VM P543r 1886 PH1LA. HOSPITAL INSANE DEPT. REPORT 1885 \ NLM QOSblQMQ fc, NLM005610406 kavagn tvnoiivn 3Nioia3w jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn y 3Ni3ia3w jc / ; ^RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIB 3NIDIQ3W jo Aavaan tvnoiivn 3nidio3w jo Aavaan tvnoiivn sNioiaaw jc NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIB Aavaan tvnoiivn 3NIDIQ3W JO AavaaiT TVNOIIVN 3NIDIQ3W JO AavaaiT TVNOIIVN 3NIDIQ3W JC NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIB 1 \A 3NIDIQ3W jo Aavaan tvnoiivn snidiqsw jo Aavaan tvnoiivn snidiqsw jc ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL Lll ARY OF MEDICINE 3NiDia3w jo Aavaan tvnoiivn snidiosw jo Aavaan tvnoiivn 3noici3w j K:0 J ^y 1 x J? i NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LI r / <"■ U\£ ^(Haaj'/IX C. REPORT \ ^0 (a/vV^ CONSULTING STAFF ("'" J V s Insane Department, PHILADELPHIA , HOSPITAL. hi DL'XI.AP * CLARKK, PRINTERS, Hastings' Building, 819 A 821 FILBERT STREET. 1/ s~>, "J W/v\ £35 NATIONAL UBHAr.V OF MEDICiiE BF.THESDA 14, MD. 4&* EEPOBT OF THE Consulting Staff of Insane Department, PHILADELPHIA HOSPITAL. Philadelphia, January 30, 1885. To the Board of Guardians of the Poor. ( Jextlemex :—The Rules given us for the Regulation of the Consulting Staff, exact from it inspection duties, as Avell as consequent reports, and suggestions for the better government of the Hospital. In accordance Avith your requests Ave have arranged our order of service, and have also made primary in- spection of the Avards; ventilation, heating, food and occupations of patients, and of the general character of the nurses called attendants, and of the mode of their appointment and dis- charge. Wards. The new Avards are comfortable, well built and heated, lighted and ventilated. The old Avards are most dismal halls, quite unfit for their present purposes, and are, on the Avhole, badly ventilated—most AATretched# of all are the attic female Avards in the old buildings, and the male violent Avards. There is a good deal of room Avasted in the noAV unused dark cells and closets, and needed space might be gained by inexpensive alter- ations. As yet, we have made no inspection of drainage. Be- Ioav Avill be found more specific statements. The Avards are kept remarkably clean and the beds and bedding are neat and 4 clean also. Probably it would be best to reform the old estab- lishment by building Avards enough like those in the hcav build- ing. We give below a report on the state of the separate wards, with the number of patients at the date of inspection, and the number of attendant nurses. Male Wards. Ward K. Patients............ 72. Attendants............ '>. (Clean.) Ward N. Patients............ 24. Attendants............ 2. (Closets filthy.) Ward O. Patients............ 23. Attendants............ 2. Ward L. Patients............ 73. Attendants............ 3. Ward 2. Patients............ 24. Attendants........... 2. WardM. Patients............ 74. Attendants............ 4 This ward contains an Infirmary room which lies between dormitories, and has about '!'> beds, and strangely enough, this the refuge of the sick has been placed in the Avard for the vio- lent and incurably filthy. It should be the best room in the house. The water closet for this Infirmary is placed in the corner of the Infirmary chamber, and is ventilated into this home for the sick. All of this ward is dreary past description ; ill ventilated; has the mouldy hospital smell, noAv so rarely encountered, and has corridors paved Avith asphalt like a sideAvalk. This is the home of the incurable, filthy, and the violent. If an effort had been made to match their hopelessness with an abode Avhich suggests nothing but a blank, it could hardly have been better done. They are ay ell fed, but the plain Avhite walls, and the absence of prints or pictures or colour must be depressing. Female Department (old wards). Ward A. Patients............ 40. Attendants............ 2. Ward B. Patients............ 40. Attendants............ 2. Ward C. Patients............ 40. Attendants............ 3, (This is the Infirmary.) o Ward D. Patients............ 35. Attendants............ 3. (This is the A'iolent Ward.) Ward E. Patients............ 3"). Attendants............ 3. Ward F. Patients............ 35. Attendants............ 3. (New Wards) Ward G. Patients............ 26. Attendants............ 3. WardH. Patients............ 26. Attendants............ 2. Ward I. Patients............ Attendants........... 2. Ward J. Patients............ 60. Attendants............ 2. This is an attic, and is altogether unsuitable for hospital pur- poses. The ceiling is low and the windows small. It must be in summer unendurable at times, Avith its number of chronic and for the most part hopeless cases. The ventilation is wretched, and the Avater supply being bad at this level, it is impossible to keep the closets Avholesomely clean. Without reasonable Avarming arrangements in relation to a system of ventilation it is impossible to have perfectly Avell aired rooms. The Avard temperatures were good at our tAvo visits, but most of the old cells Avhich are used as dormitories are now Avell warmed. Occupation. The best hospitals are distinguished by the number of insane persons avIio can be induced in any ay ay to Avork. Work is not merely a benefit as making many of them happier, but it appears to be directly valuable as a medical aid towards the restoration of health, of both mind and body. At present, all the sewing, washing and ironing for the insane male or female is done by the Avomen, Avho also do the domestic Avork of their Avards. The male patients do the do- mestic work of their department, and some labor in the kitchen, laundry and yards. The amount of A\ork thus accomplished is, of course largest among the Avomen; but even among those females Avho can Avork, or can be taught to work, there is not enough domestic labor, and there is needed for them more various, and if possible, more interesting Avork. 