°\-! Reprinted from the New York Mcdkal^LLMwah^Ttl*'*" ^ v . ^ November 21, igiy I \ HS p\ "X ;"^ *' IrM T NEED OF MORE STATE H THE INSANE By J. Allen Jackson, M. D., Philadelphia, Chief Resident Physician, Philadelphia Hospital for the Insane. Critical periods in the care of the insane in Penn- sylvania are not uncommon in history. The old adage, history repeats itself, is shown in the study of the subject. Problems of overcrowding are as serious today, as was the inhuman treatment of the insane before the days of Dorothy Dix. Bru- tality, lack of food and clothing, are not tolerated in Pennsylvania; overcrowding and lack of accom- modations, however, have become within recent years, subjects of great gravity, most marked in the southeastern and southwestern hospital dis- tricts. A study of conditions in the southeastern dis- trict, shows that the State Hospital at Norristown and the Philadelphia.Hospital for the Insane care for the insane of five counties; moreover, these in- stitutions, although originally designed to house 3,900 inmates, now house 4,900. The annual in- crease in those institutions averages 300 patients and the annual admissions exceed 1,700 patients. This necessitates that fifty per cent, of these ad- missions must be actually under treatment in al- ready overcrowded institutions. As the result of the increase in admissions during the year 1913, conditions became so alarming in one of these in- stitutions, that for the safety of the inmates already confined, its doors were closed. The fact that the Philadelphia Hospital for the Insane is not fire- proof; that hallways are used for bedrooms and dining rooms; that there is marked congestion in the refractory and unclean sections, with small Copyright, 1914, by A. R. Elliott Publishing Company. Jackson: Hospitals for Insane. ground for recreation, shows conclusively that the closing of its door was the only course to pursue. Norristown State Hospital showed conditions equally grave, and the action of the board of trus- tees in refusing patients from Philadelphia county, was sustained by the court. Existing conditions certainly hamper the proper treatment of acute cases. Those who are well versed in the scientific treatment of mental dis- ease realize the folly of attempting the best method of treatment for the acute mentally ill patient, when necessity places the acute cases side by side with those of the chronic type. It is im- possible for these institutions to set aside an en- tire section for the classification and treatment of the acutely ill patient. The recognized treatment for this group of cases can best be given in a psy- chopathic hospital. Yet there is not one in Penn- sylvania today. Where can an indigent man, wom- an, or child in this State recover from an acute mental breakdown, without carrying with him the stigma of having been committed to a hospital for the insane? When we think of the hundreds of such cases occurring annually, there can be no more crying need than for State psychopathic hospitals. Passing from the acute cases, let us glance at those of the dotage type. Many of our wards con- tain patients of this particular group; they are not suitable for almshouses, in fact they can be treated nowhere, except in hospitals for the insane. Their cost of maintenance per capita will equal or be slightly less than of those provided for at Werners- ville. Studying closely our almshouse population, we find there many cases of this type, which should be sent to institutions set aside for this class; yet there is no such institution in the State of Penn- sylvania. The treatment of the mild, chronic insane by the colony plan, opens up one of the most interesting fields in the entire subject of psychiatry; such a plan embraces an economical method of giving the pa- 2 Jackson: Hospitals for Insane. tient exercise, freedom, and good physical health. At the same time it makes him partially self sup- porting and is the most humane form of treatment. Yet Pennsylvania has not taken advantage of this method. This plan of care may be instituted by the State on a large scale, as now exists at Gardner, Mass., or on the smaller scale in operation at the Byberry City Farms, Philadelphia. The most satisfactory, most efficient, as well as the most economical plan would be the establishing of colonies or villages near to and under the supervision of each State hospital. Twenty per cent, of the patients in our hospitals at the present day can be cared for by this plan of treatment. The purchase of land and the erection of buildings will not far exceed $500 for each bed. This is a tremendous saving in com- parison with our present day methods of construc- tion of buildings for the custodial care of the same patients at $1,000 for each bed. The executive management under the supervision of State hospi- tals would not exceed the cost of executive man- agement for the same number of patients, if these patients were confined in the regular State hos- pitals. Our hope of restoring a mentally deranged man depends upon giving him