Reprinted from the Journal of Nervous and Mental Disease, January 1895. SOME REASONS. BY RALPH WAIT PARSONS, M.D. Reprinted irom the Journal of Nervous and Mental Disease, January, 1895. SOME REASONS WHY MORE ORIGINAL INVES- TIGATION AND MORE LITERARY WORK IS NOT DONE BY THE PHYSICIANS IN LARGE PUBLIC HOSPITALS FOR THE INSANE, WITH A SUGGESTION OF CERTAIN REMEDIAL MEASURES. RALPH WAIT PARSONS, M.D. Dr. S. Weir Mitchell’s severe criticism, not only of the general management of the hospitals for the insane, but also as to the lack of thorough and scientific work done by the physicians connected with such institu- tions, has caused much thoughtful consideration. It is certain that a great deal more pathological and literary work should be done, but that there are many and seri- ous difficulties in the way of pursuing careful, scientific study of the clinical and pathological material at their command, and of reporting the results thus obtained, there can be but little question. Dr. Hinckley, in his article which appeared in the Journal of Nervous and Mental Disease, September, 1894, strongly points out how frequently political interference impedes the up- building of a scientific hospital for the insane. The su- perintendent is frequently requested to do many things which he, in his best judgment, or from a sense of equity and duty, feels he ought not to do. He shows how attend- ants and other employees, who have been deprived of their positions for disobedience and neglect of duty, have on several occasions been reinstated for purely political reasons. The damaging effects of political in- terference upon the management of our public hospitals for the insane is also frequently alluded to in the letters written in answer to Dr. Mitchell’s circular letter. Dr. Hinckley also calls attention to the fact that the financial resources at the superintendent’s disposal for the advancement of the welfare of the institution under his care are frequently far too small, and that even the expenditure of a few dollars for minor surgical or lesser gynaecological operations is grudgingly allowed, and 2 RALPH WAIT PARSONS. requests to purchase apparatus for electro and hydro- therapy are positively refused. He further says, “ The great misconception of the true principles of economy, and the fatal method of forcing down legitimate ex- penses in order to make an actual showing of dollars and cents, which is too often the policy adopted by the managers of our institutions throughout the land, are fraught with the most baneful consequences.” Dr. C. L. Dana says in his letter to Dr. Mitchell, “ I believe that all over the country the great trouble is that the people do not understand what a difficult, costly and important problem the care of the insane is. Hence comes the evil of political management, and as a result the necessity of doing things economically and yet of taking care of the ‘ boys.’ ” A great deal of the superintendent’s time is taken up with purely executive work, the designing and oversee- ing the construction of new buildings, new roads, and the like, leaving him little time for scientific research, or for a systematic study of his cases. Dr. Billings, in speaking of the matter, says, “ The energies of the well- qualified asylum superintendent have been heretofore largely devoted towards increased accommodations for the insane, and their duties as administrative officers, charged with the planning and erecting of new build- ings and with the details of asylum management, have left them little time or opportunity for scientific investi- gations or for making themselves acquainted with what has been done by others in the diagnosis and treatment of insanity.” One great obstacle that the asylum physician finds to the careful and systematic study of his cases, or to the devoting of his attention to pathological research, is the immense amount of purely clerical work he is required to perform. The regulations of the State Commission in Lunacy require that a note shall be taken every day for ten days in the case of each newly-admitted patient; after this period one note every month during the first year, and after the first year one note is to be taken at least every three months as long as the patient remains under treatment. Of course, special notes are to be made concerning the progress of the case, or for other reasons, as the physician in charge of the service to which the patient belongs finds necessary. Now, sup- pose that in one department alone, say the male depart- ment, consisting of six hundred patients, thirty patients SOME REASONS. 3 are admitted per month, and suppose that one patient is admitted daily, we shall then have to make ten notes daily for the new admissions, besides those required concern- ing the mental and physical condition of the first or sec- ond preceding ten patients. Now, suppose that one-half the patients under treatment in the service have been admitted during the period of one year. We would then have to make ten notes a day besides those mentioned above, and every third month a note is to be taken of every patient in the service. It will be seen, then, that the senior physician in charge of a service of between five and six hundred patients has a great deal of writ- ing to do in order to keep up the histories of his patients. The senior, as a rule, takes the history and makes the preliminary mental and physical examination of each newly-admitted patient, and, furthermore, he is required to make a record of the prescriptions which he has deemed necessary to order according to the daily needs of the patients under his charge. Much time, also, is often taken up in consulting with the friends of patients concerning the mental and physical condition of their relatives, and frequently they insist upon seeing and ob- taining the opinion of the senior, although the other physicians connected with the service could, in most cases, answer all questions satisfactorily. After attend- ing to various other matters of executive importance in relation to the daily management of his service, it is not difficult to understand that the senior assistant