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ON HOSPITALS FOR THE INSANE.
WITH PARTICULAR REFERENCE TO
SEPARATE ESTABLISHMENTS
CHRONIC  INSANE  POOR,
      DISCUSSION,

OF THE ASSOCIATION OF MEDICAL SUPERIN-
 TENDENTS OF AMERICAN INSTITUTIONS
   FOR THE INSANE, IN CONVENTION,
        AT WASHINGTON:
COU.3L...... 
w/h
fihvrK ^u*,  loysq  che^^ 3 
PREFATORY   NOTE.
  The Discussion, reported in the following pages, took place
at the Twentieth  Annual Meeting of the Association of Med-
ical Superintendents of American Institutions for the Insane,
held in Washington during the  month of April, 1866.  The
discussion is very fully and accurately reported by the accom-
plished  Congressional stenographer, Francis II. Smith, and
leaves but  little to he said in the way of an explanatory pre-
face.
  A few words seem called for in  regard  to the  paper, read
by a member, " On  the  Care of the Chronic Insane Poor of
the State of New York,1'* and frequently referred to in the
debate.   In this paper Dr. Cook, the author, bases his argument
upon the assumption that New York is unable or unwilling, or
both, to provide sufficient hospital  accommodation for her  in-
sane, and  therefore,  some  other and cheaper method must
be devised for the care of this  unfortunate class of her children.
lie  frankly  acknowledges that, were  it  feasible to  secure
enough hospitals  of the same description as those now in ope-
ration, he would  not advocate a change, but this he believes
impracticable because,  ''for fifteen years efforts have been
made without success, to secure the passage of a bill through
the Legislature of the State  of New York, for  one or more
State Hospitals of this character;''  therefore, he asks, ^ is it
not wiser to take  it [the  scheme of providing for the chronic
insane, in separate institutions] rather  than adhere to the un-
attainable  and get nothing T   On these grounds he urges  the
  * This paper is printed in the Journal of Insanity for Jul}-, 186G. 
')
establishment of separate and cheaper institutions for the spe-
cial care of the chronic insane poor of the State.   The author's
conclusions would  be more convincing, were  his argument
based on sound premises.  That it  is not we have  ample evi-
dence.

   The history of legislation in this State, during the  fifteen
years ending  with  1865, supplies  but one example of  well
planned, well directed, and .strenuous effort, in behalf  of the
insane of the commonwealth.  In  1857, the neglected condi-
tion of the insane poor, and the necessity of further State pro-
vision, were brought to the attention of the Legislature  by the
forcible report of the Select Committee on Charitable Institu-
tions, Poor Houses, etc.   The report was accompanied by a
bill providing for the immediate erection of two State  Hospi-
tals.  This  bill passed  the  Senate.  " In  the  Assembly  it
passed a third reading, Avhen its further progress was arrested
by the premature adjournment of the Legislature."'  Thus it
failed to become a law, not through opposition to the measure,
for there was none ; but  by one of  those accidents incident to
legislation.
   The subject was  not again called up, until two years ago,
when, although,  in the  midst of civil war  of  unprecedented
magnitude, and with  an  accumulated debt of vast proportions,
the Legislature of the State responded  at once, without dis-
cussion or  dissentient voice,  to Dr. Willard's appeal, and the
Willard Asylum was created.  For this institution, the  appro-
priations have  already  reached  the  generous  amount  of
§165,000, and the State,  through its appointed commissioners,
has secured the Ovid Agricultural Farm property as a site, at
a cost greater than has ever, in any country, been expended for
a similar purpose.

   In further evidence that there  is  no disposition to evade or
ignore the just claims of the insane, and that the State hjjoten.s
et cole/is, we may mention  the fact that the Legislature, last 
3
winter, authorized the Governor to appoint a Board of Com-
missioners to select and contract for the site of a third State
Hospital, to be  located on or near the Hudson River, below
the city of Albany.
  Soon after  the  passage of the Willard  Asylum act,  the
American  Journal of Insanity called attention to some of its
exceptionable features, and  particularly to that most unfortu-
nate provision of the law, which inaugurated, in our State, a
system, that in other  conntries had been " weighed in the bal-
ance and found wanting."  The  fear was expressed, morever,
that the action of New York in establishing an asylum, solely for
chronic insane paupers, might serve  as a precedent for other
States to follow.  This apprehension, happily, has not been real-
ized.  Although California, Kentucky, Ohio, and Connecticut,
have since witnessed  the  discussion of this subject in their re-
spective Legislatures, and the example of New York has been
cited in favor of separate institutions for the treatment of acute
and chronic insanity, the proposed experiment was, in every
instance, rejected, and the extension of existing hospitals, or
the creation of new ones  substituted and adopted.

