CHAPTER IV

THE STATE HOSPITALS—THEIR ORGANIZATION AND FUNCTIONS

The efficiency of the hospital is very largely a reflection of its organization, administration and personnel, but the material equipment of the institution and the financial resources available are factors of no less importance. The future of a hospital is often settled for all time by the degree of judgment exercised in determining its location. The founders must be guided to a very great extent by the purposes which they hope to accomplish. In the location of a public institution of any considerable size, however, there are certain considerations which, if overlooked, will eventually lead to serious difficulties. The initial cost of the property is unfortunately a factor which cannot be disregarded. It is usually considered desirable for obvious reasons to choose a site somewhat removed from great centers of population. A sufficient acreage must be obtained to guarantee an adequate amount of land for farming and gardening on a fairly large scale. This not only insures a ready occupation for patients, but will materially reduce the cost of maintenance. A point which should never be lost sight of is the necessity of choosing a location which can be reached easily by railroads, trolley cars and motor trucks. The hospital must be readily accessible to the relatives and friends of patients. It is equally important that it should be convenient for employees; otherwise an adequate force of nurses and attendants can only be maintained with great difficulty. Above all, the hospital should be in the community which it is destined to serve. The patients should not be removed to any great distance from their homes. In numerous instances severe hardships have been inflicted upon all persons concerned owing to the fact that state institutions have been located in districts where they are not needed by the community and where they cannot be easily reached.

Every large public hospital should be in almost immediate contact with a railroad. Otherwise thousands of dollars must be expended annually for the transportation of coal, food and other necessary supplies. The fertility of the soil to be used for agricultural purposes is only second in importance to the necessity of obtaining satisfactory building sites. A practically unlimited supply of pure water is absolutely essential. The possibility of utilizing some existing system of sewerage or providing the institution with one of its own should be given serious consideration. Drainage must be provided for and sanitary surroundings obtained. There should always be opportunity for future expansion of the plant. Practically every state of any importance has at least one institution which has been seriously handicapped throughout its entire existence by an unfortunate neglect of one or more of these important considerations.

In 1917 a special commission was appointed by the Governor of New York for the purpose of preparing an intelligent and comprehensive plan for the future development of the institutions of the state. In a report presented during the following year the commission called attention to a phase of hospital construction the importance of which cannot be too strongly emphasized.[27] "Nearly all of the state hospitals suffer from the fact that as originally planned they were smaller institutions and of a different type from those that are now desired, and the additions which have been made from time to time during the past twenty-five years, in order to meet the immediate demands for increased space, have not always been made with a completed and well rounded institution in mind. The results are badly balanced institutions, lacking in efficiency and ease of administration.... In planning a hospital for the insane the ultimate maximum capacity should be decided upon even if it is not possible to build the entire institution at once. A well co-ordinated plan should then be developed, which would permit the building of various sections as appropriations become available, with the idea of finally having a complete institution, harmonious in arrangement, and so planned as to attain the most desirable classification and the maximum of efficiency and economy in administration." The classification of the population which an average state hospital should provide buildings for is shown by the commission as follows:—Reception building, six per cent; convalescents, four per cent; hospital buildings, two per cent; buildings for the infirm, eight per cent; noisy, disturbed, etc., twenty per cent; epileptics, three per cent; working patients, forty per cent; quiet, clean and appreciative chronic class, fourteen per cent; and tuberculous, three per cent. They also suggest that every hospital should have a small isolation building for the care of contagious diseases. Their recommendation as to the amount of floor space per patient in the various buildings is exceedingly interesting and no less important. "First, That single rooms should have about eighty square feet of floor space. A room seven feet by eleven or eight by ten, while large enough for one bed, a bureau and a chair, is not large enough to permit placing two beds end to end or alongside of each other. If a room measures ten feet by twelve, there is always a temptation to place two beds in it if the hospital becomes crowded, and the advantage of single rooms is wholly lost. The number of single rooms in an institution should be from fifteen per cent to twenty per cent of the population, varying with the character of the cases to be cared for. Second, Dormitories should have above fifty square feet of floor space per patient, and no dormitory should have more than fifty beds nor less than six. This, of course, applies to the wards for the chronic cases. An adequate system of ventilation throughout the hospital is presupposed. Third, The day space allotted should provide forty to fifty square feet per patient. Fourth, The dining room allowance should be from fourteen to sixteen square feet per patient, in order to permit the use of small tables and to provide adequate passages for the expeditious service of food."

