CARE 
OP THE 
CHRONIC INSANE. 
A PAPER READ BEFORE THE TENTH ANNUAL CON- 
FERENCE OF CHARITIES AND CORRECTIONS, HELD 
AT LOUISVILLE, KY., SEPTEMBER 2L-30, 1883, 
BY 
H. WARDNER, M. D.. 
Superintendent of the Southern Illinois Hospitalfor the Insane. 
MIDLAND PUBLISHING CO. 
MADISON, WIS., 
1884. CARE OF THE CHRONIC INSANE. 
There is no gainsaying the fact that insanity is steadily 
and somewhat rapidly increasing. Statistics compiled 
from year to year place this truth beyond doubt or dis- 
pute. Not only is the total number of insane persons 
growing larger, but the ratio of the insane to the sane is 
steadily becoming greater. 
Nor can we comfort ourselves with the thought that 
this melancholy state of affairs is either local or tem- 
porary. 
We have only to examine the statistics furnished by 
the various countries in which attention is given to social 
science in order to be convinced that this increase both 
in the total number of the insane and in the ratio of 
insane to sane persons, has been going on for many 
years and is a phenomenon common to all parts of the 
civilized world. 
It is no part of our present purpose to inquire concerning 
the causes’operating to produce this observed effect, or to 
seek-means for the removal of those causes. It may be 
that those conditions of modern life which produce the 
trouble, are capable of correction by legislative action, 
by a less strenuous and more hygienic system of popular 
education, or by some other means to be discovered 
hereafter ; or it may be that those conditions constitute 
a necessary and unavoidable part of our environment, 
and that in spite of all we may do, they must continue to 
work until, by elimination and selection, the race shall 
become fitter than it now is to endure the conditions 
enforced upon it by modern progress. 
These are interesting questions, and they are likely to 
occupy a large share of attention at the hands of com- 
petent investigators. We have now to do with a prac- 
tical problem forced upon our attention by this increase 
of insanity. While waiting for the solution of the in- 
tricate questions of cause and prevention, we have to 
deal practically with the fact that the number of the 
pauper insane is large, and still rapidly increasing. The 
cost of their maintenance is felt as a heavy burden, and 
however resolute we may be in our determination to 
bear the burden cheerfully, we cannot blink the fact that 
it imposes a heavy and increasing tax upon the industry 4 
TENTH ANNUAL CONFERENCE OF CHARITIES. 
L Friday 
of the sane members of the community. The amount 
expended by the public for this purpose is great enough 
in every State in our country, to make an appreciable 
difference in the tax rates to add a sum worthy of con- 
sideration to the amount that every direct and indirect 
tax payer must contribute to the public purse. 
There is nowhere a thought of abandoning or neglect- 
ing the duty we owe to this most unfortunate and help- 
less class of our fellow beings. The public mean to 
discharge that duty fully, cost what it may, and no sug- 
gestion looking toward a less humane system than that 
now in use, for the sake of saving the public money or 
for any other purpose whatever, would be tolerantly 
listened to by the enlightened intelligence of our time. 
But may it not be practicable to lessen the public burdens 
on this account, without shirking the public duty? 
Cannot means be found by which the duty we owe to 
this class of unfortunates may be fully discharged at 
smaller cost than is involved in our present system? Is 
it not possible to reduce the cost of supporting the 
chronic insane without reducing their comforts, abridg- 
ing their happiness or in the least degree lessening their 
small chances of complete or partial restoration to 
mental health? 
These are entirely legitimate inquiries, and indeed it 
is the duty of those who are concerned in any way with 
the practical conduct of this matter, to prosecute such 
inquiries with all the earnestness of which they are cap- 
able. If means can be found by which to diminish the 
cost of caring for the chronic insane without injury to 
their welfare and happiness, the result must be clear 
gain in every way. And if, as there is reason to believe, 
the adoption of a more economical system may be made 
to increase instead of diminishing both the happiness of 
the patients and their chances of recovery, humanity as 
well as public policy must urge the making of such a 
change. * 
It is a pressing duty to inquire what can be done in 
this direction, what modifications we need to make in 
our present system, and how the best results of that sys- 
tem may be secured at smaller cost. 