has little time left, after the regular daily routine work is over, for systematic study or pathological research. Now, as to the assistant physicians connected with a service like the one already alluded to. A large propor- tion of their time is taken up with purely clerical work; that is, making duplicate medical certificates, copying certificates into the histories of patients, and copying notes taken by the senior physician concerning the con- dition of various patients; and it should be remem- bered that the notes regarding the recent cases are often very full, so that a large amount of copying is required in order to keep the histories of the patients up to date. It will, as I think, be generally agreed that this vast amount of clerical work is of little value, as such, to the physicians whose duty it is to perform it. If an intelli- gent, conscientious clerk were employed to do this daily routine of office work, the physicians then would have a great deal more time to devote to their legitimate medi- 4 RA L PH IVA / T PA RSONS. cal work, to study of the symptoms, course and results of treatment of mental diseases, and to work in the pathological laboratory. It is urged that the histories of patients are private data, and thus that the physicians alone should do the copying in the case books. But, surely, an intelligent clerk, who has shown himself qualified to hold a posi- tion of responsibility and honor, will be no more likely to divulge professional secrets in relation to patients than a trained nurse, who is often well acquainted with private matters concerning the patient’s life and per- sonal character. As to the propriety of asylum physi- cians devoting so much valuable time to purely clerical work, which a person experienced in office routine and copying work could do just as well, or even better, allow me to quote from the letter written by Dr. Landon Car- ter Gray in response to Dr. Mitchell’s circular letter. He writes: “ Some means should be devised by which the physicians can devote a proper amount of time to the study of their cases from the standpoint of the physician and not of the hotel-keeper.” Dr. Charles K. Mills in his letter also refers to this point in no uncertain manner. He writes: “The medical staff should be enlarged. Indi- vidualization in study and treatment should be more thorough. Physicians should be relieved from much executive and miscellaneous non-medical work, to which they are now compelled to give too much valuable time.” Another plan that might be adopted to reduce .the amount of clerical work which the assistant physicians have to do, and at the same time encourage them to active scientific work, would be to divide a given service into much smaller divisions than is now done, and to more carefully classify the patients, making one small division of the recent admissions, another of the in- firmary, and larger divisions of the more chronic cases. The senior would have a special supervision of the re- cent admissions, with the aid of one of the juniors, and would also have a general supervision of all the other divisions; a junior, under the general supervision of the senior, having special supervision of each of the other divisions. At the expiration of stated periods of time the juniors would change from one division to another in rotation. Thus each physician would have only a moderate amount of writing to do, and no one of the junior assistants would have the advantage over the other members of the staff of being constantly con- SOME REASONS. 5 nected with an acute service, and other physicians the disadvantage of being in charge of divisions almost wholly made up of chronic cases. Beside this, each physician could then follow his cases much more fully and accurately, as they might be transferred from one division of the service to another. This plan could be carried out still further by the physicians in the male and female departments changing places, at certain stated intervals, in order to give each member of the staff experience in the manifestations of mental disease in both sexes. Dr. B. Sachs is strongly of the opinion that the cler- ical matters and medical work should be separate, so that the physicians might come in much closer personal contact with their patients, and thus be enabled to study their mental peculiarities more thoroughly. He says: “ I am a strong believer in the good which results from intimate personal contact between the physician and the insane patient.” He even goes so far as to recommend that there should be one physician to from ten to twenty patients. This would certainly be of great advantage to both physicians and patients, but would be impracticable in our large public hospitals for the insane. Dr. W. H. Draper writes in this connection: “ Reform also is needed in the administration of our asylums, which should provide a separate organization for carrying on the executive and medical departments.” .Another reason why, as I believe, more original work is not done by asylum physicians is, that they lack the stimulus of coming in frequent contact with specialists and general practitioners in the outside world. Many of our hospitals for the insane do not have a consulting staff. There can be no question that great benefit would be derived from having a consulting staff connected with each hospital for the insane. The great drawback is, that many of the large hospitals are located at a con- siderable distance from the great medical centres, and it is doubtful whether busy practitioners and specialists would feel that they could spare the time, if only for a few hours, six or eight times a year, to go to the hospital in the function of consultants. Several years ago a con- sulting staff was connected with the Hudson River State Hospital, but after a time the visits of the consultants ceased altogether. It would seem, then, that the spe- cialists and other eminent practitioners ought to make some concessions on their part as to time and conven- 6 RALPH WAIT PARSONS, ience toward the advancement of the clinical and patho- logical study of mental diseases. Another important drawback to