Part 41

We find among neuroses not infrequently mild convulsions. We don’t know a great deal about these convulsions; some are epileptic and some are not. The true epileptic, however, has great difficulty in making a go in the outside world. The number of convulsions per month is not an indication of his disability, entirely, because the passage of the Employees Compensation Act in the several States, has interfered with the employment of men with an epileptic past.

It is as hard for the man who has a seizure once a month to get a position as the one with four, so the question of treating epileptics is one largely of social service and compensation.

The hospitalization of epileptics has not been a success in the hands of the Public Health Service. One of the Western States that built a large colony for epileptics some years ago has now turned it into an institution for feeble-minded.

The question of vocational training is also a big problem in connection with this type of disability. A man, for example, whom I saw a few weeks ago, had been a jewelry polisher in Boston. Before the war he had to get up every morning early and go to his work. He gave most of his earnings to his family. He was suddenly taken out of that situation by the draft and put into a situation where it was simple for him. All he had to do was to get up and move around when some one told him to. He was furnished with his clothing; he was furnished with his food. When he got over on the other side he painted a rosy picture about how things were at home. When he got back home it was not like what he imagined it was. He had to get up and go back to his old job. It was hard for him to make the effort. He quit his job. He goes to the Vocational people (he had a seventh-grade education). He wants to become a civil-engineer. Obviously he cannot. He tries another occupation, etc. Now the attempt of that man to better his condition is a laudable one, but very often that desire to get away from a difficult situation is a part of his mental disorder. He must be made to understand and meet that problem frankly and not be seeking round-about paths without very much continuity of purpose. Vocational training in connection with epileptics has not been very successful. Dr. Ellison who has had charge of a hospital for epileptics can give us some valuable information on the problems of the epileptics.

I think that Dr. Wilbur, who has had charge of a large station at Chicago, can give us some valuable information about preliminary examinations, the social service aspect of these cases, the need of social service and the handling of the psychoneurotic in out-patient clinics. Dr. Wilbur and Dr. Chronquest can tell us about the problem affecting the insane. Mr. Chairman, I suggest that you call on them.

Dr. ELLISON: I want to say the program as outlined in the afternoon session is one of vital interest to me, because I have been in charge of one of the most problematic Government Institutions in the country, that is, an epileptic hospital in East Norfolk. The administrative program in hospital of this kind, taking into consideration the application of general orders, hospital regulations and internal regulations as within the hospital, is entirely different from any other class of hospital under Federal control.

The very fact that you attempt to apply certain regulations in a hospital of this kind where the morale is naturally at a low ebb, due to the mental phases under which these men are suffering, sometimes results in disaster and the breaking down of the morale you have in the hospital.

I would like to go on record in stating it is my belief that voluntary hospitalization of the epileptic is anything but desirable.

From the standpoint of rehabilitation of the epileptic, I must take into consideration the particular type of epileptic we have in the hospital. As Dr. Treadway stated, the majority of these man have not reached probably the school grade of seven years. There has been an attempt on the part of the rehabilitation department to make lawyers, doctors, diplomats out of these epileptics. It is absurd and cannot be done. These men are social and economic lepers, so far as their rehabilitation is concerned. The communities do not want them. Their families do not want them and the responsibility for their care rests upon the Government. Then what is to be the solution of the disposition of these men? I can see but probably two solutions to the question. Voluntary hospitalisation is out of the question. I believe that that part of the Bureau concerned with the compensation of these men, from an economical standpoint, must take into consideration the question of the grouping of these epileptics. There is a class which can live at home. There is another class, not definitely formidable, which does need custodial care. Then there is the psychiatric epileptic who needs psychopathic institutional care. In arriving at the disposition of these men you must take into consideration those three groups.

Then there is another group, there is a mixed group of epileptics. In many instances we have noted, after a long period of observation, that a man may react to some situation, starting out in a hysterical seizure and wind up in a definite epileptic attack. That has been true in quite a number of cases and I should like to urge upon the Bureau District officers and those concerned, this one thing:

In referring cases to East Norfolk, I think a very careful examination should be made of these men to determine as nearly as possible that they are epileptics.

At East Norfolk there is a situation existing which I have endeavored to correct; that is hospitalizing psycho-neurotics,—neuropsychiatry cases which are not definitely epileptic, which are made worse by contact with the epileptic patient. These men are being made worse every day. Some of them simulate very closely the epileptic; many have learned to bite their tongues as the epileptic does. They should not be hospitalized; about 25% of the cases are not epileptic. I think that should be taken into consideration and a careful survey made of these patients before they are transferred to East Norfolk.

As to these cases, very much the same program is carried out as Dr. Kolb’s. Complete preliminary physical and neurological examinations are made and patients are placed under observation of one man, who observes them and makes notes from time to time. As for the treatment of these men, there is little to be done in a way. I think it resolves itself into occupation mostly. I think the occupational measure as applied to the epileptic is the only solution. I think they should be kept busy every moment, for many reasons. They are naturally fault finding and if they have something to do it will lessen the time they have to think of these things. It will promote interest in their surroundings. It will lessen the liability of deterioration but as the thing now stands that cannot be done, under the present method of hospitalization. The solution covering that is, I believe, for the Government to formulate, properly taking into consideration these districts, and build an epileptic colony, under proper supervision, and I believe from an economic standpoint, it could be made almost self-supporting.

