CHAPTER VI

THE DEVELOPMENT OF THE PSYCHOPATHIC HOSPITAL

As has already been shown, the modern hospital treatment of mental diseases in this country is a development which represents the progress of nearly two centuries. Satisfactory as this has been in many respects, it nevertheless leaves much to be desired. All indications point to much greater accomplishments in the future. We are emerging from an era of custodial care and entering one of prevention, scientific investigation, and highly specialized treatment along entirely different lines. The interest of the public has been aroused in a subject which has heretofore been one to be avoided by common consent. Mental hygiene societies are no longer viewed with suspicion and curiosity. We are approaching a time when mental diseases can be dealt with, as other conditions are, without prejudice or unjust discrimination. Psychiatric wards promise to become integral parts of a completed medical organization. Psychopathic hospitals will soon be found in all of our great centers of population. The outlook for specialized institutes for purely research purposes, unfortunately, is not so encouraging at this time.

At last there is some evidence of progress in the teaching of psychiatry in medical schools, hospitals and clinics, although only a beginning has been made as yet. More noteworthy advances have been made in other countries. The appointment of Heinroth as a professor of psychiatry at Leipsic in 1811 promised developments which did not materialize to any great extent for many years. According to Sibbald,[33] psychiatric wards or clinics were established at Würzburg in 1833, Jena in 1848, Vienna in 1853, Berlin in 1865 and at Göttingen in 1866. Scholz made provision for observation wards in a general hospital in Bremen in 1875. Fürstner opened a psychiatric clinic at Heidelberg in 1878. Hitzig accomplished the same thing at Halle in 1891 and Siemerling at Kiel in 1901. The inception of the modern psychiatric clinic has generally been attributed to Griesinger.[34] In his preface to volume one of the "Archiv für Psychiatrie und Nervenkrankheiten" in 1868 he advocated the establishment of small hospitals in cities for the intensive treatment of acute and recoverable mental cases. He recommended a large staff of physicians and accommodation for from sixty to eighty patients, according to the needs of the community, but not to exceed one hundred and fifty under any circumstances. "In close connection with the organization of such institutions there is a crying need and a new, most important interest—the question of psychiatrical instruction. This is absolutely indispensable." This he proposed to accomplish by establishing a highly specialized clinic to be maintained largely by the teaching staff of a university. Griesinger's ideas were eventually carried out in full by Ziehen in Berlin, Sommer in Giessen and Bleuler in Zurich. Perhaps nothing has had more to do with the development of psychopathic hospitals in the United States than the well-known clinic established by Kraepelin at Munich in 1905. It occupies a three-story building accommodating one hundred patients and cares for between fifteen hundred and two thousand cases annually. Hydrotherapeutic and electrical treatments are used extensively. A certain number of beds are reserved for research purposes. Psychological studies receive a great deal of attention. The out-patient department is a prominent feature. The teaching of psychiatry is one of the important purposes of the clinic. Kraepelin's methods have been followed rather closely here. The remarks made by Pliny Earle[35] in 1867 were almost prophetic in character. "Carbon agglomerated is charcoal, carbon crystallized is diamond. What charcoal is to the diamond, such, I believe, is the psychopathic hospital of the present compared with the psychopathic hospital of the future.... When the defects which I have mentioned shall have been thoroughly remedied by a comprehensive curriculum, a complete organization, a perfect systematization, an efficient administration, the charcoal now just ready to begin the process of crystallization will have become the diamond and the world will possess the psychopathic hospital of the future."

Psychiatric research was inaugurated in this country by the establishment of the Pathological Institute of the New York State Hospitals in New York City in 1896. Its original field of investigation was limited to the laboratory. The name was changed to "Psychiatric Institute" on the appointment of Dr. Adolf Meyer as director in 1902 and the establishment was removed to Wards Island, where it was provided with clinical facilities by the Manhattan State Hospital. It thus became the precursor of the psychiatric clinic movement in America. The observation wards for the examination and commitment of mental cases, at the Philadelphia Hospital (1890) and at Bellevue in New York City were probably the first of the kind in this country. In 1902 the first psychopathic wards connected with a general hospital were opened by the Albany Hospital. Pavilion F, as it was designated, admitted 3,132 patients during its first twelve and one-half years. These included persons awaiting examination and commitment, voluntary patients and cases of delirium, stupor, etc., transferred from other wards of the hospital. Of 1,038 cases admitted during a period of six years, only 17.6 per cent were committed to state hospitals. In a total of 1,855 cases, twenty-five per cent were found to be suffering from some form of alcoholism and twenty-six per cent from chronic mental conditions, while thirty-five per cent were cases of the acute and recoverable class. About fourteen per cent were psychoses associated with renal conditions, neurasthenia, hysteria, tuberculosis or traumatism.