exercise, employment, recreation, and freedom of movement. To a cer- tain degree the words of Patrick Henry, "Give me liberty, or give me death," are applicable in this particular form of insanity. A total restriction of liberty is followed by a rapid mental deterioration, which with all its refractoriness, uncleanliness, and physical disease, is worse than death. The day is not far distant, in fact we can now see the halo of its sunrise upon this most important era of progress in the treatment of the mildly chronic insane. Instead of lingering in the shadows of the dark walls of institutions, we shall see these patients at liberty at the first blush of morning, fol- lowing their various pursuits. May God endow 3 Jackson: Hospitals for Insane. us with health, strength, vim, and vigor, that we may be able to erase from the canvas the horrible picture of an insane asylum so common to the layman's mind and to replace it with one showing this homelike method of treatment, where the un- fortunate is content to dwell, and his family, know- ing that the State is his guardian, may with a fair degree of peace of mind, chase their favorite phan- toms. Urgent relief is needed for the overcrowded con- ditions of our refractory sections, as well as the unclean groups. Do not infer for one moment that we insist that the State erect separate hospitals for every class of the insane, but, on the other hand, we do insist that the State of Pennsylvania give breathing space for each particular group of pa- tients. Despite the contention that proper food, the proper number of nurses, and proper ward capacity, would restore entirely these two great groups of insane, many of both classes are here and will remain as such until they have passed into the great beyond. Isolated cases, here and there, or those of a certain type respond to treatment, but they are the exception and not the rule. Our hopes for preventing such a class of patients rests in the early and successful treatment of incipient cases in psychopathic hospitals. One could continue this argument further, by saying that there should be a sufficient number of State hospitals for the insane, in order that the pa- tients in every county institution be placed under the immediate supervision of the State. Come, take a trip with me through the county hospitals for the insane in Pennsylvania. With the exception of two, or possibly three, how many do we find with laymen as superintendents? How many do we find with only one physician and no one to re- lieve him in his hours off duty? How many of these physicians are paid between $1,200 and $1,800 a year? How few of these have consulting alienists and neurologists, or regular licensed 4 Jackson: Hospitals for Insane. pharmacists! How many have well equipped hydrotherapeutic plants, x rays and pathologi- cal laboratories? How many of these have arts and crafts shops, or think of using such scien- tific treatment as reeducation, aftercare, etc. ? How many more questions could I ask concerning things which they do not have, that will be found in every properly equipped hospital for the insane, not only in Pennsylvania, but in every State in the Union. Yet the majority of those confined in county insti- tutions are citizens, bona fide residents of the State of Pennsylvania, and as such should receive the same treatment as bona fide residents of the other districts of Pennsylvania. To overcome conditions in Pennsylvania, the State should assume entire charge of its insane. There should be a general revision of our present system of State appropriations. The scope of the work of the committee on lunacy should be broad- ened, and the committee be vested with more au- thority. Plans for the construction of new hos- pitals should be standard and uniform. A program for State care of the insane must include the erec- tion of an additional hospital in each of the south- eastern and southwestern districts ; psychopathic hos- pitals, with outpatient departments, laboratories, and farm colonies available for chronic cases. A gen- eral plan of supervision for the aftercare of the insane through social service should be installed. To accomplish this will require time, money, and efficient planning by skilled physicians. It seems needless to add that this plan should not include any further provision for State aid to the respective counties, as the situation is far beyond the scope of county control. The time required for the com- pletion of such a plan will extend over a period of years. Why not let the first step be the erection of State hospitals in the southeastern and south- western districts, with the enlargement of Fair- view, Wernersville, Rittersville, and the establish- ment of farm colonies as successive units? If this 5 Jackson: Hospitals' for Insane. seems too great a task, the State could take over these county hospitals, when requested to do so by the authorities of said counties. The State cannot assume charge of all its insane at once, but only step by step can we ever reach our goal. Thirty-fourth and Pine Streets.