HOSPITAL TREATMENT OF INSANITY The era of real hospitals for the insane may be said to have begun in the 19th century, although there had been established here and there in different parts of the world certain asylums or places of restraint before this period. The prevailing idea of the pathology of insanity in Europe during the middle ages was that of demoniacal possession. The insane were not sick, but possessed of devils, and these devils were only to be exorcised by moral and spiritual agencies. Mediaeval therapeutics in insanity adapted itself to the etiology indicated. Torture and the cruellest forms of punishment were employed. The insane were regarded with abhorrence, and were frequently cast into chains and dungeons.
Until as late as the middle of the 18th century, mildly insane persons were cared for at shrines, or wandered homeless about the country. Such as were deemed a menace to the community were sent to ordinary prisons or chained in dungeons. Thus large num bers of lunatics accumulated in the prisons, and slowly there grew up a sort of distinction between them and criminals, which at length resulted in a separation of the two classes. In time many of the insane were sent to cloisters and monasteries, especially after these began to be abandoned by their former occupants. Thus "Bedlam" (Bethlehem Royal hospital) was originally founded in 1247 as a priory for the brethren and sisters of the Order of the Star of Bethlehem, and was rebuilt as an asylum for the insane in 1676.
Pinel, in 1792, struck the chains from the lunatics huddled in the Salpetriere and Bicetre of Paris, and called upon the world to realize the horrible injustice done to this wretched and suffering class of humanity ; but 25 years later, the insane, everywhere in Europe, were still treated brutally, and it was not until 1838 that in France they were all transferred from small houses of detention, workhouses and prisons, to asylums specially constructed for this purpose.
No great advance in the humane and scientific care of the insane was made till towards the middle of the 19th century. Only then did the actual metamorphosis of asylums for detention into hos pitals for treatment begin to take place. Hand in hand with this progress there has grown, and still is growing, a tendency to sub division and specialization of hospitals for this purpose. There are now hospitals for the acutely insane, others for the chronic insane, asylums for the criminal insane, institutions for the feeble-minded and idiots, and colonies for epileptics. There are public institu tions for the poor, and well-appointed private retreats and homes for the rich. All these are presided over by properly qualified medical authorities, supervised by unsalaried boards of trustees or managers, and inspected by Government lunacy commissioners, or boards of charities.
It may be said indeed that the modern hospital for the insane does credit to latter-day civilization. Physical restraint is no longer practised. The day of chains—even of wristlets, covered cribs and strait-jackets—is past. Neat dormitories, cosy single rooms, and sitting- and dining-rooms please the eye, and improved methods of treatment are adopted in the way of sleep-producing and alleviating drugs, dietetics, physical culture, hydrotherapy and the like. There are few asylums now without pathological and clinical laboratories.
Germany approaches nearest to an ideal standard of provision for the insane. The highest and best idea which has yet been attained is that of small hospitals for the acutely insane in all cities of more than 50,000 inhabitants, and of colonies for the chronic insane in the rural districts adjacent to centres of popu lation. The best of these colonies are constructed on the principle of a farming hamlet, without barracks, corridored buildings, or pavilions, being similar in most respects to any agricultural com munity. At the same time all the inhabitants are under medical supervision, and a laboratory for scientific researches forms a highly important part of the equipment. Such a colony is not looked upon indeed as a refuge for the incurable ; it is rather a hospital for the sick where treatment is carried on under the most humane and most suitable conditions, and wherein the percentage of recoveries will certainly be larger than in asylums and hospitals as now conducted.
But that the tendency in the direction of the more humane and scientific treatment of the insane is a general and a growing one is manifested in all countries by the steadily increasing abandon ment of the former huge cloister-like abodes for the detention of such sufferers.
During the World War the British public insisted that no soldier should be sent to an asylum unless proved to be suffering from an incurable mental disease, or until, after a probation of I 2 months, the disease was regarded as incurable ; and the success of this method of dealing with mental disease in the army led the board of control to reconsider the question of the early treatment of insanity.
Through the munificence of Dr. Henry Maudsley, the London County Council has built the Maudsley hospital for the study and treatment of mental diseases in the early and curable stage ; and here a real effort has been made to deal with insanity on modern rational lines.