The Psychopathic Hospital at the University of Michigan, the first of its kind on this continent, was established at Ann Arbor in 1906 as a direct result of the activities of Dr. William J. Herdman. The objects and purposes of the hospital were shown by the provision of the legislature for the appointment of "an experienced investigator in clinical psychiatry, who shall be placed in charge of the psychopathic ward, whose duty it shall be to conduct the clinical and pathological investigations therein; to direct the treatment of such patients as are inmates of the psychopathic ward; to guide and direct the work of clinical and pathological research in the several asylums of the state, and to instruct the students of the State University in diseases of the mind." It was thus an integral part of the hospital of the University of Michigan but fully coordinated with the state institutions. A subsequent act of the legislature changed its status to that of a "State hospital, specially equipped and administered for the care, observation and treatment of insanity and for persons who are afflicted mentally but are not insane." It also provided that a clinical pathological laboratory should be maintained for the benefit of the state hospitals. During a period of eleven years it admitted an average of 168.82 patients per year. Twenty-four per cent of these were voluntary cases. The psychoses represented were: manic-depressive insanity, twenty-four per cent; dementia praecox, seventeen per cent; paranoid conditions, two per cent; hysteria, seven per cent; psychopathic personality, two per cent; alcoholic psychoses, four per cent; morphine intoxication, one per cent; imbecility, two per cent; general paralysis, eight per cent; cerebral syphilis, one per cent; epilepsy, two per cent; senile psychoses, one per cent; cerebral arteriosclerosis, three per cent; unclassified conditions, five per cent; and not insane, two per cent. Seventy-four per cent of all the cases admitted were discharged after a residence of three months or less and eighty-two per cent after a residence of four months or less. Fourteen and eight-tenths per cent of all cases were discharged as recovered and 32.7 per cent as improved. Owing to the fact that it has only sixty-two beds at its disposal, the number of admissions is necessarily limited and cases are carefully selected.

The Psychopathic Hospital in Boston, the first institution of the kind established in this country as a department of a state hospital (The Psychopathic Department of the Boston State Hospital), was opened for the reception of patients in 1912. The purposes of the institution were very clearly shown by the Twelfth Annual Report of the Massachusetts State Board of Insanity (1910):—"The psychopathic hospital should receive all classes of mental patients for first care, examination and observation, and provide short, intensive treatment of incipient, acute and curable insanity. Its capacity should be small, not exceeding such requirement. An adequate staff of physicians, investigators and trained workers in every department should provide as high a standard of efficiency as that of the best general and special hospitals, or that in any field of medical science. Ample facilities should be available for the treatment of mental and nervous conditions, the clinical study of patients on the wards, and scientific investigation in well-equipped laboratories, with a view to prevention and cure of mental disease and addition to the knowledge of insanity and associated problems. Clinical instruction should be given to medical students, the future family physicians, who would thus be taught to recognize and treat mental disease in its earliest stages, when curative measures avail most. Such a hospital, therefore, should be accessible to medical schools, other hospitals, clinics and laboratories. It should be a center of education and training of physicians, nurses, investigators, and special workers in this and allied fields of work. Its out-patient department should afford free consultation to the poor, and such advice and medical treatment as would, with the aid of district nursing, promote the home care of mental patients. Its social workers should facilitate early discharge and after care of patients, and investigate their previous history, habits, home and working conditions and environment, heredity and other causes of insanity, and endeavor to apply corrective and preventive measures."

