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 REPORT OF INSPECTION AND SURVEY

OF

FLORIDA STATE HOSPITAL CHATTAHOOCHEE

Prepared by:

Marynia Farnhan, MD

T A B L E  0 F  C 0 N T E N T S

                                                                                                               Page

1. PRELIMINARY INSPECTION .......................................................1 - 9

2. DETAILED INSPECTION OF INDIVIDUAL WARDS ................10 - 17
(White Female Ward)

3. COLORED FEMALE WARD......................................................... 18 - 20

4. WHITE AND COLORED MALE WARDS..................................... 21 - 25

5. THE INFIRMARY ...........................................................................26 - 27

6. GENERAL ADMINISTRATION AND MANAGEMENT ..............28 - 33

7. MEDICAL CARE AND SUPERVISION ........................................34 - 40

8. RECAPITULATION....................................................................... 41 - 43

9. RECOMMENDATIONS ................................................................44 - 49
 
 

REPORT OF INSPECTION AND SURVEY OF

FLORIDA STATE HOSPITAL

CHATTAHOOCHEE
 
 
 
 
 

SECTION 1

Preliminary Inspection

 Prior to beginning a somewhat detailed study of the population, with reference to the possibility of determining the number Who might be discharged and with the object of offering certain other recommendations, it was thought advisable to make a preliminary inspection, by going quickly over the entire institution.

The State Hospital, aside from the maintenance and administrative divisions, consists of: a hospital, for reception and treatment, a tuberculosis infirmary3 a dental infirmary3 a general infirmary for the chronically disabled among the white patients3 and the four units for the white female, white male, colored female and colored male patients respectively.

The hospital consists of wards for the care of the acutely ill of both colors and sexes, with operating room, laboratories and x-ray department. A certain part is devoted to the reception wards, where an effort is made to hold the newly received patients for thirty to sixty days prior to assignment to the general wards. During the admission period, a thorough physical examination is done. This includes a routine blood Wasserman and Kahn examination, a Wasserman and Kahn examination of the cerebra-spinal fluid in all cases with positive blood findings and in other cases where it is indicated; a routine urinalysis; a routine examination of the stool for ova and parasites and such other special laboratory examinations as are indicated.

A history is obtained wherever it is available but in many instances the patient is received without an accompanying history. In such instances efforts are made to obtain one. These are often not successful because the data must be obtained by correspondence with the relatives or guardians as, in many instances, the patients are unable to give lucid histories b the time of their reception.

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At this time a diagnosis is made of any physical deficiencies or illnesses that may be found, and proper treatment is instituted. A psychiatric examination is made in an effort to determine the type of mental illness from which the patient is suffering, and a diagnosis of this type is made before the patient is transferred to the general wards.

In the hospital the care of the patients is given by registered nurses and nurses in training, as the hospital now conducts a training school for nurses registered with the State Department of Health of Florida.

The receiving hospital is in charge of four physicians, who take care of all of the work outlined above, as well as the routine treatment of acute physical illness which may be present when the patient is admitted. The remainder of the hospital is devoted to the treatment of acute illness, largely surgical in typo, because of the fact that there is insufficient space to take care of any except the most serious illnesses requiring treatment, the remainder being cared for in the infirmary which will be discussed later.

It is necessary also to receive into the hospital for treatment those cases who are in the most seriously disturbed and violent mental condition by reason of the fact that facilities are not available for any treatment in the general wards. The result is that acute physical illnesses as well as the acute maniacal phases of mental illness are placed together in the wards of the hospital.

On the day upon which the preliminary visit was made, the white woman's ward was in an uproar by reason of the fact that approximately six patients were there because of serious mental disturbance. Their screams were sufficient to prevent any-one in the ward being able to obtain rest, if that were indicated, and as there were post-operative and convalescent medical cases there3 it is felt that the presence in the ward of such seriously disturbed patients was bound to be detrimental to the recovery of those less disturbed.

Restraint was found to be used in the hospital, consisting usually of cloth tied around the patient's wrists and ankles and tying the patient to a piece of furniture or the neighboring wall. Leather anklets and wristlets were not generally in evidence and it was apparent that they are not provided in sufficient quantity to prevent the use of makeshift restraints, which are not suitable because they are more likely to inflict injury en the tissues than are the properly constructed leather equipment for the some purpose. A standard camisole is used for restraint of the arms.
 
 

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One reason for the lavish use of restraint is apparent,' when it is found that in the entire institution there is one, and only one, unit available' for complete hydrotherapy, this including the continuous tub, all manner of sprays and douches of the most up-to-date and accepted variety and the steam box. This unit is for the use of the white males and a second unit is being constructed for the use of white females. This will be identical in type with the exception of the fact that a sitz bath will be added to the equipment for the use of the females.

In addition there are also found in the hospital, wards devoted to the malarial treatment of central nervous system syphilis, under the direction of Dr. Mark Boyd of the Malarial Experimental Station, operated by the Rockefeller Institute where the patients are inoculated with various types of malaria as a treatment for cerebra-spinal lues. Facilities for such treatment are available for both sexes and both colors.

The wards consist of individual rooms containing two, three and four beds, representing considerable overcrowding, and a perch at the end en which beds are also placed, although the porches were not designed for that purpose and should be kept for the use of the convalescent patients whom they are able to be out of bed. It was found necessary, however, to install beds en the perch because of the intense overcrowding in the hospital.

In the white female wards, was discovered a normal male child of three, living in association with the acute physically ill, as well as a half-dozen intensely violent and disturbed patients and several other of the more deteriorated type. The mother was brought here for treatment by the father while pregnant and all efforts to find the paternal parent have been unsuccessful. Every effort has been made to have him placed elsewhere. The county of his' residence' has refused to take jurisdiction. The child, is, therefore, being maintained under the circumstances described. The community can ill afford to allow a normal child to be brought up under such demoralizing conditions.

The wards are well cared for, the nurses are apparently adequate for the number of beds, the general appearance is one of cleanliness and order and every effort is made to give the patients proper and considerate treatment within the limitation of the institution itself.

Deteriorated dementia praecox, cerebra spinal lueties, patients recovering from a toxic psychosis and recent surgery, are intermingled with patients in the most violently disturbed condition.

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when we came to an examination of the Receiving Hospital, the same division is made of the white and colored female and white and colored male wards. Here the overcrowding is pronounced, beds being less than a foot apart in most instances.

All wards are of similar construction to those in the infirmary proper with perches at the ends designed for the use of the convalescent patients. Except for that on the white male wards, the perches are now filled with beds for the use of patients.

The number of admissions averages one hundred a month and there are four physicians to carry the entire burden of the reception hospital, in addition to a variety of ether duties.

There is one situation in the receiving hospital which should be corrected immediately. The porches on the colored wards, separated from the main ward by a screened door, are now used for the colored tuberculous. It is only possible to keep a small number of tuberculous patients here and the remainder is scattered in the general wards to disseminate the infection throughout the general population. The Chief Physician is5 properly, greatly aroused over the fact that the incidence of tuberculosis is rising rapidly in the institution as a whole and oven more rapidly among the colored population. When it is understood that the colored race is particularly susceptible to infection by tuberculosis the seriousness of the situation is immediately realized.

The porch assigned for the treatment of the colored female tuberculeus is overcrowded to the extreme and contains at least three patients in the far advanced stages of tuberculosis, where the duration of life is not likely to be long. There is no provision for placing the moribund in separate rooms, neither did I observe any screening of the more seriously ill patients.

There is, in addition to this, a small tuberculosis infirmary for white female and white male patients. This is also overcrowded, the patients being toe close together for comfort and easy handling, and beds being placed in parts of the infirmary not designed for such purpose, thus limiting the space provided for these patients who are able to be up and under observation. The majority of the patients suffering from tuberculosis are also suffering from mental illness of varying degree; It is probable that a certain, although not large, portion of these patients could be cared for in a hospital for the tuberculous without any difficulty. There are several feeble-minded tuberculous patients who could very easily be thus taken care of and who have, of course, no place in an institution of this sort as they are not suffering from an

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attendant psychosis. I~ is feared unless the facilities for the care of tuberculosis are greatly enlarged1 a really serious situation will arise in the institution by reason of the rapid end uncontrolled spread of the infection, throughout the now uninfected portion of the population.

Following an inspection of the hospital, an inspection of the general wards ~ instituted. The first ward to be examined was the white female ward.

White female patients are now housed in a very old building made of white concrete bricks. It is three stories high, with porches on one side running the entire length and breadth of the building. The wards run down the center of the building and porches adjoin all the wards. These porches serve, of course, to cut off a great deal of the light and air available to the general wards. The beds are crowded so closely together that in many instances it would be impossible for the patient to reach her bed without having all the beds in the line moved, or crawling over those intervening. A small lane is loft between the tiers of beds through which an attendant might reach any individual bed by moving sideways through the aisle. More details as to the number of beds and the resulting crowding will be given in a secti6n devoted to a detailed consideration of the white female patients.

The entire ward is in charge of an attendant who is not a trained nurse and has under her a number of day and night attendants3 also untrained.

The white female building has been divided into five or six wards for the reception of different classes of patients. The patients are classified according to symptomatology, the so-called "better~class" patients being in Ward A and the various grades of deteriorated, violent and uncooperative patients in the wards from B to T; deteriorated epileptics, dementia praecox, senile and feeble-minded being herded together in one ward under the supervision of a single attendant.

A large proportion of the patients in Ward A arc able to do some form of outside work. They, accordingly, leave the wards in the early part of the morning to go to the laundries, sewing rooms or kitchens where they are assigned to some type of duty. They return to the wards at noon before being Escorted to the dining rooms, which are centralized for all patients who are able to go there and who are willing to eat, for some of the patients who are either unwilling or unable to oat, the meals arc sent to the wards from the central kitchens.

