THE OOHDITIOH 
OF THE 
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A PAPER READ BEFORE THE 
New Hampshire Medical Society, 
At its Annual Convention held in Concord 
June 18 and 19, 1878. 
BY J. P. BANCROFT, M. D„ 
SUP’T OF THE N. It. ASYLUM FOR THE INSANE. 
CONCORD : 
PRINTED BY THE REPUBLICAN PRESS ASSOCIATION. 
1878. THE COHDITIOH 
OF THE 
PAUPER INSANE OF NEW HAMPSHIRE: 
A PAPER READ BEFORE THE 
New Hampshire Medical Society, 
At its Annual Convention held in Concord 
June 18 and 19, 1878. 
BY J. P. BANCROFT, M. D., 
SUP’T OF THE N. H. ASYLUM FOR THE INSANE. 
PRINTED BY THE REPUBLICAN PRESS ASSOCIATION. 
1878. 
CONCORD: THE PAUPER INSANE OF NEW HAMP- 
SHIRE. 
At a former meeting of this society, I had the honor of read- 
ing a short paper upon insanity. In that I undertook to show 
that, in its varying forms of manifestation, in|anity is sympto- 
matic of bodily disease, and always dependent upon some form 
of physical disturbance. It was stated that, if dur means of in- 
vestigation were sufficiently delicate, we should find anatomi- 
cal lesion in the nerve structure or blood vessels, underlying and 
producing all the various aberrations of the mind. In g. word, 
it was argued that we know no such thing as disease of mind 
in the abstract, but that all disorders of mind are the result of 
disorder of its physical organ, or some of its parts. The legiti- 
mate inference from this position was, that insanity, which, un- 
til a recent date, has been a foreign subject virtually, is brought 
within the domain of medicine; that for study and practice it 
is a branch of medical science, and should have a place in every 
curriculum of medical study. Every year finds this claim i-ec- 
ognized more and more by our profession in every part of the 
world. If this be so, the diseases of the mind should not only 
be classed among medical studies, but should attract the inter- 
est and sympathy of the medical profession in a practical way. 
In respect to all other diseases, our profession, with the greatest 
propriety, assumes to instruct the public as to its protection 
and welfare ; and has been recognized as the natural custodian 4 
of the public weal in questions of health and disease. It is not 
assuming too much to say, it has been ever prominent in sym- 
pathy for those suffering from disease, and foremost in devising 
and executing measures for prevention and relief. Most of the 
great sanitary instrumentalities for the prevention of disease 
owe their origin directly to medical men. 
The history of the hospitals of the world, which have borne 
so conspicuous a part in the removal of curable diseases, and in 
the mitigation of the evils of those incurable, would show that 
most of them originated in the minds and hearts of physicians. 
The whole time allotted to this paper might be taken up with 
facts to prove this, if it were the object; but it is not. It is suffi- 
cient now to say, that history and public consent yield to our 
self-sacrificing profession the province of especially watching 
over the interests of sufferers from disease, of devising the best 
means of relief, and of leading the general public in the adop- 
tion of such means. 
If this is accepted as correct, I need no apology for asking 
the attention of this body, for a short time, to a class of those 
in our midst suffering from disease of the most dire form, who 
are entitled to the sympathy and interposition of the medical 
profession. I refer to the pauper insane of the state of New 
Hampshire. The claim of this class of persons for special sym- 
pathy and interposition from the medical profession, over and 
above that of other dependent classes, arises from the fact that 
they are not only dependent, but are also the victims of disease. 
Indeed, more frequently than otherwise, disease precedes and 
is the cause of the dependence itself. The calamity following 
disease is measured by the importance, in the economy, of the 
organ affected and the function interrupted or perverted. The 
loss of a general is greater than the loss of a private. In these 
cases disease has fallen upon those powers which nature has 
made the prime custodians of the individual welfare, and hence 
the dependence is more sweeping and complete. Other classes 
of the destitute are still in possession of those powers which 
serve the instinct of self-preservation, and may, at their option, 
watch for protection, and bring within their reach many com- 
pensations. But this mitigation is not spared to the insane. In 
the direction of self-care and provision, disease has crippled 5 
them and left them prostrate. It is this fact which creates for 
them this added claim to sympathy and protection, beyond that 
called for by the dependent whose mental faculties are intact,— 
a claim for special compensation for suspended or lost faculties. 
This claim has long been recognized in civilized communi- 
ties, and earliest and most distinctly in the foremost in progress. 
Nearly half a century ago the foremost leaders of social prog- 
ress declared the insane entitled to the guardianship and pro- 
tection of the state. The doctrine has generally been accepted 
and reduced to practice. In nearly every state in the Union, 
legislation has proceeded upon the assumption that the depend- 
ent insane, owing to the fact of mental disease, should be distin- 
guished from ordinary paupers, and made the objects of special 
surroundings and care, adapted to the peculiar necessities 
springing from the loss of voluntary self-control by reason of 
disease. In no state except our own, so far as I am informed, 
is the insane pauper left to take his chance for protection and 
care with the ordinary pauper, the tramp, the vagabond, and 
the heterogeneous crowd which makeup the average almshouse 
in these times. In the few cases within my knowledge, where 
insane paupers are provided for in connection with ordinary 
almshouses, these are made exceptional, subjected to state 
rules, and placed under state supervision. There are a few in- 
stances of this kind in the states of New York and Pennsylva- 
nia, but they are treated as temporary receptacles only, to be 
superseded on the completion of special institutions sufficient 
for the accommodation of all the insane ; and in no sense is it 
a part of the policy of those states, both of which are now, as 
rapidly as practicable, erecting asylums under state direction, 
for all their insane. Massachusetts has already accomplished 
the same thing. England, and the countries of the Continent, 
have all adopted the same principle, and long since abandoned 
attempts to combine the almshouse with the receptacle for the 
insane. The principle, to provide wholly separate institutions 
for the care of the insane and the ordinary pauper, is the out- 
growth of Christian civilization. It is only another manifesta- 
tion of the same spirit which contributes from the public treas- 
ury for the blind, the deaf and dumb, and the feeble-minded, to 
procure such special surroundings as will best compensate for 6 
their defective senses and powers. When the classes are com- 
pared, as objects of public beneficence, those who have only 
been deprived of a single sense can hardly be held to have a 
higher claim to public charity than those in whom disease has 
invaded that faculty which nature has constituted the supreme 
director of all others—the reason. The loss or absence of a 
single sense is a calamity calling for sympathy and help ; but 
this, without loss of reason, leaves much capacity for self-help 
and enjoyment in the use of the remaining faculties. But dis- 
ease which drives reason from its seat not only deprives the 
individual powers of their natural director, but introduces 
new and disturbing forces impelling to hurtful and dangerous 
acts, sends devastation through such human lives, and cuts 
the anchorage for personal peace, safety, and enjoyment. 