6 Hints as to these points may be readily had from the reports of the more kindly and intelligent hospitals, such as the London Hospital, Canada, Hanwell and NorristoAvn. The males greatly need more work and more kinds of work. The sight of these vasts, cheerless, undecorated rooms Avith their too numerous inmates, silent and dejected or in restless movement, but one and all absolutely unoccupied, suggests to the active onlooker that such of these insane as can still feel the Aveariness of hours empty of sport or of productive and therefore interesting labor must have added to their disease of mind much that Ave have no right to inflict; for we do not condemn even the criminal to the horrors of hours, unfilled by any labor. As it is the goo.d custom to send away to country hospitals as many curable cases as can be thus provided for, the sad remainder must, of course, represent an usually difficult class to help and to disci- pline. Nevertheless, it is believed that seventy per cent. could be induced to do work of some kind; that is, enough to make a difference in their happiness and chances of relief. The means of providing out-door Avork exist in the few acres of garden, now cultivated, Ave -believe, by able-bodied paupers and the gardener. More land could be used, and to make any out-door Avork valuable, more persons must be employed to oversee and instruct the patients, Avho may be thus occupied. For in-door Avork Ave advise the erection of shops, where brush, mat and mattress making may be bought and Avhefe a certain number be incited to use their oAvn trades, such as shoemakinw, etc. The means in use in England to bribe patients to Avork are : First. The giving of tobacco. Second. The addition of certain much craved articles to the diet list. Third. The privilege of sitting up later, and the use of a room AYhere should be found games, ^illustrated papers, etc. At HanAvell this system of bribes has answered admirably. Amusements, Library Books. Papers, Pictures. Some effort is made to amuse by balls, concerts, recitations, magic lanterns. In 1884 there were about tAvo balls every three Aveeks. It is very doubtful if these are of anv value, chiefly from Avant of efforts to direct and organize. If con- certs of simple nature replaced them, the change Avould be a good one. There Avere six concerts in the year, and one magic lantern entertainment. The library consists of a dolorous collection of antique re- ligious books, official reports, stray sehool books, and ragged travels. Of course but feAY of these insane can read, or de- sire to read, yet a good collection of simpler popular books would be of use. .Some novels are desirable, and, above all, illustrated books and the pictorial journals are to be desired, and Avould be sought for with pleasure by even those ayIio do not read. Twenty daily papers are sent to the hospital, and a fair col- lection is made from boxes placed in i'ailway stations : but these, though of use, do not replace the picture papers, Avhich are rarely given. Each ward has a room in Avhich patients may sit to read or play games, and Avhere at present they re- ceive their friends. There should be reception rooms for this latter purpose. Cards a.re supplied, and checkers; other games might be added, but as no effort is made to teach or personally amuse the patients, these means are little employed. The airing courts are large enough, but not having paved (■paces are muddy and difficult of use in Avet Aveather. There seem to be no set rules as to exercise out of doors. In summer, most, if not all, are out part of each day. In winter, save those who Avork, the great mass of these poor creatures never go out of doors at all. On asking A\hy, avc were told that they had no Avarm enough clothing. Really, what is wanted is organization and a desire on the parts of attendants to do something beyond the merest barren routine. There are croquet sets, but no one to teach or invite to the game; 8 while balls, shiny quoits, etc., might be of value, they Avould be of no service with the present personnel of the Avard at- tendance. The existing staff of physicians is altogether in- adequate to the due medical care of the inmates, and it is now impossible to carry out your directions to us, Avhich ask for the keeping of notes on the physical and mental condition of the patients. We advise that there should be appointed, at least one or more male, and an equal number of female resi- dent physicians to be elected each year, as are the present residents of the general hospital. There is for this vast mass of people (about 670) many of Avhom have distinct physical ailments; one night nurse for males, and one for females. These tAvo are the only A\Tatches, and they alone are afoot at night, and are expected to give Avliat medicines are needed at