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get any farther with the problem of feeblemindedness, and how long we are going to flatter ourselves that the money for ungraded classes is well spent while supervision ceases when the greatest need for it begins. There is no use training children for the scrap heap. If supervision is too expensive, ungraded classes are rank extravagance.
Finally, to sum up, a system of community supervision of the feebleminded in connection with the school system is absolutely necessary for a term of years, (1) in order to deal with the problem of control and prevention of feeblemindedness while segregation and sterilization are as yet inadequate, (2) in order to get facts regarding the feebleminded who can and those who cannot be adapted to life outside an institution, (3) in order to determine whether there is anything better than the colony plan for utilizing the labor of the feebleminded, (4) in order to educate the community to an understanding of the problem, (5) in order to justify the existence of special or ungraded classes and render them really useful, (6) in order to provide an opportunity for the study of the individual cases not a priori delinquent or belonging to the group obviously requiring segregation.
L. Pierce Clark in a recent article* in Mental Hygiene has put the matter in a nut shell when he says:
We shall never arrive at any proper understanding of the causes of preven- »tion of feeblemindedness until we reconcentrate ourselves anew to the individual case studies and make them thorough and detailed and see where they lead us, instead of studying this class en masse, which has been the popular mode of late.
Psychopathic traits, or better, conduct disorders in mentally retarded and arrested children need to be considered and studied on the broad plane of our present day knowledge of personality and psychiatry.
*L. Pierce Clark, "A Consideration or Conduct Disorder in the Feeble-minded,"
Mental Hygiene, Jan., 1918.
1. Among the facts and proposals put forward on informal discussion were the following: An instance was cited in which a factory superintendent found it difficult to get the board of education of the city to send graduates of special classes to him. On the other hand, objections were raised in some factories by the operatives, to the effect that bringing these special cases in would tend to lower wages. A juvenile court judge suggested that data be collected in the schools regarding children before they might become unsocial. It was said that the best results in getting graduates of special classes into factories might be obtained by working with them individually instead of in large groups. More difficulty is met with in getting girls into industry than in placing boys. In regard to the classification of defective delinquents, it was stated that special provision should be made for them, but that we do not yet know what kind of institution is needed.
2. Those participating in the informal discussion, besides the speakers whose papers are given, were: Mrs. Florence Godfrey, Kansas City; A. Wyle, Rochester; C. Parsons, Des Moines; W. H. C. Smith, M. D., Godfrey, 111.; J. Bruce Byall, Philadelphia; Judge C. E. Higbee, Grand Rapids.
THE ORGANIZATION OF A STATE HOSPITAL
H. Douglas Singer, M. D., M. R. C. P.; State Alienist, Department of Public Welfare, Kankakee, Illinois
The demands of the army for physicians, nurses and attendants trained in psychiatric work have resulted in a serious condition of shortage in the supply of such persons for civil service. Under these circumstances it becomes more than ever necessary to organize the state hospital for operation at the highest efficiency in order, as far as possible, to offset the deficiency in trained help.
Fortunately, the increase in the number of committable cases of insanity resulting from war conditions has so far proved to be very small and experience abroad does not justify any expectation of large numbers of cases of this kind. The main increase in mental disturbances concerns psychoneurotic and borderline conditions, the care of which will take place largely outside the state hospitals. These must, however, be prepared to assist largely in this work. The subject assigned to me for this paper deals only with conditions within the hospital and, therefore, I shall touch only incidentally upon this feature, although I am fully cognizant of its great importance.
Functions of a State Hospital
In discussing the question of organization it is necessary first to consider the functions which the state hospital is called upon to perform and the results desired. For long such institutions were regarded as purely lodging houses for the segregation of those who, by reason of mental disorder, were unfit for ordinary social life. Gradually this gave way to the so-called "hospital idea," by which was meant an approximation of methods and equipment to those of a hospital for physical disease. While this represented a decided step forward, it has, nevertheless, in my opinion, been to some extent a failure, for the reason that it has not taken sufficiently into consideration the very special character of the work to be done and the fact that many of the inmates will inevitably remain permanently within the institution, although not "sick," in the ordinary sense of the word, at all.
The recognition of the existence of mental disorder necessitating care in a state hospital does not have the same significance as the diagnosis of bodily disease requiring treatment in an ordinary hospital. Disease may, it is true, be present, but the principal fact is disorder in behavior, and in the majority of cases no evidence of disease can be detected. The hospital for the insane must, therefore, be organized primarily with the object of treating behavior, the ordinary practice of medicine being, though essential, a less important branch of its activities. Only when this is fully grasped and adequately provided for, shall we be able to achieve even an approximation to the ideal hospital for mental disorders.
Behavior is in part the result of inherited nerve connections, but to a much greater degree it is the outcome of education and training. A state hospital must, therefore, be planned primarily as an educational institution, its efforts being directed towards the correction of faulty habits and the establishment of new ones designed to enable the individual to behave in a manner compatible with social life. Even when full correction is not secured, as unfortunately must frequently be the case, either because the faulty habits have become too deeply ingrained before the individual comes under treatment or for some other reason, partial success may be accomplished, whereby the patient becomes capable of living more or less satisfactorily in a modified or simplified environment such as in that of the custodial division of an institution or under supervision outside.
