THE SOCIOLOGIC ASPECT IN THE TREATMENT OF THE INSANE BY DR. HUBERT WORK Secretary of the Interior, Washington I have occupied a semi-detached relation to the active medical profession for several years but looking back upon it, possibly I see a different picture than those who are every day in the midst of it. However, my contact of twenty years with the mentally sick, and association with superintendents of hospitals for the care of those requiring seclusion from the world, made your invitation to meet with you, grateful. Ten years ago, I served as the president of a society with a membership of nearly a thousand American and Canadian physicians who, I am proud to say, have developed psychiatry as we know it today, and with this evolution of a new science they have matured a hospitalization procedure that is recognized as a marker in the formative scheme of civilization. I see here men who have held honorable place in this achievement, who continue active in working over a by-product of human economic waste and who are incidentally perfecting the only unrestricted general management of the sick, known among hospitals. The general hospital, as we know it, is misnamed. All of the contagious diseases are excluded from them and many of the infectious also. There are many exclusive hospitals, admitting a special disease only and incidentally doing splendid service. There are a few State general hospitals and more State aided hospitals, but they do not admit mental patients. But a deranged mind, the sure symptom of physical illness, will open the doors of a psychiatric hospital to a person sick from any cause. Two years ago I was present at the public opening of two new units. of a State hospital in an Atlantic Coast State. This institution was a hundred years old. Its equipment twenty years ago was all custodial. Each patient was provided with a mechanical restraint of some device. Today it has modern laboratories, pathologic and dietetic; does minor and major surgery; the most advanced surgery is done in that old-time asylum. A ward is set apart for post-operative goitre patients, another for abdominal resections, while straight jackets and cribs have disappeared. It is not a far cry, Governor, from the present day State hospital of restricted admittance to the State general hospital, admitting patients with mental symptoms which may be too slight to compel seclusion but indicating a condition remediable in one of your own splendidly managed State hospitals for the insane, which are now more nearly general hospitals in conduct than many of those so designated. Through the medical activities of state administration lies the route to a Governor's greatest usefulness. The only lasting service a chief executive can render to a state or nation is that which benefits a constituency. The only thing in this world worth while is people, and of most vital concern to them are their health and taxes. The neglect of the former multiplies the latter in the aggregate and also depreciates the individual's earning ability. It is a travesty on justice; on the theories of a State government's responsibilities, and to the present day ideals of what should constitute human relations, that almshouses, jails and county farms continue to house those whose only offence is mental sickness. There can be no sympathetic relation between penal institutions and hospitals. There is so much more to the care of the insane than housing and feeding. I had to come from the wild West to the cultured East to learn that the distinction is not always recognized by the public and that the insane are often legally held in institutions that do not contemplate their treatment. I cannot know your internal problems and would not weigh them, but I am discussing a problem of national application, in which Maryland interested. is, of course, The list of Maryland men is long and noted who pioneered, laid the foundation and built up the structure of sane treatment of the insane. Insanity is probably as old as people. It is certainly as old as history but it remained for our generation to recognize it as symptomatic; locate its causes; appraise its relations to somatic conditions and meet its vagaries of mind with balanced minds, having scientific background; not opposing its physical excitement with strong-arm resistance or lethal medication, but removing the cause of symptoms, sources of irritating conflict; modifying environment, until nature again adapts the patient to social contact. Out of impossible and unwittingly brutal State care of the insane, have come methods of their care and treatment that have reversed the public attitude toward them. Twenty-five years ago, relatives of the insane saw them being taken to an asylum with breaking hearts, often praying that they might not long survive, a petition frequently answered. Now friends cheerfully inquire "how soon they may come home." I am more proud to have been enlisted with other men of my time in this service, than in any other of my career. A lay question having human relations, requiring scientific solution, is always inviting to a physician. I know a thousand American physicians who can answer affirmatively the question Canst thou not minister to a mind diseased From the one fact that the insane become socially difficult or impossible, compelling their seclusion, has developed the modern psychiatric hospital, and fortunately these hospitals were at first publicly supported. The private hospital is of modern conception and a luxury for the well-to-do, but the State hospital is a responsibility of State government and albeit most expensive to taxpayers. Private capital or corporate investment could not be interested in mental hospitals on a scale commensurate with growing necessities. The State must continue this eleemosynary paternalism because of its magnitude and expand its facilities for the additional reason that the State in defence of its exchequer must restrict demands upon it for lifelong care of insane, by promptly salvaging from its wrecked citizens those who may be restored. Aid in recovery of the insane must be prompt to be effective. Delay makes it of little avail. The vast majority of recoveries occur in the first year. Years ago there were many "asylum-made lunatics"; today not so many. By this is meant that admittance was delayed through lack of understanding the importance of early treatment, and that patients were often detained in hospitals past the time when the best treatment would have been home environment. The lack of adequate room for prompt admittance, quite disregarding the humane aspect, is most unfortunate, computed in dollars, for it contributes to the economic loss of the patient's earning capacity and entails