1. The incipient case would have the advantage of immediate expert care by members of the hospital staff in every branch of medicine and surgery.

2. He would have the advantage of a large hospital nursing staff instead of attendants.

3. The social considerations after recovery are most important to patients, many of whom would thus be saved from being placed in an insane asylum.

IV. PRIVATE SANATORIA AND HOSPITALS

There were in the State of New York in 1918 a total of twenty-four private licensed institutions' with a licensed capacity of 1,522 patients. It is these asylums or retreats which serve the purpose of wards in general hospitals, but they are only within the reach of those whose relatives or friends are in a position to pay from $25.00 to $100.00 or more a week. Many incipient cases are discharged as recovered or improved within a few weeks from these private institutions, in which they have been given much individual attention, more than could possibly be accorded them in the state hospitals. This does not of course mean that the state hospitals are failing to effect cures, but rather that for incipient cases some institutions other than state hospitals are at present prepared to render better service, and hence increase the ratio of recoveries, because of proportionately larger staffs, better equipment, and less overcrowding. The psychopathic wards or "Pavilion F" of the Albany Hospital are rendering a service that many of the similar institutions throughout the state should be prepared and equipped to give. This is a private institution maintained for charitable purposes and those treated there are required

1"The Insanity Law," art. 3, sec. 59.

'Mosher, J. M., The Treatment of Mental Disease in a General Hospital," The Modern Hospital, Nov., 1915.

to pay or to be paid for by relatives or friends, if they possess the means; the charges include the usual and rather moderate amounts asked for the care of the patients and for the payment of private nurses, if such are found to be necessary.1 The development of psychopathic hospitals in the large cities, of psychopathic wards in general hospitals in the smaller cities of the state, and an extension of the ten-day detention period, would prove to be important elements in the reduction of the number of committed cases, in lessening the overcrowding of the state hospitals, and in markedly increasing the early recovery of incipient cases of mental disorder.

V. CLASSIFICATION OF PATIENTS AT STATE HOSPITALS

In the preceding chapter it was pointed out that of those admitted to the psychopathic wards of Bellevue Hospital during one year, the following number of patients were committed to state hospitals:

Upon arriving at the state hospitals, the patients are as a rule sent to the reception wards or buildings, in which they are detained until properly diagnosed and classified. The superintendents of state hospitals have for a long time made

'Mosher, "Need of Early Treatment for Mental Diseases,” Amer. Jo. of Ins., Jan., 1909, pp. 501-503; Drury, William F., Evolution of Psychiatry, 1904, p. 42.

1

efforts to promote and carry out a greater uniformity in classification according to age, nationality, education, station in life and diagnosis of those assigned to particular wards.1 However, the overcrowding in all the hospitals, the large wards and the insufficiency of the staffs have made it wellnigh impossible to carry out these plans, except insofar as relates to placing patients in wards according to diagnosis, behavior, and the acuteness or chronicity of the ailment. In planning one of the large state hospitals in New York some years ago, the medical superintendent submitted plans which called for a number of cottages, each with a capacity of twenty-five patients, the purpose in mind being to permit the classification of the patients along the lines outlined above. When the total outlay for erecting and maintaining such a cottage system was estimated, the amount necessary was found to be far greater than the state had appropriated for the new institution and intended to allow for maintenance and upkeep from year to year. The result was that instead of erecting separate cottages with accommodations for not more than thirty patients, buildings housing from 125 to 150 patients were erected, with less satisfactory provisions for the separation and classification of the different groups in the hospital population.

VI. OCCUPATIONAL THERAPY AT STATE HOSPITALS

After the assignment of patients to their wards, an attempt is made to give them some form of occupation suitable to their particular needs and requirements. Several classes for the reeducation of the patients are maintained in most of the hospitals, though the total number of patients benefiting from such instruction is small. Thus, in 1918, in the Manhattan State Hospital, with about 5,500 patients in the wards, there were only 150 who received instruction

1 State Hospital Quarterly, Aug., 1919, p. 439.

in the arts and crafts classes.1 In a survey made of the Manhattan State Hospital by the New York State Department of Efficiency and Economy, it was reported that the institution obtained excellent production from the land under cultivation, as well as from the hospital industries. This statement in itself is not sufficient evidence of the efficiency of industrial departments in the hospital, for it fails to take into consideration the number or percentage of inmates employed in these industries, even though it seemingly makes allowance for the high per capita production. Mention is made of the fact that of 245 arable acres only 66 acres were under cultivation at the time the study was made.2

3

The possibility of providing occupational therapy for a larger percentage of the patients under treatment is indicated by the experiences of the Bloomingdale Hospital at White Plains, where, with a total of 437 patients in 1918, there was a daily average attendance of 97 patients in the departments of occupational therapy, in which a large variety of occupations are taught. The marked difference between conditions at the Manhattan State Hospital and the Bloomingdale asylum is due to a number of reasons, among them being the difficulty experienced in trying to educate certain types of mental cases, of which larger numbers are to be found in the state institutions than at Bloomingdale, which proportionately treats a larger number of cases of manic depressive insanity, and a smaller number of cases of senility, general paralysis, and dementia praecox; the lack of a sufficient number of properly trained sup

1S. H. C., 30th A. R., p. 201.

* McCalmut, M. E., Report of the New York State Dept. of Efficiency and Economy, "Organization and Administration of New York State Hospitals for the Insane," 1915, p. 418.

• Annual Report, Society of the New York Hospital, 1918, pp. 11-12.

ervisors and teachers of trades; the failure of the state hospitals to develop a definite policy regarding the training and education of the patients, and also the large number and variety of trades and occupations represented among the patients in the state institutions. Considering only the 790 patients dealt with in this work, the diversity of employment prior to admission to the state hospitals is evident from the following tables :