■Provision' for the Insane 
IN THE 
United States: 
A 'HISTORICAL SKETCH 
FREDEgM5 ’MtM'7 
A Reprint from the Eighth Biennial Report of the Illinois 
State Commissioners of Public Charities. 
SPRINGFIELD: 
H. W. ROKKER, STATE PRINTER AND HINDER. 
1885. CHAPTER III. 
PROVISION FOR THE INSANE. 
History of the controversy as to the care of the chronic insane—Dr. Godding’s paper— 
Propositions of the Association of Superintendents—Miss Dix—Dr. Kirkbride’s book on 
the Construction of Hospitals for the Insane—Dr. Kay on the situation in 1866—Action of 
the New York Superintendents of the Poor, in 1855—Report of the Senate Committee—Dr. 
Willard’s report, in 1865—Creation of the Willard Asylum—Tewksbury—Dr. Hill’s proposed 
“Hamlet Home,” in Ohio—The Journal of Insanity—Discussion, in the Association, of Dr. 
Butler’s paper, recommending the establishment of a State Farm for incurably insane 
patients—Dr. Cook’s paper, 1866—Dr. Walker’s resolutions—Dr. Chipley’s substitute—Mis- 
apprehension of the question at issue—Dr. Chapin’s paper, 1867—Dr. Jarvis’ paper, 1870- 
Discussion, at Toronto, in 1871—Article in the Journal of Insanity—The Illinois Conference, 
in 1869—Views of Dr. McFarland—Report of the Pennsylvania Commissioners of Public 
Charities, in 1874—Creation of the Kankakee Hospital, in 1877—Mr. Wines’ report on Euro- 
pean Institutions for the Insane—Gheel and Clermont—Gheel discussed by the Associa- 
tion, in 1879—Detached buildings in American hospitals for the insane—Growth of the 
feeling in their favor—Remarks on Kankakee—Dr. Ray’s observations on European Hos- 
pitals—Suggestions to' tliose about to build, on the detached plan—County care, and the 
Wisconsin experiment. 
In a recent paper on “Progress in Provision for the insane,” read 
at Philadelphia by Dr. W. W. Godding (the accomplished superin- 
tendent of the Government Hospital for the Insane), on the occa- 
sion of the fortieth anniversary of the Association of Medical Super- 
intendents of American Institutions for the Insane, he divides the 
history of the progress made in this country into three eras : (1) that 
of small institutions, chiefly of a curative character, from the adop- 
tion of the “propositions” of the Association, in 1851, until 1866, 
when a material modification was made in the one relating to the 
proper maximum number of patients to be cared for in a single 
hospital; (2) that of large institutions, embracing both the acute and 
chronic insane, with a centre building and wings, with all the wards 
for classification of patients under one roof, or connected by corri- 
dors, and each ward complete in itself; and (8) that of detached build- 
ings for the insane, which seems to him to have just begun. The 
creation of the Willard Asylum for the Chronic Insane, by the State 
of New York, marked the transition from the first to the second 
period, and that of the Illinois Eastern Hospital for the Insane, at 
Kankakee, marked the transition from the second to the third. 2 
The part taken by the Illinois Board of Public Charities in the 
history of this movement makes it proper for us to review it as 
briefly as is consistent with a perspicuous exposition of the charac- 
ter of the movement fo be elucidated, and of the reasons for it. We 
write this review, primarily and chiefly, for the information of the 
people of the State of Illinois. This will explain why certain names 
and events are not mentioned, to which reference might have appro- 
priately been made, and why some facts are stated with more full- 
ness of detail than would have been necessary for the information 
of specialists, to whom they are already familiar. 
There were insane people in the United States, before there were 
any hospitals for the insane. They were kept, as the insane for 
whom there is now no room in hospitals are kept, wherever it was 
possible to keep them, at their homes or elsewhere, and many of 
them, as at the present time, in almshouses and prisons. The de- 
mand for better accommodations led to the establishment of insti- 
tutions for their especial benefit. These were at first only depart- 
ments of general hospitals. The oldest American hospital for the 
insane is the Eastern Lunatic Asylum of Virginia. Then followed 
the Friends’ Asylum at Philadelphia, opened in 1817; the McLean 
Asylum at Somerville, Massachusetts, in 1818; the Bloomingdale 
Asylum, New York, in 1821; the Betreat, at Hartford, in 1824; and 
others, in succession, until the number of those now in opera!ion, 
public and private, is over one hundred. 
In 1845 was organized the Association of Medical Superintendents 
of American Institutions for the Insane, which held its first meet- 
ing in the city of Philadelphia. This Association, in 1851, adopted 
a series of twenty-six propositions on the construction of hospitals 
for the insane, which were written by Dr. Thomas S. Kirkbride, 
superintendent of the Pennsylvania Hospital. They are so admir- 
able in themselves and have exerted such an influence upon the de- 
velopment of the American system of care for the insane, that they 
are here reproduced in full. Without a knowledge of them, the 
history of the controversy, which began in 1866 and is not yet at 
an end, would be unintelligible. 
1. Every hospital for the insane should be in the country, not within less than two 
miles of a large town, and easily accessible at all seasons. 
2. No hospital for the insane, however limited in its capacity, should have less than 
fifty acres of land devoted to gardens and pleasdre-grounds for its patients. At least one 
hundred acres should be possessed by every State hospital, or other institution, for two 
hundred patients, to which number these propositions apply, unless otherwise men- 
tioned. 
3. Means should be provided to raise ten thousand gallons of water, daily, to reser- 
voirs that will supply the highest parts of the building. 
4. No hospital for the insane should be built without the plan having been first sub- 
mitted to some physician or physicians who have had charge of a similar establishment, 
or are practically acquainted with all the of their arrangements, and received his 
or their full approbation. 
5. The highest number that can, with propriety, be treated in one building, is two 
hundred and fifty, while two hundred is a preferable maximum. 
(!. All such buildings should be constructed of stone or brick, have slate or metallic 
roofs, and as far as possible be made secure from accidents by fire. 
7. Every hospital, having provision for two hundred or more patients, should have in 
it at least eight distinct wards for each sex—making sixteen classes in the entire estab- 
lishment. 
8. Each ward should have in it a parlor, a corridor, single lodging-rooms for patients, 
an associated dormitory communicating with a chamber for two attendants, a clothes- 
room, a bath-room, a water-closet, a dining-room, a dumb-waiter, and a speaking-tube 
leading to the kitchen or other central part of the building. 8 
9. No apartments should ever be provided for the confinement of patients, or as their 
lodging-rooms, that are not entirely above ground. 
10. No class of rooms should ever be constructed without some kind of window in 
each, communicating directly with the external atmosphere. 
11. No chamber for the use of a single patient should ever be less than eight by ten 
feet, nor should'the ceiling of any story occupied by patients be less than twelve feet in 
height. 
12. The floors of patients’ apartments should always be of wood. 
13. The stairways should always be of iron, stone, or other indestructible material, 
ample in size and number, and easy of access, to afford convenient egress in case of ac- 
cident from fire. 
14. A large hospital should consist of a main central building with wings. 
15. The main central building should contain the offices, receiving-rooms for com- 
pany, and apartments (entirely private) for the superintending physician and family, in 
case that officer resides in the hospital building. 
16. The wings should be so arranged that if rooms are placed on both sides of a 
corridor, the corridors should be furnished at both ends with movable glazed sashes, for 
the admission of light and air. 
17. The lighting should be by gas, on account of its convenience, cleanliness, safety 
and economy. 
18. The apartments for washing clothing, etc., should be detached from the hospital 
building. 
19. The draining should be under ground, and all the inlets to the. sewers should be 
properly secured to prevent offensive emanations. 
20. All hospitals should be warmed by passing an abundance of pure, fresh air, from 
the external atmosphere, over pipes or plates containing steam, under low pressure, or 
hot water, the temperature of which does not exceed 212° F., and placed in the basement 
or cellar of the building to be heated. 
21. A complete system of forced ventilation, in connection with the heating, is indis- 
pensable to give purity to the air of a hospital for the insane, and no expense that is 
required to effect this object thoroughly, can be deemed either misplaced or injudicious. 
22. The boilers for generating steam for warming the building, should be in a detached 
structure, connected with which may be the engine for pumping water, driving the wash- 
ing apparatus aud other machinery. 
23. The water-closets should, as far as possible, be made of indestructible materials, 
be simple in their arrangements, and have a strong downward ventilation connected 
with them. 
24. The floors of bath-rooms, water-closets and basement stories should, as far as 
possible, be made of materials that will not absorb moisture. 
25. The wards for the most excited class should be constructed with rooms but on one 
side of a corridor not less than ten feet wide, the external windows should be large, and 
have pleasant views from them. 
26. Whenever practicable, the pleasure grounds of a hospital for the insane should be 
surrounded by a substantial wall, so placed as not to be unpleasantly visible from the 
building. 
In these propositions the essential, characteristic features of a 
well planned hospital, of small size, are clearly and concisely stated. 
The majority of them embody suggestions which are likely to be of 
permanent and universal application. But it is to be noted that Dr. 
Kirkbride, at the outset, warns every reader that the number of 
patients to which they apply is, unless otherwise mentioned, two 
hundred. The attempt to make certain of them apply to buildings 
with a capacity of six hundred or more, is the exciting cause to 
which, in part, at least, is referable the agitation ou the question of 
hospital construction which has marked the past twenty years. It 
is further to be noted, that in the language of their revered author, 
they apply to “hospitals” for the care of insanity, and not to 
asylums for the insane whose malady has passed into a chronic and 
probably incurable stage of development. 
In order to obtain a just conception of the relations of this ques- 
tion, it must be remembered, on the other hand, that the wretched 
condition of the chronic pauper insane in jails and almshouses has 
been, from the beginning, the principal ground of appeal for liberal 
action on the part of legislatures in the matter of provision for the 4 
insane. Miss Dix, who has made more personal effort to secure 
such provision than any other living citizen of any country, and 
who has enjoyed the unspeakable happiness of seeing her philan- 
thropic labors crowned, in her life-time, with a degree of success- 
ful achievement beyond her own initial hopes, said, for instance, in 
her memorial to the New York legislature, in 1844, (before the 
organization of the Association of Superintendents, and seven years 
before the adoption of the propositions): “My earnest, my impor- 
tunate intercession, is in behalf of the incurable insane, who, lost 
for life to the exercise of a sound understanding, exposed to suffer- 
ing and degradation, to neglect and abuse, and often abandoned of 
friends, are at once the most dependent and most unfortunate 
of human beings.”* 
It is true, that the Association, in 1851, at the same meeting at 
which the propositions were adopted, also adopted a resolution, that 
“it is the duty of the community to provide and suitably care for 
all classes of the insane, and that * * * it is improper, except 
from extreme necessity, as a temporary arrangement, to confine in- 
sane persons in county poorhouses or other institutions, with those 
afflicted with or treated for other diseases or confined for misde- 
meanors.” But it is highly probable that undue expectations were 
at that time entertained of the result of the establishment of “hos- 
pitals” for the insane. This may have been due to an exaggerated 
estimate of the probability of effecting a cure for the disease, or to 
a want of foresight of the rapid and extraordinary increase in the 
number of the chronic insane. Be this as it may, it is certain that 
the chronic pauper insane are not named in the propositions, and 
the use of the word “patients” instead of inmates, suggests the 
possibility that they were not consciously alluded to. The proposi- 
tions did not completely cover the ground, or else they were not 
worded with sufficient precision to make their meaning and applica- 
tion unmistakable. 
