PSYCHIATRIC FACILITIES IN KANSAS PART I OBJECTIVES OF A STATE PROGRAM PUBLICATION NO. 143 NOVEMBER 19 46 KANSAS LEGISLATIVE COUNCIL SURVEY OF PSYCHIATRIC FACILITIES IN KANSAS Part I - Over-All Objectives Basic Considerations Involved In Kansas State Planning For The Care, Treatment and Prevention of Mental Disorders Report Submitted to Council Committee on Public Welfare By Dr. Paul H. Stevenson, Senior Surgeon (R) Mental Hygiene Division, U. S. Public Health Service Publication No. Ik3 November 19^6 KANSAS LEGISLATIVE COUNCIL STATE OF KANSAS LEGISLATIVE COUNCIL LIEUTENANT GOVERNOR JESS C. DENIOUS, CHAIRMAN SPEAKER OF THE HOUSE, FRANK L. HAGAMAN, VICE CHAIRMAN REVISOR OF STATUTES, FRANKLIN CORRICK, SECRETARY EDWIN F. ABELS Representative W. A. BARRON Senator RICHARD L. BECKER Representative E . A. BRIBES Senator WILFRID CAVANESS Senator GROVER L. DUNN Representative LAWRENCE M. GIBSON Representative BARTON E. GRIFFITH Senator ALFRED H. BARENESS Senator J. A, HAWKINSON Representative A, J. HERROD Senator JOHN A. HOLMSTROM Representative FRANCIS JACOBS Representative ERVIN E. LAKE Representative JOHN H. LEHMAN Senator L. C. LONG Representative C. 0, LUTZ Representative RILEY W. MacGREGOR Senator FRANK B. MILLER Representative F. B. ROSS Representative FORREST A. STAMPER Representative BENJAMIN 0. WEAVER Representative B. H. WOODMAN Senator LINN T. WOODS Representative PAUL R. WUNSCH Senator RESEARCH DEPARTMENT . F. H. GUILD, Director ‘•CAMDEN STRAIN, Asst. Director COMMITTEE REPORT MR. CHAIRMAN: There is submitted herewith, for consideration by the council and for the Information of the next legislature, a report covering Part I of the survey of psychiatric facilities In Kansas, which has been sponsored by the legislative council committee on public welfare under Proposal No. 19. Pursuant to recommendations of the committee, the council voted to request the Mental Hygiene Division of the U.S. Public Health Service to give technical assistance In carrying on this survey. In submitting this request, the council was joined by the state board of health, the state department of social welfare, and the state board of administration. In accordance with committee Instructions, the research de- partment completed negotiations with Dr. Robert H. Felix, head of the Mental Hygiene Division, as a result of which three staff members have made surveys In Kansas. A preliminary draft of this first report on the survey, pre- pared for the committee by Dr. Paul H. Stevenson, Senior Surgeon (R), Mental Hygiene Division, was presented to the council In September. Dr. Stevenson's final report, submitted herewith, deals generally with the need for psychiatric facilities and services, and does not relate specifically to the state Institutions themselves. That portion of the survey (Part II) Is covered In the separate report submitted by Dr. Samuel W. Hamilton, Mental Hospital Advisor, In which Is incorporated also the findings of the survey made by Miss Mary E. Corcoran, R. N., Psychiatric Nursing Advisor. As a statement of over-all objectives for consideration in state planning for the care, treatment and prevention of mental dis- orders In Kansas, the committee feels that this material deserves the attention of the next legislature. The committee has not attempted to make any specific recommendations based on this report, but does recom- mend that Dr. Stevenson's report be submitted to the legislature. Respectfully submitted, EDWIN F. ABELS, Chairman Committee on Public Welfare November 15, 19^+6 COMMITTEE ON PUBLIC WELFARE Representative Edwin F. Ahels, Chairman Senator A. J. Herrod Representative Richard L. Becker Senator Paul R. Wunsch Representative F. B. Ross TABLE OF CONTENTS Page General Objectives ----------- i Overall Direction and Control of State Mental Institutions ------ 1 State Laws Relating to Mental Illness - k Preventive Mental Hygiene --------7 Summary ---------------- Q 1 General Objectives In the light of present knowledge of mental disorders our approach to an ultimately satisfactory handling of the special problems pertaining thereto must be based on the following premises: first, that mental Illness is basically a medical problem, and second, that In addition to providing adequate hospital and other clinical facilities for those already mentally 111, preventive mental hygiene programs should be Inaugurated throughout the country In connection with state and local health departments. Traditionally, because of the Intimately associated economic and social factors Involved, a significantly large part of the burden of the care and treatment of mentally handicapped citizens Is accepted as a state governmental obligation. To discharge these obligations in ways com- mensurate with modern standards Is the goal of extensive planning at the present time on the part of practically all progressive states throughout the country. The present concrete situation In Kansas Indicates the need of the following objectives for Immediate state planning: 1. Modernization and expansion of state Institutional facilities to provide an amount and quality of services commensurate with state needs; 2. Provision for making these facilities readily accessible to all In need of them without legal or social stigmata; this means the abolition of archaic legal procedures that obscure the real Is- sues and the adoption of more appropriate modern concepts and procedures; 3. Development of long range preventive mental hygiene programs throughout the state as an Integral part of the existing state and local health departments' activities. Overall Direction and Control of State Mental Institutions In view of the special survey just made of the state mental hospitals and related Institutions hy Dr. Samuel W. Hamilton, detailed comment concerning the first of the above objectives Is unnecessary here. Dr. Hamilton’s report deals with the specific needs of the separate Institutions concerned. A word 2 of warning In this connection, however, is in order. Bigger and tetter ‘build- ings are notoriously easier to obtain than the correspondingly Important modern- ization of the overall administrative viewpoints and policies operating at the state level which affect markedly the ultimate usefulness of these institutions. Bigger and better buildings will not of themselves cure more patients. Only the effective skills of carefully selected, competently directed and adequately paid staffs can accomplish this desired result. The best measure of appreciation of this important fact is found in the proportion of the total state hospital maintenance costs spent for salaries and wages. The accepted standard of adequacy in this respect is that at least 50 percent of the total operative expenditures should be used for this purpose. The latest complete comparative figures show a range of from 50 to 68 percent for this factor among the various states; with an average of 52 percent for the country as a whole. In this list it is notable that Kansas, spending only percent of its total state hospital operative expenditures for salaries and wages, is separated from the bottom of the scale by only two other states. When all other factors are considered, the basic explanation of such deficiency in allowance for adequate staffing is almost invariably found in the survival of outmoded concepts and administrative policies operating at the state level of control. In the majority of Instances the officers and staffs of the institutions themselves have striven hard to bring their respective institutions into line with modern ideas and Ideals, and to justify in fact as well as in name the change from "asylum" to hospital. But the overall administrative view- point at the state level is usually still that of a public welfare problem, the beneficiaries being in the main under court jurisdiction and receiving institu- tional care of a sort where custodial economy has become the goal of administra- tive policies. Until this situation is remedied, and this entire group of in- stitutions brought into line with modern thinking regarding the basic functions 3 they are Intended to serve, these functions will continue to he poorly performed, state monies will continue to he unprofItahly spent, and the citizens of the state denied the benefits of the significant progress now being made In the treatment of mental disorders. Progressive states are handling this matter of state level administra- tion In different ways. Separate state departments of mental health or mental hygiene have been created In certain of the larger states, while separate divi- sions of existing boards of control have been set up In other instances. In some states with a relatively small number of such institutions, as Is the case in Kansas, for Instance, considerable thought Is being given to the matter of placing their overall direction under the wing of the State Department of Health or a State Department of Health and Welfare, creating therein a more or less autonomous hospital bureau with such subdivisions as may be desirable to care for the specialized requirements of different types of hospitals operated under state auspices. In all Instances, however, definite moves are being made toward the removal of control of these specialized hospitals from the framework of purely welfare administrative thinking, and placing their overall administra- tion In the hands of specialists In the fields In question. In no other way can the professional services of such Institutions be elevated to and maintained at the level of recognized modern standards. The Importance of the type of state level control under which such hospitals operate cannot be overemphasized. We are entering an age of active warfare against mental Illness, and are attacking all along the line with great- ly Increased knowledge and new techniques. The effectiveness of this attack must not be handicapped or Jeopardized by antiquated concepts and attitudes of mind operating In the top command posts. State Laws Relating to Mental Illness We turn next to a brief consideration of the second objective listed above, namely that of making the facilities provided for the care and treatment of the mentally ill readily accessible to those in need of them without unnec- essary legal or social stigmata. This again is not the simple matter it should be. Here once more we come face to face with the survival of antiquated legal concepts and procedures embodying legal fictions no longer compatible with modern thinking. The solution calls for clear thinking as to the basic Issues involved. In Kansas today the average person afflicted with mental illness and requiring psychiatric treatment or care in a state hospital faces the following ordeals. Briefly, the first prescribed step is the sworn "complaint" that must be filed with the judge of the Probate Court. The judge then issues a "warrant" legally placing the person in the custody of the sheriff and commanding that he be brought before the court for a hearing. Thereupon an Inquest is held either before a commission or a jury at the discretion of the judge. If before a jury, the person alleged to be "Insane" must be present or represented by counsel, and the judge must abide by the decision of the jury and commit the person, discharge him, or remand him to his relatives. Although the statutes provide two ameliora- tive alternatives, namely voluntary admission and "commitment for observation" for thirty days before the final adjudication is made as to "sanity," neither of these practices is encouraged, chiefly on account of the over-crowded condi- tions of the institutions. Legal commitment on the basis of a court hearing, usually before an appointed commission whereon the "examining physician" need not by law be a psychiatrist, is the commonly accepted procedure of admitting patients to the state hospitals. In other words, the admissibility of mentally ill persons to the specific treatment facilities provided by the state depends basically on the decision of the judge rather than on the decision of physicians specially trained in the field of mental disorders. 5 No amount of finesse In administering such procedures, nor any amount of discretionary common sense injected into the situation hy an intelligent Judge can alter the basic fact that such practices are outmoded, time-consuming, costly, unreliable, against the therapeutic Interests of the patient, and at times actu- ally dangerous with respect to the safety of the patient or of the public. In actual practice such procedures represent an enactment of a tragic fallacy that today is repulsive not only to common sense but usually to common decency as well. The best modern laws governing admission to mental hospitals are de- signed to give patients direct access to the facilities in question, without unnecessary delay, without prejudice to their social or legal rights as citizens, and with every consideration possible given to the feelings of the patient and the family. Such admissions in the great majority of cases should be considered voluntary, arranged for either by the patient, or by a relative or Interested friend or family physician on the patient's behalf. Questions of diagnosis, suitability or admissibility for either observation, treatment or care, as well as of financial considerations and other matters pertaining to the hospitaliza- tion, should be routine matters of hospital functioning under appropriate stat- utory provisions covering the various factors Involved. Legal commitment should be considered a measure to be used only in the Interests of the personal safety of the patient or of the family or community, and not as a provision for legal- izing the use of public funds for the care of Indigent persons in certain classes of institutions as is now frequently the case. Formal legal commitment should be granted immediately by the court, when necessary, upon the authorized certi- fication of the superintendent and staff to the effect that the patient's arbi- trarily leaving the protection of the hospital would endanger his own safety or possibly that of others. Institutions operating under some such procedures have a steadily decreasing number of patients requiring actual legal commitment, and the public has been quick to recognize the lack of implication of any threat to 6 a patient's fundamental civil rights merely on account of his being in this par- ticular type of institution. All the ordinary processes of law pertaining to guardianship and related matters are available for application if and when neces- sary, and, in cases of actual legal commitment, access to the basic safeguard of habeas corpus proceedings, if necessary, is in no way endangered. In those states where mental disease has come to be recognized as basically a medical problem, and handled accordingly by specially trained physicians under statutes legalizing their responsibilities and control, appeals from the opinions of the profes- sional staffs of the institutions concerned are exceedingly rare. The arguments supporting this attitude toward mental disease are both logical and simple. The medical profession has long been entrusted with respon- sibilities, including certain appropriate police or quarantine functions where necessary in connection with health matters affecting the personal safety of the patients concerned or of the public at large. An intelligent public accepts this situation as a matter of course. Society does not require, for Instance, that a judge or a member of the legal profession step out of his realm of competency to hold hearings on how a case of typhoid or scarlet fever shall be handled in the Interests of the patient or of the public. Instead, the logical responsi- bility and appropriate statutory authority is vested in the physicians especially trained to understand and handle the particular problems involved. No amount of rationalization or legal sophistry to the effect that special legal protection is necessary to prevent "railroading" of sane persons to "Insane asylums," or to protect the public from the dangerously Insane, will Impress Informed minds today. On the contrary, there is plenty of counter evidence of the danger to both patient and public in allowing the prerogatives and decisions of extraneous legal machinery of the kind herein described to usurp the appropriate functions of the professional staffs of the institutions concerned. 7 Modernization of admission laws and procedures Is taking place through- out the country. For brevity, directness, completeness of coverage, full con- stitutional protection for all concerned, absence of unnecessary expenditures for legal participation, and for the therapeutic Interests of the patient being placed first, the new laws now in operation In Arkansas deserve special attention (Acts of Arkansas, No. 2Ul). In contrast, recent modifications in most of the other states constitute little more than compromises, representing last-ditch stands of archaic legal prerogatives that are doomed ultimately by the simple fact that their basic premises run counter to the significant Intellectual trends of the times. It is to be hoped that In Kansas the complete revamping of the laws and procedures relating to the care of the mentally ill will be based on a frank and intelligent recognition of the essential facts involved. Nothing short of this should be accepted as worthy of the high standards of both the legal and medical professions of the state. Preventive Mental Hygiene The third objective listed above has to do with the development of long range programs of preventive mental hygiene activities throughout the state. Experience Indicates that mental hygiene In its broadest application can best grow Into an effective health measure when developed within the framework of organized public health efforts. Such application should be made operative on all the levels of organized health activities In the state, Including the various county, municipal and town levels. The beginning of such a program in Kansas Is found In the considera- tion now being given by the State Board of Health to the possible creation of a separate division for specific functioning In this Important field, particu- larly with reference to the "National Mental Health Act" of As the plans for this new division take form, and as qualified personnel become available, It 8 is likely that certain supplemental clinical psychiatric services for communities not otherwise provided for will have a part in its program. The most important function of such a division, however, would he In the direction of initiating, stimulating and coordinating a variety of less conspicuous hut more significant activities focused ideas of prevention. This phase of the program will naturally concern Itself largely with the mental health needs of the younger cit- izens of the state. Promulgation of basic mental hygiene concepts relating to attitudes and practices concerning the emotional needs of Infants and young chil- dren will he a major item in its program. Dissemination of these principles may well begin in connection with the teaching and other activities centering in pre- natal and well-baby clinics. Such dissemination should be likewise carried out through public health nursing contacts, social agency activities, as well as in nursery schools, kindergartens and the regular schools. Effective Influences should also be put to work through the coordinated activities of a variety of community agencies concerned with local child welfare problems throughout the state. In short, such a program must be aimed at getting preventive mental hygiene to work on the widest possible