupils. Residuals or formation of adhesion of iris. Contraction of iris on exposure to strong light; on accommodation (for near vision) and after shutting the eye.
Imperfect sight (reading print), improved or not by glasses, dimness of sight, limitation of field of vision, scotoma, hemianopsia, loss of color sense; anomalies of refraction. Condition of apparatus (cornea, lens, vitreous body). Ophthalmoscopy where indicated (for choked disc, optic atrophy, lesions of the fundus). Field of vision where indicated and possible (reversal of color fields in hysteria; scotomata).
3. Ears:
Discharge, otoscopy. Defect of hearing on one or both sides (use watch and tuning fork).
Conduction through skull. Tinnitus aurium (auscultation for actual sound, over the head).
4. Taste:
Test separately the anterior two-thirds of tongue and the posterior third with weak solution of sugar, quinine, acid, salt.
5. Smell:
Test each nostril with oil of cloves, bergamot, peppermint, wintergreen and lemon. Note the actual answers.
Parosmia. Put down the actual extent of discrimination and recognition, with explanation of defect (mental, local, or nervous).
6. Cutaneous Sensibility:
1. Tactile sensibility (use the finger-tip, feather, or pin). Compare both sides of face, arms, hands, fingers, breasts, inner and outer aspects of thighs and legs. (Never omit the ulnar side and the area outside and above the knee). Sole and dorsum of feet.
2. Localization of touch (time and space) and tickle.
3. Sensibility to pain (cautious pricks with a pin, localization in time and space), with or without the attention of the patient.
4. Sensations of heat and cold (cold water and warm water in a glass tube).
(a) Sense of position: See below.
(b) Stereognostic sense.
5. Subjective sensations (formication, feeling of needles and pins, numbness).
6. Tenderness of nerve trunks and muscles on pressure and percussion. The distribution to be noted on the drawings of the body surface.
7. Biernacki's sign (analgesia of the ulnar nerve); anesthesia of eyeball; of testicles.
7. Vasomotor and Trophic Conditions:
Salivation, seborrhea.
Cyanosis or pallor; scaliness or loss of hair; change of nails.
Blushing, dermatographia. General or localized perspiration. Temperature of paralyzed or anesthetic parts.
8. Motor Functions:
Mobility of facial muscles (laugh) (wrinkle the forehead and the nose; move the ears; show the teeth and shut the eyes); tongue; palate.
Muscles of the neck, trunk and extremities; gait.
Functions of the successive segments: In case of paresis or paralysis define the limits of the condition and indicate the results of the following tests: For loss of power: for the coordination of movement (writing, buttoning coat); for muscular sense (discriminating difference in weight; with eyes shut tell the position of the limbs and show with one side the position of the other). Balancing power: (walking along a straight line, stand upright with heels and toes together and eyes closed).
Never forget the test of equality of grip, flexor and extensor strength of elbow, knees and toes. For test of weakness of one lower extremity have both lower extremities raised and hold to fatigue limit. The weaker limb will sink a certain number of seconds before the other.
9. Reflexes:
1. Deep reflexes.
Masseteric: elbow, wrist, knee-jerk with or without Jendrassic, with clonus, or contralateral adductor reflex, knee-cap reflex; ankle clonus and Achilles tendon reflex.
2. Superficial reflexes:
Plantar (with full description as to the Babinski reflex), gluteal, cremasteric, abdominal, epigastric, scapular, corneal, palmar, sneezing.
10. Condition of the Paralyzed Muscles:
Firm and of good tone, or flaccid or deficient in tone. Rigid and contracted. Note attitude of limb and the limitation of the motion, active and passive. Atrophy, hypertrophy, electric reaction of nerve and muscle (galvanic and faradic irritability when required).
11. Fibrillary Twitching:
Its distribution.
12. Tremor:
Of what parts; rhythm, intensity, rapidity. Condition at rest during sleep; when first observed. Condition during motion, how influenced by will.
13. Organic Reflexes and Their Control:
Bladder; delay of micturition. Dribbling from empty bladder, from distended bladder. Peculiar sensations on micturition.
Sexual reflexes: Frequent involuntary contraction and evacuation.
Defecation: Is the patient conscious of evacuation?
14. Convulsions:
Distribution: Extending over head, trunk, extremities, one side, one member.
Character: Which parts first and most attacked, and how do the waves of the tonic and clonic spasm spread; what movements predominate?
Average duration, frequency, occurring night or day, or early in the morning.
Breathing; pupils; vasomotor condition; froth and bites.
Sphincters: Consciousness totally or partially lost.
Aura.
Equivalents: with or without what automatic movements.
Physical and nervous symptoms before and after attack.
Hysterical attacks.
III. THORACIC ORGANS:
Respiratory organs: Is there any difficulty of breathing, permanent or in attacks? Sleep with mouth open? Any pain on deep inspiration? Any cough or expectoration (where from). Nose and larynx. Shape of chest. Frequency of respiration. Respiratory movements. (Compare both sides in deep inspiration and expiration).