The particular propositions which have, occasioned the largest dis- 
pute are the fourteenth with the seventh and eighth. “A large 
hospital should consist of a main central building with wings. Every 
hospital having provision for two hundred or more patients, should 
have in it at least eight distinct wards for each sex—making six- 
teen classes in the entire establishment. Each ward should have 
in it a parlor, a corridor, single lodging-rooms for patients, an asso- 
ciated dormitory communicating with a chamber for two attendants, 
a clothes-room, a bath-room, a water-closet, a dining-room, a dumb- 
waiter, and a speaking-tube leading to the kitchen or other central 
part of the building.” 
The conception embodied in this language was elaborated, by Dr. 
Kirkbride, in a book of great value, “On the Construction, Organ- 
ization and General Arrangements of Hospitals for the Insane,” 
originally published in 1854, of which a later and revised edition 
appeared in 1880. The influence of this book, in the United States, 
has been even greater than that, in JB’rance, of the great work of 
*It is worthy of remark, in passing, that Miss Dix, in her memorial to the legislature 
of New York, used the following expression: “Cottages might be adjacent to a main 
building for the most tranquil male patients.” And again: “The true remedy will ba 
found in State asylums, on a cheap but comfortable plan, for the incurable.” M. Parcliappe, entitled “Des Principes a Suivre dans la Fondation 
et la Construction des Asiles d’Alienes.” Dr. Kirkbride’s ideas have 
been embodied in brick and mortar in nearly all of the great insti- 
tutions for the insane erected either by the several States or by 
private corporations; and every one who has seen any one of these 
institutions knows, without further description or explanation, what 
they are. The type is uniform; the differences are in the details. 
Wards, with central corridors and rooms “placed on both sides;” 
the majority of the rooms “single lodging-rooms for patientseach 
ward complete in itself; the number of wards governed by the total 
capacity of the hospital; the number of patients to a ward averag- 
ing twenty-five, more or less; all the wards for male patients 
in one wing and all the wards for female patients in the other; the 
two wings separated by a centre building for the offices and the 
officers, which may be believed to have been of moderate size, in a 
hospital for two hundred patients, but in a hospital for six hundred 
is overgrown and reminds one of a great hotel; the wings pro- 
longed, on either side, to a length of almost fabulous extent; and 
the domestic buildings detached, but usually connected with the 
main edifice by corridors or underground passages. Such are the 
main features of an American institution for the insane, constructed 
in accordance with the interpretation which has been everywhere 
put upon the propositions. The experience of half a century shows 
that the actual average cost of institutions of this pattern has been 
from one thousand to twelve hundred dollars a bed. 
It is astonishing that so great stress has been laid, in this coun- 
try, upon the form of the edifice, as if there were in it some mys- 
terious curative power and effect, and any departure from this type 
would inevitably lead to some unknown disaster. Contrast with this 
feeling of devotion to a single ideal the saying of Dr. Eutherford, 
of Lenzie, in Scotland: “Given a skilled physician and competent, 
trained attendants, with removal of the patient from his home, and 
I do not care what the house is.” Contrast with it the saying of 
Mr. Mould, of Cheadle, England: “If I had charge of six hundred 
insane people, I would not want hospital accommodation for more 
than one hundred,” a saying founded on his personal experience in 
the care of the insane in ordinary rented dwellings, and in cottages 
on his own grounds. In England, there is no such uniformity of 
architectural construction. In France, there is uniformity, to a very 
considerable extent; but the type of construction is as different from 
our own as possible. Yet insane people recover, and those w'ho do 
not recover are kindly and well cared for, in both these and in other 
countries. 
From 1851, when the propositions wrere adopted, until 1865, when 
Dr. Cook asked to have them modified by the Association, so as to 
meet what he conceived to be the altered conditions of the problem 
of provision for all the insane, their authority was practically un- 
questioned. The pressure for admission to institutions v7as so great 
that some of them were enlarged to accommodate more than two 
hundred or even two hundred and fifty patients. But neither the 
increase in their size nor in their number proved to be sufficient to 
empty the jails and almshouses of the chronic insane, who dragged 6 
out in them a miserable existence. What enlarged provision was 
made was exclusively on the lines laid down in the propositions; 
but it was inadequate to the public demand. 
We cannot better describe the situation than in the words of 
Dr. Isaac Ray,* who was, at the time of his death, in 188J, the ac- 
knowledged Nestor of the fraternity of superintendents: “In the 
early stages of this benevolent enterprise of establishing hospitals for 
the insane, one of the principal objects proposed by it was the 
proper care and custody of the old incurable cases. It was their 
sufferings, as exhibited in the jails and poorhouses of the country, 
which, some five and thirty years ago, led Horace Mann and a few 
others to begin that movement, the first fruits of which were the 
hospital at Worcester, Massachusetts. They labored, as they sup- 
posed, for the poor, the neglected, the friendless, the hopeless, not 
for the wealthy and curable, who might be safely left to the min- 
istry of their friends. For a time it seemed as if the precise object 
of their labors had been accomplished and placed beyond the reach 
of any change of fortune. The jails and poorhouses were emptied 
of their unfortunates, and an incalculable amount of relief from the 
fast extremity of human wretchedness was effected. A more curious 
change of purpose has seldom been witnessed than that which has 
been induced on this subject by the very development of the original 
enterprise itself. For whereas the object at first was to place all 
these persons in the hospitals, the question that agitates the philan- 
thropists of our day (1866) is how to get them out of the hospital. 
In the course of a few years, the hospital came to be generally re- 
garded as the only suitable place for the insane, and their claims 
on the public bounty were recognized by regular legislative appro- 
priations. There is not a community among us that thus provides 
for even one-half of its insane, unless it may be Massachusetts. In 
this condition of things, the conclusion has been generally adopted, 
that if any are to be excluded from the hospital, for lack of room, 
it should be those to whom it would be a permanent home, rather 
than those for whom a few months’ residence would lead to re- 
covery or considerable improvement. The almost universal practice 
of our State hospitals is, therefore, to discharge their patients after 
they have clearly become incurable, in order to make room for those 
recently attacked. The patients thus discharged, after exhausting, 
perhaps, the patience and the bounty of their friends, arrive, sooner 
or later, at a final home in the poorliouse or jail, and thus steadily 
increase that mass of suffering humanity whose dimensions seem to 
defy all the resources of public benevolence. To furnish hospital 
accommodations for all, is what no community here or abroad has 
yet done, and it is less likely than ever to be done in this country, 
while staggering under the burdens which the great national contest 
has heaped upon us. Are they then to be left to a kind of custody 
and care which deprives them of many a comfort and inflicts upon 
them many a suffering, without the slightest attempt to better their 
condition? This is the question which is now beginning to be con- 
sidered as scarcely second in importance to that which found its 
practical solution in the first establishment of hospitals for the help- 
less insane.” 
*Journal of Insanity, April, 1866. 7 
A condition like that described could not exist without being appar- 
ent to many, and in more than one State. Efforts began to be 
made, here and there, to remedy so great an evil. But, for reasons 
which are obvious, we coniine our attention to the movement, in the 
State of New York, which directly led to the establishment of the 
Willard Asylum. 
At a convention of the superintendents of the poor, in Syracuse, 
February 21, 1855, the following resolution was adopted: 
Resolved, That the convention do unanimously recommend to the legislature the 
establishment of an asylum for such insane persons as cannot be received by the present 
State Lunatic Asylum, but more particularly for the reception of such patients as have 
been discharged therefrom uncured. 
At an adjourned meeting of the superintendents of the poor, in 
August of the same year, at Utica, they adopted the following: 
Whereas, It is already conceded, and has been adopted as the policy of the State, 
that insanity is a disease requiring, in all its forms and stages, special means for treat- 
ment and care, therefore, 
Resolved, That the State should make ample and suitable provision for all its insane 
not in a condition to reside in private families. 
Resolved, That no insane person should be treated, or in anyway taken care of, in any 
county poor or almshouse, or other receptacle provided for [paupers! and in which pau- 
pers are maintained or supported. 
Resolved, That a proper classification is an indispensable element in the treatment of 
the insane, which can only be secured in .establishments construct ed with a special view 
to their treatment. 
Resolved, That insane persons considered curable and those supposed incurable 
should not be provided for in separate establisbments. 
The following resolution, adopted at Syracuse, in September, com- 
pleted their action: 
Resolved, First, that the present provision for the insane of the state is defective and 
inadequate. Second, that their present condition demands immediate attention and re- 
lief. Third, that the relief should be commensurate with the demand. Fourth, that a 
committee of five be appointed to memorialize the legislature, at its ensuing session, and 
recommend such action as will secure attention to the wants of this class of our citizens. 
The chairman of the committee appointed was from Oneida county. 
The memorial, which was in January, 1856, recommended 
“the immediate erection of two State lunatic hospitals, so located 
that they may accommodate the largest number of insane at pres- 
ent unprovided for.” 
A committee of the senate was appointed to visit and examine the 
poorhouses of the State. It made a report, in which it also 
recommended “the establishment of two or more asylums for the 
insane, to be under similar control and management with the State 
Asylum.” 
But although a bill was introduced for the creation of two addi- 
tional hospitals, it failed to pass; and for a number of years the 
only visible fruit was the effect upon public opinion outside of the 
legislature. 
As the result of certain action by the State Medical Society, the 
legislature in 1864 authorized the secretary of that society, Dr. S. 