cost for his keep as well. State administrations will realize that their largest single expenditure can be held down by providing adequate room for observing and treating developing psychoses, early. Precisely as the suspected typhoid is put to bed or the influenza subject kept there to avoid complications, invalidism or death. State hospitals for mental derelicts should be regarded much as State universities are. Both are intellectual institutions, the one for the formative treatment of the mind, the other for its repair; the one for preparing people to do the State's work; the other for reconstruction of those who have broken and are no longer competent; the one is a voluntary aid for the young and developing, the other may be a charity or in compensation for work begun but interrupted. Both must be provided on such an enormous scale for this growing nation that, paternalistic or not, antagonistic to the theory of public assistance to individuals as it may be, the scope of the insane's necessities and the protection of the State, if you please, against them, may only be met by the State. The one essential asset of a State is the mental strength and moral fiber of its citizens. Neither wealth nor soil nor maritime advantages nor colleges nor laws are adequate in themselves or collectively to offset, economically, a lowering average mentality. Matter is molded by mind and the integrity of the mass-mind of a community or State should be its first concern. The collective mind of a majority is the State. Abnormal mind, whether immatured or broken afterward, is a State's menace in proportion to its spread. "In the world, there is nothing great but man; in man there is nothing great but mind." It is the rapid multiplying of grown people with child minds that is our nation's greatest danger now. The bootlegger, the rapist, the petty gambler, the unprovoked murderer, the syndicalist, all have abnormal conceptions of their relation to that which is established and to normal human conception of right. Crime is the end result of a moron's concept of civil customs. To limit crime we must minimize criminal propagation and by the same token we would diminish insanity, for they are kin. The sociologic problem must be solved by men who are charged with the study of the human mind. Surely it is the largest subject and should be the most pressing anxiety of the American people. The mind's treatment when deranged, the care of the body-which is the only avenue to it-and the views on propagation of people of low mentality in such numbers that the average mental strength of the American people may be impaired-appear to one away from it, to be our nation's most vital problems. When men deteriorate moral responsibility fails and enacted laws become inert or their enforcement of existing law is evaded. Each in turn marks a step downward from our present high position of supremacy among nations. There is a definite relation between health of body and integrity of mind and morals. The physical, mental and moral status of a people have the same root. National supremacy has been determined by it and the psychiatrists are our missionaries, explorers in this comparatively new field of discovery. I have heard many speeches, and remember very few of them. Of the vast majority no part has remained with me, but if I have said one. word on this occasion that may start a train of thought, leading to adequate provision and public study of the greatest of all economic questions, I will be rewarded. REPORT OF EVENING SESSION EASTON, MD. Wednesday, September 26, 1923, 8 p.m. EVENING SESSION, NEW THEATER Dr. Harry Friedenwald, the President, presided at the meeting. Dr. Randolph Winslow, the Chairman of the Committee to draw up resolutions on the death of Dr. Herbert Harlan, read the following resolutions: WHEREAS: the Medical and Chirurgical Faculty of Maryland has lost through death its President, Dr. Herbert Harlan, which occurred suddenly on August 16, 1923, it is proper that we give expression to our sorrow and cause of bereavement upon this occasion. Doctor Harlan was born in Harford County, Maryland, on May 7, 1856; received his academic education at St. John's College, Annapolis, Maryland, and his medical degree from the University of Maryland in 1879. After a sojourn in Europe in attendance on the great clinics of Vienna and Paris he returned to Baltimore and began the practice of his profession in that city. After a short period in general practice, he decided to limit his work to diseases of the eye and ear and he became associated with the late Prof. Julian J. Chisolm at the Presbyterian Eye and Ear Hospital. He rapidly achieved prominence in his specialty and for many years was a leading oculist in this city and state. From 1880 to 1886 he was Assistant Demonstrator of Anatomy in the University of Maryland, and from 1886 to 1890 he was Demonstrator of Anatomy. He was thus trained on an anatomical basis, which served him in good stead in later years, as for many years he served on the State Board of Medical Examiners as its president as well as its examiner in anatomy; also upon the establishment of the National Board of Medical Examiners he was appointed the examiner in eye and ear diseases in this organization. In all his varied activities he made good and his efforts were crowned with success. He was elected President of the Medical and Chirurgical Faculty at the annual meeting in April, 1922, and had served in that capacity from January 1, 1923, to the time of his death. He was a skilful surgeon, a distinguished member of the medical profession and a conscientious and public-minded citizen. Now Therefore Be It Resolved: That the Medical and Chirurgical Faculty of Maryland in semi-annual session assembled deplores the untimely death of its late President, Herbert Harlan, A.M., M.D., and that it extends it sincere sympathy to his bereaved family. The resolutions were adopted. The Secretary read the following resolution: Resolved: The members of the Medical and Chirurgical Faculty of the State of Maryland assembled at Easton, Maryland, September 26, 1923, desire to express their appreciation of the courtesies extended to them by the Mayor and Citizens of Easton, the Rotary Club, Chesapeake Bay Yacht Club, and Country Club, also to the members of Talbot County Medical Society for the invitation to hold this meeting in Easton and thank them for the splendid help given the Committee of Arrangements in making the convention a success. This was endorsed by Dr. G. Milton Linthicum. The resolution was adopted. After the short business meeting, there were addresses by the following: Hon. Albert C. Ritchie, Governor of Maryland, and Hon. Hubert Work, M.D., Secretary of the Interior. |