   In California, the Assembly Committee on State Hospitals,
to  which was referred  the  Assembly Bill,  creating  a State
Hospital for e arable.*, at  some  point to be  determined by a
Board of  Directors,  and proposing  to make  the Asylum at
Stockton an institution for 'incurable.*, reported the bill back
with a recommendation that the subject  be indefinitely post-
poned.   As would naturally be inferred from the action of
the Committee, their report  expresses the strongest disappro-
 val of separate establishments for " incurables/1 Morever, the
joint Committee of the Senate and Assembly, appointed  " to
investigate the affairs  of the Insane Asylum, at  Stockton,"
and among other  matters " determine what changes, if  any,
should be  made, either in the general system [of provision for
the insane] now adopted, or in the details of the present man-
agement,"  unanimously  report: i£ The  proposal to  erect a 
4
 building at some other point for earabies, and thus convert the
 Stockton establishment into an .asylum for incarable.*, should
 be utterly ignored.  Our reading and researches establish the
 fact, that in nothing are the members of the  profession, and
 the most competent and experienced superintendents and di-
 rectors more unanimous, than in their utter condemnation of
 such a division and classification of the insane."  The Legis-
 lature indorsed  the opinions  and  recommendations  of  the
 Committees, and voted a liberal appropriation for the enlarge-
 ment of the Hospital at Stockton.

   The proposition to erect  special  Asylums for the chronic
 insane, met similar  disapprobation  and  defeat in Kentucky.
 Ohio and Connecticut; the first two making liberal grants to
 enlarge existing Hospitals, in Ohio to the extent  of  doubling
 the capacity of two of her State Hospitals, while  Connecticut
 has just passed a law authorizing the construction of a Gene-
 ral State Hospital for the insane, at a cost of S200,000.

   In this connection, we may call attention to recent legisla-
 tion in  New Jersey, Iowa, Indiana, West Virginia, Nova
 Scotia and Canada West, where  liberal  appropriations have
 been made  to enlarge or complete existing hospitals, and to
 Minnesota and Kansas,  at  present  engaged in the  establish-
 ment of State Hospitals for  their insane.

   It will  be perceived  that the discussion at Washington
 elicited, a spirited and  very emphatic expression of  the views
 of the  members of the Association upon a system of provision
 for the insane in  separate institutions, whereby the  character
 af the  disease, whether it be acute or chronic,  curable or in-
 curable (so-called,) and the  element of pauperism, are consti-
 tuted the basis of seirresation.

