Large or Small Hospitals 
For the Insane- 
Which ? 
BY 
C. E. WRIGHT, M. D., 
Indianapolis, Indiana. 
FROM 
American journal of Ensaniti?, 
July, 1890. 
UTICA, N. Y. LARGE OR SMALL HOSPITALS FOR THE INSANE- 
WHICH?* 
RY C. E. WRIGHT, M. D., 
Superintendent of the Central Indiana Hospital for Insane, Indianapolis. 
The question whether large or small institutions (hospitals or 
asylums) for the cure and care of the insane are to be preferred is 
one of interest to the general public as well as to the medical 
profession-especially so to alienists. 
To this Association do the people look for information and 
advice, and upon the consense of your opinions, plans are based 
and capital expended in the erection of proper hospitals and homes 
for the maniacal and demented. 
The subject is a practical one, for the investment of large sums 
of money depends upon its proper solution. In the language of 
Colonel Sellers, "There's millions in it." 
This may well be denominated a question, for it is a query which, 
as yet, has not been satisfactorily answered, and concerning which 
there is considerable diversity of opinion, not only among the 
people at large, but likewise among medical men. Even alienists 
and members of this Association are not united in opinion upon 
the correct answer. I feel some hesitancy in addressing this body 
of learned specialists upon a subject concerning which the indi- 
vidual members have so widely differed, and upon which they have 
more than once passed judgment and placed themselves on record 
without having definitely settled the matter. The opinions of 
the members of this body have in the past governed public 
sentiment with reference to the construction and maintenance of 
hospitals or asylums, (I use the terms synonymously here), and we 
have reason to believe that in the future the same deference will 
be paid to, and the same dependence placed upon, their decisions. 
It is therefore wise for us to take some pains to arrive at positive 
and correct conclusions. 
Being a novice in the specialty and meeting with you now for 
the first time, I feel timid in advancing my views, especially as 
they may be at variance with the expressed opinions of the ma- 
* Read at the forty-fourth annual meeting of the Association of Medical Superin- 
tendents of American Institutions for the Insane, held at Niagara Falls, June 10-13, 
1890. 2 
LARGE OR SMALL HOSPITALS. 
jority of the members here, who are better posted as to what has 
been said in the previous meetings, and it may also be as to the 
needs of the public. If I offend any, or if I misstate facts, I crave 
correction and pardon in advance. 
My understanding is that this Society has upon several occasions 
discussed a question similar in import to this, and upon one occa- 
sion determined that two hundred should be the maximum limit of 
population of insane hospitals ; while upon another occasion it was 
decided that six hundred was a preferable number. If one 
limit was correct the other was certainly wrong, for the conditions 
as to the needs of the insane have not changed-only the necessity 
to the public for better care for an increased number of the insane 
population. 
I have put my subject in the form of an interrogatory, because 
of the indefinite conclusions heretofore arrived at, and because of 
the fact that even after comparison of a number of annual reports 
of institutions, public and private, of large and small capacities, 
the determination still seems remote. At the same time I am free 
to admit that facts do not always confirm figures. 
Arguments equally cogent it would seem can be adduced for 
and against large and small asylums as well as for and against the 
congregate and segregate plans of caring for lunatics. 
If agreeable, I should like this essay considered in the light of 
a soliloquy, rather than an argument, and if you will permit me to 
think aloud for a few minutes, or to utilize suggestion, I will give 
you my opinions as concisely as possible. 
In deciding a matter of so much importance it is scarcely suffi- 
cient to rely wholly upon one's own ideas, which may be preju- 
diced, or upon one's own experience, which in every instance must 
be somewhat limited. 
It is not enough for any one to merely say " I think that two 
hundred is the proper limit of population," or " In my experience 
no more than six hundred insane persons should be placed under 
one management." These statements would hardly be convincing 
or conclusive unless one's opinions were entitled to especial con- 
sideration on account of profundity of information, or unless one's 
experience vastly exceeded that of his brethren. Our opinions 
are sometimes governed, or at least modified by our environments, 
past or present. If one has charge of an extensive asylum, his 
ideas being regulated to some extent by his surroundings, he will 
probably conclude that palatial structures containing thousands of BY C. E. WRIGHT, M. D. 