night, and to take notes. The ludicrous inadequacy of this arrangement needs not to be dAvelt upon. The character and general fitness of the nurses is very low as a rule; so much so that the apothecary, alone is intrusted Avith the giving of medicines in the day time. We propose, if desired, to make a thorough examination of nurses in regard to their general character, and their ability to read and write, etc. All attendant nurses are appointed by the Committee on the Insane Hospital, and no matter hoAv grave may be their offences ; if they be drunk, brutal, or absent Avithout leave, they are not removable by the physicians without a hearing before the Committee, a system which puts an end to all pos- sibility of exact and reasonable discipline. This system stands alone in this CommonAvealth, in this hospital, and Avould be laughable were it not too serious a question for mirth. We give in evidence as to this point, the folloAving communications from the heads of various asylums. Dr. Chapin, Pennsylvania Hospital for the Insane Phila- delphia, says : "The Physician in Chief has power to select and dismiss 9 at his pleasure all the attendants and other persons employed in the care of the insane. It is my further duty to report such discharges to the Committee. This poAA'er has been systematically exercised." We give in full, the letter of the Physician to the Pennsyl- vania State Lunatic Hospital, Harrisburg. He says: "As Superintendent, I have the poAver to dismiss a nurse or atten- dant for drunkenness, misconduct, or dereliction of dutv. This poAver is absolute, and has never been questioned. I believe that the Superintendent should always appoint and exer- cise entire control over all subordinate officers and assistants, have the entire direction of the duties of the same, and his authority to discharge them, Avhen unfaithful, should be abso- lute. Any man Avho cannot be intrusted with such authority is not competent to take charge of any institution. " According to the law and the instructions of our trustees, I am to appoint the attendants and nurses for the female de- partment of this hospital, but as the female physician must be responsible for their actions, I authorize her to nominate or appoint, control and dismiss, Avhen unfaithful, all employees necessary for the medical care of the female patients, and re- port the facts to me in each case. In this Avay, only, can her work be a success. "Very respectfully, "J. E. GERHARD, " Superintendent." Dr. John C. Hall, of the Frankford Friend's Asylum, Frank- ford, writes that he has full poAver to appoint and discharge all employees. The poAver to do this " should be in the hands of the resident officer in charge, AA-hose knoAvledge of the efficiency of the person would enable him to determine the qualifications of the incumbent. I do not think the Avelfare of the patients and the good order of the institution can in any other Avay be so ay ell secured." Dr. Schultz, Danville Hospital for the Insane, writes, Jan- uary 1"), 188">: I give a paragraph from the By-Laws: 'The 10 Superintendent shall be the Chief Executive Officer of the Hospital. He shall appoint and exercise entire control over all subordinate officers and assistants in the institution, and shall have entire direction of the duties of the same.' The quotation is taken from a section of the Act (March '21, 187-)) organizing this Hospital. Since the opening of the Hospital, the Trustees have never expressed any desire or manifested any inclination to restrict the authority conveyed in that para- graph. I have accordingly employed and dismissed attendants, etc., as my judgment dictated, Avithout official pressure from any source. I think I have been rarely fortunate in having a Board so courteous, Avho insist on results, but alloAv me the choice of instruments and methods." Dr. R. W. Chase, State Hospital for Insane, NorristoAvn, January 14, 1885, ansAvers our query by the following extracts from the Rules of his Hospital: '■Chapter III. " Sect. 2. Each of them, by and Avith the advice and consent of the Board of Trustees, shall appoint the necessary supervisors. attendants, and other employees in their respective depart- ments, and shall prescribe their duties. But shall not agree upon their compensation until the Board fixes the same. '•Sect. 8. They shall see constantly that all persons em- ployed under them, perform faithfully the duties required of them, and, from time to time, they shall give them such in- structions as may be deemed necessary to secure the exact and thorough performance of their respective duties. " Sect. 9. They shall be authorized to discharge from ser- vice any of the attendants appointed by them, as aforesaid, Avhenever they shall cease to be satisfied in respect to the per- formance of their duties, and report the same to the Board at its next meeting, for their approval or disapproval. " Sect. 10. They shall prepare a code of rules and regu- lations for the government of their employees, which shall be printed, and a copy furnished each employee." 11 Dr. Alice Bennett (State Hospital for Insane, XorristOAvn) says: "I have full poAver to dismiss an attendant for any cause Avhich seems to me sufficient, and to make the discharge prompt and final. "It then becomes my duty to report the discharge to the Trustees and to the Lunacy Committee, Avith cause of dis- charge, etc. l* I cannot conceive of holding my position under any other circumstances than these. li The most unworthy attendants are those Avho are apt to try to appeal to the Trustees ; and if the latter listened to their stories Ave Avould be involved in endless complications, and my authority and discipline Avould be greatly Aveakened. 