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department, is absolutely separate and distinct from industrial employment. The latter may, indeed, be regarded as graduate work, and in no case should the industrial needs of the institution be put ahead of the therapeutic requirements of the individual patient. The case of the institution, in this regard, does not differ from that which obtains in the world at large. The child is educated first, and only later is permitted to enter industry. To attempt to interfere with this provision in ordinary life has always led to disaster. This is evidenced by the enactment of laws prohibiting child labor, and even more emphatically, during the war, both in this country and in Europe, when efforts were made to relax the school and training conditions in order to allow early participation in work essential for the conduct of the war. Universally it has been found that there followed an enormous increase in juvenile delinquency. We may well apply this experience to the state hospitals, and realize that an effort to cut down or eliminate the training period is bound to lead to failure.
Hospital Organization and Professional Activities
The organization outlined thus far then provides for the following divisions:
1. A reception service
2. A division for the care of acute mental cases
3. A reconstruction division
4. A custodial division
To these must be added
5. A hospital division
6. An infirmary division
7. A laboratory division
The hospital division has as its function the treatment of the physically sick, and will require medical and surgical equipment similar to those of a general hospital. It must also provide for the care and segregation of various infections such as tuberculosis and the contagious diseases.
The infirmary division is a department in which are cared for the more or less helpless results of organic disease, the terminal stages of general paralysis of the insane, senile dementia, etc. This should contain the only untidy cases permissible in the institution, cases in which the lack of self-care is due to structural defect and not merely to bad habits. These latter make up by far the larger proportion of the inmates of the untidy wards of most institutions.
The laboratory division needs but little description. Its functions correspond with those of any well equipped general hospital.
The organization into divisions here outlined does not differ greatly perhaps in its general arrangement from that which obtains in many hospitals. I would insist, however, that it does differ in that it presents a clear definition of the functions to be performed and is built up around an eminently practical plan of therapeutics.
The personnel of a hospital can profitably be divided into professional and administrative branches. This subdivision means something more than mere words. I am convinced that if its true significance is realized and acted upon that very considerable economy in material may be accomplished.
The professional branch, with which alone I propose to deal, includes the medical, nursing, attendant and special therapeutic services. For all such work special and often prolonged training is necessary, and it is in these fields particularly that the greatest demands are being made by the army. It is obviously wasteful to employ a highly trained individual to perform work which could well be done by unskilled persons. In the hospital, organized as planned above, the great need for physicians trained in psychiatry obviously lies in the receiving, acute mental and the educational divisions, and it is here that they should be especially concentrated. The work in the hospital, infirmary and custodial divisions can be carried out by physicians of less psychiatric experience, but there should be some arrangement whereby cases requiring special study could receive the benefit of such experienced physicians as are available. For this purpose it would be well to provide certain wards for special observation which could be under the same direction as that of the more acute services. Under present conditions laboratory work, which will of necessity be largely routine, can be placed in the hands of trained women technicians.
A great deal of a physician's time in state hospital work is often wasted in performing simple routine duties which could well be delegated to a clerk or some similar person. We have recently instituted in the Illinois hospitals a system whereby a clerk is employed to act much as a secretary to the medical staff. By observing certain rules for minimum requirements she is able to keep track of the duties which should be carried out each day, to see that patients and records are in readiness for the physician, that the purely formal data in various reports are filled in and, by making appointments with visitors, to see that unnecessary interruptions of the physicians' time are avoided. The system also enables one experienced physician to so arrange his service that much of the necessary routine medical work can be allotted by him to assistants (women and men unfit for military duty), who are not trained in psychiatry. This has resulted in a very marked saving of waste time and greater efficiency in spite of the reduction in the numbers of trained physicians available which we, in common with other states, have suffered.
Nursing, Occupational Supervision, Social Service
The nursing service can be improved in like manner by cutting out unessentials from the duties of those who are trained. The training of nurses for psychiatric work is another field, the importance of which has been brought home to us by the war. Most hospitals today maintain training schools for nurses, but unfortunately the training given takes but little account of the special work that these nurses are to be required to do. It aims rather at producing a nurse cast in the same mold as the nurse in a general hospital. In my opinion our training schools should be planned to develop nurses fitted to care for mental and nervous cases and that we should hire, already trained, such nurses as we need for the care of bodily sickness. We have been working on such a scheme in Illinois for the last few months and hope to have the new training school at work this coming fall. The backbone of this course must be occupational therapy and habit training which we have adopted as the corner stone of our divisional organization. Such nurses will be required only in the earlier divisions considered. Attendants, adequately trained, will be employed for the care of custodial cases.
In the educational division there are needed workers especially trained in occupational teaching. Much of this work will be done by nurses of the special training school alluded to but, for the present at any rate, it seems necessary to secure some one who can devote the whole time to the supervision and direction of the activities in this division. This, of course, does not relieve the psychiatrist from the duty of deciding and prescribing the proper treatment for each individual.
Lastly, reference must be made to a division the work of which lies in part outside the walls of the hospital, the social service department. The state hospital, from the nature of conditions, possesses almost a monopoly upon psychiatrists, and is unquestionably the center from which must radiate all efforts towards prevention and after care. The staff must be so organized that the physicians can take part in the mental hygiene work of the community and there should be some provision made for the reception of patients for temporary study and observation with the object of determining the proper treatment necessary.
