Mentally Ill

Mentally Ill. In pronounced, fully developed mental diseases, there are a number of features that distinguish mentally ill patients from all other patients and lead to a special attitude toward them in legal matters, to special care for them, and to a unique organization of psychiatric care, different from the organization in other areas of healthcare. The main features of pronounced mental diseases are: the patient's inability to direct their own behavior, manage their affairs, insufficient consideration of reality, often lack of awareness of illness, social danger of some mentally ill patients, possibility of them committing improper, criminal actions, and their agitation ('violence'). Already in ancient Rome (Cicero), they distinguished between simple mental insanity, combined with feeblemindedness and calm behavior (insania), and madness, 'fury' (furor), and if patients of the first type were treated as cripples, equating them with the deaf-mute, blind, etc., and under primitive agricultural production conditions, the state left them in the care of relatives and paid little attention to them, then society from early times sought to protect itself from the latter. In the Middle Ages, the cause of madness was considered to be the possession of a patient by an evil spirit or at least communication with it, and sinfulness, and therefore as a measure of combating madness, they advocated either prayers or severe punishments, up to burning at the stake or at least imprisonment in monasteries. In ancient Rus', in the 12th century, for example, as we read in the Ipatievsky Chronicle, in Pereyaslavl at the monastery of St. John there was a 'strong dungeon' for such patients. As early as 1762, by decree of Catherine II, two monasteries were appointed to supervise the insane: in the Novgorod diocese-Zelenetsky and in the Moscow-Andreevsky, and in 1773, two monasteries (male and female) in each province. As early as the 18th century, in English legislation in the so-called Vagrant Act (1744), it was prescribed to 'dangerous madmen, on the basis of a judge's decision, to be imprisoned in prison and if necessary, to be chained in chains.' Although the number of agitated 'madmen' was small, with the development of industry and the growth of cities and increased housing congestion, the number of patients requiring isolation constantly increased, and due to the decrease in church influence and the inconvenience of keeping them in common prisons, from the 15th and 16th centuries in Western Europe, special institutions for such madmen began to appear; treatment of them, however, remained harsh here, and the means for treating them consisted of chains, whips, and solitary confinement. The science of psychiatry actually began from acquaintance with these agitated patients, and along with it the idea of a more correct attitude toward mentally ill patients and a non-mystical understanding of the causes of mental diseases. As early as the 16th century, Felix Platter (Felix Platter, 1536-1614) tried to apply for the treatment of madness 'psychological methods corresponding to the causes of the disease' and spoke out against their imprisonment in solitary confinement, etc. In Russia, the first house for the insane was opened in 1785 in the Preobrazhenskaya settlement in Moscow, and in 1786 in St. Petersburg. With the growth of the industrial bourgeoisie, with the emergence of legal concepts about the need to protect personal freedom, with the growth of materialistic worldviews, the attitude toward mentally ill patients also changed. The first powerful push to free mentally ill patients from chains and prison conditions was given by the ideas of the Great French Revolution and was expressed in the liberation by Pinel (Pinel) and his assistant, the supervisor of the mentally ill Pussin in 1792, of the patients at Bicêtre and Salpêtrière in Paris from chains. But Pinel not only abolished chains, he already advocated a number of measures that established the basic principles of proper care for mentally ill patients: 1) humane treatment with them, 2) proper hygienic conditions of their life, 3) the introduction of work for them. However, Pinel still believed that in caring for mentally ill patients it was impossible to do without violence at all, and introduced a more humane method than chains-the straitjacket (see). Esquirol, continuing Pinel's ideas, however, found that the number of mentally ill patients requiring a straitjacket does not exceed 1%. With the growth of factory industry, with the improvement of psychiatric hospital design, the number of mentally ill patients placed in psychiatric hospitals began to increase sharply, and calm patients with a milder course of the disease were also placed there, because in the conditions of an industrial city, care for them at home became difficult, and patients who had been 'agitated' in prison conditions turned out to be calmer under a mild regime than before. In England, a country where factory industry developed earlier than others, as early as 1796, i.e., before Pinel, William Tuke organized the 'York Retreat' for mentally ill patients, where for the first time all mechanical restraining measures (the 'no-restraint' system) were abolished. 