Other wards arc devoted to the patients who are unwilling to work or show no interest in working.

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Some of the patients who, while nor doing any of the work of the institution, are still encouraged to engage in some type of occupation, are assigned to what is called the "art room" a small space on one of the porches which is devoted to sew-mg and other domestic handicrafts, such as knitting and crochet. Here those patients who are interested and respond to this typo of therapy are encouraged to come and do any work with which they arc familiar. The articles made are then sold and the receipts used for the purchase of more materials as no funds are available for an occupational therapy program.

Still other patients are more disturbed and deteriorated and unwilling to engage in any forms of activity and the method of handling these patients is either to allow them to go into a small back yard, which is fenced off, more or less like corral, where they may wander about or sit down on benches provided for them. On less pleasant days, the patients are sent onto the porches if they are willing to go, but a fairly considerable number are in their beds, lying on the floors under the beds or rolled up in typical postures scattered about the wards.

The least cooperative and most deteriorated groups of patients are found in one place where they are cared for by an attendant. Many of these refuse to move at all or lie about on the floors in the manner described. Here are found seriously deteriorated epileptics who require constant attention, even to maintain ordinary bodily cleanliness as they do not control their excretory functions.

A large number of them are destructive to furniture or clothing and are consequently restrained by camisoles or tied to the chairs or beds by restraining equipment of a homemade variety. The disturbance in this ward is intense. A loud buzz can be hoard for a long distance from the building, punctuated by frequent shouts and screams. The typical activity of the seriously disturbed dementia praecox and manic depressive psychoses are seen here.

Many of the epileptics are of the most seriously deteriorated type where restraint is necessary a large portion of the time, and require feeding sometimes forcible in typo, soiling themselves and their clothing and surroundings, continuously inflecting injury on themselves and ethers if given the slightest opportunity. Others are of a loss disturbed and quarrelsome type, and, of course, frequently attacked by the more disturbed ones if not closely watched.

Every effort is made to prevent any injury of the patients by each other and no mistreatment of the patient by the attend-

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ant is tolerated. Every disturbance in the ward is reported to the head physician daily and its origin investigated. Many of these patients are difficult3 if not impossible, to control with the facilities at hand and one attendant is kept constantly busy separating patients who are crowded together on benches, lying about on the floors or standing up clinging to the iron grilling; keeping clothing en these who constantly remove their clothing; and watching the epileptics who have frequent convulsions.

A casual inspection revealed a fairly large number of patients who are apparently feeble-minded, some of whom are even of the idiot class, as well as a considerable number of patients who appear to be suffering from senile dementia of a low grade and are in no way harmful to themselves or others but require custodial care.

There was no kitchen in this building for the preparation of meals, the necessary diets being prepared in the general kitchens and sent to the wards. wherever a special diet such as that for a diabetic is required it is prepared under the supervision of the dietitian, who has charge of the diet kitchen for the hospital, and sent to the wards for the patients. No movable steam tables were seen and the consequence must be that the feed is received in a cold and unpalatable state for the patients who must eat in the wards.

This building is one of the eldest of the ward buildings and is in a seriously deteriorated state. The soft pine and no amount of cleaning will serve clean and odorless.
 
 

The sanitary facilities are also inadequate. There is one bath room for each ward in which there are approximately five basins, the same number of toilets and one large shower room with three sprays in which the patients are bathed. No privacy is possible. The patients all mingle in the toilets together. The sanitary equipment is of the oldest type, the floors are damp since they are made of an old type of concrete that is extremely difficult to keep clean. The pipes and sprays are rusty and unsightly. The wash basins are of modern enamel placed in a row exactly opposite the toilets so the patients are forced to do they're bathing while other patients arc using the toilets. Those are of the oldest and least modern type. Some of them arc provided only with toilet bowl and no seats. In general the sanitary facilities are both obsolete and inadequate as well as being unsightly.

The other wards differed in no very striking particulars from the white female ward. Of the remaining buildings, those that house the colored females seem to be of the most modern
 
 


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construction and in the best state of repair.

Fairly extensive repairs are being done on the white male ward where the writer was informed there was grave danger of collapse of certain parts of the Wards.

In certain parts of the colored male wards the Same is true and repairs have been undertaken in order to remove a serious hazard from the possibility of a cave-in of walls in several of the wards.

Throughout the institution the crowding is the same as that observed in the white female wards and the same general treatment is accorded the patients.

All the wards are similar in structure5 having porches adjoining the general wards, running the two sides of the barrak~like buildings. They are all provided with yards for outdoor exercise.

The yard facilities for the colored patients are, in general, less adequate than those for the white but in other respects there is very little difference.

The general management of the wards with the exception of that for the colored females, seemed upon superficial examination, to be fairly efficient in view of overcrowding and understating which is prevalent throughout the institution.

The patients throughout seemed to be in restraint in about the same numbers as wore those in the white female wards. Chains are used on the arms of the colored male patients in several instances due to the fact, it was said, that, because there are so few attendants, the patients couldnot be watched when placed in leather restraints and these are, therefore, immediately destroyed by cutting them on sharp protruding nails or sharp edges of wire netting which is used to screen the porches.

The attendants for the remaining wards are also untrained but the two attendants for the white male and the colored male wards seem to be competent and conscientious in the discharge of their duties and, in general, familiar with the patients, their vagaries and their needs.

There was at no time any evidence of mistreatment of the patients here and no patients gave any evidence at any time of being in fear of the attendants.

Certain deficiencies and delinquencies were strikingly apparent, even upon superficial inspection of the institution.
 
 

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It is quite clear from even the most casual examination, that the facilities for the adequate housing of the patients are entirely insufficient as well as being of an improper type. The number of attendants is grossly inadequate and results in the necessity of requiring from each attendant excessive number of hours at work and makes it impossible for him to perform his duties in a proper manner.

In spite of this, the institution gives an appearance of cleanliness and a certain amount of order which is astonishing in view of the serious deficiencies which a further and more careful inspection revealed. It is apparent that the patients are treated kindly and considerately. It is also apparent that the amount of medical supervision which is possible, is by no means sufficient for the physicians to be familiar with the patients or in any way to contribute to their recovery and possible discharge from the institution.

The impression that one obtains by such a casual inspection is of a moderately well-run institution, staffed by a group of thoroughly conscientious employees, working under crippling handicaps to give to these patients as nearly they can, the typo and amount of care which they must have if there is to be any possibility of recovery in as largo a number of cases as experience has demonstrated to be possible.

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DETAILED INSPECTION OF

INDIVIDUAL WARDS
 
 

White Female Wards

As has been previously stated, the white female patients are housed in an old, totally inadequate building of frame construction, inside and out. There are no fire escapes and fire in one of these buildings would result in a tragedy of hideous proportions. A sprinkler system has been installed and extreme vigilance is exercised in this regard,

The total white female population on the day of examination was 1670, exclusive of those who were in the reception hospital or in the general infirmary The ward is divided as follows:

The wards are in all respects similar, in that they all consist of a dormitory for sleeping purposes, with its attached sanitary facilities, and a porch to which access may be had from all parts of the wards.

In addition to this, the general ward is equipped with a large fenced in yard, descending by a gradual grade. There is considerable grass and the general aspect is not unpleasing. There is very little shade and a certain number of small shelters, as well as four or five larger shelters equipped with benches, have been placed for the use of the patients whom the

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heat is extreme. I was informed, however, that it is necessary to keep the patients indoors because of the intense heat during summer months except for a few hours in the morning and the late part of the afternoon,

The wards wore inspected individually and information obtained as to the number of patients as given above, the number of attendants, night and day, the amount of sanitary facilities and the general overcrowding of the wards as well as the typo of patients which are distributed to each ward. As has been previously noted, distribution is made according to the symptoms of violence, uncooperativeness, deterioration and physical debility.

The white female wards have only a very small and inadequate dressing room for the use of the physician in the treatment of minor illnesses and injuries. The physician in charge of this ward has no office in the ward and there is no available space for such an office whore patients may be interviewed, examined or treated.

Ward A contains 77 patients - has two day attendants and one for the night. Of the two attendants on duty during the day one is assigned to what is known as "detail". This is the duty which takes the attendant out of the wards to take patients to and from work and to and from treatments, etc. This results in one attendant being available during the day and one at night. This ward, however, contains the most cooperative, least disturbed patients and those in the best physical condition. The bulk of the patients in '[lard A are able to work and arc assigned to work in the dining rooms, linen rooms, the art room, the industrial shop, or to ward work, which consists of general household duties about the ward, such as bed making and general cleaning

There is a moderate sized, fairly adequate recreation room for the combined use of patients in ward A and Ward J, which will be described below. It is not unattractively furnished. There are some few books, a small amount of space for writing, and two or three comfortable chairs.

In the dormitories, there is an extreme overcrowding of beds, which are placed in tiers of two or three, on either side of a center aisle. The beds are no more than four inches apart at any point, and it is necessary for patients to climb over two or three beds in order to reach their own, if it is the most distant bed.

The patients in this ward do not go Into the yard as they are all assigned to seine. type of work, and, therefore, have

Page 11






no available time for recreation in the yard. They are all able and willing to keep themselves clean and attend to their own personal toilets.

There are two bathrooms for the use of this Ward each containing three toilets and five or six wash basins with a common shower room containing three sprays.

Ward B contains a recreation room between the two dormitories, It shows the same type of overcrowding As in Ward A., the beds are placed about six inches apart in three tiers as before, There are three attendants in this ward which houses 126 patients. One of these attendants is also assigned to '1dctail" duty. A certain number of these patients are assigned to work but as they are slightly less cooperative than those in Ward A, accordingly smaller number of them is able to go to work.

Some of these patients are sent into the yard daily, and whenever this is done one of the attendants on duty must go o the yard also.