Lungs: Percussion. Auscultation. Expansion.
In case of dullness or other abnormalities: Fremitus.
Contents of pleura.
Circulatory organs: Is there any palpitation? In attacks? Due to what? Subjective sensation of arhythmia? Heart: The impulse seen and felt in what area? Relative dullness (right, upper and lateral borders). Sounds and bruits (localized). Pay special attention to muffling of the first sound, to duplication; to change of murmurs in inspiration and by position. Rhythm and accentuation.
Radial pulse: Rate, quality, on lying and sitting and standing. Special attention to variability through position or motion or exertion. If desirable, sphygmogram.
Condition of radial, brachial and temporal arteries.
Arcus senilis.
Sclerosis of veins. Varicosities.
Blood pressure.
IV. DIGESTIVE AND ABDOMINAL ORGANS:
Appetite, thirst, anorexia, nausea: Relative to quantity and quality of food. Vomiting (time and form), eructations and brashes; pain (locality, irradiation and time).
Mouth and teeth. Fetor. Fauces and pharynx. Stomach (position, etc.). Digestion. Movement of bowels. Any subjective feeling of obstacle? Form of stools. Flatulence and distensions. Hemorrhoids and fistulas.
Liver and spleen.
If indicated, examination of stomach contents.
V. URINARY APPARATUS:
Micturition: Urine, amount in 24 hours, specific gravity, color, reaction, odor, albumen, sugar and indican, etc.
Macroscopic and microscopic examinations of sediment, clouds and threads; casts, epithelia, erythrocytes, leukocytes, bacteria, threads, crystals, amorphous substances.
VI. GENITAL ORGANS:
Scars of genital organs. Menstruation: regular; profuse; scanty; accompanying symptoms.
Discharges at intervals; constant; profuse; color.
Internal examination.
In men: Frequency and character of the sexual functions. Frequency of emissions, their occasional exciting causes and correlated symptoms.
Diagnostic summary and indications for further observation and treatment.
MENTAL EXAMINATION
I. ATTITUDE AND MANNER:
General appearance of the patient, adaptation to surroundings, patient's general attitude and behavior, attention and cooperation. Note any peculiarities of conduct or demeanor (peculiarity of dress, mannerisms, grimacing, affectations, etc.). Note the manner, gestures, form of intonation, rapidity or slowness of speech, or special peculiarities. Facial and general expression (sadness, anxiety, fear, restlessness, excitement, etc.). Psychomotor retardation or excitement (violence, destructiveness), care of person (whether cleanly or untidy, etc.).
II. STREAM OF MENTAL ACTIVITY:
1. Flow of thought: Give sample of spontaneous expression or productivity, if possible. If not, give reaction to questioning. Show any disturbance of train of thought (retardation, confusion, incoherence, poverty of ideas, volubility, flight of ideas, distractibility, rhyming, desultoriness, circumstantiality, perseveration, fabrication, coinage of words, verbigeration, echolalia).
2. Abnormalities in the motor reactions: Negativism, catalepsy, echopraxia, stereotypy, automatism, mutism, etc. Show loss of initiative, lack of spontaneity or slowness in action, etc.
III. EMOTIONAL TONE:
Moods and affects. Show the presence of cheerfulness, laughter, mischievousness, excitement, exaltation, depression, anxiety, fear, perplexity, tendency to be startled, irritability, constraint, confusion, indifference or apathy. Show sensitiveness, seclusiveness, suspicion, emotional instability or suggestibility.
IV. MENTAL CONTENT:
1. Hallucinations; hearing, vision, taste, smell, sensation, etc.
2. Delusions; persecution, suspicion, infidelity, poisoning, electricity, hypnotism, mind-reading, self-accusation, grandeur, etc. Show whether permanent or transitory, systematized or unsystematized.
3. Illusions.
4. Obsessions, phobias, etc.
5. Nature of sleep, dreams, etc.
V. ORIENTATION:
Time, place and person.
VI. MEMORY AND MENTAL GRASP:
1. Recent past.
2. Remote past.
3. Retention of school knowledge.
4. Fund of general information.
5. Data of personal identification.
6. Counting and calculation.
7. Reading and writing.
VII. INSIGHT AND JUDGMENT:
The judgment concerning the situation, insight concerning physical and mental health and efficiency, financial status, plans in case of discharge? In discussion of abstract and complicated topics? To what extent is he sensitive to his own errors and to comments?