In regard to the medical treatment, we have been instituting at East Norfolk a very careful treatment,—careful observation—to determine the real value of luminol in the treatment of epilepsy and we have found that it has been beneficial in many ways; that it lessens the severity of the shock, prolongs the intervals between shocks and in many instances effects complete cessation; the patient becomes more alert, more active, more interested in his surroundings. This treatment must be continued day after day. If there is a cessation, or lack of it, or a failure or inability on our part to obtain luminol, these men immediately react to the lack of it. I should say we have had at least four deaths at East Norfolk due absolutely to the lack of luminol.

DR. WILBUR: At Chicago we developed a diagnostic clinic at the Marine Hospital and had two departments: in-patient and out-patient departments. We had a capacity for in-patients of about 150. The out-patient department was unlimited and developed to approximately 160 to 175 patients at one time. The in-patient department is divided into five groups for the investigation of cases;

1. Cases which would be immediately transferred to some other hospital as soon as arrangements could be made;

2. Certain disorders taken up under direction of an officer particularly interested in such disorders and investigated as fully as possible;

3. Hyper-thyroidism, following operations, where the pulse is still high. When such cases were sent to us, an attempt was made to stabilize the patient and bring him down to a nearly normal basis so that he could go out and take Federal Board training.

4. Psycho-neurotics.

5. Epileptic and hysterical cases.

I might say that out of every fifteen cases sent in with diagnosis of epilepsy, about twelve or thirteen of them proved, after careful observation for a period of from two to three months, to be hysterical. That was about our ratio on cases sent in.

Our procedure was much like Dr. Kolb’s at Waukesha. The man was given complete physical, neurological, examination first. We had a special consultant who visited the hospital about once a week. After a man had his examination, he was checked as needing further examination in eye, ear, nose and throat, or x-ray,—whatever was indicated in the case, and that was tabulated on the chart and checked against his examination. At the end of that time each ward surgeon prepared a summary of the case and a decision was made as to whether the patient needed a short term of treatment in our own hospital,—we had there occupational therapy and other methods of treatment,—and then be discharged and sent back to his home.

In connection with the in-patient hospital work, we had a committee at the district supervisor’s office made up of one representative at the Bureau of War Risk Insurance, one from the Federal Board, the neuro-psychiatric contact officer and one representative from the Public Health Service. We tried to place the men in some definite schedule,—the Federal Board, if possible, after he was discharged from the hospital, and we would bring our problem cases to this meeting, where they would be taken up and such arrangements made for their further treatment as necessary. The contact man visited the station once or twice a week to familiarize himself with the problems of each man.

The out-patient department was naturally on a different schedule; that is, certain hours of the day were set aside and definite offices assigned to the out-patient department; they kept track of their own patients, who reported in at intervals of two or three times a week, every two or three weeks, according to the needs of the case. If the man needed some special treatment, he came into the hospital for that treatment and at the same time he saw this ward surgeon and talked the case over with him. Just as soon as that patient was ready for vocational training, he was put into touch with our contact officer and a schedule was made out for him.

In regard to the vocational training for epileptics, a great many cases during the year I was at Chicago, came up to that board for consideration. We tried the epileptic at various occupations; kept him away from machinery so as no injury would come to him, and we succeeded in rehabilitating only two epileptics out of the whole group. These two were given positions in factories that were owned or governed by some relative or friend who had taken an interest in then, disregarding the compensation laws and disregarding the inability of the men to work when they would have a seizure. In two instances only have we succeeded in putting men into training where it proved a success.

DR. MCLAKE: I represent the National Sanitorium in Marion, Indiana. Presume all of you have heard more or less about it. It was organized about a year ago; opened on the first of January as a sanitorium. During the past year we have cared for about 1500 patients. The present Census is 800.

Now this institution was opened under a provision that it was to be used for the hospitalization of reasonably curable cases. In other words, it was not to be an asylum. It was not a place for merely domiciliary residence or custodial care. The needs of hospitalization, however, this year, have been such that we have taken all sorts of cases. As this has been a matter of discussion for many hospitals and in many districts, I want to take half a minute to show you that during the past year and at the present time, I am hospitalizing at Marion nearly every variety of n.p. case which we have.

Up to the present time we have had no special accommodation whatsoever for n.p.-t.b. patients. Our institution is built on the cottage plan and in the preliminary survey and construction no provision was mode for t.b. patients. However, at the present time I have one ward which is filled with eleven of these cases. I may say in this connection that we are expecting to build a t.b.-n.p. unit of eighty beds and will start construction in about five or six months, which will be gratifying to you men who have these combined cases and would like to unload them and as soon as we can take these cases off your hands we will be glad to do so.