'Everyone here was occupied with work, and patients diligently engaged in work: women sewed and knitted, men worked the land; it turned out that productive labor is one of the most effective calming means'--a contemporary wrote about the York Retreat. However, information about this retreat hardly penetrated the continent. The theoretical justification for the 'no-restraint' idea was given by Conolly (Conolly) in Hanwell and Charlesworth and Guillemin in Lincoln (England) in 1837. The straitjacket was completely rejected; isolation rooms with soft walls were introduced; it was established that with proper distribution of patients according to their condition (division of psychiatric hospital departments into agitated, semi-calm, calm, and weak wards) and sufficient supervision during work, restraining measures for mentally ill patients are not required. Conolly's positions initially caused a heated controversy among psychiatrists, but the royal commission that inspected the hospitals in 1854 spoke out in favor of 'no-restraint' and since then this system has been officially recognized in England. This system was implemented with difficulty in other countries: Magnan and Bouchereau were its supporters and first implementers in France, Dick (1856), Griesinger and Westphal-in Germany, S. S. Korsakov-in Russia. In 1872, Bathy Tuke spoke of the further development of this system, the abolition not only of mechanical but also 'chemical' (sleep-inducing) restraining measures, of free walks for mentally ill patients, etc. (the 'open door' system). In connection with the recognition of the enormous importance of labor for the proper maintenance of mentally ill patients, in connection with the need for a free regime, the so-called 'colonies' for mentally ill patients in suburban areas began to be established. The first such colony, Guggingen in Germany, opened in 1859. Psychiatric institutions from places of 'confinement of the mad' turned into 'the most powerful means of combating mental diseases,' as Krafft-Ebing says. 'Only the smallest part of patients is kept in locked rooms, while the majority enjoys freedom of movement within the limits permitted to them.' From this time, the so-called 'patronage' system of care for calm mentally ill patients in families also began to develop widely (see Patronage-psychiatric patronage). However, under the conditions of the socialist system, of collective rather than individual economy, the patronage system, which is of great importance in bourgeois countries, must be replaced by the organization of collective farms, state farms (see below), to the organization of which steps have been taken in some places. The implementation of the no-restraint system, the open door system, has caused and still occasionally causes objections to this day due to the possibility of so-called 'escapes,' accidents with mentally ill patients. 'Indeed, with the introduction of the open door regime,' writes Kraepelin, 'it is easier to leave the hospital without permission; sometimes leaving (escape') can end in misfortune, most often suicide or death while wandering (from hunger, cold, etc.). However, it would be a gross mistake to abandon the no-restraint system because of these, in general still rare, cases. In the end, the goal would not be achieved anyway, since escapes occur even from the strongest prisons, and we would lose the main and most powerful means for treating mental diseases, we would lose the trust of patients, their satisfaction with being in the hospital.' The total number of escapes from psychiatric hospitals under a free regime is generally small: in a hospital with 1,000 patients, no more than one or two dozen, and this number should be considered as an inevitable accident, as sometimes death under the knife is inevitable for surgeons, therefore, treating the free discharge of a mentally ill patient as 'intentional leaving of him in a dangerous state' does not seem possible. The imperialist war of 1914-18 and the civil war forced attention not only to the rapidly developing forms of mental diseases, not only to the care of calm chronic patients, but also to so-called reactive transient conditions, to psychogenic conditions, the importance of the entire surrounding environment, experiences for the occurrence of mental diseases began to be studied, 'small psychiatry' (Gruhle) emerged, the psychogenic hygiene movement emerged, the awareness of the need for preventive measures-hygiene and prevention of mental diseases (see Psychogenic hygiene).

