A CONSIDERATION OF THE NEED OF BETTER PROVISION FOR THE TREATMENT OF MENTAL DISEASE IN ITS EARLY STAGE.1

BY J. MONTGOMERY MOSHER, M. D.,

Attending Specialist in Mental Diseases, Albany Hospital, Albany, N. Y. In 1902 was opened at the Albany Hospital a pavilion for the treatment of mental diseases to which patients might be admitted without formality and with the same freedom as those received in the wards for the sick and injured. It was proposed to meet the needs of certain cases of incipient or transitory mental disturbance for which no provision was otherwise made. If insanity threatened it was the practice in Albany, as elsewhere, to temporize until symptoms developed requiring judicial consideration, when legal proceedings were taken and the patients committed to an institution for the insane. If the patient became violent or dangerous he was not infrequently sent to the county jail pending his transfer to proper care, and the inhumanity of this, illustrated by some disastrous occurrences, emphasized the need of greater consideration of the necessities of these unfortunate persons.

The undertaking was a modest one, but has unexpectedly attracted attention as an innovation, probably because in public and professional opinion the management and control of the insane have long been associated with decrees of the courts of law and not infrequently with criminal proceedings. The medical relations and status of insanity have been lost from sight.

Among the visitors to Albany to whose notice this department was brought was Dr. McIntyre, the chairman of your committee of arrangements for this meeting, and to his interest and courtesy I am indebted for the compliment conveyed in the invitation to address your society. This is an especially gratifying recognition of the work done in the Albany Hospital, not only as coming from

Read by invitation of the Committee on Scientific Work at the annual meeting of the Medical Society of the State of Pennsylvania, held at Cambridge Springs, September 14-17, 1908.

the representative medical body of another state, but because Pennsylvania is pre-eminent in medical science and in progress in the care of the insane.

It may not be out of place to recall that the first and oldest hospital of this country, the Pennsylvania Hospital in Philadelphia, obtained its charter mainly on the representations in the petition therefor, of the needs of persons "Distemper'd in Mind and depriv'd of their rational Faculties," and it is noteworthy that at that early day, 1751, the pathological nature of insanity was recognized in the effort to provide a hospital for "the cure and treatment of lunaticks," in order that "they may be restored to reason and become useful members of the community." Not until forty years after were the reforms of Pinel in France and Tuke in England accomplished, though from their humane efforts is popularly dated the modern era in the care of the insane. But insistence upon the fundamental truth that the insane are sick, which stands to-day unmodified and unassailable, must ever remain the glory of the first hospital of the United States.

The medical practice of that day differed from ours, and in the light of our science may be susceptible of criticism, but it was available for the sick in mind as freely as the sick in body, if the distinction be permissible, and when Pinel and Tuke were relieving physical conditions which were a blot upon their civilization, Benjamin Rush was engaged with the scientific observations which resulted in the first medical publication by one of our countrymen on the subject of mental diseases. His recommendations were far in advance of his time and his book is still a classic in our literature.

In 1841 the wards for the insane in the Pennsylvania hospital were abandoned, and the original buildings received surgical and general medical cases only. The mental patients were transferred to the new special department in West Philadelphia. The reasons for this are indicated in the records of the hospital, and are particularly: first, the accumulation of patients who failed to recover; and, secondly, the inconvenience of a divided or interrupted authority, which occurs in general hospitals upon the quarterly rotation of attending physicians. When one visits the beautiful grounds and wards of the Pennsylvania Hospital for the Insane,

it may be easily seen that no departure from the benevolent purpose of its founders has been made.

The separation of the insane from the bodily sick was inevitable and was necessitated by conditions which could not be otherwise met. But though the work done by modern hospitals for the insane is of high order the unfortunate discrimination has not been favorable to early treatment, and the number of chronic cases has become so large as to paralyze efforts for cure. The state is overwhelmed by the constantly increasing and expensive burden, and the overcrowded institutions are essentially custodial. Sanitary dwellings, comfortable beds, proper food are provided, and diversion and occupation are utilized for the contentment of the patients, so that their lot is greatly improved over the neglect and abuse incident upon county care in almshouses and jails.