In former years much time and space was devoted to a discussion of the respective merits of the congregate type of hospital construction, the so-called "Kirkbride" or block plan (although it was in use long before Kirkbride described it) and the arrangement of buildings in groups. There is no question but what an institution that is all under one roof can be administered much more economically and operated at a lower maintenance cost. Very little, if any, advantage is derived by the patient from the group scheme. In its practical operation in the state hospitals almost the only point of difference, as far as the patient is concerned, is that he must go out of doors as a rule to get to the dining room in the summer as well as in the winter, in good weather and bad. This has been responsible for much discomfort and has resulted in a great increase in the number of escapes. When buildings are arranged in groups they should be connected with a central dining room either by corridors or tunnels. Small cottages, except for special purposes, are out of the question as far as state institutions are concerned, on account of the cost involved. As a matter of fact, in the development of a large hospital all types of construction must be ultimately employed. The reception building should be separate and detached from the other parts of the hospital, as should, of course, the wards for the tuberculous cases, the contagious building, the building for convalescents, the farm cottages, etc. The noisy and violent patients certainly should be in separate buildings far enough away so that they will not disturb others. The hospital wards, for the exclusive care of bed patients, may well be detached. The larger part of the hospital population, consisting of the quiet, orderly, chronic, custodial cases, can be cared for just as well in the large buildings as in groups or cottages.

The reception building, from the standpoint of the patient, is the most important building in the hospital. It should be equipped to care for from five to ten per cent of the hospital population, depending entirely upon the location and special problems of the institution in question and the community which it serves. In any event it should include both large and small dormitories, the larger accommodating from fifteen to thirty patients, and the smaller not more than six or eight, adequate day-room space, numerous single rooms and commodious enclosed verandas. There should, of course, be ample dining room facilities as well as diet rooms to provide for those whose condition makes it necessary or advisable for them to be served in the wards. Special provision should be made for the separate care of the noisy, violent, disturbed, etc., and they should be in a part of the building which can be isolated. The suicidal cases must be given special care and separate supervision. A well equipped hydrotherapeutic department is an essential part of the reception building. Continuous bath and pack rooms are equally necessary. No less important are admission and examination rooms, a pharmacy, laboratories, rooms for the special treatment of eye, ear, nose and throat conditions, recreation rooms, a library, space for occupational therapy, provision for social service and psychological departments, etc. At least two physicians should reside in the building. It is unfortunate that reception buildings as a rule are entirely too small. They should be large enough so that the acute and recoverable cases, as well as those found on observation not to require hospital treatment, can be returned to their homes without any further contact with the hospital or the necessity of a protracted residence with the chronic and purely custodial cases.

The experience of many years has shown quite conclusively that the supervision and general direction of a hospital for mental diseases should be delegated to a medical superintendent with such clinical and administrative assistants as the nature and size of the institution may indicate. The dual system of management frequently suggested by politicians, with a layman as the executive head and a medical director subordinated to his authority, has proved to be a failure in every instance in which it has been tried. The administrative details necessary to the successful operation of a large institution are such as to require the entire time and attention not only of the superintendent but usually of an assistant superintendent. In a large hospital the activities of the medical staff should be under the immediate supervision of a specialist whose training and experience qualify him to direct the clinical and psychiatric work of others. This is a quite sufficient task to require the constant attention and undivided energies of a clinical director who has no other interests or responsibilities. In this way recent graduates with proper qualifications may be interested in entering the psychiatric field. Every state hospital, in addition to fulfilling its entire duty to the patients in its charge, should be a training school for psychiatrists, social workers, psychologists, occupational therapists and psychiatric nurses. The hospital staff, as well as providing for the services of physicians well trained in psychiatry, must include other specialists. A hospital of any size should have a staff of consulting and visiting physicians including several internists and surgeons, a gynecologist, a neurologist, a dermatologist, an ophthalmologist, a laryngologist and an otologist. These consultants should visit the hospital regularly and direct and supervise the work of the resident staff along the lines of their specialty. It is hardly necessary to suggest today that a hospital of any size without a resident dentist is one which is not properly equipped to care for its patients.