The concept of 'mentally ill' has expanded, and whereas previously only the insane and the rabid were distinguished, now the broad concept of mental illness includes not only psychopathies (see) but also neuroses (see). Thus, we see how, with changes in production relations in connection with the needs of social life, the principles of organizing psychiatric help also change, and along with them, the very scope of the concept 'mentally ill'. Organization of help for the mentally ill At present, the psychiatric organization cannot be satisfied with only psychiatric hospitals, colonies, and patronage. In Western Europe and America, the question has been raised about open psychiatric assistance, about dispensaries for the mentally ill. Under the conditions of a socialist state, under the conditions of the country's industrial reconstruction, the forms of psychiatric organization must correspond to the era of socialist construction. Psychiatric assistance in the Soviet Union is built on the principle of 'graduated levels' (Resolution of the Collegium of the People's Commissariat of Health of the RSFSR of April 28, 1932). Starting with psychohygienic work among the broad masses of workers and collective farm members (see Psychohygiene), the network of neuropsychiatric institutions provides for the following links. A. Outpatient assistance - neuropsychiatric departments of dispensary associations, linked with psychoprophylactic work at the workplace health point and district psychiatry; at large enterprises - work of a neuropsychiatrist at the workplace health point. B. Semi-stationary and stationary preventive institutions: 1) sanatoriums (night and day) and sanatorium departments of psychiatric hospitals; 2) neuropsychiatric departments of general somatic hospitals; 3) hospitals for the acutely ill. C. Medical institutions for long-term stay of patients: 1) therapeutic-labor colonies for chronic patients requiring supervision; 2) colonies of the state farm type or simplest production collectives. D. Institutions for mentally ill disabled persons (in the system of the People's Commissariat of Social Welfare): 1) disabled persons' homes; 2) boarding schools with workshops; 3) disabled persons' artels. E. Neuropsychiatric network for children and adolescents: 1) children's neuropsychiatric departments at psychiatric hospitals (for those suffering from acute mental disorders); 2) neuropsychiatric sanatoriums for: a) preschoolers, b) schoolchildren, c) adolescents; 3) school-hospitals for child epileptics; 4) departments for mentally retarded children; 5) labor colonies for severe psychopaths. F. Institutions for alcoholics: 1) hospitals or departments for acute cases of alcoholism; 2) therapeutic-labor colonies; 3) corrective-labor colonies; 4) narcotic reception centers-sobering-up stations. At the same time, the entire psychiatric organization must turn toward production, toward better serving the shock workers - workers and collective farm members in the first place; psychiatric institutions must not be isolated from Soviet reality: the activity of each psychiatric institution must be closely linked to the participation of Soviet public organizations (party committees, health sections of city soviets, health cells of enterprises, patronage over psychiatric institutions by workers, etc.). The work of neuropsychiatrists at workplace health points is the leading link in the chain of organizing psychiatric assistance, being preventive work that prevents mental illnesses (see Psychohygiene). Accounting and examination of living conditions and assistance to the mentally ill in the population are carried out by dispensary associations and district psychiatrists (see Outpatient assistance - outpatient psychiatric assistance). The workplace health point must be closely linked with the dispensary, receiving signals from it and itself using the data of dispensary examinations. The organization of neuropsychiatric assistance must be closely linked with rest homes, resorts, and sanatorium organizations, directing there patients with initial mild forms to restore their strength, for rest and treatment. For mild forms of psychoses in leading industrial areas, it is desirable to create special sanatoriums with an open regime in suitable climatic conditions. The main type of stationary psychiatric institution should be hospitals for newly ill, curable cases. At present, most psychiatric hospitals are overcrowded with chronic patients who should be in colonies of various types. Filling hospitals with these chronic patients deprives psychiatric hospitals of any possibility of maneuvering to improve the situation of curable groups of patients, which is absolutely necessary and should constitute the main therapeutic task. Therefore, the main moment of reconstructing existing psychiatric hospitals should be the allocation of hospitals for newly ill mentally ill patients. The hospital accepts all new patients, as quickly as possible sorts out the chronic patients and directs them to appropriate colonies or under outpatient observation, while the curable patients remain in the hospital until recovery or discharge with improvement, being in the most favorable conditions both sanitary and therapeutic, to which all available means are first directed. The care of patients in the hospital should be brought to the maximum height; in addition to all types of drug treatment and sufficiently developed physiotherapy, all types of psychotherapy should be applied to such patients, not only in the form of generally accepted qualified methods, but also simply in the form of long conversations, satisfying the cultural needs of the patient during their leisure time. Labor processes should be widely developed, and the health-improving effect of labor should be applied to all except those needing complete rest. The number of newly ill mentally ill patients is relatively small. In the former Russian zemstvo psychiatric hospitals, as shown by the census of patients by their condition carried out in these hospitals in 1913 by the Union of Psychiatrists, acute patients constituted only 15% of all patients. As the Moscow census of 1911 showed, out of 6,078 mentally ill registered in the population at the time of the census, only 302 were acute, newly ill, i.e., with the then population of the Moscow province of 1,756 thousand people, only 0.18 per 1,000 inhabitants. The number of admissions to English and American (USA) psychiatric