D. Willard, who was also surgeon-general of the State, to investi- 
gate the condition of the insane in the county poorhouses. The 
investigation was made by correspondence with physicians appointed, 
by the county judges in the several counties, to examine in person 
the institutions reported upon; and their reports, in the form pre- 
scribed by Dr. Willard, were by him tabulated and a full report 
presented to the legislature, in January, 1865. 8 
After the governor had transmitted Dr. Willard’s report to the 
legislatnre, Dr. John B. Gray, of Utica, met Dr. Willard and ex- 
pressed his surprise at his recommendation of the establishment of 
a separate institution for the care of the chronic insane. He told 
him that the scheme had been tried in Europe and failed; that it 
would be injurious to the interests of the insane and of the com- 
munity at large, to adopt it in this country; that it was a retrogade 
step, unnecessary, and condemned by the profession ; and that it would 
be only the continuance of the almshouse system, disguised under 
another name. Dr. Willard asked Dr. Gray to draft a bill such as 
would, in his opinion, meet the wants of the State, which Dr. Gray 
did, simply providing for the two new institutions, one east and one 
west of Utica. Dr. Gray’s bill, or its equivalent, was in fact intro- 
duced, but before coming to a final vote, what is known as the 
Willard act was substituted for it.* 
The name originally given to the institution in the bill was the 
“Beck Asylum,” in honor of Dr. T. Romeyn Beck, but it was 
changed to the “Willard Asylum,” in honor of Dr. Willard, who 
died while it was pending. 
This act was an attempt to supersede the system of providing for 
the chronic insane in the poorhouses. It provided that all cases of 
insanity not of not less than one year’s duration should be sent to 
the State Asylum at Utica, and that no more chronic insane should 
be sent from the State Asylum to the county poorhouses, but that 
on the contrary the chronic insane in the county poorhouses should 
be transferred to the new asylum. 
Reference may be made, in passing, to the fact that .this year 
(1865) was that in which the long projected receptacle for pauper 
lunatics of the State of Massachusetts was erected, in connection 
with the State almshouse at Tewksbury. It was also the year in 
which Dr. Hills, superintendent of the Central Lunatic Asylum, of 
Ohio, proposed, in his report to the legislature, that they should 
purchase a farm of five hundred acres, and erect upon it two build- 
ings, one for each sex, each to accommodate one hundred patients, 
that other similar buildings, to be clustered in village style, should 
be erected annually, and that the new institution should be called a 
Farm Home for the Insane, or, in view of the village style of build- 
ings proposed, a Hamlet Home for the Chronic Insane. Dr. Hills 
had previously recommended, in 1859, the building of a State asy- 
lum for the chronic insane, rather than to turn back the patients 
upon the counties. 
In the October number of the Journal of Insanity, (1865), an 
article on “The Willard Asylum and Provision for the Insane” 
appeared, the object of which was stated to be: to call attention “to 
some of the fundamental principles upon which proper provision for 
the insane is based, and to show, inferentially, that the law fails to 
meet the necessities of the State,” in which it was declared that 
over the gateway to such vast establishments for the incurable 
should be written, “Ail hope abandon, ye who enter here.” The 
*Subsequently, in 1866, the Hudson River Hospital for the Insane, at Poughkeepsie, 
was created by the legislature of New York; and in 1869, the Buffalo State Asylum for the 
Insane. 9 
insufficiency of the law to meet the question of proper provision 
for the insane was pointed out and argued at length. “There is, 
perhaps, no subject connected with provision for the insane,” it was 
said, “upon which the verdict of the profession has been more 
unanimous than their condemnation of asylums for incurables.” The 
writer advocated the creation of three districts, the eastern, the 
western and central; and the erection in each of a hospital proper, 
in conjunction- with separate buildings, less expensive and of simpler 
construction than the hospital, and disconnected with it, for the 
quiet, the filthy dements and paralytics. Buildings of a suitable 
form should also be erected for the treatment of epileptics. Each 
hospital should have a farm attached to it, of from three to five 
hundred acres. Upon the farm, there should be cottages for the 
employees engaged in the various agricultural and industrial depart- 
ments of the institution. With these employees the orderly, indus- 
trious chronic or the convalescent acute patient might reside. Such 
an arrangement would permit a certain amount of family life and 
a larger liberty to this class than are compatible with the organiza- 
tion of the hospital proper. It might be found practicable, after due 
consideration, to withdraw a certain proportion of patients from the 
hospital and domicile them in . cottages, which could, in a great 
measure, be constructed at small expense by the labor of patients 
themselves. That some classes of the insane may be thus provided 
for, with advantage to themselves and at comparatively small outlay, 
has been fully demonstrated in asylums in England and on the 
Continent. It should, however, be remembered that, in the judg- 
ment of those European physicians who have had most practical 
experience, and whose medical and administrative capacities are of 
the highest order, although this arrangement is attended by the 
happiest results in certain instances, it has thus far been found 
applicable/ to a relatively small proportion only of the insane. Still, 
as an appendage to the hospital, it would add greatly to the facili- 
ties of classification. It3 capability of extension, so as to embrace 
any very large number of patients, observation and experiment can 
alone determine. 
The opinion of the law expressed in the “Summary,” in the same 
number of the Journal from which the above quotation is taken, 
was that it had given a “fictitious influence” to the exploded theory 
of separate establishments for the so-called incurable class of insane ; 
that it “was adopted during a period of civil war, when the great 
question of the day absorbed every thought;” that it was “to some 
extent based on wrong principles;” and that it was to be hoped 
that the legislature would “convene under happier auspices, when 
the defects of the present law” would be remedied. 
At the meeting of the Association in Pittsburgh, m July of the 
same year, Dr. Butler made an address on the subject of “The 
Condition of the Indigent and Incurable Insane,” which is said to 
have given rise to the most spirited debate of the session. He be- 
gan by saying that in the early history of the care of the insane in 
this country, special steps were taken in the direction of provision 
for curable cases; but at that time, when the Association first met, 
the present condition of incurable cases could not be foreseen. The 
question before the Association was: what shall we do with them ? 10 
and can we devise any plan at a rational expenditure ? He favored 
a State Farm, with all the appliances necessary for the care of in- 
curable patients. The presence of the incurables in an institution 
for the curables he believed to be an evil. 
The prevailing sentiment of the Association, as demonstrated by 
the discussion which followed, was in opposition to the separation 
of curable and incurable cases of insanity: but a committee was 
appointed to take into consideration the chronic and supposed in- 
curable insane, and the best possible arrangement for their custody 
and treatment, and to report at the next meeting. 
At the meeting of the Association, the following year, in Wash- 
ington, Dr. Butler informed the secretary, by letter, that on account 
of ill-health he had not been able to prepare a report. The Asso- 
ciation decided to discuss the question, which it regarded as of great 
importance, without a report from the special committee, and Dr. 
George Cook was requested to read a paper* prepared by him on 
“Provision for the Insane Poor in the State of New York.” 
The essential points made by Dr. Cook, in the paper read by him, 
were as follows: 
That in fifty-five counties of the State of New York, not including 
New York and Kings, there were, as shown by Dr. Willard’s report 
to the legislature in 1865, thirteen hundred and forty-five lunatics, 
confined in poorliouses or poorhouse asylums, nearly all of them 
incurable, some of whom had been returned from the State asylum 
at Utica as incurable, while others had never had the benefits of 
asylum treatment. 
That the capacity of the Utica asylum was limited to six hundred 
patients. 
That the lunacy laws of New York required the discharge from 
the State asylum of patients of the indigent or pauper class, when, 
in the opinion of the superintendent, they were not likely to he 
benefited by remaining longer, and the room occupied by them was 
needed for recent cases; and that, under the operation of this pro- 
vision of the law, the number of chronic insane in the county poor- 
houses was steadily increasing. 
That the condition of hundreds of these patients confined in county 
receptacles was most deplorable, paupers themselves, surrounded by 
paupers, cared for, or rather neglected, by paupers, friendless and 
forlorn. 
That there were but three possible answers to the question, what 
shall we do with these chronic pauper insane now in county poor- 
houses, namely: (1) Leave them where they are; or, (2) Make 
provision for them in hospitals constructed in accordance with 
the propositions of the Association; or, (3) Provide for them in 
institutions of cheaper construction, and with diminished cost of 
maintenance. 
*In the “Summary,” this is characterized as “the first labored effort in defense 
of separate establishments, in this country, for the chronic insane.” 11 
That the propositions of the Association asserted that two hun- 
dred and fifty was the maximum number of patients which should 
be provided for in one hospital. 
That to leave the chronic insane poor in the county poorhouses 
was wrong; to provide for all of them according to the propositions 
of the Association was impracticable; therefore humanity to these 
unfortunates demanded that the State should make such provision 
for them as. was within its power, even if not in accordance with 
the propositions. 
That the objections to separate provision for the chronic insane 
were fallacious; but that even admitting their force, it would be wiser 
to accept separate provision, if nothing better was attainable, than 
to adhere to the unattainable and get nothing. 
That the great obstacle to State care of all the insane was the 
cost of support under the existing hospital system; and that not 
only might the chronic insane properly be provided for in less costly 
buildings than those erected for curative treatment, but the cost of 
maintenance might be considerably reduced. 
Dr. Cook replied to the attack upon the Willard law in the Octo- 
ber number of the Journal of Insanity, in substance as follows: He 
pointed out that the propositions were adopted many yeais ago, 
and were based upon the condition and apparent wants of the in- 
sane at that time; that they looked only to the erection of small 
hospitals, mainly for the treatment of recent cases, and ignored the 
fact that the county poorliouses were as much a nart of the actual 
provision for the insane as the State Asylum, neither did they point 
out any remedy for the evils complained of. On the contrary, the 
“hospital” system, as administered, was a barrier to any effective 
action in the direction of checking the growth of the county recep- 
tacles. He insisted that an institution for the chronic insane can- 
not be properly denominated an institution for incurables, since 
“the medical solecism of pronouncing any patient incurable is 
hardly worthy of notice.” He repudiated the imputation that he 
supposed that any institution for the insane could be made self- 
supporting through the labor of the inmates. He called attention 
to the fact that the separation of the chronic insane was not an 
original proposition with the friends of the Willard Asylum, but an 
existing fact; that they were separated m the poorhouses from the 
supposed curables in the State Asylum, and would not be any more 
v separated than they already wTere, if they should be gathered 
together in a State institution, under proper medical supervision. 
