MANAGEMENT our1 oxm Indigent Insane. READ EE FORE THE Committee on Humane Institutions, In Session February II, 1879. BY RUFUS BAKER, M. D MIDDLETOWN, CONN. TO THE READER:— Prominent members of the Connecticut Legislature, and several private gentlemen, have requested the following for publica- tion, to be placed before the Members of the General Assembly now in session, for their immediate use. It was written at intervals while actively engaged in my professional duties, and intended only for the ears of the Committee on Humane Institutions; before whom it was read on the nth inst. I have had no opportunity to revise it or make corrections, and my only apology for submitting L in its present condition, is the hope that others will be aroused, by the truths presented, to do something for the amelioration of the condition of this large and unfortunate class of our fellow-citizens. R. BAKER. Middletown, Feu. 13, 187H. Management of our Indigent Insane. To the Committee on Humane Institutions : — The great era of improvement and advance in the treatment of insane was from 1836 to ’57, seventeen or eighteen public hespita’s and many private ones were established. The principles of com- paratively mild restraint were constantly gaining ground ; a large class of very able, experienced and enthusiastic physicians entered upon the work of superintendency, and there was a strong emula- tion to attain the best results of treatment. This was the era of hospital building. None cf those hospitals were allowed to ac- commodate more than 200 to 250 patients at a time. American Hospitals led the world, and delegations from Europe came over to us, to learn .vere the Dest methods for caring tor the In- sane. The per cent of cures was large, ranging from 60 to 90 per cent. All honor to such men as Wyman, Bell, Woodward, Kirk- bride, Earle, Brigham. Awl, Jarvis, Butler, and their coadjutors, for what they accomplished in ameliorating the condition of the In- sane. But in looking back upon their work now, it must be con- fessed that they fell into some errors from which, in spite of the manly protests of some of them, they and their successors arc not wholly free. One of these errors of later years is this, that the more elegant, costly and palatial the buildings for an Insane Hospital were, the grander its external architectural appearance, the more costly and perfect its arrangements of heating, ventilation, water transmission and sewerage, the more stately and beautiful its saloon, halls, and executive offices, and the more extensive its gymnasiums, courts, billiard rooms, ten pin alloys, reading rooms, etc,, etc,, the greater was the certainty of cure, accordingly for the iaht t\vcnty»ftve years, mh nmeisivo burn Hotpital h*i bttn built on a largtv icale, 4 and one of greater architectural elegance than its immediate prede- cessors, till finally, this has become the age of palace building and even likely to bankrupt our wealthiest states. The great state of New York found the burthen an intolerable one, and stopped the erection of so many palaces long before their completion; while New Jersey is even now, staggering under the cost of her gigantic folly at Morristown, on which she has already expended over three millions of dollars. The cost per patient accommodated, has risen from $300 to $500 per head to from $2,000 to $3,000. In other words, it would have been cheaper for the State to have purchased for each patient, a good house and lot in the country, than to have built these costly buildings. But this expense would have been endurable, if it had accomplished what it had premised, if the ratio of recoveries had been greatly increased by it. But so far from this, as Dr. Pliny Earle of Northampton, one of the ablest Alienists in this country, has conclusively demonstrated, the proportion of recoveries was far greater, when the buildings were plain rough barracks or rude cottages, and has been constantly diminishing with each increase of luxury, till at present, in any of our congre- gated hospitals, the ratio of cures is reduced from 60 to 90 per cent of 25 years ago, to from 15 to 25 per cent. Evil results have followed this extravagance, especially in State Hospitals :—First, That the comforts and appointments in the Hospitals, are so much better than the patients can hope for at home, that the number of re-admissions often several times in the same year, has become fear- fully large; and Second, That probably from much the same causes the increase in the number of insane persons requiring treatment, is so much greater than the population, that the states are kept constantly employed in providing new Hospitals for them. The influence of the imagination over the mind in these matters is well known, and there is no question, that the number of the in- sane would be greatly diminished, if the accommodation for them was less imposing. This satisfactory condition physically, tends also to produce a mental quiessence and hebetude unfavorable to recovery. Dr. McFarland, an able Alienist, formerly in charge cf the Asylum at Concord, N. H., after that in charge of the Illinois State Asylum, formerly President of the association of Superintendents