front with respect to the mental health problems of both adults and children. In the course of time the activities of this new division of the State Board of Health should become recognized as of de- monstrable value in its contribution to better mental health and more effective living on the part of a significant portion of otherwise neglected citizens of the state. • Summary Current advances in knowledge concerning mental disorders have shifted the emphasis and objectives of state care from the realms of legal and welfare considerations to those of active medical treatment and prevention. Recent sur- veys indicate that the most urgent present needs in Kansas are not only for (l) modernization and expansion of existing mental institutional facilities, but 9 (2) provision for making these facilities readily accessible to those in need of them without legal or social stigmata, and (5) the development of long range pre- ventive mental hygiene programs in the state and local health departments. A first step toward these goals is found in recent objective appraisal, made by a national authority in the field, of the present institutional needs with respect to construction, administration, medical staffs, nursing, and treatment. Another Important forward move is the recent decision of the State Board.of Health to Include preventive mental hygiene activities within the framework of its or- ganized public health efforts. Any approach to an ultimately satisfactory handling of the problem of mental illness will be practically nullified at the outset unless the problem is frankly recognized for what it is -- namely, not a legal or welfare problem, as considered in practice in Kansas today, but basically a medical problem to be handled by competent medical specialists under appropriate statutes legalizing their responsibilities and control. Realistic recognition of this fundamental fact must find expression not only in the placing of the institutions concerned under the direction and control of an appropriate state-level administrative body, but in the radical revision of existing state laws relating to mental Illness. FACTS ABOUT THE LEGISLATIVE COUNCIL The council Is a permanent joint committee of the legislature, meeting quarterly at the state capltol and giving advance consideration to problems expected to con- front the next legislature. Its purpose is to formulate*a program for the next session. In preparing this program, the council: l) acts as a clearing house for ideas on current legislative prob- lems by receiving proposals from any member of the legisla- ture; 2) determines and directs, through its committees and research department, the study and research necessary for proper consideration of all proposals; 3) disseminates advance information on these problems to other legislators and to the general public by means of committee and re- search reports and by discussion at and between council meetings; and k) reports directly to the legislature, one month in advance of the regular session, making recommen- dations in the form of bills or otherwise, and summarizing the material prepared for use of the legislature in con- sidering the program. All publications are available to any citizen of Kansas Interested in the particular subjects considered. PSYCHIATRIC FACILITIES IN KANSAS PART II THE FIVE STATE INSTITUTIONS PUBLICATION NO. 145 NOVEMBER 1946 KANSAS LEGISLATIVE COUNCIL SURVEY OF PSYCHIATRIC FACILITIES IN KANSAS Part II - The Mental Institutions A Report Submitted to Council Committee on Public Welfare By Dr. Samuel W. Hamilton,, Mental Hospital Advisor Mental Hygiene Division, U. S. Public Health Service Publication No. November 19^6 KANSAS LEGISLATIVE COUNCIL STATE OF KANSAS LEGISLATIVE COUNCIL LIEUTENANT GOVERNOR JESS C. DENIOUS, CHAIRMAN SPEAKER OF THE HOUSE, FRANK L. HAGAMAN, VICE CHAIRMAN REVISOR OF STATUTES, FRANKLIN CORRICK, SECRETARY EDWIN F. ABELS Representative W. A. BARRON Senator RICHARD L. BECKER Representative E . A. BRIBES Senator WILFRID CAVANESS Senator GROVER L. DUNN Representative LAWRENCE M. GIBSON Representative BARTON E. GRIFFITH Senator ALFRED H. HARKNESS Senator J. A. HAWKINSON Representative A, J. HERROD Senator JOHN A, HOLMSTROM Representative FRANCIS JACOBS Representative ERVIN E. LAKE Representative JOHN H. LEHMAN Senator L. C. LONG Representative C, 0. LUTZ Representative RILEY W. MacGREGOR Senator FRANK B. MILLER Representative F, B. ROSS Representative FORREST A. STAMPER Representative BENJAMIN 0. WEAVER Representative B. H. WOODMAN Senator LINN T. WOODS Representative PAUL R. WUNSCH Senator RESEARCH DEPARTMENT F. H. GUILD, Director CAMDEN STRAIN, Asst. Director FOREWORD This report covers the final part of the survey of psychiatric facilities in Kansas, sponsored hy the legislative council committee on public welfare under Proposal No. 19* Part I, Objectives of a State Program, by Dr. Paul H. Steven- son, has already been released as publication No. IV5. These two reports constitute the entire survey and are presented to the legislature in accordance with the report of the committee as adopted by the council on November Ik, 19k6. Members of the staff of the Mental Hygiene Division of the U. S. Public Health Service made the survey at the re- quest of the legislative council, the state board of adminis- tration, the state board of health, and the state board of social welfare. The present report was prepared by Dr. Samuel W. Hamilton, Mental Hospital Advisor, U. S. Public Health Ser- vice, and President of the American Psychiatric Association, and incorporates the findings of Miss Mary E. Corcoran, R. N., Psychiatric Nursing Advisor, from the same office. It is pre- sented as submitted by Dr. Hamilton, without additional com- ments or recommendations by the legislative council Itself. The report discusses the conditions and needs of the five state mental Institutions and makes comparisons with sim- ilar institutions in other states and with nationally recog- nized standards. Recommendations are made for Improvements, emphasizing adequate staffing, services and financing. November 50, 19^-6 F. H. Guild, Director Research Department UNITED STATES PUBLIC HEALTH SERVICE Thomas Par ran. Surgeon General- Mental Hygiene Division Robert H. Felix, Medical Director Section on Mental Health Methods Samuel W. Hamilton, Mental Hospital Advisor Advisory Committee Arthur P. Noyes, M. D., Chairman S. Spafford Ackerly, M. D. Louis Casamajor, M. D. Ross McC. Chapman, M. D. Franklin G. Ebaugh, M. D. Clarence M. Hincks, M. D. Lawrence Kolb, M. D. Winfred Overholser, M. D. Frederick W. Parsons, M. D Arthur H. Ruggles, M. D. William L. Russell, M. D. George S. Stevenson, M. D. TABLE OF CONTENTS Page BACKGROUND AND NATURE OF SURVEY 1 HISTORY AND GENERAL INFORMATION 2 Institutions 2 Financial Aspects 5-5 Maintenance Expenditures, Kansas and Selected States (Figures 1-3 and Tables I-III) 6-11 PHYSICAL PLANTS 12 Mental Hospital Beds Needed and Provided in Kansas, 1946 (Figure 4) 14 THE INSTITUTIONS 15 Osawatomle State Hospital 15 Topeka State Hospital 16 Lamed State Hospital l8 State Hospital for Epileptics 20 State Training School 21 DISTRIBUTION AND ACTIVITIES OF MEDICAL STAFF 25 Patient Load per Physician, Kansas Institutions, 1946 (Figure 5) 24 Medical Positions Recommended and Authorized, Kansas Institutions, 1946 (Figure 6 and Table IV) 26-27 Patient Loads per Physician, Kansas and Selected States (Figures 7-9 and Tables V-VII) 28-33 NURSING ARRANGEMENTS 37 Patient Loads per Nurse or attendant, Kansas and Selected States (Figures 10-12 and Tables VIII-X) 58-43 FOOD: ITS PREPARATION AND SERVICE 47 SPECIAL GROUPS AND SPECIAL TREATMENTS 50 Newly Admitted Patients 50 Tuberculosis 51 Specialized Therapeutic Techniques 53-54 Page TREATMENT OF CONVULSIVE DISORDERS 56 Hospital Care 56 Facilities 57 TRAINING AND CUSTODY OF MENTAL DEFECTIVES 58 Types of Mental Deficiency 59 Institutional Requirements 60 PUBLIC RELATIONS 60 Admission Procedures 60-61 Out-patient and Social Services 61 COMPARISON WITH NATIONALLY RECOGNIZED STANDARDS 65 The Mental Hospitals 65 The Training School 68 DISCUSSION AND RECOMMENDATIONS 70 New Hospital 71 Department of Mental Hygiene 71 Commitment Procedures 72 Specialized Groups - Sick Children, Tubercular Pptients, The Aged 72-75 Medical Staff and Activities 7l Additional Measures of Diagnosis and Treatment 75 Nursing and Ward Care 76 Food and Feeding 76 Building Program 76 * * * * INDEX 77 1 THE MENTAL INSTITUTIONS OF KANSAS I. THE OCCASION Resources Kansas is a State of 82,276 square miles, and a population somewhat under 1,800,000.(1 The number of inhabitants fell during the war, but is thought to be rising again. Most of the State is included in the Great Plains, and its wealth lies primarily in the soil. It has been said that by Intensive cultiva- tion this area could raise two-thirds of all the crops needed for food in the United States. Stimulus In Governor Andrew F. Schoeppel brought to the attention of the Kansas legislature some discomfiting facts about the mental institutions, and pointed out that they are the worse for neglect. It was decided to make a study of the many elements Involved, and to propose a program that would make these Institutions what they ought to be in order to house properly the sick citizens of the State, and concomitantly to bring equipment and personnel to a level that would insure the mentally ill of Kansas treatment as good as the medical pro- fession knows how to give. Suitable legislative committees were set up to su- pervise this study. Invitation In at the Instance of the Legislative Council, the Governor and the several departments Interested in mental, health requested the U. S. Public Health Service to make a survey of these institutions. Field Trips Miss Mary E. Corcoran, Nurse Officer, visited them in May, and Dr. Samuel W, Hamilton in July. Dr. Hamilton had had the privilege of seeing one of the hospitals on other occasions in and and his colleague in the Mental Hospital Survey, Dr. Winfred Overholser, had studied and reported on the Osawatomle State Hospital in 1958. Sources The report that follows is based primarily upon observations made and conversations had during these visits. Other sources of information are the 1. U. S. Census, 19J+O, 1,801,028; State Census, I9I+5, 1,795,066. 2 U. S. Bureau of Census, the Journal of the Kansas Legislative Council for Novem- ber, historical material in Vpshlngton and the files of the National Com- mittee for Mental Hygiene in New York, and miscellaneous information from a variety of sources. Material already collected by the Legislative Council is of the highest value. Orientation A great deal might be said about the humane service given through these institutions by the State of Kansas to its citizens for many decades. Such mat- ters have been well set forth in annual reports to the Governor and Legislature. The desire of the Legislative Council seems to be that data relative to matters that need improvement are of special Interest to them, and this report attempts to supply such data. Nevertheless it would be impossible to avoid mentioning much that is commendable, even if one might wish to. A great deal needs to be done (and can be done) to make the work of the institutions more effective, and this document is an attempt to discuss the principal issues. II. HISTORY Institutions The first legislative assembly of Kansas in 1855 enacted a law provid- ing for the appointment of a guardian for a person of unsound mind. Eight years later the Osawatomle State Hospital was established, and in 1866 the first ten patients were received. The following table shows the year of opening, the rated capacity of the institution, the number of patients in the house during the sur- vey, and the number admitted for the year ending June 50, 19^6. Institution Opening Rated Capacity Census First Admissions Re- Admissions Osawatomie State Hospital 1866 1,500 1,705 20i+ h2 Topeka State Hospital 1879 1,800 1,855 287 5^ Lamed State Hospital 191U 1,508 1,505 275 15 State Training School l88l 1,200 1,288 101 - State Hospital for Epileptics 1905 720 706 5 Supervision The State Board of Social Welfare is charged with responsibility for the oversight and management of these institutions. This arrangement has pre- vailed since 1939j when these responsibilities were separated from the State Board of Administration. Three board members give full time to their office. They are appointed for four years each, with overlapping terms. Changes have teen so frequent that positions on the Board are commonly thought of as stepping stones to something more attractive. For the appointment of hoard members there is no requirement of knowl- edge or experience in the field of institutional management. Indeed the work and needs of the institutions are quite subordinate to the responsibilities and dif- ficulties Inherent in the social welfare program of the State. Civil Service Other State agencies give some aid. The Civil Service Department classifies positions and supplies candidates for positions, when it can. This Department is said to have abolished the position of first assistant physician, placing all assistants, young and old, in the same category. A discharged em- ployee of the State may appeal to the Department for reinstatement. Health The Board of Health holds Inspections of the Institution properties in order to make recommendations about sanitary issues. The Board can hardly insist that another department of the State accept its advice, hence pasteurization of milk produced on the farms is only slowly adopted. With the help of Federal funds, the Board of Health has made tuberculosis surveys in Institutions where they were wanted. Business Manager The State Business Manager is purchasing agent and all materials and supplies come by arrangement of his office or through his permission to purchase locally. Fire Marshal The State Fire Marshal advises the institutions about questions of fire protection. All have serious risks. Agriculture The State Department of Agriculture perhaps has had more power in the institutions than any other agency outside the governing board: for two years it directed to a large extent the policies of the farms on which are raised great amounts of food. This arrangement no longer exists. Appropriation The State makes biennial appropriations for the support of the insti- tutions, and the amount allotted to salaries and wages is a lump sum. It was formerly possible for the Board at any time to raise salaries by decreasing the 4 number of employees and redistributing the fund; but the Civil Service Commission, a body only five years existent, has been made responsible for the schedule of wages, and independent action by the Board of Social Welfare is now impossible. Lack of Funds During the great depression, expenditures were cut deeply. At least un- til recently, good administration was believed to Involve spending as little as possible in the institutions. No one was so inhumane as to suggest neglect or abuse, but in many quarters there seemed to be no credence of the idea that persons of high quality and considerable number are needed to treat the mentally ill, or train the mentally deficient, and both treat and train persons who are subject to convulsive disorders. Appropriations therefore for these institutions were very low. Collections Appropriations are augmented by charges made at the rate of about $21 per month for the support of private patients. Maintenance Expenditures Since the monies expended by a State for the maintenance of its patients constitute a rough comparative index of the care and treatment provided, the amount spent by Kansas in relation to its wealth and to other States of similar population is of interest. Though this State ranked seventeenth in estimated effective buying income1 (1945), it ranked forty-first in its expenditures for the mental hospitals (1944). The increase in the annual per capita expenditures from $21+4 to $278 in 1946 reflects mainly rising living costs. When the average annual expenditure per patient for the United States as a whole is compared with that of Kansas we find that the United States' average was half again as much. The States selected for comparison in Table I and Figure 1 ranged from in Connecticut to $528 in Missouri. Salaries and Wages The most important item in hospital expenditures is the amount devoted to salaries and wages. If treatment is to be effective we must bring to bear on these sick or defective minds the benefit of association with good minds. A dis- tinguished son of Kansas,2 while discussing military psychiatry, said something that is just as true of civilian mental treatment: ".0... in psychiatric treat- ment the personality of those on our staff is the chief medicine that the patients receive. Very specifically, these include the nurses, the corpsmen, the social worker, the psychologist and the psychiatrist himself. The interplay of their personalities with the man who is ill is the most potent medicine we have, if we through training and experience know how to use our knowledge to be of help to that man." 1. Sales Management, 1944 (Mpy), 53; 98. 2. Brigadier General W1111am C. Mennlnger, American Journal of Psychiatry, May, 1946. Generally speaking, a larger budget permits employment of more and bet- ter qualified personnel. States with high standards of care devote more than half their expenditures to this purpose. For both 1946 and 1944 the amounts ex- pended by the Kansas hospitals were only somewhat over two-fifths of the total expenditure for patients’ maintenance. Though not all. the States selected for comparison In Table I and Figure 1 allocated half their budget to this purpose all spent a larger amount than did Kansas. Other Expenditures The amounts spent for purchased provisions, fuel, light, water and other miscellaneous items are Influenced by too many variables to be directly comparable. Variations in accounting procedures, climatic conditions, produc- tivity of the hospital farm and cost of living differences affect the value of these Items. Expenditures for Defectives In Table II and Figure 2 are presented data on annual maintenance ex- penditures at Winfield. For the fiscal year 1946 the institution reported an annual cost of $244 per patient, a moderate Increase over the 1944 sum of $201 per capita. Similar expenditures at selected institutions in 1944 ranged from $505 at Pennhurst State School, Pennsylvania to $598 at Coldwater State School, Michigan. Expenditures for Epileptics In Table III and Figure 5 the cost of caring for a patient hospitalized at Parsons la compared with expenditures In other States which have made separate provision for epileptics. For the year 1946 Persons spent $595 per patient, in 1944 the annual per capita cost was $541. For the same year the coat at the in- stitutions selected ranged from $549 at the Hospital for Epileptics, Ohio to $570 at Caro State Hospital, Michigan. > y z tis l| co X 1946 was 1,505- Owing to the distance from town no bus Is available and the taxi fare Is 75 cents each way. This Institution Is built on the cottage system and the pleasant rows of brick buildings, only two stories and basement in height, are agreeable to the eye. The last one erected Is much larger than the others. Ten buildings house patients and most of them are connected by tunnels of full size for traffic. 