VIII. SUMMARY: Physical and mental.
IX. DIFFERENTIAL AND PROVISIONAL DIAGNOSIS.
The question as to what benefit is to be derived by the patient from a residence in a hospital for mental diseases is one which is often raised by relatives and friends. They are quite inclined to feel that if no medicines are being prescribed nothing is being done for the patient and that he could be cared for just as well at home. In considering this question it should be borne in mind that the persons under treatment in a hospital for mental diseases are there, either because they appreciate the need of hospital care themselves, or because, as a result of mental disorders, they are incapable of directing their own affairs, or are, in the eyes of the law, dangerous to themselves or others. Their property and other legal interests must be protected during their period of incompetence. Such persons are liable, if not adequately safeguarded, to enter into improper contracts or make legal conveyances that mean financial ruin to themselves as well as others. Unfortunate sexual irregularities frequently occur. Conduct disorders of various kinds are to be expected and a tendency towards criminal acts is common to several of the psychoses. It is a well-known fact that every mentally unbalanced individual is potentially dangerous, no matter how harmless he may appear. The suicide rate of the country as shown in one hundred of the largest cities has not fallen below fourteen per hundred thousand of the sane population at any time during the last twenty years. The homicide rate in thirty-one of our large cities has not dropped below eight per hundred thousand of the population since 1909. Many of these crimes were undoubtedly committed by persons who should not have been at large and who were not responsible for their acts. The most important benefit derived by the patient in the hospital is the constant personal supervision given him by experts throughout the twenty-four hours of the day, whether he is asleep or awake. He gets the benefit of regular hours of rest and exercise, a properly regulated diet adapted to his needs, a sufficient amount of fresh air, and amusement and entertainments suited to his mental condition. He receives competent medical, dental and nursing care and is provided with opportunities for occupying himself in many different ways. Reading matter is always available for those who care for it. Even religious services are held for his benefit.
The tendency of late years is to dispense with the use of drugs as far as possible and resort to other methods of accomplishing the same results. One of the most important therapeutic procedures in common use in the modern hospital for mental diseases is hydrotherapy. This should be used intelligently if any results are expected. Sending the patient to the hydriatic department where identically the same treatment is applied to all cases whether of excitement, depression, exhaustion, etc., by an attendant who has no knowledge of either medicine, psychiatry or nursing may be referred to as the application of water to the exterior, but it is not hydrotherapy. Hydriatic treatments should be prescribed by a physician who has a thorough familiarity with that particular therapeutic procedure and every patient should receive the form adapted to his individual needs. The treatment should be given by an expert hydrotherapist. The equipment should provide for hot air, electric light, vapor and saline baths, Sitz baths, circular, rain, fan, jet and Scotch douches, dry, hot and cold packs, etc. Much can be accomplished by tonic, stimulating and eliminative therapy. Sedative treatments are much used in hospitals for mental diseases. The hot air bath[32] is given at from 134 to 170 degrees Fahrenheit for from four to ten minutes, preceded by a foot bath at from 104 to 110 degrees. The patient enters the electric light and vapor bath at the room temperature, the baths being continued from four to eight minutes usually. The needle spray is given at a temperature ranging from 96 to 102 degrees, with a pressure of from twenty to thirty pounds, and continued from one to two minutes. The fan douche starts at 90 degrees, is reduced gradually with a pressure of from twenty to twenty-five pounds and is continued for from fifteen to twenty seconds. The jet douche is first used at 90 degrees and gradually reduced, with a pressure of from fifteen to twenty-five pounds, for from ten to twenty seconds. The Scotch douche is used at a temperature of 80 degrees alternating with 110, with from fifteen to thirty pounds pressure. It should be used with extreme care. The same is true of vapor douches. The saline bath contains five pounds of ordinary salt to sixty gallons of water at a temperature of 94 degrees and is continued from ten to thirty minutes. The dry pack is usually continued from twenty to forty-five minutes, although it may be used longer with safety. In the use of the hot blanket pack the inner blanket is wrung out of water at from 140 to 160 degrees and must be applied with great care. Depending on the condition of the patient, etc., the cold wet pack is given with sheets wrung out of water at a temperature ranging from 50 to 60 degrees, although lower temperature may be used. "Neutral" wet sheet packs are often used at a temperature of from 100 to 116 degrees for approximately three-quarters of an hour, as preparatory treatments. These measures should never be attempted by anyone who has not had an extended practical experience. Much can be accomplished by hydrotherapy in the alcoholic and toxic conditions, infective and exhaustive psychoses, manic excitements, involutional melancholia, hysterical and neurasthenic conditions, as well as in occasional cases of dementia praecox. Occupational therapy has been used to great advantage in connection with the hydrotherapeutic treatments.
In the reception service and in the buildings for the noisy and violent cases ample facilities should be at hand for the continuous bath treatments. Pack rooms are also desirable. There is no means at our disposal equal in any way to the efficacy of the continuous bath in controlling excitements. The patient is usually kept in the tub from five to eight hours at a temperature varying from 92 to 97 degrees and averaging 96 degrees. In some hospitals they are kept in the tubs for periods of from two to three weeks. The continuous bath is of no value unless it means what the name implies—the continuous submersion of the body in water. In dealing with very excited cases this necessitates the use of a tub cover and a hammock, although sheet coverings are often used satisfactorily. Not much is to be gained by the tub bath if the patient is to be allowed to get out and in as he pleases and only come into partial contact with the water. The continuous bath is not without drawbacks. There is danger of chilling, scalding and drowning either by accident or with suicidal intent, etc. Too much care cannot be exercised in the supervision of the bath rooms. Every tub room in the Boston State Hospital has the following rules conspicuously displayed:—
THE CONTINUOUS BATH ROOM
1. The nurse on duty in the bath room will be held personally responsible for the safety of the patients and must be thoroughly familiar with these rules. The nurse must never leave the room unless relieved by some other nurse. Eternal vigilance is necessary to prevent the chilling, scalding or drowning of the patient.
