Our Insane Patients and their 
Hospital Relations. 
BY 
CHARLES A. RING, M. D., 
BUFFALO, €7. 
REPRINT FROM 
Buffafo jrlt2«5icaf and fournaf. 
April, 1895. Our Insane Patients and their Hospital Relations. 
CHARLES A. RING, M. D., Buffalo. 
All of us know and fully appreciate, or have done so, the phrase 
“ the family physician.” Occupying this position of confidence and 
love and honor, we have felt the responsibilities and anxieties that 
its labors have placed upon us, and more fully have we understood 
as we have intrusted to the skill of some professional brother, a 
life held dearer than our own. The maintenance of health, through 
personal hygiene or municipal sanitation ; the prevention of dis- 
ease, either by introduction or extension, and the proper treatment 
of those requiring isolation, are all points that demand the atten- 
tion and thought of the family physician. Further, it is his duty 
to know that those detailed by municipal or legislative enactment 
are efficient and competeht in the use of means provided for 
special purposes ; and he expects that those so employed shall 
furnish knowledge from their experience that shall be available 
to himself and to the public. 
And especially are we interested in our insane patients and 
their hospital relations, for I think that the time has now come 
when the thought, opinion and wish of the general medical pro- 
fession shall have more force than ever before in shaping legisla- 
tion and influencing the management of the hospitals for the 
insane. If our patients become insane, the old question of home 
or hospital treatment arises : Shall we, or can we, treat them at 
home ? May we, or must we, send them to the hospital ? If at 
home, the case is comparatively of such infrequent occurrence 
that we feel the need of special authority. Where shall we look 
for it ? If at the hospital, there may be the fears or the prejudices 
of the family that must be explained and removed. And, cer- 
tainly, for ourselves, there are some strong objections. What 
assistance can we expect from those who have made the disease a 
special study ? What objections, criticisms and suggestions can 
we make to those to whom we intrust our patients ? What 
cobperation and improvement can we expect from those in 
charge ? The duration of insanity may be so long, averaging 
between ten and eleven years, and its occurrences, direct, as 
destruction of property, assault, mutilation, homicide or suicide ; 
). Read before the Buffalo Medical Union and published by request. 2 
OUR INSANE PATIENTS. 
and, indirect, as loss of income, loss of health of other members 
of the family, loss of education of the children, are so serious that 
they demand that the patient shall be individualized, and given all 
that money and science can furnish. 
In the annual report of the Utica State hospital for 1893, Dr. 
Blumer, in a table covering eleven years, shows that in those 
admitted who had been insane for more than one year, the per- 
centage of recoveries was 10.53 ; of those insane less than one 
year, 41.22. Tables going into the months have shown that the 
rate of recoveries is higher, the earlier the patient has been under 
treatment. It is generally admitted that a case becomes chronic 
after two years, and that the percentage of recoveries in this class 
is very low, under two per cent. 
Unfortunately, I do not know of statistics of recoveries of 
the insane in private practice. Hospital authorities are constantly 
urging the necessity of sending patients to them for treatment at 
the earliest possible moment. Yet what do we find in the follow- 
ing table to be the average duration of cases before commit- 
ment : 
Under 
t 
month. 
From 
1 to 3 
m’nths. 
From 
3 to 6 
m’nths 
From 
fitott 
m'nths. 
From 
9 to 12 
m'nths. 
From 
12 to 18 
m’nths. 
From 
18 to 24 
m’nths. 
Over 
2 years. 
48 
46 
40 
20 
6 
19 
4 
196 
Utica 
12.66 
12.16 
10.55 
5.28 
1.58 
5.27 
1.06 
51.78 
36 
42 
37 
23 
10 
20 
8 
207 
Willard 
9.41 
10.96 
9.68 
6.00 
2.61 
5.22 
2.09 
54.15 
58 
70 
43 
26 
7 
43 
6 
201 
Hudson River 
12.77 
15.42 
9.47 
5.73 
1.54 
9.47 
1.32 
44.27 
54 
31 
34 
26 
8 
33 
9 
148 
Middletown 
15.71 
9.03 
9.91 
7.56 
2.30 
9.62 
2.62 
43.15 
47 
50 
27 
32 
8 
26 
7 
137 
Buffalo 
14.07 
14.97 
8.08 
9.58 
2.40 
7.78 
209 
41.02 
30 
29 
24 
10 
8 
7 
3 
114 
Binghamton 
12 77 
12.34 
10.21 
4.26 
3.40 
2.97 
1.27 
52.76 
21 
15 
20 
8 
6 
5 
4 
54 
Rochester 
15.71 
11.28 
15.04 
6.02 
4.51 
3.76 
3.01 
40.60 
St. Lawrence 
• • • • 
• • • • 
• • • • 
• • • • 
• • • • 
• • • • 
• • • • 
Number of patients. 