3 
patients are perfectly proper and necessary. But let his term of 
office expire, or let him assume charge of a sanitarium or private 
hospital, and his ideas will generally be considerably modified and 
contracted. We will then hear him discourse learnedly and elo- 
quently of "individualized treatment," home-like retreats," 
"family interest," "cheerful, home-like surroundings," "skillful 
nursing," and " personal medical oversight." To counteract the 
effects of free treatment and keep in public institutions, he will very 
likely advertise and advocate " non-restraint treatment carried to 
excess," or " a private nurse for each patient if desired," "privacy 
and freedom of domestic life," and in this manner secure a number 
of boarders for his house. He seems to feel the necessity of doing 
or saying something to counteract the importance of his brother 
alienist's influence, and expends his ink or lung power in sarcastic 
allusions to " caravansaries " and " hives of humanity," and hints 
darkly at the dangers of "holocausts." The word "caravansary" 
seems t(> contain a world of argument or satire, judging from the 
way in which it is used, for we seldom hear the subject of this 
essay discussed that this alphabetical aggregation does not put in 
frequent appearance. 
The manager of the " caravansary," inflated with the possession 
of power, looks down loftily and contemptuously upon (in his 
estimation) his less important brother, and may retaliate in kind 
with incisive allusions to " nurseries for mild cases," " kinder- 
gartens for the hysterical," and " dime museums for hypochon- 
driacal cranks." In neither case is an argument held valid because 
of the envy of one and the self-importance of the other disputant. 
My remarks are intended mainly to be suggestive, not deter- 
minate nor conclusive, and I shall be satisfied if they will tend to 
bring about the best manner of determining the proper answer to 
my query. 
The small number of reports I have examined, while not 
sufficient to afford correct conclusions, are enough upon which to 
base some general remarks, and I may say that they do not demon- 
strate that the small institutions are better either for the patients 
or for the public. 
The reports are not only meagre in statistics of real importance, 
but even those furnished are presented in styles so various that 
but little practical use can be made of them. Thanks are pro- 
fusely tendered between trustees and superintendents, and to the 
donors of cast-off clothing and second-hand newspapers, but 4 
LARGE OR SMALL HOSPITALS. 
matters of great interest are lightly touched upon or totally un- 
mentioned. 
Statistics depend somewhat upon the temperament and condi- 
tion of the statistician. A superintendent of sanguine tempera- 
ment, an optimist, will report a large percentage of recoveries, 
especially if he bases his figures upon the annual number of 
admissions or upon the acute cases. On the other hand his pessi- 
mistic brother, particularly if his liver be "out of fix," and if he 
bases his percentages upon the average daily population or upon 
the total number under treatment will not make a very favorable 
showing of recoveries. As a matter of fact one asylum reports 
only 0.85 per cent, while another reports 26.3 per cent of recoveries 
as based upon the total number under treatment, or 7.6 per cent 
and 70.7 per cent when based upon the yearly admissions. The 
object of treatment is supposed to be the cure of the patients, and 
yet, according to the published reports and notwithstanding the 
freedom with which the figures may be manipulated to make a 
favorable showing, the percentage of so-called "cures" does not 
seem to be greater in the smaller hospitals. Even with a greater 
number of acute cases and a smaller proportionate number of 
chronic cases the cures reported are not relatively any more fre- 
quent than we find in the large hospitals where both acute and 
chronic cases are admitted. Some of the private homes receive 
only acute cases, and those of a mild type, while asylums intended 
only for incurables would not be expected to furnish a very large 
list of cures, yet even in spite of "generalized" treatment they 
do sometimes occur. 
Small institutions, particularly those not aided by the State are 
mainly dependent' upon payment from week to week or from 
month to month by persons of wealth, of sums of money needed 
for running expenses, and which the managers are loth to dispense 
with. Is it not possible that in some instances at least infrequent 
furloughs or leaves of absence which may prove of the greatest 
possible benefit to the patient, are the rule; and might we not also 
look for delayed convalescence? In public institutions frequent 
recurrences will also be found for the reason that the "cures" 
are too frequent, and patients are hurried out of the house to 
make room for those who are waiting their turns for treatment. 
Prolonged recoveries are to be looked for in Sanitariums more 
than in " caravansaries." The death rate is relatively as great in 
one as in the other, and this fact would probably indicate that BY C. E. WRIGHT, M. D. 
5 
equally as much if not more attention is in large hospitals paid to 
hygienic measures and conditions, to water- supply, heating, bath- 
ing, sewerage, drainage and the like; for we would naturally 
expect a higher death rate where there were the greater number 
of physical wrecks. 