He presented to the Association an alternative method of caring 
for them, if they would not approve of the Willard Asylum, and 
said: “If there is any better practical solution of this question, I 
beg that it may be brought forward now. * * Were all the in- 
sane poor of our State provided for in State hospitals, or did I be- 
lieve that such provision could be obtained for them, I should not 
now come forward as a defender of a separate and distinct asylum 
for the chronic class. * * These less expensive buildings for the 
quiet and industrial classes might be erected upon the farms con- 
nected with our State hospitals, and separate provision be thus 
made for the chronic insane. I am inclined to the opinion that 
some plan of this kind will be eventually adopted.” 12 
The historical importance of this paper is such, that a less full 
abstract of it than that which has been here given would be in- 
sufficient for the truthful elucidation of the origin and progress of 
the controversy which followed. Its reception by the Association 
was remarkable on many accounts, but chiefly because it was so 
completely misunderstood. To a fair-minded man, in the light of 
subsequent events, it would seem that the only answer which could 
be made to it would have been to show that provision for all the 
insane, in accordance with the propositions of the Association, on 
what he terms “the hospital system,” was not (as Dr. Cook believed 
it to be) impracticable. This was in fact the ground taken at the 
time by the majority of the members present, though there were a 
few who thought as Dr. Cook did on this question.* But the gen- 
eral tone of the debate, upon which we refrain from comment, was 
such, that the author, of the paper, in closing it, very justly said 
that “the discussion had taken a wide range and much had been 
said which had little bearing upon the question presented,” and 
alluded with genuine pathos to “the denunciation which had been 
heaped upon and other friends of the Willard Asylum, as 
advocates of ‘cheapness’ and ‘inhumanity.’” 
Dr. Walker, on behalf of the special committee on the care of 
the’ chronic insane, proposed a series of resolutions, of which the 
fifth declared that “demented persons, in whose cases the disease 
is chronic and advanced, may, with propriety, be provided for in 
institutions other than hospitals, but always in buildings constructed 
expressly to meet the requirements of their peculiar condition, with 
such arrangements and provisions for their care and custody as 
shall effectually secure them from the danger of abuse and neglect 
to which, as a class, they would otherwise be specially liable, and 
under the entire control of a competent resident physician.” This 
was rejected. Dr. Chipley moved, as a substitute, the resolutions 
of the superintendents of the poor of the State of New York, quoted 
above, (page ;1) but subsequently modified his motion to include on- 
ly the first and second of the second series, which were adopted. Dr. 
Cook asked the Association to qualify the propositions so far as to 
admit that if the question presented in any State be: Shall the 
chronic insane poor continue to be confined in county poorhouses, 
or shall provision be made for them in special asylums at a less 
cost than in hospitals ? on this question the Association would 
accept the special provision, if hospitals were not attainable, and 
abolish the county receptacles. But this the Association would not 
agree to. On the contrary, it voted that “all hospitals for the 
insane should be constructed, organized and managed, substantially 
in accordance with the propositions adopted by the Association in 
* Dr. Chipley said that he conceived the combination of the asylum and hospital prin- 
ciple in one institution to be the best plan. Dr. Bancroft thought that if any modification 
of the existing system was called for, it might be accomplished by a system of classifica- 
tion under which the chronic insane should be provided for in buildings attached to regu- 
lar hospitals, under the care of the regular superintendents. Dr. Brown saw no objec- 
tion to the annexation of a department for the chronic insane to an ordinary hospital, 
under the same general supervision. Dr. Walker agreed with Dr. Brown, and added that 
in his own case in Boston he would advocate the erection of a contiguous building espec- 
ially for the chronic insane, to be under the same direction. Dr. Nichols took the same 
ground. Dr. Earle thought that the addition to the State almshouse at Tewksbury for 
the chronic insane might have been made as cheaply at one of the State hospitals for the 
insane already established. 1851 and 1852, and still in force,” and that “the enlargement of a 
city, county or State institution for the insane * * may be 
properly carried, as required, to the extent of accommodating six 
hundred patients (the number then in the New York State Asylum), 
embracing the usual proportions of curable and incurable insane in 
a particular community.” The adoption of these resolutions, taken 
together, was an affirmation of the doctrine that the incurable in- 
sane must be cared for in institutions for the curable, constructed 
after the then existing type of hospitals for the insane in the United 
States, but upon an enlarged scale. This was in accordance with 
the opinion expressed by Dr. Kirkbride, that “the only proper mode 
of providing for the chronic insane, is for every state to erect just 
as many hospitals as are necessary to provide for all the insane, 
and that the propositions of the Association of Medical Superin- 
tendents, both in regard to construction and organization, should 
be fairly carried out.” 
There is no more reason to doubt the honesty of the Association 
in its opposition to the views expressed by Dr. Cook, than there is 
to question the honesty and humanity of feeling which prompted 
their expression by him. It may well be believed that both parties 
to the controversy sincerely desired the welfare of the insane, and 
of all the insane; but the difference between them related to the 
mode of provision on the part of the- State. There was no possible 
escape from Dr. Cook’s analysis of the situation. All were agreed 
that the county poorhouses were unfit places in which to keep the 
insane, even the pauper insane. The friends of Willard said: the 
State will not build hospitals for the care of incurables; let us build 
asylums. The opponents of Willard replied: The State ivill build 
hospitals for incurables, and the proposal to build asylums is a 
suggestion to lower the standard of care of these unfortunates, which 
we must resist with all our might. 
After the lapse of nearly twenty years, with the added experience 
and knowledge gained during that period, it appears that the friends 
of Willard were right, and their opponents at fault, in their con- 
clusions. The question was argued, at the time, on the assumption 
that it was simply a question of caring for the chronic insane 
together with recent cases or separately. In reality, this question, 
instead of being vital, as it was supposed to be, was so entirely 
subordinate to the main question at issue, that it might have been 
completely ignored, as of no practical moment. The true issue was, 
whether the State could or would build hospitals, constructed in 
accordance with .the propositions, in sufficient number and of suffi- 
cient capacity, to empty the poorhouses and accommodate all the 
insane who were destitute of homes, or who could not, for any 
reason, be kept at home; and if not, whether it would be practi- 
cable and right to build up institutions of a simpler type of con- 
struction, and of a less expensive pattern, in which to collect to- 
gether the chronic insane of the State, under proper medical over- 
sight and control, rather than leave them to perish in the county 
receptacles. Whether there should be one such institution or several; 
whether it should be on the grounds of a State hospital for the in- 
sane and under the same general management, or distinct and 
separate; whether it should or should not receive curable cases for 
treatment; wTere questions wholly subsidiary in importance. 14 
At the meeting of the Association in Philadelphia, in May, 1867, 
Dr. John B. Chapin re-opened the question of provision for the 
chronic insane poor, by reading an article so entitled. A careful 
study of his paper reveals its motive, which was to secure additional 
provision by the State for the care of the chronic pauper insane, in 
such a form and under such restrictions as to secure the discontin- 
uance of the system of county care, by rendering it impossible to 
divert the provision made from its actual intention. But if separate 
provision could not be made for these unfortunates, then he sought 
to have the Association commit itself to the position that they 
should not be discharged from hospitals for the insane unless res- 
tored to reason. Under no circumstances should they be sent to 
poorliouses. He thought that institutions for the insane should be 
first curative, but also custodial, in their character — not hospitals 
only, but asylums as well. He quoted the French Commission as 
in favor of the separation of the recent and acute from the chronic 
and incurable, for both economical and medical reasons. But he 
would be satisfied if detached buildings for the reception of those 
whose sufferings he sought to alleviate,1 supplementary to hospitals, 
could be erected. One-third of all the patients would probably re- 
quire the accommodations of the hospital structure. * * * The 
establishment would permit of considerable enlargement, and the 
average cost of support thus be materially reduced; the buildings 
would not cost exceeding one-half (per capita) the amounts usually 
expended in this way; and a most important result would be ac- 
complished in the great reduction of personal seclusion and restraint 
that would ensue. 
In opposition to the views expressed by Dr. Chapin were quoted 
the propositions adopted by the Association the year before; that 
hospitals for the insane should be constructed, organized and man- 
aged in accordance with the propositions adopted in 1851 and 1852; 
and that “the facilities of classification or wabd separation possessed 
by each institution should equal the requirements of” both recent 
and chronic cases. The interpretation put upon these declarations 
was undoubtedly unfavorable (1) to classification in separate institu- 
tions, and (2) to classification in separate buildings. The separation 
must be by classification in wards of a single building; but the 
erection of a building with a capacity of six hundred patients, 
though not desirable, might be tolerated as a necessity, under the 
pressure for additional room. 
At the meeting of the Association in Hartford, in 1870, Dr. Jarvis 
gave utterance to his opinion, in a paper on “Proper Provision for 
the Insane.” After remarking on the great variety of types of in- 
sanity and the corresponding variation in treatment which this 
diversity suggests, and declaring that some of the insane may be 
restored at home, while others only require separation from disturb- 
ing causes, in order to their restoration, but that others still need 
both separation and supervision, he entered upon the examination 
of the question whether the hospital, as now constructed, is adapted 
to the various conditions and wants of all classes of patients. The 
history of the treatment of insanity shows that the original concep- 
tion of this affliction was that it was due to possession of the devil, 
and therefore the patient must either be rescued from the control 15 
of liis demoniac possessor by the intervention of supernatural agency, 
or else, as a sinner,, be punished as his case seemed to demand. 
But, as the supernatural or miraculous power of healing was not 
given to man, “the punitory method became the rule which was, 
for centuries, adopted by the world. Sometimes, according to the 
rude notions of the period, the triple purposes of religion, medicine 
and justice were combined in the treatment of lunacy. In the mid- 
dle ages, when the monasteries were, in a manner, hospitals, to 
which the sick resorted for care or relief, the Franciscans had 
especial charge of the insane. In one of their establishments, some 
of these severe disciplinarians applied to their lunatic patients the 
same rule of chastening that they did to themselves, and gave to 
each one ten lashes a day. * * The lunatic hospital, as it now 
presents itself, as a curative institution, is modern. * * The 
question arises whether hospitals cannot be so arranged as to meet 
the varied wants, capacities and liabilities of the inmates; whether 
they may not provide and offer comfortable, home-like accommodations 
for the mild and the trustworthy, as well as security for the dan- 
gerous, and all the intermediate grades of strength and pleasant 
convenience for the intermediate grades of mental disorder. * * 
Instead of one uniform construction in every part, with the same 
means of confinement for all, in a single building, there should be 
separate buildings, differing in structure and character, according 
to the necessities of the various classes of patients. While some 
may be strong as the whole now is, for the untrustworthy and 
violent, others should be built in the form and manner of ordinary 
dwellings, with generous, confiding and unbarred windows and doors, 
such as the patients have been accustomed to in health. * * In 
all of these the confinement and liberty can be measured in ac- 
cordance with the condition of each patient. * * It would be a 
boon to a large portion of the milder patients, to be allowed to be 
under the faithful care and skillful treatment that now protects and 
heals them, and yet suffer no needless pain and mortification, and 
no unnecessary circumscription of their remaining enjoyments. It 
is not proposed here to adopt the system of Gheel, nor the cottage 
system of Scotland, nor that of Clermont, but the power and virtue 
that belong to them are not to be overlooked.” 