   The following resolution  introduced by the  writer  of the
paper alluded to, received, with the exception of  the solitary
voice of the mover, a unanimous vote in the negative : 
5
  The subject of provision for the insane  poor, especially for the chronic
insane poor, having been  brought before the Association, and discussed at
some length, and the question raised as to whether some modification of the
propositions heretofore adopted, in regard to the construction and organiza-
tion of hospitals, was not required to meet the necessities of this class ; the
Association would take the opportunity to record its decided  preference for
Hospital provision for all the  insane, whether in the acute or chronic stage
of the disease.  But it is willing to qualify the propositions, so far as to ad-
mit that, if the question presented in any State be : Shall the chronic insane
poor continue to be confined in County Poor-Houses, 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 Poor-House receptacles.
   Thus, distinctly and unanimously did this influential body—
representing the highest intelligence of the medical  profes-
sion in this country, in whatever relates to the care and treat-
ment of the insane—-proclaim its positive condemnation of any
scheme, even one set  forth in the mild  and modified terms of
this  resolution, which would  provide separate asylums for the
chronic cases of  insanity.   But, not content  with  the explicit
expression conveyed in its  refusal to agree to the  above reso-
lution, the  Association  passed,  unanimously,  the following
propositions, offered by Dr. Chipley, of Kentucky :
  1.  Every State should make ample and suitable provision for its insane.
  2.  That insane persons, considered curable, and those supposed incurable,
should not be provided for in separate establishments.
   With such harmony of sentiment and action in the medical
profession, and  in State Legislatures,  a further discussion of
the subject  would seem  unprofitable.   There  are,  however,
several points in the  paper alluded  to, which demand a pass-
ing notice.
   The writer's statement, that  Dr. Brigham favored separate
asylums for  the chronic insane,  will  seem very hard to believe,
in view of the subjoined letter,* written  by Dr. Brigham to
Miss Dix, and now in the possession of this lady:
  *The substance of this letter, amplified into an article on asylums for in
curables, by Dr. Brigham, may be found in Vol. I, of the Journal op Insan-
ity. 
6
  After much consideration, I feel constrained to oppose the establishment
of hospitals solely for the incurable insane.  They would, in my opinion,
soon become objects of but little interest to any one,  and where misrule,
neglect, and all kinds of abuse would exist, and exist without detection.
  I am opposed to them, principally, on these grounds :
  1st.  Who can say which patients are and  which are not incurable 1  Of
200 now in this Asylum [Utica], neither Dr. Buttolph or myself, nor any one
else, can say of at least one-third, to which  class  they belong.  There  is
hope in their case ; but this hope would be destroyed by sending them to an
incurable establishment.  This fact—that the chances of recovery would be
diminished to even but a few—is enough to make us  hesitate before estab-
lishing such asylums.
  2nd. Many that are incurable  are monomaniacs, that are deranged but on
one or two subjects, but rational on others ;  such, surely, should not be de-
prived of  any comforts that are  afforded  to the curable class, among which
the greatest is hope of again being  restored to  society, which would be de-
stroyed if  they were sent to an incurable asylum.  Equally, or more strong-
ly, does this objection apply to cases of remission—to those numerous cases
in which insanity is exhibited for a week and followed  by several weeks ol
sanity.  Shall these be told there is no hope for them ?
  3rd.  Among  the incurable insane,  there would be no certain means of
ascertaining the neglect or abuse of them.  In all asylums, the fact that some
are well and soon to  leave the  asylum, is the  greatest safeguard against
abuse. It is so considered by all who are much acquainted with asylums
for the insane.
  4th.  No possible  good would arise from  such distinct asylums—except
they might be conducted at less expense.  But  how so, if they are to have
proper officers, physicians, etc., and if they do not, why are they better than
county houses ?
  5th. We have had no  experience of such  establishments.  I have never
seen but one such, and that was at Genoa—where the clashing of chains,
the howlings, groans, and curses, gave to the place the appearance of the
infernal regions; where no patient is ever  expected to leave until dead >
where hope never comes.
  No! do  not, in mercy to the insane, establish asylums for the incurables
alone, but  provide good asylums  for all, and let all have the same kind care,
and indulge the same hopes, (even if delusive to many,) of ultimate recovery ;
but do not drive them to despair by pronouncing them incurable.

   Dr. Gray also  is brought forward  in this paper, as having
advocated separate provision for the chronic insane, in a par-
agraph quoted from his Eighteenth Annual Report,  But we 
7
fail to discover, in the passage cited, any endorsement of sep-
arate institutions or asylums for the chronic class, absolutely
disconnected with the hospital.   For  Dr.  Gray's opinions on
this question, the reader is referred to his  remarks in  the fol-
lowing discussion:

  The writer further informs us that Drs. Butler, Hills, Work-
man, and Van Deusen a concur in recommending provision
for the chronic insane in separate asylums, or in farm cottages
or asylums, retaining a connection with the parent institution.'"
In his Report for lSfJl-O^, Dr. Van  Deusen writes :  " The
objections to a State Asylum for incurables exclusively, are
obvious enough/1   And that his views in this respect have not
changed, we have the assurance  in the following, received
since the Association adjourned:   uI should dislike,  exceed-
ingly, to go upon the record as an advocate of the erection of
asylums for the incurably insane;  and if, by the ' cottage sys-
tem,' I am to understand the proposed  treatment of  the in-
sane, in small buildings, scattered about,  with families to serve
as their attendants, I am opposed to that also/'
  We confess our surprise at  seeing the name of Dr. Work-
man in the above  connection.  This  gentleman has  always
been the strenuous advocate of the  enlargement of the Toronto
Hospital, and,  as  we had supposed, viewed  with  disgust the
little incurable establishments thrust upon him by the  Inspec-
tors  of Asylums and Prisons.  We trust  the long delay in the
accomplishment of his cherished  schemes  has not weakened
the faith of our esteemed and excellent  friend, and  that one
who has  dealt such vigorous and  stalwart blows  against the
miserable doctrine of expediency, may still maintain the truth
spoken by the poet:
             "Of all expedients never  one was good."
  jS'ow, at least, Dr. Workman has every reason  to be encour-
aged ; for, during the past year, the Board of Inspectors have
urged upon  the Colonial Government,  not  the extension of 
8
the branch asylum system, but the completion of the Toronto
Hospital, and with such success as to obtain a liberal  grant
for the purpose,  and the long wished-for consummation will
soon be reached.
  The mention of Dr. Hills's  name calls to mind his project
for a Hamlet Home for the chronic insane  paupers of Ohio;
but we  have been unable to  discover any  application of its
principles in the enterprise in which he is at present engaged,
in West Virginia.   As regards  Dr. Butler,  the  recent action
of his own  State is the best commentary upon  the policy he
has advocated.   Instead of an asylum for incurables, the State
of Connecticut has honored herself by  the creation of a Gen-
eral State Hospital for the Insane, which is to cost $200,000.
  We find but little else in this essay, requiring notice, except,
perhaps, the following, which  would  mislead those  not ac-
quainted with the actual facts.  The writer remarks: "I am
informed that the plan of building comprises a hospital struc-
ture for the paroxysmal, excited, and grossly demented, with
sections of cottages, plain and  inexpensive in their construc-
tion," etc,   This  is a mistake.   The law particularly directs
that the plans of the Willard  Asylum must be approved by
the Governor.   As the Chief  Magistrate has approved  the
hospital structure only, and has not assented to  " sections of
cottages," the plan of the Willard Asylum consists simply of
an Hospital proper. 
DISCUSSION.
   The Association reassembled at I p. m., and proceeded, as
 the regular order of business, to the consideration of the sub-
 ject of the proper care and treatment of the chronic insane.
   The Secretary stated that he had received a communica-
 tion from Dr.  Butler,  Chairman  of the Committee on the
 subject now up for consideration, stating that in  consequence
 of ill health he had been unable to  give the subject proper
 attention to enable him  to prepare a report, and desiring the
 subject to be postponed until the meeting next year.
   The President remarked that the action taken  by the
 Legislatures of several of the States upon this subject rendered
 it peculiarly important that  the subject should be taken up
 and discussed by this meeting, so  that the public  may have
 an opportunity of knowing what are the opinions of the mem-
 bers of the Association upon  the various questions involved.
   Dr.  AValker—As a matter of respect to Dr. Butler, moved
 that the  subject be postponed for one year, expressing, how-
 ever, the intention to vote himself against the motion.
   Dr.  Brown inquired whether any of the other members of
 the Committee  had prepared their views in form to bring
 before the meeting.
   Dr. Walker replied that Dr. Curwen and himself, the two
 other members of the Committee, had a consultation on their
way to Washington, and agreed upon the substance of the
resolutions they would present in case a report from the Com-
mittee was called for.   He was of the opinion that the feeling 
                            10