Those of the insane, who to a considerable extent have lost 
the power of self-regulation, and thus have become trouble- 
some or dangerous to those about them, are on this account 
made dependent on their surroundings, not only for one class 
of comforts, but for all the reliefs granted to their sad lives. 
Either the public safety or their own calls for restriction of their 
liberty, and makes them dependent on an option outside their 
own. It is this special disability which entitles this class of 
persons, when paupers, to provisions and attentions not re- 
quired by those in possession of their mental powers, and 
hence able to watch for their own safety and comfort. As this 
general principle lies at the foundation of suggestions to be 
made further on, it should be expanded a little more in detail. 
Dependence for subsistence does not deprive the ordinary 
pauper of a large share of the most enjoyable things in life. 
To him, the light, the air, freedom of exercise and labor, a good 
degree of social cheer, and the choice of associates, are open 
and free. His physical wants are supplied ; and, within the 
limits of order and propriety, he is free to consult taste and in- 
clination in the choice of enjoyments. Not so with his fellow- 
pauper who is insane. He stands at an immense disadvan- 
tage. Disease comes in and deprives him of the faculty of 
living safely under such conditions. The bitterness of his mis- 
fortune is in the fact, that, while disease deprives him of the 
self-control required to enjoy these common blessings safely, 7 
without special limitations, it does not destroy the capacity for 
their enjoyment; and hence it makes him a special sufferer, 
and to the extent, it would seem, to entitle him to extraordi- 
nary sympathy and care. This fact is brought to notice on 
account of the opinion so often expressed, that after insanity 
has become confirmed, and hope of recovery reduced to a low 
point, the obligation upon the public to furnish special care 
and treatment is discharged, and that the public can be right- 
fully relieved by allowing such insane to take the common 
chance. This theory, when practically carried out, ends in 
the virtual imprisonment of a large fraction of the chronic 
insane. A better knowledge of facts would lead to a more 
liberal and humane theory of management. The condition of 
a large majority of this class of the insane is such that they 
cannot, under the guidance of their own volition, go forth 
safely to enjoy air, light, exercise, and the sight of mankind ; 
and at the same time all these blessed stimuli are fraught with 
as much pleasure to their minds and as much health-giving 
influence to their bodies as they are to us, their more fortunate 
fellow-men ; and all that is necessary to make these pleasures 
available for them is the presence of those organized methods 
of guidance which experience has proved to be perfectly prac- 
ticable. But these surroundings cannot be realized at the ordi- 
nary pauper rates of living: and here we conflict with the the- 
ory of those who are satisfied to make no exception in favor of 
the pauper insane in the adjustment of public charities. If any 
one should doubt the correctness of the statement just made, in 
regard to the capacity of the insane to enjoy privileges which 
they are incompetent to control, and thus invalidate their claim 
to exceptional treatment, I may say that it is practically demon- 
strated in thousands of cases every day all over the land. And 
now nothing is better settled in medical science, than that even 
the acute and excited maniac can safely enjoy large liberty and 
latitude of privilege, when influences are properly adjusted for 
that end. But there is another class to be considered, furnish- 
ing other considerations in favor of my position. I refer to 
those in the advanced stages of mental disease—the demented 
and the imbecile. These ever incline, when left to themselves, 
to lapse into lower and lower states, to form lower and lower 8 
habits and tendencies. Hence they need the constant presence 
of attendants, the constant support and stimulus of the healthy 
mind. Nothing in physiology has been better proved by ob- 
servation, than the fact that when disease has impaired the 
power of the intellect and will to guide and regulate the move- 
ments of a human life, the tendency of that life is to drop down 
into the sphere of reflex action, the excitants to that action be- 
ing the animal instincts in the absence of those which in health 
come from the higher faculties. Here the misfortune of insan- 
ity appears in its strongest light. The person whose powers 
were once quick to obey the commands of a proud intellect is 
now groping in a lower sphere, and obeying simply animal in- 
stincts, without plan or purpose. I will not offend the intelli- 
gence or the moral sense of the members of this society by 
offering proof that the person whom brain disease has deprived 
of that force which is set to rule and guide all other forces in 
the system, and which makes the broad distinction between 
human and brute nature, is entitled to special sympathy and 
special instrumentalities for relief, if such exist. It has been 
fully settled that effectual help can be rendered ; that is to say, 
care and skill cait so apply the stimuli of healthy mind to 
these broken natures as to put in motion the same automatic 
forces for a higher order of manifestations. 