hospitals also gives approximately the same number: thus, in 1929, during the entire year, 44,452 mentally ill were admitted to English psychiatric hospitals, which with a population of 39,948 thousand will be 1.1 mentally ill per 1,000 inhabitants; in the USA in 1929 there were 88,963 admissions to psychiatric hospitals, i.e., with a population of 121,800 thousand - 0.72 per 1,000 inhabitants. Taking into account that an acute psychiatric bed turns over at least 5-6 times [in the Kazan Regional Psychiatric Hospital in a year with 120 acute beds, it was possible to pass 1,700 patients a year, and 66% of men and 51% of women were discharged recovered or improved from acute departments, i.e., the turnover was 14 times; the Munich psychiatric clinic of Kraepelin on 120 beds passed up to 1,600 patients, i.e., the bed turnover was also 14 times (1905-1909)], we therefore in both England and America at any given time also have no more than 0.15-0.20 acute mentally ill per 1,000 inhabitants. With such a number of patients, providing assistance to all newly ill mentally ill patients is quite a feasible task. However, one of the basic conditions for receiving fresh cases, for obtaining a high percentage of recoveries, is the proximity of psychiatric assistance to the population. So far, psychiatric hospitals have existed only in regional centers. Poor communication routes, little awareness of the population about distant psychiatric hospitals, difficulty of relatives communicating with the patient, difficulty of transporting a mentally ill patient - all this complicated the placement of newly ill patients in a psychiatric hospital. The area of the hospital's beneficial effect was limited only to the city where the hospital was located and the nearest districts, with distant districts hardly using it. Thus, in 1925, in the Kazan Regional Psychiatric Hospital, the number treated per 10,000 population was: residents of the city of Kazan - 14.6 people, residents of the nearest cantons: Arsky - 2.4, Laishchevsky - 2.2, Sviyazhsky - 2.5 people, and residents of distant cantons: Bugulminsky - 0.6, Chelny - 0.9. Therefore, the question of decentralization of psychiatric assistance was raised long ago. A number of leading Russian psychiatrists (P. I. Yakobi, V. I. Yakovenko, N. N. Bazhenov, N. A. Vyrubov, V. M. Gakkebush, etc.) spoke in favor of the need for decentralization. Questions of decentralization were discussed in 1908-14 in most zemstvos, and only the imperialist war prevented the implementation of decentralization, although in Kharkov (hospital in Svata Luchka) and in the Vyatka zemstvo decentralization began to be implemented to some extent. V. I. Yakovenko proposed to set up in each district one small psychiatric hospital (for 15-20 beds) 'exclusively for newly ill patients, but not with the aim of their temporary stay there until transfer to a central hospital, but for systematic treatment, directing only chronic patients to the central hospital.' However, most, not without reason, are opponents of such dwarf psychiatric hospitals, since in acute psychiatric hospitals it is especially necessary to divide patients according to their condition. The smallest hospital should be considered a hospital for 60-100 mentally ill patients. At present, many in the USSR also share the view on the possibility of establishing such psychiatric departments for 60-100 beds in large somatic hospitals in large industrial centers (Donbass).

In any case, all existing psychiatric hospitals should have well-equipped facilities for newly ill workers. The organization of care for the mentally ill is the most backward area in the health care front; here one must not consider the normal percentage of mentally ill in the population, but rather the accumulation of these patients over all past time. 'To exhaust this accumulation and at the same time admit all newly ill patients is economically impossible—this must be known and one must refrain from unnecessary attempts which will only worsen the situation,' said P. I. Yacobiy long ago. Therefore, striving for the most complete and best possible care of newly ill patients, it is necessary to admit from the chronic cases only those who interfere with productive life outside the hospital and require special care. Considering the number of mentally ill (see Mental Illness) to be 3 per 1,000 inhabitants, V. I. Yavenko and P. P. Kashchenko assumed that in one form or another of social care, 33-35% of all patients are in need, i.e., 1 per 1,000 inhabitants, including both patients under supervision and patients requiring assistance in their care at home. According to the 1911 Moscow census, out of 6,078 mentally ill patients, there were 664 agitated, 191 weak, 302 newly ill, and in total 1,157 patients requiring hospital treatment, i.e., 0.66 per 1,000 population, of which 0.18 were newly ill and 0.48 were chronic cases per 1,000 population. In addition, according to the Moscow census data, 200 mentally ill patients required supervision, 133 required poorhouses, and 342 required assistance in their families. In total, 1,833 mentally ill patients required public assistance out of 1,756 thousand inhabitants. Chronic mentally ill patients should be distributed in closed and open colonies and shelters. Closed colonies should be understood as hospital institutions differing from facilities for newly ill patients both in terms of the patient population, which consists entirely of chronic cases, and in terms of the basic approach to the work regimen. The entire routine, structure, and technical equipment of the colony must ensure the possibility of directing each patient toward some socially useful, economically valuable labor process, utilizing the patient's residual work capacity and thereby maintaining their human dignity and worth. In closed colonies are chronic mentally ill patients who require supervision, as they may have, even if only temporarily, motor restlessness, aggressiveness, improper actions, or who require special specialized care (paralytics, catatonics, etc.). Some of these patients must at any given time be in closed wards and work only within these wards, others may be at work under constant supervision, and only a small part works more or less freely, however also not without observation due to the possibility of a change in condition here as well. According to the Moscow census, there were 664 such patients who were occasionally agitated (of whom 