COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 27591 RC439 .P1 4 The care of the insa RECAP ■i ii " ■•.! ■ " '.i |!HA ;'|i^!. |j[|if''ijll u AhV' 'f- ' 1 i ■ 'jP 1 j 1 f n I't ]'v 1 jHi *nl iM ]!• ■] linP Hill]* 'rM4 . rl;i ■ ■( lUl i i : fi,;- •JjM-i ^-p M l..>[| |Vi ll f M ||!r ll f :5'-' -r »i!; 3 . i * .' rl > ■ <^ 1 ^^ ^ .j J ^ f r , ||.i- jHf 1' - .1'* ij'.'.Wi| p hlh li !'■ "'■■4 I,! ■ ■ ■ i l' ! li.l;'i ! ifr ti'' i"'. -i-^. 1 : ' . i ■y\.\M 111;! 5 1 :;:iih 1 iiM^ ii-il' •'.ll ' 1 rit:: : 1M ,|p.- |: .[-■ 1 Pj' jl < ^ I il' Pi 1 r i " i , ijv;.- rn f 11 .1 ' j, irM' ' ' •' 1 ir '' ' ' •I'l ih li iiWHiiiiiil'UiMjiiiP 4\h $ 1 i : 1 iii!t^ cr^i (U^rv V, ^^r-CTY*^ The Care of the Insane AND Hospital Management BY CHARLES WHITNEY PAGE, M.D. Assistant Physician Hartford Retreat, Hartford, Connecticut 1871 to 1872 and 1873 to 1888 Superintendent Connecticut Hospital for the Insane, Middletown 1898 to 1901 Superintendent Danvers State Hospital, Danvers, Massachusetts 1888 to 1898 and 1903 to 1910 Member of The American Medico-Psychological Association The Boston Society of Psychiatry and Neurology The New England Psychiatric Society The Massachusetts Medical Society BOSTON W. M. LEONARD, Publisher 1912 Copyright, 191 2, BY W. M. LEONARD Stanhope iprcss F. H. GILSON COMPANY BOSTON, U.S.A. To CAROLINE COLLINS PAGE MY WIFE WHOSE DEEP SYMPATHY FOR THE INSANE AND GRATEFUL APPRECIATION OF ALL MEAS- URES CALCULATED TO ALLEVIATE THEIR SUFFERINGS HAVE CHEERED AND GREATLY AIDED ME IN A LIFE WORK OF MANY PER- PLEXITIES AND HEAVY RESPONSIBILITIES CONTENTS. Page Introduction. — Non-mecliamcal restraint of the insane. — Con- ditions essential to its success 9 Hospital Trustees. — Method of selection. — Representative ability and character important. — Trustee duties, responsi- bilities and opportunities 15 Superintendent. — Necessary qualifications of the man. — Im- portance of wise discipline and high ideals. — Social and official duties 33 Assistant Physicians. — Discrimination in selection important. — Promotions. — ObUgations assumed. — Official duties. — Advantageous facilities for professional development 57 Laboratory — Its importance and prospects. — Superior advan- tages in hospitals for the insane 73 Management of Patients. — What " non-restraint" stands for. — Methods of treatment should vary to meet needs of dif- ferent cases and classes. — Obviating restraint better than condemning it. — Patients' visitors. — Congregate dining room 79 Attendants and Nurses. — Characteristics of many candidates. — Difficult duties. — Prime necessity for self-discipline. — Intelligent sympathy the keynote. — A case showing how kindness, tact and perseverance win. — Moral elevation result of humane effort. — Coping with iasane patients devel- ops the nurse's mental ability and moral character. — The inducements of high ideals properly presented 105 Appendix. — Managing a case without restraint. — The impor- tance of the card index in hospitals , . , , , . 133 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/careofinsanehospOOpage INTRODUCTION. Insanity is the most grievous malady ever inflicted upon mankind. Unable to observe accurately or to reason correctly, the insane man's narrow, ego-centric world quickly alienates him from his normal associations and interrupts habitual lines of conduct. The resulting aimless, erratic or hazardous manifestations bring upon him antagonism and too frequently cruel abuse. Thanks to science and advancing civilization, his treatment in modern times has been radically changed for the better. But of those familiar with hospital conditions as they exist to-day, few, if any, would venture to assert that the custodial management of the so-called violent insane is wholly satisfactory, or that the highest standards of moral and scientific treatment have been universally adopted. Notwithstanding it is now more than a century since satisfactory results were obtained by managing the insane without restraining their actions through the use of mechanical apparatus, it is to be feared that a majority of those medical and non-medical individuals who have been responsible for or engaged in the treat- ment and care of the insane have not fully comprehended 9 10 CARE OF THE INSANE' just what the *' non-restraint "system of managing the in- sane comprises. Pinel in France, Tuke, Hill and Conolly in England, were the pioneers in this himiane method. Dr. Conolly, superintendent of the insane asylum at Hanwell, England, through his devotion to the cause, his speech and writings on this subject, and his con- spicuous success without restraint in a large institu- tion for the care of the insane, forced the question of "non-restraint" upon public attention. He not only fostered "non-restraint" ideas and developed the sys- tem for the benefit of patients under his immediate care, but he utilized his experience and success as an object lesson to other superintendents for the benefit of the insane wherever confined and for all time. Conolly, having thoroughly mastered the many details and prob- lems involved in conducting a large public institution for the insane on the "non-restraint" basis, was justi- fied in expressing the following sweeping and well- considered convictions upon this subject, viz.: "After five years' experience with the non-restraint system, I have no hesitation in recording my opinion that with a well-constituted governing body, animated by philan- thropy, directed by intelligence and acting by means of proper ofiicers, there is no asylum in the world in which all mechanical restraint may not be abolished, not only with safety, but with incalculable advantage." CARE OF THE INSANE II While a few prominent hospital superintendents have, since Conolly's day, openly condemned his methods, scoffed at his claims or questioned his judgment, doubt- less a majority of those responsible for the management of the insane have regarded his ideas as extreme, and many have viewed absolute '' non-restraint" as imprac- ticable. In explanation of this opposition and indif- ference, it may be considered probable that those who have been antagonistic to the system of "non-restraint" failed to apprehend Conolly's viewpoint. Doubtless many hospital officials acting upon a superficial concep- tion of Conolly's practice have regarded the elimina- tion of mechanical appliances, strait-jackets, wristlets, bed harnesses, etc., as the object sought; whereas, he used the term "non-restraint" to characterize a com- prehensive non-coercive method of dealing with the insane. He had in mind a broad, complete system of hospital management so saturated with the spirit of "non-restraint," and so actuated by kindness, patience, consideration and tact, that the insane would not be provoked into acts of physical resistance, consequently situations or conditions suggesting the necessity for restraint would seldom arise. Those who have under- stood his theories and his practice so imperfectly as to suppose they had accomplished the ends he aimed at when they avoided the application of mechanical 12 CARE OF THE INSANE devices through severe discipline, harsh, intimidating treatment of excitable and obstinate patients, or by the use of chemical agents, have naturally enough failed to discover any value or merit in '^non-restraint.'* Other worthy hospital administrators have no doubt been so engrossed in the study of scientific questions pertaining to mental disease and pathology that they have simply failed to give sufficient attention to the humane, social and moral elements which are funda- mental considerations of the true *' non-restraint" mo- tive. Did the successful adoption of the "non-restraint" principle in hospitals for the insane depend simply upon official edicts forbidding the employment of old-time mechanical instruments of restraint, unquestionably hos- pital authorities would universally prefer the more hu- mane form of treatment. That Conolly understood what it signifies to man- age a hospital for the insane successfully on "non-re- straint" lines is shown by his declaration in which he specifies four conditions that are essential to success. These requisites are, first, "a well-constituted govern- ing body"; second, such a body "animated by phil- anthropy"; third, philanthropy "directed by intelli- gence"; and, fourth, "proper officers" — an executive force of assistants and nurses responsive to the high- est hospital ideals, which must be entertained and per- CARE OF THE INSANE 13 sistently inculcated by the superintendent. When we realize that thousands of inexperienced men and women yeariy join the nursing staff in state hospitals, that young medical men are constantly entering such insti- tutions to assume official duties, and that a large 1. r- ber of private citizens — ladies and gentlemen — are annually appointed to serve on visiting committees or supervisory and directing boards in connection with such public institutions, we can appreciate the neces- sity for a comprehensive statement in the form of a manual or handbook from which interested persons can obtain a working knowledge of the best hospital methods and possibilities, and can qualify themselves to analyze hospital conditions as they find them, or trace to their obscure origin or cause intruding results which may demand attention. In the absence of such a printed guide, these official recruits are unable to adjust themselves correctly to hospital duties or to early satisfy a personal desire to promote as fully as possible true philanthropy in this most promising and too much neglected field. Having had thirty-five years' service as a medical officer in hospitals for the insane, much of his effort in later years having been given to the practical elabora- tion of methods employed by Dr. Conolly, the writer has been persuaded that his experience and observa- 14 CARE OF THE INSANE tions, concisely stated, may be of service to those who desire a fuller knowledge of the internal workings of institutions where ^^non-restraint" is the practice. He therefore respectfully submits, to whom it may concern, his established convictions regarding the management of institutions which care for the insane. "A WELL-CONSTITUTED GOVERNING BODY.'' A medical superintendent thoroughly qualified to fill the position of executive head of an institution for the insane, and ambitious to rank with advanced men in his profession, may, if he attempts to manage the pa- tients under his charge in accordance with "non- restraint" ideals, have his good intentions frustrated by conditions beyond his control. The most formi- dable obstacle to his success that can possibly confront him, especially in the beginning, is a badly constituted governing body, unsympathetic or antagonistic trustees, a board chiefly interested in securing the objects which political interests ^deem important, or unwilling to as- sume responsibilities for those purposes which appeal mainly to humane sentiments. If the members of a board hold positive notions favoring the employment of mechanical restraint, the superintendent cannot pru- dently disregard their well-known conceptions on this important matter, and he may discover that his faculty for stating things or his powers of persuasion fail to convince them that "non-restraint" is feasible or worth the special efforts necessary to manage patients without using mechanical instruments for restraint. IS 1 6 CARE OF THE INSANE When Conolly referred to ''a well-constituted gov- erning body" as something essential to success with *' non-restraint" treatment of the insane, he had in mind, no doubt, the failure of his immediate predeces- sors, Drs. Charlesworth and Hill. They were medical superintendents and had satisfied themselves that Tuke's "non-restraint" treatment of insane patients at the York Retreat was not only a sane but a safe system, and should be the common practice in all hospitals for the insane. Yet in their own hospital wards its appli- cation in detail was only partially successful owing to the opposition of the governing boards under which they held office. Because injudicious and absurdly opin- ionated persons are sometimes found on boards of trustees and may unwisely overrule the better judg- ment of a superintendent, the proposal to aboHsh such governing bodies cannot be seriously considered, al- though such a step has been suggested in some parts of this country. A superintendent constantly feels the need of official advice and should be thankful when a board in a friendly spirit points out defective or faulty decision, errors liable to happen even to the best men. Then, under a democratic form of government, there seems a necessity for a duly appointed board to control the general affairs of each public institution; to hold real and personal property for the state; to appoint CARE OF THE INSANE 1 7 the executive officers; to formulate or sanction rules of management; to supervise the entire plant and repre- sent officially and legally the state's interests as occasion may require. The scope of their powers and the peculiar respon- sibilities which trustees must assume suggest the im- portance of exercising especial care in their selection. And yet positions on such boards are generally obtained through the favor of the predominant political party, or its highest state representative. Often political con- siderations decide the character of such important boards. And boards thus chosen are virtually respon- sible to the community at large for the operations of broad, altruistic schemes based upon the most refined phases of pure philanthropy. Doubtless institution trustees as a rule intend to discharge their responsible duties honestly and exercise a fair degree of intelligence in doing so. But there are exceptional instances, and it is beKeved that many individual trustees, occasion- ally at least, entirely misunderstand the legitimate field for their activities. This is especially true of those appointees who receive such hospital positions as a reward for pohtical service. It is not surprising that trustees enter upon their institutional duties with erroneous conceptions in re- spect to their official functions and privileges, since the 1 8 ^ CARE OF THE INSANE province of the hospital trustee is so ill defined by statutes that personal interpretation or inclination may naturally enough measure a trustee's conjecture as to his authority and prerogative. While a trustee now and then may make mistakes in beginning his public service with misdirected zeal, the great majority de- liberate too long before taking an active part in the hospital work. Hospital trustee boards are open to criticism chiefly through the neglect of their members to study the problems really involved in the work they presume to supervise. This common indifference to duties volun- tarily assumed, or carelessness in such respects, may be charged in most cases to the fact that these boards — these supervising or directing units — are each com- posed of several members, varying in number; conse- quently individual responsibility is so divided that any one member may easily estimate his own share as of little account, arguing that he constitutes but a frac- tional part of the organization. This inactive, ineffi- cient way of discharging their official obligations is especially true of the new and less prominent members of a board where one or two of longer experience unhesi- tatingly assume to possess complete knowledge of in- stitution affairs and a mastery of the situation. Thus, through the modesty and tacit consent of the other CARE OF THE INSANE I9 members, practically a single individual on the board often controls the policy of an institution. With a purpose to obviate the faults of divided re- sponsibiHty and a hope of fancied gain through sys- tematizing conditions in the various institutions of the state, a general commission with one supervising mem- ber has been proposed as a substitute for the usual local boards. Considered superficially, this method would seem to insure a more complete and careful oversight and a keener sense of official responsibihty. But under such an arrangement the commissioner might be inclined or forced to devote either too httle or too much attention to any one hospital. If attached to but one or two, he could scarcely fail to trench upon the executive field, overshadowing the superintendent and thus dispossessing him of incentive and pride in his official duties. If in control of a group of institutions, his attention would extend over such a wide field of activities that he would be unable to follow out details and be obliged to depend upon the several superin- tendents for information, virtually accepting their ob- servations and adopting their suggestions, or he would enforce upon all institutions a common system of man- agement that would operate to suppress local ambi- tions and eHminate hospital individuahty. Machine methods and standards are never conducive to prog- 20 CARE OF THE INSANE ress in the domain of science or philanthropy, and when applied to the public institutions of the state will possibly foster political schemes. Reasons may be adduced why the suppHes of several pubHc institutions should be obtained by a central commission, but economy should not be expected as the natural result of thus concentrating official pur- chases. In his report to the State Charities Aid Asso- ciation,^ Mr. H. C. Wright demonstrates that the more complete and rigid the system of central control over purchases in state institutions, the greater the discom- fiture of local officials, and where the cost of such cen- tral control is included in the cost of maintenance financial results the opposite of economy are reached. His conclusions are based upon a thorough study of conditions in New York and Iowa, where four slightly varying systems of central purchasing agencies are in operation. The ideal hospital board should be composed of carefully selected men residing within the hospital dis- trict, each one a prominent representative of some profession or business interest. The best judgment obtainable in the hospital locality should thus be at the service of the state, as it can be obtained gratis if the * Report on Methods of Fiscal Control of State Institutions. Henry C. Wright. New York, 19 lo. CARE OF THE INSANE 21 appointing powers will ignore political influence and select for such honorary positions only citizens of estab- lished reputation in respect to ability, judgment and character. The expert knowledge collectively possessed by a board thus constituted would safeguard the inter- ests of the state, as well as those of its wards, and be gladly welcomed by all superintendents, as the daily management of the usual state hospital calls into req- uisition special knowledge in many professional and business lines. Then the whole field of institutional activities is certain to be examined and criticized by a properly interested public, and the probabilities are that every step in hospital work and development will be examined and criticized by outside judges, each ex- pert in his own line of activities. In this way, sooner or later, whatever is accomplished will be gauged according to the highest standards in each particular department. The laws of the state, their import and appHcation to altered circumstances and new conditions, call for frequent interpretation. Medical questions are ever pressing for consideration and their solution calls for scientific knowledge in medicine, surgery, dietetics, psy- chiatry, etc. Engineering problems in connection with construction, heating, ventilation, water supply, sewage disposal constantly appear. Connected with many 22 CARE OF THE INSANE hospitals is a farm department which will not escape the critical attention of the agricultural public unless it is conducted upon advanced theories regarding stock raising, milk production, crop rotation, truck farming, etc. With such burdensome duties always on hand to test the common sense and technical knowledge of hospital trustees and superintendents, the importance of securing for service on each institution board a promi- nent lawyer, a scientific physician, an able engineer or contractor, a pubKc-spirited business man experienced in general affairs, a practical farmer, or similar recog- nized leaders in other business pursuits, would seem to be sufficiently obvious to create a strong, compelling public sentiment, influencing, if not controlling, such appointments. The addition to hospital boards of one or more ladies possessing keen perceptions, broad sympathies and balanced judgment insures a more careful consid- eration of the social aspects of institutional life and service, much of which might otherwise escape official attention. By virtue of their ofhce, hospital trustees must expect to carry heavy responsibilities, and they should live up to the requirements of the position faithfully and cheer- fully. They must arbitrate the often conflicting inter- ests of the public, the executive officers and the state CARE OF THE INSANE 23 wards. Therefore, they should weigh well their deci- sions, which may produce some unforeseen results. It is their duty to determine the practical boundaries of public disbursements and to adjust the economical expenditure of state funds. They must discriminate between legitimate demands and selfish desires. They need to devote much time and careful attention to the details of hospital business before vouching for outlays and receipts. They should endeavor to secure for the patients those attentions and measures which will be most conducive to their recovery, physical comfort and peace of mind. In this work theyj must have their feelings enlisted and their sympathies taxed without sacrificing their sense of proportion. Personal inclina- tions must at all times be held subservient to public expediency. If a well-ordered, smoothly conducted, successful hospital is the ambition of a trustee board, it must secure an able executive head and endow him with well-nigh autocratic powers, although the board would be blame-worthy if it failed to keep informed as to the guiding principles enforced, the general results of their application and all important hospital episodes. Different boards will obtain the facts pertaining to such matters through various methods; the manner of acquiring this information is largely determined by 24 CARE OF THE INSANE habit, hospital tradition, the personality of the board members and the superintendent. Often the most active member of the board, usually the president, entertains a lively interest in hospital work and being sufficiently free as regards private business, will de- vote all the time necessary to his official duties. Thus he acquires intimate personal acquaintance with the superintendent and the hospital staff and supervises in general the actual workings of the hospital regime. Naturally he reports to his colleagues a summary of what transpires within his cognizance, which practi- cally covers the daily round of hospital activities. When such a representative trustee is diHgent enough to include the whole field of hospital operations, is sufficiently well informed and well balanced to correctly interpret what falls under his observations, and is actuated by a high sense of honor and desires to promote both individual welfare and public weal, his associates show wisdom in following his initiative. But a board that blindly or willingly supports a self- assertive member who accepts as authentic floating gossip and rumors from disgruntled employees and se- cret agents, allows carelessness or prejudice more force than is consistent with reason. The more common and the better way, by which a board can keep in practical touch with the internal CARE OF THE INSANE 25 management of the institution it represents, consists in dividing hospital operations into departments and appointing from its membership special committees to oversee, investigate as necessary, and report upon each section. By the interchange of information thus in- telligently obtained and by free discussions, the entire board can keep reasonably well informed upon all essen- tial details of routine and even exceptional occurrences. It is also good policy for trustees to visit, unattended, all parts of an institution. But in so doing it should be remembered, especially when making infrequent trips, that the underlying motives and the interest displayed may be the subject of surmises on the part oi many in whose interest such tours are planned. A trustee should at all times beware of flattery, open or veiled, from patients or subordinates. If he enters into familiar relations with them, some will take ad- vantage of even sKght opportunity to ingratiate them- selves, and, if possible, injure the standing of others. Victims of unwarranted suspicions or pure delusions will often endeavor to establish such a S3anpathetic understanding with a trustee that they may transplant into the official mind their own