19 Recommendations of the architectural survey contain nothing drastic. Some changes are needed in existing buildings. It may be remarked that two buildings are in- conveniently arranged and so badly ventilated that certain partitions should be knocked out. Fire risks are fewer here than in the older institutions. There is no assembly hall. Fly screening was complete but some screens have been removed. No consulting staff exists though one of the two registered physicians in the county is near enough to be called in consultation occasionally. The su- perintendent, Dr. James T, Naramore, had some neurological and psychiatric ser- vice before going on the staff of the State Hospital for Epileptics in 1921. He rose to the superintendency and came here by transfer at the beginning of 19^5• He is a member of the American Medical Association and its subsidiaries. Two assistant physicians constitute the whole medical staff; the superintendent car- ries a service of 150 patients and many employees. A dentist comes one day a week. Five autopsies were made from 237 deaths in a year. A nurse Issues drugs from the pharmacy and compounding is done by physicians, if anyone. Occupation of Patients, Lerned State Hospital, June 30, 19^6 Men Women Total Patient Census 795 715 1,506 Out of doors 72? 637 1,364 In ted 6l 64 125 Taking medicine 58 58 116 Shock therapy 15 39 52 Special diet 54 42 76 In restraint 50 55 83 In seclusion 9 14 25 Taking sedatives 56 46 82 Untidy 82 120 202 Working 356 540 676 Farm, dairy, garden 83 - ~B3 Grounds 16 - 16 With mechanics 9 2 11 Kitchen, dining room, bakery 59 125 182 Laundry, sewing room 14 41 55 Offices, quarters 9 15 22 Ward work 1 46 159 285 Occupational therapy - 22 22 20 Neither smallpox vaccination nor typhoid Inoculation Is given nor Is milk pasteurized. The tiny County Medical Society (six members) meets here. For- merly university students of medicine came here for two weeks, seven being the largest number In a year. The hospital has five kitches and ten dining rooms. Special diets are prepared in the kitchen of the hospital building by the regular cook. Only three voluntary patients were admitted last year. State Hospital for Epileptics Parsons is a city of IT;000 in the southeastern part of the State. One of its three railroads has Important shops. The presence of an ordnance plant in the neighborhood increased the population considerably during the war. The hospital owns 650 acres, and since the land Is not so fertile as that of other Institutions, another 55 acres is rented. The campus Is a level plot, outside the city when purchased, but now surrounded. The layout was good and though modified has not been spoiled. The campus was nicely planted and now the trees and bushes make the grounds pleasantly attractive. The hospital was established In 1899 and began to receive patients In 1903. The maximum annual census was 870 In On July 1, It was 706 of whom 324 were males and 382 females. The excess of women over men may be a re- flection of the general economic situation, for men even with serious handicaps have been able to get work during the last three years. The official capacity is said to be 720. Eight hundred can be easily accommodated and eight hundred and fifty-two beds are set up. The number on parole In one of the war years (I9MO was men and 95 women. More men than women are always on parole status and the proportion of men Is higher than usual of late. The ground has no attainable bedrock and some buildings are reinforced with steel cables. The architectural survey has recommended that three buildings be abandoned and that sections of other buildings be reconstructed. Considerable repairs also are advised. The early buildings were of only two stories, a later one was raised to three. Even In two-story buildings are patients who rarely get out of doors and accidents due to convulsions on staircases are said to be frequent. The ca- pacity of some of these buildings runs as low as 17 and 18 beds. Such figures are looked at with disfavor by those whose Ideal Is cheap administration. For the benefit of the patients, there should be several groups thus small. The Ad- ministration Building contains also the assembly hall with seats for Unfor- tunately this structure Is on the second story, a highly unsatisfactory arrange- ment . Fly screening Is complete. No medical consultant has been appointed but all members of the County Medical Society are available. The acting superintendent, Dr. Paul E. Davis, spent some years on the staffs of two of the State hospitals and on his recent discharge from military service assumed this position. He Is a member of the American Medical Association and the American Psychiatric Association and a staff 21 member of a general hospital in town. Two other physicians of mature experience make up the medical staff. One supplemented private practice by public health work and came here nine years ago, the other was in private practice until last autumn. Two of the staff attend general hospital conferences downtown. A den- tist comes to the hospital two mornings a week. Before the war he made regular surveys of the population. It is stated that no autopsies have been made in four years. Drugs are distributed by the medical technician under supervision of a physician. Most special prescriptions are sent downtown. Smallpox vaccination and typhoid inoculation (ages up through 12 years) are performed on admission. Revaccination is planned for every five to seven years. Milk is pasteurized. The County Medical Society meets here in December. Clinics for crip- pled children have been held here. Ten kitchens are in use and ten dining rooms. Special diets can be prepared in the Hospital Building. Much the largest number of patients is on voluntary status. A large part of these children need schooling and the act setting up the institution required the maintenance of a school but the State makes only puny appropriations to meet that need and has had no teacher for two years. A psychological survey will be made this autumn by a State Teachers' College faculty member. Music is now cultivated by group singing at Informal parties for women and girls. A choir sings except in summer at Protestant chapel services. State Training School Near the eastern edge of the pleasant city of Winfield, College Street runs off from Route 50 at a right angle and north into the country. The first hill that It climbs is surmounted by a college whose gleaming dome can be seen for miles. Farther out and beyond the city limits the road par- tially climbs and then skirts another hill on top of which are solid struc- tures, three of them are four stories high, which rise like a medieval town above the plain. The Training School is three miles from the busiest corner in town and one and one-haIf miles from the nearest bus line. The institution was started at Lawrence in l88l and was relocated here in 1885. Mentally deficient children are accepted up to the age of 21 and older ones may be received if there be space. The State owns k22 acres and is renting another 560. The soil is fertile and its returns under cultivation are considerable. This hilltop is really only a jut from a considerable plateau and crowding the buildings together in this fashion was not at all necessary. What plan was followed is doubtful; probably it was thought to be more econ- omical to have all the buildings close to each other. The present and later 22 generations pay the penalty for this economy in constant Inconvenience, in lack of proper facilities for outdoor exercise and in what appears to he continual worry about the mingling of sexes. The first building was demolished and three so-called custodial buildings took its place. These are four-story structures, up the stairs of which elderly employees pant and patients with any ailment struggle. Two of these buildings have been completely renovated with steel and concrete construction and probably will therefore never be displaced. Other dormitory buildings were erected in 1929 and 1935* The Hospital and Administration Buildings were put up in There is also a frame house occupied by small children. Accordingly, six buildings house patients. Beds are tightly spaced and 125 are double deckers. The crowding of day- rooms and the Inadequacy of water sections can be Inferred. The architectural survey recommends that the third four-story building be further reconstructed to match the other two. Unhappily it recommends the demolition of the building that has the pleasantest atmosphere, namely the cot- tage for little children. The arrangement of the farm buildings is described as excellent. One might wish that the buildings for patients were as good. The assembly hall is one of the best features of the institution. It was constructed under the P.W.A. and seats 1,000. Underneath it is an unused storage space which in emergencies has housed 125 patients. Fly screening is complete. This is not a medical institution. The superintendent, Mr. Lewis C. Tune, came in 1923 as accountant and rose to the superintendency in 1937* Fol- lowing a change in political control Mr. Tune took his old position of assistant superintendent from since when he has headed the institution. He be- longs to three local organizations. He has recently joined the American Associa- tion on Mental Deficiency. A medical director lives in town and comes to the institution every day and at other times on call. He is appointed by the same Board that chooses the superintendent. Dr. Hawke is a member of the American Association on Mental De- ficiency and has been widely heard on surgical subjects. There is no consulting staff but another physician substitutes when the medical director is away. The County Medical Society meets here about twice a year and dermatologic as well as psychologic clinics are given to physicians and others. A dentist comes three mornings a week. He states that he surveys the entire population three times a year. All patients on admission are vaccinated against smallpox and again if the disease is in the neighborhood. Typhoid inoculations are given when in- dicated. All new admissions are given diphtheria toxoid. The milk is not pas- teurized. Dysentery recurs but no information about its nature has come from cultures. Two or three autopsies are made in a year. Drugs are distributed by the nurses in the Hospital building. Cooking for patients is done in two kitchens. Special diets are pre- pared by a patient in the poor diet kitchen of the Hospital Building. Eight dining rooms are used for ambulant patients. As the name of this Institution Indicates it is supposed to he a school. The authorities have taken this responsibility lightly. The horse ham was con- verted to school use hy splitting one floor into two large stalls. Salaries are available only for elementary teachers and with difficulty two were impressed. These ladles do useful work, but It should be obvious that the principal and at least one assistant should be trained special education teachers. Suitable study of the population should find enough work for more than two teachers. Constant study of abilities should be carried on. As It Is, outside psychological service gives an idea of every child’s Intelligence quotient, and common sense and experi- ence decide which ones shall have the benefit of what schooling is given. This school provides no physical training program and no music. Social training receives only meager attention in the institution, though politeness is encouraged. Training for Industry is sketchy. Boys who work on the farm are often able to earn some money outside. The superintendent's apartment Is the only place where girls have training In the niceties of table service. It Is doubtful whether a boy who has worked In the kitchen Is equipped to do a good Job In a restaurant as bus boy In ordinary times though that is one of the Jobs traditionally alloted to such lads. The institution Is poorly organized; when the superintendent Is away no one Is equipped to take over his duties and make decisions on the variety of problems that must be settled. The superintendent hopes sometime to visit simi- lar institutions and compare experience but It is difficult for him to predict when he will be able to take that much time. Patient Load 854.0 372.8 743.0 1,284.0 366.0 FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION patient rJCoaJt per Aician Kansas State Institutions: 1946 Now cares for these patients* * Each patient group represents 100 patients. Each Physician Employed Osawatomie Topeka Lamed Winfield Parsons Figure 5 25 V. DISTRIBUTION AND ACTIVITIES OF THE MEDICAL STAFF Superintendent s Four superintendents are physicians, and all had served as assistant in one or more of these Institutions before promotion to his present grade. The head of the school for defectives rose through business training. The general policy is that the superintendent hires all employees, assigns their duties and dismisses those who prove unfit. He is responsible for upkeep of real and mov- able property, and the care and replacement of furnishings. He decides the suit- ability of patients for retention, confers on their treatment and passes on their parole or. discharge. Usually he presides at staff conferences. Assistant Superintendent Formerly the institutions had assistant superintendents but that grade has been abolished. The superintendent designates who shall exercise his func- tions in his absence. Quarters All physicians live on the grounds of their institutions except at Winfield which has only part-time medical service. Not much can be said for the quarters offered. This matter has already attracted the notice of the Leg- islative Council. Services Every physician has a service of some hundreds of patients. Most of them take turns in examining new patients. This procedure lends Interest to their work, but it puts the patient in the position of being expected to give his confidence to a doctor who may thereafter have no control of his treatment. Probably this is of less consequence now because there are so few physicians. A few physicians have offices and examining rooms on their services, as they should. Mostly the offices are in the Administration Building, and several physicians (if there are that many) may occupy adjoining desks. This makes consecutive thought impossible and Interviews unsatisfactory. Ratio Leaving the Training School out of account, the institution at present best supplied with physicians is at Parsons, the worst at Osawatomle. Superin- tendents are not counted here because their time is largely consumed with ad- ministrative matters (See Table IV and Figures 5 and 6). If the hospitals are to meet the minimum standards for adequate psychiatric care recommended by the American Psychiatric Association, Osawatomle needs five more physicians in ad- dition to the four positions now vacant; Topeka lacks seven, with one authorized position vacant; Lamed six plus two vacancies. The State Training School also could use two more physicians to great advantage. Parsons might employ another physician and should fill the position now vacant. (See Table IV and Figure 6). (Text continued on page Jk.) 26 Institution Full- -Time Assis tant Pays iciansx Patient per Physician Recommended Number Author ized Number Deficit Number Total- ? idled • •Va .cant Authorised' 'Employed Osawatoraie n(3 6 2 /. Hr 3 284*7 834-0 Topeka re 1—1 6 3 1 7 310.7 372.8 Lamed 10^3 4 o C 2 6 371.3 . 743.0 Winfield 2.3^ 0.3 0c3 _ n 1,284 1,284 (part-time care) Parsons 4 2 1- 1 244.0 366.0 lo Superintendents and interns excluded. 2. Based on the average daily patient population. 3o To provide an adequate medical staff the American Psychiatric Association recommends, in addition to the superintendent, 1 physician for each 100 annual admissions plus 1 physician for each 200 resident patients. 4. The American Association on Mental Deficiency recommends at least 1 physician to every 500 cases. SOURCE: Data for the year ending June 30, 194-6, supplied by the institutions named. TABLE IV RECOMMENDED ADD AUTHORIZED HUMBER OF PHYSICIANS AHD RATIO TO PATIENTS', KANSAS STATE INSTITUTIONS, 1946 FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION tljejicaf positions /v» omntentleJ ami orized Kansas State institutions: 1946 Deficit—Additional positions recommended Authorized positions * Each figure represents one medical position. Filled Vacant Number Osawatomie Topeka Lamed Winfield Parsons Figure 6 28 State Authoris Total ed Medical ■ Filled•■ s Positions^ Vacant^ 3 Patient Load per Authorized Assistant Physician l%6a Kansas 16 10 6 316,1 19Ub Kansas 17 12 5 294*3 Connecticut 61 22 39 125 o0 Missouri 4 2 21 21 210,9 Nebraska 30 17 13 143.2 South Carolina 23 12 11 202 o 7 United States 1,899 1,200 699 220,3 1„ Superintendents and interns excluded. 2o Incomplete reporting from some States. 3o Based on the average daily resident patient population0 SOURCE: a0 Supplied by the Kansas State mental hospitals for the year ending June 30, 194-6. b. U0S0 Bureau of the Census, Series M.P0, ho, 8, released July 26, 194-6 and unpublished data collected by the U0S. Bureau of the Census0 PATIENT LOAD PER AUTHORIZED ASSISTANT PHYSICIAN IN STATE MENTAL HOSPITALS, KANSAS AND SELECTED STATES TABLE V FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION Patient Load / attent rJ*oaJ. uzed State Mental Hospitals, Kansas and Selected States: 1944 Cares for these patients * * Each patient figure represents ten patients. Each Authorized Physician KANSAS Connecticut Missouri Nebraska South Carolina United States Fisure 7 30 lo Medical superintendents included0 2„ Incomplete reporting for some institutions. Based on the average daily resident patient population. SOURCE: a. Supplied by the State Training School, Winfield, for the year ending June 30, 194-6. b, Unpublished data collected by the U„ S* Bureau of the Census„ Institution Authorized Medica Total Filled .1 Vacant^ Patient Load Authorized Physician 194-6a State Training School, Kansas 0o5 0.5 1,284. 