294 
283 
225 
145 
53 
153 
41 
1,057 
Average per cent, of admissions 
13.30 
12.31 
10.42 
6.35 
2.62 
6.30 
1.92 
46.82 OtfR INSANE PATIENTS. 
3 
I do not give the figures of the last annual report of the St. 
Lawrence state hospital, as they do not balance, and I was unable 
to obtain correct ones. 
We find that, of 2,251 patients admitted to the state hospitals 
during the fiscal year 1892-93, 1,057, or 46.95 per cent., had been 
insane two years or over. These are practically chronic or incur- 
able cases, as the rate of recovery among them is less than two per 
cent. Some of these were transferred from county asylums under 
the state care act, but the percentage was not large, and even these 
do not figure, as they had been transferred from the state to the 
county asylums as chronic cases. Had these 1,057 cases been 
placed under treatment as late as even up to one year’s duration of 
insanity, 41.22 per cent., probably, would have recovered, but as 
10.53 per cent, of all cases recover, we find 30.69 per cent., or 324 
patients that might have been treated successfully, and their main- 
tenance saved. The average cost per week of maintenance of the 
eight state hospitals, as reported to the State Board of Charities, 
was |4.56. To maintain these would cost $77,086.12 a year, and 
for eleven and one-half years, $886,491.40. To this direct loss of 
the state, must be added the indirect which a competent student of 
social science must estimate ; and what can we say of the family 
circles, broken by an affliction worse than death ? 
Now, why is it that patients are not sooner placed in hospital 
care ? Is it because of want of confidence on the part of the 
family physician, who sees and studies the various reports that are 
courteously sent him ; or because of prejudice, or, worse yet, from 
fear on the part of the family that the physician is not able to 
overcome ? 
The percentage of recoveries is so low that it shows insanity 
to be one of the most incurable of diseases, and yet we find that 
the number of insane patients in the care of a single physician in 
the state hospitals is very much larger than in the general hos- 
pitals ; and it would be larger yet, if we should take out the 
superintendent, who is mostly engaged in affairs of an executive 
character. The system of internes has been suggested, and par- 
tially adopted, but this seems to be somewhat of an evasion. 
At the present time, the item for the maintenance of the insane 
is the largest in the yearly state budget ; and up to the present 
time, the cost of construction per bed has increased, and very 
largely. If there had been a corresponding increase in the per- 
centage of recoveries, the complaint might not have been so 4 
OUR INSANE PATIENTS. 
great. As long as “ Gray’s Folly ” stands, it shall be a rebuke 
to the system that made the glory of the institution the point 
of departure, instead of the individual patient. But hold ! 
There has been some change since the time of that most famous 
and successful medical lobbyist, for now, besides “The Third 
House,” there is a “ Commission ” that reports directly to the 
legislature, and is it not rumored, or openly stated, that that 
“ Commission ” is opposed to any present appropriation for the 
cottage system at Collins—a system recommended by philanthro- 
pists and experts unconnected with the present system ? 
It would seem to me to be good financial policy for the state 
to appropriate enough money to secure the services of the best 
medical men, and enough of them, to meet all requirements. We 
can all see, physicians and legislators alike, that the interest alone 
on the worse than useless investments of the past would more 
than pay for medical attendance. 
Cost of building. 
Number of 
physicians. 
Number 
of 
patients 
Average No. 
of patients to 
1 physician. 
Cost per bed. 
Cost 
per 
week. 
Percent, of 
recoveries. 
Utica 
$ 830,000.00 
6 
923 
154 
$ 899.24 
$4.64 
9.20 
Willard 
1,134,515.00 
9 
2,140 
238 
614,25 
2.99 
1.90 
Hudson River. 
1,921,384.12 
6 
940 
157 
2,044.02 
4.93 
9.50 
Middletown .. 
1,024,500.00 
6 
976 
163 
1,049.69 
5.57 
10.96 
Buffalo 
1,463,183.90 
5 
600 
120 
2,438.63 
4.53 
17.02 
Binghamton .. 
661,000.00 
7 
1,258 
180 
524.43 
3.24 
2.54 
St. Lawrence . 
1,750,000.00 
5 
632 
126 
2,768.98 
5.20 
11.23 
Rochester .... 
193,000.00 
4 
395 
99 
488.60 
5.39 
6.05 
The inception and planning of Utica, Hudson River, Middle- 
town, Buffalo and St. Lawrence State hospitals were under the old 
asylum system, and were carried out at an average cost of 
11,839.71 per bed per patient. Willard is the result of agitation 
started in the New York State Medical Society in 1865, by Dr. 