2. Patients are to be given continuous baths only on the written order of a physician.
3. Patients going to or from the bath room must wear a nightdress or bathrobe and slippers when not fully clothed.
4. Tubs not in good condition or not properly equipped must not be used.
5. Only patients under treatment are allowed in the room.
6. Toilet each patient just before the bath. Patients may be removed from the tub for toilet purposes when necessary.
7. In preparing for the bath, warm the tubs with hot water and then regulate the temperature so that a small amount of water at 96 degrees will be flowing continually.
8. Adjust the hammock to the tub and place the patient in the bath resting on the hammock. Adjust the cover to the tub, with patient's head through the neck opening unless sheets or other covers are used.
9. The temperature of the water must be taken in each tub at least every half hour. Feel the water in each tub frequently. If it seems too warm or too cold, take the temperature at once. If you find it varying from 96 degrees adjust to that temperature by adding a small amount of hot or cold water. If the temperature cannot be kept between 95 and 97 degrees, let the water out of the tub and remove the patient immediately. The physician in charge and the chief engineer should be notified at once. The bath tub key must be fastened to a special cord worn by the nurse on duty. It must be delivered to the nurse in charge of the ward when the bathroom is closed.
10. If the patient is very noisy, restless or flushed, fasten an ice poultice to the tub cover so that as the patient lies in the water the back of the head or neck will rest upon it. Replace with a fresh one before the ice is entirely melted.
Intensely excited patients may have cold compresses to the neck, changed often, for periods of 20 minutes.
Sponge all faces with cold water once an hour.
11. Patients are to be permitted to drink as much cool water (not iced) as they desire, and must be offered a drink at least once an hour.
12. The nurse must record the following: 1. The water temperature and the patient's pulse rate (temporal or facial) every half hour. 2. The amount of sleep in the bath. 3. Bowel movements. 4. Nourishment. 5. Medicine administered. 6. Hours of each patient in the tub. 7. The name of each nurse and the exact time of going on or off duty.
13. In case the patient shows symptoms of fainting or convulsions, makes any attempt at drowning, shows suicidal tendencies or becomes too violent to remain in the tub with safety, let the water out and remove the patient at once.
14. In the event of any serious accident or injury or sudden illness the patient should be removed from the tub at once and the physician notified.
15. Patients are not to be allowed to feed themselves but must always be fed by the nurse. The inlets to the bath may be closed for twenty minutes while patients are being fed.
16. During the day the warming closet must always contain one sheet and one towel for each patient in preparation for drying. It must also contain washable rugs for patients coming out of the tubs to step upon; also two blankets for emergencies.
At least one hour before the patients are to be removed from the baths the garments they are to wear after the bath must be placed in the closet.
17. The temperature of the room should be kept as nearly as possible at 76 degrees Fahrenheit. If the temperature of the room cannot be kept above 68 degrees discontinue the bathing.
When the care and treatment of mental diseases was first undertaken in our state institutions it was soon found necessary to take advantage in every way of such material assistance as could be offered by the more intelligent class of ablebodied patients in carrying on the routine work of the hospital. There were never employees enough to dispense with their services. In this way it came about that they were employed in the farms and gardens, assisted with the kitchen and housework, shared the tasks of the nurses and attendants in the wards and were busily engaged in almost every department of the hospital activities. It became apparent that occupation, undertaken originally for purely economical purposes, constituted one of the most important therapeutic agents at the disposal of the institution. The next step was the development of industries. Patients were taught by instructors to make clothing, underwear, stockings, shoes, brooms, mats, brushes, mattresses, furniture and many other useful products needed by the hospital. The end products were in every instance utilitarian. These accomplishments led to a still further development—purely occupational in character. Women were encouraged to take up such activities as rug making of all varieties, basketry, weaving, crocheting, embroidery, and needlework of every description. Men usually make towelling on looms, weave rugs, renovate mattresses, do repairing of all sorts and manufacture small articles which interest the masculine mind. Brass work, clay modelling and making jewelry of various kinds have been extensively employed.
All of these forms of employment mean, of course, that the patient must leave the ward and go to some place designed for the purpose. The others, however, have not been overlooked and occupational therapists, who devote their entire time to stimulating the interest of the patients who cannot leave the wards, on account of their mental or physical condition, in some absorbing and diverting occupation, are an important part of the personnel of every institution. No other form of treatment employed in hospitals for mental diseases has been so productive of results. It is interesting to note that the medical officers of all of the forces engaged in the recent war found that occupational therapy was of great value in cases of shell shock and war neuroses.