It is a fact of daily observation, that persons whose intellect 
and will-power are so abolished by brain disease, that if left 
alone their manifestations would be nothing above the brute, 
are passing the rounds of daily life with decency and a degree 
of propriety of manner of which society need not be ashamed ; 
and this is all effected by supplying the place of the diseased 
mind and will by the healthy mind and will of another as an 
excitor in the automatic processes of the patient; and the mo- 
tor acts are thus transferred from the lower to the higher plane 
of life. The attendant in psychological medicine is to the fal- 
tering patient what the crutch is in surgery; and the mental 
product is as much better in the one case as is the gait in the 
other. I could show you, to-day, in any well regulated institu- 
tion for the insane, wrecks of human beings neatly clad, in the 
enjoyment of much latitude of out- and in-door life, using their 
various powers with propriety and decency, conforming, appar- 9 
ently to the general demands of society, and so carrying them 
selves that a superficial observer would think them quite self- 
sustaining, who, if their exterior helps and attentions, which 
take the place of their own lost faculties and give direction to 
their movements and habits, were to be withdrawn, would 
lapse at once into habits and conditions differing little from 
those of the lower orders of animal life, and become simply 
objects of disgust and pity. The reason of this wide difference 
of results, under the different circumstances, will be at once 
apparent to medical men. 
When it is considered how large a portion of the actions of 
a human life, in the normal state, is simply automatic, excited 
by the remote influence of the reason and will; and when it is 
borne in mind that when once thus set in motion it is the na- 
ture of this reflex action to continue to do the same thing, with 
ever increasing facility, acquiring the momentum of habit,— 
when such facts are fairly estimated, it is not difficult, in case 
of loss of the self-directing will-power, to appreciate the value 
of any foreign agency which, at this unpropitious moment, may 
assume the place and function of the lost powers, and furnish 
the stimuli capable of holding the motor acts and habits up to 
the highest practicable place in the scale of human life.- Mod- 
ern experience has demonstrated that the best known agency 
for this work is found in an institution organized and operated 
for the specific and only purpose of treating and influencing 
the insane. 
I have dwelt somewhat on this general topic, as it furnishes 
the only true philosophy to guide us in any practical efforts at 
ameliorating the condition of the pauper insane in our state, 
as well as a good reason why the subject is brought before the 
members of this society. What I have desired to say thus far 
is this: that the insane portion of our pauper population is 
emphatically a distinct and separate class of sufferers ; that, 
since disease has deprived them of the use of their higher and 
self-protecting faculties, they have extraordinary claims on the 
public,—claims for means to mitigate calamities which ordi- 
nary beneficiaries of public charity have not suffered ; and 
that for these reasons they should be made the objects of that 
special provision and cai'e without which their peculiar dis- 10 
abilities cannot be relieved. This distinction is now univer- 
sally admitted and acted upon in the dispensation of public 
charity throughout the civilized world. Fifty years ago the 
pauper insane were supported in alms-houses; and because it 
was not safe and practicable to give the latitude afforded to 
sane inmates, they were found in secluded, dark, and foul 
places, often, for the safety of others, chained, and deprived of 
all liberty and the enjoyment of all society. Their condition 
attracted the attention and enlisted the sympathies of the philan- 
thropic everywhere ; and inquiry soon resulted in the general 
acceptance of the principle just announced, that these sufferers 
are entitled to separate care, and that it is the duty of the state, 
by proper legislation, to make them directly its wards. In every 
part of Great Britain the care of the insane is assigned to insti- 
tutions constructed to meet their peculiar wants, and placed 
under direct governmental supervision. There is no such thing 
there as authority to dispose of the insane pauper by any power 
not directly delegated by the government and answerable to it. 
Institutions organized expressly for the insane, and for no other 
object, are provided in sufficient numbers for all the insane 
who require special care, and these are committed and detained 
only under the established forms of law ; and no pauper officer 
can place an insane person in any general pauper or criminal 
receptacle. The same is true in Germany and other countries 
on the Continent. 
Most of the United States, also, have proceeded in their leg- 
islation on the same principle, and as rapidly as practicable 
provided institutions to keep pace with the increase of the dis- 
ease. In some instances the increase of the numbers of the in- 
sane has been greater than that of accommodations for them ; 
but still the principle has been fully recognized by legislation. 
Thus, the state of New York has taxed itself millions within 
the last few years to provide institutions for the insane ; and 
now these institutions, so far as completed, are filled with 
persons many of whom had previously been kept in town or 
county almshouses. The states of Pennsylvania and New Jer- 
sey have been for many years, and still are, doing the same 
thing. In Pennsylvania there is now in process of erection an 
asylum sufficient for the accommodation of 800 pauper insane 11 
persons, who have heretofore been in a department of an im- 
mense almshouse in Philadelphia. Every effort to do justice to 
these people in connection with the general establishment has 
failed, and an enlightened public will no longer tolerate the at- 
tempt. That state pursues a settled policy to provide asylums 
for all its insane, and hold them under direct state supervision. 
The state of Massachusetts, as you know, pursues the same pol- 
icy, although much less economically, in some instances, than 
many of its citizens deemed wise or necessary. Some years 
ago it was proposed, in that state, to provide for the most quiet 
portion of the chronic pauper insane, as a department of a state 
almshouse, and the experiment was inaugurated at Tewksbury. 
This experiment was unsatisfactory to the public, and has been 
virtually abandoned, by gradually transferring the institution 
into a state asylum, with a medical head and other special feat- 
ures found in their regular asylums. 
I need not take more of your time in adducing historical 
facts to prove that it is the accepted theory of Christendom 
that insanity entitles its victim to special care, and that that care 
should be provided in institutions devoted to that alone, and in 
their construction and organization adapted to their peculiar 
work, and under direct state supervision. 
Having now shown what is the almost universal verdict of 
public opinion on this subject, and what are the grounds of that 
opinion, I come to its practical application, as related to the 
pauper insane of New Hampshire. How do we stand as com- 
pared with the rest of the world ? 