And first the question arises: why is our present sys- 
tem so costly? How did it come about that so expensive 
a system was adopted, not in one place, but well nigh 
everywhere, if a more economical method of caring for 
the chronic insane is practicable? 
The answers to these questions will be found in the 5 
Morning.'] 
CARE OF THE CHRONIC INSANE. 
history of insanity, and of the public attitude toward the 
insane. 
In less enlightened times than ours, insanity was uni- 
versally regarded as a demoniacal possession. Some- 
times the sufferer was reverenced as the subject of 
inspiration, but the far more common opinion was that 
the victim of insanity was possessed of devils. He was 
not pitied as a victim, but censured rather as a sinner, 
inasmuch as the devils were supposed to enter only at 
the invitation or consent of the man into whom they 
came. Cruel treatment of the insane was held, there- 
fore, to be both deserved —because of the individual 
sinfulness of the sufferer and necessary as a therapeutic 
agency a means of driving out the devils. Accord- 
ingly the insane were incarcerated in loathsome jail 
cells, chained like wild beasts, or half-starved and wholly 
maltreated in poor houses. 
JLittle by little this superstitious diagnosis gave way 
before intelligent investigation. Little by little the truth 
dawned, and men learned that insanity is disease or the 
symptom of disease, as truly as fever is. 
Then a reaction took place. It was felt that careful 
and intelligent treatment at the hands of physicians 
might be hopeful in cases of insanity as well as in other 
physical ailments. But treatment in most cases of in- 
sanity was necessarily different when the patient was 
kept at home. Proper care and the intelligent execution 
of the physician’s plans, were in most cases, out of ques- 
tion. 
Moreover, it was impossible for the physician in ordi- 
nary practice, to give to an insane patient that measure 
of attention which was needed, and so long as physi- 
cians saw only the few cases of insanity that fell to 
their care in the course of general practice, it was im- 
possible for them to make broad and thorough studies of 
the pathology and therapeutics of lunacy. 
For these reasons, and because most of the insane re- 
quire special supervision and restraint, it was early 
obvious that hospitals exclusively devoted to this class 
of patients were necessary. The hospital once estab- 
lished, soon became an asylum, also a house of refuge 
for hopelessly diseased minds. This was the natural 
course of development. But the reaction in the public 
mind already spoken of, soon took the form of works 
meet for repentance. As if groaning under an uneasy 
consciousness of its own former cruelty, the public 
sought to make atonement by lavishing compassion upon 
the class of afflicted persons who had before suffered 6 
TENTH ANNUAL CONFERENCE OF CHARITIES. 
[Friday 
neglect .and harshness. Where our forfathers dealt 
cruelly with the wretch who was supposed to entertain 
devils more or less willfully, we look with tenderest pity 
upon the victim of the most direful affliction known to 
man. 
In our eagerness to express this passion in acts, we 
surround many of our insane fellow beings not only 
with every appliance for their comfort, and every safe- 
guard against unnecessary sufferings, but in many in- 
stances also with every luxury that can be provided. 
Many of the hospitals we build are palaces in which we 
house them, and we place them in the midst of a life of 
idleness, such as ninety-nine out of every hundred of 
them never knew before. We exempt them not only 
from the usual responsibilities of life for which their 
malady unfits them, but also from that smaller measure 
of responsibility which they are generally capable of 
assuming, and the assumption of which would be posi- 
tively beneficial in most cases. 
All this is as it should be, so far as the feeling involved 
is concerned. It is right that we should cherish these 
unfortunates with loving compassion, and seek to bring 
as much of sunshine into their darkened lives as possible. 
But not every well meant effort of man is wise, and 
there are good reasons for believing that in our efforts 
to do our duty to the insane we have sometimes exceeded 
the limits of necessary expenditure, and have even 
wrought discomfort and unhappiness by our mistaken 
efforts to produce the opposite effects. 