prejudiced opinions and warped judgment. With the kindest intentions, an incautious trustee may accidentally encourage the foolishness of some well-meaning person, who, unable 26 CARE OF THE INSANE to comprehend more than one-half the truth or one side of an issue, is honestly mistaken, and therefore the more insistent upon securing absurd official action. Not infrequently malicious falsehoods will be narrated with such assurance and circumstantiality that imless the occasional ward visitor is exceptionally discreet and diplomatic in his comments he may feel some degree of humiUation when the facts and the actual situation are finally forced upon his understanding. Whether investigating for a special purpose or acting upon indi- vidual responsibility, a trustee should never decline to hear a complaint. Yet ordinary prudence should lead him to suspend judgment and to insist that every charge of neglect or misconduct be reduced to writing and be properly signed by the author of the complaint. .' In all institutions rumors, especially those interesting or startling, circulate with surprising rapidity among both inmates and employees, therefore trustees should con- stantly guard their speech lest they may thoughtlessly answer or comment in terms which patients can quote to the injury of others, especially to the subordinate ofi&cials. And yet trustees should give the hospital population ample opportunity to voice their response to the discipline enforced — their dissatisfactions and their alleged grievances. Then the whole mass of infor- mation and misinformation — truth and fabrication — CARE OF THE INSANE 27 should be submitted to the superintendent to be sifted and explained as fully as possible. In no other way can trustees obtain a comprehensive knowledge of the conditions with which a superintendent has to contend and thoroughly qualify themselves for intelligent con- ferences and helpful suggestions. Besides, they may through such thorough canvassing of patients' wards learn things of weighty or serious import which had not come to the superintendent's knowledge, since it is not imusual for patients to persistently withhold from him material facts and helpful intimations which they will voluntarily report to trustees upon .the first op- portunity. Trustees should not be surprised when a superintendent confesses inabihty, without personal in- vestigation, to controvert some plausible charge or un- ravel some amazing story communicated by a patient. The patient may have cunningly omitted essential de- tails by which his peculiar view of things could be easily recognized. To ascertain from some patients, representing certain forms of mental disorder, the key which will decipher their garbled or counterfeit state- ments requires the skill which comes only from long experience with the insane. Then, a superintendent can- not be onmipresent, and cannot, because of the limited time at his command, keep intimately informed of all that transpires within his jurisdiction. However vigi- 28 CARE OF THE INSANE lant himself, he must trust his staff assistants with considerable independent authority and depend upon their honor and judgment for the variety and minute- ness of their detailed reports. Unfortunately ready ex- planations from executive officers, who may have been suddenly called upon to correct ugly rumors, or clear up incriminating statements, should not be accepted by trustees as satisfactory and final imder all circum- stances. Especially is caution in this respect neces- sary when by the proffered answer the veracity of some other person is impeached or when the trustees burden themselves with serious and unnecessary responsibility through overconfidence in a subordinate. Cirami- stances can be imagined under which it would be ad- visable for them to assume that a superintendent even, when interrogated closely, might offer misleading an- swers or fictitious excuses, designing thereby to pre- serve false pride or conceal inexcusable ignorance and personal neglect of duty. Of course this is a mere possibiHty, but that trustees will occasionally differ with a superintendent is a probability. Opinions may honestly differ as opposite convictions upon many questions in dispute logically follow observations made from different viewpoints. Each party to a contro- versy should therefore in simple justice make certain his judgment does not rest upon a narrow, prejudiced CARE OF THE INSANE 29 basis. Then, it is well to bear in mind that the spirit engendered in most quarrels, rather than the facts in- volved, perpetuates uncompromising conflicts of opinion. In any case of serious clashing, however originating, the board has the major share of responsibility, as it holds the vantage by virtue of its legal authority and official rank. It can therefore determine how a solu- tion of the difficulties shall be effected. It can act summarily and defy consequences, yet it had best be conciliatory and first exhaust more gentle methods. Without sacrificing authority or dignity, it can in a friendly spirit dispassionately review with the superin- tendent the points at issue and their development. If unsuccessful in reestabhshing working relations with him, a board will by resorting to benignant treatment secure credit for a moral victory and merit the support of public opinion. When trustees cease to respect a superintendent their official relations should terminate for the good of the cause, which cause may be regarded as a grand commission for unselfish devotion to afflicted fellow men. Eleemosynary institutions are monuments indicat- ing the degree and strength of philanthropic sentiments in a community — not memorials dedicated to past achievements, but energetic centers where compassion for misfortune and suffering is practically demon- 30 CARE OF THE INSANE strated through the agency of scientific skill, deeds of mercy and the arts of genuine sympathy. Hospital trustees should cherish the signal honor which is con- ferred upon them through their official position, and not only plan and vote in accordance therewith, but endeavor to impress their subordinates, by example and precept, with a constant sense of deep obligation to the helpless patients — God's unfortunate children in a spe- cial sense — for whose sole benefit such benevolent in- stitutions are founded and maintained. So far as possible, trustees should agree upon all important questions of hospital management. Dissen- sions in a board, if serious and prolonged, can scarcely fail to reduce the efficiency of the hospital. As a conse- quence of board friction executive officers will imbibe the virus of uncertainty and may gravitate into oppos- ing cliques, while employees will presume upon relaxed discipline and the baneful results will have to be endured by the innocent patients. When trustees view their official duties in the light of a solemn trust for the uplift of afflicted humanity, there would seem to be little opportunity for personal differences concerning the means to be employed. Experience with a model board in this respect has demonstrated the possibiHty of practical harmony in hospital work. Under wise leadership, minority objections to any proposition were CARE OF THE INSANE 31 treated with entire respect, and final action deferred while each member endeavored to reexamine his con- victions from the viewpoint advanced by others. That self-respect which accords such marked consideration for the opinions of an associate has an inherent power that will force a spirit of humility and a burden of self-conviction upon any manly opponent if he is not certain of his position, and insure the ultimate adop- tion of his views by the majority if he is absolutely right. When a trustee board adopts a standard of high ideals and secures a competent, ambitious superinten- dent, excellent results should follow. But a board must utilize its opportunities with skill and use its power with masterful restraint, if it would fully dis- charge its special obHgations to the pubHc as well as to the state wards. Having established with the super- intendent a mutual understanding concerning the set- tled poHcy and the general plans to be pursued, the board; should delegate to him adequate authority to enforce his orders and maintain a position of dignity. Only under exceptional circumstances should a board, acting as a committee of the whole or through its pre- siding officer, assume direction in executive affairs. The superintendent must be the acknowledged com- mander, free to select his working force, to formulate 32 CARE OF THE INSANE details of operation, and to establish his own system of discipline. Finally, after their hospital has been put in working order, the board can render the most effective service by occupying the position of rear guard. As trustee officials they cannot escape the position of buffer be- tween the hospital management and the general public. Therefore it becomes their duty, as well as their privi- lege, to aid the formation and growth of a public senti- ment favorable to the hospital. This they can do by cheerfully answering all pertinent questions; by cor- recting unfounded rumors; by disarming hostile criti- cism, and by freely and fairly discussing with any interested person the quaHfications, the aims and the ambitions of the resident officials. SUPERINTENDENTS. The responsibility of hospital trustees assumes its maximum proportions when the board essays to select a medical superintendent, as successful hospital admin- istration depends almost wholly upon the individual chosen for that office. The attainments and character of the chief executive, his medical qualifications, his business instincts, his executive capacity and his per- sonaHty have each an important value in fitting him for the varied duties inseparable from the position. Should the candidate possess acknowledged, even con- spicuous, ability in any particular field, medical, com- mercial or sociological, such preeminence does not sig- nify that he possesses the ability to organize hospital work successfully and maintain proper discipHne. It is a much safer policy to fill the position, with its various lines of duty, by appointing an evenly balanced, ^^all- roimd'^ man, who in addition to the requisite medical knowledge and business capability is blessed with abundant common sense, quick perception, a ready judg- ment and a passion for justice; for not only must a superintendent see that the patients receive the best 33 34 CARE OF THE INSANE medical care, that hospital funds are prudently han- dled, that employees conduct themselves properly, but in him should reside these finer qualities of mind and heart, — patience, sympathy, courage, enthusiasm, etc., — since such attributes of higher manhood must char- acterize his administration in order that his life and official influence may tone and energize the interrela- tions of the whole hospital community. It has been the custom to a considerable extent, in hospitals for the insane, to promote assistant physi- cians whenever the position of superintendent became vacant. But the exceptions to this rule have been frequent, and the medical chief has sometimes been selected from the class of general practitioners of medi- cine. In former times, when there was an actual dearth of specially instructed, promising candidates for such positions, selection from the non-specialist field was almost a necessity, and, as a matter of fact, some medi- cal superintendents who entered upon their hospital duties without previous special experience in the treat- ment or management of the insane made a good record. In recent years, however, the number of ambitious young medical men possessing hospital experience and a knowledge of psychiatry has largely increased, owing to the fact that the number and size of hospitals for the insane have rapidly increased, necessitating a much CARE OF THE INSANE 35 larger staff of assistant physicians and graduate "in- ternes" to perform the increased professional labors which new views of this work and improved methods demand. Therefore, when a reasonable degree of dis- crimination is exercised in filling the minor staff posi- tions, the promotion of assistants to fill higher vacan- cies would seem logical and fitting, especially in those institutions where the established hnes of management are- satisfactory to the trustees and all supervising offi- cials. Certainly an assistant physician, who after years of faithful, continuous service in the hospital has be- come familiar with the routine work and the capacity of the various heads of departments, upon whose intelli- gence and integrity much depends, ought to receive the first consideration as a candidate for an advanced position. When a superintendent is selected from the staff there follows little occasion for suspense on the part of the working force, whereas when a hospital is placed in charge of an outside man, considerable time is usually required for the readjustments which naturally follow. Besides, when it is the rule of an institution that worthy assistants, if qualified, will be promoted as vacancies occur, ambitious men will the more readily turn to this line of work. They will regard such prom- ises for the future as strong inducement to enter the service, and, once engaged, they will work the more 36 CARE OF THE INSANE diligently to perfect their knowledge and fit themselves for the duties of the advanced positions. While it is a practical impossibility for a superin- tendent to become an expert in all departments of medicine, he should be well grounded in the general science of medicine and have special interest in all that pertains to nervous and mental disorders. In large hospitals the assistant physicians will necessarily have to take charge of details in the clinical, psychiatric and pathological work. But the superintendent is often obliged to express opinions and make decisions on med- ical questions of a wide range, and he has to accept, by virtue of his position, the responsibility attending whatever measures, medical, hygienic and disciplinary, that anyone introduces under his management. He must therefore inform himself concerning the essential contents of a wide range of medical Hterature, and inter- est himself in all that affects the preceptions and judg- ment of those physicians engaged in treating mental disorders. If especially interested in scientific medi- cine and appreciative of the superior opportunities for research work afforded by the large aggregation of permanent patients always found in hospitals for the insane, he will not rest content unless competent workers on his staff are engaged in laboratory studies, searching for the origin of, and the cause for, disease, as CARE OF THE INSANE 37 well as deciding the multitude of clinical conditions which arise in the wards. Although the superintendent may be unable to devote sufficient time to any one line of scientific work to master details and dictate the measures to be adopted, still all department workers should be subordinate to his authority in respect to appointments to the positions, the general scheme of investigations to be made, and in all matters related to discipHne. Without such a superintendent, command- ing the whole hospital organization, whose authority is recognized and respected by all, harmony of depart- ment labors and interests cannot be secured and a systematic development of the institution work cannot be expected. For the same reason, it is not advisable to place the general business affairs of the hospital under the con- trol of a steward or manager acting independently of the superintendent's authority. True, the medical head of the modern large hospital for the insane, if attentive to medical matters, hospital discipline and the personal welfare of the patients, cannot be expected to note with minute oversight the daily financial trans- actions of the institution. He cannot keep himself posted upon market fluctuations and perfect his judg- ment regarding the quality and intrinsic value of food- stuffs, fabrics and other commodities, which are being 38 CARE OF THE INSANE replenished constantly and in wholesale quantities. But he should, as a matter of duty, interest himself at times in the quantity and quality of suppHes pur- chased, see that the purchasing agent proportions his current expenses to the yearly financial resources, and be ready at all times to counsel the official buyer and, when necessary, to assume responsibility for any im- portant business transactions. When the superinten- dent is the recognized chief over all hospital depart- ments, he can, as he deems fitting, delegate to a steward all the latitude and authority necessary for his semi- independent business activities, and be able at the same time, upon occasion or necessity, to supplant his passive attitude towards the purchasing agent with positive vetoes and commands. And this he can do without scruple or risk of friction, when the business depart- ment is officially subordinate to the superintendent. It must be admitted that hospital affairs have been successfully conducted under the divided executive system and apparently without developing jealousies. But such happy issues under the vexatious dual system are exceptional and depend upon the fortunate per- sonality of both the medical and the lay director, who usually attempt to administer the affairs of a hospital unit thus organized not conjointly but working inde- pendently of each other; each controlling separate sec- CARE OF THE INSANE 39 tions where cleavage is imperfect and duties tend to overlap, where individual interests are certain to con- flict, and where arbitrary trustee rules become necessary to establish the bounds of each man's province. When asylums for the insane were first estabhshed in this country, the then prevalent English system of man- agement was adopted. A resident physician or medi- cal superintendent was appointed to treat and manage the patients; but a lay superintendent, or steward, was quartered upon the premises and all business affairs were conducted under his independent authority. Among the other duties of this non-medical head was the employment and official discharge of attendants and nurses. Under that form of management, in those days, it was generally understood that an irritating degree of hospital discord was the result. The medical head chafed under a sense of injured dignity, finding his plans frequently obstructed and the scope of his ambitious ideals restricted in ways that provoked re- sentment and effectually humiHated many worthy but sensitive medical superintendents. When, as was the usual case, the trustees maintained more intimate rela- tions with the business than with the medical head, the professional man had no recourse and perforce exhausted much of his power for better things in suppressing sour complaints and imagining the happy outcome possible 40 CARE OF THE INSANE under more agreeable and more favorable conditions of management. If there ever existed any substantial reason for the adoption of such schemes of hospital control, calculated chiefly to discredit the executive and business ability of the professional official, its vaKd- ity was never admitted by medical men. In recent times, public opinion on this question has changed so radically that nearly all large hospitals, those treating general diseases as well as the special institutions, are now placed in charge of superintendents possessing a medical education and a doctor's degree. When such a superintendent in a general or special hospital is assigned no active medical duties, still his medical training is regarded as an essential quahfication for the position, as it alone enables him to clearly comprehend the aims and objects of the organization as a whole and to harmonize the interests and adjust the activi- ties of the several departments. His technical knowl- edge tends to eHminate friction, as it inclines him to cooperate with the staff physicians and enables him to recognize the necessity of numerous but important accessories which are requisite to perfect the hospital equipment. But the education, medical and general, possessed by a hospital superintendent is of little avail unless he is gifted with native talent for executive work. Genuine CARE OF THE INSANE 41 executive ability can scarcely be acquired, although the cultivation of natural aptitude increases its efficiency. It is the inborn faculty of recognizing things in their correct relation to each other; of seeing at a glance where and when to initiate action which will naturally produce desired results. It is that variety of abihty which enables some men to utilize advantageously the combined services of others in working out the details of broad plans. It is an instinctive capacity to appre- hend causes, to marshal events, and to select competent men for each post of duty, and depends upon a fertile imagination controlled by logical mental processes. A superintendent should possess quick and accurate perceptions so he can acquire and assimilate informa- tion rapidly. He should employ his time to advantage, and, to cover the whole field of his interest, he should be able to note mentally the chief or accidental details of whatever requires even his momentary attention. He must be able to store his mind with a large fund of knowledge and comprehend practical results without adopting the slow process of asking questions. Com- mendable business prudence on his part should be self- evident in his reports to trustees and his everyday intercourse with those who have business relations with the hospital. To command respect, a superintendent must be a 42 CARE OF THE INSANE wise disciplinarian. The glory of a large hospital or- ganization depends upon its machinelike action in pro- ducing results of a high order. Human beings in a mass, each with individual opinions and interests, are brought into active association for a common purpose. Officers of various ranks, several grades of employees and a large community of irresponsible patients must here adjust their several relations, each with others; living in concord and working in harmony for purposes which the superintendent formulates. Orders emanat- ing from this supreme official should stimulate and regu- late activities at every post and in all grades of the organization. If the working of the system appears to be automatic, if only the regularity and smoothness of the daily movements attract attention, and if happy results only are realized, then it may be safely assumed that the person in command is a good executive and a thorough disciplinarian; firm, judicious, and consistent in exercising his authority. In this sphere of duty the superintendent must assert his sovereignty, command obedience, reprove inefficiency, reward the faithful, and trust his own judgment. Circumstances often compel him to delegate more or less power to subordinates, yet he will have to accept responsibility for all orders and decisions thus given in his name. It is therefore very important, considering his interests and reputation as CARE OF THE INSANE 43 well as the comfort and satisfaction of his staff, that all who come into official contact with him should clearly understand his views, his methods of reasoning and his theories concerning rewards and penalties. Members of his staff should be able to predict how he would act in case any given hospital rule were violated. This is possible only when his system of discipline is based upon well-established principles, consistently interpreted. In his conduct towards others, officials, employees and pa- tients, he should aim to be just. Then let his process of discrimination be accurate and he will soon establish in the minds of his associates a reputation for righteous deahngs which everyone can comprehend and his sub- ordinates may copy. All men respect him whose acts bear the hall mark of rectitude, and have no difficulty in deciding what attitude such a person would take imder any known circumstances. If a superintendent allows personal timidity, favoritism or prejudice to warp his judgment, if he temporizes with offenders because of their threats to seek revenge or because inconvenience to the management will result if such are discharged, if two employees commit like misdemeanors and one is discharged while the other is retained in service because of his musical or ball-playing ability, confusion will follow. Subordinates in the hospital will thereafter evade questions of discipline, ignore 44 ; CARE OF THE INSANE ' minor faults, and defer judgment in more serious cases. As nothing more quickly vitiates discipline than dis- charging employees unjustly, the superintendent should make certain that he fully comprehends the situation before extreme action is taken. It is especially fortu- nate if one, in a responsible position, has the capacity for correctly and promptly reading human nature, as it greatly aids in reaching conclusions regarding