The building has a capacity of one hundred and ten beds. The institution may be said to differ from other psychopathic hospitals in being an establishment essentially of the temporary care type, not designed primarily either for the reception or for the care and custody of obviously committable cases, but rather for the observation and treatment of incipient mental disorders as well as psychopathic conditions not properly coming within the scope of the state hospitals. It has been as a rule the policy of the court to commit directly to other institutions for the insane all cases showing clearly the necessity of an extended hospital residence. The fact that only forty per cent of the temporary care cases have been committed shows that a preliminary period of observation before these cases are definitely disposed of is unquestionably warranted. The legal status of cases admitted may be described as follows:—1. Temporary care (not to exceed ten days); 2. Boston Police cases (Persons suffering from delirium, mania, mental confusion, delusions or hallucinations, or who come under the care or protection of the police); 3. Observation cases (for a period of thirty-five days, pending commitment); 4. Cases pending examination and hearing; 5. Emergency commitments (not more than five days); 6. Voluntary admissions; 7. Cases held under complaint or indictment.

An analysis of the work done by the Psychopathic Department from 1912 to 1920 shows a total of 14,922 admissions to the wards,—an average of 1,865 per year. Of these, 59.77 per cent were temporary care (10 day) cases, 18.56 per cent "Boston Police" cases, 1.38 per cent observation cases (thirty-five days), .50 per cent emergency cases, .61 per cent committed "pending examination and hearing," 1.02 per cent under complaint or indictment and 16.96 per cent were voluntary cases. The entire temporary care group, including all of the above classes except the voluntary and criminal cases, constituted 81.34 per cent of the admissions. It is interesting to note that the principal psychoses represented by the cases coming into the hands of the Boston Police are dementia praecox, alcoholic psychoses and mental deficiency. The number of emergency cases is very small, as is the number committed by courts for observation. The number of voluntary admissions, an average of 316 per year, constituting 16.96 per cent of the total, is very significant as showing the response to be expected from the public to an opportunity for hospital treatment without the formality of any legal procedure. Of the 14,922 cases admitted between 1912 and 1920, 38.45 per cent were subsequently committed as insane and 3,797, or 25.44 per cent, were returned to the community as not requiring further hospital care or treatment.

It has been shown that the special field covered by the Boston Psychopathic Hospital consists of temporary care cases. The principal psychoses represented by 12,252 admissions of that class were as follows: alcoholic psychoses, 9.25 per cent; dementia praecox, 25.0 per cent; senile psychoses, 3.16 per cent; general paresis, 6.06 per cent; manic-depressive psychoses, 10.14 per cent; arteriosclerosis, 3.23 per cent; epilepsy, 1.85 per cent; and without psychoses, 20.63 per cent.

This latter class (without psychosis) is looked upon by some as constituting the most important field of a psychopathic hospital. It is exceedingly interesting to note the conditions which bring such individuals to the institution. An analysis of 1,430 cases shows the principal mental types represented to be as follows:—mental deficiency, thirty-four per cent; psychopathic personality, 15.17 per cent; hysteria, neurasthenia and other psychoneuroses, 11.2 per cent; epilepsy, 8.04 per cent; alcoholism, 6.08 per cent; conduct disorders, 4.2 per cent; syphilis, 2.03 per cent; organic brain diseases, 1.68 per cent; neurosyphilis, 1.26 per cent; drug addictions, 1.4 per cent; somatic conditions, 1.19 per cent, etc.

No less interesting and instructive is a study of the voluntary cases. An analysis of 1,807 admissions of this type shows the following distribution of psychoses: alcoholic psychoses, 5.64 per cent; dementia praecox, 18.43 per cent; manic-depressive, 6.81 per cent; involution melancholia, .99 per cent; senile psychoses, 1.11 per cent; general paresis, 7.9 per cent; epilepsy, 1.05 per cent; psychoneuroses, 3.59 per cent; and without psychosis, 34.64 per cent.