11 ■ Perhaps, I should say that I aim never to act hastily, and of course my assistant, in similar circumstances, tries to do justly by all. ■k Yours, very respectfully, "ALICE BENNETT." Dr. Cur ay en, of Dixmont, Avrites that he has full power to dismiss for drunkenness, misconduct, or dereliction of duty. Ancient evil usage in the Philadelphia City Lunatic Hospital has left the appointment and discharge of nurses, etc., in the hands of a lay committee, and so made the physician respon- sible for so-called subordinates, Avhose insubordination he can- not punish, and ayIio look beyond him for an appeal to his superiors. Cruelty, oppression, and great wrong to the feeble and mind- less must have come out of this in the past, and there is no day when it Avill cease to be productive of disgraceful conse- quences. We earnestly advise that the power to appoint and dismiss employees be lodged with the Physician in chief, and that some such rule as that Avhich governs the matter at the Norristown 12 Hospital be adopted by your Board. This power having been given, the physician should be held to strict accountability for his subordinates. It is to be desired that in time the work of the Training School for Nurses be extended to the Insane Department of the Philadelphia City Hospital. In conclusion, we Avould most earnestly and respectfully call your attention to the need there is for more provision for es- cape in case of fire. The Avomen's side of the building we conceive to be much better prepared than the men, in that it is provided Avith tAvo fire escapes; neA'ertheless, much of that Avhich Ave shall say in detail in regard to locks, etc., of the male wards, applies to the female department. We Avould also point out for your consideration that the ex- posed portions of the front fire escape of the women's building are only protected by a low railing, over Avhich, in case of a rush, persons Avould certainly be precipitated into the arena below. We are informed that already one death has been caused bv falling or jumping over this railing, and think that the slight expense of putting up stout Avire nettings to prevent further accident should be at once incurred. On the men's side the Avards, so far as concern escape from fire, are essentially the same on each of the three floors. In order to get to the fire escape from the large general sleeping rooms, it Avould be necessary to pass through four doors, each of them ahvays kept locked. Several of these doors are not sufficiently large to alloAV two large men to pass easily at a time, and three of them open into corridors, so that should an un- controllable rush be made tOAvards the point of escape, the whole mass of sixty panic stricken lunatics would jam against the first door, Avhich would have to be opened against them. If this door Avere opened through, the patients would then be joined by the inhabitants of the ward, or so many of the latter as could get out of their cells, ami at each successive 13 door the jamming and difficulty of passage Avould be increased by the continual augmentation of numbers. More than this, in the second Avard, 20 of the lunatics are locked up at night in as many cells, the heavy doors of which are further secured by stout iron latches that can only be opened from the outside.. As stated previously, there is but one night Avatchman for the Avhole building, and there is no means by which he, Avithout leaving the building, could raise a general alarm in case of his finding a fire, and when it is remembered that the process of liberation above described would have to be done upon three floors that are separated by locked doors, it is plain that the old man who acts as Avatchman during the night Avould have his hands full to awaken the nine attendants on these three floors, and these attendants would require to be remarkably cool headed to control the 260 lunatics, and unlock the 12 corridor doors and the 60 cell doors. We find that the locks require several keys, and are from long usage difficult to open, and require several minutes when there is no cause for a panic. We believe that in case of such a panic as ought to be expected if a fire occur, the attendants Avould be practically poAverless, and a large proportion of the inmates would be burned to death. There are in addition to the fire escapes, four interior stair cases in the building. One of these stair cases is boarded over and may be left out of consideration, the second is in the centre building, and would probably be found more serviceable in case of a fire than the fire escapes, because more easily gotten at. Only one locked door is betAveen it and the luna- tics in the large wards. That is a majority of all the patients. To wet at the third stair case, two habitually locked doors must be opened, the fourth stair case is very narrow, and is habitually kept locked at the bottom. The probabilities of the destruction of life in case of fire is further manifest, when it is remembered that upon the fourth floor are lodged between 20 and -50 paralytics, who could not 14 help themselves easily ; that the Avhole