There is, therefore, only one attendant on duty in the ward at any time.

There are eight toilets for the use of those patients and two sets of showers as in Ward A.

Ward D contains 126 patients - has assigned to it four attendants for the day, of which number two are assigned detail, and one attendant for night.

The patients in this ward are be~n;innin0~' to show some signs of deterioration and there are more patients of the quarrelsome, uncooperative and noisy variety. A smaller number of these patients is assigned to work, and the major portion of the work done by them is of the ward type. A fairly large numberofthose patients spend good dale of their time in the yard.

The overcrowding here is similar to that found in the previous two Wards.

Ward F contains 136 patients - hL¼n four day attendants one assigned to detail, and three night attendants.

Here the overcrowding has been taken care of by placing beds on the porches, thus seriously reducing the amount of porch space available for recreation bed rest.

A small number of these patients do sons work in the art room and the linen rooms, and a large number do some ward work.

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In this ward are found a fairly considerable number of untidy patients who do not take care of themselves and require a considerable amount of care, both day and night.

This ward was visited at a time when the beds were being aired and the mattresses were observed to be in an extremely filthy condition from bein0 used by patients who arc untidy. The odors were what might be expected and it was felt that to place the patients who are personally clean, on mattresses of this type is improper. Rubber sheets are provided only for those cases known to be untidy with the result that ultimately all the mattresses become contaminated,

The sanitary facilities are the same, with eight toilets for the use of 136 patients and the common shower rooms and wash basins.

Ward E contains 137 patients - has three day attendants, two on detail, and two night attendants.

Thirty of these patients are able to work and they are assigned to the wards, to the linen room, or to the art room, according to their own preferences and thinned for assistance.

There are eight toilets for these patients and the usual remaining facilities.

A recreation room is also provided of the same type as that for the other wards.

Beds are also placed on the porches in this ward because of the overcrowding and consequently the patients only have a small space for outdoor use unless they go to the yard, which a fairly good number of them do,

Ward G contains the epileptics and other deteriorated, noisy 'and untidy patients.

Only two of those patients do any work at all and these are assigned to help in the wards.

This ward is cared for by five attendants with the help of patients assigned from other wards.

The majorities of the patients in this ward, of which there are 105, are untidy and require a great deal of personal attention. It in often necessary to change their clothing as many as four or five times a day because of their persistent soiling.

Many of these patients are in restraint, some of them in camisoles. Restraint may be applied by any attendant in any of

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the wards, a physician's order not being required for its use. It is used for the control of any typo of disorderly conduct such as tearing clothes, destruction of bed linens, violence to other patients or toward the attendants, or for tendencies to inflict self-injury. The patient is then usually tied to one of the benches with a camisole strap, although it is the practice to take patients out of camisoles twice a day for exercise.

The writer has witnessed scenes of' the most frightful brutality in this ward where quiet patients have been cruelly attacked by the violent. Attendants have no choice but to handle these patients in the most brutal manner as there are too few attendants to make anything else possible. At times attendants are forced to drag patients by the hair in order to control them while placing them into camisoles. There are no rooms for such disturbed patients and they must consequently be tied up like animals. The cruelty of such procedures needs no comment. They are dangerous iii the extreme as patients and attendants alike can be seriously injured in such struggles. The injury to the patient1s mental state is indescribable. Such conditions are intolerable and the community permitting them is open to the severest censure.

All of these patients require the attention of an attendant for bathing and are bathed once a week.

There are five toilets for the use of these 105 patients.

Of the epileptics, seven or eight have serious convulsions daily and require attention, both during and after the convulsing period.

During the time the ward was visited there was only one attendant to take care of about 60 to 65 patients, one of whom was recovering from a recent convulsion, several others in restraint and some wandering about on the porches or lying on the floors in typical nos½res.

Wards H and K show the same type of overcrowding, having 23 and 35 patients respectively, with two day attendants for each ward.

The patients do no work except a small amount of ward work and are allowed to go into the yard.

These wards contain the suicidal and homicidal patients and only a few are, therefore, allowed in the yard as it is a practice not to allow "run-aways", "suicides" or "homicides" in the yard.Care is taken to prevent these patients from obtaining instruments of any type with which they might injure them

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selves. A large portion of them must be In restraint at all times because of their violent tendencies.

Ward L contains 48 patients and has four day attendants and two night attendants.

This ward contains the bulk of the violent patients. Some of them do a small amount of the yard work. None 'f them are assigned to outside work of any type but they are allowed to go into the yard under the supervision of attendants or in a restraint, as the case may be,

Here are the patients most commonly thought of as ""maniacs"". There is an intense uproar in the ward at all times with screaming , attacking the furniture, kicking, violent attacks upon each other, struggling in restraint, and all of the usual pictures of the seriously disturbed mentally sick person.

Since no facilities are available for the treatment of the disturbed period of the illness in the case of female patients, it is necessary to employ restraint along with the use, at times, of some sedative to induce sleep during the period of violence. Their distress is necessarily greatly prolonged as the patients must be deprived of treatment, and have inflicted upon thorn the aggravation of restraint which is assimilated into their already disturbed and disoriented mental life, to add further distress to one that has already become too great for them to bear without violence. It is not implied that restraint can never be properly used. It is understood that at times it is necessary, but it is only rarely needed or used in properly equipped institutions. Furthermore, prolonged use or restraint cannot but increase the patient's symptoms and ultimately prolong the period of his detention arid perhaps postpone, if not entirely prevent, his recovery.

The remaining Wards O, S, T and J are given over to the physically debilitated, partly helpless patients who never leave the ward except in some instances to go to the yard. They do not work. Many of them are unclean, a fair proportion them arc uncooDerrt5ve and at times violent, and in one ward a large number arc partly or totally incapacitated by reason of cerebral hemorrhages, hypertrophic arthritis and other chronic incapacitating diseases of the later years of life. Many are in wheel chairs, a fairly large number require feeding, and a few are kept under restraint from time to time.

These wards contain almost 200 patients and have a total of seven dry attendants ~d four night attendants to give all the necessary care and attention to the patients.

The ward work is done by other patients assigned to the

Page 15




wards and by the attendants.

It is apparent that a fairly considerable number of these patients could be cared for in county homes if such wore available in the homes of their families if the families were willing to accept them, or in boarding homes of the better type.

The general care of the patients is excellent.

With the exception of the more difficult and deteriorated patents there is a general appearance of cleanliness of person The beds and bed linen arc kept clean and in order although the mattresses are, in many instances, not fit for use. The attend-ants are entitled to the highest praise, for while they work a twelve hour day, six days week for a wage that is pitifully inadequate, they seem to be of a uniformly high order. They are, none of them, trained except insofar as they are trained by experience in the wards. They re at all times quiet and considerate of the patients and at no time have I observed any evidence on the part of any patient that "he is afraid or an attendant. This can only be ascribed to the excellent discipline and the generally high character of the attendants themselves.

The facilities for the care of the patients are totally and completely inadequate. It must be repeated that there State is greatly increasing its own expense for the care of this type of patient by false economy in withholding the proper facilities and personnel for the care and treatment of those patients, thus prolonging their stay in the hospital and in many instances preventing their ultimate recovery.

There is no possibility of any patient having any privacy whatever; dressing and undressing as well as all the toilet operations must be done in common.

Those patients come from a. wide variety of backgrounds and education's. Many, if not most of them, are hypersensitive individuals or they would not have reacted to the stresses and strains of life by a retreat into mental illness. Here they are forced into a type or life to which they 're not accustomed and which, in many instances, is repellent in the extreme.It cannot be questioned but that the patient who is only slightly ill finds his symptoms aggravated and his progress toward recovery retarded by the constant association with patients who are violent, deteriorated and in many instances so ill that their behavior is very little better than that of an animal. A patient who is recovering from a period of violence and quarrelsomeness which arises out of his illness and not through any intrinsic character trait may be precipitated into another attack, or prevented from recovering from the original attack by the fact that It is impossible for attendants at all times to prevent the more

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disturbed patients Cram attacking those who are near him. All of these things, no doubt, contribute to the failure of the patient to recover or to the prolongation of his illness.

This cannot be justified by any consideration of expediency as it is economically, as wall as socially and medically, unsound and untenable.

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COLORED FEMALE WARD




Following the inspection of the white female wards, the same method was pursued in the examination of the colored female wards, which are designated as C-10 to 22.

The wards are on three floors and each floor is considered as a unit, although it is divided into four smaller wards. It is immediately perceptible upon entering the colored wards that the treatment and general handling of the colored patients is inferior to that of the white females. The wards are kept in a fairly clean condition. They are in charge of a white supervisor and assistant supervisor, the remainder of the attendants being colored. The type of attendant here is distinctly inferior to that in the white female wards.

It must be said at the outset that the supervisor of the colored female wards is totally unfit for the position she is occupying and should be removed at once. Her unfit-ness lies entirely in an intellectual incapacity, which necessarily results in poorer discipline, less adequate supervision and a generally inferior tone to the entire ward.

There are a total of 671 patients with 28 day attendants and 15 night attendants. As is the case with the white females, a fairly considerable number of assigned day attendants are on detail duty, taking the patients to and from outside work, to and from treatments, etc., and the result is that the number of available attendants is greatly reduced.

The Wards C-11, 12, 13 and 14 contain 196 patients, have seven day attendants and four night attendants.

There are only four toilets for the use of the patients on this floor. A large percentage of these patients are of the less disturbed type and are able to do work outside, in the dining rooms, linen rooms and kitchens.

This ward contains a fairly large number of pellagra patients, who are not allowed out of doors and who are receiving special pellagra diets.

On this floor was observed one child of nine, who was quite obviously feeble-minded and who, according to attendants, has been in the ward since infancy.

page -18 -




Wards C-I5, 16, 17 and 18 contain a poorer class of patients, more deteriorated, more disorderly, less cooperative.