and a thorough convert to the cottage system of treating the in- sane without restraint, except in urgent cases, and with continued labor, says, in a letter to me of Dec. 19th, 1878, referring to Dr. 5 Earle’s Northampton report : “He gives some suggestive facts with regard to the moral effect of stupendous buildings and elaborate furnishings, which seem to prove that curative results, are in in- verse ratio to these apparently favorable surroundings. He says, my own theory on this point is, that the sight of too much done with the sp:cial object of doing every thing conceivable for the in- sane, as a set off and petted class, weakens the mental and moral stamina of the subject. The sight of what money, taste, study, etc., can do, and is doing for them, produces a morbid self-satis- faction not favorable to curative results. The statistics given from the McLean Asylum (quoted by Dr. E.,) seems to show this fact remarkably.” Another error, is the result of ignoring all of the best teachings of the past ; that lab >r, regular occupation of such kind as to require some concentration of the mental powers, is the true remedy for disease of the mind, and that plays, amusements, theatricals, masquerades, dancing parties, tableaux and farces, lec- tures, magical or chemical entertainments, military drill, gymnas- tic exercises, proc 'ssiom! w ilks, are very poor and insufficient sub- stitutes for active, thought-compelling labor, the labor which shows these poor creatures that they are accomplishing something as other people arc,—the labor that produces quiet sleep. You are are no doubt familiar with the results at Gheel in Belgium. 'The testimony of the Monks of the Pyrenees long ago, is to the point : “We cure, said the good fathers, almost all our lunatics, except the nobles, who would think themselves dishonored by wrorking with their hands.” The testimony of the most successful of the English and Scottish Superintendents on the subject of labor at the present time, is, that some kind of labor is absolutely necessary to success- ful treatment of the Insane, Dr. Earle of Northampton, is decid- edly in favor of this continued labor. As long ago as 1844, Dr. Ray, in his Hospital report for that year, says, “of all the remedies for mental disease none can compare with labor, wherein I include all useful employment. In most highly excited patients the surplus nervous energy will be consumed, if no other way is provided, in mischief and noise, but let it be expended in useful labor and although the work may not always be perfectly done, yet the patient thinks it is, and he experiences that kind of satisfaction which springs from the consciousness of having done a good thing, and consequently, so far as it goes, is a sound and laudable feeling. Indeed many a patient will refrain for the first time, from destroy- ing or tearing his clothing, or abusing his attendants on being rl- lowed the privilege of going to work. Even some of the most de- mented will be found capable of doing something, and though it may not be very profitable, yet it keeps them out of mischief, etc.” I)rs. Batty Tuke and Fraser, of Scotland, speaking of the Cot- tage plan of treatment for the Insane, say, that “they believe these conditions, viz: the homes in cottages coupled with constant oc- cupation, result in greater contentment and general happiness among the patients, better conduct in every one, i. e., less excite- ment, the preservation of the individuality of each patient, lessdeg- radation, and greater vigilance and care on the part of the atten- dants. Occupation is what we have the utmost confidence in • its results are most beneficial. Almost every male can fill and wheel a barrow, and the majority can use a spade, and so almost every female can use a needle and thread or a knitting needle.” But a still greater error though connected in part with the preceding, is that the patients who should be placed in the most favorable cir- cumstances for recovery, are really in the least favorable for that purpose. They should have as much out-door and open air life as possible, whereas they are in most instances confined to the cor- ridors, halls, and saloons and wards of the hospital; their condition should be as home-like as possible, but the life in a great hospital is as unhome-like as possible, the power of the will over the mind should be developed by putting them on their parole as far as pos- sible, while now, they are not trusted. I believe that the Insane should be well and amply provided for, and that everything should be done for them which will tend to their speedy restoration to health and citizenship, but a life of luxurious idleness, for which the taxpayers are called upon to pay exorbitant sums, does not tend to this result. With the constant increase in the number of the In- sane, and the constant decrease in the number of cures there is danger that there shall not be enough sane left, to support the In- sane; and a wise economy which shall tend to their recovery is ab- solutely demanded by our overbounded tax-payers. In regard to the medical treatment of the Insane, many of the Superintendents and as a general thing, all their assistants, having