The time has come for another step in advance. Insane patients may be divided into two classes, those revealing an inherent or congenital defect of mental development, and those who break down under the stress and exactions of life. The latter may be regarded as possessing normal minds which have succumbed to disease, usually some form of exhaustion or toxæmia, or both. They require and respond to proper treatment. By neglect they pass on to incurable dementia and swell the number of helpless incompetents. Law and custom make no distinction between these two classes. It is the practice in the larger commonwealths to place a state hospital in each of several districts, into which the state is divided, and to this hospital to "commit" the patients from the district. The "commitment" is made by a judge or magistrate, and no patient may be received or detained without the judicial order, and no patient may obtain this order until his mental symptoms have become so pronounced as to warrant the court in making the order, for the preservation of the public peace, or the safety of the patient. Cure and restoration are matters of chance. From the medical standpoint this reflects a less enlightened age than our own. In no other department of practice would it be tolerated. It may properly be regarded as analogous to refusal to treat a case of pulmonary tuberculosis before the formation of a cavity; and such a rule, if applied to cases of tuberculosis, would be a repudiation of all efforts recently made to intercept the

ravages of this disease in its incipiency. Yet this neglect of the only promising stage of mental disease has been quietly accepted by the profession, notwithstanding the efforts made by hospitals for the insane to popularize their special knowledge by the adoption of laboratories and other sources of investigation common to general medical practice. The results of laboratory work, it is true, have been negative, but this may be regarded as fortunate, in so far as it points the way to another field.

For the first suggestion toward better treatment tribute must be again paid to Pennsylvania and its famous hospital. In a paper read before the American Medico-Psychological Association in 1882, and published by the State Board of Charities, Dr. John B. Chapin, Medical Superintendent of the Pennsylvania Hospital for the Insane, directs attention to the custodial character of state institutions, and proposes the organization at each of a small hospital block for the active treatment of recoverable cases. He says:

"In every institution for the insane are to be found a certain number of cases of acute mania with exhaustion, acute delirious mania, nervous prostration with incipient mental disorder, insomnious conditions, cases of melancholia, which in respect to the prospect of recovery from mental disorder or a prolongation of life may be said to be in a critical condition. They are misplaced in the ordinary wards, surrounded as they are by all of the disadvantages to which allusion has been made. They may be feeble, extremely susceptible to noises, suicidal, and need an unusual amount of personal attendance for their proper care, as well as much tact and persistence in their management. They may require, and should have, if necessary, two or three attendants available for their care every twentyfour hours, and the medical superintendent might properly organize a special service composed of the best trained attendants for this class. All of this service can be best provided for in a detached hospital block convenient of access to the medical superintendent, and under the care of a medical officer assigned to the building. The number of patients for whom this special accommodation would be required would not be large, and rarely exceeds five per cent. The plan should provide for complete isolation of a patient if necessary; rooms arranged and constructed so that all noise and confusion existing in other wards could not be heard; and so accessible that a patient could be received into the hospital and in some cases even discharged, without contact with the unpleasant scenes, discomforts and depressing associations of which some properly complain before and after their discharge."

The class of patients enumerated by Dr. Chapin is susceptible to treatment and restoration to health. The conditions which lead

to insanity are social and personal, and cannot be met by wholesale preventive methods such as may be applied to contagious and epidemic diseases. The community may purify its water supply and wipe out typhoid fever; it may quarantine and disinfect diphtheria, scarlet fever and tuberculosis, and stay the ravages of these diseases. But no comprehensive or universal decree reaches the victims of the stress and worries of life, the financial difficulties and domestic incompatibilities usually concealed, the anxieties, distresses, discouragements and despair which slowly undermine the nervous resistance and are not revealed until some sudden and critical mental explosion results.

It may now be said that recovery from mental disease is to be sought in the application of clinical methods to early cases, and in this only.

This suggestion, unheeded for sixteen years, now promises to bear fruit. In New York it is proposed to add to the state hospitals separate buildings for the active treatment of recent cases of insanity, and the lunacy law has been amended to permit the reception of patients who apprehend insanity, or, in an incipient stage seek relief. Clinical methods and an active ward service are to be adopted. The great benefits to be derived from this plan cannot. be underestimated. The large institutions will become less custodial in character, and the medical staff are to be stimulated by the study and treatment of the individual, to which the physician has been consecrated since the days of Hippocrates. It is a matter for deepest regret that the humane purpose of large institutions is not more generally appreciated, and that their conscientious medical officers, laboring patiently under great responsibilities, should be isolated from their colleagues. There are no greater monuments to our calling than the institutions for the insane, and every effort toward hospitalization and the recognition of insanity as disease should be encouraged and emphasized.

But when all this has been done, and the state has provided for the care of helpless chronics and the restoration of acute cases, an obligation remains upon the general hospital. Recognition of this by the physicians and local authorities led to the organization of the department for mental diseases at the Albany Hospital. The state hospital to which patients were sent was seventy-five miles