In the first place, it is well to consider the legal relations of 
the insane in this state, and see to what extent they are placed 
under the protection of the law, and to what extent their dis- 
abilities are legally provided for. This state has from time to 
time shown its sympathy with the spirit of the age, and its so- 
licitude for its unfortunates, by enacting laws for their better 
protection and care. These laws guard jealously three points: 
first, against improperly taking the personal liberty of the in- 
sane ; second, for the good care and treatment of those whose 
liberty has been taken, according to the forms of law, while 
they are in custody ; and, third, against the continued detention 
of these after the cause of commitment ceases. The first of 12 
these objects is secured by the following statute, namely, “ No 
person shall be committed to the asylum for the insane without 
the certificate of two reputable physicians that such person is 
insane, given after a personal examination made within one 
week of the committal; and such certificate shall be accom- 
panied by a certificate from a judge of the supreme court or 
court of probate, or mayor, or chairman of the selectmen, testi- 
fying to the genuineness of the signatures and the respectability 
of the signers.” The second object is accomplished by the stat- 
ute requiring some one of the board of trustees to visit the asy- 
lum, without previous notice, at least twice in each month, 
and to give suitable opportunity to every patient who may de- 
sire it, to make to him, in private, any statement he may wish 
to make ; also to examine into any facts relating to the welfare 
of the inmates, and order a correction of any practice which 
may not be found judicious. To guard still more carefully 
the welfare of the insane while in custody, the law makes the 
governor and his council, the president of the senate, and the 
speaker of the lower house, a standing committee, with unlim- 
ited authority to exercise such supervision as their judgment 
may deem necessary to secure the ends of the law. To make 
good the third point, and prevent the unnecessary continuance 
of confinement, the law provides that any three trustees may 
discharge any inmate if they think it proper, and requires them 
to do so if they find the cause of commitment has ceased, or a 
further residence is not necessary. 
Thus it appears that our laws carefully close the doors 
against improper committals; provide for vigilant observation 
of those actually in custody ; and, lastly, keep the doors open 
for the earliest practicable discharge. Now, this is admirable, 
and all that humanity could ask. It is as good and carefully 
guarded a law as exists, and I have no doubt it is faithfully 
complied with, for, in my long observation, I have never seen 
more than a single instance in which commitment was sought 
for any other motive than that contemplated in the law, and in 
that instance the object was to shield from justice. Now it 
remains to inquire whether these admirable laws accomplish 
all they seem to do on the surface. It will be observed that 
all these statutes apply in terms to the “ New Hampshire Asy- 13 
lum for the Insane,” and no other institution. This would be 
all-sufficient, and secure its humane intention, if there were no 
other institution in the state liable to have custody of the in- 
sane. So far is this from being true, that there are probabty to- 
day more insane persons in the custody of other institutions in 
the state than there are in the New Hampshire asylum. 
That institution has in its charge a large majority of private 
boarders, and these have the double protection of the laws re- 
ferred to, and the watchful interest of relatives and friends. A 
small number, also, of pauper insane are there, and these, too, 
get the full protection of the statutes ; but beyond these the 
laws are a dead letter. More than three fourths of the pauper 
insane of the state are disposed of without the slightest refer- 
ence to the statutes supposed to exist for the security and ben- 
efit of the insane as a class. This fact would probably surprise 
many intelligent citizens, and perhaps even legislators, who, in 
enacting the statutes already referred to, supposed they were 
doing it for the protection of the whole insane population of 
the state. As briefly as possible, I will explain the situation. 
As the laws of settlement have from time to time been mod- 
ified, reducing the number of town settlements, the care of the 
larger pauper population has fallen to county authorities. The 
insane paupers as well as other classes are subject to the same 
authorities. As no law has been enacted making any excep- 
tion in favor of the pauper who is insane, the county commis- 
sioners have full power to dispose of them as they see fit; and 
these officers are wholly exempt from the conditions supposed 
to be and made necessary for all other classes of citizens in 
dealing with the insane. There is only a single exception to this 
statement. If the county commissioners should propose to 
place an insane pauper in the New Hampshire asylum, they 
would then be obliged to comply with the requisitions of the 
statutes above named. Unless the courts should direct as to 
the disposal of any particular insane pauper, the county com- 
missioners are as independent of any restrictions as though no 
law existed on the subject. As large county establishments 
have sprung up, it has been assumed to be in the interest of 
economy to support the insane as well as other paupers in them ; 
and as no law opposed, this became the general rule. In this 14 
attempt it was soon learned, as before suggested, that the lia- 
bilities to danger and other evils were so great as to render it 
wholly impracticable to domicile the insane with the general 
pauper families. This fact led to the erection of separate build- 
ings, in connection with most of the county almshouses, for 
the more safe keeping of the insane portion of the inmates. In 
this way there have grown up several asylums in the state aside 
from the state institution. Owing to the incidental manner in 
which these institutions have sprung up, no legislation has been 
had in regal'd to them, with a view to make the existing laws 
applicable to them. The result is, that the insane, in any num- 
bers, if they chance to be paupers, can be placed in custody in 
these asylums, without reference to their conditions of mind, 
health, or necessities, at the mere option of county commis- 
sioners. Institutions operating on these conditions have in 
charge not much under three hundred persons at the present 
time. The number, however, is not material, for it is not my 
object to criticise these institutions, or at present to discuss the 
merits of their construction or management, but simply to re- 
fer to them in a general way, so far as they illustrate the main 
subject in hand, and show the present exposed condition of the 
pauper insane. I make no quarrels with them: it is the whole 
plan that is objectionable and faulty, and it needs no abuses to 
show it so. The most faithful administration under it cannot 
succeed. The great wrong, then, is this,—that while the public 
rests secure in the assurance that the state has thrown around 
the insane the shield of law, it appears that the dependent por- 
tion of them is entirely cut off from its benefits, and subject to 
the option of political officers responsible to no tribunal for 
their proceedings. Constantly persons are being placed in 
these independent asylums without medical examination, or a 
vestige of any legal proceeding. The only things requisite for 
admission are, that the candidate should be dependent for sup- 
port, and the consent of the county commissioners. These 
conditions existing, the alleged insane person may remain in 
custody indefinitely ; and no legal authority is charged with 
the duty of inquiry whether such residence be well or ill for 
the subject of such confinement. I have just stated that one of 
the requisites for admission to these asylums is poverty; but 15 
this is not strictly true. So far as any law prevents, a candi- 
date for admission need not be a pauper: any citizen or person 
can be made an inmate of one of these asylums on the simple 
agreement, upon terms, between a party desiring a proposed 
committal, and the officers controlling such asylum. Here let 
it be understood, I am not saying this possibility has yet been 
abused ; that any person has been in office who would misuse 
such a power. It is the legal possibility of such wrong that is 
open to objection. Unless all the laws heretofore enacted for 
the protection and benefit of the insane are a farce, the absence 
of any law regulating the relations of the insane to these insti- 
tutions is a fatal oversight, and one which opens wide the door 
to all the evils supposed to be provided against in the statutes 
already enacted. Under the existing state of the laws, there is 
no difficulty in the way of perverting these institutions to the 
vilest and most mercenary purposes. If you or I had a heart 
for such an enterprise (and history shows men capable of it), 
and had, also, a relative with large wealth which we might 
wish to manipulate ; if that relative were of defective mind, 
and our convenience would be promoted by having this person 
out of the way,—‘-there is no legal barrier in the way of quietly 
using one of these institutions to further our ends, providing 
terms could be adjusted between us and the authorities in charge. 