had little or no experience in general practice of medicine, have fallen into a routine practice, which is wholly unfavorable to the production of the best results. Insanity is dependent on, or complicated with often severe organic or functional diseases, requiring the highest skill of an experienced physician. It is because the English, Scottish, French, and German Physicians and Alienists, have dis- 7 covered these errors in our methods, that they have been advanc- ing while we have remained stationary, or rather have been retrc- grading, that for the last twenty-five years, they and not we, have taken the lead in the treatment of the Insane. The very able Commission who have had in charge the subject cf increased accommodations for the Insane poor, evidently have in view, the necessity fora different plan of treatment of Insane ; as I learn they recommend the building of plain, substantial, home- like buildings for their accommodation. I doubt not your honor- able body are deeply impressed with the necessity of doing some- thing for the three or four hundred unfortunate Insane poor un- provided for,* and the question what does humanity and true economy require, is the one to be answered by you. At the risk of appearing to arrogate to myself superior knowledge on this sub- ject. I beg leave to suggest the following:—That plain, substantial cottages be built, not more than two stories in height, at a dis- tance from the barrack hospital of at least one-half mile. The cottages might be built of wood with substantial frames and well filled in with brick, roofed with galvanized iron or slate, and kej t well painted with some of the fire proof paints. If well built, they will be in less danger from fire, I think, than ordinary slightly built brick houses. They should be in groups of five or more. Should not have more than thirty patients to each, and with nothing of the appearance of a hospital about them. If the number of the Insane accumulate faster than there is provision for them, the milder and chronic cases might be boarded out among the rural population,—the institution still being responsible for them— they being looked after by a competent physician. This plan has work- ed most beautifully at Gheel for hundreds of years, and has been successfully adopted by other European institutions. I would next find some useful employment for each patient, who could do any- thing, which would at the same time be pleasant as well as profit- able. In this I would include gardens, orchards, market gardens, as well as meadows and grain lands and all under high cultivation. The culture of small fruits and flowers may be made profitable. * Since this paper was read before the Committee on Humane Institutions I have read the very full report by the Commission appointed “to investigate the necessity for the erection of another Hospital to afford further accommodation for the Insai e Poor of this State,” and although it may be a "new departure” so far as the erection of cheaper additions to the Hospital goes, yet it seems to me to recommend the per- petuation of tho old plan of treating the Insane. Their ideas of labor are good, la t should not the patient labor whether “triliiiuj" or not, as well as to obey any other rule that is considered for his good? There might be encouraged a rivalry or emulation between the dif- ferent cottages, as to their productions, which would have a good curative influence if controlled. Would think it indispensable to pay moderate sums to the patients for excellence in labor. A great many of the simple trades could be carried on to advantage, some for men, and some for women; millinery, dress-making, tailoring,—the making of underclothing both for men’s and women’s wear,—the putting up of garden and flower seeds, fancy wood, ivory, or bone turning, fancy-box making,—the manufacture of mats, brooms, or brushes, and for women, tidies, shawls, and crochet work generally. For those of more cultivated tastes and skill, some forms of decorative art. The cooking and washing for the whole group of cottages might be done in one of the buildings, and the inmates of that cottage should be those to whom these descriptions of housework would be most agreeeble. That cottage should be fitted up with the best appliances for doing the work most economically, and in the best way, and except the superin- tendence, it should be done by the patients. The meals should be served at this cottage or at each cottage at a given hour, as may be found most convenient. The utmost order and cleanliness should be maintained, and it might be well to have rules of order, which the patients themselves should suggest or approve, posted in each cottage. As far as possible everything in the rules and arrangements should be devised with the special purpose, of calling out the self control of the patients, and compelling them to ex- ercise their will to repress any insane act. The two sexes should be in different groups.