in the community on the subject was such as called for imme-
diate consideration and action on the part of the Association.
He therefore hoped a postponement would not take place, and
was ready when called upon to present resolutions prepared
by himself and Dr. Curwen, as members of the Committee.
  The motion to postpone was disagreed to.
  The President then called for the report of the Committee.
  Dr. Brown said that Dr. Cook had prepared a paper upon
the  Condition and  Care  of the Insane  Poor of the  State of
Xew York, and in order that the Association might have this
paper before them in the  discussion to follow upon the resolu-
tions of the Committee, he moved that Dr. Cook be requested
now to read his paper.
  The motion was agreed to.
  Dr. Cook, with the  prefatory remark that the  paper had
been prepared after consultation with the  Chairman of the
Committee, Dr. Butler, read his paper.*
  The President then called for the report of the Committee.
  Dr. Walker—It will be recollected by the members of the
Association that the general subject of the care of the chronic
insane, and  questions  incident thereto, was brought to the
attention of the Association in a paper read by Dr. Butler, at
the meeting at Pittsburgh last spring,  and that the subject
was  then referred to a committee, consisting of Drs. Butler,
Curwen and myself.  AAre, of course, awaited the summons of
the Chairman of the Committee to call us together, but ill-
health prevented his  attention to the subject.   Until our
arrival in \ATashington we were not aware  that he had pre-
pared no report, but had requested that the  subject be laid
over.  It was then  too late for us to prepare a report, that
should present elaborately, well-digested views on the subject;
but having had some consultation on our way here, we deter-
This paper appeared in the Journal op Insanity for July, 1866. 
11
 mined to embody our views in a series of resolutions, which I
 am now  prepared to present, and which we  thought might
 prove a medium between the conflicting views held  by differ-
 ent members of the Association.   The Committee are painfully
 aware that the public mind, in many directions, i* moving in
 this matter, and  that the public are waiting  to hear of "the
 action of this Association upon the subject.  In whatever they
 have done and are now doing in this direction, they are moving
 in  the dark, and  by way of  experiment.  It seems to us that
 the time has come for this body to act in regard to the matter
 m some  practical  way, or else alloAv communities  throughout
 the country to move on in their own way,  without regard to
 us  or our opinions.   In  view of these facts, we  have prepared,
 and now submit the following resolutions:

  No. 1.  Every State should make provision for the care and treatment of
 all the insane within its limits, whose relatives, by reason of limited resour-
 ces, are unable to make proper provision for them.

  No. 3.  Every hospital should be located as near as may be in the centre
 of a given district, so as to lessen the expense and risk of  life incurred in
 conveying the insane thereto.

  No. 3.  It is unwise and opposed to pure humanity,  as well as to true
 economy, to attempt to make the labor of the insane pecuniarily remunera-
 tive, or even as a primary object, contributive to their support.

  No. 4.  No class of insane, except that of chronic and advanced dementia,
 should be cared for otherwise than in hospitals properly constructed, equipped
 and organized.