per- sonal reliabihty and merit. Occasionally it may be expedient to make an exception to an estabHshed rule, but the neglect or abuse of a patient should never be overlooked or excused. The superintendent's respon- sibility for the custody and proper treatment of large numbers of defenseless patients under exposed condi- tions admits of no deviation from the rule. In managing patients some show of discipline must be observed, but rigid and severe measures should never be adopted, except as a last resort, after mild methods have been found unavailing. Under all circumstances, mildness, consideration and mercy should characterize the enforcement of discipline with insane patients. It should be remembered that if they were legally respon- sible they would be elsewhere. If such persons retain moral responsibility of any degree, it is wise to culti- vate what exists rather than submerge it in feelings of bitter resentment. The superintendent's relations with CARE OF THE INSANE 45 his patients include that of '4n loco parentis." His established reputation for high ideals of manliness and justice is the only guarantee which the public can de- pend upon that the inmates of hospitals for the ins^r- ^ will be kindly and properly treated. They are in his keeping. They class legally as children, and it is his solemn duty to protect them in those privileges ana rights which the state especially bestows through their commitment to his care. Thus are their legal rights estabHshed, and all should recognize that their moral rights are vastly increased because of their helplessness and the legal restrictions to which they are subjected. As regards personal conduct in hospitals for the insane, the superintendent is lawgiver, judge, jury and sheriff. But, above all, he should be the guardian of, and advo- cate for, the patients. Let justice requite the faults of the patients as well as those of the employees; but, in the case of the patients, let it not be a bhndfolded dispenser of law, such as is suggested by the conven- tional, emblematic statue of Justice, but rather a clear, open-eyed apostle of recompense, who, through humane, compassionate sentiments, recognizes that their calam- itous mental condition totally changes the nature and degree of individual responsibility in the case of the insane. Unless a superintendent's attitude towards his pa- 46 CARE OF THE INSANE tients is inspired by a warm heart, and unless his in- terest in their condition and needs is tinctured with spontaneous sympathy, his power for good in his own institution will be seriously restricted. But his sym- pathies must be of the rational, intelligent order that color and soften his judgments and commands; not the blind, hysterical sort that will sacrifice an ultimate good for temporary emotional satisfaction. Occasions will arise, no doubt, when the sympathetic inclination must be overruled, but usually it will suggest the better policy, produce most comfort and the best results. In state hospitals there will always be a large class of inmates who require little if any medical treatment, but whose mental distress and sense of loneliness can be largely effaced through the agency of sympathetic, moral treatment. And such treatment must be adopted and persistently practiced by those who endeavor to avoid the employment of mechanical restraint. The spirit of the man in authority can but affect each person within the circle of his rule, and therefore, if a super- intendent is possessed of large sympathies and has the courage to exercise them, he cannot fail to soften the views of his subordinates and thus aid all who depend upon him. He must have the courage to give and the courage to withhold as circumstances appeal to his judgment. But in all his dealings with subordinates CARE OF THE INSANE 47 and patients he should be positive. He should have well-grounded convictions and the courage to shape in accordance therewith his own life and their line of duty. He should cherish high ideals and expend energy in striving to reach his adopted goal. His success will largely depend upon his native fortitude. If he at- tempts to cross the channels of institutional habits, however unwisely established and blindly followed, or if he proceeds to substitute the "non-restraint" system for the long-used strait-jacket and isolation cell, there will be serious obstacles to overthrow, plausible argu- ments to refute, and institutional inertia to remedy and energize. If accidents occur under the workings of new methods which he had adopted upon convictions as to their beneficial results, he should be resolute enough to de- fend his working principles. Let him modify and per- fect his details, if necessary, but defend a system which he knows to be correct and work with ripened experi- ence and renewed faith. The long-delayed reform in the treatment of the insane is explained by the lack of courage on the part of the old-time custodians. They feared to act contrary to tradition, and saw no reason why they should voluntarily assume burdens of respon- sibility for the sake of helpless and friendless insane persons. Public opinion, intrenched in old supersti- 48 CARE OF THE INSANE tions and trammeled by fear and timidity in respect to mental disorders, approved the most galling methods of restraint. Security, not restoration, seems to have been the only object for which the insane were seques- tered and the only motive which consigned mental invalids to lives of horror within prison dungeons. When no one questioned the propriety of tying the hands and feet of an insane man, strapping him firmly to beds and chairs, or chaining him securely to the wall, custodians conceived of no reason why inmates under their watch and care should be permitted to destroy clothing or get an opportunity for escape or suicide. Pubhc sentiment was unenlightened with re- spect to the necessity for this condition of affairs, and the feehngs even of religious people towards the in- sane were hostile. What the insane have suffered through the absence of sympathy and courage on the part of those whose duty it was to protect, cherish and cure them, we cannot adequately realize. May the future, by humane and kindly methods of treating the insane, atone in some measure for past neglect and wrong! Tuke was sympathetic and courageous when he took the Quaker insane out of the government asy- lums and treated them in the York Retreat like sick, inoffensive children. Pinel exhibited heroic courage when he removed from the insane in Salpetriere the CARE OF THE INSANE 49 irons and chains which they had worn for years, espe- cially when in doing so he had to defy official protests and ignore universal predictions of resulting confusion, accidents and even homicides. Medical officers in all hospitals for the insane fre- quently come into relation with cases calling for coura- geous action. Within comparatively recent years a male patient was released from an isolation-room in a New England hospital after he had been kept in seclusion about thirty years because of his hostile demonstrations and repeated acts of ferocity. Prior to his attack of mental disease he was a prominent lawyer, and he firmly beheved his confinement was illegal. In the presence of hospital officials, attendants and visitors he always protested against the fancied injustice of being kept with the insane. By way of expressing his vehement objections to hospital imprisonment, he spent hours daily kicking the heavy oaken door which prevented his egress. So long-continued and so vigorous had been this habit that considerable deformity of both feet had resulted. Finally a resolute assistant physician termi- nated the isolation of this long-feared maniac and he was permitted to mingle freely with other patients in the general ward and upon the hospital lawn. He injured no one, and within two months could have been seen en- gaged in ball playing with other patients on the grounds. 50 CARE OF THE INSANE At a still more recent date and in another New Eng- land hospital a young medical officer who possessed the courage to act upon his convictions removed from the wrists of a patient manacles which had been worn for many years, because the other hospital officials had mis- judged the patient's mental attitude and magnified his capacity for vicious conduct. The irons had been worn so long that rust prevented their removal by the use of a key, and the arts of the blacksmith were required to unshackle the man. During his subsequent hospital history this patient gave no trouble whatever. Every superintendent who has inaugurated radical improvements in the management of the insane has been proclaimed a fanatic by timid officials and criti- cal onlookers, until practical success demonstrated the wisdom of his innovations. To-day, while politicians and the pubHc press assume to work for the benefit of the inmates of hospitals, their narrow views of hospi- tal methods and their hasty, ill-considered criticisms of hospital management through inordinate desires to gain sensational notoriety actually increase restrictions upon the insane, since they often overawe and intimidate superintendents who desire to extend more freedom and parole to insane patients in hospitals. It is good fortune for all concerned, both officials and patients, if a medical superintendent is possessed of a CARE OF THE INSANE 51 sanguine temperament and is dominated mentally by optimism — not the fanatic sort, but a spontaneous spirit of hopefulness which conforms to practical experience and is regulated by common sense. Often his line of duty and progress will be blocked by obstacles formi- dable enough to thwart his best intentions unless he is gifted with an overmastering tendency to prefigure mentally the blessings and benefits certain to follow perseverance in the course he had carefully mapped out. If he have faith in his own judgment and confidence in his ability to attain success, he will overcome all oppo- sition by persistent struggles. When the opposition is too strongly intrenched for direct attack, he will devise a flank movement and succeed through skillful man- euvers. Optimism dissolves doubt, countervails timid advice, lifts one above the commonplace grooves of rou- tine, and favorably modifies the force of traditional authority. When it characterizes a superintendent's official relations with his medical staff and lay workers, their mental horizon expands and their desire for a use- ful career takes on fresh vitality because of the expectant possibilities before them which his optimistic interpre- tation points out. It is the basis of that enthusiasm which is essential to the most successful leadership. The wise master avoids the arbitrary tactics of the boss, but stimulates the aims and energies of his subordinates 52 CARE OF THE INSANE through persistent and consistent presentations of the brilliant prospects ahead which invite their ambitious pursuit. When hospital officials and employees actually read into their daily toil new meanings freighted with promise and illumined with elevating sentiments, their capacity for labor becomes augmented and weariness from effort is almost abolished. Patients who fall under such salutary influences are taught to cultivate expectation, and to foster the bright- est prospects that are reasonably within their grasp. By this process of sympathetic encouragement, some will recover hope and develop a faith which will aid, if not engender, the process of recovery. Many cases, chronic and hopeless as regards mental restoration, may thus become imbued with the buoyant spirit and pos- sibly find comfort in the reflection that their condition might possibly have been worse than it actually is. Thus the superintendent's feelings and spirit are diffused through the whole hospital group and his optimistic out- look may glow in the faces and mark the speech of both officers and patients, to such a degree that even casual visitors may note the prevalent tone of good cheer and hope and therein discern the keynote of the hospital ad- ministration. A pessimistic physician is out of place as the head of a hospital for the insane. His constitutional tendency to look for and dwell upon the facts and cir- CARE OF THE INSANE 53 cumstances of a disquieting character which are strik- ingly obvious in most cases of insanity, intensify the morbid propensity of despondent patients to indulge ideas and reflections which are most painful and which prevent or retard a possible recovery. Then the over- shadowing, myopic philosophy expressed in the phrase, " What's the good? " smothers the happier and stimu- lating sentiments which alone render bearable the hos- pital existence of the average chronic patient. Under such gloomy supervision the ambitions of assistants are checked and employees view their obhgations to patients in a perfunctory way. In all enterprises where social questions and human sentiments are involved, the cyni- cal, pessimistic man is a foredoomed and pestilential failure. Finally, the act of resigning his position before the in- firmities incident to advancing age impair his executive abilities is a supreme test of a superintendent's wisdom. When he has accompHshed his immediate aim and done institutional work which has favorably impressed the medical profession and the general pubKc, he will be strongly tempted to remain in the service too long, living upon his well-earned reputation, and will un- consciously fall into routine operations because his potential capacity for initiative has passed its meridian. Under such conditions, he can add nothing to his fame 54 CARE OF THE INSANE and may impede progress which younger men, stand- ing perhaps upon foundations which he had earlier established, will have the foresight and energy to inaugurate. When a man's lifework has received due acknowledgment from those who understand the situa- tion and whose judgment is valued, he may retire satisfied; and, calhng to mind the fact that one can- not expect to be a personal power for leadership except with his immediate contemporaries, he should willingly step aside and open an opportunity for new men with fresh energy and ambitious aims. His ex- ample, his fame, his high purposes and good works are more inspiring to others than would be his continued efforts, through subsequent years of dechning physical and mental vigor. Continual progress is the natural order of events in social and scientific affairs, and the man who has concentrated his attention, year after year, upon certain lines of advance has probably magnified his objective points until they are out of correct propor- tion as he sees them. It is eminently fitting, therefore, that medical superintendents with a record of long ser- vice, especially those who have been devoted to the ad- vancement of certain features of management and have in fair measure realized their ideals, should, before cir- cumstances compel abdication, vacate the positions with which they have been identified, and permit successors CARE OF THE INSANE 55 to enter the field of operations. The broad, open- minded ex-superintendent should in the end find his greatest satisfaction in realizing that his own work will be utilized by those who come after him as a stepping stone to still higher achievements; in cheering on those who take up the work where he left off; and in the serene conviction that they will estabhsh greatly desired ad- vances in medical science and in the treatment of in- sanity which he could but fondly anticipate. THE MEDICAL STAFF. Assistant physicians should be appointed, or pro- moted, only upon the recommendation of the superin- tendent. For interested trustees or practical politi- cians to force the nomination of a particular candidate against the free judgment of the superintendent is sub- versive of that discipline which he must maintain if his administration is to command respect. In settling pre- liminary questions regarding appointments, it is emi- nently proper that the superintendent should confer with trustees, especially with medical members of the board ; but the fact remains that he can best decide as to the kind of man required to fill the vacant post and best judge of the candidates' capabiHties, notably so in cases of promotion. In selecting assistants, great care should be exercised to ascertain the facts regarding the applicant's character, his habits, his guiding principles and his predominant sentiments. A record for brilliant scholarship should not of itself be permitted to outweigh established repu- tation for sobriety, truthfulness, habits of industry, and tenacity of purpose. An assistant physician whose word cannot be depended upon is a stumbHng block for 57 58 CARE OF THE INSANE the management and a menace to the good name of the hospital. When a superintendent relies upon the word of an assistant who is guilty of misrepresentation, most painful embarrassments will naturally follow. Patients even distrust and condemn untruthful medical assist- ants, and the friends of patients resent being imposed upon by falsehoods when they have the undoubted right to know the facts. Then, the hospital records kept by assistants must bear the stamp of honesty, as scientific work is impossible when the medical records, even to minute details, are not absolutely reliable. Young medical men should feel honored when they receive a hospital appointment and strive through right conduct and honest work to add dignity and impor- tance to the position. While occupying subordinate posts they should be loyal to their superior officers; not because tenure of office may depend upon such observances, but for the reason that fidelity is a basic principle of true manliness. It is not advisable to en- cimiber the personal movements of staff officials with many inflexible rules and regulations. Assistants who cannot be trusted to regulate their general conduct according to the code of gentlemen, who cannot treat employees with kindness and courtesy without sacri- ficing official dignity, and those who on the hospital premises, whether on duty or off duty, ignore the social CARE OF THE INSANE 59 distinctions which their official rank confers, ought not to be promoted, possibly not even retained in the service. Rules outlining duties must be estabhshed to system- atize the procedure of such community workers. But men competent to fill staff positions must have out- grown the necessity for petty restrictions. Their plain obligations and sense of honor should suffice as ample guides for deportment. However, it should not be taken for granted that the burden of obligation rests wholly upon assistant physicians; that their reasonable claims for faithful labors are wholly liquidated by a meager salary. That they have some moral claims upon the manage- ment should be admitted. When they voluntarily sub- scribe to the supreme authority of the superintendent they must of necessity trust him to pilot them wisely, to instruct them in the best methods of hospital manage- ment, to facilitate their quest for scientific knowledge, and to assist the worthy ambitious in securing promotion either imder his management or elsewhere as opportu- nity may offer. A superintendent who in his relations with his assistants rests satisfied upon his opportu- nities to pose for admiration, all the more flattering if mingled with envy, violates his deeper obhgations and disregards noblesse oblige inherent in his official position. Officially and socially, he should treat them 6o CARE OF THE INSANE with the respect due members of his official family. He should encourage them to rise above trivial amioy- ances and personal jealousies which too frequently in- vade official families in public institutions. He should make it emphatically plain to their comprehension that the first and highest duty of every hospital official relates to the care and treatment of the patients, pro- tecting them from abuse and promoting their restora- tion to health through an exhaustive study of their cases, scientific treatment, and the arts of a true phi- lanthropist. Young physicians entering upon staff duties should be aided to adjust themselves to the re- quirements of their new responsibilities. Invested with delegated authority from the superintendent, they will be required to aid in enforcing discipline, and, where ''non-restraint" of patients is insisted upon, they must feel considerable uncertainty as to what attitude to take where perplexing conditions are wholly new and their experience is hmited. If they are inclined to accept the views and conclusions of the superintendent, it will require time and numerous observations for them to clearly apprehend the principle of ''non-restraint," the great importance of its enforcement, and the best methods of its application to the ordinary and extraor- dinary incidents which daily occur in the hospital wards. For a time they can do no better than respect CARE OF THE INSANE 6l the superintendent's scheme of management, accept his suggestions and refer all complicated cases to him for solution. When assistants make mistakes, he should take the first occasion to analyze the faults, point out the errors and explain how satisfactory results would have followed wiser action on their part. If a second lesson on the same subject becomes necessary, the super- intendent should make his instructions sink deeper if possible. When circumstances will allow consideration to be shown, even a serious mistake, if honestly re- gretted by the assistant, may be overlooked; yet it should be made plain that a repetition of serious blun- ders could not be condoned. It is impossible for a superintendent to review all the doings of his assistants, but new men should be cau- tioned against the too free employment of drug medi- cation. Young men fresh from the schools incline to prescribe hypnotics to excess, and to use hypodermic needles too freely. The details of ward work must be left to the assist- ants, but the superintendent must retain oversight and discharge his obligations to both assistants and patients. So far as the professional medical work applies, he can best serve both parties by adopting the practice of a daily clinic to be conducted each morning by the assist- ant physicians under his supervision. In no other way 62 CARE OF THE INSANE can he take time, with his many executive duties, to thoroughly satisfy himself that the physical and mental state of each patient has been carefully investigated; that complete and reliable records of the condition of all patients are being promptly made; that the junior mem- bers of the staff understand their work and are making satisfactory progress in the study of insanity. In short, every large hospital for the insane should be converted into a speciaHzed medical school for graduate students, where clinical and pathological work can be correlated and pursued to the best advantage. If, through the superintendent or the laboratory director, a close con- nection with the teaching force of some not-too-distant medical school can be arranged, the association may be made one of much advantage to the hospital by attract- ing students to the special work of hospitals, stimulating members of the staff to produce better results, and by giving the hospital a better standing among members of the medical profession. The superintendent should see that every patient entering the hospital becomes in due time the special V subject of a clinical conference. In large hospitals with frequent admissions — as many as five or six hundred new cases yearly — this broad system of clinical demon- strations has been practiced year after year to the com- plete satisfaction of all officials. The simplest method is CARE OF THE INSANE 63 to list in two classes, male and female, all patients ad- mitted. The assistant physicians should also be listed in two groups, — those who have charge of the male and female wards, respectively. Keeping the male and female departments separate, the assistants in regular rotation should have assigned to their charge the patients in the order of their enrollment on the admission books. By this arrangement, favoritism, collusion and selfish- ness are guarded against and each doctor has a fair and equal chance of getting the easy and the interesting cases, while choice, or exchange, of cases should not be permitted except with the superintendent's approval. The assignment of a patient to a particular physician under this scheme signifies that he must make the physi- cal and mental examinations, ascertain the previous history of the patient, and by questions, verbal and written, addressed to the patient, his relatives and friends, accummulate all possible information that bears upon the patient's mental endowment, developmental epochs, education, youthful and adult habits, the appar- \J ent cause for the mental disorder, its progress and its tendency towards recovery or dementia. All such evi- dence, his personal observations, etc., should be dic- tated to a stenographer, or