Family History. Maternal aunt committed suicide after killing

her own daughter.

Patient's History.

According to the patient, she became nervous two years before coming to the clinic. At that time the agent frightened her by telling her he would put her out of the house because she used too much coal. After that, whenever she saw him, she felt stirred up and nervous. Her heart "almost jumped out." (The man often spoke unkindly to her.) She constantly feared they would be put out of the house. When questioned more closely, it was found that the more marked nervous symptoms developed after the husband lost his position six months before. The support of the family then depended solely on her. She did extra work. Besides acting as janitress, she answered the telephone and did various other things, together with her own house work.

She fretted under the strain, became cross, irritable, wondered what would happen to them. Further light was thrown on the situation by the investiagations of the social worker. The home was often in turmoil, the mother cursed at her children, so did the father. The agent was really not so bad as pictured.

About this time two of her children, a girl and a boy, aged 13 and 15 respectively, began to show peculiar behavior at school. The boy had recently been demoted. The teachers, he said, told him it was because of his conduct. The girl had also been demoted and was said to be nervous.

Because of the change noted in these children the teachers thought their mental condition should be investigated. They were referred to the State Charities Aid Association about the time the mother's mental condition began to attract notice. The result was that the mother and the two children were all sent to the clinic on the same day. The children, when questioned, seemed quite normal. The mother was found to be under much tension. She told of her difficulties as previously mentioned. While she laid most stress on her troubles with the agent, to us the situation looked quite different. We saw before us a woman, who in a difficult situation, was attempting to do more than she was capable of doing. The obvious remedies were: First, to limit the amount of her work; second, to assure her that she and her family would be provided for in an emergency. The suggestion was also made that she be given a small allowance until her husband found employment.

Some months later we learned that a great transformation had taken place in the home. Once more peace and harmony reigned.

In brief it may be said that readjustment was made possible in some of these cases because they came, as a rule, quite early, that is, before their habits and ideas had become fixed, and while they were still amenable to suggestion.

Of the other cases it may be said that their surroundings were improved and that they received more judicious care and attention.

To the third group of cases, those requiring early institutional care, the clinic also is frequently of much value, since it is often possible to prevent their being committed to the workhouse for disorderly conduct before their mental condition is recognized.

The various social agencies who recognize the value of early diagnosis have for some time past been in the habit of referring cases of this type to us for an opinion as to the most suitable plan of caring for them.

No consideration of this subject, however, would be complete without acknowledgment of the great value of the social workers in carrying out this work. Without their assistance, suggestions, and co-operation, much that we try to accomplish would be void of result.

THE MANAGEMENT OF DISTURBED AND

EXCITED PATIENTS

BY DR. ERNEST M. POATE,

Senior Assistant Physician, Manhattan State Hospital.

From the very beginnings of psychiatry the problem of handling excited patients has been a vexed one. Spirited controversies upon the subject of restraint have marked the progress of our specialty from the days of Pinel to the present; the orthodoxy of the psychiatrist has been measuredtoo often, perhaps-by his adherence to the dogma of the moment.

With but few reverses, the party of non-restraint has been dominant for long; long enough to have grown, like many another dominant party, somewhat lax in doctrine. After the horrors of the old-time asylum, a reaction toward complete non-restraint was but natural, and this movement reached its fullest flower in those English hospitals where patients once jumped gaily from unguarded windows, rejoicing in their freedom from restraint—until they reached the ground. Soon complete non-restraint was seen to have its disadvantages, and the pendulum began to swing back.

Complete non-restraint at present is but a roseate ideal, admittedly impractical in this imperfect world. Unfortunately, a sentimental affection for this ideal persists, to the hindrance of a sturdy pragmatism. As in the arts, so in the sciences, one finds the eternal conflict between the God of Things as They Ought to Be, and the God of Things as They Are. The writer subscribes himself a follower of the latter.

The rash adventuring of one so inexperienced into this stormy sea, still tossing in the winds evoked by the discussion of our forefathers, may seem to be impertinent. Perhaps it is. It is the writer's belief, however, that very much of this discussion has been dogmatic, based upon a sentimentally atavistic reaction. Regardless of personal likes or dislikes, any method of treatment must be judged finally by its results; and, with this in view, an attempt has been made to compare the methods of handling disturbed patients in the New York State hospitals.

As a beginning, let us define the terms to be used. The dictionaries of English define "restraint" as the state of being restrained, limited, checked or repressed; and, in the writer's opinion, no generally used word ought to be limited in meaning for any technical purpose. A patient is restrained by guards on the windows, by locks on the doors; by the very process of commitment his liberty is restrained. However, the term "restraint" has been limited by custom to describe only such mechanical appliances as may be placed directly upon the body of a patient to restrain his physical activity; and even here the term is restricted to exclude packs, which require restraint for their application. Restraint, in this paper, then, means that applied directly to a patient's body, without the interposition of wet sheets.

As a further feat of iconoclasm, the writer wishes strongly to protest against the distinction which has been made between restraint and treatment. Restraint is as surely treatment as is any other procedure designed to preserve life with comfort. As the writer knows from personal experience, the protection-sheet, as a means of treatment in the acute excitements, is often of much greater value both in quieting patients and in hastening recoveries than is any form of hydrotherapy. Later on, further reference will be made to this. In this paper, therefore, restraint, hydrotherapy, (this is, packs and the continuous bath) and the use of sedative drugs will be considered equally as treatment. The question as to what patients shall be considered disturbed is one more difficult to settle. Despairing of any other definition, the writer has decided to consider as disturbed only those patients whose excitement is so intense as to demand treatment by restraint, seclusions, packs, the continuous bath or some sedative drug. As will be seen, manual restraint is here ignored. This is because it is quite impossible even to estimate the extent to which it is used. At the Manhattan State Hospital, it is used very little; upon this writer's service, it is never used, except as is necessary in the application of some form of treatment, because of the very great danger of injury to patients.

To regard as disturbed only those patients who require

treatment of the sort mentioned furnishes, at least, some calculable basis for statistical comparison. It must be remembered, however, that the amount of such treatment must always vary inversely with the amount of individual attention which disturbed patients can be given. Whereever the excited patient can receive the entire attention of one trained nurse, the necessity for drugs or restraint is greatly diminished, if not obviated. This is one great reason for the efficacy of the continuous bath. Therefore, hospitals having a small proportion of excited patients should be able to do with a minimum of restraint, since each case can receive individual care.

As a beginning, the writer has attempted to estimate the number of potentially disturbed patients in each hospital; that is, the number who may be expected, at one time or another, to require treatment as outlined above. Such an estimate, at best, can be only approximate, for the following

reasons:

The estimated number of disturbed patients will vary1. With the personal equation of the individual making the estimate.

2. With a number of incidental factors, such as the proportion of disturbed patients to the total population, the ratio of attendants to patients, and the percentage of overcrowding in the hospital, all of which render it more difficult to give excited patients individual attention.

3. With the admission rate. Studies at the Manhattan State Hospital have shown that from 25 to 30 per cent of all patients admitted have at some time during their first two weeks residence become sufficiently disturbed to require special treatment. On the other hand, less than 15 per cent of the total population may be expected to become disturbed, and only about 5 per cent of the total population is continuously disturbed.

4. With the ratio of foreign-born, and especially of nonEnglish speaking patients to the total population. Such patients are always more likely to become disturbed because of their inability to understand hospital conditions; moreover, the insane of certain races show proportionately a very high rate of disturbed patients.