The highest development perhaps of occupational therapy has been in its application to strictly reeducational work in dementia praecox. This consists in a graduated and systematized reeducation of interests in apparently deteriorated individuals. The success of these efforts depends largely on the fact that very simple lines are followed at first. The patients are interested in marching to music, simple drills, calisthenics, games, basketball and purely physical exercises. Some can be induced to sort out raffia and ultimately take part in basket making. Others cut out pictures or put puzzles together. The women sometimes are willing to do plain sewing or make paper flowers. They progress by easy stages to more advanced and elaborate undertakings leading eventually to occupational work in the wards or possibly in the industrial rooms. Some of the apparently most hopeless cases have, as a result of these reeducational efforts, been able to return to their homes greatly improved. The mental improvement goes hand in hand with a resumption of their interests in their former work or some new occupational venture which may have proved attractive.
Every effort should be made to avoid the possibility of long hours of idleness in the wards. When not actively employed in occupational work, ward games, reading, etc., the patients should be taken out of doors for fresh air and exercise. This, of course, suggests the necessity and importance of attractive surroundings. Nothing can be more depressive or detrimental to the welfare of the patient than a prisonlike appearance either inside of the buildings or on the grounds. The successful operation of a hospital is dependent in no small measure on the amount of attention devoted to the preparation of food. There must be a general dietary for the active ablebodied class, one for the working patients, an entirely different one for the tuberculous and epileptic cases and a special diet for the strictly hospital wards. In an institution of any size this requires the constant supervision of several dietitians.
The advances of recent years in our knowledge as to the etiology and nature of general paresis have led to the introduction of highly specialized therapeutic methods in the treatment of that disease and of cerebro-spinal syphilis. This is an important feature of the work of our hospitals at the present time. The interest recently shown in the study of the endocrine system has already brought about a new line of therapy which is destined to receive much attention in the future.
Even the amusements necessary for the individual are given special attention in the treatment of mental diseases. This refers not only to methods of recreation and diversion in the wards day by day but includes moving picture shows, dances and various other special entertainments. Not the least important consideration is the patient's bodily health. This is often a determining factor in bringing about a restoration of mental integrity. It very often happens that there are diseases of the eye, ear, nose, throat, skin, nervous system, etc., which may require attention. Dental, surgical, gynecological and other special treatments sometimes prevent ordinarily acute and recoverable psychoses from terminating unfavorably.
In a word, the modern hospital treatment of mental diseases may be said to consist of a direct personal supervision of the mental and physical hygiene of the patient, supplemented by such specialized therapeutic procedures as may be indicated in the individual case.
CHAPTER VI
THE DEVELOPMENT OF THE PSYCHOPATHIC HOSPITAL
As has already been shown, the modern hospital treatment of mental diseases in this country is a development which represents the progress of nearly two centuries. Satisfactory as this has been in many respects, it nevertheless leaves much to be desired. All indications point to much greater accomplishments in the future. We are emerging from an era of custodial care and entering one of prevention, scientific investigation, and highly specialized treatment along entirely different lines. The interest of the public has been aroused in a subject which has heretofore been one to be avoided by common consent. Mental hygiene societies are no longer viewed with suspicion and curiosity. We are approaching a time when mental diseases can be dealt with, as other conditions are, without prejudice or unjust discrimination. Psychiatric wards promise to become integral parts of a completed medical organization. Psychopathic hospitals will soon be found in all of our great centers of population. The outlook for specialized institutes for purely research purposes, unfortunately, is not so encouraging at this time.
At last there is some evidence of progress in the teaching of psychiatry in medical schools, hospitals and clinics, although only a beginning has been made as yet. More noteworthy advances have been made in other countries. The appointment of Heinroth as a professor of psychiatry at Leipsic in 1811 promised developments which did not materialize to any great extent for many years. According to Sibbald,[33] psychiatric wards or clinics were established at Würzburg in 1833, Jena in 1848, Vienna in 1853, Berlin in 1865 and at Göttingen in 1866. Scholz made provision for observation wards in a general hospital in Bremen in 1875. Fürstner opened a psychiatric clinic at Heidelberg in 1878. Hitzig accomplished the same thing at Halle in 1891 and Siemerling at Kiel in 1901. The inception of the modern psychiatric clinic has generally been attributed to Griesinger.[34] In his preface to volume one of the "Archiv für Psychiatrie und Nervenkrankheiten" in 1868 he advocated the establishment of small hospitals in cities for the intensive treatment of acute and recoverable mental cases. He recommended a large staff of physicians and accommodation for from sixty to eighty patients, according to the needs of the community, but not to exceed one hundred and fifty under any circumstances. "In close connection with the organization of such institutions there is a crying need and a new, most important interest—the question of psychiatrical instruction. This is absolutely indispensable." This he proposed to accomplish by establishing a highly specialized clinic to be maintained largely by the teaching staff of a university. Griesinger's ideas were eventually carried out in full by Ziehen in Berlin, Sommer in Giessen and Bleuler in Zurich. Perhaps nothing has had more to do with the development of psychopathic hospitals in the United States than the well-known clinic established by Kraepelin at Munich in 1905. It occupies a three-story building accommodating one hundred patients and cares for between fifteen hundred and two thousand cases annually. Hydrotherapeutic and electrical treatments are used extensively.