  No. .").  Demented  persons, in whose cases the disease  is chronic and ad-
 vanced, may, with propriety, be provided for in institutions other than hos-
 pitals, but always in buildings constructed expressly to meet the  require-
 ments 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.  The
persons to be provided for as above should be selected  by a commission,
composed in  part, at  least, of experienced superintendents of hospitals for
the insane, and no one should be thus provided for who has not previously
enjoyed the benefit of hospital treatment. 
12
  Dr. Chipley—I move, as a substitute for the resolutions
just read, the resolutions adopted by a Convention of  Super-
intendents of the Poor of the State of Xew York, in 1S55, as
follows:
  Resolved, That the State should make ample and suitable provision for all
its insane.
  Resolved, That no insane person should be treated, or in any way taken
care of, in any county poor or alms house, or other receptacle provided for
paupers, and in which paupers 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 con-
structed with a special view to their treatment.
  Resolved, That insane persons considered curable, and those supposed in-
curable, should not be provided for in separate establishments.
  Dr. Brown—Every one present knows how readily an indi-
vidual who has once suffered from an attack of insanity falls
again into the second attack.  The proposition which I made
yesterday, in reference to another subject, and which seemed
generally to  have been accounted to me for insanity instead
of wisdom, that we should not discuss the subject further had
very nearly risen  to  my lips in regard to  this, because, after
Dr. Cook's paper was read, the Committee appointed  by the
Association presented a series of  resolutions, the last of which
seemed to concede all  that Dr.  Cook asked  for.   If that,
therefore, is to be considered as the  sense of the Association,
we might  save ourselves a great deal of time, and much wear
and tear of  thought and tongue, by saying nothing on  the
subject.   You perceive that Dr. Walker's fifth resolution pro-
poses that " demented persons, in whose cases the disease is
chronic  and advanced, may, with propriety, be provided for
in institutions other than hospitals."
  I repeat that if the fifth  resolution of the Committee is to
be the sense  of  this Association, although it is not  yet acted
upon, it would concede all that Dr. Cook claims in the matter
of special provision, and perhaps for special institutions for
the chronic insane.   And, had it not been for the other pro- 
13
positions which Dr. Chipley has presented as a  substitute, I
think I should not have tried the patience of the Association
by offering any other remark.  However, the matter is to be
discussed;  that  is  decided,  and I will therefore say a  few
words upon the general subject.
  First—I desire to say I see no special reason for the estab-
lishment of institutions for  the  chronic insane.  My views
upon this question have been known to many of the members
to go to the extent of looking somewhat with disfavor upon
private institutions for the insane.   But there is a portion of
the community who desire and demand such provision, and I
am not unwilling that it should be given by such  institutions;
yet I desire very much that they be placed under such control
and supervision  as to insure safety and protection, both to the
patients and to the public.  And I have entertained  similar
views in regard  to  institutions for the chronic insane.  The
time may arrive when their  establishment may be demanded
as the  last method  of meeting a great want which prevails
throughout our whole community.  But that is not the ques-
tion at the present time.  The question which presents itself
to every community and every State is:  AArhat is the  best
method of providing for the insane of that  Commonwealth?
After the class of persons whose circumstances permit them
to provide for their own friends, are  cared for, another  class
of persons require protection—the indigent and poor.
   It was the object of the Legislature of the State of Xew
York, in the law passed in respect to the admission of  indi-
gent patients into the State  Asylum at Utica, to make ample
provision for  that  class, but at  present we know that, as a
class, they are not  sufficiently provided for.  For a correct
understanding  of Dr. Cook's  proposition,  and  to  meet the
question fairly upon its  merits, it seems fair to say that I un-
derstood him to remark that any other form of  provision for
the insane poor of the State was not to be expected or hoped
for,  and that he therefore had proposed the system that he 
14
presented here as a means of  improving the  condition of a
class who wTere otherwise to be abandoned to the abominations
of the county-house system.  I have only to say in respect to
that, that if  Dr. Cook's  plan is based  upon the necessity of
such institutions in the State of New York, his apprehensions
have  already, I  trust, been removed, for within  the last few
weeks a law has been passed directing the establishment of a
new State Hospital of the usual character, and I understand
there is a probability that, sooner or later, within a reasonable
time at least, a similar one may be established in another por-
tion of the State.  If, therefore, the Doctor's object be merely
to provide for the insane of the State in the usual hospitals
or in the manner which  he proposes, to be adopted as a sub-
stitute for a better method, it seems unnecessary, so far as the
State of New York is considered, to go at length into the
consideration of the present  necessities of that  State.   AVere
it  not so, the question,  then,  would arise, what is the best
method, in the  abstract, of  providing  for  the  indigent and
]!>oor insane of any given  State'(  We are not obliged to resort
to theory merely upon the subject, because we have examples
before us of  institutions established  under the different sys-
tems, and we may compare one with the other.   The State of
Massachusetts, for example, has adopted the policy of erecting
smaller institutions in different portions of the  State, with the
view of their receiving the larger part at least of her insane.
AVhether they do so receive them or not, others can say better
than m}Tself.   If not, it would  seem to me their present hos-
pital  system  only requires expansion to embrace  all of the
class  of insane requiring the aid and  support of  the State.
And  that is what I believe Dr. Cook  considers preferable, if
it  can be accomplished.   If hospitals can be sufficiently nu-
merous  to  provide each for all the insane cases  in its neiffh-
borhood  in the most humane manner, without compelling
them to travel a long distance to reach the hospital, and addi-
tional buildings  erected in connection with the present insti-
tutions  sufficient for the care of the chronic insane, I think 
15
that would meet the necessity of the case fully.   The article
by Dr. Jarvis in the last number of the Journal of Insanity,
showing the  proportionate number of insane persons in  any
community, treated in hospital, as compared with  the approx-
imate  distance of their residence  from the  hospital, would
seem to settle the question of the relative number of hospitals
called for in  any given  State.