Notwithstanding the fact that in some small hospitals, where, 
on account of the patient's financial standing, the "individualized 
treatment " is carried to excess and " non-restraint method in the 
extreme" is the rule, (and which usually means that the patieit 
shall be followed about by a special attendant who generally 
becomes a most intolerable bore and tires the patient of life), 
suicides do occur as frequently as elsewhere. Nor are homicides 
unheard of in the small retreats. In fact for a refined patient to 
be compelled to submit to the autocracy of a person of inferior 
education and coarse instincts, day and night, without cessation 
under the fallacious idea that non-restraint is being practiced 
would certainly be considered sufficient cause for homicide by 
some maniacs. Attendants so numerous as to be in each other's 
way do not always prevent self-destruction by the insane. 
Should suicide or homicide occur in the smaller institutions 
there is evidently a greater incentive for concealment of facts and 
a greater possibility of keeping the matter quiet than in the 
larger public asylums where everyone considers himself privileged 
to tell all he knows. Besides, the latter are subject to frequent 
visits and investigation by legislative committees, boards of 
charity, and self-constituted inspectors and commissioners in 
lunacy. That is to say, that facts concerning homicide or suicide 
must necessarily crop out and be made public, which in a retreat 
could and doubtless would be concealed from the public eye and 
ear. Less carelessness will be found, greater watchfulness is the 
rule; and consequently fewer suicides, homicides and elopements 
occur in public asylums, excepting in the homes where only the 
milder cases are treated. 
On account of closer espionage by friends of patients, by the 
people and by the press, the probabilities against abuse and neglect 
of patients are in favor of "caravansaries." Private interest 
operates against exposure of irregularities in private institutions, 
and patients may there be neglected or abused, notwithstanding 
" personal medical supervision," by the most competent, careful 
and conscientious physician. A large institution may be properly 
conducted, while a smaller establishment may be most grossly and. 
villainously mismanaged, and vice versa. 6 
LARGE OR SMALL HOSPITALS. 
As regards danger of fire and consequent loss of life thereby, 
the opponents, the " caravansary " system, can certainly boast but 
little. The Longue Point Holocaust matched and followed so soon 
by the burning of the inmates of a smaller asylum at Norwich, N. Y., 
furnishes no argument for either side of this controversy. 
Criminal neglect of proper precautions against fire cannot be 
too severely condemned in anyone who has charge of human life. 
And if the published reports be true as regards the lack of prep- 
aration for the prevention of fire and for combatting the flames 
in the Canada Asylum, a fearful responsibility rests upon the 
managers. Is it not likely where a greater number of people are 
housed that there will be greater care exercised in preventing fire 
and arresting its spread ? I do not defend the Longue Point 
management, but I do venture the assertion that in all of the 
largest asylums for the insane greater care is exercised against the 
causes and spread of fire than in an equal number of the smaller 
asylums in the country. 
The per capita cost of maintenance is a question which can 
always be easily and accurately determined, and is one in which 
the taxpayers are deeply interested. That, " caravansaries" can be 
more economically managed appears from the published reports; 
and yet the managers of the smaller institutions affect a profound 
contempt for the "niggardly," "grudging," "skimping" superin- 
tendent who dares to manage his hospital with ordinary economy, 
such economy as he would practice had he to pay the bills instead, 
of the State. Greater economy, greater care and supervision 
must be practiced or else the superintendent will hear from the 
dear people who pay the bills. There is relatively a smaller 
degree of waste, prices rule lower-wholesale rates for food, cloth- 
ing, etc., better and more varied diet can be furnished at the same 
general cost of maintenance. These facts must be borne in mind 
in collecting and comparing statistics. Smaller institutions 
generally depend upon patronage of those who wish to avoid the 
publicity of confining their friends in a public asylum and are 
willing to pay roundly for privacy and for extra service and 
luxuries. Public asylums must by reason of the limited appropria- 
tions, based upon per capita cost and probable number of inmates, 
together with sufficient margin to cover possible contingencies, be 
conducted economically. The cost of maintenance must be con- 
sidered in every institution whether private or public, large or 
small. If the people donate a sum of money to provide for the BY C. E. WRIGHT, M. D. 
7 
insane, the insane should receive the full benefit of such donation. 
The funds should be handled as carefully, conscientiously and 
economically as if they were our own, and if in excess of the 
actual needs the surplus should be religiously covered back into 
the public treasury. However we may rail at economy of manage- 
ment as " niggardly " and " grudging charity," and although the 
quality of charity, like that of mercy, should not be strained nor 
benevolence " weighed with an apothecary's scale," yet it must be 
remembered that public benevolence is a public burden, and tax- 
payers should not be compelled to bear unnecessary expense. 
