State Mental Hygiene Activities.

This comprehensive interpretation of Mental Hygiene as a public health activity is not applicable in every detail to a state situation, but the broad underlying principles are the same. It is not possible at present to conduct a campaign of such magnitude as that outlined by the Public Health Service, in fact it seems advisable that the formation of a State Mental Hygiene policy be, for the time being, a matter of evolution, dependent on situations and opportunities. There are definite tasks awaiting a mental hygiene body controlled and financed by the state. It seems desirable to discuss a few of the situations constituting some of the modern problems in mental medicine as well as the opportunities for Mental Hygiene work.

The treatment of mental disease is the greatest single enterprise in which the state is engaged. It is an enterprise in which the state has practically a monopoly. It is not only the greatest enterprise carried on by the state but it is the greatest medical enterprise carried on within the borders of the state, for the number of beds in the hospitals for the insane is larger than the total number in all other hospitals in the state. This is true although the State cares for a relatively small proportion of the total number of the mentally afflicted.

The mentally afflicted might be arbitrarily grouped in four classes, such classification depending on the nature of the care the patient should receive.

I. Those who have a mental disorder but who could be adequately treated outside of state institutions. There are many such individuals, they surely many times outnumber the mentally diseased cared for by the state. In this group are found some of the incipient as well as the temporarily mentally aberrated and even some of the mental defectives, who often could best be treated in their own community, were the mental clinics, psychopathic wards in connection with general hospitals and special classes in schools provided. Such provisions are not going to be generally made until some strong, reputable body, such as the State Board of Health, urges it.

2.

Those who should be cared for in a mental hospital but are not receiving such care. There are several factors responsible for the existence of many mental sick patients in this state who need but do not receive hospital treatment. Under the present system of commitment to state hospitals, the town pays part of the cost of the care of the indigent and paupers. Under such a system it is frequently difficult to persuade the selectmen of towns to authorize the commitment of any patients except those who constitute a menace to the community. This is one example of where the community's purse is considered, rather than the health of the sick patient. The instigation of commitment proceedings for indigent and pauper mental patients could advantageously be placed in the hands of the health officers. If local health officials were given the authority and expected to see that mentally diseased individuals were promptly committed to hospitals for treatment, the present evil of not committing the pauper mental case to a hospital because of the expense incurred by the community might be obviated.

There are today, in spite of the state law to the contrary, undoubtedly individuals being detained in almshouses who need treatment in mental hospitals. A strong, constantly alert, centralized authority is needed to prevent mentally afflicted individuals from being kept indefinitely in almshouses.

3. There are the mentally ill who are being cared for in hospitals, either private or state. A division of Mental Hygiene could help the state hospitals by assisting them to obtain the needed facilities for caring for their patients, and although we are justly proud of the splendid State Hospitals in Connecticut, no State Hospitals in the United States are yet so perfect that they could not be improved.

This State has an unusually large number of private hospitals for the treatment of mental disease. Some of these hospitals are splendid institutions, but it is a well known fact that some of them exist here because they could not do so under the regulations in New York. The scientific supervision of the private mental hospitals in the State, although important, is negligible.

4. The patient who has been discharged or paroled from a

mental hospital. These patients receive practically no supervision from the state after leaving the hospital. Very few states as prosperous and socially inclined as Connecticut fail to do this. It is debatable whether or not the hospital paroling or discharging the patient should not supervise the patient during convalescence. It is imperative that someone should be responsible for such follow-up work; if the hospitals are unable at present to do this, some department of the State government should undertake this work.

One of the important undertakings of a State Department of Health is the dissemination of information relative to disease and conditions causing it. Such information, because it is sponsored by the State Department of Health, usually has a wide circulation and receives careful consideration. Mental disease is universally misunderstood by all of the laity and part of the medical profession. It is necessary that the laity be taught that insanity is a form of disease and be made to realize that as soon as an individual is suspected of being mentally ill treatment should be instituted. However, the dissemination of such knowledge will be of little practical value unless the members of the medical profession are familiar with the usual forms of mental disease and their treatment. It is not unusual to find some laymen who are as familiar with mental disease as the average physician. The organized departments of health have already accomplished much in raising the standards of medical care, especially in infectious diseases; they might help to accomplish a similar reform in psychiatry. Not only the individual physician but also the medical schools must be shown the great importance of increased psychiatric instruction.