  With reference to the  institution which lias been directed
to be constructed by  the Legislature of Xew York, for the
care of  the  chronic insane, the "Willard Asylum," I may
say, that it had my earnest sympathy under the circumstances
related to me as existing;  and it would  still have, if those
circumstances and facts had not been, and could not be, modi-
lied.  I was  informed that the Legislature of New  York, at
that time, was unwilling to expend money for the construction
of additional hospitals of the usual form, but that they were
willing to erect  a hospital at a less cost, or an asylum for the
insane, where might be gathered those now suffering in county-
houses.  A very serious objection to that was, that  it was to
be  a single  institution, located in the central portion of the
State, and persons from a distance would thereby be prevented
from seeing  their friends, and from receiving such attentions
from them as would otherwise be natural and  desirable.  It
would subject those friends who might desire to see them to
great expense in visiting them, and the  matter  of expense
would deter large numbers of them from ever visiting their
friends.   The transfer of patients to that institution would,
therefore, be a  complete and  iiiial  separation of  members of
families.  When, however, the matter came to be considered
by  the Legislature at a subsequent session, they were made to
believe,  and  properly, in  my opinion, that a better system ex-
isted already in our present  hospital organization; and, I am
glad to say, that they adopted  that better system.

  When the matter of a third  institution  was before the last
Legislature,  at  the request of some of the members, I  stated 
16
my belief, in a letter, that if the proposed system of the Wil-
lard Asylum bill should be entered upon, it would soon  be
found that it could  not be carried to the extent contemplated
by its  advocates; that a  proper care  of the patients would
limit the number to  be provided for much  below the point
proposed; and furthermore, that  a hospital building for par-
oxysmal cases would be necessary, and  that  it will soon  be
found  that the institution would become necessarily another
central State  hospital.  In that view it  seemed to me to  be
very unjust to more distant portions of the State that a second
institution of this kind should be located so near the Asylum
at Utica.  I suggested that it might be well to reconsider the
whole  matter, and  act  upon it with reference to the relative
claims of other sections of the  State.  Whether this letter had
any influence  in the  minds of the members I do  not know.
It seemed to  me the course I mentioned was one having a
bearing on the whole question as applying to other communi-
ties as well as ours.