Public charity should not be used to cover public plunder. 
A decided disadvantage under which the management of a large 
public hospital labors is the incentive and opportunity sometimes 
offered to politicians of the very worst type to obtain and to retain 
control of it for party purposes alone. To be sure politics can 
occasionally be used to good effect in cleaning out a lot of worth- 
less, corrupt and vicious old party hacks, who cannot make a living 
elsewhere, who have done a little party service, just sufficient to 
afford an excuse for their appointment, and who are given places 
to keep them from being a burden to their friends or to the county. 
A large hospital controlled exclusively by a political party affords 
a bright and shining mark for the envy and malice of the opposi- 
tion, who do not hesitate to attack and malign the management in 
the most outrageous and villainously untruthful manner. Besides, 
the managers must be subject to all sorts of political dissensions 
and changes and suggestions and demands by bummers and dead- 
beats. The most competent are removed sometimes without cause 
save that they do not vote right, and yet to counterbalance this 
hardship we occasionally find that benefit is rendered to the pa- 
tients and the State by political changes which remove some fossil 
who has outlived bis usefulness and by his egotism and intolerance 
prevents progress. But, taken altogether, the chances offered for 
corrupt and wholly unqualified persons to secure places, and in 
spite of vicious conduct and utter lack of all the elements of 
fitness, through political influence alone to retain positions, and 
for years to defy decency and the better sense of the community, 
furnishes one of the best if not the most potent reason for limited 
hospitals. 
" Individualized treatment," or " personal medical supervision " 
is largely dwelled upon by advocates of small institutions, who 
possibly consider that only the superintendent should look after 8 
LARGE OR SMALL HOSPITALS. 
the moral, mental and physical welfare of the patients. To be 
sure an institution of whatever kind will largely partake of the 
character of the man at the head; but if the superintendent is to 
be held directly responsible for everything there seems to be but 
little use for a medical staff. 
The superintendent's functions are multifarious and vastly 
diversified; the demands upon his time are endless and exacting; 
his duties are professional, moral and executive. If he properly 
fills his place in all its requirements he must needs be a perambu- 
lating encyclopaedia of information about things natural and 
supernatural, things physiological and psychological, things terres- 
trial and celestial. The superintendent cannot well perform his 
executive and managerial duties and at the same time practice indi- 
vidualized treatment upon two hundred nor five hundred any more 
than one thousand patients. The medical staff should be compe- 
tent and be expected to exercise the personal medical supervision 
of the patients. With a properly selected staff who, while admit- 
ing the authority and right of the superintendent to maintain 
general, or even direct supervision of any or all cases if he wishes 
to, in an institution sufficiently endowed, or with an appropriation 
ample enough to afford good salaries to medical men, there need 
be no lack of "individualized treatment." With a number of 
qualified medical men to give special and sole attention to indi- 
vidualized treatment certainly the results must be better and more 
satisfactory than where the superintendent is expected to be omni- 
present and to do impossibilities. 
There seems to be a crying need of a better and more uniform 
mode of publishing and collecting statistical information in the 
annual reports of institutions for the insane. If one superin- 
tendent gives certain data based on "admissions" during the year, 
another upon the "daily average number present," the third upon 
the " total number under treatment," while the fourth fails to 
furnish any statistical information whatever, but fills his pages 
with the consideration of ordinary text-book subjects, or some 
abstruse psychological problem and self-laudatory remarks about 
what he does not do in the way of restraint or seclusion, or the use 
of "narcotics and other deadly drugs," there will be no reliable 
information upon which to base any conclusions whatever. 
As it is now it would seem that the statistical tables, so-called, 
are, occasionally at least, intended more for the personal aggrand- 
izement of the superintendent and to enhance his general and BY C. E. WRIGHT, M. D. 
9 
professional reputation, than for the benefit of the patients who 
receive the treatment or for the public who pay the bills. 
A practical matter, entirely within the jurisdiction of this Asso- 
ciation, would be the adoption of a standard series of statistical 
tables, in which there would be uniformity of registry, classifica- 
tion, percentages and other information which could be made 
available. If such a plan of collecting and publishing statistics, 
therapeutic, vital and economic, should be formulated by this 
Association, and adopted by the managers of all institutions in the 
country, the settlement of the subject of this essay and other 
matters of interest to us as alienists and public servants could be 
accomplished.