19Wb State Training School, Kansas 1 1 (part-time care) 1,231.0 Wrentham State School, Massachusetts 9 6 3 211,8 Coldv/ater State Training School, Michigan 5 4 1 176 o 2 Laconia State School, New Hampshire 2 2 34-3 = 5 Vineland State School, New Jersey 6 4- 2 262.8 Pennhurst State School, P ennsylvania 10 5 226.5 PATIENT LOAD PER AUTHORIZED PHYSICIAN IN STATE INSTITUTIONS FOR MENTAL DEFECTIVES, STATE TRAINING SCHOOL, KANSAS, AND SELECTED INSTITUTIONS TABLE VI Patient Load FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION patient cJloatl per Physician State Training School, Kansas and Selected Institutions: 1944 Cares for these patients * * Each patient figure represents ten patients. Each Authorized Physician STATE SCHOOL, KANS. Wrentham State School, Mass. Coldwater State School, Mich. Laconia State School, N. H. Vineland State School, N. J. Pennhurst State School, Pa. 00 6) i— 3 00 tZ 32 Authorize d Medical Positions^ Patient Load per^ Institution Total Filled Vacant Authorised Physician 1946a State Hospital for Epileptics, Kansas 3 2 1 244.0 imb State Hospital for Epileptics., Kansas 3 3 - ' 258o7 Monson State Hospital, Massachusetts 8 7 1 183.6 Caro State Hospital, Michigan 8 4 4 173 el State Village for Epilep tics, New Jersey 10 7 3 146.9 Craig Colony, New York 12 8 4 184.8 Hospital for Epileptics^ Ohio 13 4 9 152o8 FABLE VII PATIENT LOAD PER AUTHORIZED PHYSICIAN IN STATE INSTITUTIONS FOR EPILEPTICS, STATE HOSPITAL.FOR.EPILEPTICS, KANSAS, AND SELECTED INSTITUTIONS 1o Medical superintendents included 20 Based on the average daily resident patient population» SOURCE: a, Supplied by the State Hospital for Epileptics, Parsons, for the year ending June 30, 194-6 b0 Unpublished data collected by the U. S, Bureau of the Census„ Patient Load FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION Cares for these patients * ■' Each patient figure represents ten patients. State Hospital for Epileptics, Kansas and Selected Institutions: 1944 flatten! rjCoatl / Aldan Each Authorized Physician HOSPITAL FOR EPILEPTICS, KANS. Monson State Hospital, Mass. Caro State Hospital, Mich. State Village For Epileptics, N. J. Craig Colony Hospital for Epileptics, Ohio Figure 9 Causes This woefully high ratio of patients to physicians Is partly the result of policy, partly of the war. The Stats has not thought it Important to maintain first class phychiatrlc services and except for a while at Osawatomie never pro- vided them. The military establishment and lure of private practice have taken some physicians away. Now a neighboring State has begun to offer more attractive conditions. Result When the patient load grows too heavy, the work of the hospital physician becomes less psychiatric and more like that of the general practitioner. He has not time for the long, confidential talks that are so helpful to many patients. He must spend much time on incidental physical ailments and some on routine admlnlstra tive work. Until adequate numbers of trained physicians are employed to care for the mentally ill and defective in the Kansas institutions there will be little oppor- tunity for effective psychiatric treatment. In the long run, both as regards hos- pitalization costs and the loss of earning power to the patient and his family, it is far more expensive to provide custodial care for life than to supply proper treatment and training to effect the eventual return of the patient to the commun- ity. Comparison In Tables Y-VTI and Figures 7-9 comparison is afforded between the medi- cal staffs authorized in the Kensas institutions and in institutions of other selected states. Research At present there is little spirit of research in these Institutions, though in previous years studies have been made here. An outside medical agency is studying some of the physiological conditions in the eunuchs at Winfield, Laboratory Laboratories exist in every institution but some are badly crippled. While at least one is equipped to make almost any test wanted, none is apparently used extensively. Autopsy Autopsies are rarely done. Not even the minimum rate acceptable to the American Medical Association is met. 35 Records Clinical records are somewhat useful but nowhere of high standard. They are kept in raanila folders. A few facts are likely to get several repeti- tions, hut many things that one would like to know are omitted. Two sources seem to be depended on for knowledge of how the patient developed and what he became: questionnaire information and the patient's own statement. However it is said that the sheriff who brings the patient is interviewed and that relatives may be included in that interview. Supplementary information from other visitors seems non-existent. An admission note may or may not be present. A definite dated mental status is hard to piece together, since apparently the observations of several days get into one document. A test of the sensorlum is filled in by the patient or some attendant in some of the institutions., The physical status is likely to be more specific, but is not ended with a summary statement of body build and deficiencies, hence the inquirer must read through all the negative findings to catch the positives. Wassermanna are reported from the Board of Health laboratory. The urine has usually been examined once and perhaps twice, and sometimes the spinal fluid. The initial weight is re- corded. Dental reports appear after the patient dies; before then they are kept in the dental office. Accident reports appear occasionally. Nurse's notes if made are generally filed. A striking weakness is lack of progress notes, but one hospital keeps them up with occasional brief entries. Cause of death and the fact of discharge may be found on the cover sheet. Correspondence is filed with clinical records. Perhaps this is for- tunate for it may tell more about what has happened to the patient than does the record. In most institutions all these papers are clipped into masses but at Persons where the manila cover is more substantial but less adequate in size, some papers are clipped and others are a litter in the folder; physicians there write their record in longhand. The most important document in the best histories seems to be the sum- mary, in which many facts from other sheets are repeated, but with little anal- ysis. This leads to a diagnosis, the high point of the record. Let it be said that some histories from before the war are fuller and more informative than those of today. Staffs were larger then. Libraries Medical libraries are mostly unsatisfactory, but in some Institutions new books are bought every now and then. That no high value is attached to them may be deduced from the fact that nobody in particular is in charge of the li- braries and no staff meetings are ever held to discuss medical literature in orderly and critical fashion. There is a genuine desire on the part of superin- tendents to have books and magazines available to their assistants. Medical Needs It is of the highest importance to attract and retain able physicians in this service, so as to give the patients consistently good care and treatment. Salaries and living conditions should he put on a competitive basis. What a profes- sional man's preparation merits in these regards is not the issue. The issue is econ- omic; what will draw to these institutions the men and women that Kansas patients should have? Physicians are attracted by opportunity to take a refresher course every few years. The Veterans' Administration is at this time capitalizing on this ambition and has at Topeka a large number of physicians taking such a course in psychiatry. Postgraduate courses are open in some States to every State hospital physician. If there be none given in the neighborhood, the physician may have financial help to go away (e.g. from Missouri to New York City) to take such a course. No such plan pre- vails here. Conference Staff meetings are held in four institutions. Patients are considered pri- marily for diagnosis. At a later time the staff may consider the question of parole or discharge. No especial thought seems to be given to the patient's comfort during the conference and she may occupy the stiffest chair in the room. She may also be required to listen to all the hospital records in her case, including quite embarrass- ing and even humiliating material. Conferences are held weekly at Osawatomie, twice a week at Persons when new cases are available, twice at Lamed and three times a week at Topeka. A classi- fication conference is held annually at Winfield, and dally household conferences. Consultants Specialists are not easily available in all parts of Kansas. The institu- tion staffs must often use their ingenuity as does the general practitioner. By so much is their attention diverted from the thing that brought the patient to the hos- pital - his mental disorder. Local resources are not overlooked. Osawatomie has attending Internist and surgeon, Topeka a surgeon, Parsons a surgeon and ophthalmo- logist. Other specialists may be called, but seldom are. Surgery Every institution has a usable operating room and at least fairly good equipment. At Osawatomie, Topeka and Parsons a surgeon from the neighborhood comes to operate. The attending physician at Winfield is a surgeon. The county in which Lprned is located has only two practicing physicians outside the hospital and the resident staff do most of their surgery; Indeed some operations are done by resident staff members in any of the institutions. Most operations are sterilizations, which do not demand unusual skill. Brain surgery is available at the State Medical School. Dentistry Considerable dental work is done, the most urgent procedures predominating. Plates are made usually at private expense; all hospitals report finding money for dentures for the indigent occasionally, and Topeka frequently. Where a hospital has a full-time dentist, he carries on periodic surveys of all patients' mouths. 37 Only Osawatomle and Topeka now have resident dentists. An outside den- tist makes one to three visits a week to the other institutions. This work needs to be stepped up. The American Dental Association tells us that one resident dentist can be kept profitably busy caring for a thousand patients. Programs of dental hygiene also should be overhauled and activated. Psychology The work of a psychologist in mental Institutions is of very great help. Especially in dealing with the young is it important to know the assets and liabilities that the psychologist is peculiarly equipped to disclose. Only at Topeka is a psychologist employed; his service is so well thought of that some work assigned to him would ordinarily be allocated to well prepared physicians. Persons and Winfield, with all their children, have no resident psychologist. The physicians at Parsons can occasionally take time to make one of the simpler tests, but this is minor service. Psychologists from the Wichita Child Guidance Clinic make an intelligence test on new chil- dren at Winfield twice a year, and a second one on those recommended for sterilization. This is commendable, but far from adequate. VI. NURSING ARRANGEMENTS Organization Each institution has a group of supervisors, and each supervisor re- ports directly to the medical staff. Osawatomle has five supervisors, Topeka four. Lamed three, Persons two, and Winfield six. Unitary nursing control has not teen attempted, and not seriously considered. Any employee is eligible for promotion to supervisor, and those chosen when a vacancy occurs are ward employees whose energy and loyalty are well rated. They are the backbone of the service. Graduate Nurses The aggregate of graduate nurses on duty in this State service of 7,000 patients numbers three; five additional positions at Lamed are vacant. Only remotely can they be said to set standards of care. No doubt their influ- ence is pervasive to some extent, but few wards look as if a nurse were running them unless one actually is. Osawatomle and Parsons get along without a nurse. Attendants The people who spend most time with the patients and whose ministra- tions make them comfortable or otherwise are the attendants. It has never been the practice in these institutions to engage many above the minimum that can keep track of things and tell the working patients what to do. During the war the younger employees went into the military establishment and Industry and but few have come back. (Text continued on page tt.) 38 State Authorized Ward Personnel 2 Patient Load per Authorised Craduate Nurse or Attendant All Ward Personnel Gradual ,e Nurses Attendants Number p % Number p % Total Filled Vacant Total Filled• ■Vacant 1946a Kansas 363 7 2 5 1.9 356 308 48 98.1 13.9 Osawatomie 127 - - - - 127 no 17 100*0 13.4 Topeka 130 1 1 - 0*8 129 118 11 99.2 14.3 Lamed 106 6 1 5 5*7 100 80 20 94 o3 14 c0 1944b Kansas 361 21 20(3 1 5.8(3 340 269 71 94 0 2 13.9 Connecticut 1,437 192 70 122 13 o4 1,245 603 642 86.6 5 o3 Missouri 897 46 20 26 5.1 851 775 76 94.9 9o9 Nebraska 523 32 16 16 6»1 491 390 101 93*9 8*2 South Carolina 427 32 32 - 7o5 395 395 - 92.5 10.9 United States 48,051 4,333 2,749 1,384 9oQ . 43,718 31,207 12,511 91.0 8.7 1. Incomplete reporting for some States. 2. Based on the average daily patient population. 3o A number of positions were not filled by registered graduate nurses. SOURCE: ac Supplied by the Kansas State mental hospitals for the year ending June 30, 194-6o bo Uc S . Bureau of the Census, Series M.P., No* 8, released July 26, 19-46 and unpublished data collected by the Uo S0 Bureau of the Census. TABLE VIII AUTHORIZED HUMBER OF WARD PERSONNEL AND RATIO TO PATIENTS IN STATE MENTAL HOSPITALS, KANSAS AND SELECTED STATES Patient Load FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION cjCou JP*- 11urU ot* orized State Mental Hospitals, Kansas and Selected States: 1944 Cares for these patients * * Each patient figure represents one patient. Each Nurse or Attendant Authorized KANSAS Connecticut Missouri Nebraska South Carolina United States Figure 10 Author!2 ed War d Pers lo CD H ■p Patient Load"” Institution All Ward Personnel Total Graduate Nurses Number Filled Vacant1 % Total Attendants Number Filled Vacant1 % per Authorised Graduate Nurse or Attendant 1946a State Training School, Kansas 37 1 1 2.7 36 32 4 97.3 34.7 I944b State Training School, Kansas 64. 2 1 1 3.1 62 50 12 96,9 19.2 Wrentham State School, Massachusetts 260 3 3 1.2 257 129 128 98.8 7 o3 Coldwater State Training School, Michigan 144 3 3 2.1 141 134 7 97.9 6.1 Laconia State School, New Hampshire 57 3 3 5.3 54 54 r . 94.7 12-1 Vineland State School, New Jersey 104 7 6 1 6.7 97 92 5 93,3 15 c. 2 Pennhurst State School, Pennsylvania 120 17 11 6 14.2 103 64 39 85.8 18.9 TABLE IX NUMBER OF WARD PERSONNEL AND RATIO. TO PATIENTS IN STATE INSTITUTIONS FOR MENTAL DEFECTIVES, STATE TRAINING SCHOOL, KANSAS, AND SELECTED STATES 1, Incomplete reporting for some institutions... 2 c. Based on the average daily resident patient population „ SOURCE: ac Supplied by the State Training School, Winfield, for the year ending June 30, 1946, b. Unpublished data collected by the U, S. Bureau of the Census, Patient Load FEDERAL SECURITY AGENCY U, S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION rjCoaJ *1JurSe or lUenilant orizeJf State Training School, Kansas and Selected Institutions: 1944 Cares for these patients * * Each patient figure represents one patient. Each Nurse or Attendant Authorized STATE SCHOOL, KANS. Wrentham State School, Mass. Coldwater State School, Mich. Laconia State School, N. H. Vineland State School, N. J. Pennhurst State School, Pa. Figure 11 Author!z ed Wan Patient Load1 Institution' All Ward Personnel Total Graduate Nurses Number Filled Vacant % fotal Atte: Number Filled ndants Vacant 7o per Authorized Graduate Nurse or Attendant 1946a State Hospital for Epileptics, Kansas 53 0.0 53 53 100.0 13.8 l%4b State Hospital for Epileptics, Kansas 55 0.0 55 55 - 100.0 14.1 Monson State Hospital, Massachusetts. 274 21 18 3 7.7 253 113 140 92.3 5.4 Caro State Hospital, Michigan 172 10 6 4 5.8 162 158 4 94.8 88.1 State Village for Epilep- tics, New Jersey 128 5 3 2 3.9 123 50 73 96.1 11.5 Craig Colony, New York 305 67 46 21 22.0 238 128 no 78.0 7.3 Hospital for Epileptics, Ohio 196 1 1 0.5 195 186 9 99.5 10.1 NUMBER OF WARD PERSONNEL AND RATIO TO PATIENTS IN STATE INSTITUTIONS FOR EPILEPTICS, STATE HOSPITAL FOR EPILEPTICS, KANSAS, AND SELECTED INSTITUTIONS 1, Based on the average daily resident patient population. SOURCE: a. Supplied by the State Hospital for Epileptics, Parsons,’ for the year ending June 30, 194-6. b. Unpublished data collected by the US. Bureau of the Census.. TABLE X Patient Load FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE MENTAL HYGIENE DIVISION rJCoa or tlfiril utit orlzeJ State Hospital for Epileptics, Kansas and Selected Institutions: 1944 Cares for these patients * * Each patient figure represents one patient. Each Nurse or Attendant Authorized HOSPITAL FOR EPILEPTICS, KANS. Monson State Hospital, Mass. Caro State Hospital, Mich. State Village for Epileptics, N. J. Craig Colony Hospital for Epileptics, Ohio Figure 12 Ratio The ratio of all ward employees to patients, in whatever light it he stu- died, is sadly inadequate. Including all positions, filled and vacant, the patient load per author ized ward person was 13 • 9 for and For the latter year the United States average was 8.7 patients and States selected for comparison in Table VIII and Figure 10 ranged from 3-5 in Connecticut to 10.9 in South Carolina. Similar data in tabular and graphic form afford comparison between Win- field and Parsons and other institutions of similar type (Tables IX-X and Figures 11-12). Character Most of the attendants ai% persons of middle age or older. This is fair insurance against precipitate action, which often Irritates patients unneces- sarily. Among them are persons of very fine spirit. They have not continued in this work from expectation of future reward, for Kansas has no retirement system. As several of them said, they prefer work with people to employment in factory or office. They do hope for better working and living conditions some day. Lack The patients can be well supervised by those of mature years. Such a program is however insufficient if the State wishes to restore to the community as many of its sick citizens as possible. In addition to those now employed, there is need of some younger persons who can carry on a program of activity. Too much sitting disintegrates ambition. Training No formal training for the important duties of an attendant exists in this State. The new employee goes to work under an older employee, and perhaps with little supervision. Hours These institutions still run on the two-shift system though it has generally been discarded. Attendants are on duty from 10g to 13 hours six days a week, making 63 to 78 hours a week. Quarters Living conditions for employees are Inadequate in all the institutions, and consideration of their comfort not great. Many of them live in patients* buildings and no small number in rooms in the wards. It was noted that women living in a building for male patients at Topeka have no toilet or bath facil- ities of their own. 45 Responsibility Since the physicians are carrying excessive case loads, rounds in some Instances become perfunctory. The attendant Is asked whether all is well, and points out any data that Impress him as needing attention. Sickness and death become unimpressive matters. Attendants of native intelligence and Interest in their patients do verywell; nevertheless it should not be the responsibility of untrained employ- ees to decide when a patient needs a sedative or seclusion or restraint. Transportation Osawatomle, Topeka and Parsons are near enough the business district to be served by public bus. Several trips a day to town are made at Winfield. Lamed is least well served, since taxi fare is more than a dollar each way. Young people resent isolation, and avoid it. Housekeeping All the institutions are clean and floors highly polished. Consider- able interior painting has been done lately. Comfort One gets the impression that in too many wards the maintenance of order takes precedence over the comfort of the patients. Chairs stand in stiff rows. Little attention is paid to getting adequate light for one who reads. Chairs with cushions are reserved for employees. Patients lie on the floor in many instances, and out of doors they have to sprawl on the ground because there are seats for few beside the employees. One hospital reports an abundance of park benches on the grounds., Decoration Many pictures hang on some walls at Osawatomle and Topeka, few else- where. Size, subject, frame and lighting have not always been well considered in hanging. Drapes and table covers are seen in various places. One of the most cheering evidences of interest is the number of plants and flowers in some wards and dining rooms. Furniture Furnishings are skimpy. Mpny beds need painting and some should be repaired. One bureau to 30 or 40 women is not generous. Hundreds of patients have no proper place to keep their treasures. On the other hand the liberal provision of rockers is cheering. Care Custody to prevent wandering or running off is generally adequate. In- dications of physical abuse were nowhere evident. At Topeka a woman is on duty in every ward but one, an arrangement that discourages roughness. Supervisors were found devoting their own time to errands for their patients. On the other hand