There are eight day attendants and four for night. None of the patients are able or willing to do any work but a certain number of them go into the yard.

There are a large number of epileptics and seriously deteriorated central nervous system luetics in these wards and they require a very large amount of personal attention and care as a vast majority of then are entirely untidy and must be bathed, dressed and undressed.

Wards C-19, 20, 21 and 22 contain 183 patients and are very similar to the previously mentioned wards.

There are ten day attendants and four night attendants. The condition here is about the about the same as that in the four proceeding wards, with many deteriorated and untidy patients and some few in restraint.

Ward C-10 is located on the basement floor, at The level, or just below the level, of the ground.

Here are housed all of the physically incapacitated and senile patients, few of whom are disturbed or noisy or quarrelsome, many of whom are untidy and a large number of whom are entirely helpless, requiring continuous nursing care.

It is to be noted that no provision is made in the colored female wards for any recreation rooms and on the days when the weather is unfavorable, as it was on the day on which the wards were visited, it is necessary to crowd the patients into the wards where, of course, there is insufficient space for the patients to sit, the result being that a large number of them lie about on the floors and it is impossible to determine whether or not this represents deterioration or is the result of necessity.

The clothing of the colored female patients is of a decidedly poorer type than that issued to the white females, many of then being in ragged and patched clothes, and some of them being extremely dirty. It is, of course, understood that it is impossible to keep some of the patients clean, regardless of the efforts directed to this end. Certainly with the insufficient personnel, a desirable- result could not be obtained.

Colored female patients are provided with a yard which

-19-






is less adequate than that for white female patients in relation to their numbers. It is also very much less pleasant in appearance.

It is noticeable that there are considerably fewer patients among the colored females requiring restraint. This is believed to be due to the fact that the colored patient in all probability is less susceptible to the more common functional psychoses, such as manic depressive and dementia praecox, than is the white patient. There are a correspondingly larger number of central nervous system luetics among these patients.

                                                                      - 20 -

WHITE AND COLORED MALE WARDS




The white male ward and the colored male ward were visited and inspected in the same manner as the female wards.

The white male ward contained 1183 patients on the day of the inspection, divided as follows:

                            Patients

Ward No. 1........ 190

Ward No. 2........ 199

Ward No. 3 ........131

Ward No. 5 ........87

Ward No. S ........95

Ward No. 7 ........92

Ward No. 8 ........129

Ward No. 9 ........131

Ward No.10 ........131

With the exception of Wards 1, 2 and 3, which are provided with eleven toilets each, there are five toilets in each of the six remaining wards, regardless of the number of patients housed there.

The wards are constructed in the same manner as those found elsewhere, each ward having an adjoining porch for use of the patients when it is toe cold or unpleasant to be in the yard. No beds are placed upon the perches in the white male wards. The result is that the crowding in the wards is extreme, the beds being placed with no space between them except for the center aisles which are left between tiers of beds.

The white male wards are provided with two yards, one of which is kept for the use of the better class of patients and the other for the mere violent and deteriorated patients. The yards are wholly inadequate and very unpleasant in appearance and outlook. The ground is a brown clay upon which nothing can grow. It slopes by a fairly steep grade downward, is full of holes and uneven areas which are definitely hazardous. The hole is fenced in by a so-called "hog wire" fence. The fence is inadequate to prevent escape and the attendants assured me that attempts at running away are the order of the day here. Shacks are placed here and there as protection against the sun during the summer months. There is a little shade from a few trees scattered about. Here, as in the ether yards, no recreation is available. Therefore, one gets a picture of these patients roaming about in the yard, precipitating quarrels one with another, and in oven larger numbers clinging pathetically to the wire fencing which a hostile world has erected between itself and them. Small wonder that with nothing to do but wander about and brood upon their misery and misfortunes, those patients do not show a tendency to recover to a point where discharge is
 
 

- 21-

possible.

Of the 1183 patients in these wards 235 are assigned to work outside the buildings. The patients work on the farms3 in the field, in the kitchens, laundries, mattress factories and all the various maintenance shops. They are sent to work under the supervision of an attendant who accompanies them whenever they are sent out of the building.

All patients who are able and willing to work and are so certified by the attending physician, are assigned to some by type of work with the exception of the recurrently homicidal or suicidal patients and those who are persistent runaways.

This Department has 46 day attendants and 15 night attendants5 In addition to this there are a certain number of attendants assigned to accompany the patients who are sent out to work.

In general the same type of symptomatic segregation is undertaken here as throughout the institution; mere violent from loss violent, noisy and quarrelsome from quiet and cooperative, tidy from untidy. This segregation is, of course, only approximate, as the wards are not large enough to make it possible to separate patients in this manner. Any ever-' flow from a non-violent ward will have to be placed wherever space is available because of the overcrowding and lack of adequate number of beds. Epileptics are largely segregated in Ward 9, but there arc scattered epileptics throughout the wards, depending on the state of deterioration and violence.

Restraint is used rather freely in the white male wards at the discretion of the Chief Attendant, who must be notified it is applied. The same judgment is used here as elsewhere in the use of restraint, for the preventing.

destructive habits against clothing or furniture, violent or quarrelsome attitudes.

All of the patients must ta1.ce their meals in the general dining room as these who are toe feeble to go to their meals have been segregated in the infirmary, which will be discussed in later paragraphs. They must go to their meals whether the weather is favorable or not, as there is no provision whatever for having meals sent into the building.

There is a physician in attendance in this ward at all times. He has charge of the care of miner illnesses and injuries which are treated in the small dressing room provided in this building and he devotes a large portion of his time to the general observation of the patients.
 
 


-22

A second physician has general charge of the wards with assignment to the examination of those patients about whom there is correspondence and the answering of that correspondence.

This building is provided with one small sitting room on the main floor, which is used only for those patients who have visitors and is in no way regarded as a recreation room. Aside from this space there are no rooms available for recreation indoors in case of unpleasant weather when it is too cold to permit the p..ntist¼t'to remain out of doors or on the perches. They must be allowed to sit about in the wards where the available space is totally inadequate for the number of patients.

It must be said of this ward, as of all the others, that the number of attendants is completely inadequate for the number of patients. it does not permit super-vision close enough to prevent frequent quarrels and attempts to escape while in the yard. It is even impossible to keep the patients clean under the circumstances surrounding their care. We must repeat, that the attendants give scrupulous attention to their tasks - gentle and considerate handling to the patients, and do everything in their power to perform their duties conscientiously and properly. They are faced with an impossibly difficult situation.
 
 

COLORED MALE WARDS

Precisely the same situation prevails in the colored male wards. These are divided into ten wards with a total population of 740, divided as follows:

                                 Patients

Ward No. 1 ..............108

Ward No. 2 ..............263

Ward No. 3 ..............93

Ward No. 4 ..............28

Ward No. 5.............. 91

Ward No. 6 ..............84

Ward No. 7 ..............35

Ward No. 8 ..............131

Ward No.10 .............57

Ward No.11 .............89

For these 740 patients there are 20 day attendants and l0 night attendants.

Two hundred and ninety seven of these 740 patients are employed in doing various types of work about the insituation, in the laundry, on construction and necessary.

 -23-

building and repairs, on the farm in various capacities,

in the engine and boiler rooms of the heat and power plants, in the kitchens and dining rooms and, in fact, in every type of task required in the maintenance of the

institution.

those wards are a little less crowded than the others but are still housing many more patients than should be in the space available. The building ???? and one of the wards has only recently been repaired to make it safe for the patients as the two side wards showed signs of Collapsing inward. It is quite ?????? for habitation as the floors are old and sagging ???? is impossible to keep them clean, although it is ?????? apparent that a great deal of tine and effort is put into attempting to do so.

It is impossible to keep the patients clean with the number of attendants provided, and the Chief Attendant assured me that, except for the fact that every patient is cleaned before being sent to the dining room, but was entirely incapable of maintaining personal cleanliness with the number of attendants assigned to him.

With the exception of 89 patients on Ward 11, all of whom are old and feeble, all of those patients go to general dining room for their meals.

In this ward, which is termed the "nursery11, there are eleven young children, all of who are feeble-minded, several of the idiot grade.

In the Colored male wards, it is necessary to use ????? on some of the patients, always in order to prevent destruction of their clothing or the furniture. There are so few attendants that it is impossible to preventthem from destroying the leather cuffs usually needed for this type of restraint. While there is no evidence that the patients suffer more when being restrained in chains than in leather cuffs, nor did the writer see any case in which the patient had been injured there-by. It is still not proper to use chains for restraint. There is an inescapable correlation between the use of these measures and the idea of a prison and punishment and the psychological and moral effect is degrading even thoughthere may be no physical injury.

The care of the wards here, as elsewhere, is done by the patients who are able to work, with the assistance of attendants.

In addition, to the population of the colored male

- 24 -

wards this supervisor has charge of 23 patients housed in the criminal building which closely adjoins the colored male wards. Here, also, the attendants are entirely inadequate personally to take care of the patients, keep them clean and prevent frequent quarrels between the mere violent ones.

In this connection attention must be called to the use of the se-called sweat box. Here there is no sweating but the recalcitrant patients who have been sent to the hospital, because adjudged insane, are disciplined by being locked into this box-like structure where it is impossible to lie down.

A certain number of the patients in the colored male wards are allowed almost entire freedom. They are net required to report back to the wards from work but are allowed to go directly to the dining rooms for meals and from there they are allowed to wander freely in the small yard between the colored male and female wards, reporting in at various times during the evening.

One of these patients, who has dementia praecox, is in charge of all the charcoal burning' of the institution and he frequently does not finish work before time to return to the ward, around ten or eleven o'clock at night. He is not under supervision of an attendant at any time although he is regarded as dangerous and unfit for discharge.