Let us take the character and cost of the buildings 
provided for this purpose as an illustration. The average 
cost of Asylums in this country is about one thousand 
dollars for each patient, some hospitals costing as high 
as five thousand dollars per capita. The best estimates 
on the other hand, show that the average cost of housing 
the people of this country in their separate homes is 
less than two hundred and fifty dollars per capita. This 
estimate includes even the costly homes of city million- 
ares whose insane relatives are rarely found in public 
institutions, so that an average of two hundred and fifty 
dollars per capita is considerably more than the cost of 
housing the great mass of the American people. It fol- 
lows that we lodge our insane four or five times more 
expensively than the people generally are lodged. We 
take them from ordinary homes at best, and from hovels 
in many cases, and place them in duress palatial, and it 
is proper to inquire whether so radical a change is either 
necessary or conducive to the happiness of the patients. Morning.] 
CARE OF THE CHRONIC INSANE. 
It is proper to ask whether the chronic insane might not 
be housed equally well at less expense, and whether in 
other ways the cost of their maintenance might not be 
reduced without in any way reducing their comfort 
or interfering with their welfare. We believe that this 
may be accomplished easily, not only without injury, 
but with positive benefit to them and greatly to the in- 
crease of their happiness and comfort. This conviction 
rests firmly upon well understood facts in mental 
hygiene, and upon the results of practical experiment. 
It may be laid down as a rule to which there are no 
exceptions, that human nature requires employment. 
Work is an essential condition of happiness and even of 
comfort. Idleness, except as a brief relaxation from 
work, is a source of weariness, unhappiness and ill- 
health both of body and mind. It is only within the nar- 
rowest limits that what we call the luxuries of life. 
contribute to human enjoyment and content. A life of 
habitual idleness in the midst of luxurious surroundings 
is always and everywhere a life of morbid discontent. 
These are truths which every student of human nature 
recognizes. We know that in work, and especially in 
self-supporting, responsible work, we find the only real 
balm there is in Gilead, the only condition essential to 
the well being and comfort of body and mind. 
And yet in our dealings with the insane, we too often for- 
get these truths, and act as if they were the exact reverse 
of true. We shut up these unfortunates within palatial 
asylums, where they are condemned to lives of listless 
idleness, without occupation and void of all responsi- 
bility. We give them nothing to do, and rob them of 
healthful self care. Their lives are regulated for them. 
Their wants are supplied without effort or responsibility 
of their own. They are condemned to the daily con- 
templation of their own and others’ afflictions. They 
■are invited, nay even compelled, to resort to introspec- 
tion as their only sure intellectual occupation. We do 
indeed seek to provide amusement for them, but there is 
no seriousness, no earnestness of purpose, no absorbing 
interest in such occupations as are possible to the ma- 
jority of patients in an ordinary asylum. 
It is not necessary to enlarge this account of the prev- 
alent idleness, ennui, discontent, and other conditions 
which exist in nearly all asylums, and which must con- 
tinue to exist until a change is made in the system. 
The nature of the evil suggests the remedy. We need 
to recognize the fact that a great number of the chronic 
insane have a positive and urgent need of daily employ- 8 
TENTH ANNUAL CONFERENCE OF CHARITIES. 
[Friday 
ment at some obviously useful work. Most of them 
would be better and happier, too, if more simply housed 
in smaller masses than at present. In other words, 
most of them need to live more natural, more industri- 
ous and more responsible lives than they do or can 
under the existing system, and conditions of greater 
healthful ness and comfort may 'be found, we are con- 
vinced, in a system looking toward the less costly man- 
agement of asylums. 