recording machine, to be v typewritten and massed together in the individual case portfolio. A careful analysis of the mental condition 64 CARE OF THE INSANE should be given and, when obtainable, enough of the patient's conversation, answers to questions, flight of ideas, incoherent utterances, etc., should be quoted at sufficient length to fully illustrate the patient's mental state. The diagnosis, or provisional diagnosis, should be stated and a differential diagnosis should be elab- orated and recorded. Work of this sort, when done with nice discrimination, will add much to the value and in- terest of the hospital records; besides, it will rapidly develop the examiner's diagnostic sense. Finally, he should write out his opinion regarding prognosis. As soon as all these details have been considered, decided upon and t3^ewritten, the examiner should announce his readiness to present the case and arrange with the superintendent a date for this purpose. Ordinary cases can be properly presented in thirty minutes, and there- fore at least two cases should be in readiness for each clinic. An early morning hour, prior to time for regular ward visits, affords the most convenient time for such clinics. They start the day's work promptly and in a decid- edly stimulating way, and at this early hour the super- intendent is less Hkely to be called away by visitors and business engagements. Prompt attendance by the whole medical staff should be insisted upon. The super- intendent should regard his own attendance upon the CARE OF THE INSANE 65 conference as imperative. He should brook no delay- but be present at the moment appointed and preside as at a formal medical meeting. The assembling place should be near the main office. The hospital library often proves convenient, but a room with abundant sunlight should be selected if practicable. When the patients are too excitable or too infirm to be transferred from the wards for clinical demonstrations, adjourn- ment to the patient's room or bedside can be ordered after the case records have been read and the condi- tions explained. Before the patient is brought into the presence of the staff, the examiner should read his com- plete records of the case. Then, producing the indi- vidual, if in suitable condition, he should, by questions, explanations, and by the aid of various tests, demon- strate the existing evidence of mental disorder in the case, call attention to nervous conditions, specify indi- cations of physical defects or injuries, and point out the special features of the case which he had described in the history and explanations previously read. It should be his aim to convince all present that he had properly canvassed the case, skillfully grouped the salient symptoms and correctly interpreted their significance. Then the other assistants present should be at liberty to examine the patient, ask questions, expose addi- tional or obscure symptoms if detected. When all pres- 66 CARE OF THE INSANE ent have availed themselves of reasonable opportu- nities in this respect, the patient should be dismissed and returned to his ward or room. As soon as the patient leaves, the superintendent, or the temporary chairman, should call upon each physician in turn to express his opinion of the case. If anyone thinks he has observed sufficient evidence to warrant the venture, he will probably regroup the distinctive symptoms and contend for a diagnosis different from that advanced by the original examiner. Such discussions become es- pecially interesting and instructive when arguments are supported by quotations from recognized authorities. The substance of all remarks made in the clinical dis- cussion should be recorded at the time in a special journal kept by the staff, each member in turn serving for one month as secretary, unless a stenographer can be employed for this service. When the condition of the patient subsequently undergoes a marked change, the case should be again presented at a staff clinic, and all patients should be thus carefully examined immedi- ately before their discharge. At such final appearance before the staff a statement covering each patient's hos- pital experience should be elicited and complaints or fancied grievances should be fully recorded. This staff- meeting record will become more and more interesting as time lapses and will be consulted surprisingly often as CARE OF THE INSANE 67 a case progresses, is discharged, is readmitted, or termi- nates by death. All the clinical and staff-meeting rec- ords should be rendered available for special study by a suitable card index carefully kept.^ One hour a day spent in such staff -meeting clinics will enable the super- intendent to obtain full information concerning the patients under his care, to make certain that none is overlooked in respect to such critical examinations, and that the assistant physicians are diligent and thorough in their professional work. The fact that many of the cases thus written up and discussed will eventually be found in the autopsy room, where the pathological con- ditions can be definitely determined, when and where the opinions recorded on the case sheets and in the staff- meeting journal can be confirmed or refuted, spurs on each physician to do his best work, and continuous work of such a character perfects his medical education. The fact that a physician examines, watches over and reports a case does not necessarily consign that case to wards over which he presides. The condition of the case will probably determine its classification and ward location, and all patients in a given ward should be managed and prescribed for by the assistant in charge of that division. New cases as a rule go into the reception wards, and consequently all the assistants * See Card Index in Appendix. 68 CARE OF THE INSANE will have patients under special observation in the male or female admission wards at the same time, as each man must follow his cases, at least during the acute stage or until he has completed the preHminary case records and presented the case at the clinic. This system permits every man on the staff to engage in studying fresh, acute cases, even when his regular ward duties are in sections of the hospital occupied by chronic patients. It might be supposed that such a mixed arrangement would result in friction between members of the staff, but where the scientific spirit is properly encouraged jealousies are dispelled and the men work side by side in peace and with mutual advantage. Although no one can predict in advance whether any particular case will eventually be the subject of an autopsy, it becomes necessary to prepare the clinical records of every case with sufficient care to render them available and useful, provided the autopsy ever does occur. A searching examination should therefore be given every case, and under that practice no case, however forlorn or demented, is uninteresting. Nearly all the patients are pleased by having their condition, their infirmities even, made the subject of serious investiga- tion, and the friends of such patient's always appreciate the special interest shown by critical examinations. Junior assistants should commence to take their share CARE OF THE INSANE 69 of assigned cases early in their hospital service, and in- ternes, if graduates or advanced medical students, should take some cases for practice in making examinations, writing histories and conducting clinical demonstra- tions. Inexperienced men will for a time require some aid and suggestions in this work, but the necessary help can always be obtained from the experienced senior assistants. Staff physicians devoted to laboratory work should attend the morning clinics, taking part in the discus- sions, and express opinions when called upon; but unless they are anxious to spend time in studying psychi- atry they may as well be excused from making case examinations and clinical demonstrations. Their spe- cial field of work renders it encumbent upon them to make the laboratory examinations and findings inter- esting and profitable to the clinical assistants. One or more evenings each month should be set apart for lab- oratory staff meetings, at which the laboratory chief, by the aid of microscopes, or, what serves the purpose much better, a projection apparatus, should exhibit tis- sue changes in the brain and body organs as found in recent post-mortem subjects. In connection with the display of pathological conditions, let him review the clinical records in the cases represented and note the erroneous, as well as the correct, diagnoses therein re- 70 CARE OF THE INSANE corded by the clinical workers, and again they are reminded of the importance of wide and accurate medi- cal knowledge as well as of skill in applying it. When the members of the medical staff realize the advantage they derive from thorough autopsy work and interest themselves in obtaining permission from the relatives for such examinations, consent can be secured in more than half the deceased cases; and when assistant phy- sicians have every reason to expect that at least fifty per cent of their patients will eventually be subjected to post-mortem and microscopic examinations, that any one of the many patients under their care may by chance come into the post-mortem class, their professional work will be done with the utmost care without urging or nagging from the superintendent. Requiring such exacting work of assistants will not be resented by men of ability and ambition, as they must admit that thorough examination and careful treat- ment of patients are reasonable demands, and they must also realize that the proficiency they acquire by such painstaking examinations, critical discussions and clini- cal demonstrations becomes a valuable personal asset of their professional capital. It invests them with such a degree of confidence and self-rehance that they can appear with credit before any medical society, present- ing cases and taking part in discussions. CARE OF THE INSANE 71 In hospitals where careful professional work is done, the physicians' time becomes too valuable to be spent in clerical labors. Even internes in all hospitals should be spared such time-wasting work as writing case his- tories with the pen. Dictating to a stenographer, or a recording machine, not only economizes time but is time well spent because it rapidly improves one's diction. Another line of duty usually imposed upon staff physicians in well-organized hospitals consists in giving lectures to nurses in the training school. This task should be welcomed, as the practice more than repays the lecturer for all the mental application expended upon that work. Men engaged in hospital work on a scientific basis should be granted liberal vacations. Many of their duties are exacting and nervously exhausting, and where they faithfully work out their case histories and attend routine ward duties they require frequent resting spells. Without doubt men can accomplish more first-class work within a year, when at least one month is given up to change of scene and relaxation from ofiicial duty. Hospital managers make a mistake if they allow an assistant physician of ability and promise, with a satis- factory record, to resign when he would remain in the service if free to marry and suitable apartments were 72 CARE OF THE INSANE provided for him. The additional expense to an insti- tution incurred by caring for married assistants and their families is usually a good investment, as it insures a contented ofi&cial and the long-continued services of an interested and experienced man. HOSPITAL LABORATORIES. The laboratory has come to be the vital center of hospital work, as. it is impossible to practice medicine at the present day without employing laboratory meth- ods to determine the real basis for many physical dis- orders. Pathogenic bacteria are associated with so many diseased conditions which call for intelligent positive management that apparatus and material for bacteriological cultures, stains, and identifications must be conveniently accessible on the premises unless a public board-of-health laboratory be estabHshed in the vicinity. Sooner or later, every large institution has to cope with epidemics of germ diseases, — typhoid fever, diphtheria, dysentery, etc. Having at command labo- ratory facilities for determining the facts regarding the character of such diseases, their precise locality, their extension or subsidence, and, by reason of such knowl- edge, being able to apply the exact remedy in the right place and at the right time, mitigates by more than half the worry and sense of responsibility thrust upon the management of the hospital by an epidemic out- break. Then the most delicate blood examinations 73 74 CARE OF THE INSANE should be matters of daily routine. Diagnosing certain diseases, producing autogenous vaccines, settling ques- tions of immunity, controlling dosage in the specific treatment of tuberculosis, etc., are among the prob- lems which the laboratory alone can decide and which ought to be decided within each institution. All hospitals should be able to keep up to the times with pathological work. Specimens, in the form of mounted microscopic slides, from every diseased organ, in all cases examined post mortem, should be kept in cases so marked and numbered that any desired one could be found whenever needed. Laboratory equipments in connection with hospitals for the insane suggest the propriety of making research investigations in order to obtain more definite knowl- edge regarding the causation of insanity. The physical cause for some phases of insanity may be one of the obscure secrets which can be discovered only through experiments with the blood serum. That wonderful fluid is known to contain and retain so many specific marvels which seem not to interfere with one another that there is much promise for light upon some forms of insanity in this field of inquiry. Few, even among physicians, realize the superior advantages for medical research work to be found in the modern large hospital for the insane where a complete laboratory outfit is CARE OF THE INSANE 75 under the management of a competent corps of medi- cal specialists. Very often the enthusiastic investiga- tor into bio-chemical secrets, physiological anomalies, pathological conditions and causes, works upon some important problem, isolated from interested associates who might aid him in excluding the personal equation and other misleading factors. Frequently he is handi- capped by inadequate laboratory accessories, or searches vainly for material enough to give the results of his labors a basis sufficiently broad to command respectful attention. But in large state hospitals every variety of laboratory implement can, and should, be provided. Working side by side and in harmonious efforts to secure a better understanding of the diseases they are investigating are grouped the clinician, the chemist and the pathologist, who are thus able to control or supple- ment one another's work. Besides, within the same institution walls there re- sides a large number of permanent patients under their immediate observation and absolute control, and among this aggregation of invalids, case after case of some dis- eased condition, in varying stages of development, can be observed. In this promising field they can work, and, testing out theories as they proceed, they can establish on a practical basis any discovery made and verify again and again any claims they may consider worth pub- 76 CARE OF THE INSANE lishing. Research medical work in hospitals for the insane in its results cannot be restricted to that which alone interests the mental specialist. Any new fact established through scientific work there will be of such fundamental character that it will enrich the literature and extend the scope of general medicine. Unfortunately, hospitals for the insane are often re- garded as undesirable neighbors in a town or locality. Be they popular or unpopular, they can, in a large measure, compensate the surrounding public for their presence by generously permitting neighboring physi- cians to enjoy in their private practice the assistance which the hospital laboratory can render. Especially when hospitals which maintain first-class laboratories are situated in country districts, remote from centers where board-of-health laboratories are established to aid in determining many health questions vital to the community, they should extend to the general prac- titioners of medicine within a reasonable distance the benefits of the laboratory facilities and the skill of the laboratory staff. Bacteriological and pathological ques- tions from such outside sources should be fully consid- ered and the best expert ability should be at the service of the medical men outside the institution. Possibly it might be advisable to charge for such work the act- ual expense incurred. But if rendered gratuitously, the CARE OF THE INSANE 77 hospital would profit by its benevolent intention, since the amount of outside work would seldom interfere with regular duties, and would, while interesting and stimulating the laboratory operators, secure the good will of the profession and general pubhc. Should such outside work necessitate the services of an extra assist- ant, the additional expense would be an excellent in- vestment for the citizens at large, by whom such insti- tutions are owned and supported. MANAGEMENT OF PATIENTS. The modern large hospital for the insane, palatial in respect to its proportions and architecture, surrounded by ornamental trees, shrubs, flower beds and a beauti- ful landscape, with spacious, artistically decorated inte- riors amply stocked with comfortable furniture, is not intended for prison purposes. Security for the patients committed to his care is not, at the present day, the only burden of the superintendent's responsibility. Public sentiment requires that insane patients in hos- pitals shall, as far as possible, be restored to normal health, and that all patients, both acute and chronic, shall be provided with substantial comforts, shall be protected from abuse and unnecessary hardships, and shall enjoy a reasonable degree of freedom. It is well known that the insane were subjected to shocking treatment in earlier times, and no doubt insane patients in hospitals set apart for their proper care and treat- ment still suffer much at times from the hands of those employed to nurse and watch over them. Such abuse of the insane cannot be wholly suppressed until the 79 So CARE OF THE INSANE old system of coercion, with its severe discipline and mechanical appliances to substantiate threats, is eradi- cated from hospitals for the insane, and practical com- passion, with gentle arts and persuasive measures, is adopted by the entire management, nurses and medical officials, as the ruling principle in managing the patients. The management of the insane in conformity with the Tuke and Conolly practice has come to be desig- nated as the ^'non-restraint" system. That term does not signify the whole scheme, but it suggests the key to this humane hospital policy, because strait-jackets, wristlets, bed harnesses, etc., are the obvious and tan- gible insignia of the harsh, repressive methods too com- monly enforced in hospital wards. Then, the pacific, mollifying arts involved in properly treating the insane cannot be successfully inculcated and enforced except where mechanical restraint is wholly discarded. There- fore, '' non-restraint" has properly enough been accepted as a significant word s>Tnbol for the highest ethical development of hospital management in the care of the insane. As used by Conolly, the term means very much more than the absence of restraining implements. The essential feature of this method is the underlying spirit of humane endeavor which, when intelligently directed, will obviate the apparent necessity for using restraining measures by happily qualifying all the rela- CARE OF THE INSANE 8l tions between patients and employees throughout their entire association. Strict rules admonishing nurses and attendants to avoid abuse of patients, abolishing instruments for me- chanical restraint and increasing the wages of the em- ployees are commendable steps towards improving the condition of the insane. Yet such measures will fall short of protecting troublesome, unreasonable patients in hospitals where for the greater part of the time they are under the absolute control of thoughtless, dictatorial attendants and depend for their comfort upon what abridged rights and restricted freedom they can obtain from employees. Where the ward management of tur- bulent patients is left largely to the discretion of attend- ants who have never been taught, or have never seen in practice, methods of controlling the insane without threats, and without mechanical restraint, the unwise attendants naturally assume that patients must be kept under rigid discipline, and held in such a state of sub- jugation that they will promptly obey any command given them. The ignorant and undisciplined inclina- tion of such employees incites them to bully the pa- tients, often compelling obedience to unnecessary orders as if simply to test their docility. And some of the rougher class of attendants will deliberately attack a new patient to give him a practical demonstration that 82 CARE OF THE INSANE pain will be inflicted and many privileges will be sus- pended unless he passively submits to such tyrannical discipline. One motive for which such cruelties are visited upon new patients in hospitals is to early im- press them with a fear of consequences should they report to medical officials instances of abuse which they may suffer or may see inflicted upon other patients. If patients who have been badly treated by employees suppress the facts and refuse to answer ques- tions, a reign of intimidation is the most probable ex- planation for their attitude. When the pitiless attend- ant is cautious enough to fear detection, and possible discharge, if it becomes known that he assaulted an insane man, he can usually irritate and provoke the patient into expressing his resentment by resisting or striking the aggressor, and when the patient has actually struck the first blow his fate is sealed. Under the plea of self-defense the attendant can, until satisfied, safely pommel the innocent victim of his malicious motives. PubUc opinion is occasionally fanned into indignation by published reports of hospital abuses. At such times an investigation of the reported death or serious injury of some insane patient may be ordered by the governor or legislature. As an outcome, some employee may be censured and discharged, but more frequently the final report will minimize the outrage because the situation, CARE OF THE INSANE 83 as represented by interested hospital parties, was one of great peril to the employee. All are led to believe the employee was in personal danger and simply de- fended himself. In the findings, the sad results of such "hospital accidents" are always regretted, but are deemed unavoidable so far as the investigators could judge. Such official investigations are almost always superficial, and the verdict serves little purpose beyond softening the process of closing the incident. The com- mittees naturally have to restrict their examination to details of the particular encounter which ended disas- trously. An advocate who could comprehend the whole affair and would be able to point out the defects of such inquiries seldom appears for the patient. In such trials testimony will not be adduced to show what was the probable fact, — that the patient was a long-suffering victim of irritating taunts, minor abuses and repeated threats which finally produced an insane craving for revenge, — and no one will volunteer to argue the pa- tient's right to defend himself when he had cause to believe himself in danger from a persistent enemy. As a rule, in all such cases the "commission" or "commit- tee" consider only the final result in a long chain of circumstances, more or less extended as to time, but all leading up to the logical catastrophe. Happily such hospital conditions are exceptional, al- 84 CARE OF THE INSANE' though the time was when troublesome patients were very generally abused. It is not intimated here that such methods are practiced in the better-regulated hos- pitals of the present day. But without doubt a minor phase of ward despotism does exist, not infrequently, in some wards of most hospitals for the insane. Too often there exists a condition of internal affairs where attend- ants order patients about in rough terms, often with profanity, and manifest a degree of impatience that ex- asperates nervous invalids, who are threatened with removal to back wards, seclusion-rooms, or with strait- jackets, unless they respond instantly when addressed by the ward ''dictator." The great majority of patients submit to such treatment — some meekly, some sul- lenly. But occasionally