Ignorance of the legal procedures incident to the care of mental patients has held mental medicine back almost as much as have the antiquated procedures themselves. Some of these laws are indefinite, some obsolete, and many not enforced. Therefore, the laws relating to mental disease and defect have been abstracted and interpreted by the Mental Hygiene Division of the State Department of Health, and will be included in the Manual of State Laws relative to public health which is issued by the Department of Health.

The physician at present occupies a position in psychiatry similar to that of the doctor in our army-he is necessary, but a nuisance. This is true because mental medicine is almost completely under the control of legal authorities. The judiciary and legislative bodies listen more or less attentively to the medical profession, then calmly dispose of the care of the mental patient in accordance with traditional ideas of political economy. A few individual physicians cannot alter this situation, but an organized body, endowed with legal authority, and a medical viewpoint, functioning as a state department, can do so.

Conclusion.

There have been mentioned only a few of the most evident psychiatric problems which are the result of the medico-sociological conflict. In solving these, a State Department of Mental Hygiene, either as a separate department or operating under the Department of Health, can be of service to the community, the sick individual and the physician; for this reason it deserves the support of the medical profession.

There may be other methods of accomplishing the desired results but no other method seems as fully applicable to the needs of this state, nor capable of such broad scientific expansion, as does the plan outlined. With mental hygiene interpreted as a public health movement we may expect to see the day when the community and the physicians will give as much attention to the prevention and treatment of mental disease as they now do to other major branches of medicine.

DISCUSSION.

DR. WHITEFIELD N. THOMPSON (Hartford): Dr. Terhune has laid out a very ambitious programme. Some of you who have not given attention to this work may feel that he has added something for good measure. I think this is not the case and that time will justify the requirements he has laid upon the Mental Hygiene movement. One suggestion made overtops all others in immediate and practical importance,—provision or opportunity for the care of recent or acute cases in insanity under such arrangements of relations with a general hospital that patients and their friends cannot offer the objection now usually met, that the severity

of the illness is not such as to require sanatorium care or commitment to an insane hospital. Individual comfort and happiness, and public safety, interest, and economy will be served and enhanced when hospital care is provided as freely and under as acceptable conditions for incipient and recent cases of insanity as for various other physical ills. Aversion and objection to such innovation as a psychopathic or psychiatric ward or annex in a general hospital is general and widespread, notwithstanding the fact that it was first successfully tried more than a hundred years ago and has been carried out in a most satisfactory way in recent times. It is a reproach to the medical profession that this attitude is assumed in a final and positive way without taking into account the great good that could be accomplished without sacrifice of the comfort of other classes of patients and without the addition of more care and responsibility than would be occasioned by the inclusion of any other classes of cases, whether lying-in, tuberculous, or what not. There would be abundant justification for giving over a suitably equipped wing to the care of the insane if nothing more were accomplished than the training of nurses and internes. Such training would enable physicians to recognize oncoming mental troubles, and would make it possible to secure the services of nurses who would be of use, rather than a hindrance as is so obviously true now with the general hospital trained nurse. It is in the period of the earliest deviation from the patient's normal that something really worth while can be done in the way of treatment. Under present conditions no patient is ready for hospital treatment, in the eyes of the family, until home care has become impossible. Aside from the fact that much valuable time is lost, the patient is very often drugged in order to keep him at home until the true features of the illness are quite beclouded. Even those cases that cannot be benefited by hospital care ought to be placed under observation for a sufficient length of time to determine, if possible, whether or not they are likely to be a menace to themselves or to the community. I am sure that much could be gained if every hospital interne could have a period of service in the observation of insane cases, and that psychopathic wards as readily accessible as surgical wards would abort many cases of threatened mental illness and would save tragedies that are of almost daily record in the press.

DR. MAX MAILHOUSE (New Haven): Dr. Terhune has covered so much ground and brought out so many features of major importance that we cannot in the discussion touch upon more than a very few of them. He truly says that this must be a matter of education, and of public education just as well as a matter for State Boards of Health. It took a long while to educate the public in health matters, and now that they are demanding so much of the medical profession, it will be the