the close and thorough study of clinical material in our public hospi- tals for the insane is the small number and inferior quality of attendants, for it is a well-known fact that physicians are often much aided in their study of cases of mental disease by the careful description of their words and actions given by an intelligent and observant attendant. Many insane patients have considerable vol- untary control over their intellectual processes, and knowing that the physician is the judge as to their sanity or insanity, will control their words and actions in his presence, but as soon as he has left the ward will freely manifest these evidences of insanity in the pres- ence of their attendants. In many of our State and county institutions the attendants are drawn from the less intelligent classes of society, and are often coarse and clumsy in their ways, and some of them are even stupid. They may have been day-laborers, factory hands, farmers, and, in general, men “out of a job.” The women have done housework, are often illiterate, and have only a faint idea, if any, as to the responsibility connected with the position which they seek to fill. These persons often secure and retain their positions as attendants through political influence, although they maybe wholly unfitted for their positions. Dr. Hinckley, in his article already referred to, in speaking of political influence in our pub- lic asylums, says : “ Positions of grave responsibility are filled by employees whose stupidity, illiteracy and total lack of adaptability are painfully apparent.” It has been the general experience of medical super- intendents of hospitals for the insane, however, that nurses who have been originally trained in general hos- pitals are not well adapted to the work of caring for the insane. The best nurses for this class of work are those who, having the proper mental and physical qualifica- tions, have received their original training in a hospital for the insane. The pecuniary and other considerations, such as accommodations, food, and opportunity for learn- ing, which they receive, should be such as to induce a good class of men and women to take and hold these positions. It is certain that every hospital for the insane should have a training school connected with it. This would SOME REASONS. 7 be a great advantage to the institution, the physicians and the patients. The attendants should have a system- atic course of didactic and clinical lectures on the ele- mentary principles of anatomy, physiology, surgery, therapeutics and psychiatry concerning the care, man- agement and nursing of patients suffering from mental and nervous diseases, and in general nursing. Through the medium of a well-organized training school a great advance in the study and treatment of insanity could be made. But, imder existing circumstances, it is very discouraging to endeavor to instruct attendants, many of whom are illiterate and who take little interest in their work, and who remain in the service of the hos- pital only a few months, and then resign their positions to engage in some other occupation. To make this point more clear. I resigned my posi- tion on the staff of the Hudson River State Hospital about a year ago. At that time there were connected with the male department between seventy and eighty attendants. On a recent visit to that institution I ob- served that there were not more than six or eight attend- ants connected with the male service who had been there a year ago, and of these not more than three or four were connected with the hospital when I entered the State service in 1890. I believe that the constant changes in the corps of attendants, resulting from causes already mentioned, are pernicious, both to the interests of the institution and to the interests of the patients. Not only would the comfort and welfare of the insane be promoted, but I feel sure that the total percentage of recoveries would be increased through the services and co-operation of experienced attendants. The intellec- tual and moral control that intelligent attendants are often able to exert over their patients is large, and thus many cases of insanity are favorably influenced by the power of the stronger mind over the weaker. In conclusion, I would sum up as follows, to wit: 1. The superintendent should be relieved of much of the executive and non-medical work which he is now called upon to perform. In order to obtain this object each large public hospital for the insane should have an assistant medical superintendent, who will share the executive work with the superintendent so much that each may have time to devote to the study of their cases and to the advancement of the work in the domain of psychiatry; and furthermore, they would thus stimulate 8 RALPH WAIT PARSONS. their assistants to the careful and accurate study of the phenomena of mental and nervous diseases, and to thorough pathological investigation. 2. A sufficient sum of money should be appropriated each year, which the superintendent can have at his dis- posal for the purchase of instruments for laboratory work and for scientific and therapeutic purposes. 3. The assistant physicians should be relieved, as far as possible, from the large amount of purely clerical work they now have to perform by either providing a clerk for the purpose or by increasing the staff so that the non-medical work assigned to each physician might be reduced to a minimum, thus allowing much more time for the systematic study of their patients and for patho- logical and literary work. 4. Men and women of intelligence and with the neces- sary qualifications should be appointed to fill positions as attendants, without reference to politics; and they should be given a sufficient salary, in order that it may be to their interest to hold their positions and thereby promote the interests of the institution and the welfare of the patients consigned to its care. 5. Every hospital for the insane should have an at- tendants’ training school connected with it, in order that the best results of treatment may be obtained. The Alliance Press, Office: 692 EIGHTH AVENUE, NEW YORK.