Mental diseases: a public health problem. James Vance May
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satisfied, after an investigation by the Department of Mental Diseases, that such a person may be discharged "without danger to others." Persons charged with a crime "other than murder or manslaughter" and acquitted by a jury by reason of insanity may also be committed by the Court to a state hospital "under such limitations as it deems proper" and such orders may be revoked at any time.
A recent enactment (Chapter 415, Acts of 1921) provides that "Whenever a person is indicted by a grand jury for a capital offense or whenever a person, who is known to have been indicted for any other offense more than once or to have been previously convicted of a felony, is indicted by a grand jury or bound over for trial in the superior court, the clerk of the court in which the indictment is returned, or the clerk of the district court or the trial justice, as the case may be, shall give notice to the department of mental diseases, and the department shall cause such person to be examined with a view to determine his mental condition and the existence of any mental disease or defect which would affect his criminal responsibility. The department shall file a report of its investigation with the clerk of the court in which the trial is to be held, and the report shall be accessible to the court, the district attorney and to the attorney for the accused, and shall be admissible as evidence of the mental condition of the accused."
The whole question of methods of commitment was made the subject of an extended study by the National Committee for Mental Hygiene in 1919. A comprehensive report covering such legislation as was deemed necessary was submitted by a committee consisting of the following:—Dr. George M. Kline, Commissioner, Massachusetts State Department of Mental Diseases; Dr. Charles W. Pilgrim, Chairman of the New York State Hospital Commission; Dr. Owen Copp, Superintendent, Pennsylvania Hospital, Department for Nervous and Mental Diseases: Dr. Frank P. Norbury, of the Board of Public Welfare Commissioners of Illinois; and Dr. Frankwood E. Williams, Associate Medical Director, National Committee for Mental Hygiene. In addition to the ordinary form of commitment by a court of record in a civil proceeding, they recommended legislation in all states authorizing temporary and emergency care, observation pending the determination of insanity, and voluntary admissions. In a general way, the legislation recommended followed the lines of the present laws of Massachusetts and New York.
CHAPTER IV
THE STATE HOSPITALS—THEIR ORGANIZATION AND FUNCTIONS
The efficiency of the hospital is very largely a reflection of its organization, administration and personnel, but the material equipment of the institution and the financial resources available are factors of no less importance. The future of a hospital is often settled for all time by the degree of judgment exercised in determining its location. The founders must be guided to a very great extent by the purposes which they hope to accomplish. In the location of a public institution of any considerable size, however, there are certain considerations which, if overlooked, will eventually lead to serious difficulties. The initial cost of the property is unfortunately a factor which cannot be disregarded. It is usually considered desirable for obvious reasons to choose a site somewhat removed from great centers of population. A sufficient acreage must be obtained to guarantee an adequate amount of land for farming and gardening on a fairly large scale. This not only insures a ready occupation for patients, but will materially reduce the cost of maintenance. A point which should never be lost sight of is the necessity of choosing a location which can be reached easily by railroads, trolley cars and motor trucks. The hospital must be readily accessible to the relatives and friends of patients. It is equally important that it should be convenient for employees; otherwise an adequate force of nurses and attendants can only be maintained with great difficulty. Above all, the hospital should be in the community which it is destined to serve. The patients should not be removed to any great distance from their homes. In numerous instances severe hardships have been inflicted upon all persons concerned owing to the fact that state institutions have been located in districts where they are not needed by the community and where they cannot be easily reached.
Every large public hospital should be in almost immediate contact with a railroad. Otherwise thousands of dollars must be expended annually for the transportation of coal, food and other necessary supplies. The fertility of the soil to be used for agricultural purposes is only second in importance to the necessity of obtaining satisfactory building sites. A practically unlimited supply of pure water is absolutely essential. The possibility of utilizing some existing system of sewerage or providing the institution with one of its own should be given serious consideration. Drainage must be provided for and sanitary surroundings obtained. There should always be opportunity for future expansion of the plant. Practically every state of any importance has at least one institution which has been seriously handicapped throughout its entire existence by an unfortunate neglect of one or more of these important considerations.
In 1917 a special commission was appointed by the Governor of New York for the purpose of preparing an intelligent and comprehensive plan for the future development of the institutions of the state. In a report presented during the following year the commission called attention to a phase of hospital construction the importance of which cannot be too strongly emphasized. [27] "Nearly all of the state hospitals suffer from the fact that as originally planned they were smaller institutions and of a different type from those that are now desired, and the additions which have been made from time to time during the past twenty-five years, in order to meet the immediate demands for increased space, have not always been made with a completed and well rounded institution in mind. The results are badly balanced institutions, lacking in efficiency and ease of administration. … In planning a hospital for the insane the ultimate maximum capacity should be decided upon even if it is not possible to build the entire institution at once. A well co-ordinated plan should then be developed, which would permit the building of various sections as appropriations become available, with the idea of finally having a complete institution, harmonious in arrangement, and so planned as to attain the most desirable classification and the maximum of efficiency and economy in administration." The classification of the population which an average state hospital should provide buildings for is shown by the commission as follows:—Reception building, six per cent; convalescents, four per cent; hospital buildings, two per cent; buildings for the infirm, eight per cent; noisy, disturbed, etc., twenty per cent; epileptics, three per cent; working patients, forty per cent; quiet, clean and appreciative chronic class, fourteen per cent; and tuberculous, three per cent. They also suggest that every hospital should have a small isolation building for the care of contagious diseases. Their recommendation as to the amount of floor space per patient in the various buildings is exceedingly interesting and no less important. "First, That single rooms should have about eighty square feet of floor space. A room seven feet by eleven or eight by ten, while large enough for one bed, a bureau and a chair, is not large enough to permit placing two beds end to end or alongside of each other. If a room measures ten feet by twelve, there is always a temptation to place two beds in it if the hospital becomes crowded, and the advantage of single rooms is wholly lost. The number of single rooms in an institution should be from fifteen per cent to twenty per cent of the population, varying with the character of the cases to be cared for. Second, Dormitories should have above fifty square feet of floor space per patient, and no dormitory should have more than fifty beds nor less than six. This, of course, applies to the wards for the chronic cases. An adequate system of ventilation throughout the hospital is presupposed. Third, The day space allotted should provide forty to fifty square feet per patient. Fourth, The dining room allowance should be from fourteen to sixteen square feet per patient, in order to permit the use of small tables and to provide adequate passages for the expeditious service of food."
In former years much time and space was devoted to a discussion of the respective merits of the congregate type of hospital construction, the so-called "Kirkbride" or block plan (although it was in use long before Kirkbride described it) and the arrangement of buildings in groups. There is no question but what an institution that is all under one roof can be administered much more economically and operated at a lower maintenance cost. Very little, if any, advantage is derived by the patient from the group scheme. In its practical operation in the state hospitals almost the only point of difference, as far as the patient is concerned, is that he must go out of doors as