There is no physician on constant duty en this ward although one of the physicians makes what is known as "daily rounds", consisting here, as elsewhere except for the white male wards, of a daily insp4ction of these patients who request interviews with the physician or who are apparently ill. There are here no facilities for any type of treatment and only a small and wholly inadequate treatment room for the care of miner illnesses and injuries, of which there are, of course, an unusually large number.

- 25 -

THE INFIRMARY

 This is a two story, frame building entirely surrounded by porches for the care and treatment of the White patients of both sexes who require practically constant nursing;;: care but are net acutely ill and, therefore, do net require hospital treatment.

This Department is in charge of a Registered Nurse who has no student or registered nurses under her. The care is given entirely by attendants under the direction of the registered nurse.

Here are housed and cared for, a large proportion of the aged white patients who arc paralyzed and unable to walk, feed themselves, dress themselves, or attend to any of their personal needs. here also are these who ore suffering from chronic, in-curable diseases such as cancer and diabetes of a severe type.
 
 

Here also are a considerable number of patients who are eat and consequently require tuba feeding, which is done by the head nurse or one of the attendants under her direction.

There are two children in the infirmary, both of whom are feeble-minded, neither of who is psychotic.

All of the patients in this building are completely untidy, requiring; day and night attention to keep them clean. All of the care is given by ten attendants during the day and five attendants during the night.

The meals for the patients in this building are brought in to them In containers and served in a small kitchen on the second floor. There are no facilities for keeping the food warm while it is being served.

During the winter, beds are kept on the porch of the male ward and the patients allowed to sit about in an inside room. This situation is reversed in the summer, the beds being moved indoors and the patients placed on the porch. A considerable number of those patients are bedridden and, therefore, require constant nursing care. care.

The bathrooms are inadequate, having two tubs for the women patients and two showers for the men patients. In the case of the helpless males it is necessary to wheel them into the shower in a wheel chair and bathe them in that manner as

 - 26-

it is quite impossible to give them bath cane with the number of attendants that are available.

The building- itself, being of frame construction represents a great hazard in the case of fine as none of these patients would be able to walk out of the building if fire were to break out.

Here are apparently a large number of patients who might be cared for in institutions of other types. Many are too old and feeble to be violent on dangerous and some have been admitted for conditions other than mental illness. A detailed study of this population will be given below.

-27-

GENERAL ADMIINISTRATION AND MANAGEMENT




 The institution is at present under the general direction and supervision of a Superintendent. The present holder of that position is not a physician and ha5 had no previous experience in the management of similar institutions. He received his training in the army where he served for a period of years. He has complete control and supervision of all the details of the institutional management but, in general, ho defers to the judgment of the Chief Physician and his staff of physicians in all matters pertaining directly to the care of the patients.

However, the entire routine of the hospital is under his direction and since, properly, there is no part of the institution which should not be directed toward the best care of the patients," we find what amounts to a dual control.

For example, in the assignment of work, the physicians designate whether or not the patient is able to work and are fit to be placed with other working patients but the work is assigned at the direction of the Superintendent.

In connection with the institution there is operated an 8000 acre farm, of which some 2500 acres are under cultivation. The usual live stock and poultry are raised for the use of the institution and there is a large herd of dairy cows for the purpose of supplying the needed milk. Nearly all of the necessary vegetables are growing on the farm, as well as some small grains and necessary fodder for the livestock.

The general supervision of this branch of the institution is also under his direction. There is a general farm manager, who carries out the Superintendent's orders but he maintains a close supervision ever this division as well as over other branches of the hospital. He controls all of the personnel, directs all of the purchasing, and, in gem-oral, exercises all the duties of the Chief Administrative Officer of any institution.

Largely because of this situation, there is apparent a distortion of the purpose of the institution from that of rendering to the sick patients the necessary care, service and treatment to hasten their recovery and discharge, to that of successfully operating the farm connected with it. This is not a matter of intent but one of unconscious emphasis. A lay person cannot, by the very nature of his
 
 


- 28

training and experience, have any knowledge of mental illness and since he gives the direction and emphasis to the institution, it is "inevitable that the administration will reflect that direction. He is scrupulously conscientious and devoted to the interests of the institution and the patients there. He has done much to improve their conditions. He is always thoughtful of their welfare and, wherever possible, their happiness. He is rendering a valuable service, but it is impossible to expect of a person untrained and uneducated in the problems of mental illness to give the skilled and effective direction which the institution mast have, if it is to function to the best interests of the patients and so to the best interests of the State.

There are operated in connection with the hospital and farm, all of the various necessary maintenance divisions, including sewing, laundry, shoe repairing, mat-tress making and general furniture construction and repair shops, as well as the necessary kitchens, bake shops and administrative offices

The hospital maintains its own power and heating plant as well. These are under the immediate direction of more or less trained employees but are operated in part by the use of patient labor. The patients are working in all branches of maintenance work and they are essential to the functioning of the institution. That is to say, there are not a sufficient number of employees to operate the institution in any of its branches without continuous help from the patients. This inevitably works to the detriment of the patients as it is impossible to choose the type of work for which the patient is best fitted, or which will be most beneficial to him. He must, on the contrary, be assigned to a type of work which is most essential to the orderly operation of the institution.

This includes even the care of other patients. They may be called upon to give every type of care to other patients, including, as the writer has observed, assistance in the restraint and control of disorderly and violently disturbed patients. It is open to very serious question whether such a practice can be defended, in view of the very likely ill effects upon the patient and his or her removal from ether occupations which night serve to rebuild and rehabilitate him to a point where he might be discharged.

There is a further ill effect of using patients to perform essential work in the hospital. He is likely to be-' come useful to the extent where there is a reluctance to discharge him when he is sufficiently recovered to be proper for discharge. The patient may, and frequently does,

- 29

share this reluctance. He becomes dependent upon institutional life and is apprehensive about engaging in the more arduous and demanding exchanges of a normal community. This is not as it should be. Every patient should have his mind directed carefully and guardedly toward recovery and eventual return to a full participation in family and community life. For many this is tragically forever impossible. For everyone this must be the objective never lost sight of, only relinquished after the most meticulous study and treatment has demonstrated its impracticability.

It is clearly understood that work is one of the most valuable adjuncts to the successful treatment of the mentally ill, but to be beneficial and contribute to their recovery and replacement in a normal community, it must be given under the direction of an individual trained to an understanding of the value of occupational therapy, and a knowledge of what type of occupations have boon proven to be most beneficial in various types of illness. Since it should be regarded as a portion of the patient's treatment, it should inevitably be undertaken under the direction or delegated direction of the physician in charge of that patient

There can be little question but that the institution should be supplied with an adequate staff to operate all of its divisions without the assistance of patients. If work is to be provided, as it should unquestionably be, it should be chosen in accordance with the principles enunciated in the previous paragraph. The present practice is not one of choice but of necessity. These in charge of the institution are forced to operate With an inadequate staff and they are, therefore, forced to use patient labor.

It is not within the province of such a report to examine into the operation of the maintenance divisions except insofar as they directly affect the care of the patients. They are commented on accordingly.

The kitchens arc operated in part by trained employees and in part by patient labor. The service in the dining room is rendered by patients under the supervision of attendants and in general seems to be satisfactory.

The food, however, is of an inferior grade. The diet is not always found to be properly balanced to insure the maintenance of the best health in the patients, who should, because of their confined and abnormal lives, be assured of a perfectly balanced diet if they are net to suffer injury to their health.
 
 

30

The meals are planned and prepared by a so-called steward with the approval of the superintendent, who in turn submits the proposed menus to the Chief Physician for comment and criticism. Syrup is used excessively, fresh fruit
is rarely on the menu. There is persistently an excessive use of starch, for example, one menu examined was as follows:

Beef stew, Irish Potatoes, grits, macaroni, light bread, syrup. Neither training nor experience is necessary to see that such a meal should not be served to persons in perfect health, much less to individuals who are ill. It is not remotely suggested that such a meal recurs regularly but the occurrence of such food combinations proves conclusively that the person preparing the diets does net understand the nutritional requirements necessary for a balanced diet

Furthermore, the food is grossly unpalatable in its manner of preparation and service. whenever it must be sent out of the wards there is no provision made for keeping the food hot and it consequently is received by the patients cold and necessarily unpalatable.

One of the most difficult problems that arises in the handling of the physically, as well as the mentally, sick is that of nutrition. It is of the utmost importance that the nutritional condition of the patient be maintained at a maximum level of health.

Many types of mental illness have as part of their characteristic symptomatology, a reluctance to eat, and it requires the greatest amount of tact and persuasion on the part of attendants to induce then to take an interest in their food. It is hardly necessary to point out that if food is cold and unpalatable, patients who are unwilling to eat may be brought to the point of refusing food entirely or of eating too little for their general health.

The diet kitchen, so-called, is under the direction of a trained dietitian, who is capable of planning the necessary special diets for patients suffering from pellagra, diabetes and ether chronic diseases of which the treatment is mainly dietary. All the meals for patients in the general infirmary are also planned and served from here. As has been stated, those for the general kitchens are not prepared under her direction.

The dining rooms, like the remainder of the institution, are greatly overcrowded, with the result that the patients are in very close quarters and there is an enormous amount of confusion, disturbance and quarreling in the dining rooms, all of which combines to prevent the patients from eating properly.

- 31-

The service in the dining rooms is partly performed by patients and partly by employees. It is extremely bad, the food being served in the crudest and most revolting fashion by being slopped into battered tin trays.

The general administration and maintenance of the wards is of a uniformly high order. There is an atmosphere of orderliness and cleanliness that pervades all of the wards. while the patients are not always kept clean this, the writer believes, lies not in the intent of the attendants to neglect the patients, but rather in the absolute inability of one attendant to do the work which should be assigned to four.