It has an out-patients' department, and 150 beds for males and females, together with a qualified staff of medical officers. The Maudsley hospital is a recognized school of the London Univer sity, and a course of lectures, together with practical instruction, is given to medical men who are desirous of qualifying for the diploma of psychological medicine. The London County Council give study leave to their medical officers of asylums, and now require officers who apply for senior appointments to possess a university diploma of psychological medicine or a diploma of the conjoint board of the Royal College of Physicians and Surgeons. Opportunities for research in the pathological laboratory are afforded to suitable applicants by the committee.
The Maudsley hospital, being a rate-aided hospital, is primarily intended for those who have a London settlement, and the charge made varies according to the means of the patient. All inmates of the hospital are voluntary and uncertified. This allays the fear of the patients that they may be made permanent inmates, and inspires them with confidence in their treatment. Out-patients are thereby encouraged to attend the hospital, and in this way a more favourable prognosis is secured, for mental disorders and diseases are thus observed and treated in their incipient stages.
In most London general hospitals special out-patient depart ments exist for mental diseases, and there is an attempt being made to link up the general hospitals and mental institutions. A few actually admit in-patients with mental illnesses of a type con sidered suitable to be treated in such an environment.
BIBLIOGRAPHY.-D. K. Anderson and others, "Occupational Therapy," Bibliography.-D. K. Anderson and others, "Occupational Therapy," Jn. Ment. Sci. lxxi. 59 ; J. Macarthur, Mental Hospital Manual (1921) ; A. M. Barrett, "The State Psychopathic Hospital," Amer. Jn. Insanity, lxxvii. 3o9 (192o-21) ; Sir J. Crichton-Browne, "The First Maudsley Lecture," Jn. Ment. Sci., lxvi. 199 (192o) ; J. V. May, "Functions of the Psychopathic Hospital," Amer. Jn. Insane, lxxvi. 21 (1919-2o) ; J. P. H. Murphy, "Therapeutic Use of Occupation in the Treatment of the Insane," Internat. Clin. (1918) . (X.) The United States.—Most of the intensive work in treating insanity is naturally done in special hospitals, but more and more is being done in schools and even in the pre-school period, in habit and child guidance clinics, in outpatient departments, in mental hygiene organizations, in private practice, in general hospitals, in nursing homes and sanatoria. There is much demand for a greater variety of provisions in harmony with the needs of a great variety of patients. The theory and practice of psychiatry (q.v.) to-day include all conditions in the treatment of which familiarity with personality development and personality problems and with disorders and diseases of personality is required.
For the treatment of mental disorders the United States show a wide range of unusually inadequate and many unusually modern provisions. In some regions the gaol is still an intermediary sta tion between home and State hospital (some State laws making the sheriff and juries and the gaol the agency for first aid). In only a few States, as in New York, the health officer has to pro vide intermediate help pending admission to the State institution. As intermediate stations, there are creditable reception hospitals in a number of cities.
As the ideal for treatment there should be reception and treat ment hospitals not too far from the homes, either detached or as special divisions in general community hospitals, with country annexes and colonies for cases that would do better outside of cities, and various types of colony provisions for protracted care. A most important task will always be the service in the com munity, outside of institutions—the "extra-mural psychiatry." Unfortunately, to maintain adequate hospitals and hospital or ganization in small as well as in large communities appears to call for too great an expenditure for disorders which the general medi cal profession and the public—up to but a few decades ago and in many places up to the present—have largely left to charity and moral advice and exhortation and to the "asylums" now called hospitals.
The first really reasonably well supported hospitals in the United States for mental cases were a few private institutions (New York hospital, Massachusetts General, Pennsylvania and similar hospitals) or special foundations (the Hartford Retreat, Butler hospital, Sheppard and Enoch Pratt hospital). For the rank and file, increasingly well-conducted State institutions and State care acts have helped to replace the makeshifts provided by the counties and certain townships, by no means wholly supplanted. Much care should be taken lest the dependence on private philanthropy might have a retarding effect on the educa tion of the tax-paying public.
Psychiatric institutes, clinics and training schools, research centres and especially the National Committee for Mental Hy giene, are doing valiant work for progress. Better training of the average physician, education of the public by child guidance clin ics and community service and examples of organization of local and State work are marking the present trend in many States and in Canada. (AD. M.) See H. M. Hurd, ed. Institutional Care of the Insane in the United States and Canada (4 vol., 1916-17) ; H. M. Pollock and E. M. Furbush, Comparative Statistics of State Hospitals for mental diseases (1922) ; J. A. Goldberg, Social Aspects of the Treatment of the Insane (1921) ; J. V. May, Mental Diseases, a public health problem (1922), and reports of the various State departments which have the State institutions under their care.