The work of the out-patient service includes in a general way the study of cases referred to that department from the wards of the hospital or by its social service staff; cases referred by courts, schools, social agencies, and other institutions, as well as those sent by practicing physicians and individuals coming on their own initiative. The response on the part of the public to the facilities offered by the out-patient department is shown by the fact that 9,273 new cases were reported during a seven-year period, an average of 1,324.7 per year. Fifty-seven and six hundredths per cent of these cases were adults, 17.8 per cent were classified as adolescents, 24.25 per cent as children and .89 per cent as infants. The source of origin of these cases is exceedingly interesting. Four and eighty-seven hundredths per cent were referred to the out-patient service by courts; 4.65 per cent, by schools; 11.77 per cent, by hospitals; 9.77 per cent, by physicians; and 3.55 per cent, by individuals. Fifteen and five tenths per cent came from the wards of the Psychopathic Hospital; 9.96 per cent, from the social service department and 13.3 per cent came on their own initiative. The question as to why these cases are sent to an institution of the psychopathic hospital type can now be answered. Fourteen and fifty-two hundredths per cent were examined solely for the purpose of determining the existence of probable mental diseases and 21.88 per cent on account of suspected mental defects. Four and fifty-two hundredths per cent were sex offenders. In 8.64 per cent the only question at issue was the possibility of a psychoneurosis and in 7.97 per cent the purpose of the examination was to ascertain whether or not syphilis was present. The diagnoses show the nature of the cases encountered in an out-patient mental clinic. Four and eighteen hundredths per cent were cases of dementia praecox; 1.7 per cent of alcoholism; 2.26 per cent of alcoholic psychoses; 2.39 per cent of epilepsy; 15.72 per cent of mental deficiency; 9.0 per cent of psychoneuroses; 2.14 per cent of manic-depressive insanity; 2.09 per cent of psychopathic personality; 1.21 per cent of general paresis; and 2.94 per cent were unclassified. Two and thirty-two hundredths per cent were diagnosed as suffering from syphilis in some form and 6.27 per cent were either delinquent, defective, subnormal, retarded or distinctly feebleminded. In 3.76 per cent no disease was found, either mental or physical. The great bulk of these cases were diagnosed either as mental deficiency, psychopathic personality or epilepsy. The ultimate disposition of 2,741 cases, covering a period of two years, serves as an index of the practical operation of such a department. In 42.03 per cent of these cases no care or observation other than that of the out-patient department was required. In 1.69 per cent of the cases commitment was recommended to hospitals for mental diseases, in 7.15 per cent, to schools for the feebleminded and in .11 per cent, to penal institutions. General or psychopathic hospital care was recommended in 11.31 per cent. In 2.74 per cent of the cases a report was made to courts; in 1.61 per cent, to schools; in 18.75 per cent, to social agencies; and in 1.13 per cent, to physicians.

The functions of the social service department in a general way may be summarized as follows:—1. The after care and supervision of patients at home; 2. Advice to families of patients in regard to their cases; 3. Advice given other members of the family; 4. Financial relief; 5. Reference to other social agencies or institutions; 6. Information obtained for case histories; 7. Inquiries relative to home conditions when discharge of a patient is under consideration, etc. The routine operation of the department is well illustrated by the annual report of the Boston State Hospital for 1920. The number under social service supervision during the year was 428. Of these, 278 were new cases. Thirty-two and thirty-seven hundredths per cent were referred by the out-patient physicians; 59.71 per cent by the ward service; 7.19 per cent by other social agencies; and .73 per cent were brought by relatives or friends. The principal reasons for their reference to the social service workers were shown as follows:—For medical history, 50.36 per cent; assistance in securing employment, 9.35 per cent; financial aid, 3.6 per cent; supervision, 7.2 per cent; advice, 19.42 per cent; convalescent care, 2.87 per cent; home care, 2.87 per cent, etc. An analysis of the cases under supervision shows the principal psychoses represented to be as follows:—Arteriosclerosis, 1.8 per cent; general paresis, 4.68 per cent; alcoholic psychoses, 1.8 per cent; manic-depressive psychoses, 4.68 per cent; dementia praecox, 16.55 per cent; paranoid conditions, 4.31 per cent; psychoneuroses, 9.35 per cent; undiagnosed psychoses, 6.84 per cent; and without psychoses, 44.24 per cent. This latter group was made up mostly of psychopathic personalities (28.45 per cent) and mental deficiency (26.29 per cent). The purely social problems presenting themselves in connection with these cases were reported as follows:—Mental disease, 75.54 per cent; physical disease, 2.16 per cent; poverty, 2.88 per cent; criminality, 3.24 per cent; juvenile delinquency, 2.52 per cent; sex offenses, 2.16 per cent; alcoholism, 2.16 per cent; family dissension, 6.12 per cent; ignorance, 2.52 per cent; and bad environment, .36 per cent. In addition to this, 299 discharged soldiers and 543 out-patient cases were reported as being under the supervision of the department, as well as 532 special cases studied in connection with the investigation of syphilis.