the mass of patients cannot be expected to have the personal attention they deserve un- til there are enough employees to give It. Security Large numbers of patients are locked In their rooms or dormitories when the day employees go off duty and many of them are not let out till the next day when the day employees again appear. Many chamber vessels are In use. Since the Institutions are generally crowded, and heat and ventilation receive anything but expert handling, one must conclude that foul odors develop in plenty during the night. Saf ety Fire hazards are very considerable. How all the locked doors could be opened and the rooms evacuated amid swirling smoke can only be imagined. Light and Air Ventilation receives much less attention than It should. Perhaps elderly employees like rooms hot. Not much attention either Is paid to proper lighting. Goal Twenty years ago the American Psychiatric Association recommended as a minimum ratio of ward employees to patients the figures 1:8, for the two-shift system. Certainly no poorer ratio can be expected to give the results that hos- pital physicians know are possible and most desirable. Any serious effort to build up personnel must carry superior Inducements. These Include: (1) Decent living conditions. Better arrangements for those who live in the Institution and cash allowances that will encourage more employees to live outside under conditions of their own choice. (2) Salaries that compare favorably with those In industry. Provision for stated increases, sick benefits and retirement pension. (5) Hours of duty embracing not over a total of In six days. (4) Educational programs for workers. (5) Transportation service to town where it now Is lacking. VII. FOOD: ITS PREPARATION AND SERVICE Organization In every institution the matron is at the head of the dietetic depart- ment. Some matrons have had admirable experience and know their departments from the ground up. Theirs is a heavy responsibility, for the needs, desires, moods and efficiency of every patient and employee may be affected by their deciaioiB . Under the matron's direction are cooks and dining room help. The num- ber nowhere seems to be large enough to assure comfortable working conditions. Vacancies occur often, and with disastrous suddenness. Nevertheless the meals must be served. Central Purchase Articles not raised in the gardens are bought through a central office at the capltol. Central purchasing Is economical In that lower prices can be got through bidding. One need not rehearse the difficulties that arise from slow delivery and occasional lapse In quality. Complaints regarding service given in Kansas seem to be fewer than one hears In many other places. Special Handicap • That all purchasing has been difficult during the war is known to all. Even the canning program has suffered somewhat through lack of cans. Glass con- tainers have been substituted. Ordering Orders for foodstuffs are not based on well planned menus that supple- ment scientifically what Is produced on the farms. The matrons are Informed from time to time what they may expect from farm and store and may then make the best of the situation. Menus Menus are prepared by the matron, usually a week in advance. She has been told by the steward what supplies will be available In the storeroom. From the farmer she learns what Is ripening. He likes his department credited with goodly poundage and she must try to persuade him to pull his woody vegetables while they are still tender. Kitchens, Dining Rooms Osawatomie has 8 kitchens for patients' food and 22 dining rooms, Topeka 8 and 25, Earned 5 and 10. Parsons has ten kitchens and ten dining rooms, Its cottages being planned for self sufficiency, Winfield 2 and 8. Kitchens are Menus of many sizes. Too many are in ill-ventHated basements, as noted in the Hotel and Restaurant Board Inspection. Equipment As duly noted in that same report, much kitchen equipment is worn and out of style. There is hope of replacements for some items. Not every institu- tion has even one dishwasher. Tables are generally oblong, seating eight or more. Some table tops are of. plain wood, some are covered with oilcloth, and here and there are table- cloths. A few painted metal tops were seen. In several places it is intended to put linoleum on tables when supplies are available. Benches are used to a great extent, but chairs are seen in other locations. Both crockery and metalware dishes are used, and a few drinking glasses. Most patients have knife, fork and spoon. Hours The usual long hours that employees work are an advantage for the patients in that the usual three meals need not be compressed into a short period. Since kitchen workers everywhere are demanding and getting a briefer working day, plans should be afoot to reduce the number of kitchens in the larger institutions and provide modern transportation of cooked food to the dining rooms. Steam tables will be needed in several locations. Service At the appointed time, usually well in advance of the meal hour, food is sent in buckets or other containers to the dining rooms, where it is dished out. When the patients are admitted to their meal the food has been standing uncovered and unprotected for twenty minutes or more. When summer scorches the plains, food on the dining table may stay hot. The rest of the year it is only tepid, at best. Choice No choice of items is offered in the dining rooms. Quantity Patients so far as observed had plentiful portions and some employee was on duty to see that second helpings were available. Quantities are restricted at Parsons, not from any lack of Interest in the satisfaction of the patients, but because of the notorious inclination of the epileptic to forget to stop eating, and thereby suffer more convulsions. Appearance Much good food was seen. It varies with the skill of the cook and this is a time when the best cooks are hard to capture. These cooks are used to feeding crowds of hearty eaters, and even the sick appear to have a heavy diet. Delicacy of flavor is not always attained. Stews and gruels predominate. Poultry may be served three or four times a year. Dried fruit or pudding is sometimes served to the patients. Fresh fruit is rare. Pie and cake were prepared weekly in one hos- pital before war shortages developed. At one time 500 women patients in one of the hospitals - by no means an attractive or favored group - had griddle cakes occasionally, but that time is gone. Ice cream, the typical American dish, is seldom served; it was a cause for gratulatlon at one of the institutions because ice cream is served every Fourth of July and sometimes at Christmas. Special Diet Special diets are little called for, though the physically ill and tuberculosis patients usually have extra food. Some branches of medicine achieve surprising benefits by skilled use of special foods, and psychiatric workers should not be deprived of similar opportunities. No institution has a special diet cook. The Training School comes nearest by employing a patient in the hospital kitchen. M3 Ik A standard allowance of milk is a pint and a half dally per person fed. Figures for these institutions stand as follows: Dally Allowance of Milk Produced Per Person, 1945-6 Osawatomie Topeka Lamed Par sons Winfield Milk produced (in gallons) 95,558 125,91^ 105,757 75,553 1.02,024 Persons fed 1,905 2,068 1,626 855 1,569 Per diem allowance per person fed (in ounces) 17.6 21.4 22.8 50.9 (approx.) 26.1 Canning Considerable quantities of vegetables and fruit are preserved every summer. These institutions do not have first class canning establishments and the policy has been to let them depend on the State Prison cannery. This policy might well be reviewed. Employees Employees receive a better diet than do patients. Many of them eat in the patients’ dining rooms, where their special items of food may cause Jealousy. The late William A. Bryan considered it an economy to have only one menu for the hospital; officers, employees and patients. 50 Weighing Patients are weighed on admission and rarely after that except at Topeka. Comparisons are made by estimate, not be scale. A patient might eat poorly and even suffer malnutrition unless someone In the dining room comments on the matter. Comment In general it may be remarked that the way we feed our patients in Ameri- can mental Institutions has been under scrutiny and criticism for several years. Many deficiencies are painfully evident. An Idea that used to be expressed in some places was that this method or that result (such as tossing bread around the table from the hand of a half washed helper, or stew every day) was "good enough" for the patients; that they are unappreciative. Much better arrangements have been demon- strated In many places (for instance Massachusetts, Colorado) and should be the goal everywhere. We must not cling to ways that other kinds of hospitals have abandoned. The Improvement of service may be a slow matter, but ladies and gentle- men should be encouraged to preserve as many of the decencies and even niceties of the home as possible. Closer supervision of handling food must doubtless wait on Increases in personnel. VIII. SPECIAL GROUPS AND SPECIAL TREATMENTS Newly Admitted The new patient deserves special consideration. He (or she) may he for the first time entering a hospital, and most reluctantly. He has heard the unpleasant fact that he will he among persons whose minds are affected and whose actions he cannot predict. His own mental Illness has invaded his sense of security and his new surroundings may he accepted only with forbodlng. Obviously he should he received In pleasant surroundings hy an admirably capable and encouraging per- sonnel Into an atmosphere of recovery. How well do we approximate these require- ments? Osawatomle has a good building set apart from others. Two wards receive new patients and the other two contribute little to the situation except that some agreeable patients are housed there. The administration of the building Is mediocre, medical and nursing personnel being Insufficient, and no active program exists. Topeka receives first admissions and unobjectionable readmissions on the first floor of Its Hospital Building. This is a good structure. Acute bodily sicknesses also are treated here; there la difference of opinion as to whether this is good or poor for the new patient. Decrepit patients and those with long established mental states are received in wards of the Main Building. Lamed has a large building with five ward units. Not only is the sur- gical and medical service located here, but also tuberculosis; the building has no porches. At Parsons the new patient stays four to six weeks In the Hospital Building among older patients who may be more Informative and suggestive than help- ful. At Winfield the same course is followed and the new patient gets rather well exposed to tuberculosis which Is cared for In the same wards. 51 Thought exercised on the mental comfort of the new patient is a good investment in any Institution., Acute Illness As noted in the previous section, four Institutions have a medical- surgical building combined with the reception service. Osawatomie has a separate building designed for that service but now used quite differently. Perhaps all that is essentially helpful is done for the sick; at any rate they get the best the institution affords. Most of the personal attention is given by other patients, of course under direction. It is thought that com- plaints are rare. Yet it is hard to see how the people of Kansas can forever be satisfied to have their sick relatives cared for by a mere handful of gradu- ate nurses, a few overworked attendants and willing but often unskilled fellow patients. Much more nursing should be provided. Chronic Illness Chronic diseases seem to get less attention than they deserve, but a restful existence and occasional special diet (as for diabetes) may delay the day of dissolution. Contagion Contagious diseases are generally said to be cared for in the Hospi- tal Building of each institution. Cases of measles and chlckenpox were seen at Winfield staying in the wards where they developed. This may be the less of two evils. Perhaps measles would not be properly Isolated in the Hospital Building and would imperil the surgical cases. One might expect some sort of segregation rather than merely letting the epidemic burn out where it happens to start. Tuberculosis The tuberculosis program is very faulty. Federal money has made pos- sible surveys of all chests in such institutions. After a survey the active cases should be segregated and put on proper treatment, suspicious cases should be kept under X-ray surveillance, and the chests of all new patients radiographed soon after admission. Collapse therapy and other surgical methods should be practiced in suitable cases. The fight should be unremitting, and in a few years such a fight is found to cut down the number of cases, Osawatomie had a survey, which is said to have omitted 700 of its 1,700 patients. No tuberculosis cases are know to be in the Tuberculosis Building for men; no separation of tuberculous from non-tuberculous cases is maintained in the Tuberculosis Building for women. Topeka has not yet been surveyed; many cases are in a special building. Parsons is fortunate in having no known case, though its survey is complete. 52 Winfield had a survey three years ago hut pictures have not been taken on later admissions. Cases when recognized are mixed in with other patients in the hospital wards. Lamed has a service that looks professional. It is not al- together conveniently placed in the Hospital Building, for the patients must lead a life more restricted than their tuberculosis necessitates. In fundamentals the program seems sound. Employees take measures for their own protection and the safety of those with whom they associate outside the ward. Surgical measures have not been undertaken. Syphjlls Standard methods of treatment for syphilis are generally employed. Fever treatment is not used at Osawatomie, and it is stated that returns to the community of their treated paretics hardly pass 20 per cent. Mentally 111 Criminals At Lamed is a large building unfortunately called "The Criminal In- sane Building" in two wards of which mentally ill criminals are housed. This arrangement gives these patients 90 beds out of a population of kkj. The build- ing is new and fairly convenient. An elevator is misplaced so that it 1s un- usable because it opens into one of these wards for patients with criminalistic bent. Alcoholism, Drug Addiction No special provision is made for alcoholic and addict patients in Kansas. Alcoholics, unless they have developed mental Illness, are not within the purview of the commitment law and hospital authorities are careful to reject them. Drug addicts are few. The Disturbed In most locations the simpler forma of repression seem to be relied on to control disturbance. One hospital reports systematic use of electric shock. No activity program is undertaken for these patients whose need is for extra but better directed exercise. Indeed few employees are in the period of life when so much activity could be carried on by them. The prolonged bath is used only at Topeka. Little disturbance was noted during these visits. Mechanical Restraint The common types of mechanical restraint are employed freely. Usually the ward personnel apply apparatus in accordance with their judgment and report the matter to a physician in person or on the dally ward report. An unusual ar- rangement was seen at Osawatomie where a woman was fastened to a bed and a broad leather strap encircled her neck and was hitched by a strip of cloth to the he?=!d of the bed. So long as she was quiet the apparatus probably cause little discom fort. Whatever the point of controversy may have been, the patient was offering promises of proper conduct. Seclusion Patients are locked up in daytime when the personnel do not trust them to be about. Many more are locked up at night when still fewer employees are on duty. Aged and Infirm The aged and Infirm Increase In numbers in the institutions of Kansas, as they do throughout the country. This comes about because of almost doubled expectancy of human life, and consequently a much greater number of middle aged and old people throughout the community. In Osawatomle two-fifths of the resi- dent patients and the first admissions are 60 years and over; in Lamed over one-third. The old are very liable to mental disorder. Future provision for these patients should be mostly in one-story buildings, since going up and down stairs makes too much effort for aged hearts. Psychotherapy In mental disorders the most complex functions of a personality are disturbed. Many emotional conflicts have roots in the experience of early life. To disentangle these difficulties time must be taken and interviews - several or many - held preferably in the undisturbed quiet of a physician's office. With- out such assistance some illnesses are unnecessarily prolonged, convalescence may be only partially satisfactory and the patient may not develop the capacity to live in his old environment. The employment of measures whereby the activities of one mind play helpfully upon another in a studied effort to bring about a state of satisfac- tion and a reestablished feeling of confidence and security may be defined as psychotherapy. Such procedures are fundamental in the practice of mental medicine for which mental institutions are created. Unhappily the physicians of the Kansas State service have little time for such procedures. Shock Therapy Electric shock therapy is carried on at all three hospitals. It is simple to administer and has sufficient merit so that its use is attractive even in some questionable situations. Its application to quiet disturbance is fairly effective but should be considered still in the experimental stage. No insulin shock therapy is employed. It is more effective than electric shock for some mental states, but is more expensive in that it takes more time of physicians and nurses. 54 Hydrotherapy Suites for stimulative hydrotherapy have teen installed in all three hospitals and the one in Topeka is still in use. The same may he said of the prolonged bath for sedative hydrotherapy. It is stated at Lamed that the tubs were in use so late as last winter. Occupational Therapy The skilled application of craft work in stimulating the indifferent and bringing the satisfaction of creation to a great variety of patients is re- spected in Kansas, but not far carried out under present conditions. The hos- pital that perhaps has done most work suspends it in summer. Leaders with training and vision should be sought and put in charge of such activities. Physiotherapy A few lamps for radiation are scattered through the instjtutlons. Lerned reports its ultraviolet lamp used. Physical Training A physical training program of guided activity for patients who are restless and perhaps inclined to destruction is economical in savings of State property and improving the state of mind of the patients. For those who are sluggish or disturbed or timorous such programs are of the highest value. Un- fortunately no such programs exist. Not even the children at Winfield are offered physical education. Music No systematic application of music is made in any of the institutions. Children or adults here and there are encouraged to sing and one group at Winfield was particularly uninhibited and enjoyed their own music. Osawatomle and Topeka have many pianos, which are seldom tuned. Library Every institution has some sort of a library but no professional manage- ment. Accessions are usually by gift. No one knows what the circulation is and no systematic effort is made to increase the amount of reading in the wards. Mall Patients' letters are usually read by whatever attendant picks them up. Then they are likely to be read by the supervisor and a few are read by a physi- cian. Any material considered improper is suppressed. Letters to the Governor or the Board of Social Welfare are forwarded unexamlned. Incoming packages and many letters are opened by the patient in the presence of a supervisor. 