I will not take your time to multiply possible cases which 
might arise under this state of things. It is enough that the 
facilities exist for the commission of such wrong. If no official 
now in power could be made a party to such transactions, time 
may bring such persons to the surface. All history shows that 
it is not prudent or wise to throw temptations in the way of 
the weak points in human nature ; and I know of no special 
gift of virtue, inherent in the constitution of any class of polit- 
ical office-holders, exempting them from the common liability 
to wrong-doing, and thus relieving them of the need of super- 
vision of their acts, and of accountability to a higher tribunal 
in the management of delicate social and personal interests. 
But the laws are defective, not only in leaving the doors of 
these asylums open for the indiscriminate reception of inmates 
alleged to be insane, without any responsible medical voucher 
for the fact, or the fitness of the person, whether pauper or 16 
independent, for confinement; but they are equally faulty in not 
providing any standard of care of such after they are in cus- 
tody. Civilization has pronounced against the practice of leav- 
ing institutions, having in charge those rendered helpless by dis- 
ease, to do duty at their option, without the supervision of law. 
It has become the universally and cheerfully accepted doctrine, 
that institutions for the custody of the insane shall be under the 
direct legal supervision of the state ; and all history shows the 
necessity of this. But our county asylums in this state have no 
shadow of such supervision. There is no vestige of law in ex- 
istence requiring any inspection by any officer of the state gov- 
ernment of one of these institutions. The state authority has no 
instituted channel of information as to their condition, the meth- 
ods of care, or the treatment adopted in them. What may or may 
not be done, it is entirely at the option of the county commis- 
sioners to communicate or not. The good or bad condition 
and treatment are suspended on the slender accident of the fit- 
ness or unfitness of the ever-changing officials, subject to all 
the uncertainties incident to the fluctuations of political af- 
fairs. It is simply repugnant to the common judgment and 
sentiment that such numbers of unfortunate persons, helpless 
for their own comfort, should be thus laid aside from the pub- 
lic interest and sympathy ; and the facts only need to be stated 
to settle the verdict of the public on such a state of things. 
Taking the most guileless view possible of human nature, the 
state of our laws on this subject is a fearful strain upon the vir- 
tue of those in charge of these institutions. The entire absence 
of state supervision throws a heavy responsibility upon them, 
and one of which many of them, at least, desire to be relieved. 
For a quarter of a century the public mind has been highly 
sensitive in regard to the insane in asylums, and they have of- 
ten been made the subject of legislation. Some silly and ab- 
surd acts have been passed in a few states, where ignorance and 
passion were for the time in the ascendency ; but, as a whole, 
sensible and wholesome laws have been enacted in most states, 
which thoroughly protect the interests of the insane ; and the 
liability to the occurrence of any wrong is exceedingly small. 
This is true in our own state, so far as the state institution is 
concerned, but no further. It would seem a matter of surprise, 17 
that in the midst of all this interest, while the press has been 
teeming with its discussion, and sympathy for the insane has 
been supposed to be at fever heat, several asylums should 
have sprung up in our very midst, and have taken into custody 
an actual majority of the insane of the state, and quietly placed 
them beyond the operation of existing laws. And yet this 
is unvarnished fact;—at least six such asylums exist, and re- 
ceive the insane for care and treatment. They are received 
without medical examination or certificate of disease. No per- 
son is required by law to visit these insane patients, to learn 
whether they are in cleanly rooms, have proper food, medical 
treatment, light, pure air, and warmth ; to learn whether requi- 
site intelligence, skill, and kindness are employed in their 
daily personal care ; and to report to state authority the facts 
in any form. As before designated, they are independent, and 
are left to dispose of all the psychological and hygienic ques- 
tions involved, without any of the aids deemed vitally neces- 
sary in the organization of state institutions for the same pur- 
poses. 