132 were agitated at that moment, and there were 191 weak patients requiring special care). From this calculation, i.e., 0.48 per 1,000 (with 20% of them in closed wards), the size of closed colonies should be calculated. Open colonies should provide an equivalent to a series of institutions, some now existing, some having existed before, and some only projected by individual psychiatrists and never realized. We have the beginnings of such open colonies in some of the existing psychiatric hospitals: for example, houses in Igren (Dnepropetrovsky district), a state farm in Kharkov, work departments with open doors and self-service in Kharkov, Poltava, a small 9th department in Kazan, etc. Patients of the supervision type, with the elimination of this individualistic-capitalist form of care, should also be placed in open colonies. Finally, open colonies should compensate for the absence of so-called psychiatric labor settlements, the project for which was developed in Kharkov by Dr. Ilion. We must envision open colonies as agricultural institutions of the state farm type with a relatively small hired staff of workers and a staff for guidance and supervision, with the main working force being the mentally ill patients. In case of occasional exacerbations of mental illness and somatic diseases, a ward for 10-25 beds should be available at a colony for 500-600 patients. The number of mentally ill patients requiring open colonies, i.e., those very close to a state where significant social rehabilitation and inclusion under supervision in work at the actual production site is possible, is closely related to the characteristics of the entire current production life. It can only to a certain extent be compared with the number of mentally ill patients who previously required supervision and assistance in their families. In any case, open colonies should not set as their task the covering of all chronic mentally ill patients. All mentally ill patients should be under dispensary registration, but they are placed in psychiatric institutions only for social indications. The task of the psychiatric organization of a socialist society should not be the isolation in various types of psychiatric institutions of all those who have fallen mentally ill, but rather the striving 'to include a larger percentage of those who previously remained outside the socialist construction process' in the general process. Weak, calm, non-working mentally ill patients, not requiring special psychiatric supervision, can be transferred to the shelters of the People's Commissariat for Social Welfare. Care of the mentally ill. In caring for mentally ill patients, one must consider a number of duties that distinguish this care from care for other patients. First of all, due to the great duration of mental illnesses, the entire living conditions of the psychiatric hospital acquire particularly great importance. Psychiatrists more than any other doctors need to care about the comfort of the entire hospital environment; wards should be furnished with flowers, pictures, comfortable furniture, so that the severity and sparseness of the environment does not have a depressing effect on patients. The correct distribution of patients in departments (agitated, semi-agitated, weak, recovering, etc.) and even in individual wards is of enormous importance; one should strive for sufficient supervision over those patients who require it, while calmer patients should have sufficient freedom, and at the same time one patient should not disturb another. It is also necessary to take care of the reasonable cultural use of patients' leisure time, to provide them with opportunities for entertainment, games, reading (library, newspapers), and cultural conversations with them. While carefully observing changes in patients' conditions, one must timely prevent their strong excitement by bed rest, long baths, and timely administration of sleeping pills (in necessary cases, prolonged narcosis). Since mentally ill patients often do not notice their own physical illnesses, it is necessary to examine patients physically as often and thoroughly as possible; it is necessary to monitor the cleanliness of patients; it is necessary to instruct all personnel so that no one argues or quarrels with patients, is not rude to them; it is necessary to patiently endure various improper actions and verbal offenses from patients; it is necessary not to bring various kinds of gossip into the life of mentally ill patients, not to talk with them about incidents in the hospital, about various rumors in the city, about individual hospital staff and their relationships. Although cases of strong excitement in well-equipped psychiatric hospitals are rare, there are still cases when it is necessary to restrain mentally ill patients by force; here especially important are self-control and purely technical skill to restrain a mentally ill patient with less force and rudeness. Each such restraint should occur in the presence of a sufficiently cultured and knowledgeable person (usually a member of the middle staff on duty). All complaints from mentally ill patients about rudeness should be thoroughly investigated, and in any case the doctor must know exactly the origin of every bruise, every scratch on the patient. When restraining, one must remember the fragility of bones (especially ribs) in paralytics and the elderly. Unfortunately, we still cannot manage without violence when dealing with mentally ill patients, therefore various kinds of accidents are possible, but for the doctor the entire picture of the accident and its inevitability must be completely clear. All patients prone to impulsiveness, to suicide attempts, must be in so-called 'observation' wards with particularly strict and constant supervision; such patients must be escorted to the toilet, not left there alone, as experience shows that accidents happen particularly often in toilets. Medicines should in no way be left near the patient; they should be distributed by staff each time, and it is necessary to ensure that they are drunk in the presence of staff; medicines should be distributed not near the medicine cabinet in special rooms, but in the patients' wards. The impulsive unexpected actions of patients, their persistent desire for suicide, the necessity sometimes of violence when 'restraining' them from aggression—all this leads to a certain number of accidents in psychiatric hospitals being unavoidable.