55 Religious Services Religious services are held in all institutions. It is doubtful if they are carried on with the system and attention that would produce the most helpful results. The consolations of religion are denied to quiet patients when disturbers are included in the congregation. The Interest of the medical staff in this matter is vital to any improvement. Recreation Amusements may be in charge of the superintendent or a supervisor. Dances and moving pictures are the usual programs. Sometimes other performances are held. Christmas is generally celebrated and in some places a few other hol- idays. At Parsons, softball league games are played on the grounds in daylight and by artificial light, about three times a week. Freedom of the Grounds A considerable number of patients in all institutions have the privi- lege of going about unattended. Probably more could be done in this direction if there were more employees to look after the wards. When patients without privileges are well cared for a larger number of them reach the level of trust- worthiness. Wages It is possible to put helpful patients on the payroll at verlous small amounts, and this has been done considerably during the present shortage of labor. The scheme stimulates the industry and pride of the workers, and when wisely used, benefits those who are thus rewarded. Too often it results in service by some who are hardly equipped for their new responsibilities. Data on Care Clothing is considered adequate at the moment but men's garments are very hard to get. Women's dresses are attractive. Nightgowns are supplied to patients in bed, but ambulant patients usually have none unless they come from home. Supplies Towels are supplied on bath day, perhaps at other times. Toilet paper is scarce. So is soap at times. Care of Head, Face, Feet Shaving is generally done by ward employees. Once a week is the minimum and some patients use their own razors daily. Lamed and Parsons have so-called beauty parlors. Elsewhere the ward personnel gives attention to the 56 looks of women patients, but only those who have private funds and are in a com- fortable state of mind may go to town for the elaborate treatments so much appre- ciated by women nowadays. Chiropodists are seldom employed, but one at Topeka has answered several calls. Bedding Many very small pillows were seen. The following table shows the number of sheets and blankets on hand at the last Inventory. Institution Number of Patients Sheets Ratio Blankets Ratio Oaawatomie 1.705 5,629 2.1 k,3n 2.6 Topeka 1,855 9,690 5.2 6,092 5.5 Larned 1.505 6,166 k.l 5.230 2.1 IX. TREATMENT OF CONVULSIVE DISORDERS Incidence Every community has an appreciable number of persons who suffer from convulsive disorders. The prevalence of these troubles Is well known to physicians; occasionally a worker In this field gives out information about It based on private or institutional experience, but the public Is unaware of such Information and Is usually shocked when draft figures are released to learn that what they consider un- common Is really a frequent malady. Course Most persons with convulsive disorders stay at home and work effectively, some in positions of considerable responsibility. Others are In poor homes or homes with too small resources to support an Invalid; again a patient may become In some way difficult to manage. These are the patients who go to State Institu- tions. Many of them are mentally deficient but some are smart. Some of them show little change under medication but others respond well to a regular controlled life and administration of suitable drugs; hence some patient is always improving and leaving the hospital. Hospital Care Advantages accrue from having a special Institution for such patients, If the institution is vigorously and adequately administered. This proviso Implies that the financial support of the institution must not he niggardly if it is to accomplish recognized possibilities. Observance of regular hours can he required in an institution. Useful direction of one's energies can he cultivated. Dietary control is important to many persons with convulsive disorders and diets are better managed in such institutions. Incidental Upsets Some convulsive patients develop mental illness and are cared for in a State hospital. They may recover from the mental Illness. Unfortunately there is an inclination to provide too few beds in institutions for epileptics, thus making it difficult or impossible for epileptic patients who have once gotten into a State hospital to be transferred out of it. Provision Kansas has made more liberal bed provision than even Massachusetts and there is no reason to urge greater structural accomodation than exists at present, though many structural changes need to be made in existing buildings if this hospital is to remain on its present site. It is said that in one of the State Hospitals there are probably 100 patients suitable for treatment at Parsons and smaller numbers may be residing in the other two institutions. This matter should be canvased. Facilities Such an institution should have proper provision for a few very dis- turbed patients; some of these may be in a post-convulsive excitement and others develop an abnormal state that may last a considerable time. The total number is always small. Most of the patients in such an institution are mentally deficient, and it should have a very good school. The teachers should have been trained for special-class work and salaries should be such as will attract and hold fine teachers with this special training. Not all these children are mentally deficient, some of them Indeed brilliant, hence special teaching should be available for all elementary classes. Occasionally a teacher carries a boy or girl into high school work and this is good Investment, for such children are likely to attain control of their convul- sions and go back to the community. Accordingly it is obvious that a good Institution for patients with convulsive disorders does some of its work according to the standards of mental hospitals and some according to the standards of schools for mental defectives. It is equally true that such an institution has special problems of its own. Medical Integration The staff of such an institution are likely to feel Isolated unless special measures are taken to relieve them of their unhappy situation. These 58 institutions are treasuries of neurological material and such cases should be made available for teaching the medical students of the nearest university. A well in- tegrated State service should provide facilities so that assistant physicians In mental hospitals will have opportunity to work a few months at the institution for epileptics without loss of grade and status In the home hospital. Assistant phy- sicians In the hospital for epileptics should be encouraged to add to their ex- perience by doing other forms of psychiatric work a while without losing their status In the special Institution where their chief Interest lies. Connections Such an institution properly contrives excellent connections with the nearest school of medicine and should have definite relations with hospitals In which the best brain surgery Is done. The staff of the hospital for convulsive disorders should be advisors to courts and welfare agencies all over the State In matters relating to convulsive disorders. The State Hospital for Epileptics has been described on page twenty. Shift of Site A special problem at Parsons Is whether to keep the present site or sell it. Several buildings are to be rebuilt or abandoned, and the land is not satisfactorily fertile. The city has now surrounded the hospital and ground values have risen. A better tract of land on the other side of town, with plen- tiful water, suitable sewage treatment and established pipelines, Is to be marketed by the Government. Perhaps it would be better to move, use the buildings of the abandoned Army hospital a few years and gradually replace them with suitable one- story buildings for the State patients. The matter should be Investigated. X. TRAINING AND CUSTODY OF MENTAL DEFECTIVES Definition In any community can be found an appreciable number of persons whose abilities do not measure up to general standards of achievement. They are known as "feeble-minded," or "mental defectives," and have had special attention In various ways. These persons were originally of Inferior ability or else they suffered Inflammatory Injury to the brain In early life and never developed so well as other children. All degrees of mental, defect exist, from a few help- less vegetative organisms up to those who are accepted by their neighbors as normal and responsible, but turn out not quite able to meet competition. Distribution Only a part - and not very large part - of the defectives in a commun- ity need to go to a State Training School. Fine families have a feebleminded member who is well brought up, carefully trained, and would gain nothing for the 59 community or for himaelf by going to such a school. The superintendent at Win- field has pointed out than many of the test families of Kansas are represented in his school population. But In other families such a child is an undue burden, and the pub- lic school may not have a special class than can adequately supplement what the family can do for him. And of course there are some inferior families that can- not see what training their feebleminded member needs, and public authorities have to interfere in order to assure him decent surroundings. Types Accordingly the persons who need care in a training school may be roughly divided into two groups: (1) Those who are relatively helpless and incapable of much de- velopment. It is the policy of society to give these persons humane care so long as may be necessary; their lives are usually not very long. (2) A larger number whose native capacities are limited - per- haps sharply limited - but who by properly directed training can be brought to a higher level of social existence than is possible if they are left to themselves and their families. Obviously they need special schooling of definite and well understood nature. Most mental defectives are never cared for in a public or private in- stitution. Much work that is considered monotonous by others is faithfully and better done by them than by persons with more intelligence. Those that spend a few years in a Training School should be carefully taught with slow persistence to do kinds of work that involve considerable repetition and not much initiative Mental Upsets Mental deficiency is no barrier to emotional disturbances. There should be on the staff of every institution for defectives a psychiatrist much of whose time can be profitably employed in helping patients who develop de- pressive or other abnormal states of mind. Waiting List About 85 now stand on the waiting list. It is probable that other children for whom admission has not been asked would be sent to the institution if the State of Kansas were to be more liberal in its policies and accomodations Sterll1zation Sterilization of defectives is a loudly advocated procedure, advocated partly to make life easier for the subject of the operation, mostly to make it easier to care for him. Kansas goes farther than most Occidental communities and has castrated some 475 men and boys, giving preference to those they thought 60 likely to remain in the institution. This is said to abolish sexual misbehavior toward boys, and also some behavior that is very vulgar though not medically im- portant . Institutional. Requirements Obviously such an institution should have a strong psychiatric department One or more capable clinical psychologists should be included in the organization. A strong school should be staffed with teachers who have been trained for "special class" work. The training program should be well planned and children should be taught to help in a variety of vocations. Acceptable behavior in all situations should be inculcated, for mental defectives learn good habits more slowly than do brilliant children. Until these things are done the training program of Kansas must be con- sidered of inferior quality. The superintendent is well Justified in asserting these needs to his board and the legislature. XI. PUBLIC RELATIONS Need In a period when the inadequacy of mental hospital care and the frequent and pathetic absence of Important types of treatment Is luridly discussed in maga- zines and newspapers all over the land, it is particularly important that relations between institutions maintained by the State and the citizens of the State should be on a level of high confidence. Some of the matters mentioned below - particu- larly legal phases of admission and discharge - grow out of what people think of their institutions. Unless such laws are progressive, they saddle on the next generation a backward view of the State's duty and privilege, and increase popu- lar distrust. Voluntary Admissions In mental hospitals as in other hospitals there should be no question about the reception of voluntary patients. Voluntary admissions disclose to some extent the confidence in which a hospital is held by the public. They are legal in Kansas but no great effort has been made to increase them. For the last year they numbered at Osawatomle 32, at Topeka 35> at Lamed 3- It should be possible for any citizen of the State to present himself at a State hospital, discuss his feelings with the superintendent or another staff member and be received when he has signed an application. It should not be necessary to appear before a Judge. In some quarters fear la expressed that an easy admission law will bring to the hospitals a flood of people seeking mere rest. Whoever knows the popular ideas about mental hospitals has no such notion. Commitment Anyone may file a petition with the Judge of the probate court, naming two witnesses. If the certificate is lacking the Judge may appoint a doctor to Issue a certificate. The judge may Issue a writ commanding the mentally ill person to appear in court for a hearing, hut usually this step is not required. The physician's certificate may state that the patient's physical or mental con- dition is such that it would be improper to bring him to court. The patient must be represented by counsel. If the Judge decides on a commission rather than a Jury, he appoints two qualified physicians. The Inquest may be held in open court or a chamber or the patient's horns. This procedure la not identical with what occurs in the case of alleged crime, and the probate Judge perhaps comes nearer to being a friend of the family. Procedure should be such as to avoid an attitude on the part of the public that is summed up in the unpleasant word "stigma-" Commitment for Observation It 1s now possible to get a commitment to a State Hospital for thirty days more expeditiously than the usual order for an indefinite period. An ap- plication is accompanied by the certificate of one physician. Before the end of the period of observation the superintendent of the State Hospital reports his findings to the probate court, and the patient is either recommitted for as long as may be necessary, or discharged. This procedure makes it possible to get a patient into a hospital quickly and without so much that is distaste- ful to the family. Waiting Liat Because of the number of patients already in the institutions a waiting list has been set up, and the Board of Social Welfare passes on ap- plications. In the case of the mentally ill, this means delay at a time that may be the most critical. Thirty-five patients are said to be thus waiting. In the case of mental defectives, the need is less urgent. On grave lack is that the Training School has no social worker of its own, through whom to visit and get an authoritative report on the conditions of those who wait. Waiting Place Since the commission may sit at the home of the patient whose admis- sion is sought, perhaps he will be kept by his family during the period of delay. Otherwise the Jail 1s always open. Transportation Most patients are taken to the hospital by a deputy sheriff. These peace officers have the reputation of handling the patient and the family as gently as they can, but neither the State nor the county gives them training in nursing procedures. They would not be charged with the care of a patient with physical Illness, if a nurse could be found. Several States, large and small, provide that upon notification of a commitment, trained employees of the hospital go and bring the patient in. Relatives might well prefer this arrangement, and patients too. In addition 62 to populous States like New York and sparsely settled ones like Idaho, Illinois Is now In the process of changing over to this system. Trips Home As a rule the hospitals encourage the patients to make short trips home. Good judgment must he used In this matter because some of those who are most en- thusiastic about going home are least fit to do so. It Is, however, significant that a good understanding exists between hospitals and the community that these short trips are usually encouraged. Discharge The superintendent has full authority to discharge any patient except those under criminal orders. Visiting Visiting Is permitted In most Institutions every day either morning or afternoon. This arrangement has advantages to the relatives and It Is Intended to maintain the Interest of the family. Many years ago It was shown that a de- finite relation exists between the regularity of visiting and the prospect of the patient’s ultimately leaving the institution. An arrangement should be made by which physicians will not be called away from the wards to talk to visitors. SterllIzatlon The superintendent of any of these institutions may certify that the mental or physical condition of an Inmate would be improved by sterilization or that procreation would result in defective or feebleminded children with criminal tendencies and that the patient's condition Is not likely to Improve. Ultimately this recommendation Is passed on by the Board of Social Welfare, supplemented by the secretary of the Board of Health and the superintendent of the Institution in which the patient Is. This Board of Examiners then decides whether an operation shall be performed and whether It shall be merely a measure that prevents procre- ation or whether complete asexuality shall be Imposed. They then designate a surgeon to do the operation. Under this law the Board must predict that children with criminalistic tendencies are likely to be propagated by the mentally 111 patient. In former days some had the unscientific notion that by this procedure poor heredity stock could be terminated and even epilepsy, mental disease and criminality be ulti- mately abolished, but this idea has largely vanished. The usual argument in Kansas Is that these persons should be relieved of the burden of bringing up children that they might not well support. It Is believed also that any off- spring of feebleminded or mentally 111 persons may be another defective and sterilizing a possible parent Is likely to save the community the support of a dependent child. The hospitals seek operation on those who may go back to use- fulness in the community, for when a simple sterilization Is done, the patient Is protected from the perils of parenthood and may leave the institution without giving public officers concern about having to support his progeny. 