It does not invalidate the objections I am urging, to say that 
these asylums receive only chronic cases, and that therefore a 
full equipment of these appliances is not necessary. If it were 
true that their operations were limited to chronic cases, which 
it is not, and cannot be, still that would not relieve the diffi- 
culty. To say the least, two thirds of the insane, in a major- 
ity of the asylums of the country at any one time, are chronic ; 
and yet the highest medical authorities, and nearly all state 
legislatures, pronounce it no less necessary to make elaborate 
provision to secure the best hygienic conditions in all the par- 
ticulars just named, and skilled service to render them practi- 
cally available. Moreover, it is known to all who are informed 
on the subject, that the fact of chronicity does not remove the 
case from the necessity of many of the special appliances re- 
quired for the acute. The chronic insane are often subject to 
such variations of condition as to transfer them practically into 
the acute or active class ; and at these times their welfare re- 
quires the same surroundings and the same skilled management 
demanded for the recent and acute ; and without these no justice 
can be done to their morbid liabilities. 18 
It is in view of this fact that institutions, organized under 
state authority for chronic cases exclusively, are placed under 
the care of medical men, and all other departments made sub- 
ordinate to that. It is because the main woi'k is provision for 
disease, rather than the discharge of political duty. For the 
same reason, the state makes all departments answerable to it- 
self, and sends servants of its own selection to inspect, regulate, 
and report results. The principle underlying all this is, that 
in the care of these insane, the state recognizes disease as the 
prime feature, entailing special weakness and dependence, and 
thus creating a valid claim to public sympathy and protection. 
Hence, it makes them the subjects of special legislation, instead 
of suspending their comfort and welfare on the intelligence and 
skill of mere political servants, who, to say nothing of qualifica- 
tions, can spare only a small fragment of their time and atten- 
tion for this distasteful part of their duties. The state of New 
York has established an asylum for the chronic exclusively, 
and still it follows the same principle of organization and care 
required in those for the recent and acute. The state of Massa- 
chusetts, some years ago, in the supposed interest of economy, 
commenced a receptacle for chronic quiet cases in connection 
with the Tewksbury almshouse, without a medical head, or the 
special appliances deemed necessary for recent and acute cases. 
The inmates were placed under the care of the general man- 
ager of the establishment. Experience proved a better teacher 
than theory, and soon steps were taken gradually to recede 
from the plan, by adopting the methods and usages of regular 
hospitals. Every year has witnessed more or less changes in 
that direction, and now it is placed under the direction of a 
competent resident physician ; and the theory that the insane, 
though chronic, can properly be made a department in a gen- 
eral pauper establishment, and under the business superintend- 
ent, is virtually abandoned. 
I have said incidentally, that so far as the law is concerned, 
these asylums in our state are not limited in their operations to 
chronic cases, or even to paupers, but are open to recent and 
acute, and private patients as well. To what extent they are 
so used I have taken no pains to learn, since it is not the ob- 
ject of this paper to arraign these institutions or their man- agement, but to discuss the general plan of their organization 
as bearing upon the interests of the pauper insane ; but I will 
digress so far as to remark, in this connection, that private cases 
have been admitted without medical examination, and on no 
other authority than an agreement on terms between the com- 
mitting party and the overseer. The simple fact is enough for 
our purpose, namely, to show that these institutions are open to 
misuse. Therefore the insane are not properly protected ; for 
if there is any reason in the nature of insanity for legislative 
interference in its management in any case, there would seem 
equally valid reasons foi it in all cases, unless it be true that 
there is some special guaranty of such preponderance of intel- 
ligence and rectitude, when you enter the domain of county 
institutions, as to supersede the necessity of protective legisla- 
tion. On this question of fact I offer no opinion. It has been 
the popular belief that instances have occurred, however rarely, 
in which persons have been admitted into institutions for the 
insane, and detained, who were not proper subjects for such 
treatment. If such facts are liable to occur, then there is 
good foundation for the general sentiment that all such institu- 
tions should have their authority directly from and be answer- 
able directly to the state. To this there should be no excep- 
tions. It is a salutary principle, not to tempt human nature in 
the direction of its weak points, or to overburden with trust 
the sternest virtue. 
I will now return to the distinction between recent and chronic 
cases, already referred to. I know it is the professed rule 
with the county asylums to receive the chronic only; but the 
line between the acute and chronic, the curable and incurable, 
is a very vague and uncertain one, and it will seriously task 
the skill of the most learned and experienced in mental dis- 
eases to trace it in a large number of cases. The exact time 
when curative efforts may be abandoned, without too much 
risk, it is difficult to find. And even if it be found, it may still 
be a grave social question at what point the state can afford to 
drop alleviating and mitigating influences, and leave its fallen 
ones in the march to a simply vegetative existence. In point 
of real economy, and as a pure financial question, the state 
gains nothing by a too early abandonment of effort to save the 20 
victims of mental disease, for this is the point where figures tell 
both ways. One added to the hopeless list is one subtracted 
from the producing list. The principle in the operation of 
these county asylums being simply cheapening the expense of 
support, the tendency of officers is always to press the patient 
forward from the acute into the chronic and incurable stage 
as rapidly as possible; or at least so to construe them, espe- 
cially if they belong to the quiet class, that they may pass at 
the earliest possible time from the more into the less expensive 
division. The pressure of this motive is so great as often to re- 
duce the period of curative effort to a very limited time, much, 
I think, to the damage of the patient. This is the unavoidable 
result of the situation. The whip of economy is ever hanging 
over the commissioners, reminding them of the strict account 
soon to be rendered to the exacting public ; and the struggle 
between private moral conviction on the one hand, and the sup- 
posed demand of public duty on the other, is not to be envied. 
I have known some, at least, in whom this struggle has been 
the bitterest ingredient in the official cup. If it be objected to 
these views that they are too liberal for application simply to 
paupers, and that the public will not tolerate more liberal 
outlay for them, I may say, that while I do not think the objec- 
tion valid as relating to any class of paupers, yet there would 
be more force to it if none but the tramp, the criminal, and the 
refuse of foreign countries were among them ; but it is not so. 