Nothing is more important in the modern hospital than the training school for nurses. It is the nursing care of the patients more than any other one thing perhaps that has made the difference between the old time asylum and the psychiatric hospital of the highest type. The state hospital training school of the present day offers its pupils a three years' course of instruction, including a year of practical experience in an affiliated general hospital. Its graduates, moreover, are trained not only in psychiatric and general nursing, as well as the care of neurological cases, but in hydrotherapy, occupational therapy, reeducational, industrial and social work. The nurse of the future who has had no psychiatric training and experience is one whose education is not complete. Every effort should be made to encourage the training schools of general hospitals to send their senior nurses to a hospital for mental diseases for a service of at least three months. The specialized care and treatment of cases suffering from tuberculosis has been neglected in many institutions. It should not be necessary to suggest that such cases have no place in a ward with other patients who have not contracted that disease, and yet in many of our large and important hospitals there are no separate buildings for that purpose. It has been shown by statistical studies that persons suffering from dementia praecox have an unusual and remarkable susceptibility to tuberculosis. Unfortunately, it has never been possible to completely segregate the epileptics in our public hospitals for mental diseases. They constitute a special problem and should receive a different diet as well as an entirely different type of treatment. Their presence in the wards with mental cases is highly detrimental to both. This is equally true of drug cases and mental defectives, and especially the so-called defective delinquents.

There are many reasons why every hospital of any consequence that is engaged in the care of mental diseases should be provided with a well trained and experienced pathologist. Examinations of urine and sputum must be made daily. Widal tests are sometimes necessary for the diagnosis of typhoid fever. Analyses of water and milk should be made at frequent intervals. Bacteriological vaccines should be available at any time. Only laboratory investigations can throw any light on the source of the frequent infections which are found in large institutions. Diphtheria is a disease which must be guarded against constantly. Lumbar punctures, Wassermann tests, the colloidal gold reaction, cell counts, etc., are daily necessities in a large hospital. We lose much information of value to us if autopsies are neglected. A definite program of pathological research work should be carried on in every hospital for mental diseases. It has been suggested frequently that the microscope has no part to play in studying the etiology of the psychoses and that they are purely functional in origin. Many of them are functional. It is nevertheless equally true that we have a definite pathological basis for the traumatic psychoses, the senile conditions, cerebral arteriosclerosis, general paresis, brain syphilis, cerebral growths, mental deficiency and many other brain and nervous diseases. The psychosis most clearly understood from the standpoint of etiology, pathology, symptomatology and diagnosis is general paresis. Our definite knowledge of that condition was obtained entirely from the laboratory. Further information may be secured in the same way. While it is true that we have not had any great amount of success as yet with the treatment of general paresis with salvarsan, the positive knowledge that the disease is of syphilitic origin should encourage us in our efforts to solve the problem of curing it. Histological, pathological, bacteriological, chemical, clinical and psychological researches must be pushed vigorously if psychiatry is to keep pace with the general progress shown by modern medicine in other fields.

In connection with this subject some reference should be made to the general neglect of statistical studies. They should be based on detailed, accurate and exhaustive clinical records, which unfortunately are not now available to the extent that they should be. It is true that in a general way some progress has been made. The studies instituted by the American Psychiatric Association will ultimately tell us quite definitely the frequency of the various psychoses, the recovery and death rates to be expected, etc. We should not be satisfied with that alone. The great wealth of material which we have in our hospitals, together with the excellent clinical and laboratory facilities at our disposal, should enable us to accomplish much more. An analysis of our case records, if properly made, would give us definite information as to the clinical aspects of the mental diseases we are dealing with. These should be made the subject of exhaustive study by the scientific institutes and other research departments conducted by the various state authorities to an extent never yet undertaken or even attempted. If it cannot be done by the states it should be instituted by the federal government.