some irritable or semi-demented person will continuously ignore the commands of the churlish overseer. Then follow louder and more terrible menaces, until the baffled petty autocrat, intent upon maintaining his idea of discipHne, strikes or seizes the "rebellious subject," who may then unexpectedly show much fighting ability, and as a consequence some one gets injured, usually the poor patient. The order given may have been imnecessary and unreasonable, but once engaged in a contest to demonstrate his autocracy, the attendant, if a novice, will be anxious chiefly to main- tain his assumption of power and his false conception CARE OF THE INSANE 85 of dignity, failing entirely to anticipate the ^'accidental" or natural consequences. In such positions, ''experi- enced," hardened attendants will proceed in the same way, disregarding all chances of serious results to the patient, confident that they can mislead officials re- garding their responsibility. The cases where patients resent such harsh, imperious discipKne by physical re- sistance may be infrequent, but the hardship and injus- tice incident to such ward management, when visited upon large groups of patients, aggregates an immense sum total of unhappiness and misery which might be obviated by the substitution of rational methods by which to control insane patients. And yet, the attendants who inflict such discomfort and misery have some defense for their conduct. The hasty, arbitrary measures enforced by the average state hospital ward attendant may represent his best judg- ment and be the measure of the meager or erroneous instruction he has received, as well as the faulty char- acter he is developing for himself because of inadequate instruction and incompetent guidance. To insure the proper treatment of the insane in large hospitals, the individual members of the nursing staff should have their ideas trained to understand the propriety and the importance of controlling patients by gentle, persuasive measures. Their sympathies for the patient should be 86 CARE OF THE INSANE awakened and cultivated. They should be inducted into the practice of leading patients by suggestion, de- Hberation, conscious mental power and the advantages of position. They should take professional pride in winning mental victories over the turbulent insane and deplore the subjugation of confused and terrified insane men and women by using brute force and strait-jackets. In managing insane patients, measures calculated to in- spire confidence should be adopted when possible; but it is no more necessary to reveal the whole truth to them, upon all occasions, than it is proper to keep sane patients informed of every shade of opinion concerning their cases which may be entertained by their medical at- tendants. With the insane it is important to engage their attention and if practicable secure their coopera- tion. With some patients the simple truth will serve every purpose, but with certain others it will not succeed and diplomatic methods must be called into requisition. Only imsympathetic physicians will at all times dis- close their conceptions of personal facts to insane pa- tients. Hope and confidence in the insane can seldom be developed through such mistakenly honest inten- tions. In truth, such brutal frankness could be ex- pected from those only who discover nothing but good in using strait-jackets. It may be true that hospital CARE OF THE INSANE 87 physicians often criticize those who use deception in committing patients to hospitals for the insane, and it is seldom wise or necessary to do so; but there are in- stances when painful and even serious consequences to the patient and his friends may be obviated by resorting to stratagem and diplomacy. When persons fully recover from insanity they will show no resentment against old friends who in the try- ing process of incarceration obscured the truth. How- ever captious respecting the conduct of patients' friends in this respect hospital physicians may be, it is safe to assume that those with experience seldom go through their own wards addressing and replying to the patients with literal candor. Of course no self-respecting physi- cian treats his patients having mental disorder by falsi- fying. Yet he should vary his style of communication and exercise more or less reservation to pertinently meet the complex mental conditions with which he has to deal. He should guard his tongue and not tell too much truth. He should often mask his opinions and be prepared to veto patients' whims, baffle their inten- tions and evade their direct questions without defi- nitely committing himself or arousing their antagonism. To command the situation at all times, he will have frequently to insinuate and suggest rather than affirm, employ figurative speech freely instead of giving cate- 88 CARE OF THE INSANE gorical answers, and project captivating schemes befit- ting the humor of the patient or his mental peculiarities. Many patients, incoherent or demented, have no power of discrimination, while others may be exceed- ingly penetrating and subtle. Hallucinations and delu- sions should be kindly corrected, again and again, by cogent, logical explanations. Not that truth and reason will certainly dissolve such errors of sense and judg- ment, but they do have weight in some cases. Sufferers from mental depression need mental stim- ulus, and to them attractive and interesting subjects should be so charmingly presented as to evoke thoughts along new channels. Restless, overactive cases should have provided a safe outlet for their excessive kinetic energy, which cannot be thwarted but can be modified and diverted. Manic cases with an exaggerated ego and prolific activities, playfully rather than viciously inclined, can always be induced to expend their augmented mental and physical force in some harmless way. Such cases usually puzzle the physicians, and worry the employees, as they become naturally rebellious under strict disci- pHne. But they are always tractable when properly handled. For them some unusual and interesting line of conduct should be devised, — something congruous with their prevailing conceit. They are easily be- CARE OF THE INSANE 89 witched with a notion of doing something fantastic or most exceptional, and under a giddy exterior often re- tain a semi-correct sense of propriety and a whimsical code of honor.^ Such cases cannot be expected to conform to a rigid system of ward discipline. The hospital management ought to be sufficiently elastic and reasonable to pro- vide exceptions and variations adapted to the individual requirements of these exacting patients. This class of patients is never large and the acute condition is seldom prolonged. They generally recover in time and recol- lect all that transpired during their mental excitement. The author of "A Mind That Found Itself" most graph- ically describes the mental conditions of such a case.^ ''Non-restraint" in its literal, narrow sense may be made the rule of an institution without bettering the treatment of the patients. There are other processes more painful and more dangerous than wearing the 1 See illustrative case reported in the Appendix. 2 "A Mind That Found Itself," an autobiography by Clifford W. Beers, published by Longmans, Green & Company, 443 Fourth Ave- nue, New York City. In this book the author tells of his experi- ences while a patient in sundry private and public hospitals for the insane during the years 1900-1903, and suggests a plan for a national movement in mental hygiene, and for the improvement of conditions among the insane. This plan has since been put into effect under the auspices of the National Committee for Mental Hygiene, which has come into existence as a result of the publication of "A Mind That Found Itself." 90 CARE OF THE INSANE camisole, which can be employed by tyrannical attend- ants to frighten and intimidate defenseless patients. Doubtless patients will occasionally present critical con- ditions which seem to necessitate mechanical restraint, and when the use of such appliances would result in no injury, mental or physical, to that particular pa- tient. Could the treatment of such a case be entirely dissociated from all other cases in the minds of the physicians and nurses, the use of straps and jackets might be regarded as unobjectionable. But in institu- tions for the custody of the insane, the general welfare of the whole body of inmates depends very much upon the morale of the nursing staff, and with its members the demoraUzing effects of making exceptions to the ^^non-restraint" rule are so pernicious and wide-reach- ing that yielding to the use of mechanical restraint with occasional patients would sacrifice the best interests of a multitude of other cases having equal claims upon the management for protection from imnecessary restraint and ignominy. The superintendent who imagines he is controlling the use of mechanical restraint in the hospital where he directs affairs, when he reserves to himself the power of deciding whether mechanical restraint can be used in any given case, does not see himself as others see him. Even the nurses understand the situa- tion better than he. They clearly realize that the CARE OF THE INSANE 9 1 judgment of such officials on this point of restraint is always an inspiration from themselves. He receives by messenger, or through the telephone, a report from nurses that some patient is desperately suicidal or dangerously maniacal, with a request that permission for restraint be granted. He dare not decide against their evident wishes under such circumstances. The nurses may assume to be physically incapable of further effort. The executive chief is mentally and morally helpless when thus appealed to unless he has previously established the "non-restraint" treatment as the imdeviating working practice in his hospital. Occasionally a medical superintendent who believes in the use of mechanical restraint, for exceptionally trying cases at least, will cite an affray with an insane patient, stating conditions which actually confronted the attendants, and request a solution of the situation from some "non-restraint'' advocate. Such superinten- dents misapprehend the "non-restraint" theory. It is possible that nothing short of some form of restraint or seclusion would instantly meet all the requirements of the case as described. The correct and the better method had been too long neglected. Rational treat- ment should have been applied to the case reported weeks, months, possibly years, before such a violent culmination of threats and neglect by incompetent em- 92 CARE OF THE INSANE ployees occurred. The cure for such troubles consists in educating nurses and attendants to become true nurses, with a thoroughly humane conception of their duties. They must be willing to follow helpful sugges- tions and apply correct principles in efforts to influence rather than coerce the insane over whom they have charge. While the superintendent who asks in sincer- ity how nurses are to extricate themselves from impend- ing conflicts with patients without using force may feel justified in his attitude with the answer he receives, by his question he unwittingly exposes to the experienced "non-restraint" patron the prevaiHng lack of proper system of ward management in his own institution. The superintendent who seriously desires to avoid the use of mechanical restraint will have not only to forbid and aboHsh it, but to keep a careful watch over the nurses and their dealings with patients, especially in those wards where new and troublesome cases are located. The number of patients Hkely to get into trouble with the nurses is not large in any one well-con- ducted hospital, and concerning the treatment of these the superintendent can and should exhibit constant solicitude. He should personally investigate every in- stance of violence between nurses and patients and keep a record of his findings. This can be done by requiring all employees to report in writing, and without delay, CARE OF THE INSANE 93 every instance of accident to or trouble with a patient. Special blank cards for this purpose should be in the hands of all nurses, to be filled out in every case of fric- tion with a patient.^ These cards the superintendent should file under the patient's name after having made a personal investigation of the affair reported. This means additional burdens of care, labor and responsi- bility for him, but the best interests of the patients re- quire it and the interested public should expect nothing else. Unless the superintendent takes an active part in organizing and conducting a "non-restraint" cru- sade, the work will be superficial and spasmodic. Nurses will lack continuous initiative unless stimulated by his interest in the general scope and many details of this policy. He will need to utilize the services of deputy assistants and supervisors who understand his views and who can be trusted to act with intelligence and loyalty. It is imperative that all wards, in which are placed patients likely to give trouble, should be under the charge of head nurses in every way competent to man- age patients without restraint and who are willing to teach their ward helpers the art, its principle and the details of its application. Such head nurses must them- selves scrupulously observe all the requirements, or they will weaken their influence and control over their ap- prentices. Irresponsible employees could be quickly dis- ^ See Card Index in Appendix 94 CARE OF THE INSANE posed of and the abuse of patients could be effectually checked if only a number of such head nurses in each hospital placed at strategic points would faithfully re- port each instance of infraction or neglect of duty. In most hospitals for the insane there prevails among nurses a fictitious sense of honor which favors employees and does not protect or vindicate the patients. The superintendent should in all possible ways adopt plans which will facilitate the successful working of the "non-restraint '' policy. The overcrowding of wards, especially those appropriate for the care of noisy and fractious patients, should be avoided. He may not be able to regulate admissions to the institution, but over- crowding is such a serious interference with skillful nursing he should register his protest when conditions prevent the best work. The proper classification of those patients likely to cause trouble is a great aid to the *^ non-restraint" meth- ods. Not that all disorderly inclined patients should be herded in back wards, for irritable patients react upon each other and should be frequently changed from ward to ward so they may engage in forming new compan- ionships and avoid tiresome associations. In making such changes, personal antipathies between patients, or patients and certain nurses, should receive consid- eration. But nurses should not be permitted to force CARE OF THE INSANE 95 such changes where it is evident they are chiefly con- cerned to rid themselves of the care of troublesome patients. Unless some patients are transferred from a noisy to a quiet ward before the excitement has wholly subsided, their convalescence may be retarded. Such a transfer from back to front ward, and then returning, repeated several times, is often the correct way to stimu- late them to exercise self-control. Seclusion may be necessary at times, but it should be remembered that prolonged seclusion is bad practice. The shorter the period of seclusion, as a rule, the better the effect upon the disturbed patient. Noisy, destructive patients are seldom improved by solitary confinement. Exercise out of doors to the point of physical fatigue, with a compe- tent guard of nurses, is a much better form of isolation from other patients, and a practical way of treating such cases. Ample facilities for prolonged warm baths must be provided. When the temperature of the water is maintained a degree or two below blood heat there is little risk of heart failure. Persistent destruction of clothing is fostered, not cured, by the use of ill-fitting canvas dresses. Better supply material having bright colors and striking figures — something that will appeal to what vestige of pride may exist — that will attract the eye and, possibly, alter the purpose of the victim of destructive habits. 96 CARE OF THE INSANE Daily out-of-door exercise for all able-bodied patients should be insisted upon whenever the weather is suit- able, and all patients who are physically able to work should be urged to engage in some form of labor, at least a part of each day. Let those who object to physical exertion accompany those willing to labor, even if at first they simply stand around and watch the busy workers. Under such circumstances, the influence of a good example is suggestive, frequently inducing idlers to participate in useful employment. Patients who work faithfully and diligently should receive some re- ward. Occasionally, a small sum of money regularly paid as a gratuity will secure their good-will and stim- ulate their exertions. Special diet, extra clothing, to- bacco, occasional excursions, may be profitably granted as inducements to render efficient and continued service. Compelling patients to work should be strictly forbid- den, as serious conflicts have resulted frequently through attempts on the part of attendants or nurses to force patients to serve them at ward duty or in performing some disagreeable task. Inducing patients to work or to conduct themselves properly through gifts, rewards or favors is a prominent and legitimate feature in the "non-restraint" system. Head nurses over all wards where restive and seemingly obstinate patients dwell should be Hberally suppHed at all times with extra food, CARE OF THE INSANE 97 fruit, candy, pictures, etc., for use in distracting the attention of excited patients and as a ready means by which to estabhsh friendly relations with patients who are suspicious. It may be proper to keep medicines in each ward under the care of the head nurse, but dangerous drugs — those with which suicide could be effected — had better be elsewhere or securely placed. Medicine in- tended to produce quiet and sleep should be kept in the administration drug room. The more free the use of hypnotics with the insane, the more noisy they are at night and the greater the demand for more hyp- notic medication. By the use of such drugs a tempo- rary, quieting effect may be produced, but the reaction which usually follows intensifies the original condition, and patients thus indulged become impatient for a repetition. Hypodermic medication of this class should seldom be employed, as a drug habit is easily contracted and tenaciously held. Hypodermic needles and tablets should not be entrusted to the nurses lest some patient some day get a hypnotic injection that was not ordered by the physician. Nervous, restive patients should be assigned to large, roomy wards whenever possible, so they may freely roam about, greet new acquaintances before they tire of enforced companionship and vent some explosive en- 98 CARE OF THE INSANE] ergy while aimlessly tramping about the long wards. Cramped accommodations and restricted movements are decidedly irritating to the insane and should be avoided except when exhaustion is Hkely to supervene upon too prolonged physical exertion. Noisy, talkative persons should be taken into the fields and woods to correct their impleasant habits, not consigned to out-of-the-way dark rooms. The more close the restrictions, as when in a cell or strait-jacket, the more intense the irritation, fear and suffering; consequently the more persistent the noise and the louder the shouting. As a result of natural laws, it is to be expected that painful mental tension incident to extreme limitations of space or mo- tion will gradually relax, to be succeeded by a sense of relief and quiet as the restrictions are mitigated and gradually transformed into a state of freedom. The relation of instinctive mental conditions to vary- ing degrees of space ought to be considered in planning ac- commodations and treatment for the insane. A greater nimiber of nurses should be employed when mechanical restraint is abolished, as the duties and actual labor with excitable and depressed patients are increased un- der the ''non-restraint" methods. In large wards, ac- commodating acute or intractable cases, nurses should be constantly posted at several points about the room in order to suppress quarrels among patients and to CARE OF THE INSANE 99 detect violent conduct in its incipient stage. Patients with suicidal tendencies should be assembled in a special ward or dormitory where continual watch can be kept over the whole company, both day and night. Their every movement should be under trained observation. Practically all departments for patients should be kept under strict watch at night. Night supervisors and night watchmen should be employed and competent nurses should be kept both day and night in all wards occupied by untrustworthy patients, so the old practice of locking patients in single rooms at night can be discontinued. Watched dormitories are more suit- able sleeping places for the majority of patients than ordinary single rooms. There cannot be too much watchfulness in hospitals for the insane. No power on earth so effectually controls the conduct of men as human vision, and so the eye of a qualified nurse aided by a prudent tongue can control nearly all insane pa- tients without any physical exertion. There are good reasons why it is advisable to open hospitals for the insane to the public often and fully. When public inspection or visiting days recur frequently, the nurses are stimulated to keep their wards in a pre- sentable condition, as they know the general appearance of the halls and rooms, as well as the patients' cloth- ing, will fall under critical observation. This constant lOO CARE OF THE INSANE anticipation keeps both nurses and patients more active and more cheerful than would the dead level of hospital routine. The patients' hopes are awakened and their spirits are stimulated by coming into close contact with people of the outside world. When pub- lic visiting days occur twice weekly, as in some institu- tions, and a large number of strangers pass through the wards each open day, the patients become so accustomed to the spectacle that they regard the visitors with com- paratively Httle curiosity, maintaining a good degree of dignity and seldom exhibit undue excitement. With frequent repetitions, the sight of outsiders becomes a simple matter of course and the patients appear self- possessed and natural, while patients who seldom meet strangers will flock about a visitor in their wards, many talking at the same time, each intent upon securing recognition or exacting some promise. Properly conducted hospitals for the insane no longer afford such grotesque and shocking spectacles as, ac- cording to Pepys and Hogarth, were on exhibition in old '' Bedlam." No doubt many persons at the present day are prompted to visit hospitals for the insane out of curiosity, but the tables are practically turned in hospitals where frequent ward visiting is the rule: the parading visitors provide the exhibition. Their evident timidity and unconscious stupidity often interest the CARE OF THE INSANE lOI patients, who quietly note and enjoy the passing show, which they may subsequently criticize or analyze with jest and merriment. Besides, it is a needed and valu- able object-lesson to the public. The world at large still entertains too many exaggerated and erroneous opinions concerning the internal conditions of such institutions. When the visitors enter the better-class hospitals and walk through ward after ward without detecting anything remarkable, it is a revelation to them. They note the large, pleasant Hving rooms, well- furnished tidy sleeping rooms and attractive dining halls, with appointments, in many respects, superior to those provided in the patients' homes. They observe the scrupulous cleanhness which generally prevails, the pic- tures and ornaments displayed in most wards, and are especially impressed with the natural appearance and good behavior of the patients. In this way they re- ceive impressions and carry away convictions which go far towards correcting the prejudicial traditions con- cerning such institutions, which have been treasured and often repeated in the very circles represented by such visitors. Friends of patients err when they deprecate such pub- Kcity for the insane confined in hospitals. Few of the insane are sensitive respecting their condition, and the majority pine for friendly associations. False pride I02 CARE OF THE INSANE should not be permitted to immure them so completely as to cut them off from sight and sound of sane Hfe, and permit them to see only the faces of their fellow patients and custodians. The greater the publicity of the man- agement, the less opportunity there is for injustice to the patients. As a rule, visits