In such a system there is room for considerable va- 
riety with respect to details, but my own experience and 
observation lead me to the conclusion that the best so- 
lution to the problem is to be found in the substitution 
of large farms for the large asylum buildings. There 
should be provided not less than an acre for each in- 
mate up to one thousand, and half an acre for each in- 
mate in excess of that number. Upon such a farm the 
chronic insane should be housed simply but comfort- 
ably, notin one large building but in several of smaller 
dimensions, which can be built, ventilated, drained and 
maintained at less expense. The inmates sliould be en- 
couraged to work each according to his capacity 
some in tilling the ground and others at various mechan- 
ical employments, each contributing something toward 
the support of the Institution, and all enjoying the ben- 
efits, bodily and mental, which arise from regular re- 
sponsible industry, and from a consciousness of personal 
usefulness. The work should for many reasons be vol- 
untary, arid experience shows that the desire to work is 
sufficent inducement to prompt many to share in the 
employments going on about them. It will be for the 
physicians and attendants to restrain undue eagerness 
and to see that each patient performs only so much labor 
as is good for him. They should treat the work chiefly as 
a hygienic and therapeutic agency —as a means of 
promoting the health and happiness and, above all, the 
contentment of their wards. But the work must be of 
a useful kind in order that the patients may be inter- 
ested in it, and it should be made to contribute to the 
support of the workers, both for their sake and in 
the interest of economy. The cost of the buildings 
necessary to the carrying out of such a plan, will be 
much smaller than the necessary cost under the preva- 
lent system, and the cost of maintaining the patients 
as experience shows —is also less than in an ordinary 
Asylum, while the work done by the inmates in farm- 
ing, gardening, road-repairing, etc., may be made to 
defray a considerable portion of this reduced expense. Morning. ] 
CARE OF THE CHRONIC INSANE. 
9 
This plan of asylum constitution and management is 
suggested not less in the interest of the patients than in 
that of a public which is heavily taxed for the support of 
the insane. There can be no doubt that the universal 
human need of healthful employment for mind and 
body exists with the insane as well as with the sane, and 
the observations of hospital physicians shows that the 
insane, at least many of them, eagerly welcome every 
opportunity for such employment. 
But in addition to the teaching of ordinary observa- 
tion in this direction, we have some notable testimony in 
the reports of extended experiment, and such testimony 
uniformly shows that the insane feel the need of pre- 
cisely what it is here sought to give them, namely, a 
more natural daily life, free access to the open air, a 
sense of release from restraints of asylum life, earnest 
work and a qualified responsibility for themselves and 
their support. 
With respect to one of the two features of the plan 
suggested, namely, the cheaper and simpler housing of 
the insane, I may be allowed to cite some passages from 
my report of our enforced experiment at Anna during 
the summer of 1881. The burning of a wing of the 
asylum in April of that year compelled us to furnish 
temporary quarters for two hundred and sixty-four 
patients. A simple building or barracks, well ventilated 
and drained, furnished with hot and cold water, and 
lighted with gas, was erected at a total cost of only thirty- 
seven dollars per capita for the patients it accommo- 
dated, and the results of its occupation were so favorable 
in every way, especially in the gratification of the 
patients, that the structure, although intended at first 
only to serve a temporary purpose, is now being completed 
for permanent use. I quote as follows: 
“ The patients assigned to these quarters were chronic 
cases, a considerable portion of them being demented, 
epileptic, or paralytic. In noting the result of this forced 
experiment, we observed that the change was highly 
pleasing to these afflicted people. A poor, demented, 
old man who had been unable to get out of the hospital 
with the others in their daily walks exclaimed, ‘ I thank 
God my foot is on the ground once more.’ 
“They delighted in the free, open air of the court 
yards, which, by the way, were well shaded with forest 
trees and amply furnished with seats. They lost the 
sickly pallor usually observed among patients kept 
within walls. The ample space left each man free to ex- 
ercise in his own peculiar way without infringing upon 10 
TENTH ANNUAL CONFERENCE OF CHARITIES. 
[l'rid-ai 
the privileges of his neighbors; and consequently the ir- 
ritation and assaults, especially among the epileptics, 
provoked by limited quarters, and personal contact, have 
been reduced to the minimum. During the entire sea- 
son there have been but three or four occasions to use res- 
traint, and those arose from epileptic excitement. These 
patients have been remarkably healthy during the sea- 
son, no case of serious disease having originated or devel- 
oped among them. They have been contented and the 
number of escapes has not been more than in previous 
years. 