—The women in each cottage should be under a judicious matron or house mother, and the physician who should be experienced in his profession, should see them all at least once every day. The men in each cottage should be under a kind and judicious house father, and if he needs assistance that assistant should be a young man of excellent character in training for a nurse or house father. I am not advancing any new or chimerical ideas, similar plans (and this plan also) are being tried with wonderful success in many parts of Europe and to some ex- tent in this country. I am satisfied that if this plan can be carried out untramelled, it will show a much larger per cent of real cures by far, than by the hospital plan, and that those who are dis- charged recovered, will be in more vigorous health, from their active and out door life, and as many of them would really learn trades, and being accustomed to active labor, they could better 9 take care of themselves, and be less liable to a recurrence of the insanity. As before stated, labor, not excessive but proportioned to their strength, is the best restorative in the large class of melan- cholic cases, diverting the mind, enlisting the thoughts, and rous- ing the ambition ; and if the stimulation of moderate pay to the patients for their labor is added, that it will give them a motive for exertion, which will call into action the restraining power of the mind over the body, which is recognized everywhere except in In- sane Hospitals, as the most powerful agent for restoring both men- tal and bodily soundness. The small pay that the patients may re- ceive for their labors should be so managed, that there shall be no injudicious use made of their earnings. This can easily be ar- ranged. The expense of construction and furniture need not be more than $300 per patient accommodated. All the palatial ed- ifices require from $750 to $3,000 per patient. The expense of management can be much less, because much of the service and attendance can be done by the patients, and besides there would be not a little profit from their well directed labor. The superin- tendence of these cottages should be under the control of an able and experienced physician, with able and experienced assistants, who should live among them, cat with them, and give them their entire personal supervision, subject only to a board of medical in- spection, of which I will presently speak. They should be men of iarge practical experience in both acute and chronic diseases, as the various phases of disorders of mind, depends on as great a va- riety of causes, and is accompanied with as great a variety of func- tional or organic changes, as is found in the general practice of medicine with other or healthy mental conditions. The present extensive and extravagant hospital building is on hand and is full. It wras evidently built with the idea that insanity is an absolute condition, requiring substantially the same treatment for each individual, operating as an utter disqualification, and ta- booing its subject as soon as he comes within its walls, from or- dinary human relations. It is one of the greatest misfortunes of the Insane that every one is accustomed to look upon his condition as an absolute one, that as soon as it is whispered abroad that he is Insane, he finds that he is at arms length with the rest of the world, viewed with distrust, and gazed upon much as we would on animals in a menagerie, and given to understand on all hands, that a mysterious something, makes him a social exile. This large hos- pital can be used for the violent and excited, those requiring some 10 form of restraint, perhaps the epileptic, the completely idiotic and others. It is absolutely indenspensable to the success of this new mode of treatment, that the controlling authority over it, should be heartily and fully in sympathy with it. I think this is impossible in the case of any of the superintendents on the old plan,—that that close corporation, the American Association of Superintend- ents, are too completely wedded to their splendid palaces and princely livings, and as long as human nature remains the same, 1 do not expect to see them come down to the humble position de- scribed for our cottage superintendent, at least, until they are ob liged to do so. We all know how hard it is to make innovations in old customs and theories. Who could have convinced our naval officers that their splendid ships of war were not the very best that could be devised, till their worthlessness was demonstrated by a half day’s battle with an Krichson’s monitor, in Hampton Roads ? What opposition has been raised against all discoveries that tend to uproot and destroy old ideas? Even the mower, the reaper, the sewing machine, have been regarded as innovations not to be tolerated. Yet see how much has the toil and sweat of labor been lessened by these discoveries: and who does not look back with sympathy on the toils and hardships of the laborers of the past ? As an illustration of the blinding influence of old ideas upon an individual, even when proof of an opposite condition is before the mind, I beg leave to present a short extract from a late Report of the Superintendent of a Virginia Hospital:— “There have been seven escapes during the year. One was so quiet on reaching home, after a walk of eighty miles, that his friends refused to surrender him. He had been notoriously the most violent and