The Psychopathic Hospital in Boston started on a new chapter in its history on December 1, 1920, at which time it was formally separated from the Boston State Hospital and became a separate institution under the direction of Dr. C. Macfie Campbell.

The Phipps Psychiatric Clinic at the Johns Hopkins Hospital in Baltimore was established in 1913. An integral part of a large general hospital and intimately associated with a medical school, it conforms rather closely to the plan of the German psychiatric clinics. A study of its activities shows that during a period of five years (ending January 31, 1918) the admission rate averaged 403.8 per year. Fourteen and three-tenths per cent of the cases were diagnosed as dementia praecox or schizophrenic reaction and 13.7 per cent conform apparently to the classification of manic-depressive psychoses. Ten and five-tenths per cent were diagnosed as neuroses or psychoneuroses; 6.1 per cent as general paresis; fifteen per cent as agitated depressions; 2.3 per cent as alcoholic psychoses; and 6.1 per cent as constitutional inferiority or constitutional psychopathic states. Seven and nine-tenths per cent were cases of anxiety neuroses, agitated depressions or anxiety psychoses; 2.3 per cent were paranoic states or reactions; 3.5 per cent were cases of alcoholism, and 3.7 per cent of drug habits. The dispensary service of the Phipps Clinic has reported an average of 565 cases per year, representing a total of 2,260.5 visits annually.

The work of Drs. Meyer, Hoch and Kirby at the Psychiatric Institute, of Dr. Barrett at the Psychopathic Hospital at the University of Michigan, of Dr. Southard at the Psychopathic Department of the Boston State Hospital, and that of Drs. Meyer and Campbell at the Phipps Psychiatric Clinic in Baltimore has brought the subject of psychopathic hospitals very prominently before the public. Various other establishments of a similar nature have been planned and some are in process of construction, or already in operation. The State Psychopathic Institute at Chicago and the Psychopathic Hospital of the University of Iowa should be mentioned in this connection. Psychopathic hospitals have been planned for New York City and one is to be built by the State of California. The legislature of Colorado has already made an appropriation of $350,000 for the establishment of an institution of this type in the city of Denver.

The work already done in this field shows quite conclusively that general hospital methods are not inconsistent with the developments of modern psychiatric progress. The large percentage of voluntary cases received and the number of persons consulting the physicians in the out-patient departments shows an unexpected demand on the part of the public for institutions of a new type. As Dr. Adolf Meyer[36] has pointed out, "Our organized system for the care of mental disorder is in many respects forbidding. It throws together all kinds of diseases, and shocks in that way the already sensitive patient who fears the worst for himself or herself. It comes at once with an outspoken declaration of insanity in the very commitment to a hospital, an expression which carries a humiliation to the patient and adds insult to injury. It often means carrying the patient off to a remote asylum which is too widely supposed to have the inscription, 'Leave hope behind all ye that enter here.' Helpfulness rather than coercion must take the place of all this." What the psychiatric clinic may be expected to accomplish in remedying this difficulty was summarized by Dr. Meyer[37] in the following words:—"It is eminently necessary to get model institutions in which medical students and physicians can learn how to deal with the many problems of the disorders of the organ of behaviour from their inceptions into all their ramifications. The clinic must do the work for at least one limited district, with its out-patient and social service and consultation department, and with its hospital wards. Everything must be done to make help in mental disorders more acceptable and convincingly helpful. More patients must learn to look to it for help and the organization must be so as to give the patient and the physician and the public at large a conception very different from that to-day associated with insanity. It is not so much the issue of more help to the curable, but the issue of more work near where the troubles begin, and work against that which breeds trouble. For this we must learn to put the chief weight on hospitals and organizations for natural districts for intensive work rather than upon the mere economy of large hospitals far away from where the troubles develop."