Dr. Jarvis’ paper was not discussed until the following meeting, 
at Toronto, in 1871. Among those who favored the views which he 
expressed were Dr. Landon, who said.: “The cottage system, I be- 
lieve, is desirable, because it gives liberty and domesticity.” Dr. 
Parsons said: “Asylum accommodations can be increased so as to 
be admirably adapted to the wants of these classes (the quiet and 
the incurable) by the erection of detached buildings, one or two 
stories in height, at a little distance from the main structure—near 
enough for convenience of administration, but so far off as not to 
interfere with the completed plan. These buildings should be con- 
structed in a simple, economical manner. There need be no separate 
rooms for patients, and no strong guards for the windows. Con- 
siderable advantage would be gained by erecting these buildings two 
stories in height, using the upper story as an associated dormitory, 
and the lower story as a day-room. The large day-room and the 
associated dormitory are admirably adapted for quiet, but untidy and 16 
filthy cases, that require constant supervision throughout the whole 
twenty-four hours; while the situation of the day-room on the first 
story so diminishes the trouble of getting the patients out into the 
open air, that in point of fact they will enjoy this agreeable and 
healthful mode of life to a much greater extent than they would if 
a flight of stairs intervened between the day-room and the airiug 
courts.” Hr. Hughes said: “In my own experience, I do know 
that there are numerous patients who certainly derive benefit from 
being assigned to nicely constructed cottages upon the asylum prem- 
ises, allowing them the utmost latitude compatible with their phy- 
sical and mental welfare, and not having them under lock and key. 
It is a much more economical system than the present one.” On 
the other hand, Hr. Ray questioned whether the patients would be 
any happier from being managed in the way proposed by Hr. Jarvis; 
also whether the supervision absolutely necessary to the proper 
management and treatment of the insane could be secured in scat- 
tered buildings. He thought that the facilities for elopements and 
escapes would be better. Hr. Kirkbride said that he had built a 
cottage on the grounds of the Pennsylvania Hospital, in 1854, but 
that experience had taught him not to build a second; even the 
highest officer would find himself making excuses for not visiting 
these detached structures on cold and stormy nights, and on other 
inconvenient occasions. The system only leads to the transfer of 
responsibility to subordinates. Hr. Gray said that just such views 
as those advocated by Hr. Jarvis, sent forth to the public, are more 
injurious to hospitals than even th<5 public prejudice that exists 
through ignorance and superstition. 
In the July number of the Journal of Insanity, following the meet- 
ing of the Association in 1870, an important article was printed, on 
“Hospital and Cottage Systems for the Care of the Insane,” in which 
the position that “the best arrangement for all the material pur- 
poses of a large asylum, so far as a good experience goes, is that 
of connected buildings, either under one roof, or so adjacent and 
communicating by protected passages that they may all be readily 
accessible, at a moment’s warning, by the superintendent and attend- 
ants, without exposure to the weather, and that all necessary trans- 
fers or removals of patients may be promptly made without a like 
exposure and without much observation,” was maintained by a num- 
ber of arguments. “Such a plan excludes the idea of detached 
buildings, except, perhaps, porters’ lodges, tenements for gardeners 
and workmen, and such external conveniences as may be demanded 
for outside service. The compactness and order of such an arrange- 
ment, as compared with detached buildings, call them cottages or 
what you will, is so advantageous for economy of structure, of re- 
pairs, of supervision, of attendance, of removals, of classification, 
of recreation and diversion, and of household service, that such cir- 
cumstances should give it, as they have done in this country, a de- 
cided preference.” “It is proposed by some that the cottages should 
be scattered about in the vicinity of a central hospital building and 
its offices; sufficiently remote for isolation, but not so distant as to 
be removed from the supervision of the hospital officers. On the 
score of economy, which seems to be the chief pretext for such an 
arrangement, they must signally fail. In a sanitary view, the cot- 17 
tage system in any way of management, by isolating chronic cases 
from the rest, adds to the unhappiness of a state already sufficiently 
unhappy.” 
These citations will suffice to show the new form which the con- 
troversy as to the best practicable mode of caring for the insane 
had now assumed. It was no longer a question of separate estab- 
lishments for incurables. In fact, only four such establishments, 
owned and controlled by states, and not by counties or municipal 
corporations, have ever been founded in this country,—Willard and 
Binghampton, in New York; Tewksbury, in Massachusetts; and the 
State Farm, at Cranston, in Bhode Island. These are not, strictly 
speaking, for “incurables,” but for chronic insane paupers. 
It was at this moment, when the question under discussion had 
so far changed its form, that it was rather that of separate build- 
ings than of separate institutions, that the Board of State Com- 
missioners of Public Charities for the State of Illinois was created, 
in 1869.* Without hesitation, and as if by instinct, it assumed the 
position that the classification demanded by the interests of all 
parties, especially of the insane themselves, was not in separate 
wards of one building, on the one hand, nor in separate institutions, 
on the other. It took the only remaining alternative—separate or 
detached buildings, for the care of both recent and chronic cases, 
in a single institution, under a single head. This was really middle 
ground between extreme views on both sides. It was not unaccept- 
able to Dr. Cook and his friends, for Dr. Cook had said, at the 
meeting of the American Social Science Association, in New York, 
in 1867, “The proposition in behalf of the chronic insane poor is 
simply this: Either in proximity to our present state hospitals for 
the insane, or in connection with those to be built hereafter, or 
separate from either, if necessary, build for them suitable homes. It is 
impossible to secure the necessary conditions in our county poor- 
houses. Give them a hospital building, with every convenience for 
the care and treatment of the smaller number of excited and 
paroxysmal cases, and, for the more quiet and industrious class, 
erect less expensive buildings, at suitable places upon the farm, as 
necessity and convenience may require.” The Illinois Board in 
effect acted upon the principle “in medio tutissimus ibis.'” 
The Board was organized, April 27, 1869, and at its October 
meeting ensuing, it issued a call for a conference of the State 
officers, together with the trustees of the three insane asylums of 
the State, to consider the respective merits and demerits of the two 
systems, (one large building, with wards, or separate and smaller 
buildings), with a view to determining which of them should be 
adopted in the erection of the two new institutions at Elgin and at 
Anna. It applied to every superintendent of every hospital for the 
*Three similar boar'ds were then in existence, in the states of Massachusetts, New 
York and Pennsylvania. 18 
insane in the United States for an expression of opinion upon this 
question; and when the conference met, in Springfield, November 
10, their replies were submitted to it :* 
Three superintendents of insane hospitals were present at this 
meeting: Drs. McFarland and Patterson, of Illinois, and Dr. Wood- 
burn, of Indiana. The principal address was made by Dr. McFar- 
land, who said: “For those who do not need them, the bolts and 
bars found in all our asylums are not only no advantage, they are 
positively injurious. They irritate many patients and retard their 
recovery. The present system of architectural construction adapts 
the entire institution to the demands of its smallest and worst class, 
while for the great majority all of these appliances are utterly 
unnecessary. Besides irritating the patient, confinement abridges 
his sources of recreation. * * Under the existing system of con- 
finement, he has not sufficient useful employment. * * The 
insane asylum, constructed upon the monastery plan, is a costly 
institution. * * We need more of the element of home life in 
the treatment of the insane. * - * I would not abolish the old 
form of the institution. I hail the fact that the two systems may 
exist side by side. I would have the central hospital in the fore- 
ground. At a little distance I would have a group, not of cottages— 
they should be houses, of two stories in height, each to accommo- 
date its forty inmates. * * Under this system, the facility of 
extension would be very great. * * Classification could be more 
complete. * * We shall rather protect than weaken the close 
*Dr. Barstoic wrote: “The plan proposed for the new State asylum in Illinois is one 
which commands my warm sympathy and approval. * * In my judgment, the 
arguments in favor of the family system far outweigh those against it.” 
Dr. Tyler: “lam delighted that Illinois is disposed to step out of the long-followed 
track. * * Let there be the hospital proper for the care of those acute cases which 
require restraint; and then let the rest be cared for in houses of cheaper construction, 
more domestic aspect, and with less of the machinery of restraint.” 
Dr. Bemis: “For five years in succession I have pressed upon our trustees the neces- 
sity of adopting vhe segregate system. Within three months past, I have purchased an 
estate of about two hundred acres, within the city limits, (Worcester, Mass.,) for the 
purpose of carrying out my plans, and my trustees have voted to petition the legislature 
for permission to execute them at once. The plan is briefly this: A central hospital, for 
about one-third of our whole number, comprising of course the violent and dangerous, 
the acute cases and the very feeble. On the one hand- at a little distance from each 
other, a group of houses for the females; and on the other hand, at a little distance from 
each other, a similar group for the males. * * I hope to execute it.” 
Dr. DeWolf: “The proposal to erect a building upon the present plan, and to supple- 
ment this by detached cottages near the main structure, is a scheme which commends 
itself as worthy of trial on this side of the Atlantic. It has been found to work well, for 
years past, in Devonshire, England, and elsewhere.” 
Dr. Earle: “As I am far from the positive belief that the general plan of our hospitals 
for the insane is the best that can be devised, I should be glad to have a trial made of the 
plans mentioned in your letter.” 
Dr. Schultz: “Our successors, fifty years hence, will probably look back upon the 
present mode of treating the insane, with feelings akin to those which we now experience, 
when we think of the bars and chains iu use at the time when the reforms were inaugu- 
rated in England and France, half a century ago. * * Your letter, and the meeting 
at Springfield, I believe, should be taken as an omen of some substantial advance, not 
very remote, in the care of the insane.” 
Dr. Jarvis: (To Dr. Chas. A. Lee, of Poughkeepsie, N. Y., read by permission). “In 
regard to hospital construction, my main idea is: repression limited by the needs of the 
patient; hospitals diverse in their parts—not built in one magnificent block, to suit the 
architect’s eye, and be praised by the outer beholders, but varied to meet the wants of the 
patients. The hospital should be in detached sections; the houses separated and diverse; 
all the parts as nearly like an ordinary house as possible, to remind the inmates as little 
as possible of repression and confinement. Few of them should have gates or locks. 
They should have wooden-saslied windows, and light, airy rooms, looking not on another 
wing, like itself, with strongly barred windows, but on trees, lawns, fields, or other atti ac- 
tive dwellings.” 19 
supervision which a good humanitarian propose dictates. * * I 
believe that the influence of this discussion, whatever may be the 
immediate result, will sooner or later be felt by the entire nation.”* 
The following resolutions were unanimously adopted: 
Resolved, That in the judgment of this eonferenee, a combination in insane asylums 
so far as practicable, of the cottage system with that at present in vogue, is desirable. 
Resolved, That there are weighty reasons for the belief that such a combination is 
practicable, and that it would increase both the economy and efficiency of asylums for 
the insane. 