determined patient, perhaps, that has ever been in the Asylum, and his escape by force and his continued absence without the permission of the proper authorities produced a very demoralizing effec;. I can see but one remedy, which is to enforce the penalty provided by law against an officer who refuses to obey a warrant to arrest an escaped lunatic.” A hard case truly! The patient at home and well, and the Doc- tor greatly outraged that he cannot be brought back and be just as as he was before,—probably the demoralizing effect upon the other patients was, that they could not escape and get well in the same way. 11 I have made reference to the necessity of medical inspectors. The importance of these officers in every State, will, I think, soon be fully appreciated. They will soon be found indispensable to the success of any system of treating the insane. I think three of these inspectors would be enough ; chosen without reference to politics, nominated by the Governor, and elected only by a three-fourths vote of both houses. Two should be physicians, men of large medical experience and of the highest character: no superintendent or ex-superintendent of an insane hospital should be eligible. They should be men whose character and reputation is so high that they could not be approached or influenced. The third member of the board should be a lawyer, but thoroughly versed in medical jurisprudence. They should visit the hospitals of the State once a month, at least, and oftener if they judge nec- essary, being careful, always, to make their visits unexpectedly; and in the presence of the Hospital Superintendent and the Super- intendent of the Cottages, alter careful examination, should detail those patients who are to be assigned to the cottages;—the mild- ness of the form of insanity, the freedom from maniacal violence, from marked suicidal or homicidal propensities, and the presence of bodily ailments requiring special medication, being the principal points influencing the decision. They should also have power to discharge any patient, when they think his condition or health re- quires it. The finding of the inspectors should be final, as to the control of the patient. They should thoroughly inspect the hospital at each visit, noting the condition of the building the character of the food, the treat- ment, the discipline and all particulars which concern the highest efficiency of these institutions ; and should have power to redress any wrongs or abuses even to the extent, in extreme cases, of re- moving the Superintendent. They should not neglect the investi- gation of any reasonable complaint on the part of the patients or their friends. They should also, at the recpiest of any Judge of the Superior Court, investigate any cases of alleged lunacy and make an annual report to the Legislature, specifying their acts, and the needs of the insane of the State, and give any other neces- sary information. They should be elected for a term of perhaps six years, with eligibility for re-election. Their pay should be ten dollars per day, of each day of actual service, and their necessary travelling and incidental expenses. My reasons for their appoint- ment are, that irresponsible power is always liable to abuse, and 12 nowhere more so than in the care of the insane,—they ire like out unfortunate Red men, with no one to take their part, or believe their stories of wrong. It may be, that the parties who thus abuse their power, are unconscious of any wrong motives, but the abuse is not diminished by that fact; and men in permanent stations are not always proof against temptations. There are also many cases where the abuses are the results of errors in judgment: there should be a power of appeal somewhere. The insane are the wards of the State, and they should be protected from wrongs, either in- tentional or unintentional. There is now no appeal except to the Courts, and this is slow, expensive and uncertain. The appeal to the inspectors would bo prompt, inexpensive and sure of justice. Their duties in examining into cases of alleged lunacy may often sive expensive law suits, and families and unfortunate victims of rapacity and malignity, from life-long sorrow. It is not an uncom- mon thing for us to learn from our morning papers, that persons who were perfectly sane, have been confined in Insane Asylums, in order to get rid of them, or to seize upon their property, and who cm tell the number of unwritten cases that go down to death, in sorrow inconceivable ? You are aware, gentlemen, that there arc cases now pending, or recently decided, in New York and New Jersey, where it is already proved beyond a doubt, that persons perfectly sane, have been con- fined in Insane Hospitals, in order to get rid of them, or seize upon their property, and if I am correctly informed, one or more such cases are to be found in our State. Another reason for these In- spectors lies in the fact that Superintendents generally, 1 think, are opposed to such inspection, and even to medical men being placed on Boards of Trustees—this fact is of itself, to say the least, a little •suspicious. The American Association of Superintendents, in res- olutions passed at one