Southard has raised the question as to the correct designation of institutions of the psychopathic hospital type:—"A word is again necessary as to the meaning of the term 'psychopathic hospital.' For various reasons the term has become so attractive in propaganda that a comparatively large number of institutions of whatever scope have been founded or recommended to receive the term 'psychopathic hospital,' 'institute,' 'department' or 'ward.' Thus there is developing a tendency in state hospitals to denominate the receiving ward 'psychopathic.' There can be no advantage in this designation other than that of calling old ideas by new names. The idea of the receiving ward for committed cases destined to receive the ordinary probate court group of cases is not altered or improved in any manner by the designation 'psychopathic.' The best opinion seems to be that a psychopathic hospital or institute shall be an institution in which all types of mental cases, from the probate court group on the one hand up to the most dubious and difficult cases of mental disorder on the other, may be examined; but if an institution is primarily or chiefly concerned with patients of the medicolegal, committable or custodial group, to serve merely as a vestibule through which committed cases pass, such an institution has by no means the broad scope which the very general term 'psychopathic' implies. The institution is not a modified or sublimated form of receiving ward for a great district hospital."

There is, of course, no reason why the reception service of an ordinary state hospital should be spoken of as constituting a psychopathic ward. This accomplishes nothing more, perhaps, than to raise some question as to what the functions of the rest of the institution may be. The designation psychopathic hospital has been rather loosely used and is, as Southard has definitely shown, of American origin. It has been applied somewhat indiscriminately from time to time to practically every form of activity related to the care and treatment of mental diseases outside of the generally recognized state hospital field. These may be summarized as follows:—

1. Detention wards, pavilions, etc. Intended for no purpose other than the custody of the "insane" pending commitment.

2. Psychiatric wards of general hospitals—such as Pavilion F in Albany. There would appear to be no reason for the use of the word psychopathic in such cases, the term psychiatric being much more clearly applicable.

3. Institutes designed primarily for research only or for research and instruction, with or without clinical facilities.

4. Psychopathic hospitals. Independent units or integral parts of a general hospital—with or without facilities for research and instruction. Designed exclusively for mental cases, without regard to legal status, whether committed or voluntary, their detailed examination and careful observation with intensive treatment in the wards for limited periods when indicated, or their supervision and direction in out-patient departments, serving also in some instances as receiving and distributing centers supplying other institutions.

Owing to their limited size, the necessity of treating large numbers in a short space of time, and the fact that institutional care is already amply provided for in the existing state hospitals, the obvious field of the psychopathic hospital is primarily the acute and recoverable psychoses and the milder forms of mental disorder which may or may not require a residence in the wards. Only a thorough examination and a brief period of observation can determine whether or not that is needed. The question at issue is largely that of determining the necessity of a more or less indefinite committed status. These problems arise particularly in dealing with the so-called psychogenic disorders and the psychopathic states—hysteria, neurasthenia, psychasthenia, the psychoneuroses in general and the episodes which characterize the psychopathic personalities. Traumatic psychoses often come into consideration, as well as cases of cerebrospinal syphilis, toxic conditions, drug addictions, the psychoses of infection and exhaustion, and above all, of course, manic-depressive insanity and incipient forms of dementia praecox. Many of these cases require only a brief hospital treatment and are able in a short time to return to home surroundings and resume their former occupations. Often a contact with the chronic and custodial classes is not only without advantage but actually detrimental. The psychopathic hospitals thus exercise a sort of clearing house function and return to the community many patients who otherwise would be subjected to the stigma, if there is one, of a legal commitment. While questions relating to the public health cannot be analyzed in terms of dollars and cents, the saving to the state which is made by substituting a short period of supervision and treatment, for a protracted residence in an institution of the custodial class amounts to millions. In view of the difficulties encountered in obtaining adequate appropriations for the proper maintenance of the enormous population now housed in our state hospitals, this is a factor which cannot be disregarded.