from strangers have less objectionable results upon the patients' mental condi- tion than frequent visits from near relatives. Rela- tives and friends cannot understand why their visits to the mentally sick should produce harmful results, and yet such is the frequent outcome of premature or too frequent visits by injudicious kindred and friends. Convalescing patients are likely to be set back by a re- vival of emotions linked with family associations, and many chronic cases are kept in a state of unrest and smothering rebellion through unwise sympathy and ill- expressed friendship proffered by timid kindred. Hospital life is necessarily monotonous, and liberal diversion is the rational antidote with which to counter- act its bad effects. Amusements varying in character should be provided at short and regular intervals for the entertainment and mental relaxation of the patients. Anything which agreeably enlists and engrosses the attention fulfills the requirements. Music and dancing can always be depended upon to produce satisfactory results. CARE OF THE INSANE 103 A congregate dining room can be utilized to add vari- ety to the patients' daily life, to change the drift of morbid thoughts and inclinations, and to introduce nor- mal conditions as fully as possible into hospital meth- ods. Both male and female patients should be accom- modated in the same dining room, their tables being separated by a wide passageway through the center of the hall. No kind of food should be placed upon the tables until all have been seated. Food can then be distributed from rubber-tired cars in the center aisle, or be served from sideboards against the walls, by selected patients acting as waiters, one waiter to each table. The meals should be so planned that the food can be served in a number of courses, the more table etiquette the better, allowing fully one hour for dinner and forty- five minutes for breakfast and supper. In such dining rooms haste is objectionable, and five hundred to fifteen hundred patients can be managed and be properly fed with ease and quietness. The time patients thus spend at table and consume coming from and returning to their wards will amount to at least three hours a day. An orchestra should be employed to furnish music all the time patients are present, morning, noon and night. Only those who have had experience with such meal arrangement can appreciate the power this method of meal serving has towards promoting the self-respect I04 CARE OF THE INSANE of the individual patients and tranquilizing ward condi- tions throughout the whole hospital. The aim and pur- pose of such dining-room practice should be to cultivate good table manners, to occupy the patients' time agree- ably, to increase the self-respect and self-control of the patients by adopting as fully as possible the dining- room customs of large aggregations of normal people. Incidentally, it allows ample time for quiet meals to be served attendants and nurses, usually in one section of the same room. It also removes from the living wards objectionable odors and annoying housekeeping duties, and, last to be considered, it is decidedly economical as regards cost for food, waste and service. The music is an important, probably an essential, fea- ture. Many patients listen with pleasure, and it affects the outward manifestations of all present. Without music there would be more noise, more loud talking, and some patients would find it difficult to repress an inclina- tion to lecture the officials or others present, and make statements leading to rejoinders and disputes. With attractively arranged tables surrounded by plants and flowers, and with neatly attired patients, entertained by good music, little more is required to make the congre- gate dining room the acknowledged social center of the establishment, from which will emanate good influences to tone and characterize the whole institution. NURSING STAFF. In hospitals for the insane the patients have to de- pend chiefly upon the nurses for sane companionship, as the medical officers can of necessity devote but httle time to individual cases. Therefore, the general intel- ligence and natural disposition of the nurses, supple- mented by their conceptions of duty and knowledge of nursing the insane, determine, in a large measure, the domestic and social atmosphere by which the patients are surrounded during their whole hospital residence. All superintendents appreciate the importance of se- lecting employees with especial care as regards their qualifications for the trying positions offered them, but the fact that preliminary arrangements with hospital employees have in most cases to be negotiated by corre- spondence renders it impossible to cull from the Hst of appHcants only those who can be depended upon to make satisfactory nurses. Objectionable candidates may be occasionally barred by requiring in advance a condi- tional contract, duly signed, in which the applicant agrees to observe all the rules and regulations and to obey all orders, written or verbal, issued by the hos- pital authorities. 105 Io6 CARE OF THE INSANE It is to be regretted that ambitious young women with a high-school or collegiate education do not more generally become interested in this special work, which is well compensated and which offers numerous oppor- tunities for promotion. Women superintendents of gen- eral hospitals and training schools for nurses are always in demand at liberal salaries. While some of the duties in state hospitals are ad- mittedly unpleasant, there are compensations other than the financial consideration to interest and repay the faithful worker in such hospital wards. Under present conditions and the ordinary understanding as to what such positions offer, this service attracts young country people more than other classes of wage earners, as the wages paid are higher than in agricultural or domestic pursuits and where only more laborious situations are open to them. Beginners in stores and factories usually receive less remuneration for labor than the hospitals pay. Hospitals have to depend largely upon much in- competent, inexperienced help, since nursing the insane seems to present little attraction for other classes of wage earners. Then, of the many who engage in hospital ward work, few remain in the service longer than six months, and the ranks of the nursing staff are continuously recruited, almost wholly from country districts. But how to se- CARE OF THE INSANE 107 cure a better class of nurses to care for and manage the insane is not simply a question of advancing the scale of wages, although more thoroughly competent graduates from the training schools should each year be induced to remain in the service by a liberal increase of salary. Higher initial wages would accompKsh very little, as few candidates who could command equal wages by teaching or clerking would willingly submit to the dis- cipline necessary to fit them for successful nurses in hospitals for the insane. If increasing hospital wages did secure employees with a higher grade of education and better general information, such broader mental experience in itself fits no one for ward service in hos- pitals for the insane. Men and women thoroughly com- petent to care for and manage the insane are never born with perfect endowment for that peculiar service, nor can such qualifications be developed outside hospital wards. When inexperienced employees enter upon ward duties they are usually suppKed with a rule book which con- tains many fundamental laws intended to regulate their general conduct towards the patients. Concerning the treatment of patients who give trouble, certain prohibi- tions will be recorded in these booklets, but such man- uals give scant information as to the correct principles of nursing those suffering from mental disorder. Indeed, I08 CARE OF THE INSANE in many training schools little attention is given to this special and most important branch of mental nursing. Pupils are expected to acquire all that is necessary in this direction by ward experience. The consequence is that in most hospitals for the insane the majority of attendants and nurses are poorly prepared for the diffi- cult and perplexing tasks they are occasionally com- pelled to undertake. Young men and women, with an education no better than the country common school affords, with such mental and moral discipline only as may be derived from isolated family life in rural abodes, and with no practical experience in adjusting themselves to a social environ- ment where the ordinary rights and privileges of each individual may conflict in some manner or degree, are placed in wards crowded with insane patients and are assigned duties the discharge of which would at times tax the mind of a mature philosopher and the heart of a veteran in philanthropic work. It is not surprising that they frequently make a sad failure of the under- taking. In earlier hospital days, some attendants, by long experience and with good counsel, became pro- ficient workers with insane patients in hospitals, be- cause of their inborn capacity and love for the work. But now hospital demands for employees are so great that the necessary number of willing and apt pupils CARE OF THE INSANE IO9 must be obtained from any possible source and then be carefully taught the theory and practice of mental nursing, if better results are to be required of hospital management. The ordinary nursing instruction given in the aver- age nurses' training school is useful knowledge and an excellent foundation for practical experience in high- class work. But as a preparation for proper work in hospitals for the insane, pupils must be drilled upon the proper attitude the nurse should assume tow^ards the insane upon all occasions. They must be taught much that is scarcely considered in the nursing books. They must be induced to school themselves in habits of self- control. They must be made to comprehend that phi- losophy which teaches how to conquer the perversities of human nature by indirect means rather than by pro- hibition. They must become proficient in overcoming evil notions by the substitution of good ideas in the minds of their patients. They must by practice acquire skill in a difficult art, — the art of leading by clever sug- gestions obstinate human beings whom no hving person could drive. Nurses commencing this form of hospital work should be early impressed with the difficulties and trials before them, as well as the ample rewards awaiting all who finish the course and graduate after two or three years of study and ward work. Their personal ambition no CARE OF THE INSANE and enthusiasm regarding this work should be cultivated through repeated graphic representations of the advan- tages — educational and characterwise — which nurses may expect to derive by following after high ideals in nursing and managing insane patients. The unfolding and interpretation of this art of nurs- ing instruction cannot be entrusted solely to supervisors and principals of training schools. The executive chief of the whole estabhshment, the superintendent, must interest himself deeply and work industriously if he hopes to develop in his hospital wards the right hospital spirit and the better ways of nursing. If humane methods are to prevail in hospitals for the insane, nurses must be allowed to take some risks with bad patients, and this they cannot be expected to do without the approval of the superintendent. They must act for him in such work, and he must be ever ready to support and defend all subordinates who conscientiously and intelligently endeavor to manage the insane with- out restraint or other harsh measures. The outlines of a desperate case and some of the methods employed to change the patient's mental habit will suggest the dangers involved and the necessity for deviating from hospital routine in caring for such cases. A seventeen-year-old girl from the West Indies drifted CARE OF THE INSANE III into a state institution. She had occasional epileptic attacks with some hysterical indications, and suicidal impulses persistently recurred. While the convulsions were infrequent, for days at a time she would appear morose, nervous and irritable. During such spells she sometimes made vicious attacks upon nurses and unless closely watched would endeavor to strangle herself by twisting articles of clothing, twine, or strips of cloth about her neck. She often packed rags, paper and small articles in her mouth, nose and throat, and so stealthy were her movements that nurses in the room with her sometimes became aware of her suicidal at- tempt only when her face became dusky as the result of obstructed respiration. This case gave the doctors and nurses an endless amount of trouble and anxiety. They feared the girl would kill herself unless her hands were restrained by mechanical appHances. But she was so unusually supple she could squirm out of any ordinary restraining appa- ratus. Yet in time they devised a special bed harness from which she could not escape. After several months of such confinement she was removed, by official orders, to another institution where the '^ non-restraint'' system of treating patients had been adopted. The nurse who conducted the transfer said the change was made because at the first institution they ^^ could do 112 CARE OF THE INSANE nothing with the patient." When asked if mechanical restraint had been employed, she replied, ''Yes, she has been allowed out of it only two hours each day." In the second institution this patient remained three or more years, being at no time subjected to mechanical or chem- ical restraint. Such a record was possible only as the result of concerted work by the superintendent, assist- ant physicians and the nurses. Naturally the most difficult part fell to the lot of the nurses. They were given to understand that the case was certain to test ''non-restraint" nursing, and their best efforts were enhsted. The nurse in charge became devotedly in- terested, and her personal attentions to the case repre- sented vigilance personified. She possessed unusual tact, was fertile in devising expedients, and fathomed human motives with facility. She quickly discerned that van- ity was the patient's distinctive characteristic, and this furnished a clue to the proper method of procedure cal- culated to regenerate this uneducated but cunning epi- leptic. The girl was praised and flattered upon all pos- sible occasions, and constant efforts were made to give her pleasure and encourage her self-esteem. All con- spired in a laudable spirit to give her special attention. She was provided with pretty dresses, decorated with ribbons, and scented with perfume. When nurses went out for a day they usually brought her some present CARE OF THE INSANE 113 such as candy, fruit, cheap rings, beads, etc. They secured special articles of food for her and invited her to share their extra lunches and little feasts, and all made a pet of her. The ward physicians aided in these plans by giving her special prominence and compliment- ing her good appearance. They would accept from her reports concerning other patients which had been sug- gested by the nurses. To encourage her self-esteem, nurses often requested her to watch some troublesome patient, and found they could depend upon her good conduct and fidelity when her usefulness was thus magnified. They gave her the use of a drawer with a private lock in the linen room, and permitted her to wear the key on a tape around her neck. They often requested her to keep their small, personal belongings, and never was such confidence mis- placed, while she would pilfer from nurses in other wards without hesitation. She was frequently taken out of doors for special walks, to the storeroom for ward supplies or personal knickknacks and to the greenhouse for flowers. As her general conduct improved, she was taken to the congre- gate dining room for meals and to the weekly dance. On such occasions she was decked out with especial care, and often wore by permission a nurse's watch or other jewelry. To arouse her from her morbid brood- 114 CARE OF THE INSANE ings, the nurse sometimes gave her the ward key and requested her to visit other wards to convey a message or receive a report. This was done at times when the nurse had so little confidence in the patient that a pre- vious arrangement was made with the other nurse to put night locks on outside doors and to watch the patient carefully. Gradually under such influences her despondent periods became less frequent and less pro- longed, and in time she actually enjoyed Hmited parole outside the hospital wards. After several years spent under such friendly and stimulating associations, she was again officially trans- ferred to another institution. Room for acute cases was urgently needed in the hospital, and, mindful of her epileptic infirmity, she was this time taken to an asylum for chronic cases. But the asylum management continued the methods em- ployed in institution No. 2. She was constantly under kind, judicious watch. She was provided with toys, amusing games, attractive pictures, bright-colored orna- ments, etc. As a rule she responded to such pleasant surroundings in a satisfactory manner, but on several occasions while in the last institution she almost suc- ceeded in committing suicide. Eventually, however, her improvement was so pronounced that the state authorities deemed it prudent and justifiable to deport CARE OF THE INSANE] II5 her to her native island, where her brother lived and was to take charge of her. The special attention given this case was costly to the state and burdensome upon officials and nurses, and yet it was money well expended and personal efforts well directed. Of the many nurses who freely gave, to this afflicted child, mind and heart service which riches cannot command, none ever regretted her contribution or failed to reap her reward. The moral effect of such a triumph over serious mental conditions was well worth the state's financial investment for the good it accom- pHshed in the two institutions which faithfully endeav- ored to discharge their moral obligations to a thankless alien. . Officers and employees must be impressed with the paramount importance of gaining the patient's confi- dence and good-will through kind measures and gentle treatment, at and from the time they enter the hospital. Beginning in the right way with new patients is all- important, but unfortunately for nurses as well as pa- tients current rumors of hospital iniquities and popu- lar prejudice against employees in hospitals for the insane are so widely spread and so deeply seated that very many patients enter such institutions with a keen apprehension of ill usage and punishments to come. The science of mental nursing emphasizes the impor- Il6 CARE OF THE INSANE tance of neutralizing as quickly as possible the baneful effects of such painful anticipations. Arguments with distracted individuals will not dispel such enthralHng vagaries. Substitution is the only effectual remedy. The patient's mind must become preoccupied with ideas of an opposite character. He must be favorably im- pressed by persistent kindness. Agreeable surroundings and reassuring observations must serve to crowd his dismal forebodings into the background of his thought and memory. Unless this rational, humane method be adopted, the patient will retain his horrifying convic- tions and possibly reenforce them by unfortunate expe- riences. Under such regrettable conditions, the patient may naturally come to view the ordinary conduct of the nurses in the light of his preconceptions. Atten- tions to himself, prompted by kind motives, may be misunderstood and be resented. Gentle attempts to aid him in undressing and dressing, in bathing or serv- ing food, will be magnified and distorted by his dis- ordered imagination and faulty reasoning into assaults and homicidal designs. Such vagaries he will firmly believe, and his conduct will accord mth them. If he does not completely recover, he will always retain such convictions and subsequently relate them to friends and others as facts. Who could reasonably expect to sooth and quiet a distracted person, or reassure a wor- CARE OF THE INSANE 117 lying and suspicious insane man, by sharp commands, hustling movements, and threats of a dark room or the strait-jacket? And yet such are the means which naturally seem proper for the purpose to the nurses and laymen who are ignorant concerning better meth- ods, or who feel they possess an agency in mechanical restraint with which the obdurate patient can be effec- tually subdued. It is this conscious command of effec- tual physical power held in reserve that destroys the making of a good nurse in hospitals when straps and strait- jackets are allowed. When a nurse is certain that a patient can be humiliated or rendered helpless at her pleasure, by the application of ties, straps or canvas jackets, she will not long tolerate unkind and abusive words from the patient. She will not tax her strength and mental power in attempts to calm the patient's excitement with soothing words. She will not suffi- ciently exert herself to divert the patient's attention. Neither will she bestow upon the confused or distressed patient genuine sympathy, the indulgence and cultiva- tion of which serve important functions in improving the character of the nurse while it is often effectual in awakening the better sense of the patient. When em- ployees make frequent use of strait-jackets on patients that are noisy, destructive to clothing, or violent, they sacrifice their finer sensibilities, their normal compassion Il8 CARE OF THE INSANE for pain and mental torture is rapidly blunted, while their acquired indifference to the humiliation and pun- ishment they inflict upon irresponsible, helpless human beings brutalizes their nature and perverts their char- acter. Ex-employees have been known to boast of their cruel, fiendish treatment of weak but noisy insane patients twenty-five years after they left the hospital service. Mechanical restraint of the insane is so an- tagonistic to the spirit or principle which must pervade all rational schemes for controlling the insane that it should be totally abolished, or teaching ^'non-restraint'' methods to nurses will avail Httle. The possibility of restraint lodged in the mind of the nurse smothers serious efforts to influence the patient by the charm of pity and the power of the intellect. It depends almost wholly upon the superintendent of each institution whether mechanical restraint is used in his hospital wards. The stand he takes upon this important question of management will be under- stood by all his subordinates and influence them in their dealings with the patients. If he is determined that restraint shall not be used, he will caution the whole hospital force of workers upon every convenient occasion. He will show his appreciation when they have managed cases well and repeat optimistic sugges- tions concerning their success if they ever waver in CARE OF THE INSANE II9 their convictions. He should continually remind oj0&- cers and nurses that the secret of ^^non-restraint" — if there be any mystery regarding the question — consists in preventing or avoiding situations where restraint might be thought necessary by those who ap- prove its use. Those who argue that insane patients will take advantage of the milder methods of treat- ment and that an absence of strict discipline will re- sult — a condition which spells riot in their school — little appreciate the power that well-poised, properly taught, expert nurses can exercise over the insane by mental suggestion, calm persuasion and innocent arti- fice. Ward disorders can be more easily prevented by the judicious words of a quiet, self-possessed, gentle- toned nurse than by the threats and stormy commands of a ferocious keeper. A loud-talking patient can be quieted often by a polite request whispered in the ear. Because women nurses exhibit less show of force, avoid threats and stern commands, they manage patients in the male wards with less irritation and fewer outbreaks than occur when male attendants are in charge. For this reason female nurses should be employed in the male wards of hospitals as soon as a sufficient number of well-instructed, sensible women nurses can be ob- tained. Slender, light-weight girls have managed wards for excitable female patients quite as easily as women of I20 CARE OF THE INSANE greater weight and strength because the smaller women had acquired the real art of managing insane patients. To be eminently successful in this work, a nurse ought to be endowed with some capacity for offhand romancing. Persons who cannot conceive of a well-behaved, fairly quiet ward of insane patients, without mentally exalt- ing the idea of discipline, used in its repressive sense, evidently are uninstructed or mistaken as to the char- acter and quaHty of measures most efficient in control- ling the insane. The