A certain number of beds are reserved for research purposes. Psychological studies receive a great deal of attention. The out-patient department is a prominent feature. The teaching of psychiatry is one of the important purposes of the clinic. Kraepelin's methods have been followed rather closely here. The remarks made by Pliny Earle[35] in 1867 were almost prophetic in character. "Carbon agglomerated is charcoal, carbon crystallized is diamond. What charcoal is to the diamond, such, I believe, is the psychopathic hospital of the present compared with the psychopathic hospital of the future.... When the defects which I have mentioned shall have been thoroughly remedied by a comprehensive curriculum, a complete organization, a perfect systematization, an efficient administration, the charcoal now just ready to begin the process of crystallization will have become the diamond and the world will possess the psychopathic hospital of the future."
Psychiatric research was inaugurated in this country by the establishment of the Pathological Institute of the New York State Hospitals in New York City in 1896. Its original field of investigation was limited to the laboratory. The name was changed to "Psychiatric Institute" on the appointment of Dr. Adolf Meyer as director in 1902 and the establishment was removed to Wards Island, where it was provided with clinical facilities by the Manhattan State Hospital. It thus became the precursor of the psychiatric clinic movement in America. The observation wards for the examination and commitment of mental cases, at the Philadelphia Hospital (1890) and at Bellevue in New York City were probably the first of the kind in this country. In 1902 the first psychopathic wards connected with a general hospital were opened by the Albany Hospital. Pavilion F, as it was designated, admitted 3,132 patients during its first twelve and one-half years. These included persons awaiting examination and commitment, voluntary patients and cases of delirium, stupor, etc., transferred from other wards of the hospital. Of 1,038 cases admitted during a period of six years, only 17.6 per cent were committed to state hospitals. In a total of 1,855 cases, twenty-five per cent were found to be suffering from some form of alcoholism and twenty-six per cent from chronic mental conditions, while thirty-five per cent were cases of the acute and recoverable class. About fourteen per cent were psychoses associated with renal conditions, neurasthenia, hysteria, tuberculosis or traumatism.
The Psychopathic Hospital at the University of Michigan, the first of its kind on this continent, was established at Ann Arbor in 1906 as a direct result of the activities of Dr. William J. Herdman. The objects and purposes of the hospital were shown by the provision of the legislature for the appointment of "an experienced investigator in clinical psychiatry, who shall be placed in charge of the psychopathic ward, whose duty it shall be to conduct the clinical and pathological investigations therein; to direct the treatment of such patients as are inmates of the psychopathic ward; to guide and direct the work of clinical and pathological research in the several asylums of the state, and to instruct the students of the State University in diseases of the mind." It was thus an integral part of the hospital of the University of Michigan but fully coordinated with the state institutions. A subsequent act of the legislature changed its status to that of a "State hospital, specially equipped and administered for the care, observation and treatment of insanity and for persons who are afflicted mentally but are not insane." It also provided that a clinical pathological laboratory should be maintained for the benefit of the state hospitals. During a period of eleven years it admitted an average of 168.82 patients per year. Twenty-four per cent of these were voluntary cases. The psychoses represented were: manic-depressive insanity, twenty-four per cent; dementia praecox, seventeen per cent; paranoid conditions, two per cent; hysteria, seven per cent; psychopathic personality, two per cent; alcoholic psychoses, four per cent; morphine intoxication, one per cent; imbecility, two per cent; general paralysis, eight per cent; cerebral syphilis, one per cent; epilepsy, two per cent; senile psychoses, one per cent; cerebral arteriosclerosis, three per cent; unclassified conditions, five per cent; and not insane, two per cent. Seventy-four per cent of all the cases admitted were discharged after a residence of three months or less and eighty-two per cent after a residence of four months or less. Fourteen and eight-tenths per cent of all cases were discharged as recovered and 32.7 per cent as improved. Owing to the fact that it has only sixty-two beds at its disposal, the number of admissions is necessarily limited and cases are carefully selected.