building is very com- bustible and not at all fire proof; that the single^^^iman would, like enough, be in the beginning paralysed ilffTeciding to choose whether to attempt to get out the people] or to put out the fire; that there is not a fire plug, a foot of hpse^or a fire extinguisher, in the whole building, and that in the xrpjW stories there is no certain supply of water. To sum up, in a very combustible building with 260 lunatics and 30 disabled paralytics on the fourth floor, controlled by 75 locks with vari- ous keys, besides numerous latches; there is but one night Avatchman, and he is said to be infirm, to discover the fire and alarm the people, and there is no means provided to raise a general alarm. There are only nine attendants to control the patients and open the doors, no apparatus to extinguish the fires, and no one to use such an apparatus unless it be the lunatics themselves and some untutored employees, who, Ave be- lieve, mainly sleep away from the Avards. We believe that a second fire escape might be very well erected in connection with the men's department, but it is per- haps not essential if certain precautions Avhich can be readily taken are now carried out. We Avould respectfully suggest the folloAving: That the number of Avatchmen be increased. That the employees be so distributed through the Avards as to be available in case of fire. That fire apparatus, both in the form of plugs and hose and fire extinguishers, be distributed throughout the building. That a bell be so placed that a Avatchman could, if necessary, raise the alarm Avithout leaving the floor on which the fire was discovered. That ncAV locks be placed upon all the corridor doors to be opened by the one key, so, that the latter should give access to either any ward, in either the male or the female department. That no patient should be locked in a cell at night, as these cells are provided Avith latches Avhich cannot be opened from 15 the inside, it must be a very rare lunatic who requires further securi*-'*N*N often as may be necessary, both patients, attendants, iyees be thoroughly drilled in the art of escaping building rapidly and quietly. We believe that such could be very readily made a source of amusement to the patients. S. WEIR MITCHELL, II. C. WOOD, CIIAS. K. MILLS. /r V Oroupation, Avhen admitted, of male patients in I January 2:1, JSS">. La borer................................12'.) Clerk.................................. 10 Weaver............................... 1' Baker.................................. ■> Carpenter............................. •"> C< k >] >e r.................................. 1 .Moulder............................... -1 Shoemaker........................... 'I Barber.............. .................. .'! Cigarmaker........................... •> Dyer................................... 3 Machinist............................. 3 Tailor.................................. .'! Bki.-ksmith .......................... 2 J5rii.lv maker.......................... 2 Bartender............................. 2 ('ul i; net maker........................ 2 Engineer.............................. "J Fanner............;__................. "J Fireman..........'.'■.'!.................. 2 (rardener.............................. 2 Hatter................................. 1 Hostler................................. ] Janitor................................ 1 Messenger............................ 1 Mill-hand...........'"' :.:........... 1 Newsl )o y....................,......... I Printer................................. J Piano tuner........................... 1 Pnddler................................ I ! 'h y sieia n............................. J Plasterer.............................. 1 Kagpieker........................... ! Skin dresser.......................... 1 Shoo fitter............................ i Soldier................................. 1 Storekeeper........................... J ,i> department. ' waicli... ,n deciding Stonemason............ or \Ci \-::\ Sbipjoiner...............\u>^^ ,,,. ;J Type i'nislier................. r,." ' U It) XT leanifi'er.......................:..X ' Tanner................................ T e a i.: i i (".-1•.............................. Upholsterer.......................... i Marble polisher..................... "J !Y<;dier................................ -J Sailor.................................. '2 Stone cutter.......................... 'J Ya rnisher........................,.... •_' I'u (eher................................ ! Broomiied;er (blind i...........__ ] Boilermaker.......................... 1 Hasket maker......................... 1 Bricklayer.......................... I Ciiticr.."............................... Confectioner......................... Coachman............................. Coml'inaker.......................... C'( ■;; i; >' >M 1 (,r.......................... Druggist.............................. Dentist................................. Foundry man......................... Fi lemakcr............................ Cilder................................. ] Huckster............................... j W11 eel v.TJght......................... ] Waiter................................. \ Wool grader......................... i W.< teli man........................... t Wood carver......................... 1 >>o occupation........................ 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