Tliese resolutions exerted no immediate influence in the modifica- 
tion of the plans for the institutions at Elgin and at Anna; but 
they prepared the way for the establishment of the institution at 
Kankakee, some years later. 
r The want of space compels us to pass without notice many of 
the indications of progress in thought upon this subject, during the 
next few years; but we must quote, from a special report to the 
Pennsylvania House of Eepresentatives, in 1874, relating to the 
insane, the language employed by the Commissioners of Public 
Charities of that State: “Although every hospital built and projected 
[in Pennsylvania] has been recommended to the legislature with the 
same view, namely, with a view to provision for the indigent insane, 
the system pursued in this State since 1861 has not extinguished and 
never will extinguish or even abate the evil. The unnecessary ex- 
pensiveness of these hospital establishments for the indigent insane, 
and the liberal admission into them of ‘paying patients,’ forbid the 
realization of the intentions and desires of the legislature and of the 
public. The high cost of these structures is on every ground un- 
necessary and injurious to the interest of the class for whom they 
are provided. We believe that it is practicable to attach, to all the 
hospitals for the insane of the State, supplementary buildings, for 
the accommodation of quiet, tranquil patients, who usually find 
their way to poorhouses, jails, etc. These buildings can be con- 
structed, including steam, water and gas, for not over five hundred 
dollars per patient.” 
The history of the origin of the Kankakee Hospital for the Insane 
may he given in a very few words. The act by which it was created 
was passed by the legislature of Illinois in 1877; the plans (in part) 
were adopted in January, 1878, and work commenced during the 
spring of that year. The committee which recommended its creation 
had said : “We have left the question of the mode of construction 
open to examination and decision by the board of trustees, in the 
hope that they may be able to ascertain and demonstrate the feasi- 
bility of a reform, by the adoption of the village plan of construc- 
* This was not the first public utterance by Dr. McFarland on this question. In 1868, 
at the meeting of the Western Association for the Promotion of Social Science, in Chi- 
cago. he had read a paper entitled: “What shall be done with the Insane of the West?” in 
which he said: “A single type has given impress to all our institutions. Nothing has broken 
in upon the stereotyped monotony of their interior. It would seem as if the insane man 
was regarded as a species of mollusk, whose shell must concrete about him in a form 
pre-determined since creation. * * The radical fault of this system is, that the in- 
dividuality of the subject is stifled and lost in the immensity and compactness of the or- 
ganization in which he exists. * * Insane asylums must be, as it were, decentral- 
ized; so much of their truly good features retained as adapt them to the necessities of the 
appropriate class, and into the remainder must be incorporated so muck of the home 
element, in construction and care, as the great classes above excepted [the chronic, harm- 
less insane] imperatively demand.” 20 
tion, with detached buildings.” The trustees hesitated to take the 
responsibility of the innovation, but consented to accept a plan 
which was so devised as to admit of the construction of certain 
portions of an establishment which might in the outcome assume 
either the congregate or the detached form, and to let the next 
General Assembly decide whether detached buildings should or 
should not be erected. Mr. Wines, Secretary of the Illinois Board 
of Public Charities, was sent to Europe, in 1873, by the State, to 
attend the International Penitentiary Congress, at Stockholm, and 
during his journey he made such observations on the methods of 
caring for the insane, in Great Britain and upon the Continent, as 
enabled him to submit to the legislature of Illinois a report, which 
resulted in the making of appropriations for detached buildings at 
Kankakee. Thus the policy of that institution was determined and 
forever settled by the highest authority known to the law, under 
the constitution. 
At this point, it is proper to remark that, much as Gheel and 
Clermont and the Scotch system have been discussed in this country, 
the application of foreign experience to our own needs has not been 
correctly apprehended by some of those who have taken a prominent 
part in the debate. They have spoken as if it were proposed to 
imitate that which exists abroad, in disregard of the different con- 
ditions to be found in the United States. The true bearing of the 
many reports which have been made on foreign care of the insane 
is to show that the method of care practised in American hospitals 
for the insane is not the only practicable method, and that it is 
therefore susceptible of modification, in accordance with the con- 
ditions which exist this side of the Atlantic. Whoever makes the 
tour of foreign countries in the interest of the insane will find that 
they are, in one place or another, very comfortably and successfully 
cared for outside of institutions, and in institutions of the most 
dissimilar types of construction; that they can dine in common 
dining-rooms, instead of each ward having in it a separate diniug- 
room; that they can sleep in associated dormitories, instead of in 
single lodging-rooms; that they can be held, without bars on the 
windows, and even in rooms with unlocked doors; that the “corri- 
dor” required by the propositions of the Association can be dis- 
pensed with, and a day-room on the ground floor be substituted for 
it; that instead of heating wards by steam, they can be and are 
heated, in some institutions of the highest reputation, by fires in 
open grates; that the number of patients in a separate ward may 
vary indefinitely, from one to eighty; that insane patients can be 
and are trusted in the fields and upon the public highways, with or 
without. an attendant in charge, and in large numbers; that the 
proportion of them who may be usefully employed is very large, and 
the proportion who require mechanical restraint very small. These 
discoveries shake the faith of the observer (who cannot distrust the 
evidence of his own eyes) in the supposed necessity for an absolutely 
rigid adherence to a single type of hospital construction, and tend 
to convince him that detached buildings are not so impracticable 
nor so objectionable as the advocates of the “main central building 
with wings,” whose enlargement “may be properly carried to the 
extent of accommodating six hundred patients,” have been in the 21 
habit of insisting. That is all. It is not necessary to substitute 
either Gheel or Clermont for the existing American institution for 
the insane. A new combination of the elements which enter into 
successful care and treatment of these unfortunates is possible; and 
at Kankakee such a new combination has been attempted. It is not 
the only possible combination; it may not be the best possible com- 
bination ; but it demonstrates the possibility of a departure from 
the corridor plan, and that there are certain advantages in such a 
departure. But Kankakee resembles neither Gheel nor Clermont, 
any more than it resembles Danvers or Morris Plains. 
Gheel was discussed at the meeting of the Association of Super- 
intendents in 1879. Dr. Shew, of Connecticut, had visited it and 
reported his impressions. In the debate which followed, Dr. Lath- 
rop said: “I think that an institution for the harmless and incur- 
able should be established on the grounds of a hospital adapted to 
the treatment of acute cases, and under the same superintendent. 
Undoubtedly, as Dr. Bancroft has said, the people demand cheaper 
buildings than many of the large hospitals.” Dr. Nichols said: “It 
has long seemed to me that the only practicable solution of the 
difficulty is the one just suggested by Dr. Lathrop. It is certain 
that the added wards for the chronic patients need not cost, per 
patient provided for, more than one-third of the cost of our original 
establishments for two hundred and fifty or three hundred cases. 
It is my strong impression that the chronic, poor insane can be 
comfortably and properly taken care of at considerably less cost 
than the acute and active cases. The chronic, dependent insane, 
of whom there are large numbers, must be taken care of, and the 
question is: what is the best plan of doing it, that the representa- 
tives of the people will adopt ? Such additions may be detached or 
otherwise, to suit the site, or the views of those in immediate charge 
of a particular hospital. The Association has not approved of de- 
tached wards, but, while I think a continuous structure preferable, 
I do not think detached wards as objectionable as some of my 
friends in the specialty do.” But Dr. Kirkbride said: “My friend, 
Dr. Nichols, has expressed sentiments that I trust the Association 
will be very careful about adopting. I trust we shall be exceedingly 
careful how we give countenance to the idea that the chronic insane 
are to be treated in a different kind of structur from what is 
proper for the acute cases, and especially how we countenance the 
idea that the people of this country are not able and willing to take 
proper care of all the insane, no matter what is their condition.” 
Notwithstanding the opposition to provision for the chronic in- 
sane “in a different kind of structure from what is proper for the 
acute cases,” the growth of the conviction that such provision is 
necessary and desirable, as well as practicable, has been most 
rapid, as the following citations from recent reports of institutions 
for the insane will show: 
Alabama: "Another expedient for meeting the demand for more room is the enlarge- 
ment of the present accommodations here in Tuskaloosa. This can be done, either by 
adding new sections to the ends of the present building, or by the erection of a detached 
building for the exclusive occupation of the harmless and incurable insane. Of these two, 
our preference is for the latter. The cost of erecting the detached building will be less in 
proportion to the numoer accommodated. Intended only for the quiet and harmless in- 
sane, the wards can be made much larger and fewer in number, and the furniture and ap- 
pointments far less exDensive, than those of the present building. The difference in the 
cost of supporting the acute and chronic cases is much greater than would be supposed 22 
by those who have had no experience in their care and treatment, and in a separate build- 
ing the cost of support of the chronic class can be very materially lessened. For many 
other reasons, sanitary and economic, the segregation of the two classes in separate 
buildings is very desirable—so much so. indeed, that I should recommend that system in 
the construction of every new hospital for the insane.” 
Connecticut: “The philanthropic spirit of the age demands cheerful halls, large 
windows, light furniture, open doors, and the total abolition of mechanical appliances for 
personal restraint. And these demands are just, when applied to the great principles 
which should govern us in the treatment of ordinary cases of insanity. * * Our 
new south hospital for the chronic insane has been occupied more than two years. This 
experience convinces me that the plan of supplemental buildings adjacent to the central 
hospital is the true solution of that most difficult problem—how best to provide for the 
chronic insane. In this respect we followed the lead of the Willard Asylum, at Ovid, N. Y. 
Since then. Dr. Godding has adopted the same policy at the Government Hospital for 
the Insane at Washington, D. C. And now the State of Illinois is erecting buildings at 
Jacksonville, modeled after the plans of our new south hospital. Let me not be misun- 
derstood in advocating the plan of separate buildings. I deem it of paramount import- 
ance that each building should be large enough to employ all of the time and best energies 
of an assistant physician, who, with his family, should reside in the building, and be res- 
ponsible to the superintendent for its proper detail management.” 
Iowa, (Independence): “When all parts of Iowa have been provided with curative 
institutions, then detached buildings, for such incurable insane as are quiet and in good 
physical condition,can be erected, when needed, in connection with either hospital. Such 
a building, may be made two stories in height, and large enough to accommodate one 
hundred patients of either sex. It would be less expensive than accommodation for an 
equal number in the hospital proper, because it need not be divided into single rooms; 
the second story would be one large associated dormitory, to be used by all at night; the 
first story would contain a large dining-room and a day-room. This detached building 
would have a kitchen, but no bakery or laundry. Such a building would serve well in 
connection with a hospital, but not at a distance from and independent of It. Even if 
snitable cases are selected for such quarters at the outset, one and another will soon be- 
come unfit for the ‘congregated’ mode of life. Sickness or excitement will make it neces- 
sary to remove patients to one of the hospital wards. Exchanges can be made, and 
suitable cases supplied, without inconvenience or expense, if these buildings for incura- 
bles exclusively are connected with the hospital.” 