Thus, in English psychiatric hospitals over the last decade, the following number of suicides occurred: 1920-47; 1921-45; 1922-52; 1923-39; 1924-44; 1925-47; 1926-55; 1927-69; 1928-64; and in 1929-61. According to data from the Chief Medical Inspectoror, in tsarist Russia in psychiatric hospitals in 1913, out of 57,545 treated patients, there were 10 suicides; in 1906-17 (out of 71,966 treated patients), in 1908-29, in 1912-16. One suicide occurs for every 40 attempts. Even in the reports of the best psychiatric hospitals, other accidents are described. For example, in the report of the New York Manhattan State Hospital for 1907, out of 5,895 treated M. patients, there were 6 accidents: one patient poisoned himself with corrosive sublimate, one disappeared and was not found anywhere, one hanged himself, one died from a fracture of 3 ribs, and the investigation did not find that he had been roughly restrained (senile psychosis), one patient broke a glass and swallowed glass shards from it, one patient quickly jumped out of the dining room window, managed to run to the river and drowned. The psychiatrist's duty is to thoroughly investigate the circumstances of all such cases and to bring each case to the public's attention, to eliminate noted organizational shortcomings, and in case the cause of the accident was negligent and criminal attitude of the staff, they should be brought to trial. To combat the most severe symptom of mental illness - motor agitation - sedatives remain: bed rest, quiet, sleeping pills (Paraldehyde 5.0-in alcoholism, chloral hydrate, luminal, veronal, etc.); in recent times, the very good effect of prolonged narcosis (Dauersnarkose) for several days and weeks is mentioned, during which the patient only wakes up to eat; then baths (neutral, temperature 27-29°), during which long (hours and even days) baths are of great importance. When rapid calming of the patient is necessary, scopolamine-morphine is usually used (Rp. Scopolami gr. 0.01, Morphii mur. 0.1, Aquae 10.0- 1.0 for injection). All kinds of mechanical restraining measures, tying up, are completely unacceptable in modern psychiatric hospitals. Often, so-called "wet (Pribram's) wraps" also turn into tying up, therefore, if they are permissible in psychiatric hospitals, it should only be on a doctor's order at a predetermined time of day, for a specified period, but it is better not to use them at all due to the possibility of abuse, and to replace them with baths. In well-equipped psychiatric hospitals with a proper daily routine, with activities for patients, in an uncrowded hospital, there is absolutely no need for isolation cells, but where overcrowding forces their use, isolation should only be prescribed by a doctor, for a short time, and the time of isolation for each patient should always be precisely established; prolonged isolation undoubtedly leads to the patient's becoming wild and coarse, increases their asociality and aggressiveness, and makes them hostile to doctors and staff for a long time or even forever. Due to the tendency to refuse food, weakness, and inattention to surroundings, careful attention must be paid to feeding patients. Great attention must be paid to weak, untidy patients. One of the best means of preventing soiling with urine and feces is regular (1-2 and even 3 times a day) enemas; bedpans and immediate washing after each untidiness are necessary. Bedsores, with careful observation, should be a rare exception in a well-equipped psychiatric hospital. Labor therapy has enormous significance in the life of a psychiatric institution. Idleness and time not filled with productive labor increase the feeling of inability and helplessness in patients. Active labor therapy necessitates the presence in every psychiatric hospital of appropriate workshops and instructors, but labor therapy should also be carried out in wards, including those with agitated patients. At the same time, labor therapy should not aim only at physical strengthening, motor training of patients, or filling free time, imparting only technical skills, but should strive to create in M. patients appropriate experiences and emotions of a collective-class nature, arousing the patient's social activity and raising labor therapy to the level of social psychotherapy, developing a correct attitude toward labor. Social-labor activity is an inseparable part of a person; a healthy person cannot do without the opportunity to creatively participate in collective labor activity, without the opportunity to experience the joy that a finished product of labor brings to its creator. One of the foundations of mental illness is precisely the inability to work in the direction required by the consciousness of this specific historical person (social conflicts, rupture of the integrity of the personality). Therefore, labor therapy, arousing confidence in the possibility of further work with the collective, should be the main psychotherapeutic factor in all those cases when the person themselves, for various biological or social reasons, begins to lose this confidence. On the other hand, labor activity, using the residual labor resources of chronic patients, also allows them to maintain their connection with society, to preserve the remnants of human personality and consciousness. It is known that in psychiatric hospitals where the work of patients is poorly organized, a whole series of cases of so-called "hospital dementia" is observed, deterioration of mental illness under the influence of lack of labor. The introduction of labor even into the agitated ward of patients undoubtedly serves to calm them. Therefore, the use of labor as