medical superintendent of every hospital for the insane in the United States would no doubt gladly aboHsh mechanical restraint if he thought his employees could manage the patients without it. But employees never will control the insane by the "non-restraint'' practice until they are taught the proper methods and have been compelled to adopt them, not only in the letter but in the spirit, which is far-reaching. Discharging or even imprisoning a few attendants guilty of serious assaults will not end asylum abuses. Inves- tigations by legislative committees cannot set up and supervise the only competent agency which will reduce to a minimum the hardships and wrongs needlessly in- flicted upon the insane in hospitals. The superintend- ent is the only person in the institution who possesses sufficient authority to adopt the "non-restraint" system of management and to enforce its observance. To sue- CARE OF THE INSANE 121 ceed, he will have to spend much time over the details of difficult cases, as he cannot afford to have the nurses fail, and must therefore convince them of their inherent ability to succeed, and encourage perseverance. Nat- urally, some will succeed much better than others, and those who are doomed to failure through unfavorable temperament or inadequate power of application will voluntarily resign early in their experience. To keep some nurses from carelessness or mistakes will require dehberate watching and frequent aid with suggestion. When the superintendent appreciates their success in controlling irritable and violent cases and bestows mer- ited commendation as they improve with practice, the nurses are greatly helped and stimulated to do even better work. They will often depend upon his sym- pathy and encouragement to withstand the prolonged strain which some hard cases will cause. Dr. Conolly, who succeeded in managing the insane in accordance with '^ non-restraint" ideas, — something which so many other superintendents have deemed im- possible, — devoted a surprising amount of time and personal attention to each trying case in his hospital. He made repeated visits at night, as well as by day, to wards where troublesome patients were worrying the nurses. He thoroughly informed himself of the diffi- culties to be overcome in case after case, and of the 122 CARE OF THE INSANE ability of properly trained nurses to master all possible situations, before he published his sweeping conclusion, viz., that '^all insane patients can be managed without mechanical restraint" and that all superintendents who desire to conduct hospitals for the insane on the *' non- restraint" plan ''will succeed if they are in earnest." Results of so much consequence, both to patients and nurses, should not be sacrificed because officials lack earnest endeavor to pursue the methods by which alone they may be secured. To redeem the ward management of hospitals for the insane from the sway of untaught, rough and unsym- pathetic attendants means physical comforts, mental cheer and hopefulness to afflicted multitudes who are entitled to our compassion. To improve the under- standing and enrich the character of the great body of nurses in these special institutions is a worthy object and one of great promise. Primarily, the occupation of hospital nursing should be given an improved standing. Higher conceptions of its dignity and its educational possibilities should be held by officials and by them in- stilled into the minds of the ward workers. Ideals of devotion, self-sacrifice and humane service should be recounted for their benefit. Then the educational, sci- entific and humanizing acquisitions which will redound to the faithful student and the patient worker in this CARE OF THE INSANE 1 23 field should be more widely understood. They should be taught to regard ward work in the light of laboratory experience in solving interesting and important prob- lems relating to science and humanity. Associated with this work there are some repugnant duties, some trying situations, but such objectionable features of the service can and should be minimized by contrasting them with the personal gains and the unlimited benefits which they bestow upon patients when the nurses are wisely and conscientiously discharging their hospital duties. If one expects to have nurses hold their posi- tions with, such ideals in mind, he must extol the ad- vantages they will receive by pursuing such a course in training until they can read into humble duties the promise of higher things. There is much that can be adduced to prove that the submissive, painstaking nurse will be well repaid for devoted work. Her command of the EngKsh language will be improved by mastering lessons in text-books on nursing and by writing reports and examination papers. She will become well informed upon the laws of hygiene, learn how infectious diseases spread and are suppressed, understand the significance of pulse and temperature variations, — all practical mat- ters, the knowledge of which she can utilize to her per- sonal advantage through her life; or she can turn them to account by taking up private nursing as a career. 124 CARE. OF THE INSANE Graduate nurses, trained in hospitals for the insane where the correct "non-restraint" policy is enforced, meet with the greatest success in private nursing. Be- fore entering the field for family nursing, it is advisable for these graduates to take a supplemental course in some general or special hospital. But, with or without extra or special instruction and experience, their self- command, their readiness to meet the unexpected, their tactful methods with all persons, are accomplishments which they acquired in the hospital for insane and which will continue in evidence and will prove their best recommendation. After years spent with insane persons who have been held in check or stimulated into action and have been again and again turned from hasty or destructive purposes by her calm persistence, inven- tive genius and mental alertness, the nurse has devel- oped her latent mental capacity and force of character, and if normally well endowed will be able to adjust her- self to the temper of ordinary people or the caprice of sick folks without effort or delay. Nervous, peevish invalids are not puzzles to her. If the mood of the patient changes, she alters her mode of approach. If the patient is depressed and disconsolate, she avoids recalling matters concerning which the patient is sensi- tive by ignoring such subjects and promptly finding an opening for some interesting and optimistic suggestions. CARE OF THE INSANE 1 25 If the patient is obsessed by some depressing reflection, the properly educated nurse eschews the words *'Do not," and all requests expressed by a negative phrase, because such phrases revive the unfortunate mental association. She quietly interests the patient's atten- tion in an opposite direction. She should never be at a loss for expedients suitable to serve her purpose. Such expert comprehension of the moods peculiar to invalids can be acquired nowhere else so quickly and so thor- oughly as in the wards of a hospital for the insane where mechanical restraint is never used or thought of. This consummate tact is the natural outgrowth of mental nursing when the nurse is deprived of all means by which to inflict penalties or punishments, and where she and the patients about her know that threats are idle expressions. Dispossessed thus of coercive power, imder all circum- stances she must retain her presence of mind. She will have to appeal to friendly feehngs, be able to interpret intentions rapidly and reach positive conclusions as quickly. She will also have to depend upon novel and fascinating schemes invented at a moment's notice to fit the requirements. She must remain calm when others are excited, must control her temper when tantalized, insulted or defied, and must accustom herself even to receive blows without showing resentment. In this work 126 CARE OF THE INSANE the nurse can be aided by general rules only, because it is impossible to anticipate the exact conditions that will enter into any perplexing situation. No two patients are wholly alike, and the mental aspect of each patient varies with time and circumstances. Then, the per- sonality of the nurses will differ, each from the others, and all these variations in temperament and temper call for modifications in methods of approaching patients. Hence it is that only practice in such surroundings insures perfection in the art. To have acquired such an art means that the nurse who has mastered it has brought into working order all the mental resources with which she was endowed. She will then be fitted to measure her ability with that of any person with whom she may come into association — sane as well as in- sane. It is doubtful if any other established educa- tional course will, in the same length of time, better develop the practical capacity of a student nurse, or better fit her to cope with the struggle incident to her lifework. The same ''non-restraint" kind of mental nursing is excellent practice for character building. It induces habits of self-discipline by necessitating deliberation, self-restraint, serenity under provocation, and the ha- bitual practice of good deeds in return for indifference and possibly evil intentions. To maintain their influ- CARE OF THE INSANE 127 ence over the patients, nurses must be invariably kind. When a nurse considers the misfortune of the insane through compassionate eyes, her humane sentiments are cultivated. Scrutinizing mental wrecks, resulting from degeneracy, dissipation and disease, as nurses must, for some germ of manhood that may respond to the sunny influence of kindness, sympathy and good counsel, enables them to appreciate the better side of humanity in general. Pitying those who suffer from painful delu- sions as truly as though the cause for the anguish ex- perienced were genuine develops depth of feeling and emotions regulated by intelligence. Giving cups of water to thirsty but helpless patients and ministering to their many necessities with kind attention and a cheerful spirit reveals to the true nurse the one certain method by which personal happiness can always be realized. Such are the constant opportunities for exercising benevolent sentiments confronting every nurse in hos- pitals for the insane. If this moral and ethical phase of nursing were pre- sented in the right way and sufficiently often, the major- ity of nurses would respond favorably. From this point of view, nursing in hospitals for the insane calls for high- class work, approaching in many respects the heroic. The superficial impressions of nursing the insane 128 CARE OF THE INSANE which freedom-loving youths and maidens usually ob- tain by entering upon the preliminary courses in train- ing schools are often repugnant, and few who enter the classes continue the work long enough to render intelli- gent service or to discover in its pursuit as an occupation much that is agreeable or satisfactory. Those who remain in the training school long enough to graduate generally do so because of the financial considerations only, and feel little inclination to con- tinue such exacting duties. If prevalent ideas concern- ing this important field of work could be radically changed for the better, if devotion to the service of mental nursing in hospitals commanded the interest and consideration it is entitled to receive when undertaken with intelligence in the right spirit, there might be re- tained permanently in hospitals for the insane an ample corps of serious-minded, faithful nurses who would act in obedience to the high sentiments and unselfish mo- tives befitting this ennobhng occupation. Can such desirable ends be consummated? Can devoted nurses be so attracted to this worthy cause that they will intelligently undertake a lifework in behalf of those, many of whom are incapable of appreciation, and who often resist or blindly attack their best friends and bene- factors? Certainly not through coercive measures or restrictive legislation. Not until promptings to render CARE OF THE INSANE 1 29 unselfish service to insane patients spring from the convictions and high sense of duty of the individual nurses. They cannot be frightened or effectually driven into the mental state that insures the right conduct towards patients any more than nurses can by force compel patients to effectively improve their manners. How to improve and elevate the grade of insane hospital nursing is a problem involving the action and reaction of human nature and the force of cultivated ideals. The work should be presented to nurses in attrac- tive, interesting terms comporting with high social and professional standards. Its importance, its dignity, its self-sacrifice and also its compensations should be ap- preciated and acknowledged in words and deeds by both hospital officials and an interested public. Nurses should be allured to this special field of devotion by a desire to share in the inherent glory which results from serving thankless insane patients for the cause of hu- manity. But this is a very practical age and few young persons are willing to sacrifice a life of commercial and social opportunity even for so high and humane a calhng. As a rule, good nurses cannot be expected to ignore or reject more tempting emoluments offered them for nurs- ing the sane sick in private families or for some less exacting business occupation. Teaching the act of nurs- 130 CARE OF THE INSANE ing the insane in hospitals and inculcating the ethics involved to small classes in scattered institutions are laborious duties devolving upon hospital officials; and when the comparatively meager results are considered in connection with the broader field of hospital require- ments, the necessity for educational centers with a broader foundation and a wider reaching influence, en- thusiastically engaged in this work, is clearly appre- hended. For this end, state commissions would act wisely in establishing schools for high-class instruction in nursing the insane. Some religious or benevolent order that would duly heed the scientific and practical aspects of the work would, if engaged in this line of service, accomplish great good. If a national guild or non-religious society of nurses engaged in caring for insane patients could be formed and maintained with a chapter in each hospital, officered and conducted by the nurses themselves, hav- ing a simple ritual and the literature necessary to keep before them high ideals of nursing and calculated to foster enthusiasm for the work, it is possible that the right ideas and the right spirit could be more widely and more rapidly disseminated. Such an organization should have a central bureau of administration, with proper officers to regulate its work and agents to super- CARE OF THE INSANE 131 vise the work of the chapters. Graded ranks should be established, and promotions from rank to rank should depend upon personal character, length of service and acquired proficiency in the art of managing insane patients. A system of marking for rewards and pro- motion should be entrusted to the chapters, but all reports should require the indorsement of the local hos- pital officials before fihng for subsequent use. To be entirely successful, such a central organization should be started with a substantial foundation, having sufficient funds to manage affairs, to provide insurance for loss of time in sickness, an old-age pension, and medals or gratuities for special meritorious acts. If a monthly compensation could be granted members of the higher circles, it would promote ambition to rise in the order. A scheme of this character would in no way antagonize the local management of hospitals, and would, no doubt, be sanctioned by all superintendents and aided by them, as it would mitigate their responsibility. Its members and agents should avoid criticizing hospital manage- ment except to the officials interested. The order should be animated by that philosophy which inspires efforts through presenting patterns of excellence in nursing the insane. Possibly hospital managers would gladly pro- mote the work by establishing a Hberal scale of wages depending upon the rank attained by the employee. Of 132 CARE OF THE INSANE course, all members should hold and wear, when on duty, badges representing the grade to which they had advanced. This IS a most worthy object, as it is calculated to benefit two greatly neglected classes of human beings which will never diminish in number, — the insane and their custodians. The insane have an acknowledged claim upon our sympathies, while the daily but unher- alded acts of genuine heroism displayed by true nurses in hospitals for the insane deserve some official recogni- tion, and must receive it if the examples of such devotion are to be imitated in sufficient numbers to cover the field of necessity. APPENDIX. After the main section of this book was written friendly critics ^advised the introduction of concrete illustrations — a description of actual cases — which would supply clues to the methods by which the rules and suggestions advanced might be applied. The fol- lowing account is deemed too long for^^ insertion in the theoretical text. One or two episodes in the experi- ence of a patient will serve to illustrate how force and mechanical restraint can be avoided in managing patients, especially manic cases where exhilaration of spirits is associated with flighty and expansive ideas. The case of a man in middle life suffering from attacks of recurrent maniacal excitement may be dted. This patient had passed through several previous attacks, each characterized by such restlessness, abnormal de- grees of self-assertion and unreasonable conduct that hospital restrictions had been necessary. Each time he had been committed to the same hos- pital, where he had established a reputation for cimning, incorrigibility and destructive capacity. With insignifi- cant instnmaents he had accompHshed surprising results through shrewd, persistent efforts. For nights and days in succession he seemed to require no sleep, and re- 133 134 CARE OF THE INSANE peatedly destroyed clothing, furniture and fixtures. Al- ways intent upon escape from the hospital, ever ready with plausible, ingenious explanations for his conduct when interviewed by officials, and remarkably skillful in distorting facts to impeach his attendants, he became the object of their dread and hatred. He never lost his temper, usually joked and laughed when restrained by strait-jackets, and was reported to have once remarked, when able to catch his breath while being subjected to the "water-cure treatment," "Boys, you are on the right track. The devil is in me and you may drown him if you keep on." When subjected to such rigid measures he often expressed satisfaction, saying his was a detective's mission and he was anxious to experience the worst, as he contemplated publishing a book expos- ing insane hospital barbarities. The care of this patient was a burden to the manage- ment, and in time arrangements for his transfer to a similar institution in another state were perfected. A junior assistant physician who at an earlier period had for a time held some official relations with the patient volunteered to conduct the transfer. The patient, by his mental alertness^ endless schemes and good-natured acceptance of the inevitable, had interested this young physician, who had experienced no difficulty in manag- ing him. Through a change in the service, about three months prior to the date of transfer, an older, more ex- perienced hospital physician had assumed entire charge of the ward in which this patient was located. Owing to the progress of the disease, or some other cause, the CARE OF THE INSANE 135 patient's worst propensities developed and trouble with him was of almost daily occurrence. The night before the transfer he planned a campaign, probably an escape, and opened it by barricading the door of his room. When this fact was discovered by the night watch he considered the situation sufficiently grave to notify the physician in charge. The doctor's apprehensions re- garding this patient were such that he hastened to the ward and personally directed efforts to dislodge the maniac. After various milder measures had proved futile, at two o'clock in the morning the doctor pro- cured a crowbar and demolished the heavy door. The following morning at nine o'clock the junior physician and the patient set out for the other hospital, 160 miles distant. The doctor in charge of the hospital they left offered to send any desired number of strong attendants along to insure custody of the patient. When this offer was declined he urged the employment of one or more city policemen. When that proposition was rejected and he realized that no semblance of force was to be employed in the transfer, he predicted disaster to the enterprise. This recognized authority, who as medical chief had previously managed one of New England's most prominent hospitals for the insane during a period of two years, remarked, ''It cannot be done; you will never get the patient into that hospital without help." The patient had in some measure been prepared for this trip. With this object in view, the junior assistant had visited his ward several times, had expressed re- grets that the patient had become involved in so much 136 CARE OF THE INSANE friction with employees and officers, and in low, confi- dential tones had predicted that a time would come when they two could leave the hospital together. When they were finally outside the institution the physician raised the question of their destination. The patient's sense of gratitude upon finding himself so free no doubt prompted the response that he would be wholly guided by his companion's judgment. Whereupon the latter suggested a trip to a distant city, where in the suburbs was located the hospital that had engaged to receive and care for the insane man. By good fortune it hap- pened to be election day in the city which was their destination. The patient's well-known weakness for detective honors supplied a key to the doctor's scheme of procedure and a text for earnest discussion the live- long day. The glittering rewards for that detective skill which could expose crooked political ways were considered and reconsidered. As they journeyed along, newspapers were purchased at every opportunity and their columns were eagerly scanned to discover predic- tions of fraudulent voting and suggestions of bribery. By such devices the patient's attention was kept fully engrossed. They finished their day's railroad trip early in the evening. All voting places were closed, but crowds of expectant men were gathered before public bulletin boards and in hotel offices. After mingling with several small groups in succession, they sought a pubhc house for supper. Later they started out again and without arousing the patient's suspicion the doctor gradually led the way to the outskirts of the city and CARE OF THE INSANE 137 finally discovered the entrance to the hospital. He assumed much surprise upon finding himself so near the good doctor who superintended the institution and im- mediately resolved to call upon him and invited the patient to go along as his friend, assuring him that they would receive a cordial welcome for the night in virtue of his official connection with an institution of the same class. The patient balked. He refused to go into the hos- pital, but stood and listened to the doctor's exhorta- tions, which pointed out the folly of neglecting such an opportunity to exercise his detective ability, such a chance to peer into hospital secrets, and extolled their good fortune in stumbhng into another promising field for investigation just when they had completely failed to make good in connection with poKtical games. Then the patient's long-cherished project of exposing hospital abuses was recalled, and the importance of gaining a wide and varied experience before attempting to formu- late general conclusions was emphatically dwelt upon. The idea that his version of hospital management, or mismanagement, would attract more than local interest if his published observations were Hmited to a single institution was derided. It was admitted that he as- sumed some risk in entering, but to conceal his identity and limit the hazard of being detained as a patient a slight change in his name was suggested. His fam- ily name chanced to be a compound word, and he was advised to use the initial instead of the first two syl- lables and adopt the last word as his surname. For a 138 CARE OF THE INSANE long time they stood before the administration building while such suggestions were hurled at him and his ob- jections were discussed. Apparently nothing the doctor said influenced him. He seemed determined to go no farther. Finally he said, ^'You go in and spend the night with the superintendent. I'll go back to the city and meet you in the morning." The