Clothing, while it is unattractive, is kept fairly clean and it is adequate in amount except that there is not a large supply of outer clothing. The linen supply is adequate to keep the beds clean. The practice of placing rou0r:h dried clothing on these patients is one which may be a matter of necessity but which, undoubtedly, contributes to the patients1 general feeling of being ill-used and discontented. Patients who have came from a background of meticulous attention to personal hygiene and the care of their person cannot but be offended by the total disregard of this aspect of living.

The patient; who is mentally ill may not be, and often is not in any way deteriorated, nor should ho be regarded in any other light than a patient who is physically ill. It is true that there is a certain class of patients who do become deteriorated, who lose all interest in themselves and their surroundings, become increasingly reclusive and personally untidy and finally reach a level of complete apathy. These patients require nothing but custodial care, attention to their health and general cleanliness. But there are an equally large number of patients of whom this is not true, and every effort must be made to maintain their surroundings at a level of decency which will encourage them to every effort to readjust themselves to a normal type of living and not destroy and injure their efforts to return to normal health.

Personality is a delicately balanced and fragile entity. The injury to personality involv3d in mental illness is of the most various and shifting quality. Some typos of mental disturbances, in no way alter or dislocate the individual's traits or tastes, merely involving a profound disturbance of emotional tone and at times an alteration of judgment and a delusion trend which initiate anti-social conduct. These patients do not become "animals". They may, and frequently do, have maniacal attacks but return to a quiet and cooperative attitude. They suffer quite as do normal persons from the necessary restraints and limitations of their activities.
 
 


32 -

They require and must have an environment superior to that needed by those who are net so afflicted

Can any sensitive person consider what it must mean to such persons to be deprived of every privacy, to be herded together for every activity, to sleep in quarters so congested that it is impossible to move between the beds; to be constantly in association with persons who are deteriorated and untidy in their persons. It may be well to point the case in This way - many normal individuals have a dread and fear of insane persons. They would not voluntarily go through a hospital for such sick individuals. when we consider that many mentally sick have this same horror and dread, can we fail to realize what must be the suffering they endure when forced to live in close association with other persons more seriously ill than themselves.

We do not punish in this way, persons who are physically ill. The community removes them from their environment if proper care cannot be given there. The hospital is made into an environment precisely operated for the amelioration of the symptoms and the removal of the cause of the illness. Every effort is made, no expense spared, to provide them with the needed care and treatment to return them to robust health and allow them to reenter their community.

In what way should the mentally ill differ from the physically ill? They to, have broken down under a strain too great for their strength and constitutional endurance. They require the same especially dir6cted treatment and care to assist them to regain their health. Their ability to do so is largely dependent upon the environment in which they are placed.

 - 33-

MEDICAL CARE AND SUPERVISION

The medical care of the patients is vested in n. group of physicians under the direction of a Chief Physician. There are at present nine physicians, including the Chief. Their duties are divided 5 follows:

The Chief Physician, as the title indicates, has entire direction of all the matters pertaining to the care of the patients, the nurses, employees, arid their families. He performs or directs the performance of all major surgery for the entire group of patients, employees and convicts. He has the supervision of 11 attendants and nurses. He directs all the instructions to the nurses in training but the physicians give some time to this work. It occurs from time to time that the Board of Commissioners of State Institutions order the admission to the hospital of certain persons who are not mentally sick, and it falls to the Chief Physician to give the necessary medical and surgical treat-met to such persons. In general, he has all of the multifarious detail of the c' re of everyone in the institution.

Physician A is assigned to the care of white female patients in the receiving hospital, the treatment of white female patients in the hospitals, both the general and tuberculous; the conduct of the clinics for the treatment of venereal diseases in white female patients, and the care of the white female employees. In addition to this, he gives instructions to the nurses.

Physician B is assigned to the reception of white male patients, the treatment of these patients in the hospital, the management of clinics for white male patients and the entire care of white male employees. He also has charge of the treatment of white male convicts from the convict camp located at the hospital, when such convicts become ill and are placed in the hospital proper.

Physician C is assigned to the reception of colored female patients, the treatment of these patients in the hospital, the care of the colored female employees, the care of the colored female patients on the general wards, all correspondence regarding those patients, all minor surgery and fractures in all patients of both sexes and colors. He also conducts a clinic for the treatment of syphilis in colored female patients. He has the responsibility for all emergency surgery among the convicts and families of employees, as well as the same duties for all emergency cases brought in from the highway, and, as the Florida State Hospital is the only hospital for a very large area, a

 - 34

fairly considerable amount of this work arises. He also gives C a certain amount of instructions to the nurses.

Physician D is assigned to reception of colored male patients, the treatment of those patients in the hospital, the care of colored male patients in the wards, the care of colored male employees, the correspondence regarding colored male patients, the entire care of forty colored convicts who have been assigned from the State Prison Farm to work in the State Hospital, and to do the urological work for all patients of both sexes and colors He further conducts clinics for the treatment of syphilis in colored male patients.

Physician E has the routine care of t3ie white female patients in the wards and the correspondence regarding these patients, the care of white female attendants, nurses and nurses in training. He is also assistant to the Chief Physician in all major surgery performed in the hospital. He is in charge of the work of performing physical examinations required on all new white female attendants and nurses. He has charge of all illnesses of a medical nature in white female employees when they are of sufficient seriousness to require admission to the hospital. He assists in all the urological work.

Physician F has charge of the correspondence regarding white male patients, general supervision of the white male wards, the care of all white male convicts, the giving of all general anesthetics in the hospital and the operation of the X-ray department. He is camp physician for the forty-two white male convicts located at the hospital prison camp..

Physician G is a specialist in diseases of the eye, ear, nose and throat for all patients - of both sexes and colors. He also performs the routine duties when any of the other physicians are off duty.

Physician H is in continuous attendance at the white male wards and in charge of the treatment of minor illnesses and injuries among white male patients. In addition to this, he examines all new white male attendants and new white kitchen and dining room workers.

In addition to the nine' physicians, there are dentists who give all of the dental care to the patients and employees. These dentists also have charge and perform all of the dental work for the 440 boys at the Industrial School at Marianna.

It requires only a glance at the list of these duties to recognize that the hospital is seriously understaffed with physicians.

35 -

When we consider the fact that there is a population of 5,000 persons to be cared for, 4,000 of who should have daily contact with a physician, it is clearly evident that the need for additional physicians is urgent. The Chief Physician cannot give time to the care of individual patients. One of the remaining physicians gives only special treatment for diseases of the eye, ear, nose and throat. Certainly a third physician is required to be on duty in the reception hospital and a fourth for care of the acutely ill. With the recurrent need for assistance in the X-ray Department and the surgical division, fifth physician is steadily occupied. The remaining four men are required to give the routine care to the forty-five hundred patients not included in the hospitals or infirmary. Does anyone suppose that it is possible for any physician to give daily supervision and care to one thousand people? Any such idea is clearly ridiculous. Small wonder, that many patients cannot be seen for years at a time!

Each ward is visited daily by one physician. He visits those patients who request an interview with the physician, complain of being ill or, in the opinion of the attendants, appear to be ill. He, also, examines and interviews from time to time, those patients regarding when correspondence has been receive a requesting information about their condition.

The physician further makes an effort to see the more recently received patients at frequent intervals following;- their reception. If their condition does not show any change within a comparatively short period of time, ho will be forced to discontinue this manner of observation in order to give his attention to patients more recently received.

Since the development of mental illness is of long duration, resulting as it does from years of tension and strain in a situation which has set up conflicts resulting in illness, the cure and relief of mental illness is usually also of long duration. It can only come about through a gradual process of rest and rehabilitation brought about by a favorable environment devoid of strain and through the assistance and understanding of physicians skilled in the application of every method of approaching the mentally sick.

The physical care of the patients is in general adequate, in fact, it is little short of amazing that the physicians so grossly overworked, are able to give scrupulous attention to the physical condition of the patients.

All illnesses are properly cared for. Necessary surgery is performed skillfully and with excellent results. All minor injures are given speedy attention. It is not always possible for the attendants to recognize symptoms of illness as soon as they make their appearance, with the result that patients are

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not seen early in the illness. In general, however, the general health of the patients is well supervised.

The physicians hold regular staff meetings once a week, at which time there is a general examination by the entire group of certain selected patients. The patients are selected for one of two reasons. Either there has boon some difficulty in making a diagnosis of the particular psychosis from which the patient is suffering, or the attending physician is anxious to obtain an opinion as to the propriety of discharging a given patient who has come under his observation. In general, a patient 'is more frequently brought before the staff for the latter reason.

It has not been possible to examine a large number of patients individually to consider the correctness of the diagnosis arrived at. This, however, is coming to be considered as of less and less importance in the treatment and handling of the mentally ill. There are no specifics for the treatment of certain psychoses with the exception of syphilis of the central nervous system. All cases of this type are diagnosed by moans of laboratory procedures and proper treatment is instituted. For the rest, a recognition of their symptoms and a diagnosis to assist in arriving at an Opinion as to the ultimate outcome is, no doubt, sufficient. In general, this is adequately performed. There is apparent some tendency to use an easy covering diagnosis when farther study would reveal a different condition but that is the result of pressure of work and consequent lack of time It is frequently found that the diagnosis would net appear to be correct in view of the findings given in the patient's record.

As the history of the patient is often of the greatest value in determining the proper diagnosis, an effort must be made to obtain a thorough going story of the patient's past life. This has been almost uniformly unsuccessful. In very few, if any, of the cases has anything even approximating a thorough or satisfactory history been obtained. In order to procure such necessary data, it would be necessary to have a staff of social workers trained in the technique required. They should be available to go to the district from which the patient has been received and obtain the history from the family or friends who are in possession of the information. Until this is done, there is no probability that records and diagnoses will be accurate, complete and correct.