The fact that the field of influence of our public institutions should extend far beyond the walls of the hospital is one which has received general recognition only within the last few years. Every hospital has a large number of patients still within its legal custody but who have been allowed to return temporarily to their homes or occupations while still under observation pending their final discharge. These are now, to a very limited extent, under the supervision of social workers. The hospitals have unfortunately, owing to a lack of funds, never had a sufficient number of social workers to look after them properly. The hospitals as a rule now maintain out-patient departments where those who have been allowed to go home on visit or resume their occupations are encouraged to come for assistance and advice. The public is gradually learning to take advantage of this opportunity to obtain expert advice on matters relating to mental hygiene and secure professional opinions as to the disposition and treatment of members of the family showing symptoms of incipient mental disorders. This field of influence extends even further. Clinics have been established in various locations outside of the hospitals in the larger cities in several states. In New York they are conducted by state hospital physicians in Binghamton, Brooklyn, Buffalo, Plattsburg, Dunkirk, Jamestown, Olean, Salamanca, Poughkeepsie, Peekskill, Yonkers, Mount Vernon, Mineola, Newburgh, Kingston, Rochester, Middletown, Ogdensburg, Malone, Watertown, Utica, Schenectady, Ovid, Ithaca and New York City. Physicians and social workers are in attendance at all of these places. The last published report of the New York State Hospital Commission (1919) shows that 7,203 visits were made to these clinics during the year. Paroled patients made 5,102 of these, discharged patients 265 and others who had no connection with the hospitals at all, 1,836. In addition to this the hospital social workers made 3,496 visits to paroled patients as well as four hundred and sixty-two visits to other patients for the purpose of preventing mental diseases. Situations were obtained for one hundred and sixty-seven discharged patients. An enormous amount of work was also done in history taking, etc. Numerous clinics have been established in Massachusetts by the Department of Mental Diseases.[28] During the year ending November 30, 1919, a total of 4,333 visits were reported. Of these 3,057 were first visits. The number reported by the various hospitals was as follows:—Worcester State Hospital 1,278, Taunton State Hospital 182, Northampton State Hospital 458, Danvers State Hospital 282, Westborough State Hospital 177, Grafton State Hospital 129, Gardner Colony 65, Monson State Hospital 70, Foxborough State Hospital 27, Massachusetts School for the Feebleminded 541, Boston State Hospital (Psychopathic Department) 2,112. Clinics were maintained in the following localities:—Athol, Boston, Brockton, Danvers, Fitchburg, Foxborough, Gardner, Grafton, Gloucester, Greenfield, Haverhill, Lawrence, Lynn, Malden, Medfield, Monson, New Bedford, Newburyport, Northampton, Pittsfield, Salem, Springfield, Taunton, Waverley, Westborough, Worcester and Wrentham.

This is a gratifying evidence of progress. There are indications of an awakening. The hospital treatment of mental diseases will eventually be conducted on a much higher plane and along lines more nearly comparable to those of the general hospital. A study of legislation relating to mental disease shows that efforts are being made very generally to make their treatment a medical problem rather than a legal question. It has been no easy matter to obtain treatment for mental diseases, assuming a desire on the part of the individual to take advantage of such an opportunity. A review of our legal enactments shows that as a general rule it means a formal application, properly verified, an elaborate examination by two qualified physicians, an order of commitment by the judge of a court of record, a legal notice and an opportunity for a hearing if one is demanded. Pennsylvania as early as 1883 made provision for the immediate admission of such cases as required it, pending the usual court procedure. As has been shown in another chapter, arrangements have been legalized in many states for the emergency reception of mental cases, at least for those persons who are known to be dangerous to themselves or others. Temporary care enactments have been written into the law in various communities, making it possible to keep mental cases under observation for a limited period of time. In a large number of states it is now possible for a person requesting treatment voluntarily to receive it on his own application without any other legal formalities. Perhaps the greatest advance is the custom, not so infrequent now, of sending persons held by courts under a criminal process to a hospital for observation as to their mental condition. The fact should not be lost sight of that it is still possible to find "insane" persons in jails, poorhouses and county institutions in many parts of the country. Worse than this, however, is the custom of delegating their care to police officers. Nevertheless, distinct progress has been made.

As has already been shown, a study of methods of care in this country indicates that every state has passed through several very definite preliminary stages. These may be summarized as follows:—

1. A period of home care only. During the colonial days mental cases were cared for at home or not at all. There was nothing else that could be done for them at the time.

2. Confinement with criminals. In cases of unusual violence, dangerous persons were confined in jails, lockups and prisons. If necessary, under certain circumstances the law in some states even authorized the use of chains.

3. Almshouse care. There has been a time in practically every state when the poorhouse has been looked upon as the proper place for the insane.