The Psychopathic Hospital in Boston, the first institution of the kind established in this country as a department of a state hospital (The Psychopathic Department of the Boston State Hospital), was opened for the reception of patients in 1912. The purposes of the institution were very clearly shown by the Twelfth Annual Report of the Massachusetts State Board of Insanity (1910):—"The psychopathic hospital should receive all classes of mental patients for first care, examination and observation, and provide short, intensive treatment of incipient, acute and curable insanity. Its capacity should be small, not exceeding such requirement. An adequate staff of physicians, investigators and trained workers in every department should provide as high a standard of efficiency as that of the best general and special hospitals, or that in any field of medical science. Ample facilities should be available for the treatment of mental and nervous conditions, the clinical study of patients on the wards, and scientific investigation in well-equipped laboratories, with a view to prevention and cure of mental disease and addition to the knowledge of insanity and associated problems. Clinical instruction should be given to medical students, the future family physicians, who would thus be taught to recognize and treat mental disease in its earliest stages, when curative measures avail most. Such a hospital, therefore, should be accessible to medical schools, other hospitals, clinics and laboratories. It should be a center of education and training of physicians, nurses, investigators, and special workers in this and allied fields of work. Its out-patient department should afford free consultation to the poor, and such advice and medical treatment as would, with the aid of district nursing, promote the home care of mental patients. Its social workers should facilitate early discharge and after care of patients, and investigate their previous history, habits, home and working conditions and environment, heredity and other causes of insanity, and endeavor to apply corrective and preventive measures."
The building has a capacity of one hundred and ten beds. The institution may be said to differ from other psychopathic hospitals in being an establishment essentially of the temporary care type, not designed primarily either for the reception or for the care and custody of obviously committable cases, but rather for the observation and treatment of incipient mental disorders as well as psychopathic conditions not properly coming within the scope of the state hospitals. It has been as a rule the policy of the court to commit directly to other institutions for the insane all cases showing clearly the necessity of an extended hospital residence. The fact that only forty per cent of the temporary care cases have been committed shows that a preliminary period of observation before these cases are definitely disposed of is unquestionably warranted. The legal status of cases admitted may be described as follows:—1. Temporary care (not to exceed ten days); 2. Boston Police cases (Persons suffering from delirium, mania, mental confusion, delusions or hallucinations, or who come under the care or protection of the police); 3. Observation cases (for a period of thirty-five days, pending commitment); 4. Cases pending examination and hearing; 5. Emergency commitments (not more than five days); 6. Voluntary admissions; 7. Cases held under complaint or indictment.
An analysis of the work done by the Psychopathic Department from 1912 to 1920 shows a total of 14,922 admissions to the wards,—an average of 1,865 per year. Of these, 59.77 per cent were temporary care (10 day) cases, 18.56 per cent "Boston Police" cases, 1.38 per cent observation cases (thirty-five days), .50 per cent emergency cases, .61 per cent committed "pending examination and hearing," 1.02 per cent under complaint or indictment and 16.96 per cent were voluntary cases. The entire temporary care group, including all of the above classes except the voluntary and criminal cases, constituted 81.34 per cent of the admissions. It is interesting to note that the principal psychoses represented by the cases coming into the hands of the Boston Police are dementia praecox, alcoholic psychoses and mental deficiency. The number of emergency cases is very small, as is the number committed by courts for observation. The number of voluntary admissions, an average of 316 per year, constituting 16.96 per cent of the total, is very significant as showing the response to be expected from the public to an opportunity for hospital treatment without the formality of any legal procedure. Of the 14,922 cases admitted between 1912 and 1920, 38.45 per cent were subsequently committed as insane and 3,797, or 25.44 per cent, were returned to the community as not requiring further hospital care or treatment.
It has been shown that the special field covered by the Boston Psychopathic Hospital consists of temporary care cases. The principal psychoses represented by 12,252 admissions of that class were as follows: alcoholic psychoses, 9.25 per cent; dementia praecox, 25.0 per cent; senile psychoses, 3.16 per cent; general paresis, 6.06 per cent; manic-depressive psychoses, 10.14 per cent; arteriosclerosis, 3.23 per cent; epilepsy, 1.85 per cent; and without psychoses, 20.63 per cent.
This latter class (without psychosis) is looked upon by some as constituting the most important field of a psychopathic hospital. It is exceedingly interesting to note the conditions which bring such individuals to the institution. An analysis of 1,430 cases shows the principal mental types represented to be as follows:—mental deficiency, thirty-four per cent; psychopathic personality, 15.17 per cent; hysteria, neurasthenia and other psychoneuroses, 11.2 per cent; epilepsy, 8.04 per cent; alcoholism, 6.08 per cent; conduct disorders, 4.2 per cent; syphilis, 2.03 per cent; organic brain diseases, 1.68 per cent; neurosyphilis, 1.26 per cent; drug addictions, 1.4 per cent; somatic conditions, 1.19 per cent, etc.
No less interesting and instructive is a study of the voluntary cases. An analysis of 1,807 admissions of this type shows the following distribution of psychoses: alcoholic psychoses, 5.64 per cent; dementia praecox, 18.43 per cent; manic-depressive, 6.81 per cent; involution melancholia, .99 per cent; senile psychoses, 1.11 per cent; general paresis, 7.9 per cent; epilepsy, 1.05 per cent; psychoneuroses, 3.59 per cent; and without psychosis, 34.64 per cent.