Willard, the secretary, to remove the insane from alms-houses, 
and carried on by the circulation of petitions by physicians 
throughout the state. It was proposed to call it the Beck asylum 
in honor of Dr. Romeyn Beck, of Albany, author of Beck’s medi- 
cal jurisprudence, but Dr. Willard dying before the asylum was 
opened in 1869, it was named as a memorial for him. Bingham- 
ton was formerly the New York State Inebriate asylum, and 
Rochester, the insane department of the Monroe County alms- OtTR INSAKE PATIENTS. 
5 
house. The average cost per bed per patient in these three is 
1542.52. 
And herein comes another violation of another fundamental 
law of political economy, viz., that a man should do all that he 
can towards his own support. The insane, under an efficient sys- 
tem of employment, can do very much on the farm, in the shop 
and about the institution to reduce the cost of maintenance. In 
one year, when Willard and Binghamton were used for chronic 
cases, the proportion of maintenance raised by the patients was 
between twenty and twenty-one per cent, in each institution. Two 
or three years later, at Willard, it had fallen to sixteen. How far 
below the English and continental institutions ! I will not more 
than mention the value of systematic employment, not occupation, 
as one of the means of successful treatment; nor will I more than 
mention that class of terminal cases that an eminent German 
alienist termed “ Recovery with defect,” who, relieving the state 
of their support by their absence to their homes, should, in those 
homes, carry out the habits of industry that had been taught them 
in the institution. And in this connection I would say that I 
think there should be, on the staff of the hospital, a farmer, a 
practical scientific man and a graduate of an agricultural college; 
also a mechanical polytechnic to take charge of the shops or to 
start them. 
As necessary as a competent medical staff is a competent corps 
of attendants. Much has been done to increase the efficiency of 
the present class of attendants in the establishment of training 
schools, discipline and morale. But there are" essential elements 
wanting which cannot be obtained until better wages are paid. 
The attendant should be the equal of the patient socially, educa- 
tionally and morally. And when this obtains, there will be few, 
or none, of the allegations and scandals regarding brutality 
towards the patient which have been so detrimental to the success 
of hospitals for the insane. 
Of all the specialists, those connected with the insane in hos- 
pitals give us the least literature, either in the way of text-books, 
or papers in journals, or before medical societies. Although the 
American Journal of Insanity is one of the oldest of periodicals, 
its circulation is very limited among general practitioners. It 
has been asserted by one entirely competent, that this division of 
medicine has made so little progress in the last forty or fifty years, 
that its place in the general line of advance is practically lost, nor OUft INSANE PATIENTS. 
is its support counted upon. The cause of this is twofold. The 
first is that of the extreme exclusiveness and conservatism of the 
association of asylum superintendents, which gradually destroyed 
an influence that was at first all-powerful, and had the confidence 
and support of the public and of the profession. Second, had 
there been even the most liberal tendency, the medical staffs have 
been so small that, engaged in the general routine of the institu- 
tion, there has been no time for scientific work, research and 
thought. 
Relatives and friends visiting patients for the first time are 
very often unfavorably impressed by the formality and coldness of 
those in charge of the reception room. Sympathetic courtesy 
always develops thoughts and feelings which approve and sustain 
discipline. On this first visit they expect to see the one called for 
within a few minutes, and as the time passes to half an hour, then 
to an hour or longer, impatience passes into suspicion and anxiety, 
and by the time the patient arrives, they are often ready to believe 
that he has been and is kept in an unpresentable state. And if the 
patient makes numerous complaints, or gives his opinions as to the 
daily life and occurrences of the ward, they are all accepted as 
confirming the suspicions. 
Too frequently there are deaths in hospitals for the insane 
under very suspicious circumstances. The post mortem examina- 
tions show contusions, fractures and other injuries that could 
hardly have been produced by the patient himself. The press 
reports the matter as of the daily news or occurrences which are 
more or less interesting to the public. And people ask, “Why do 
not the authorities know what is going on ? Why are not the 
guilty detected ? Why is it that we never hear of legal punish- 
ment ? ” And the people are right in asking these questions. 
There are peculiar secret means that can be used to obtain cor- 
roborative testimony ; and, if necessary, competent testimony from 
patients can be introduced. And especial legislative enactments 
have been made for the punishment of those offending against the 
insane. The detection of offenses by the hospital authorities and 
the furnishing of evidence for prosecution and conviction would 
be assurance which the public would most gladly accept. The 
trial might show peculiar revelations, but the press could be 
depended upon to present the matter fairly to the public for its 
thought and judgment. 
I think it is a great mistake that the press is not taken into the OUR INSANE PATIENTS. 
full confidence of the institution, and its corresponding coopera- 
tion or protection secured. 
128 Fargo Avenue.