Sleeping as they have in such large associate dormi- 
tories seems to have had the effect to keep them more 
quiet, and with the exception of occasional excitement 
from epileptic attacks, there has been no more disturb- 
ance than might have occurred had the same number of 
sane people been lodged in the same room. Those who 
had previously been noisy and disturbed their neighbors, 
while occupying single rooms or small dormitories, out 
of consideration for others, or in consequence of the re- 
straining influence of numbers, and the eye of the night 
attendant, became quiet and acquired the habit of keep- 
ing still, if not of sleeping well. In fact a general im- 
provement has been observable both in physical and 
mental conditions.” 
The Asylum at St. Joseph, Missouri, met with a simi- 
lar misfortune in 1876, which forced upon the manage- 
ment the necessity of providing temporarily for their 
patients during the reconstruction of the Hospital. 
In the biennial report of that institution for 1881, the 
Superintendent, Dr. Catlett, asserts that his experience 
in providing for the insane in cottages and farm dwell- 
ings, during the reconstruction of the hospital, a period 
of fourteen months, has in his judgment established the 
expediency and practicability of providing for all classes 
of insane in far less expensive dwellings than the model 
asylum edifice. The Doctor notes particularly the bene- 
ficial effects of the free out-door life upon the irritable, 
excitable and enfeebled patient. He concludes his re- 
marks upon the subject in the following language: 
“I extract from the valuable crucible of experience lessons in 
therapy and provisions for insane, which tend to convince me that the 
model asylum edifice of this era of psychological activity is perhaps 
erected both at the too great expense of the humane public, as well as 
opposed to the best hygiene and curative interest of the impx-oved and 
chronic insane; or, in other words, I am almost persuaded to assert 
my belief that less expensive segregated cottages, erected on asylum 
farms, for the treatment of the improved and chronic insane, suffi- 
ciently near the main edifice where all can be under one supervision, Morning.] 
CARE OF THE CHRONIC INSANE. 
and where exchange of patients may readily be made, when the con- 
dition of the patient requires it, would be a very great improvement 
in the present mode of provision and treatment of the insane.” 
It is to the Willard Asylum of New York, however, 
that we must look for the best light of experience with 
respect to both features of this plan. That asylum was 
organized as a well considered experiment. Its purpose 
was to separate the chronic from the acute cases, and 
separately to maintain the chronic insane at less cost 
and in better conditions than are possible under the mixed 
asylum and hospital system. 
The experiment has passed from its experimental stage 
and is a pronounced success, so that the results achieved 
may be fairly regarded as those that must follow every 
well conducted scheme of a similar kind. In addition 
to such farm, garden and mechanical work as is con- 
templated in the farm plan here suggested, the patients 
at Willard Asylum have been employed upon special 
undertakings connected with the institution or conducing 
in some way to its better and cheaper conduct. 
In the report of the Trustees for 1882, we read as fol- 
lows: 
“ Under the permission granted by the last Legislature a road bed 
has been cleared and graded, four and one-third miles in length. The 
work was not enforced from patients, but was voluntarily and cheer- 
fully performed. Although occupied for over three months almost 
continuously, they closed the work in better health, improved in both 
mind and body, than when they commenced. * * * It required 
more effort to restrain overwork on the part of the industrious than 
to induce the labor of others. Judged by this experiment, in which 
one hundred and fifty to two hundred a bleb died lunatics were 
laboring together, the inference is conc'usive that under proper man- 
ag ment and with due care it is not only safe for them to labor, even 
in unusual occupations, but that it is conducive to their mental com- 
fort and health. Employment diverts from morbid fancies and 
troublesome hallucinations.” 
The testimony of the Medical Superintendent is to the 
same effect. He speaks confidently of the great influ- 
ence regular occupation is “ known to exert upon the 
health, comfort, quietude, and contentment of the in- 
sane, particularly the insane of the chronic class.” 
Upon the plan which seems to me to offer the best and 
surest solution of the problem, such work as railroad 
building is not contemplated. The scheme looks chiefly 
to the employment of the chronic insane in man’s most 
natural work, namely the cultivation of the soil. I 
would have the state provide large asylum farms, each 
capable of comfortably accommodating a large number 12 
TENTH ANNUAL CONFERENCE OF CHARITIES. 