Records of the patients are very poorly kept. In only very few instances are they're found any interval notes of the patient's mental condition. This is unquestionably duo to the fact that 4t are impossible to observe the patients at frequent intervals or with any regularity. In most, if not all, cases

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the history of the patient's stay in the hospital consists of nothing but nothing reports of fights between the given individual and others. Record is made also of acute physical illness from which the patient has suffered.

It is accepted that part of the duty of physicians is to keep accurate and continuous record of their patients progress. This is essential for many reasons. It is the only way we have of obtaining a complete picture of an individual1s condition. Disease, mental or physician, is not static. It is a dynamic condition, progressing or retrogressing, dependent upon many factors. What is true at one time is not true at another. Judgments cannot be made unless the progress is known and noted. A patients record should, to be useful, show his condition at any given time. It is useful as 'reference when information is desired. It is the only available ~7u1de to the proper decision as to his ability to adjust to a normal typo of living.

As to treatment for the mental illness, there is little that is under direction and control. Treatment is various, depending upon many factors. For the seriously disturbed patients, the accepted form of treatment is hydrotherapy. This requires fairly extensive equipment in the form of tubs and sprays. Except for an inadequate set-up for white male patients, none is available. This is a serious deficiency which should be met immediately

Each ward should be supplied with full equipment for hydrotherapyAt present, as we stated above, it is necessary to transfer the patient to the general infirmary if he or she becomes too violent to be handled in the wards. With the over crowding of the infirmary, only the m¼st seriously disturbed patients are transferred and, of these, only a very small portion receives treatment. This results, of necessity, in an excessive and very harmful use of restraint.

As to one of the most Important phases of treatment - occupational therapy - or treatment through work - facilities are totally inadequate and direction is lacking. This phase of the situation has been covered in previous paragraphs and it is sufficient to state here that work is chosen for the patient on the basis of what the institution needs most, rather than what will nest benefit the patient. Space is insufficient and there is no trained Individual giving supervision and direction to the program.

One small bit of work that is being done here deserves comment and commendation. In a small space, called the "art room" a very real and successful effort is being made to apply occupational therapy. Here the patients are provided with materials for doing handicrafts of various sorts. Many patients respond most

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favorably to this type of treatment. The writer has seen great improvement effected by a period of work In this department.

The further type of treatment - psychotherapy - or treatment by the physician through skilled interviewing and contact is, of necessity, ne0~lected. For this type of treatment, privacy, space and time are required, in addition to the skilled physician. The first three are entirely lacking and the fourth requirement only partially met. There is no quiet, restful room in the wards to which the patient may come and try to work out his difficulties through contact with the physician who, by his understanding and sympathy, can give much help to his patient. Even were there such space, no physician has the time to give to this type of work and the patients, therefore, are left to muddle their way alone to that understanding and acceptance which means mental health. His recovery and discharge is delayed and the cost to the State is proportionately increased.

It cannot be too emphatically stated that a hospital cannot be successfully operated unless sufficient physicians are available to render proper care and treatment to the patients. We have called attention to the fact that there is no equipment for the amelioration of the mere violent and distressing symptoms among any but a very small proportion of the white male patients. There are no facilities, neither is there any time, for the physicians to make periodic examinations of the patients in regard to their mental symptoms.

The whole outlook and attitude of the institution must necessarily be colored by this inadequacy. The physicians cannot be expected or hoped to maintain an attitude toward the patients which would be beneficial to their recovery when he is well aware that the mere performance of routine duties will consume all available time. The institution becomes less a hospital and more a custodial establishment and thus negates its own objectives and operates against the best interests of the patients as well as the State.

Since the physicians have no opportunity of examining patients before they are admitted into the institution, since a large number of unsuitable patients are admitted the physicians are unable to obtain their discharge because of the refusal of the districts to take jurisdiction, there is a likelihood that this situation will be intensified, unless some steps are taken to alter it.

Too much cannot be said for the conscientious attitude of the physicians toward the patients, their attention to every possible detail of their physical care, their Interest in improving the patients' conditions and making them fit to resume
 
 

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their normal position in the community. Especially should the Chief Physician be recommended for his efforts in this regard. Without adequate assistance, with improper and insufficient equipment, he has managed to create an institution in which there is at least an interest and alertness In regard to the problems of mental health, In which there is scrupulous attention to the details of physical care, where there is a most careful, humane and considerate treatment of patients by attendants, an atmosphere of orderliness and discipline throughout.

It should be added that he has repeatedly, both in letter, through personal interviews and through the medium of his annual reports, called the attention of the Legislature to the serious situation which is arising from overcrowding and under staffing but has never been able to obtain a sympathetic hearing.

The training of the physicians in general is the routine training obtained in medical school; with little or no addition-a]. training in mental disease. It is, however, true that the physicians who have been in the hospital over a considerable number of years have acquired a large amount of information about mental diseases. We cannot but feel that the institution suffers a serious handicap through this deficiency and that the employment of specially trained physicians will do much to improve the hospital.

One thing which militates against the physicians and prevents their getting additional training is the fact that the hospital has no medical library. It is necessary for those in the practice of any science to keep abreast of the latest developments of that science. This can only be done through regular reading and study. It is essential that every hospital be supplied with the standard textbooks and periodicals covering the fields of medicine met with in. that hospital.

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RECAPITULATION

For convenience, we will summarize the findings of the previous pages under sectional rather than departmental headings:

PHYSICAL EQUIPMENT

This has been demonstrated to be grossly inadequate. Buildings are insufficient in size; of improper construction for the purpose and not equipped for their function; beds are too close together for safety or comfort. There are insufficient sanitary facilities of a poor quality. Space is not provided for needed recreation nor is there equipment for it. Kitchens are lacking in the wards for emergency use.

The space for the treatment of the tuberculous is grossly inadequate, necessitating the congregation of some of these patients on porches in more or less close contact with uninfected patients.

Facilities are lacking throughout for the treatment of the disturbed patients. The wards must rely upon the use of restraint for the control of violent patients rather than the much to be preferred hydrotherapy.

Physical equipment is lacking for occupational therapy and it is much needed.

Yards are too small for the number of patients and do not give that sense of freedom and lack of restraint for which they should be, in part, designed.

The general infirmary is too small to meet the needs. Its equipment is more adequate than that of any other part of the hospital. In general, except for the limitation as to size, the infirmary is adequate for its purposes. It is not of fireproof construction and, therefore, represents a very serious hazard.
 
 

 PERSONNEL

We cannot be too emphatic in pointing out the inadequacy of the personnel.

There are insufficient employees in every department. is absolutely necessary to the operation of the All maintenance divisions are largely staffed by

41 -




patients. This includes even the care of disturbed and mildly violent patients.

Attendants are seriously inadequate in number. Only 236 attendants are available for the entire institution. They are forced to work 12 hours a day, 6 days week, and their wages are ridiculously low. This serious under staffing is very deleterious to the best interest of the patients. Quarrels and resulting injuries are too frequent by all odds. Ideally, there should be no possibility of quarrels between patients. Furthermore, the hazard to the attendants is heightened. They could not control the patients at anytime if there were concerted action toward escape or injury of the attendant. Several have been injured; some have been killed by patients. Physical care and cleanliness must, at times, be neglected because of the lack of vitally necessary assistance to care for the patients. There are no trained attendants in charge of the wards. Medications are given by untrained persons under the direction of untrained supervisors.

While the attendants are untrained, they appear to be of a high order of integrity. They are zealous In the performance of their duties; they are uniformly kind and considerate of the patients; they are well disciplined.. All in all, there are scarcely words to describe the fidelity and conscientiousness of these men and women working under such discouraging circumstances.

Tile inadequacy of the medical staff is perhaps the most serious handicap under which the institution operates. Nine physicians must give all the physical and mental care to almost 5,000 persons. Four thousand of these are ill at all times. There should be, at a minimum, twenty to thirty physicians to render adequate cure to this number of patients. None of these physicians has had special training in mental diseases. It is highly desirable, if not imperative, that a certain number of them should be so trained. Others might be accepted for training in that case.

Records are seriously incomplete, in some instances even identification data not being available. Interval notes of patient's mental progress are almost uniformly lacking. Neither is there any provision for filing and recording under the direction of a competent record. historian.

Social service personnel are not provided for. This is universally accepted as being a necessary part of any hospital, whether for mentally or physically sick. Properly trained social workers render essential services in obtaining histories, keeping contacts with families and guardians, and in establishing; ability of the patient or his family to pay for the hospital

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care. They may be useful in assisting the physicians in treatment and are most necessary in following patients who are out of the institution on a provisional release.

Personnel is lacking to direct occupational therapy. This being regarded as one of the essential and most effective parts of the treatment of the mentally sick, it is of the greatest importance that can adequate provision be made for the employment of properly trained personnel to direct this branch of the work.

No recreational program is carried out under the direction of on individual trained to give guidance and organization to such a program.

 GENERAL MANAGMENT

This is under the direction of a superintendent who is layman. The institution is well managed but because of the superintendent's lack of knowledge of the problems of mental health, the proper direction is lacking;. Emphasis is found to be placed upon efficient management of the farm and maintenance divisions rather than on the care and treatment of the mentally sick.

The diet is frequently poorly balanced and is usually inferior in quality and always unpalatably prepared and served.

Clothing is stereotyped and unattractive, coarse in quality, and returned to the patients without being ironed.

The general direction is orderly and has an atmosphere of discipline and considerations surprising. when we consider the limitations under which the employees are working.