The education required does not differ in principle from that which is given to the child. We cannot hope, even if it were desirable, to remove feelings, desires and passions which are inherent in life itself. Our efforts, therefore, must be directed towards providing means compatible with social existence for the outlet of the energy which these emotions represent. This implies occupation endowed with interest. This is what we try to develop in our children, even though we perhaps do not plan our educational system with this consciously in mind. It must also be the corner stone of state hospital organization.
In planning the organization this central feature must be kept continuously in mind if we are to develop any purposeful and orderly system. In the past many of the arrangements have developed more or less in a haphazard way, alterations being adopted to meet emergencies without any organized efforts towards revision of the system as a whole.
The Patient's Institution Experience
Probably the simplest plan to follow in this article will be to trace the path of a patient through the hospital and to indicate the various possibilities to be considered. This will afford a ready means for indicating the various subdivisions of the institution and defining their functions. Following this a few remarks on professional personnel and their economic employment will not be out of place.
The patient when first admitted will go into a reception division, in which he is examined and studied with the objects of determining the particular problems to be met and of deciding the course of procedure to be adopted. A soon as this has been accomplished—a process which may take from a few minutes to several weeks—he will be transferred to the division in which it has been concluded he will receive the necessary treatment and care. The decision must be based upon the actual needs of the patient and not upon any convenience in administration, which means that the various divisions must be organized upon a basis of therapeutic equipment.
At the time of admission the patient frequently shows more or less severe disturbances of conduct (often called symptoms of acute insanity), which represent the reactions to the difficulties, of whatever nature, which have brought about the demonstration of faulty habits or behavior or, in other words, have precipitated the insanity. During this stage of acute mental disorder it may be necessary to await the arrival of a calmer period before attempting more active education and to confine our activities to meeting exigencies and dangers as they arise. This calls for expert skill and special equipment, particularly in the nursing force. It, therefore, will constitute a separate division, which may be called the division for acute mental cases. It should be constructed in small units to permit separation of patients and be planned especially to promote rest. Prolonged baths and conveniences for packs are essential. Facilities for simple employment, not as training but as an outlet for energy, must also be provided.
After the subsidence of this acute period, or immediately if such a stage does not exist, the patient should pass into a special division devoted to education. Such a division must provide for various kinds and grades of instruction and must be regarded as the most important branch of the institution. It corresponds exactly with the reconstruction work which is being planned for disabled soldiers after the wounds causing the disability have sufficiently recovered. This division should be able to provide material assistance to the government in planning and carrying out such work. Upon the success accomplished here the whole future of the individual depends.
It will be realized that, following the abatement of the acute stage of of mental disorder, the condition of the patient may vary enormously. Let us take two extreme illustrations. The first patient is stupid, careless and untidy, shows little or no evidence of interest in his surroundings and, as is often said, is in appearance more or less completely demented. In most hospitals such a patient is promptly transferred to the untidy, or back, wards of the institution, there to receive a postgraduate course in idleness and degradation. The proper destination of such an individual is an environment in which continuous efforts are made to arouse interest and to re-establish the former selfrespect. The man may have to be trained like a baby even in the simpler habits of self-care, but if nothing more than this is accomplished the problem of his maintenance in the institution becomes enormously simplified. In connection with the treatment of such cases various stimulating forms of treatment, hydrotherapeutic, diversional and otherwise, are valuable.
At the opposite extreme, the subsidence of the acute stage may be followed by an apparent return to the individual's previous norm. He is said to then be convalescent. Nevertheless the problem to be faced concerns not only his immediate recovery, but still more the question of the prevention of future breakdowns. This may require special and even prolonged training in suitable habits of reaction and industry with the object of equipping the man better to meet the conditions of life on the outside.
Between these two extremes lies every possible gradation and variety, each with its special problems, the number being almost a*s great as the number of individual patients.
The functions of this educational division are those of habit training, which is to be accomplished by graded occupational teaching, and the provision of graded responsibilities. It should be the prime object of the hospital to see that every patient who leaves the institution is better equipped to meet the world than when he entered and that those who remain shall be prepared to be made useful to the full limit of their capacity.
Bearing on Permanent Disposition of Case
As a result of the information gained from a study of the patient under these conditions and the progress he makes as a consequence of the training there will develop, in the course of a variable time, some definite grounds for the determination of the future mode of life which it is desirable for each to adopt. This may be life outside the institution (with or without certain restrictions) or, on the other hand, it may be more or less permanent segregation from the complicated conditions of life in the world.
Leaving for the moment those persons who are released from the institution, we may consider the division of the institution devoted to the care of those who will remain permanently within its walls. This division, the largest in most state hospitals, must.be designed with a view to providing varying degrees of complexity of environment (which is largely a question of individual responsibility) and also towards the making of the lives of the inmates as comfortable and as home-like as possible. This does not imply either a hospital life or a life of idleness. To be happy, every individual must be occupied. The form of occupation should be selected by reason of its fitness and interest for the individual, but here with due consideration for the needs of the institution itself. The custodial division is thus also the industrial division, and not only will economy in administration be promoted by this arrangement, but the welfare and happiness of the inmates will be greatly enhanced. Systematic industrialization of the state hospitals is a most urgent need, for nothing is more detrimental or more heartrending than the rows of idle so-called dements who fill their chronic wards.
The training given in the educational division may well be planned to prepare such patients as are expected to stay within the institution for the performance of the various kinds of industrial work which are being undertaken by the institution.
It cannot be too strongly insisted upon, however, that occupational therapy, the name customarily given to the work of the educational