The work of the out-patient service includes in a general way the study of cases referred to that department from the wards of the hospital or by its social service staff; cases referred by courts, schools, social agencies, and other institutions, as well as those sent by practicing physicians and individuals coming on their own initiative. The response on the part of the public to the facilities offered by the out-patient department is shown by the fact that 9,273 new cases were reported during a seven-year period, an average of 1,324.7 per year. Fifty-seven and six hundredths per cent of these cases were adults, 17.8 per cent were classified as adolescents, 24.25 per cent as children and .89 per cent as infants. The source of origin of these cases is exceedingly interesting. Four and eighty-seven hundredths per cent were referred to the out-patient service by courts; 4.65 per cent, by schools; 11.77 per cent, by hospitals; 9.77 per cent, by physicians; and 3.55 per cent, by individuals. Fifteen and five tenths per cent came from the wards of the Psychopathic Hospital; 9.96 per cent, from the social service department and 13.3 per cent came on their own initiative. The question as to why these cases are sent to an institution of the psychopathic hospital type can now be answered. Fourteen and fifty-two hundredths per cent were examined solely for the purpose of determining the existence of probable mental diseases and 21.88 per cent on account of suspected mental defects. Four and fifty-two hundredths per cent were sex offenders. In 8.64 per cent the only question at issue was the possibility of a psychoneurosis and in 7.97 per cent the purpose of the examination was to ascertain whether or not syphilis was present. The diagnoses show the nature of the cases encountered in an out-patient mental clinic. Four and eighteen hundredths per cent were cases of dementia praecox; 1.7 per cent of alcoholism; 2.26 per cent of alcoholic psychoses; 2.39 per cent of epilepsy; 15.72 per cent of mental deficiency; 9.0 per cent of psychoneuroses; 2.14 per cent of manic-depressive insanity; 2.09 per cent of psychopathic personality; 1.21 per cent of general paresis; and 2.94 per cent were unclassified. Two and thirty-two hundredths per cent were diagnosed as suffering from syphilis in some form and 6.27 per cent were either delinquent, defective, subnormal, retarded or distinctly feebleminded. In 3.76 per cent no disease was found, either mental or physical. The great bulk of these cases were diagnosed either as mental deficiency, psychopathic personality or epilepsy. The ultimate disposition of 2,741 cases, covering a period of two years, serves as an index of the practical operation of such a department. In 42.03 per cent of these cases no care or observation other than that of the out-patient department was required. In 1.69 per cent of the cases commitment was recommended to hospitals for mental diseases, in 7.15 per cent, to schools for the feebleminded and in .11 per cent, to penal institutions. General or psychopathic hospital care was recommended in 11.31 per cent. In 2.74 per cent of the cases a report was made to courts; in 1.61 per cent, to schools; in 18.75 per cent, to social agencies; and in 1.13 per cent, to physicians.
The functions of the social service department in a general way may be summarized as follows:—1. The after care and supervision of patients at home; 2. Advice to families of patients in regard to their cases; 3. Advice given other members of the family; 4. Financial relief; 5. Reference to other social agencies or institutions; 6. Information obtained for case histories; 7. Inquiries relative to home conditions when discharge of a patient is under consideration, etc. The routine operation of the department is well illustrated by the annual report of the Boston State Hospital for 1920. The number under social service supervision during the year was 428. Of these, 278 were new cases. Thirty-two and thirty-seven hundredths per cent were referred by the out-patient physicians; 59.71 per cent by the ward service; 7.19 per cent by other social agencies; and .73 per cent were brought by relatives or friends. The principal reasons for their reference to the social service workers were shown as follows:—For medical history, 50.36 per cent; assistance in securing employment, 9.35 per cent; financial aid, 3.6 per cent; supervision, 7.2 per cent; advice, 19.42 per cent; convalescent care, 2.87 per cent; home care, 2.87 per cent, etc. An analysis of the cases under supervision shows the principal psychoses represented to be as follows:—Arteriosclerosis, 1.8 per cent; general paresis, 4.68 per cent; alcoholic psychoses, 1.8 per cent; manic-depressive psychoses, 4.68 per cent; dementia praecox, 16.55 per cent; paranoid conditions, 4.31 per cent; psychoneuroses, 9.35 per cent; undiagnosed psychoses, 6.84 per cent; and without psychoses, 44.24 per cent. This latter group was made up mostly of psychopathic personalities (28.45 per cent) and mental deficiency (26.29 per cent). The purely social problems presenting themselves in connection with these cases were reported as follows:—Mental disease, 75.54 per cent; physical disease, 2.16 per cent; poverty, 2.88 per cent; criminality, 3.24 per cent; juvenile delinquency, 2.52 per cent; sex offenses, 2.16 per cent; alcoholism, 2.16 per cent; family dissension, 6.12 per cent; ignorance, 2.52 per cent; and bad environment, .36 per cent. In addition to this, 299 discharged soldiers and 543 out-patient cases were reported as being under the supervision of the department, as well as 532 special cases studied in connection with the investigation of syphilis.
The Psychopathic Hospital in Boston started on a new chapter in its history on December 1, 1920, at which time it was formally separated from the Boston State Hospital and became a separate institution under the direction of Dr. C. Macfie Campbell.