a therapeutic factor in chronic patients, changing attitudes toward labor in these conditions in mental illness through psychotherapy should be widely used in the treatment of mental patients, of course, taking into account the peculiarities of the patients, the need for many newly ill patients, somatic patients, at the proper time also for increased rest. The number of working patients in German psychiatric hospitals reaches up to 98% (Titt) or 87% (Ilberg). Labor is the powerful means that activates the healthier elements in the patient's psyche, distracts them from delusional ideas and pathological manifestations, and makes them calm. The staff should also, along with the patients, take an active part in labor, by no means being only supervisors and drivers of labor processes. All these care and regime measures in a psychiatric hospital should by no means, especially in hospitals for newly ill patients, exclude the use of all means of medicinal and physical therapy. Proper implementation of the regime in psychiatric hospitals requires trained, sufficiently cultured, and dedicated staff. Unfortunately, in our USSR in the USSR, we still have to use random people as orderlies, staff turnover is enormous. Nevertheless, all measures must be taken to train each new orderly, to establish short-term courses for their preparation. Many psychiatrists find that female care is much better than male care. In tsarist Russia, the director of the Oryol psychiatric hospital, German, especially advocated for the introduction of female care in all departments of the psychiatric hospital, however, at that time, the reason for this was largely the much lower cost of female labor and the possibility, as a result, of better selection of staff at low pay. Undoubtedly, among the male staff we also have dedicated, excellent orderlies, and raising the question of the need to replace all male staff with female staff is not a necessary and fundamental requirement. In each psychiatric department, in addition to the constantly on-duty orderlies, there should always be a member of the middle staff on duty in our conditions. For the training of middle staff, special psycho-neurological technical schools have been organized recently. Legal status of the mentally ill. Hospitalization. The lack of awareness of their illness observed in many M. patients, their danger to society and to themselves (suicide, underestimation of the situation, impulsiveness, etc.) create the need for their compulsory placement in psychiatric institutions, and naturally the question arises about the legal limits of the necessity of this violence and the legal norms for its implementation. Concern for the protection of the personal freedom of M. patients first manifested in France during the revolutionary era, when the investigative commission appointed for this matter discovered many abuses in the commitment of "mad" and "eccentric" persons to monasteries by royal decree; this commission prompted the National Assembly to issue on March 16 and 27, 1790, a law protecting M. patients from violence upon placement in a hospital. Tuscan legislation was the first to apply this principle in practice, and then it entered into the practice of legislation in almost all Western European and American countries. Usually, the law prescribes that when a M. patient is forcibly placed in a psychiatric hospital, a police commissioner must be present, two medical certificates must be presented, and no later than 24 hours, the district prosecutor must be informed of such placement.

In addition, psychiatric patients are subject to the control of special judicial-social commissions, and the law provides for patients in psychiatric hospitals the right to communicate with supervisory authorities. However, in recent times, there have been increasing complaints that the complex procedure for admission to psychiatric hospitals often delays the admission of the most acute cases, and therefore, in addition to closed psychiatric hospitals in Western Europe and America, open psychiatric hospitals are beginning to be established for voluntary admission, which is especially necessary in view of the expansion in modern psychiatry of the very concept of 'mentally ill.' However, such hospitals not only provide the right for free admission but are also obligated to freely discharge patients at their request. In view of the special composition of patients in these hospitals, and to avoid their being traumatized by agitated patients, it is recommended that such psychiatric hospitals be set up separately from closed psychiatric hospitals or at 'somatic hospitals.' Examples of such hospitals are Hôpital Henri Roussel in Paris (Prof. Toulouse), West-End-Hospital in London, and others. The Congress on Mental Hygiene believes that at the present time 'open psychiatric hospitals should be at the center of care for the mentally ill.' In the USSR, the involuntary commitment of the mentally ill is determined purely by medical indications and is carried out by health authorities, but according to Article 148 of the Criminal Code, 'the placement of a healthy person in a hospital for the mentally ill for mercenary or personal purposes is punishable by imprisonment for up to three years.' Guardianship. Due to the inability of the mentally ill to manage their affairs and property, the legislation of all countries contains provisions for the imposition of guardianship on the mentally ill. In Soviet legislation, Articles 8 and 31 of the Civil Code state: Article 8- 'Adults may be declared incompetent by institutions if, due to mental illness or feeble-mindedness, they are unable to manage their