Kentucky, (Hopkinsville): “We have had, for some years, detached quarters for a 
class of quiet male patients—accommodations better, in many respects, in my judgment, 
for such persons, than can be had in any very large building. I have been anxious to 
make similar arrangements for a few females, as a test of the expediency of establishing 
a more domestic mode of life for such as can be trusted; to give them a larger liberty 
than is usually found in asylums for the insane; and to remove them as far as possible 
from the disagreeable associations unavoidably incident to a residence with any consid- 
erable number of insane people. Such provision will also obviate the necessity of send- 
ing those ill with certain nervous troubles to private asylums out of the State, where bet- 
ter surroundings and more privacy may be obtained than in most public charitable insti- 
tutions. As means are available, such additions to this and others of the State charities 
should be multiplied. To secure the ends suggested. I have built a substantial and 
well-finished cottage, at some distance from the main building, yet near enough for con- 
stant medical oversight, with all the appliances of a home-like dwelling, including open 
fire-places, dining-room, kitchen, bath-room and water-closet. It will be handsomely 
furnished, then put in charge of a responsible matron and needed attendants. I believe 
that in this cottage, and another now in use, it will be demonstrated that a system of de- 
tached buildings is, in most respects, preferable, for a large class of inmates, to the pres- 
ent manner of asylum construction.” 
Maryland: “Cottages could be built in connection with the institution, for the quiet, 
chronic class of insane, who do not need the restraints of the large, strong hospital, but 
who are not able to manage for themselves away from some hospital.” 
Massachusetts, (McLean): “ We tried thd experiment, the past year, of a cottage on 
the sea-shore, at Lynn, for some of the patients, during the summer months; and the re- 
sults were so satisfactory, that it will be repeated, the coming summer, on a somewhat 
larger scale. * * Six ladies spent all or a part of the season there; and communi- 
cation by railroad being easy, nearly every week parties of ladies were sent to spend the 
afternoon there, to dine or take tea. This usually included some pleasant hours spent in 
strolling on the beach or sitting on the rocks, and was altogether a source of much 
pleasure and benefit. 
Michigan, (Pontiac): “A more feasible means of relief would be the erection of sup- 
plementary buildings in connection with each of the present asylums for the insane, for 
the care of selected patients in good bodily health, who do not require constant supervi- 
sion and care. Such buildings need not be expensive. The great bulk of patients occupy- 
ing them could be cared for in dormitories, and a large degree of personal liberty could 
be afforded. * * Buildings of the character mentioned can be operated in connec- 
tion with the present asylum buildings at less proportionate cost than institutions for the 
chronic insane simply, and their working would be vastly more satisfactory. After a 
careful considerate m of the subject, I am of the opinion that thirty per cent, of the pres- 
ent inmates of asylums could be provided for thus.” 
Missouri, (SI. Joseph): " I am almost persuaded to assert my belief that less expen- 
sive segregated cottages, erected on asylum farms, for the treatment of the improved and 
chronic insane, sufficiently near the main edifice, where all can be under one supervision, 
and where exchange of patients may readily be made, when the condition of the patient 
requires it, would be a very great improvement on the present mode of provision and 
treatment of the insane.” New York, (Willard): "Guided by our observations here, were we to undertake a 
new or similar work, such as we have been engaged in, we would advise further changes 
in the direction we have taken, which we are more firmly convinced, with every year’s 
added experience, was a move in the right course. The Willard Asylum now consists of 
a central hospital structure, accommodating five hundred and fifty patients; four groups 
of detached blocks, each group embracing five blocks; and the former State Agricultural 
College building, modified as was practicable for the insane. We know of no good reason 
to depart from the general idea which has prevailed; but experience has suggested de- 
sirable changes and modifications. If the plans of an asylum or hospital contemplated 
provision for fifteen hundred patients, a central hospital building, adapted to the care of 
three hundred cases of the acute or paroxysmal class, would suffice and prove to be a lib- 
eral allowance. With the general plan of our groups, and the conveniences of adminis- 
tration they furnish, we are well satisfied, and have no changes to suggest, except as to 
the interior arrangements. It would be better to place patients on the first floor during 
the day. and on the second floor at night, to sleep, dispensing with many of the partitions 
now in use. For the care of dements, paralytics, epileptics, and helpless, bed-ridden pa- 
tients, and patients with dirty habits, we would propose a special provision in the nature 
of a one-story structure, the essentials of which would be; a large dav-room, with a broad 
veranda on all sides; a large dormitory adjoining, and communicating with a few single 
rooms for temporary isolation of noisy patients at night; and ample provision for a night 
service.” 
Ohio, (Cleveland): “The construction of additional buildings on the grounds of this 
asylum is feasible, and, if adopted, would bring relief to the district. I have, in former 
reports, advocated this method, and still am of the opinion that it possesses many advan- 
tages.” 
(Dayton): “The open ward, spoken of in the report of last year, has been continued as 
such. It is gratifying to note that, during the year, but two patients from this ward have 
eloped; and one of them, after four days’ absence, returned of his own accord. I am con- 
vinced that a number of those who have occupied this ward have been benefited, and 
their recovery hastened, by having the comfort and satisfaction of going out and in at 
pleasure.” 
Rhode Island, (Butler): “Plans have also been prepared, and are on file at the hos- 
pital, for detached cottages, one for each sex, designed to receive a few such patients as 
need care and treatment away from home associations, but desire more ample accommo- 
dations than the ordinary wards of a hospital can give. One of the proposed cottages 
will accommodate half a dozen boarders, giving to each a parlor, dining-room, sleeping- 
room and bath-room, with attendant’s room adjoining, and, if desired, a private work- 
room or library. They will be situated near the main hospital, but entirely screened by 
trees, and will command some of the finest views of the landscape and the river to be 
found upon our grounds.” 
South Carolina: ‘The ‘Kankakee’ system is essentially a combination of the hos- 
pital and cottage systems; a substantial central building for the proper custody and 
treatment of violent and acute cases, and simpler detached houses which form th<‘ homes 
of the homeless incurables. * * I have thought that this system, which I have ob- 
served in practical operation, is, in its main features, the one best adapted to our require- 
ments. It, in fact, is doing from choice, and therefore with more system, what we have 
been doing from necessity. Five years ago, when the main buildings became crowded, 
and we had no appropriations for their extension, we began the erection of plain but 
comfortable frame houses in the various courts. In this way we have from time to time 
provided for the increasing population, until now we have more than two hundred quar- 
tered in these detached buildings.” 
We have so fully described the Kankakee hospital, in former re- 
ports, that it is unnecessary to repeat the description here. The 
institution is only fifty-six miles from Chicago, on the Illinois Cen- 
tral railroad, and is easily accessible. 
The principal ends sought in its construction were: (1) the 
cheapening of the cost of building, in order that a larger number 
of the insane of the State might, with a given appropriation, be 
furnished with proper quarters, attendance and medical oversight, 
thus relieving the county poorhouses of the pressure upon them; 
and (2) the application of the principle of graduated restraint, or 
differentiation in the treatment of the insane, so as to allow to each 
patient the largest measure of personal liberty of which he is in- 
dividually capable. Some of the incidental results hoped for were: 
the introduction of a simpler and more natural mode of life; the 
disuse, so far as possible, of mechanical restraints; and an increase 
in the amount of useful labor by patients. These ends have to a 
very considerable degree been attained, particularly that of diminu- 
tion in the cost of construction, which is due to the diminished 24 
height of the buildings and the smaller number of rooms and 
passages. All the appropriations thus far made, for land, buildings, 
and furniture, including the sewerage, water-supply, gas-works and 
improvement of the grounds, with all the out-buildings, aggregate 
something less than one million dollars, while the capacity of the 
institution is fifteen hundred patients. The per capita cost of con- 
struction, therefore, is about one-half the average cost of hospitals 
on the corridor plan. The effect will be to accomplish, for the 
present, the great design of emptying the county poorhouses of this 
State. 
The main features of the plan adopted are: A complete system 
of sewerage, lighting and water-supply, by mains laid down in regu- 
lar streets, with gravelled roads and sidewalks, bordered by shade- 
trees ; a hospital proper, on the corridor plan, for three hundred 
patients, fire-proof throughout, with a centre building for the medi- 
cal staff; detached buildings of various sizes, and with different in- 
ternal arrangements, for groups of patients of both sexes; (most of 
these detached buildings are without bars on the windows; all of 
them have large porches for the use of patients in the summer sea- 
son) ; all the domestic buildings commonly found in institutions for 
the insane, such as a general kitchen, laundry, boiler-house, etc., 
with the addition of a general residence for employees, a general 
dining-room for a portion of the patients, a general bath-house for 
women, and a general store-house for supplies, with offices for the 
transaction of business and keeping of accounts, separate from the 
medical department; all of these buildings are of stone, and well 
and substantially built. The impression made is that of a village 
for the insane; not a commune like that of Gheel, in Belgium, where 
patients board in the cottages of peasants, singly or in pairs; nor 
a colony like that of Fitz-James, at Clermont, in France. It is a 
village, in which all the sane residents are salaried employees of 
the State, with its dwellings, its shops, its chapel and its theatre, 
all free to the insane inhabitants of Illinois. 
The advantages of this system are: 
(1) Comparative exemption from the perils of conflagration. 
(2) Improved sanitary conditions in the detached buildings, in 
consequence of their smaller size. 
(3) Diminished social pressure and friction among the inmates, 
on account of the diminution in density of population. 
(4) The elimination of a large part of the irritation occasioned 
by rigid confinement under lock and key, behind grated wundows. 
(5) Variety in the life of the insane, by means of occasional 
transfers from one house to another, the houses being dissimilar in 
plan and internal appearance. 
(6) A larger amount of life in the open air, owing to the ease 
with which patients can go out of doors. 
(7) Increased sense of responsibility on the part of attendants, 
which implies increased efficiency. 
(8) More individual treatment and less routine. 
(b) Facilities for night-nursing, in large associated dormitories. 25 
(10) Provision for an increased number of insane persons, be- 
cause of the smaller cost of such provision. 
(11) A marked decrease of the prejudice and distrust felt by the 
public toward the institution itself, and a corresponding increase of 
confidence and good will on the part of the friends of patients. 
The three characteristic distinguishing features of an institution 
for the insane, on the detached plan, are, two-story houses, large 
associated dormitories, day-rooms on the ground floor, and unbarred 
windows. With respect to these, no less an authority than Dr. 