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  RECOMMENDATIONS

 We believe that the data a given on in the preceding paragraphs points inevitably to the conclusion that with the present equipment, personnel and general management of the hospital it is impossible adequately to render proper care to the patients who are committed there. Certain changes have been shown to be immediately necessary if the hospital is to perform the functions for which it has been established. Unless such changes are instituted the problem of mental illness in the State will inevitably become increasingly serious and the to the State as a whole cannot but be deleterious. In view of these facts we are submitting in the following paragraphs certain recommendations as to changes, and changes which we believe will serve to improve the institution to the point where it may adequately serve the purpose for which it has been established.

If these recommendations are acted upon there should inevitably result an ultimate saving to the tax payers in spite of the fact that the institution of those recommendations will require a considerable increase in expenditure. However, such increase should promptly produce results which will finally lessen the costs of mental illness. They would serve to make possible some efforts toward the prevention of mental illness, which is generally accepted as the most affective measure designed toward the reduction of cost. Prevention is always less costly than treatment, whether it be of physical or mental illness. They would further serve to increase the facilities for treatment and would thus increase the number of patients who might be discharged from the institution as cured and bring about a shortening of the duration of time required to produce such cure.

To accomplish this purpose the following changes are Essential:

1. A building program which will gradually provide sufficient space for all legal residents of Florida who are in need of care for the prevention or cure of mental illness.

In preference to enlarging the present institution to this size, we recommend the division of the State into two separate areas approximately equal as to population for the purposes of administering the care of the mentally ill. It would then be advisable to proceed as fellows: rebuild the institution at Chattahoochee to supply modern facilities for the care of the insane from one of such areas, and construct second unit at a point
 
 


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to be selected as centrally located for the second area.

All such institutions should be constructed in accordance with the now generally accepted principles of the typo of building required for the proper care of the mentally sick. It is a truism to say that adequate space should be provided in accordance with the general idea's of hospital construction with sufficient space between beds, space for personal possessions of patients, and adequate rooms provided for recreation indoors, as well as adequate space for offices, examining rooms, etc.

The wards should be constructed on a more comprehensive basis, that is, each ward should be made more completely a unit. Complete facilities should be provided for the treatment and handling of patients who are disturbed. Each unit should be equipped with equipment for hydrotherapy for such patients, so that there would be no necessity for removal to a central treatment unit. Adequate space should be allowed for the equipment of separate rooms for the housing of patients in the most disturbed condition, to remove them from the undisturbed patients, thus producing benefits to both groups.

Facilities should be allowed for complete and adequate office space for the physicians in charge of the various units so that examination and treatment of miner illnesses and injuries could be taken care of in the various units and the physician could have space large enough and of the proper type, for the interviewing of those patients for whom psychotherapy is indicated.

A large enough outdoors recreational area should be provided so that there will be no sense of restraint or confinement. At present the recreational yards are too small and unpleasant in aspect.

It is equally essential that sufficiently large units be built for the care of acute illness, and, in particular, we should mention the necessity for the erection of a proper infirmary for the isolation of all patients of both sexes and both colors who are suffering from tuberculosis, so that the present deplorable situation may be terminated at once.

There is need for the construction of certain maintenance units such as new laundries so clothing may be more easily washed and the possibility of ironing the outer clothing of the patients may be considered.

Without provision for sufficient space for the proper housing and treatment of the patients it will be quite impossible to conduct the institution in accordance with generally accepted
 
 


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modern principles.

2. There should be an immediate allowance made for additional personnel of all types. An adequate number of personnel for the general maintenance staff should be made available immediately in order to remove the present improper situation requiring the services of a large proportion of patient labor for the operation of the institution itself. Patients are sent to the institution because of illness and for the proper care to cure that illness. They should not be used as essential labor to operate the institution. Work is essential but the type of work, in order to be beneficial, must be carefully chosen and carried out under skilled direction.

Allowance should be made for employment f the attendants who care for the patients, in the proportion of not loss than one attendant to' every 4ight patients. Attendants are now employed in the proportion of one to every eighteen patients. Even this figure does not give a proper view if the situation as no provision is made for sufficient number of attendants to keep this proportion regular, since a certain number must necessarily be off duty at all times and cretin others are out of the wards at all times. This results often in leaving one attendant to care of as many as sixty to sixty-five patients.

The provision of a sufficient number of employees who can give direct care to the patients is essential if it is to be hoped that the hospital is to be more than a custodial institution for the incarceration of these patients without any attention to their treatment. As we have stated above, the number of attendants now employed is insufficient to prevent almost incessant quarreling among the disturbed patients with its resulting large number of minor and major injuries. The use of restraint is greatly increased by the fact that the attendants cannot give individual attention to patients who show destructive tendencies to themselves? their surroundings and other patients.

We cannot forebear mentioning at this point, the grossly inadequate wages now paid to the attendants who, personally, give all the care to the patients in the hospital. The wages range from $l8.50 a month for the colored female attendants and up to $25.50 a month for the white male attendants. It is calculated that the total cost of their maintenance amounts toapproximately $13.00 a month. It is, therefore, clear that no attendant in the institution, receives more than a wage amounting to $38.00 per month. This, it is quite apparent, is insufficient for them to maintain themselves in the standard of comfort and decency which should be required, if the hospital is to have the services of personnel who will be capable giving the type of care required.
 
 


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3. It is strongly advised that the present situation of employing a lay person as Chief Executive Officer of the institution should be discontinued and that the requirements for the Superintendent of the Hospital should be as follows: he shall be a physician, licensed to practice in the State of Florida, A graduate of accepted medical school, whether incorporated or non-incorporated, having had at least five years training and experience in the care of the mentally ill, two of which years shall have boon spent in a hospital for the mentally ill accepted by the American Psychiatric Association, during which two years he shall have been under the supervision of a physician fully qualified as a psychiatrist. All personnel should be under his supervisions and subject to removal by him with cause.

It is suggested that the present Superintendent should be made the Business Manager of the Institution to profane all the duties of the management of the routine maintenance of the institution. This arrangement will result in relieving the superintendent of any of the details of business administration, but trill place in his hands, the general directions of the institution. In this manner it would be possible that the objectives of the hospital be clearly defined, and the superintendent would direct all of the operations of the institution toward the one function for which it is designed, namely, the care and cure of the mentally sick.

It is recommended that in addition to the superintendent, who is the Chief Physician, there should be employed a staff of physicians under his direction in the proportion not less than one to every 150 patients in the institution, and of not lass than one to every 40 patients admitted annually.

There are now employed at the institution nine physicians, including: the Chief Physicians, which results in the proportion of one physician to each 400 patients in sharp contrast to one physician to every 150 patients, which is the desired number. Of this number of resident physicians, a certain proportion should be trained psychiatrists whose qualifications should be as follows; they must be physicians licensed to practice in the State of Florida, graduates of accepted medical schools and have had not less than two years additional training in the care of the mentally ill, such training to have been obtained in a hospital for the mentally ill, which has been accepted by the American Psychiatric Association as having proper standards for such care.
 
 

'-47 -

4. In addition to the staff of resident physicians there should be provided a staff of consulting specialists in the following-. specialties; internal medicine, general surgery, organic neurology, diseases of eye, ear, nose and throat, and radiology.

5. There should be provision for the employment of a sufficiently large number of trained psychologists for the purpose of performing psychological tests and doing the generally accepted work of such especially trained persons

6. There should be organized under the direction of a trained individual, a Department of Occupational Therapy with sufficient staff to provide proper types of occupations for all the patients for whom this type of treatment is indicated. Such a director of occupational therapy shall be trained and qualified for such position by an adequate period of service in an accepted institution for the mentally

ill. The director of this Department must be under the supervision of the Chief Physician and subject to removal by him.

7. There should be established a Social Service Department under a Director of Social Service, WIXO shall be a trained psychiatric social worker, a graduate of an accepted school of social work, preferably, having had trainers through service in the social service division of a hospital-d for the mentally ill. There shall be employed a sufficiently large staff of social workers under the direction of the Director of Social Service to adequately perform the duties of a social service division.

8. The management of the diets and the planning of all meals should be placed under the direction of a competent dietitian who shall work under the supervision of the Superintendent,

9. Sufficient funds should be provided for a proper medical library to consist of standard books and the current periodicals treating the subject of mental illness as well as general medicine.

10. The employment of a recreational director to plan and carry out by means of a small staff, the treatment of patients, by physical exercise and recreational games under the general direction of the Superintendent.

11. The employment of sufficient number of nurses under the direction of registered nurses, portion of not less than one to four patients in for the acutely ill, this to include the general hospital and the tuberculosis wards, as well as the units in the

48 -

wards for the administration of hydrotherapy to disturbed patients

12. The employment of a trained hospital record historian, who shall establish and maintain a system of recording and filing In accordance with a method accepted for such purpose.

13. The establishment of a mobile unit consisting of two physicians who should be trained psychiatrists, one psychologist, one social worker, and one nurse.

The functions of this unit shall be to hold through-out the various districts of the State, clinics for the purpose of examining patients who are alleged to be suffering from mental illness, to have frequent contacts with patients who are out of the hospital on provisional release, and to Give what treatment is possible, to those patients who can be treated through fairly frequent contacts with a clinic of this type.

If such a unit were established for each of two hospitals, clinics might be held in central points which would serve three or four counties at frequent enough intervals to render some valuable service in the prevention of mental illness and the rehabilitation of patients out

of the hospital on provisional release.

It is an undoubted fact that the acceptance of the

above recommendations would necessitate a large expenditure of Moines as well as an increased appropriation t for the care of the mentally sick. It is, however, contended and has been demonstrated, in fact, by the experience of other governmental units that such methods of organization and administration, ultimately result in a saving to the community.

Since human life is in itself, the greatest asset to the community, it cannot be denied that any institution or organization which will preserve to the community its manpower and prevent the loss of that manpower through physical or mental illness should be supported by what-over expense is necessary to permit it to perform its functions satisfactorily.

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