Reference was made above to the maintenance of special observation wards in connection with the acute (as opposed to custodial) service for special study of difficult cases. These same wards should also be open for the reception of temporary care, or voluntary cases brought in from the outside for diagnosis and not necessarily subjects for commitment. It is this class of case which is being brought more prominently forward by war conditions and which the state hospital must be prepared to assist. Since, however, the subject of extra-mural activities is being dealt with by another speaker, I do not propose to enter into it further.
WAR NEUROSES AFTER THE WAR: EXTRA-
Mary C. Jarrett, Chief of Social Service, Boston Psychopathic Hospital
A practical consideration of this topic, extra-institutional preparation for the care of war neuroses after the war, presents itself in the form of three questions,—Do we know what the problem will be? Have we knowledge of the way in which such a problem should be met? And can we be prepared to apply such knowledge as we have to the problem as we foresee it? From the experience of our allies, of Canada especially, we are able to foretell approximately the extent and nature of war neuroses to be expected among our own troops. Since it has been established that the neuroses of war are essentially identical with the neuroses of civil life, for the treatment of which a considerable body of medical knowledge exists and is at present being applied in a small number of centers in this country, the second question may also be answered in the affirmative. The answer to the question, "Can we be prepared to meet the situation?" is still in doubt and depends upon the energy and activity of those who know the subject and their success in bringing their knowledge to the public, in such a way that legislatures may be moved and the people stirred to recognize adequate care for war neuroses as a humanitarian and social necessity in our war program and to go out to meet with civilian measures the extraordinary efforts of the government to care for the mental as well as the physical health of our soldiers and sailors.
It will not be long before we shall have, coming every month from overseas, three thousand invalid soldiers, of whom, Col. Bailey has estimated, 400 will be suffering from nervous and mental diseases. In addition to the neuro-psychiatric cases, neuroses occurring in patients suffering from physical injury or disease must be taken into consideration. We are told in Canada that 90 per cent of all invalid soldiers show symptoms of nervous disorder of some kind. The Canadian Patriotic Fund states that one of the chief difficulties they meet in reconstructing family life after the discharged soldier returns home is the man's nervous condition, which makes it almost impossible for him to hold a job. Return to civilian life after months or years of army discipline is in itself a difficult feat of adjustment. When we consider in addition the effects of the intolerable strain and horror of this present war, it is to be expected inevitably that the mental adjustment required of a man who survives and returns to civil life will in a majority of cases be difficult to a degree that calls for medical help.
We may expect three types of neuro-psychiatric cases requiring different kinds of provision. There will be men suffering from mental disease, temporary or chronic, who will need prolonged treatment in hospitals, the so-called insane patients, for whom government and state hospitals must be fitted to provide. Second, among the shell-shock cases, there will be many in which recovery is slow and care in a government hospital for months or a year may be required, followed by a period in a convalescent home. In some of these cases moreover symptoms may recur from time to time. Finally we must expect neuroses in men discharged for physical disability, cases in which the nervous or mental symptoms may not appear until after the man's discharge.
It may be well to review briefly what provision for cases of these three classes already exists, in order to point out how completely inadequate our present institutions are to meet either the war situation or the current civilian need. There are 156 state hospitals for mental disease in all the states of this country. Many of these hospitals are constantly over-crowded. For observation and treatment of early cases of mental disease and cases of neuroses not suitable for admission to the state hospitals there are 6 psychopathic hospitals and 11 psychopathic wards in the country. Provision for out-patient treatment is so rare that a mental clinic in any community is a conspicuous institution. Compare the 73 mental dispensaries and out-patient departments, which is the total number that the office of the National Committee for Mental Hygiene has been able to discover, 59 of which are New York and Massachusetts, with the existing innumerable clinics for bodily diseases. At one of the cantonments a few weeks ago the medical officer in charge of the psychiatric ward said that men were being discharged continually from his ward who should have out-patient treatment. When I asked if any arrangement was made for them to receive it, he said, "You know there aren't any out-patient departments where these men come from to send them to. What can you do?" The psychriatrists of the army are discovering nervous and mental disorders at the rate of 2,000 a month for which there are almost no means of treatment. A young man found to have neurosyphilis and discharged from the army goes home and continues to develop general paresis, unless he has the rare faculty of realizing his condition and discovering for himself a physician qualified to treat him; and the man suffering from a neurosis discharged from service even if he has the gift of initiative will probably not be able to find a physician to treat him. This is the situation that we shall have to change if we are to be prepared to care for war neuroses after the war.
We have however more knowledge than we have means; for in some institutions it has been possible to advance medical and social practice in the treatment of neuro-psychiatric cases, so that effective methods have been demonstrated and are available for use, whenever the means may be found to increase the existing number of hospitals and dispensaries and to train additional psychiatrists, social workers, and other required lay workers. The difficulties are enormous, but the situation would be heavy with difficulty of an entirely different quality if we did not already know what to do. We know what should be