[Friday 
of persons and affording them abundant occupation. 
Upon these farms should be built structures of moderate 
size and cost, well ventilated and drained, and placed at 
convenient distances from each other. In these build- 
ings the chronic insane can be housed at much less cost 
per capita than at present, with greater freedom of ac- 
cess to the air and sunshine at all hours. The able- 
bodied men should be expected to cultivate the land in 
farm and garden crops suitable for the maintenance of 
the institution. Those who understand mechanical 
trades should be set to work at them, chiefly at asylum 
work. 
The women can be employed at ordinary women’s 
work household labors, sewing, etc. In brief, all the 
patients should be made to live as nearly as possible 
after the manner of sane people, each group constituting 
a household under the general charge of proper attend- 
ants, in which the inmates may live comfortably rather 
than luxuriously, while contributing by their labor to 
their own support. We have sufficient experience 
already to be certain that a scheme of this nature is en- 
tirely practicable, and if the plan is ever generally 
adopted, experience from year to year, will point the 
way to its gradual perfection in details. 
The considerations in favor of the adoption of some 
such plan may be summarized as follows: 
Ist. It should greatly cheapen the cost to the public of 
supporting the chronic insane, whose support in model 
asylums is now a very serious burden upon the industry 
of the people. 
2d. It will benefit the insane themselves, improving 
their physical and mental health, increasing their com- 
fort, and freeing them from conditions which tend to 
morbid introspection and discontent. 
The only objections that can be urged against the plan 
are founded either in a mistaken notion of duty, or in a 
misapprehension of the conditions which best promote 
their welfare and happiness. Upon this point I cannot 
better present the true view than by quoting a passage 
from the report of the Medical Superintendent (Dr. John 
B. Chapin) of the Willard Asylum, for 1882. Dr. Chapin 
writes as follows: 
It would be a matter of regret if any erroneous impression should 
prevail relative to the employment of such insane persons in asylums 
who, in the judgment of the physicians, have the capacity and strength 
to work. Patients and their friends have sometimes, though quite 
rarely, ventured an opinion that having gained admission to an asylum, 
or being committed against their will, they were entitled to a generous Morning.] 
CARE OF THE CHRONIC INSANE. 
13 
support in ease. We know of no principle of social ethics which 
exempts any member of society from contributing according to his 
capacity, to his suppoit, neither can there be any valid objection to the 
application of the avails of the labor of the insane, situated as they are 
here, to the reduction in some measure of the cost of their support. 
Labor, employment and occupation are the common lot and burden of 
the larger portion of every community. No one claims exemption from 
conditions, which all human experience shows to be, on the whole, most 
conducive to health, happiness and contentment. If these principles 
may properlv be said to be applicable to the sane, they are in a quali- 
fied i-ense to be borne in mind in devising a system for the care of that 
portion of the insane who are in that stage of their disease in which 
they do not require the administration of medicine, or for those who 
are not suffering from appreciable physical infirmity. We refer, of 
course, t > the able-bodied chronic insane. They need plans of build- 
ings adapted to their varied and variable state. They need, as nearly 
as practicable, the surroundings of domestic life and facilities to carry 
on the occupations to which they have been accustomed when sane. 
They should be brought as closely as possible in accord with the duties, 
occupations and relations that have governed them when sane. The 
central thought outlining any systematic employment of the chronic 
insane must needs regard occupation as one of the great moral agen- 
cies which may be brought to bear upon the disordered mental state, 
with the hope of converting the operations of the mind into normal 
channels of thought and action. The results of continued and pro- 
longed occupation cannot be more strongly expressed than by reiterat- 
ing the statement made in a previous report, that the diversion of “ a 
large proportion of the insane from a mental state in which they are 
incapacitated for self-support or self-preservation to their ordinary 
avocations, is a result to be achieved, second only to recovery. The 
habits, sleep and physical condition are improved, life is rendered 
more tolerable, mental quietu de is promoted, and paroxysmal excite- 
ment is lessened.”