of their sessions in 1874, say— “If the time shall ever come when the Legislature, in its zeal for the public good, shall establish a board of officers to supervise the medical practice of the State, with power to enter every sick man’s chamber to inquire respecting the medicine and diet prescribed, and any other matter connected with his welfare, and report the results of their examination to the constituted authorities, then it may be proper to consider the propriety of extending the same kind of paternal visitation to the hospitals for the insane.” I)r. Charles F. Folsom, Secretary of the State Board of Health of Massachusetts, remarks as follows :— 13 “ Whatever opinion we may have as to the necessity of govern- mental supervision, there can never be any analogy between the two cases until our laws arc different frem these now in force. A sick man, in his chamber, is surrounded by his dearest friends and relatives, who sacrifice their own comfort to his needs. In the asylum, his wants are administered to exclusively by those who are paiil to do so; he cannot select his physician, he cannot change his nurse, he cannot order his food or discharge his cook, and often does not communicate with his friends for many weeks. It is diffi- cult to conceive that such a position could be taken, except from a very narrow standpoint, and with an undue sensitiveness as to pub- lic opinion.” Gentlemen, I offer you these thoughts, not without having given the subject a good deal of attention, and having had in the last thirty years considerable experience with insane patients. The sys- tem which I have imperfectly sketched I believe is what we need for our insane poor, viz.: cottages not expensive, mental and bodi- ly occupation, open-air life, encouragement, trust, confidence in the patients, suitable and skilful medication when needed, and a more intelligent, elastic and progressive system of management. This system is economical, successful in inducing recovery,—natural in its processes,—specially adapted to our country, climate and people, —humane in its character, yet repressive of the increase of insanity. Shall it not be tested? Sinc e reading this paper before the Committee on the i ith inst. I learn that an important meeting was held in Boston last week, for the purpose of taking into consideration measures for ameli- orating the condition of the insane. Several gentlemen well known to the whole Country took part in the proceedings. A dispatch was read from Dr. William A. Ham- mond, of New York City, in which he said: “Things in this State are even worse than with you.” Resolutions were adopted favor- ing the establishment of Commissioners of Lunacy, who shall have free access to all Asylums and patients, and authority to discharge a patient whenever necessary from the condition of his health or otherwise. Another resolution demanded that “a greater freedom of correspondence should be allowed patients.” And a third, rec- ommended the adoption as fast as can be, of the Gheel system building small cottages for the lunatics. I have read with great care, the report of the Commissioners on further accommodations for the insane poor, and see in it very much to commend. From this report I am satisfied that not less than three hundred insane poor should at this moment be provided for as to care and cure, by our State. That the location should be at Middletown is evident, and abundantly proved by the Com- mission, but nevertheless it does not follow that they should be cared for and treated by the Superintendent of the large Hospital. While institutions are necessary for care as well as the cure cf the insane, the possibilities of cure should not be lost sight cf. The Willard Asylum for the Chronic Insane, may report but two* cured out of fourteen hundred, though its recent report tells a very dif- ferent story: but that institution is too much on the barrack system and its table altogether too low; the result at Gheel among the same class, is the recovery of fifteen per cent, where an open air and cottage life, with peasant’s fare, and as much labor as they arc- able to perform, is the principal means of cure. The proposed method of attendance (page 13 *) proposes greatly to increase the present irresponsible power of the superintendent. He is to have supreme control of the “ annex ” as well as the main hospital; yet he is not expected nor desired to visit the patients. The assistants, the inexperienced doctors, can report when his attendance is advis- able. The only check upon this irresponsible power, which is greater in degree than the Autocrat of all the Russias, is, that the super- intendent would naturally be ambitious that all its parts should be well kept up, and would recognize that his reputation might be in- jured by neglect in one part as well as in another.” If any superin- tendent should be canonized in advance by the Pope and the whole college of Cardinals, he should not be trusted witli this arbitrary irresponsible power over these poor, helpless, insane people, with any expectation that he would not be liable to abuse it. In the matter of expenditure for this proposed “ Annex," I think tho State v,’quU\ be financially the l