doctor, with a suggestive inflection, answered, "Yes, if you are able to find me to-morrow," and turning about deliberately walked towards the hospital. Before taking the train at the railroad station in the morning, the doctor had purposely slipped out of the patient's sight for a short time apparently wholly in- different regarding further companionship with him. This movement early disarmed any lurking suspicion the patient may have entertained, and through the whole day up to this time he had simply dogged the doctor's footsteps. And now at this critical juncture was a similar ruse going to be effectual? There was great uncertainty, and the doctor was seriously anxious for a time as he advanced along the walk without hesitation or back- ward glances. By the time he had covered fifty feet the mental strain relaxed, as he distinctly heard the patient's peculiar step approaching in his rear. The patient had a round bald head with a full face, a large- sized body, very muscular and well knit; but his legs were abnormally short, much bowed and of unequal length, consequently his footfalls always resounded like an irregular tattoo, so unusual that once heard they CARE OF THE INSANE 139 could never be forgotten. The distance between them gradually lessened and practically closed as they en- tered the institution reception room, where a supervisor was in waiting, and addressed the doctor by name. The doctor immediately introduced the patient as his friend and requested he be shown a quiet room at once, explaining his seeming haste on the ground that they had passed a fatiguing day and that his friend had been unable to sleep the previous night. "What is the pa- tient's name?" asked the supervisor. Immediately he shifted the weight of his body from the short leg, his usual pose, to the longer limb, thus presenting a bolder attitude, and elevating his chin to better typify his sense of self-importance he gravely enunciated the abbre- viated name so recently devised. With a simple good night they separated and, so far as the physician antici- pated, never to meet again. Naturally the physician was gratified with the success of his stratagem; many of his projects having been adopted suddenly to meet unexpected conditions or to gain advantage by follow- ing chance suggestions, he never suffered any conscien- tious scruples concerning the ethics of his conduct, although admitting that as a rule employing decep- tion in committing the insane to hospitals cannot be approved. The circumstances surrounding this case were so un- usual the methods employed seemed justifiable. The patient was not being removed from his own home — from kindred or trusted friends. He was leaving an institution where his presence was deplored and some I40 CARE OF THE INSANE of his experience had been bitter. He was placed in a hospital famed for the consideration shown its pa- tients, and introduced to new associations where preju- dice against him was non-existent. He was fully in- formed respecting the character of the institution which he voluntarily entered, and he was not misinformed re- specting his ability or inability to extricate himself. He was misled in some respects, but he was not the vic- tim of naked falsehoods. When alternative measures are considered, the mercy of the successful plan is obvi- ous. Had this transfer been conducted by policemen, he would have been exposed as a culprit to crowds of people along the way and probably would have been unnecessarily stigmatized by wearing handcuffs. Had hospital attendants been utilized as guards, he would have suffered constant irritation, would have attempted escape or would have offered resistance, and few men were his equal as regards physical strength or power of endurance. Perhaps it would be more interesting, if less impor- tant, l-^ learn how the patient regarded the doctor's proffered friendship. Did he treat the affair as a joke, or did he revolt, nurse his wrath and resolve to be re- venged should opportunity offer? The sequel will suffi- ciently answer such questions, for, curiously enough, they subsequently met and resumed the masquerade. While on a vacation trip two or three years later the assistant physician spent a few days in New York City. The then new post-office building, architecturally con- spicuous in City Hall Park, attracted his attention on CARE OF THE INSANE 141 one occasion. Having ample time to indulge his fancy, he entered and sauntered through its spacious corridors admiring their massive elegance. He thus inspected several stories in succession. Ascending the broad stair- case to the upper floor, he casually glanced upward and beheld, to his great surprise, standing calmly on the edge of the landing, his old patient and companion for a memorable day's travel, whom he had neither seen nor heard from after the hospital door had closed shut be- tween them. With an exclamation of surprise and great interest he advanced to complete the usual form of greeting, but his quondam partner in simulation held himself in reserve. With a mien of the traditional North American Indian he dehberated for a time, and then drawled out, '^I don't know about you. I am in no haste to resume acquaintance with a man who played me such a trick as you did." The doctor expressed re- gret that their past relations were susceptible of such opposite interpretations as his own views and those held by the patient. He begged a reconsideration of the whole affair and gradually compelled the patient to ad- mit the transfer had been made imperative by other parties — that those responsible for the change would have planned the trip without the slightest considera- tion of the patient's comfort or feelings and would have publicly subjected him to humiliation by a conspicu- ous exhibition of poHce or hospital authority. He also acknowledged he was much more kindly treated at the latter hospital and ought not to treasure up resentment against one who voluntarily and without personal profit 142 CARE OF THE INSANE had actually saved him much annoyance, possibly physi- cal suffering, and had favorably changed the drift of his experience. When this debatable point in their previous alhance had been thoroughly exploited, the doctor asked when and how he had left that northern hospital, how he happened to be in New York City, and what he pro- posed to do. Answers to a few such questions enabled the doctor to fully comprehend the situation. The pa- tient had been well treated at the last hospital, but one night, after about six months' residence, he had quietly sUpped out of the building, determined to walk home. It being the autumn season, he readily found employ- ment with farmers along the route, working a few days in each of several places, and finally reached home in good condition with surplus cash in his possession. His mental condition had changed with time, and when he met his relatives he presented the subacute reactionary stage of his mental cycles, and being a bachelor he was welcomed by his brother who lived at the old home- stead. He had remained there more than two years, quiet and agreeable to all. He had undoubtedly made himself useful about the house and in the garden. But now his periodical mental ebullition was in evidence, re- flecting his emotional intoxication. His proHfic fancy, disregarding logical bounds, involved him in chimerical schemes. Again he was in his own imagination a mas- ter detective. He declared he was a secret-service man in the employ of the United States government. He as- serted that serious affairs on the Pacific Coast required CARE OF THE INSANE 143 his immediate attention and presence, and that he must start for California not later than the following morn- ing. He had been disappointed in trying to find the office of the government transportation agent, although a gentleman in the street had directed him to the upper floor of the post-office building. Thus came about this accidental meeting which neither party anticipated or desired. As the history of mental disorder, such as was repre- sented by the patient, concerning both the delusions entertained and the personal conduct, repeats itself, the doctor instantly realized that the patient had relapsed, had surreptitiously left home, and that his relatives must be anxious regarding his whereabouts and his welfare, and that measures to protect him ought to be promptly instituted. The doctor's recollection of the patient's history embraced the fact that a nephew was a New York City business man, and a call upon him was proposed. The patient emphatically refused to have anything to do with his relatives. But at length he so far yielded to continued persuasion that he named the street and number but seemed most unwilling to ven- ture there. Yet an hour's pleading did prevail, and eventually he led the way, only a short walk, to the office of his only brother's son. The young man was agreeably surprised to see his uncle enter his presence, but for a time he regarded the doctor with suspicion, not readily accepting the ex- planation of attending circumstances; being unable to comprehend why a stranger to him should from disin- 144 CARE OF THE INSANE terested motives come there with this man whose ner- vous manner and flighty conversation stamped him as decidedly pecuKar. Soon he ushered his uncle into a private room, and, leaving him there after a long con- versation, he interviewed the doctor. After repeated conferences of that order, and finding that each visitor confirmed the other's statements, and that his own fam- ily history was well known by the doctor, he accepted in good faith the claim that the doctor, knowing the patient, appreciated the condition in which he found him and simply wished to deliver him to his relatives. The young man then expressed his appreciation for the service rendered and drew from his pocket a telegram which read as follows, viz. : *' Reuben has gone on another tear; he ran away from home. Will probably go to New York. If he turns up there have him arrested and confined on the Island imtil I can arrange his commit- ment to the Retreat." The message was from his father, who was a physi- cian, and the son proposed to act upon it literally, and at once, by handing his uncle over to the city police. Such an unpleasant termination to a call which was the result of his solicitation had not been anticipated by the doctor, and he strenuously objected to the plan. Then followed a long discussion upon future manage- ment of the patient. Various expedients were sug- gested, but all met with objections. The nephew would not go with his uncle. He felt he could not leave his business, and admitted he lacked the necessary courage to undertake even temporary management of the case. CARE OF THE INSANE 145 In time the patient was admitted to the conference. The doctor plainly told him their convictions that he ought to go to the hospital for care and treatment. Of course he protested at first, but his opposition to the plan faded as the doctor pointed out the improbability of his success as a poKtical detective and assured him that his earlier conception to reform insane hospitals was a much more promising proposition ; that much of hospital life and methods remained unknown to him; that he ought to witness how a change in hospital man- agement could alter ward conditions and note how changed the life of patients became when the old coer- cive practice was no longer the rule; that he ought to revisit his old hospital haunts and compare present con- ditions with such as he had formerly encountered there; that, with the exception of the informant, every ofhcer in the hospital as he knew it had gone and new men now filled the positions. The patient became so much interested in this suggestion that he offered to return with the doctor. The doctor regretted he could not cut short his vacation to accommodate his old friend, whereupon the patient complacently announced that it would be entirely agreeable to him to remain in New York until the physician's vacation expired. This con- cession on his part could not be favorably entertained. While puzzHng over the difficulties to be met, the doctor had an inspiration and taking the patient aside suggested he go alone to the hospital. The boldness of this pro- posal strongly appealed to his imagination. The doctor elaborated the proposition. He proposed giving a let- 146 CARE OF THE INSANE ter of introduction to the new superintendent, asking him to receive the assistant's old friend and former patient and treat him like a guest until the assistant's return. He finally confided to the patient the contents of the telegram he had just read, showing that the brother and nephew would insist upon his commitment, and that the police would be requested to arrest him if he left their presence; that, once in the hands of the poHce, there would follow court proceedings, temporary jail residence and ultimately a journey to the hospital under the espionage of rough policemen. Why not with this warning and such an opportunity give his family the surprise of their lives — why not checkmate them in the game they were playing! The audacity involved in executing such a counter move was too captivating for him in his peculiar state of mind to resist, and he eagerly responded, ^'I'U do it." The nephew was then informed that all difficulties had been solved and the terms of the capitulation were imparted to him. He regarded the arrangement as decidedly visionary and refused his sanction. The doc- tor defended the plan and assured the nephew that the patient, having given his word of honor, could be de- pended upon to fulfill his agreement. To be upheld as a man of honor before his doubting relative and by the assistant physician of an institution where as he knew his name had usually been regarded as synonymous with perfidy, flattered his vanity, of which he always retained a good measure, especially when in his elated moods, and he became eager to substantiate the doctor's CARE OF THE INSANE^' 147 prediction concerning his reliability. ^'Will you hon- estly do it?" asked the nephew. ''Yes," responded the patient. "The doctor hoaxed me once, but no matter, I'll go anywhere he says, if it is to h — 1." Misgivings still lingered in the nephew's mind. As he started with his uncle for the 42nd Street Station, turning aside he remarked to the doctor, ''What will father think of me if uncle breaks his promise? Now we have him in our power, it doesn't seem sensible to trust him alone." Nevertheless he duly performed his assigned part. He saw his uncle off in the train for Hartford with a through ticket in his hand. Messages and letters were dispatched to the hospital authorities announcing the coming of the patient and requesting his safe custody until relatives could perfect arrange- ments for his continued treatment. This "irrespon- sible" man kept his agreement in every particular. When he left the train he entered a public carriage and ordered the driver to convey him to the Retreat. Upon reaching the institution he hurried into the business office and requested the clerk to pay the hackman and charge the amoimt to him. He then presented his letter of introduction to the new superintendent and was assigned a room in the patients' department, where the assistant found him on his return. For several years he remained at the hospital as a patient, but never afterwards did he attempt to escape. Nor did he become involved in serious difficulties with employees or officers. His relations with the doctor who induced him to return to the hospital from which 148 CARE OF THE INSANE his former deliverance had seemed to him like a tri- umph in the thick of calamities continued most cordial to the end. The revolution in his hospital conduct may be largely credited to the consideration he received and the freedom he enjoyed during this his last sojourn there. Instead of being constantly regarded with the irritating suspicion of tactless keepers, as in former days, he escaped such thralldom by having parole of the premises, or the city, the greater portion of the time. Whereas in previous attacks he had been confined to narrow quarters as a rule, being frequently locked in a strong room to expiate past misdeeds, or to forestall his aggravating pranks, which, it must be confessed, some- times degenerated to the level of malicious mischief, he was now at liberty to work off his abnormal energy in walking about the country. Instead of restrictions in numberless ways which had been his former lot, he was permitted to busy himself in the garden, and for a time he canvassed the city for the sale of some book or kitchen device. Hence he came to look upon the hos- pital as less a prison and more his hotel. CARD INDEX In hospitals for the insane the card index is no doubt generally utilized for convenience of reference in ordinary business matters. But comparatively few institutions, it is believed, keep a card index of all important facts to be found in the case records. Unless such records, already voluminous in some hos- pitals, are made available through a classified card-index system, the vast amount of high-class professional work being done and recorded in the leading institutions, can- not be utihzed for scientific papers and generalization; ends too important to be ignored. If the task of indexing back records seems too formi- dable to be undertaken, certainly current records should be so kept that all essential points could be easily noted in a card index. By providing for each case an index sheet bearing a printed list of all important symptoms of nervous and mental diseases as well as a classification of insanity and vital facts incident to personal histories, the assistant physician can easily check the appropriate terms in such 149 150 CARE OF THE INSANE an index as the history and hospital development of patients become familiar. The checked index on the individual sheets can at convenient intervals be transferred to a card-index sys- tem by office clerks. Blank space on the case-index sheet should be provided upon which may be written features special to any one case as may be required. When individual case port- folios are provided for all patients the index sheet is filed with the other papers, therefore it is advisable to use colored paper for such sheets so identification may cause no delay. When a superintendent attempts to keep control of hospital discipline, the card system would seem to be a necessity. Otherwise many minor troubles entirely escape his attention; a condition which should not be al- lowed if the more serious affairs are to be avoided. For the purpose of keeping posted upon ward friction, cards should be kept in every ward for use in reporting all instances of trouble with a patient. The employees should understand that they must fill out a card promptly under conditions stated on the card, viz. : when a patient escapes, attempts to escape, receives an injury, by acci- dent or otherwise, has to be handled with force, or is secluded. The card should then be given at once to the assistant physician for his signature and he should turn CARE OF THE INSANE 1 51 it over to the superintendent. At his early convenience the superintendent can take the card to the ward and institute a private investigation sufficiently thorough to satisfy himself as to the responsibility of the several parties. He can then make his decisions and write comments on the back of the card and file it under the name of the patient. If complaints of the treatment of patients are made to him in his office, such memoranda at hand will afford him satisfaction and assure the complainant that the patient is not being neglected. By this method a superintendent can keep himself posted upon all the bad history the hospital is making — just the things most essential for him to know. Besides learning at once if the attendant has shown the right spirit in the incident reported and demon- strated good sense in managing the affair, such interviews as must follow each report can be made the occasion for a private lecture to the employee in which the impor- tance of managing the patient with skill instead of through threats and force can be enlarged upon. Even when the trouble is of little consequence, the employees usually will be more thoughtful before getting involved again, as they soon dread the pointed instruction which is their due under such circumstances. When such a reporting system is estabhshed, neglect 152 CARE OF THE INSANE to make a report should never be excused. If a report is withheld by the nurse, the chances are that some patient will remind the superintendent, the first good opportunity, that something occurred which should have been reported. They get so accustomed to his investi- gations that they suspect something has gone wrong if he does not appear soon after troubles occur to quiz the patient and attendant. The admonition, telling what to report, may be printed in small type across one end of the cards. If a superintendent desires to aid his medical staff in acquiring a thorough knowledge of psychiatry, and make the study interesting, he can promote that object by providing and maintaining a card index of the litera- ture of insanity as found in standard works on the sub- ject, and in current periodicals in English, German and French. Where the daily clinic is practiced, and where the cases are carefully analyzed, such an index will enable the whole faculty to obtain and utilize a broad knowledge of insanity. For this purpose the cards should not be used for quotations so much as for a concise typewritten statement in English of the writer's claim or argument, the point made, or the fact stated. The aim should be to epitomize without losing the writer's point of view or misstating his conclusions. Good judgment and discre- tion must be exercised to avoid putting second-hand and CARE OF THE INSANE 153 worthless statements on the cards. Borrowed ideas and restatements, of no scientific or controversial worth, should be ignored. Single cards should carry single ideas only. When authors bring together different subjects or different phases of one subject, the several items should each have its card to be filed in its appropriate place. Otherwise, one searching for information on a given point might be unable to find the correct card. When the information to be indexed is of uncertain bearing or of doubtful apphcation, duphcate cards can be made, each filed in separate sections under the right guide card. In order to file cards so that each one is quickly avail- able as occasion may desire, a comprehensive scheme for fifing must be elaborated, and a copy kept at hand to aid in phrasing the card as well as in fifing it. In the card drawers a word must serve as a guide, and this word should be kept in mind when the abridged card content is dictated or written. The subject of Insanity should be divided into great divisions such as historical, etiology, symptomatology, diagnosis, prophylaxis, pathology, treatment, medico legal, etc. Each division should be divided into sub- divisions, and subdivisions into heads, and heads into subheads, so the guide cards will embrace all conceivable 154 CARE OF THE INSANE points upon which information concerning insanity may be foimd. Under the several major divisions, heads and subheads may be duplicated. Every physician can keep a card index of his reading, and, if that is not extensive, a simple arrangement of cards may answer. But hospitals for the insane ought to have a complete summary of the literature upon insanity, and in order to make it thoroughly practical a very complete system of guide cards should be formu- lated in advance. A form should be printed on each card to assist in filing and in sorting if accidentally mixed. The department or division should stand out conspicu- ously. The author's full name should always occupy the same position on the card. The date of the publi- cation, as well as the title and page, should be clearly stated. If a journal, the name, year, number and page should be given. As duplicate cards could be filled in at comparatively little additional cost, it would seem advis- able for the several hospitals in a state, or from a wider district even, to combine in the preparation of such an index. There is nothing chimerical in this proposition for a broad card system covering the whole field of hterature on insanity. Indeed, such a card system pertaining to tuberculosis has been devised and brought down to date by an eminent specialist,* who has managed a private * Dr. Karl von Ruck, Asheville, N. C. CARE OF THE INSANE 155 sanitorium and attended to much outside business while perfecting such an index, which now has about 13,000 guide cards. The owner has either signified what the contents of the cards should be, or, when assistants have been en- gaged in making cards, he has inspected each one before it was filed. DUE DATE rla£ i 7 fO^i M lyy*! 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