Many now paupers were but yesterday producing, tax-paying 
citizens. The insanity in some is the last weight which turned 
the scale to the side of dependence ; and that disease itself was 
the product of the long, hard struggle to maintain independence, 
against sickness and misfortunes not self-inflicted. I know to- 
day an insane professional brother, intelligent, honest, honor- 
able, generous, respectable, the fruits of whose arduous labors 
have ever been freely used for public welfare ; and now that 
disease has invaded his brain, and borne his mind from its an- 
chorage, he is dependent on the public for all that he is to have 
for the remnant of his sad life. This is no solitary case. Does 
the state owe such as these no debt but that of simple subsist- 
ence of the cheapest kind, stripped of all amenities ? When in 
health we give up the fruits of our industry, to support public 21 
order; of our contributions, to sustain public institutions whose 
benefits are to run on into the future ; our charities, to lessen 
the sufferings of the unfortunate, and thus lighten public bur- 
dens,—does the public incur no obligation in return when the 
day of our calamity comes ? The voice of Christian civiliza- 
tion answers the question ; our individual hearts all answer it. 
If it were put directly to them to say, the overwhelming majori- 
ty would give an emphatic affirmative to the question of afford- 
ing from the public treasury special offsets, mitigations, and 
reliefs for the victims of mental disease. The public generally 
respond heartily to measures for the relief of those suffering 
minor disabilities,—the blind, the deaf and dumb, the maimed : 
will they not much more respond for the relief of sufferers in that 
organ the integrity of which is essential to the use of all others? 
When the question can come up as a simple one, complicated 
with the success of no scheme or party, the popular voice will 
be cordially given for the furnishing of such surroundings for 
the dependent insane as will afford the best chance of relief to 
the curable, and a wise and reasonable share of amenities to 
those who may have no hope of restoration. I am no advocate 
of palatial residences and expensive furnishings for those in be- 
half of whom I speak. The essential reliefs, which it is im- 
possible to realize on the system of county asylums, are ■prac- 
ticable without extravagant expense, when the subject is ap- 
proached in the light of knowledge and experience, and with 
the single purpose to accomplish the greatest good in a modest 
and prudent way. 
This leads me to the last branch of the subject; and what re- 
mains to be said is in answer to the question, Is there a better 
way for the state to discharge its obligations to its unfortunate 
victims of disease of the mind, and one consistent with that de- 
gree of financial prudence which characterizes our state policy? 
I fully believe there is such a plan,—one which is entirely 
practicable, efficient for the end in view, and, in the long 
run, hardly more expensive than the present impracticable and 
exploded plan of county asylums. 
This is not the place to propose any plan in detail; but I must 
be content to suggest, in skeleton form, the leading features 
which are essential to any plan adequate to the wants of the 22 
case. In the first place, as has been already implied, it may be 
said, negatively, that it is a financial impossibility for the sev- 
eral counties to provide and operate small asylums which will 
satisfy the intelligence and moral convictions of the public ; for, 
no sooner will they attempt to erect suitable buildings, and 
throw around the insane privileges beyond the most simple sub- 
sistence, the expense will transcend the bounds prescribed, and 
thus defeat the only object of the whole attempt; for I take it 
no one seriously proposes our county asylums for any other 
reason than economy. Undertake in one of them to provide 
efficient ventilation, exercise in the open air, mental and physi- 
cal occupation, and social contact for the agitated and irrespon- 
sible, and failure is certain,—for success would entail heavier 
expense than the prescribed limit. Every attempt to make the 
small county asylum a success has so far failed. It was ex- 
haustively tried in New York, and condemned by public opin- 
ion ; and the Willard asylum, now with 1,200 chronic patients, 
was organized by that state for the very purpose of emptying 
the county asylums, and bringing their inmates under direct 
state care. On the county plan the whole cost allowed must 
be expended in mere subsistence, and no margin left for wants 
arising from disease. This is the reason why the agitated and 
untrusty in these small asylums must spend, as they do, most 
of their time in seclusion. Liberty would be dangerous without 
supervision, but supervised liberty cannot be afforded ; so the 
management is in a dilemma. What it would do, that it can- 
not; and what in truth it would not do,—namely, confine the 
restless inmate,—that it must, for lack of means to do more. 
The asylum with twenty-five patients will have as many classes 
represented as a larger one. There will be the aggressive and 
the timid, the exalted and the depressed, the frank and the 
treacherous,—and to attempt to meet their varying needs there 
must be variety of resources : the bed of Procrustes will not do. 
It is plain to common-sense that these peculiar wants cannot 
be economically met on so small a scale. It needs no argu- 
ment to make this plainer, more than it would to show that 
the house-wife, with her spinning-wheel and hand-loom, cannot 
compete with the cotton mill. 
The inference from all this is, that if the presumed 300 pau- 23 
per insane in the state could be provided for in one institution, 
a long step would be taken towards a union of efficiency with 
the desired economy ; but any attempt of the several counties 
to establish and operate a common institution, would be, for 
obvious reasons, impracticable. 
This leads to the first, and, in my estimation, the indispensa- 
ble initiatory step in the solution of the problem. The depend- 
ent insane, who by reason of this disease may need special 
surroundings and care, should first be made legally the wards 
of the state. I have already stated features in their condition 
entitling them to this protection in the day of their misfortune, 
aside from claim on the score of duty done for the state. It has 
been proved, too, by experience elsewhere, that a state can ac- 
complish vastly more with a given expenditure under its own 
single administration, than can be done on any plan of sub- 
division. It has also been made clear, I trust, that the interests 
involved, both to individuals and the public, are too sacred to 
be left absolutely to any authority not answerable to the state. 
These considerations are a solid basis for the measure pro- 
posed. This is the policy adopted now in nearly every state 
in the Union, and in the countries of Europe ; and it has been 
adopted after many experiments and the failure of all less com- 
prehensive plans. 