affairs rationally'; Article 31- 'Transactions made by a person who is completely or temporarily incapacitated and unable to understand the significance of their actions are invalid.' According to Article 68 of the Code of Laws on Marriage, Family and Guardianship: 'Guardianship and curatorship are established to protect the person of the incompetent, their legal rights and interests, as well as to protect property in cases provided for by law.' According to Article 79 of the Civil Code: '... The guardian of a mentally ill or feeble-minded person must take measures for the treatment and maintenance of the ward in conditions corresponding to their state of health.' Article 103: 'Regional, provincial, gubernatorial, district, and county guardianship and curatorship authorities, in the presence of sufficient data on the need to establish guardianship over the mentally ill and feeble-minded, appoint a special commission for examination under the chairmanship of the head of the health department... consisting of at least two physicians, one of whom must be a psychiatrist.' The rights and obligations of guardians and curators are set forth in more detail in Articles 71-102 of the Civil Code. Articles 107-109 of the Civil Code deal with the removal of guardianship in cases of recovery. Of great interest is Article 6 of the Code of Laws on Marriage, Family and Guardianship, according to which 'marriages between persons, at least one of whom has been recognized in the established procedure as feeble-minded or mentally ill, are not subject to registration.' Crimes by the mentally ill. Since the mentally ill are unable to control their actions due to their illness, they were considered not only incapable (guardianship) but also not responsible for their actions even under Roman law (see Responsibility). All modern legislation recognizes the mentally ill as not responsible for criminal acts. However, criminal systems that do not provide guidance to the court on how to proceed with irresponsible mentally ill who have committed a punishable offense, but merely indicate the irresponsibility of the act, are now being criticized. Later legislation contains a whole system of so-called 'measures of social protection' and 'security measures,' which are recognized as fundamentally different from punishments and are applied to persons who have committed an externally criminal act while in a state of mental illness. The difference between punishment and security measures is reflected in their application in that a particular security measure is not linked to a specific criminal offense, and its choice depends primarily on what the subject of the act is like. Soviet criminal law generally does not set itself the task of punishment and retribution, does not seek to build the fight against crime on the principles of revenge and intimidation; the workers' state does not punish, but protects itself from socially dangerous acts, regardless of who commits them: 'responsible' or 'irresponsible.' The protection of the workers' state is permeated with the principle of expediency, and therefore, if it is expedient to protect oneself from a mentally healthy offender by corrective-labor measures (e.g., imprisonment and compulsory-labor education), it is completely inexpedient to protect oneself from the same measure against a mentally ill offender, since the only expedient measure of protection against such a person is medical intervention (for example, placement in a medical institution). Therefore, Article 11 of the Criminal Code states: 'Measures of social protection of a judicial-correctional nature cannot be applied to persons who have committed a crime in a state of chronic mental illness, or temporary disturbance of mental activity, or in any other pathological condition, if these persons were unable to understand their actions or control them, as well as to those persons who, although they acted in a state of mental equilibrium, but by the time the verdict is rendered have fallen ill with mental illness. Only measures of social protection of a medical nature can be applied to these persons.' Among the measures of social protection of a medical nature for mentally ill persons who have committed crimes, the Criminal Code distinguishes: a) compulsory treatment, b) placement in medical institutions combined with isolation (Article 24). When the question concerns mentally ill persons in the narrow sense of the word (e.g., psychopathic personalities, trauma cases, and alcoholics without gross personality changes), i.e., those not covered by Article 11 of the Criminal Code, it is possible, according to Article 26 of the Criminal Code, to combine measures of social protection of a medical and judicial-correctional nature. Therefore, in certain cases, in addition to treatment, it is possible to 'prohibit holding a particular position' (Article 37), 'impose the obligation to compensate for the harm caused' (Article 44), and in other cases, the establishment of penal institutions with a psychiatric orientation. The procedure for court proceedings, the procedure for summoning experts in cases where there is doubt about the mental state of the accused, is determined by Articles 63-65, 162, and 169-174 of the Criminal Procedure Code; Articles 196-198, 199-201; the procedure for expert examination in court-Articles 298, 300. When rendering a verdict, the court is guided by Articles 321, 322 of the Criminal Procedure Code. As for persons serving measures of social protection of a judicial-correctional nature who have fallen ill with mental illness, Articles 457 and 458 of the Criminal Procedure Code are applied to them.

Yudin.