63 In the Training School, operations are done mostly on patients who will stay and become quieter inmates. At present the School houses 315 who have undergone operation. A private agency is authority for the statement that the total number of sterilizations officially reported is higher in Kansas than in any State ex- cept California and Virginia, numbering 2,855 up to January 1, Of these operations, 1,992 were performed on the mentally ill. Opinions differ as to the effect of all this on the community. It certainly sets the patients in these institutions apart from the general popu- lation in an unpleasant way. A call to come into a public hospital and be sterilized is not a cordial invitation to a sick man. In this predominately Protestant community only a few objections on religious grounds have been filed. The following table shows the sterilization record of the last six years. Sterilizations in Kansas State Institutions 1939-19^5 Vasectomy SsIpingectomy Casti •at ion Total Male Female Male Female Male Female Osawatomie 111 80 6 2 117 82 Topelca 71 71 44 Larned 25 15 15 56 15 Parsona 22 8 22 8 Winfield TO 74 10 81 8o 254 215 95 12 527 227 Civil Rights When a patient is committed to the State hospital he loses his civil rights. This is an unnecessary affront and should not continue. Commitment should be in the nature of a quarantine procedure by which a person who is up- setting (but not "dangerous" to the community) or is unable to take proper care of himself is separated from the community for a period of treatment, and that only. Restoration If a patient is discharged as recovered, his civil rights are restored, otherwise he must go to court. Courts are sympathetic in this matter. This re- sponsibility for the legal status of the patient in the community should not lie upon the medical staff, whose diagnosis of condition is made on medical, not social, grounds. Out-Patient Servloe Patients are sometimes "brought to the hospitals by their relatives to be examined. No service away from the hospital has ever been Instituted. Public agen- cies and others should be given the benefit of psychiatric knowledge and advice. Not many psychiatrists are In private practice outside of Topeka and Kansas City. The State should strengthen Its medical staffs In order to provide this clinical- service . Social Service For purpose of economy no social workers are provided to these Institutions. It has been thought that an occasional report from a county social worker Is all that is needed. This Is not the case. Mental hospital patients should have the best at- tention possible. Not only should the details of patients' histories be obtained from various helpful sources but information should be obtained about the home to which the convalescent patient Is expected to go. Expert aftercare helps many a patient to stay at home who otherwise might have to come back for another period In the hospital. Teaching All these institutions conduct clinics for students of the social sciences from various schools and colleges. Programs are occasionally given to the physi- cians of the local County Medical Society. None of these staffs has ever considered seriously their responsibility to the medical profession In other counties. Several types of college students do field work in mental hospitals in other States and such arrangements should be developed here. Students of social service, students of physical education, students of occupational therapy, students of theology and students In law have all shared such privileges. Nurse Instruction No pupils of nursing are given Instruction In these institutions. Nurse educators greatly desire such service In all parts of the country and these hos- pitals should be put In position to supply It to the pupil nurses. Popular Education Addresses to any type of local organizations such as service groups, Parent-Teacher Associations and Mental Hygiene Societies are rarely made now by the hospital staff. Very rarely is a communication offered to a medical organi- zation. In every mental hospital the results of the continual study of patients should be reported to medical colleagues as occasion offers. Private Care Private institutions for the mentally ill are licensed by the Board of Social Welfare. The Board has no machinery for recurring Inspection. Family Care Family care exists in several European countries and many of the States in this country use it for suitable patients. One or more men are boarded in a home; they are visited at suitable Intervals by a social worker, a nurse, or phy- sician from the hospital. Family care has not been considered here. Kansas is a land of strong opinion and forthright utterance. Unhappily, those who know most about states of mind and mental aberrations in the State do not always work happily together. It is to be hoped that both in the Kansas So- ciety for Mental Hygiene and the Kansas Psychiatric Society united support will be given to the present movement to give better care and treatment to the men- tally ill and related groups. On the other side, it may be hoped that State officials and hospital staffs will get for their patients every possible aid from outside agencies. XIIc COMPARISON WITH NATIONALLY RECOGNIZED STANDARDS The Mental Hospitals In 1926 the American Psychiatric Association recommended a aeries of minimum standards for public mental hospitals. The following comparative notes indicate points at which Kansas State Hospitals are maintaining these standards and some regards in which lower standards have been accepted. "1. The chief executive officer must be a well qualified phy- sician and experienced psychiatrist whose appointment and removal shall not be controlled by partisan politics." Of late years this requirement seems to be met. "2. All other persons employed at the institution ought to be subordinate to him and subject to removal by him if they fall to discharge their duties properly." • Authority appears to be undivided, subject to Civil Service Commission rules. A discharged employee might be reinstated after a hearing by that Con - mission. "3. The positions and administration of the institution must be free from control for the purpose of partisan politics." This standard appears to be met. "}+. To provide an adequate medical staff, the physicians should be well qualified and, in addition to the Superintendent, in numbers sufficient to provide one physician for every 200 resident patients, plus one physician for each 100 annual admissions. There should be a full time qualified dentist for each 1,000 resident patients." These ratios were never met. The best showing 1s made at Topeka. 66 "5* There must be a staff of consulting specialists at least in Internal medicine, general surgery, organic neurology, diseases of the eye, ear, nose, throat, and radiology, employed under such terms as will ensure adequate services. A record of their visits must be kept." Only a few consultants were ever appointed. "6. The medical staff must be organized, the services well de- fined and the clinical work under the direction of a staff leader or clinical director." The work of the physicians is well defined. Each superintendent is his own clinical director. "7. Each medical service must be provided with an office and an examining room, containing suitable conveniences and equipment for the work to be performed, and with such clerical help specially assigned to the service as may be required for the keeping of the medical and administrative records." Few physicians have offices on their services, "8. There must be carefully kept clinical histories of all the patients, in proper files for ready reference on each service." The histories are carefully kept. Except for the period immediately following admission, they are meager. Topeka keeps up occasional noting. "9. Statistical data relating to each patient must be recorded in accordance with the standard system adopted by the Association." The system acceptable to the U. S. Bureau of the Census is followed. "10. The patients must be classified in accordance with their mental and physical condition, and with adequate provision for the special requirements for the study and treatment of the cases in each class, and the hospital must not be so crowded as to prevent adequate classification and treatment. The certified capacity of each insti- tution should be determined on the basis of approximately fifty square feet of bed space per patient." Crowding Interferes with classification. Certification of capacity has apparently not been made. "11. The classification must Include a separate reception and intensive study and treatment department or building, a special unit for acute physical Illnesses and surgical conditions, and separate units for the tuberculous and the infirm and bedfast. Each of these units must be suitably organized and equipped for the requirements of the class of patients under treatment." Such services are maintained, but adequate staffing does not exist in most of them. "12. The hospital must he provided with clinical and patho- logical laboratory, equipped and manned in accordance with the minimum standards recommended hy the Committee on Pathological Investigation." Clinical laboratories exist but their activities are reduced below the level of proper clinical service. Neuropathology is not studied. "15. The hospital must be provided with adequate X-ray equip- ment and employ a well qualified radiologist." The institutions have X-ray equipment with which good pictures have been taken. No technician is employed, but a student at one hospital and an attendant at another do creditably. The resident staffs do all the reading. "14. There must be a working medical library and journal file," The libraries need building up. Journals range from one to several. "15. The treatment facilities and equipment must include: (a) A fully equipped surgical operating room. (b) A dental office supplied with modern dental equip- ment . (c) Tubs and other essential equipment for hydrotherapy operated by one or more specially trained physiothera- pists. (d) Adequately equipped examination rooms for the speci- alties in medicine and surgery required for the schedule. (e) Provision for occupational therapy and the employ- ment of specially trained Instructors. (f) Provision for treatment by physical exercises and games and the employment of specially trained in- structors . (g) Adequate provision for religious devotion and for recreational and social entertainment." Surgical and dental facilities exist. Hydrotherapeutic Installations exist but are used only at Topeka. Examination rooms could be found if needed, but no regular visits by specialists occur. Occupational therapy claims one worker at Lerned, is discontinued for the summer at Topeka, was dropped at Osa- watomle in 1958. Physical training is non-existent. Chapel services are held. "16. Regular staff conferences must be held at least-twice a week where the work of the physicians and the examination and treat- ment of the patients will be carefully reviewed. Minutes of the conference must be kept." Staff conferences are held one to three times a week. "17. There must be one or more out-patient clinics conducted by the hospital in addition to any on the hospital premises. An adequate force of trained social workers must be employed." No out-patient clinics are maintained and no social worker employed. 68 "l8. There must be an adequate nursing force, for a 12 hour day, in the proportion of not less than 1 to 8 of the total patient popu- lation, the ratio to be sufficient to permit one attendant or nurse to patients requiring Intensive treatment and the acute sick and surgical patients. If the hospital operates with a working day shorter than 12 hours corresponding adjustments are to be made In the ratio. Provision must be made for adequate systematic Instruction and training of the members of the nursing force." The ratio of nursing personnel to patients Is far lower than recommended. "19. Mechanical restraining and seclusion, If used at all, must be under strict regulations and a system of control and record by the physicians, and must be limited to the most urgent conditions." Mechanical restraint and seclusion seem to be little regulated. "20. For the health, comfort and mental well being of the patients, food Is of great Importance. Kitchens should be scrupulously clean, the personnel competent (preferably under the direction of a trained dieti- tian), the equipment sufficient so that food may be served at proper temperatures. The dietary to be sufficient In quantity, varied, and containing all the essential food elements in the proportions of a balan- ced ration." Cleanliness prevails. Dietitians are unknown. Menus could be Improved in variety and balance. The Training School Some Items In the "Practical State Program for the Care of the Mentally Deficient," adopted In hy the American Association on Mental Deficiency, may he compared with the present situation In Kansas. "I. State Institutional Care and Social Control." "1. Extent. Beds to accommodate at least 0.1$ of total State popu- lation, with ratios of staff as In I 5*" No definite number of beds Is available, since a variable number of men- tal defectives Is carried In the State Hospitals, At present the Training School provides for about 1,300 patients (many of them In doubledeck beds), the Hospital for Epileptics for perhaps 600, and the three State Hospitals for the Insane for about 150 more. The total figure constitutes more than the recommended figure, but not suitably distributed. "2. Nature. Service to be flexible in order to provide for all degrees of defect and all types of social behavior. To Include among other services regular habit training psychiatric treatment and voca- tional training. To be directed to socialization not custody." This service is devoted principally to custody. Vocational training needs development. Psychiatric treatment is absent. 69 "5* Administration. A central Board, or its equivalent in the integration of service in institutions and state departments, to carry guardianship, govern all admissions, transfers and discharges, pro- vide a central registration of all cases, indicating those merely known and those actively under care. A local authority under county or municipal office through which the state authority may work. Se- lections for admissions to institutions to be based upon promise of social adjustment, degree of deficiency and anti-social tendencies, and physical status, not merely the degree of mental defect. For complete records a distinction to be made between notifiable and certifiable cases." The central board does not have these functions. "4. Specialized Service. Separate care for defective (psycho- pathic and convulsive) delinquents, either in special institutions, or where the state population is small, in special separate units." This standard is not met. "5. Social Study and Control. Staff large enough to provide adequate service and supervision, both within the institution and within the community. At lease one doctor to every 500 cases. One social worker to 50 cases in rural areas and 75 in urban areas, as- suming no other work is required of these workers. At least one trained psychologist to each 500 cases. One teacher to every 25 children of school age. Standards of psychologists and psychiatric social workers are referred to in II, 2c." Such standards are unheard. "II. State Extra-Institutional Service." "1. Intermediate care. Provision (in addition to parole ser- vice) of forms of care intermediate between institution and commun- ity, both before and after commitment, such as colonies, hostels, family care, supervised clubs." Kansas has no colony, hostel, supervised group of family care. "2. Clinic Service. Public clinics for Identification and regis- tration, treatment and recommendations, with follow up either by clinic staff or cooperating agencies. (a) Extent. If service for mental defectives is included with child guidance, one clinic unit to every 100,000 of population is indicated. Service for mentally der fectlve borderline and dull normal only would require one clinic to some 150,000-200,000 population. (b) Nature. Examination and recommendations to Include mental, educational (or vocational if over school age), and social. (c) Standards of Personnel. To conform to standards such as those published by the New York City Committee for 70 Mental Hygiene. These do not attempt to cover various technical aids such as psychometrlsts as long as the cards are entitled." There is no public clinic. "IV. Research." "Since mental deficiency is diverse both as to causes and effects, research needs to be broad and Include facilities for pursuit into sever- al scientific fields, biological, chemical and clinic, psychological, etc. 1. Incidence 2. Causes 5c Treatment (both in institution and community) Social planning" Research by an outside agency has been permitted. XIII. DISCUSSION AND RECOMMENDATIONS Goal The present attitude of many persons with leadership in Kansas affairs and the favorable financial situation of the State government have created an opportune time to lay plans to make the Hospitals and Training School not only as good as they ever were, but distinctly better than they ever were, with standards befitting a great, humane and wealthy State, What has already been accomplished makes a very good foundation. Improving the treatment of 7,000 patients is a complicated matter and requires collaboration. There are things for the legislature to do, for the Board of Social Welfare to do, for the hospital staffs to do. Among them all, the Gover- nor serves as coordinator and stimulator. None of those named should fall into a dependent attitude and leave the betterment of the hospitals to somebody else. It is assumed in this report that the Legislative Council is seeking advice on better- ment, rather than any assessment of good versus poor accomplishments. Several matters must be presented at some length. After that, a con- siderable number of items will be formulated as specific recommendations. Rejection The State is behindhand in mere provision for its sick citizens who are in need of hospital treatment. Overcrowding. The 5 hospitals are already over patients in excess of capacity. That abhorrent document, a waiting list, has existed for some time. Citizens who have been duly examined and found in need of hospital care are kept out, perhaps in overburdened homes, perhaps in jail where the jailer or deputy sheriff does his best to be a psychiatric nurse. 