Isaac Ray, (Observations on European Hospitals for the Insane, 
1846), has said: “It is to be deeply regretted, that in many of the 
later erections in this country, the day-rooms, which, in the older 
establishments, had often dwindled down to the smallest dimensions, 
have disappeared altogether, and their place is supplied by that 
wretched substitute, a long, narrow gallery, lighted imperfectly at 
the ends, and lined on both sides by sleeping-rooms.” “Limited as 
the use of (associated) dormitories must necessarily be with us, I 
am so strongly convinced of their benefits in certain classes of 
cases, that I do not hesitate to recommend their adoption, as a 
measure warranted by the proportion of those who are perfectly 
willing to sleep in them, and those who, whether willing or not, 
would be all the better for sleeping in them. There is a class of 
timid, nervous patients, who would be far more comfortable in an 
associated dormitory, especially when they first enter the institution. 
They are far better also for those suicidal cases which we now 
manage by having an attendant sleep in their rooms, by the side 
of the bed. Many filthy patients, too, when tranquil, are no doubt 
better managed in dormitories, because the supervision there exer- 
cised is sufficient to improve their habits by exciting their self-con- 
trol, and also secures that attention to their wants which they can- 
not receive so effectually when sleeping alone.” “In connection with 
such elaborate contrivances for saving the glass and securing the 
patients, I was sometimes surprised by seeing arrangements that 
indicated how little such safeguards were needed. In an asylum 
where the windows of the rooms were regularly covered every night 
by a wooden shutter, the gallery windows were unguarded, both in- 
side and out, and so loosely confined in the frames, that it would 
have required very little ingenuity to get them out. But escapes 
from that asylum were very rare, and seldom if ever from the win- 
dows.” “Third stories should be avoided, if possible. It is better to 
obtain the requisite room by extending the erections, than by in- 
creasing the stories above the second.” 
With respect to the question of increased facilities for escapes, it 
may be said that patients of the class for which detached buildings 
are meant do not often attempt to escape. The escapes and acci- 
dents at Kankakee have been almost wholly on the part of patients 
confined in the wards of the close hospital proper. As to super- 
vision, the use of the telephone and the electric light have greatly 
augmented the ease with which an institution can be governed by 
the superintendent; attendants are just as much out of his sight in 
a ward as in a detached building; and the watchfulness of under 
officers is increased, under the detached system. Practically, no dif- 
ficulty has been experienced in the matter of thorough supervision, 26 
and none is anticipated. Much of what might otherwise have been felt, 
has been obviated by the minuteness of the daily reports and the 
care with which they are examined and recorded. But for a full 
account of the practical working of the system, reference may be 
made to the published reports of the medical superintendent, Dr. 
R. S. Dewey. 
The system has been adopted in the territory of Dakota and the 
States of Ohio and Indiana; and something of a similar nature is 
contemplated by the city of New York, for the new pauper asylum 
on Long Island. 
There are, however, objections to Kankakee, which we will frankly 
state. The chief of these is its size—the great number of patients 
there aggregated together. No arrangement of buildings can over- 
come our conviction that such aggregations of misfortune and de- 
fect, in any of their forms, are unnatural and injurious. We will not 
enter into the elaboration of reasons why this must be so. We 
tolerate the evil of which we complain, only because, if we do not, 
the public will compel us to assent to a still greater evil, the total 
neglect of these wretched victims of a diseased brain, in county jails 
and poorhouses. The time wTill come, we believe, when the results 
of such undue enlargement of institutions will become so apparent 
as to occasion a re-action in public sentiment, and it may even be 
that the original proposition of the Association will be accepted, in 
its literal significance: “The highest number that can, with pro- 
priety, be treated in one building (one institution) is two hundred 
and fifty, while two hundred is a preferable maximum.” 
However this may be, Kankakee marks, as has been said, a transi- 
tion from one system to another diametrically onposite. It was to 
be expected that the transition would not be sufficiently thorough; 
that traces of the old would be found in the new, even where they 
were incongruous and out of place. This is precisely what has 
happened. An institution on the detached system should be so 
planned exclusively and not bound by precedents derived from the 
necessities of the corridor plan. This is an objection to additions 
proposed to existing hospitals. They cannot be so satisfactory as 
.an institution would be with a single motive, and with all its parts 
in harmony with one general design. 
If we could rebuild the hospital at Kankakee, with our present 
experience, we would observe the following suggestions, which may 
be of use to others: 
(1) The amount of land to be purchased should equal one acre 
for every patient to be provided for, and it should be remembered 
that land can be bought for a less price when the institution is first 
established than at any time thereafter. 
(2) The first step to be taken, is to lay out the ground, with the 
aid of a skilled engineer, in such a manner as to insure thoroughly 
good and sufficient sewerage, and a proper distribution of water- 
pipes, gas-pipes and pipes for steam-heating, so arranged that they 
can be directly connected by branch-pipes with every building. The 
plan adopted for the placing of buildings should have reference to 
this system of pipes. The pipes should follow the lines of the streets 
which are laid out. The land bn each side of these streets should 
be subdivided into building lots, in sufficient number to admit of 27 
the gradual development of the institution by the addition of a few 
buildings at a time, and of sufficient size to avoid crowding the 
patients in consequence of the too close contiguity of houses. All 
thought of connecting the “blocks” by corridors should be aban- 
doned. 
(3) Large tracts must be reserved for pleasure-grounds, for both 
sexes. 
(4) Not more than from one-fifth to one-third of the total capacity 
of the institution should be in the form of a close hospital, and the hos- 
pital proper, instead of being made the prominent feature, should be as 
inconspicuous as possible. This end may be attained by dividing 
it, and having a separate hospital for each sex. There should be 
no centre building for the use of the officers of the institution; least 
of all should the officers be collected together in the building de- 
signed for the care of the acute and paroxysmal cases of insanity. 
Separate residences for officers and their families, scattered over 
the grounds, are in every respect preferable. 
(5) The medical offices should be entirely separated from those 
devoted to the transaction of ordinary business. The business offices 
should be in a distinct building, in connection with the store-rooms 
for general supplies; and it is this building, not the hospital, which 
should be ornamented and made to attract the attention of visitors 
as the principal feature and central point of the architectural de- 
sign. It should be devoted exclusively to business, and there should 
be in it no sleeping apartments or living-rooms. If, however, it is 
desired to give it additional dignity, the hall for amusements may 
be inclurled with it and occupy the upper floor. 
(6) There is no rule for the construction of the detached build- 
ings. In respect of size, capacity and arrangement, they must be 
adapted to the probable classification of patients and the needs of 
each class, remembering that the same arrangement is not equally 
suited for all patients, and that uniformity is as objectionable in 
detached wards as in any other form of construction. Generally 
speaking, such buildings should be only two stories in height; base- 
ments should, as much as possible, be discarded; the day-rooms 
should be on the lower floor; the upper floor should consist of large 
associated dormitories; the amount of floor-space to be allowed is 
about fifteen square feet per patient for dining-rooms, thirty feet for 
day-rooms, and forty-five feet for dormitories. Bars and gratings 
should be left off the windows. A single building may contain one 
ward or more, according to circumstances; but the larger the build- 
ing, the nearer the approach to the system for which detached build- 
ings are a substitute, and the sacrifice of the advantages of the 
new system is proportionably great. In planning these buildings, it 
must constantly be borne in mind that each ward does not need to 
be complete in itself; and that general dining-rooms, bath-houses 
and clotliing-rooms obviate, to a certain extent, the necessity for 
elaborate arrangements for these uses in a portion, at least, of the 
detached wards,—not in all of them. Neither is it necessary to have 
a resident physician in each house. 
(7) The abandonment of the “main central building with wings” 
renders it possible to introduce entirely new arrangements of the 
kitchens, laundries, shops, boiler-houses, etc., in which the work 
of an institution is carried on. They may be placed wherever it is 28 
convenient to have them, without being in a line at right angles to 
the main structures, and in the rear. They need not be connected 
with each other. The entire structure is, by the fundamental prin- 
ciple of the detached system, broken up; and the more completely 
this principle is carried out, the more satisfactory the final result 
is likely to be. But care must be taken not to under-estimate the 
capacity of these domestic buildings and their appurtenances, in- 
cluding boilers, pumps and machinery, for the work of a large com- 
munity. Some of them might possibly be duplicated, with advan- 
tage, for each of the two sexes separately. These and other similar 
details must be left to the good sense of the designer, who needs to 
be an architect of no small experience and of more than ordinary 
intellectual force. 
Whatever may be the defects of the detached system, it is justi- 
fied by the arguments advanced by Dr. Cook, in 1866; that no State 
will provide, or ever has provided,-sufficient accommodations for all 
its insane, on the corridor plan, and that therefore a modified plan 
is indispensable, if the chronic pauper insane are not to be left to 
accumulate in county jails and county poorhouses. The United 
States census of 1880, reports a total insane population of 91,959, 
of whom 40,942, or less than one-half, are in hospitals for the in- 
sane; while 9,302 are in almshouses, and 397 in jails and prisons, 
which is very nearly one-fourth the number in hospitals, and probably 
greater than ever before in the history of the country, notwith- 
standing all the efforts put forth by the Association of Superin- 
tendents and by benevolent men and women not identified with the 
Association. To take 10,000 insane from the jails and almshouses 
will cost on the corridor plan, twelve million dollars; on the de- 
tached system, six millions. The first-named sum may be out of 
our reach, but the latter is not. 
The system is further justified by the balance of advantages, which 
seems to be in its favor. Its advantages, and not its comparative 
cheapness, are its chief recommendation. It was not born, as has 
been charged, of the spirit of parsimony. It is not the foolish, 
ignorant conception of men who know nothing of insanity and of 
the requirements of the insane. It originated in a broad view of 
the situation and needs, not merely of the insane who are in hos- 
pitals and properly cared for, but of those who cannot be admitted 
and retained in hospitals, and are therefore neglected and forlorn, 
who appeal most strongly to the sympathies of the humane. The 
rapidity with which it is spreading proves its adaption to meet a 
public want, and its power to elicit popular appreciation and approval. 
The only practicable alternative is county care, under State super- 
vision and control—the system which is in process of elaboration 
under the careful administration of the Wisconsin Board of Chari- 
ties and Deform. That and this are both experimental. We give 
all honor to the State of Wisconsin for what it is doing, and regard 
its work as a most valuable contribution to the solution of this vexed 
problem. But we claim for the State of Illinois whatever degree of 
recognition properly belongs to it, in connection with the endeavor 
to embody in actual practice the maxim of that great citizen of 
Massachusetts who first declared, “The insane are the wards of 
the State.