4. Asylum care. As a result of the agitation of Dorothea Dix and others, mental diseases were eventually given custodial care in asylums.

5. Modern hospital care.

In 1894 Dr. S. Weir Mitchell[29] delivered the annual address at the semi-centennial meeting of the American Medico-Psychological Association in Philadelphia. It was a very painful occasion for many. His remarks may be summed up as a vigorous arraignment of the asylum methods of that day. He severely criticized the public, the state legislatures, boards of management and the hospital superintendents. His principal charge was that they were operating asylums along the lines of the past and were perfectly satisfied with what they had accomplished. He pointed out the necessity of properly qualified physicians, more scientific methods and modern treatment. "We have done with whip and chains and ill usage, and having won this noble battle have we not rested too easily content with having made the condition of the insane more comfortable?" It seems incredible that in the case records of that day he should have found no evidences "of blood counts, temperatures, reflexes, the eye-ground, color fields, all the minute examinations with which we are so unrestingly busy." One institution was unable to furnish Dr. Mitchell with a stethoscope or an ophthalmoscope! One of his criticisms was that few institutions for mental diseases had a training school for nurses or any provisions for hydrotherapy. His last words were almost a prophecy: "Fifty years hence, when we must all have been swept away, another will possibly stand in my place and tell your history, and to him and the bountiful wisdom of time I leave it to be declared whether I was right or wrong." Dr. Mitchell's description of the asylums and their methods was bitterly resented. Who is there today who would not feel that he was fully justified?

The time has come when we must again look to the future and prepare for it. The purely custodial care of mental diseases has led to a dread of asylums on the part of the public. There are unfortunately too many hospitals that are asylums in everything but name. The establishment of psychopathic hospitals and psychiatric clinics and the way in which they have been welcomed by the public is suggestive. The problems of mental diseases, as far as possible, must be approached from a general hospital point of view and the psychiatric hospital of the future must have a modern equipment, an efficient staff and adequate facilities for the employment of the latest methods. Above all, the institutions must be such that they will be looked upon by the community not merely as a place to which the insane may be sent for final disposition, but as hospitals where the development of mental diseases may be prevented and where recoveries may be reasonably expected if the patient is given early treatment. This should be the principal object of the state hospital of the future. "The concept of its beneficent ministration to the mind diseased as any physical part of the human body," as Copp[30] has pointed out, "is just appearing in shadowy outline in public consciousness. The effacement of this barrier to early treatment is slowly but steadily progressing. Its pace will be hastened if every mental hospital continues to become, as speedily as may be, the real hospital in the broadest sense, with emphasis laid upon its treatment function and subordination of its control relation within the reasonable limit of caution. The mental hospital and the general hospital are essentially alike. Mental factors predominate in the former, but are potent influences in the latter. The difference is one of degree only. All the imperative requirements of the one must be met by the other. They are supplementary agencies in curing and alleviating disease and must be, eventually, viewed in the same light and administered in the same spirit on even planes of humaneness and efficiency."

One thing should be made clear at the outset. A comprehensive and progressive program for further development means an expenditure of money. If the state hospitals are to fulfill their obligations to the community which they serve they must have more physicians. Provisions must be made for directors of clinical psychiatry, pathologists, internists, surgeons, dentists, and specialists of various kinds. Experts in hydrotherapy, massage and electrical treatments are necessary, as well as dietitians, industrial instructors, occupational teachers, specialists in reeducational work, psychologists, social workers, etc. Furthermore, they must be provided in sufficient numbers if anything is to be accomplished. As a matter of fact, no very great outlay of funds would be required in making a tremendous increase in efficiency. Although the institutional expenditures have increased enormously of late years, largely as a result of war conditions, increased costs, higher wages, etc., the amount actually invested in this humanitarian movement by the various states is not commensurate in any way with the results which are to be obtained. If we leave out of consideration everything except the saving in dollars and cents to be effected by methods which will in many instances render a protracted hospital residence unnecessary, the outlay involved would be well warranted. It should be brought to the attention of the public that very few states are expending as much as one dollar per day for the maintenance of the individual patient. Modern hospital treatment of the highest type, under these circumstances, is manifestly impossible. The time has come when we should no longer be satisfied with the purely custodial care of mental cases.