In this way this important public charity will be taken at 
once out of the catagory of politics, and placed on high human- 
itarian grounds. There is no reason in the nature of the case 
why the dispensation of this noble charity should be made a 
mere incident in the duties of a political officer without knowl- 
edge of its peculiar demands, as it now is. While the state 
makes a specialty of education, even agricultural; of the im- 
provement of delinquent youths ; and every other interest re- 
quiring special knowledge or skill,—why should it leave the care 
of its dependent insane, with all their exceptional and peculiar 
needs, as a minor charge in the hands of men whose principal 
duties are anything but a fitting for these? I have no doubt if 
the private feeling of our various county commissioners on this 
simple question could be obtained, it would be that provision 
for their insane is a difficult and unwelcome duty, one for which 
they have not proper appliances, for which they are not quali- 24 
tied, which they cannot discharge to their own satisfaction, and 
which they would most gladly surrender if they could. This, I 
know, has been the avowed sentiment of many of them after 
due experience, and an honest attempt to harmonize their sense 
of duty to the insane, as men, writh their official obligations to 
their constituents under the financial limits imposed on them. 
Suppose, then, the state should take into its direct care such 
pauper insane as demand exceptional surroundings, and many 
times medical treatment, and thus relieve the counties of this 
embarrassing part of their charge, much would be gained. 
They would at once be in the charge of the highest authority, 
and have a guaranty of humane and enlightened treatment 
equal to the pride and dignity of the state. This plan is not 
objectionable on the score of expense, for it commits the state 
to no particular grade or style of living for its beneficiaries. 
The field is all left open, from the most elaborate to the most 
simple and plain surroundings. 
The state would then doubtless do justice to its intelligence 
and its humanity, as well as to its economy. It would at once 
hold an immense advantage, in point of economy, over the 
present system, for it would make no attempt at provision on 
the plan of distribution into smaller or larger groups, but pro- 
vide for all its pauper insane in a single institution, which, in 
its plan of construction, should be fitted for its special work, 
and be charged with no other function. Although the number in 
the state is not sufficient for the highest degree of economy, 
simply considered, in building and operating, still it is a very 
favorable number for a happy average of economy and general 
efficiency for the best results. 
It is not the province of this paper to advance any opinion as 
to the exact degree of liberality with which the state should 
provide for its dependent insane ; and hence it only remains for 
me to point out some of the objects which should be secured, 
at all events, in any plan which might be adopted,—objects 
without which no plan can meet with final and permanent ap- 
proval. 
First, buildings must be constructed on such a plan as to 
give all classes the hygienic advantages demanded by the laws 
of life. These must include abundance of sunlight, means for 25 
free circulation of fresh air through every apartment, and facil- 
ities for graduating temperature to the degree of vitality and 
state of health of all classes. Space must be so divided and 
adjusted as to afford facilities for associated life, and classifica- 
tion according to the varying conditions resulting from tem- 
perament, habits of life, and results of disease. Reasons for 
these practical necessities have already been given. 
Second : any plan, to be successful, must embrace, as its lead- 
ing feature, the presence and guiding influence of attendants ; 
that is to say, the adjustment must. be such that healthy mind 
shall be brought in contact with mind diseased, and by its 
presence, its enlightened support, and its invigorating stimulus, 
suPply ie guiding force which disease has taken away. It has 
already been shown that this is the prime and necessary condi- 
tion of liberty of the insane, and that the alternative of supervised 
liberty is the doom of prolonged seclusion ; and this is a bane 
the world has, for half a century, been seeking a way to avoid. 
I hardly need repeat, by way of application, that, in our county 
system, the financial inability to establish intelligent supervi- 
sion sufficient for liberty is its fatally weak point, and marks the 
difference between an equipped asylum and an institution where 
the care of the insane is subordinate and incidental. The state 
will either adopt a system in which personal attendance for the 
chronic as well as recent stands at the head of measured, or it 
will lapse into the whole sad train of evils which Christian 
civilization long ago pronounced against. The public will 
not long be satisfied with the political plea, that, when the cura- 
tive period of insanity is passed, special supervision is not 
needed, for the result is, to doom the chronic victim of disease 
to a fate worse than we visit upon the criminal,—that of solitude. 
What has been said has already suggested the third condition 
which should enter into any institution for the care of our pau- 
per insane ; and this is the last I shall name. Under the author- 
ity of the state, it should be placed in the immediate charge of 
a resident medical man. If I were addressing a committee of 
legislators, it might be necessary to set forth specifically the 
reasons for this jjosition; but to medical men, who are fa- 
miliar with the forms of cerebral disease, of which insanity is 
the manifold result, with the subtle sympathies existing between 26 
the great nerve centres and all bodily organs and functions, and 
with the grave disturbances constantly liable to arise therefrom, 
seriously affecting the comfort and welfare of the patient,—to 
you I need only to name this requisite to have it appreciated 
and endorsed. You will see at a glance, that questions of 
physiology, of pathology, and of medicine will meet one every- 
where,—questions not readily settled by the business man, 
however expert in finance or in the management of the tramp 
and the vagabond,—questions requiring another education and 
other experience. 
You will agree with me, then, that it is not too much to ask 
for these sufferers that they should be committed to the care of 
those who can make a study of the mind, and acquire skill in 
devising ways to alleviate the sufferings of its disorders, and of 
infusing into the balance of the sad lives, even of the hopelessly 
insane, as much as possible of cheer and indirect compensation 
for the crushing loss they have sustained. To do less than this 
is to retrograde, to court sympathy with the discarded faults 
of a past age. 
Fellows of the Society : As I said in the beginning, our pro- 
fession has always been foremost in devising means to relieve 
the sufferings of disease. It has been ready always to step to the 
front, to contribute its knowledge, its skill, and its moral influ- 
ence to advance sanitary reforms for the public welfare. Here 
is a demand for our help. We have in our midst a class of per- 
sons suffering from the worst of diseases, who are not, at pres- 
ent, provided for in accordance with the best knowledge of our 
times. I ask for them the sympathy of those who know a better 
way. 
Let the state hear the voice of her medical profession, uttered 
through this society, reminding her of her duty to those suffer- 
ers within her borders who have fallen, and are helpless for 
their own relief. Let it not be said of us that we were not 
true to our mission as medical men ; that we did not in time 
advise the state of her duty, in a matter of which it is our 
special province to know and to counsel.