71 Temporizing The experience of other States indicates that Kansas has a concealed load of some 4,000 patients who would be properly in mental hospitals but have not yet made application. Altogether provision should be made for some patients. The only proposal thus far has been to add a building here and another there to the three existing hospitals. This procedure results in breaking down one service facility after another; the kitchen, the bakeshop, the storehouse, the powerhouse, the sewage disposal plant - one after another their capacity is overloaded and they must be stretched and replaced. In this connection the com- ments of the engineers on the disposal plant at Lprned are a model of cautious warning. New Hospital The time has come to provide another hospital. The southeastern sec- tion of the State has an increasing population and the northwest could well sup- port a hospital, old districts being revised. In either section a good site should be obtained and plans for a new and fine institution prepared. Since the increase of hospital population is everywhere among the older members of the com- munity, many of whom are feeble and the victims of chronic disease, the new hos- pital should be made up mostly of one-story buildings. Board Another subject for serious consideration is the administrative machin- ery for ensuring the welfare of these sick citizens. The Board now charged with that responsibility is not primarily a hospital board. Their interest, their experience, their very title places them in another field. The legislature should be slow to criticize them for lack of a vigorous, broad and forward-looking pro- gram - they are very busy and sometimes embarrassed with a program of another kind that they cannot leave to others.. Let it be remembered that a sound and comprehensive mental hygiene program such as Kansas should have will cover not only the intricate operations of these five institutions but also community provisions so that the mentally ill of any community in the State can be assured of proper treatment, if not in a physician's private office, then in a State clinic. There will be no competi- tion with private practice, but the public agencies and the children's courts will receive the service and advice that now they get in only a few centers. Betterments To attain the best standards, a Department of Mental Hygiene should be created. If the obvious honesty and good faith of the Board of Social Welfare lead the legislature to wish them to continue to struggle with these other prob- lems beside their primary duties, then they should be given a highly competent specialist in this field who will be their inspector, their advisor, and (sub- ject to their decision on policy) their administrator in matters of mental health and mental illness. 72 Commitment A matter of very serloua concern to patients and to their relatives and friends - in fact to every friend of the mentally ill. - is the iniquitous commit- ment law. It was designed to protect certain rights of the sick man and the com- munity and no harm was ever Intended, hut it now works to the detriment of many patients for it rohs them of their fundamental right, the right to "timely re- lief," as the law of another State phrases it. The law has been Improved by the addition of provision for thirty days of observation. It should be further modern- ized by removing the requirement that the patient must go through a hearing when he does not want to (and few indeed want anything like a court procedure) and by abolishing the Interference with the exercise of civil rights. Commitment for mental Illness should be patterned on quarantine. No patient with smallpox is hauled into court, he is picked up by the health department and put under care. So it should be with the mentally ill. Nobody proposes depriving a litigious per- son of the privilege of Invoking all the court procedures he now can demand; very few patients want that unpleasant publicity. Another step should be taken, and without a court order it should be possible on the certificate of two practicing physicians or the request of a health officer to receive a patient in a State Hospital for a ten-day period of observation. The validity of the request would be determined by the superinten- dent before admitting the patient. Support In a general way let it be said that what these institutions do is de- sirable. How they do it is sometimes good and sometimes crude. They need much better support. We know how to do many things for our patients, and we know that these things if well done will be beneficial, but most of these good procedures need able workers to carry them out: physicians, nurses, attendants, technicians of several sorts, physical training directors, occupational therapists, social workers; even a librarian and a musician. For our mental defectives we need teach- ers of book learning and teachers of hand work. And all the while, in every insti- tution, we need to have a continuous training program going on. Three special groups should be better planned for: the tuberculous, the aged, and the mentally sick children. Sick Children Sick children are the smallest group, and a very pathetic group. They are unwanted elsewhere. They do not fit in a general hospital or a children’s hospital. They are not mentally deficient and so do not belong in a school like Winfield. They do not have convulsions. They are out of place in the mental hospital when located in an adult ward. They do very well when properly placed in their own sec- tion of a mental hospital with skillful people looking after them. Several years ago provision was made at Osawatomie for a few mentally ill children. Such a service should exist somewhere in the State service. It should be headed by a physician who has had experience with children, and staffed with nursing and social service of high quality. Tuberculosis A much larger group is composed of the mentally ill who also have pul- monary tuberculosis. It is the time for another advance in the management of pulmonary tuber- culosis in our mental institutions. Ontario led the way some years before the war. Several States have profited by her experience and their own studies and have instituted more vigorous programs. The Federal Government has made funds and equipment available for competent and early diagnosis on a large scale. Such patients might be assembled from the several institutions in a unit constructed according to the advice of experts in tuberculosis. This could be in the new hospital or in one of those now existing, if it were relieved of other patients. No doubt the most satisfactory structural arrangements could be made in a new hospital. A physician of experience in the field of tuberculosis should be put in charge. His salary should assure a man of senior rank in this field. He would be responsible directly to the superintendent who would give him every support in a campaign of both diagnosis and treatment. He could soon be taught what is necessary to know about his mental patients and would have all his colleagues to call upon for advice on psychiatric problems. Suitable chest surgery would be done by him or by a consulting surgeon. The head of some tuber- culosis sanitarium should be made consultant to all this program. Provision would doubtless be needed for about 260 mentally ill and 50 or kO defectives. The law establishing the hospital or better still the whole Insanity law should be drawn to give the governing Board authority to transfer a tuberculous patient from Parsons or Winfield for special treatment, and trans- fer him back when treatment is completed. The Aged A large and growing group in mental hospitals all over the country are the old people, some of whom are well preserved and active, others of whom are feeble. Since the expectancy of life has almost doubled in the last six decades and since elderly folk are particularly liable to mental illness, we must expect many such patients for a long time to come. Some inveigh against the families of these patients and declare that the young no longer have respect for their elders and "want to get rid of them;" this is not only an unsympathetic view of the situation but also an unintelligent one. Incidentally it may be remembered that several million of our youngsters have given an account of themselves in the last five years before which we oldsters may well pause, humbly. Many of these patients have been useful all their lives till lately and some of them have been outstanding in their communities. They should be made comfortable, given what little luxury the hospital affords, be under excel- lent supervision, and not have to climb stairs. One-story construction is needed for them in Kansas and Just as practical as in Illinois where the State hospitals have great numbers of one-story cottages. It may now be in order to reduce recommendations to a series of items. Some of these matters call for changes in the law, some for Improved methods, most of them for able workers. Such workers exist, are in great demand today, and are worth bidding for. 74 Matters Perhaps Requiring Legislation 1. The Board of Social Welfare should have such a central organization that it will be able at all times to determine policies, maintain effective in- spection, and supervise the institutions placed under its control. 2. Objectionable features should be eliminated from the commitment law and a progressive mental hygiene law constructed. Measures Requlrlng Action by the Board of Social Welfare 5* Salaries and wages should be revised, with frank appreciation of the difference in value of the dollar twenty years ago and now. Unless Kansas is willing to compete for the best, she must expect to employ only mediocrity - or worse. k< Out-patient service should be provided to courts and welfare agencies throughout the State. Psychiatric social workers are needed in all these institutions, and should be provided. 6. Every institution should have at least the part-time service of a registered pharmacist. 7. Suitable patients should be transferred from the State Hospitals to the Hospital for Epileptics.. 8. The institutions at Parsons and Winfield should be granted necessary funds to build strong educational departments. 9. The Board of Social Welfare should study the subject of family care and be ready to institute it whenever economic conditions permit. 10. The four institutions that lack them should be given competent clini- cal psychologists. 11. Fire drills should be maintained in all institutions. 12. The medical staff should Include several grades of physicians. When the time comes that there is any competition for the privilege of serving the State of Kansas, the Civil Service Commission can move to set standards for each grade. Medical Staff and Activities 15. Consulting staffs should he built up and called on freely. In some instances the consultant must come from a distance and should be suitably reim- bursed. Ik, The number of assistant physicians at Osawatomle should be raised to 11, at Topeka 15, at Lamed 10, at Persons 4 and Winfield should have psychiatric service. 75 15. Modern medical practice makes frequent use of laboratory aid. Both the practice and the laboratories in these Institutions should he improved. 16. Every medical staff should immediately raise its autopsy rate much - beyond the minimum proposed by the American Medical Association for an acceptable hospital. 17. Better clinical records should be developed. 18. Dental service should be strengthened in every institution that has not already a resident dentist. 19. No slipshod practice in handling tuberculosis should be permitted. Chest surveys should be completed throughout the patient and employee popula- tion. Separation of infective persons should be definite and speedy. Treatment should be of high type. 20. Smallpox vaccination should be kept up to date in all institutions. 21. Research should be encouraged in all institutions under the Board of Social Welfare. An alliance with the University Medical School should be formed. 22. When dysentery occurs, thorough laboratory studies should be made and followed by vigorous action to stop the progress of any infecting organism. 23. Practices regarding the management of contagious disease might well be reviewed with the Department of Health. 2k. The Hospital for Epileptics should give broad service to the state in study and advice on convulsive disorders and the complicated social problems arising therefrom. 25. Conditions of work and living should be made sufficiently attrac- tive to draw young and ambitious physicians into this service. Every hospital staff should have a stable nucleus of older, experienced physicians who can be depended on for direction and guidance, and a group of younger men who have come to learn while they work, and many of whom will pass on to other medical activ- ities after a couple of years. 26. By joint planning, the Board of Social Welfare and the Society for Mental Hygiene should ensure intelligent interest in these matters on the part of the citizens of Kansas. Additional Measures of Diagnosis and Treatment 27. Physical training should he organized for all adult patients and physical education for the youngsters. 28, The use of crafts in the treatment of the mentally ill and allied groups should he developed under a high level of skilled leadership. • 29* Berbers and heautltlana should he employed. 76 30. Programs of religious instruction and consolation should be taken seriously and the best service promoted in each institution. 51. All cultural influences should be available in these institutions. Libraries should be under professional direction. The drama should be employed. 52. Music should be widely used in these institutions and a full or part- time director installed in each. In the two children's schools music should be a prominent part of educating and the Parsons and Winfield bands widely known. 33* All ambulant patients should be weighed regularly and frequently, at intervals of a week to a month. Reception facilities should be restudied and the new patient pro- vided with a cheerful and hopeful environment. The physically ill should be sheltered from the inroads of new and perhaps ill-adjusted patients, and new patients should be protected from the discouraging remarks of long-time patients. Nursing and Ward Care 35* The advantages of unitary nursing control should be considered. For chief nurses, persons with the best of psychiatric training and outlook should be employed. 36. Wprd personnel in the hospitals should be raised in numbers till it stands in ratio to patients at 1:8. Mpny more of these workers should be graduate nurses. Food and Feedln, 57* Dietetic departments should be encouraged to develop better menus and much better service of food. 38. All sick persons should have the service of a dietitian. 39* Dairy herds should be improved to a level of production that will allow l|r pints of milk a day for every person fed. Building Program UO. A new mental hospital should be planned and hullt. Immediate steps should be taken to acquire a suitable site. 41. Possible advantages to the state In moving the institution at Parsons and selling Its site should be weighed. k2. A new group of buildings should be developed at Winfield so that the present overcrowding will be relieved and better classification made possible. i+3. Separate buildings for administrative offices and recreational ac- tivities should be provided at Lerned. 77 44. Adequate plumbing should be Installed in all wards. More toilet seats and drinking fountains are particularly needed. 45- New construction should largely take the form of one-story build- ings. The supply of taller ones is already more than adequate. Acknowledgment is freely made to the many persons who made this.study not only possible but pleasant. Particular thanks are offered to Dr. Frederic H. Guild, Research Direc- tor of the Legislative Council, who kept a most helpful hand on all movements and promptly produced any data requested. INDEX Administration, central 2, 69, 71, 74 (See Social "Welfare Board) Admissions 2, 50, 60, 66 Aged 55, 75 Alcoholism 52 Attendants 57, 44-46, 49, 72, 76 Autopsy 15, 18, 19, 21, 22, 54, 75 Building program 12, 71, 76-77 Capacity 12, 13, 14, 57, 66, 68, 70, 71, 76 Care 45, 46, 55, 56 Civil rights 63 Classification 66, 76 Clinic service 21, 69, 74 Clinical records 35> 66, 75 Commitments 60, 6l, 72 Consultants 15, 18, 19, 20, 22, 36, 66, 74 Contagion 51, 75 Convulsive disorders 56-58 Criminals 52 Dentistry 15, 18, 19, 21, 22, 36, 57, 67, 75 Diet 18, 21, 22, 49, 57, 68, 76 Dining rooms 16, l8, 20, 21, 22, 47, 48 Discharge 62 Drug addiction 52 Education 57, 60, 64, 68, 74 Epileptics, Hospital (Parsons) 2, 5, 10, 11, 15, 20, 2k, 26, 27, 32, 33, 56, 42, 45, 45, 50, 51, 57, 53, 63, 75, 74, 75 Equipment 48, 67 Expenditures 4-11 Family care 65, 74 Farms 5, 13 Fire risks 15, 19, 46, 74 Food 47-50, 68, 76 Furnishings 45, 56 Hours of duty 44, 46, 48 Hydrotherapy 54, 67 78 Kitchens 16, l8, 20, 21, 22, 47 48, 68 Laboratory 54, 67, 75 Lamed State Hospital 2, 12, 18, 24, 50* 65* 74, 76 Legislative Council 1, 2, 12, 15* 70 Libraries 55* 54* 67 Mail 54 Maintenance expenditures 4-11 Mechanical restraint 68 Medical staff 15* l8, 19* 21, 25, 55* 57* 65* 66, 67* 74 Mental defectives 21, 58* 59* 72 Mental Deficiency, American Association for 68 Mental hospitals, state 6, 7* 14, 28, 29, 38, 39, 65-68, 74 (See Lamed, Osawatomie, Topeka) Mental hygiene law 71* 74 Mental Hygiene, Society for 75 Menus 47* 68 Milk 49* 76 Music 54* 72, 76 Newly admitted patients 50* 76 New hospital 71 Nurses 57, 64, 68, 72, 76 Observation 6l Occupational therapy 54* 55* 67* 72 Osawatomie State Hospital 1, 2, 5* 12, 15, 24, 56, 57* 45* 50, 51* 65* 72, 74 Out-patient service 64, 67, 74 Patients 16, 17* 19* 20, 76 Patient load per physician 24-54, 65 Patient load per nurse or attendant 58-44, 46, 68, 76 Pharmacy 5, 15, 18, 19* 21, 74 Physical illness 51 Physical plant 12, 15, 15* 17* l8, 20, 22 Physical training 54, 67* 72, 75 Physiotherapy 54, 67 Private care 64 Psychiatric Association, American 65 Psychiatric treatment 68, 74 Psychology 57* 60, 74 Psychotherapy 55 Public relations 60 Quarters 25* 44, 46 Reception 66, 76 Recreation 55* 76 Religious services. 55* 67, 76 Research 54, 70, 75 Restoration 65 Restraint 46, 52* 55* 68 Salaries 5* 4, 46, 74 Shock therapy 55 Sick children 72 Social service 64, 69* 72 Social Welfare Board 2, 4, 70, 71* 74 Special treatments 50, 67* 69 Staff conferences 56, 67 State agencies 5 (See Social Welfare Board) State Institutions, Special Com- mittee on 12 Sterilization 59* 62, 65, 74 Superintendents 15, 18, 19* 20, 22, 25* 65 Supervisors 57 Surgery 56, 67 Survey personnel and sources 1 Syphilis 52 Teaching 21, 25, 64, 72 Topeka State Hospital 2, 12, 16, 24, 56, 37, 45, 50, 51, 63, 74 Training programs 25, 68, 72 Training School, State (Winfield) 2, 5, 8, 9, 21, 24, 26, 27, 30, 51, 40, 41, 50, 52, 59, 63, 68-70, 73, 74, 76 Transportation 18, 45, 46, 6l Tuberculosis 51* 75* 75 Voluntary admissions l6, l8, 20, 21, 60 Visiting 62 Waiting list 59* 6l, 70 Ward conditions 45* 46, 76 Weighing of patients 50* 76 FACTS ABOUT THE LEGISLATIVE COUNCIL The council Is a permanent joint committee of the legislature, meeting quarterly at the state capltol and giving advance consideration to problems expected to con- front the next legislature. Its purpose is to formulate*a program for the next session. In preparing this program, the council: l) acts as a clearing house for ideas on current legislative prob- lems by receiving proposals from any member of the legisla- ture; 2) determines and directs, through its committees and research department, the study and research necessary for proper consideration of all proposals; 3) disseminates advance Information on these problems to other legislators and to the general public by means of committee and re- search reports and by discussion at and between council meetings; and 4) reports directly to the legislature, one month in advance of the regular session, making recommen- dations in the form of bills or otherwise, and summarizing the material prepared for use of the legislature in con- sidering the program. All publications are available to any citizen of Kansas Interested in the particular subjects considered.