  There is another consideration  in connection with the mat-
ter, which I trust Dr. Cook will  pardon me for speaking of if
it should seem, for any reason, to be invidious, because I should
be included, in some  measure, under the same reason myself.
Dr. Cook's institution is in the western portion of the State of
New York, and  as  is known  to  the members present, is his
own private property.   The institution with which I am con-
nected is at the other end of  the State, a chartered hospital,
depending wholly on  the income derived from patients for  its
support.  Both institutions would, in some measure, be affected
by the establishment of a State  hospital in their vicinity.
Feeling this, at the time I wrote the letter spoken of, I stated
that  of the number of patients in the Bloomingdale Asvlum
at the present time, 43 per cent, pay less than the cost of their
support, and that it is only by the higher rates paid bv more
affluent patients that the institution is enabled to sustain itself.
Now, a very  considerable number of that 43 per cent, will 
17
probably be removed, and those who would otherwise be their
successors will go  into  the  new hospital which is ordered to
be constructed on  the  line of the Hudson  river.   I do not
mean,  of course, that such considerations would  affect the
views of either Dr. Cook or myself,  in the discussion of this
general subject, but it is an element which  others would be
very willing to take into consideration, and I think, therefore,
it  is due  to ourselves to consider it also.   The force it may
have is this: that the erection of a large asylum for the chro-
nic insane, by gathering these persons into its enclosure, taking
a considerable number from the Asylum at Utica, leaves room
for more acute cases; but at the same time it keeps communi-
ties at a distance from Utica from furnishing any considerable
increase of patients, as  shown  by the article  already alluded
to from Dr. Jarvis, and I have  no  doubt our own institution
and Brigham Hall  would both  thrive better in the next ten
years if another State hospital is not erected in our immediate
neighborhood.
   Dr.  Cook, in his paper, referred to a proposition made some
years ago to limit  the  number of patients in State hospitals.
I do not feel myself fully competent to speak upon that subject,
because my experience in most  of my asylum life has been of
a  different character, although  I was connected as Assistant
Physician with  the State Institution  at Utica, and with that
in Vermont also, for a time.   But I must say that my views
concur with those  who think the number proposed too small.
I see no reason why a State institution cannot be increased in
capacity very  considerably beyond  the limit  mentioned, nor
can  I see why additional accommodation  for the  chronic
insane may not very properly be made in each case.  The
extent to be determined by the experience of those  who are
best capable of forming an opinion.
   Dr. \"an Nostrand—I do not propose, at this late hour, to
take up much time in the discussion of this matter, and I can
express the views  I have to give in very few words.   So far
       B 
is
as the State of Wisconsin is concerned, I should most strenu-
ously oppose a separation  of the two classes of patients  in-
different institutions.  I think they can be better provided for
in the same institution.   It seems to me that combining in the
same establishment the characteristics of  hospital and asylum
profits  both classes of patients.  The matter of the employ-
ment of patients comes up incidentally in  considering one of
these resolutions, and, in my judgment, that of itself furnishes
a very strong reason for permitting both the chronic and acute
patients to be treated in the  same institution.  Most of the
labor of the institution of which I have  charge is performed
by the chronic insane.   They are more  to  be trusted to per-
form work than acute cases, and they labor to more advantage
to themselves.  Many of the acute cases who are able to labor
at all, will have  to be  taken  from the  garden, the barn, or
wherever they are in a very short time, because  the exercise
exhausts them ; while many of the chronic cases will perform
as much labor as ordinary men in a sane condition.   During
the winter, in consequence of  the circulation of blood  being
usually poor in the chronic class, it  is not practicable to keep
them out of doors for  any considerable portion of time.   They
would  freeze almost  immediately on being  exposed to  a cli-
mate like  ours, where  the thermometer goes as  low as 40*
below zero.   Our patients, therefore, mostly remain within
doors, and in the spring they are much poorer in health than
they were in the fall.  I think the labor, in season, which they
perform is not only a  source of economy to  the institution, but
of benefit to the patient.   Four-fifths of all our farm labor is
performed by the chronic insane.  Last year we raised  many
thousand bushels of roots and many hundred bushels of corn.
Some of our chronic insane, who, until they entered the insti-
tution had  never done a day's labor, turned  out and  assisted
in this  farm wrork.   I remember one man who for ten  days
stood like a stake in  a field, showing no disposition  to  move
hand or foot in assisting in the work.   But after a while  he
went to work, became a valuable hand, and before fall was 
19
 much improved.  I should certainly very much regret to see
 AVisconsin build another institution for the insane, and put
 all the incurables  into it.  I think it  better for both classes
 that they should be treated together, and I shall be Aery sorry
 if this Association, composed certainly of men better able to
 judge in this matter than any others in the country, should
 finally decide by vote that it was proper to do so.  I  shall
 certainly cast my  own vote without any hesitation  against
 such  a proposition.
   Dr. A\rALKER—I beg that the members of the Association
 will not be  governed by the course Dr. Brown  has taken in
 begging the  whole question, by  saying that the last resolution
 of the Committee yielded all that was  claimed by Dr. Cook.
 Bear in  mind that the last resolution applies only to insane
 persons  in an  advanced stage of dementia.   It does not say
 anything about chronic insane.   If the resolution should be
 passed and carried into effect, there  would still be left a  large
 class  of chronic insane to be provided for in the hospitals.  In
 the discussion of this subject, therefore, I hope this difference
 between the resolutions  of  the Committee  and  Dr. Cook's
 paper will be borne in mind.
   Dk. Peck—My very short experience  in this specialty would
 not permit  me  to  enter into  an elaborate discussion of this
 matter.  I wish, however, to state emphatically that I should
 regret exceedingly to have any action taken in my own  State
 (Ohio) for the  separation of the two classes under considera-
 tion.   I  have labored since our last Annual Meeting to pre-
 vent any such thing taking place.   Our people in Ohio  have
 been  somewhat  led in that direction by my predecessor, and
 the new Legislature, when it came together last winter, feeling
 that something  must be done  for the  chronic insane of the
 State, came  together  imbued with the  idea that a gigantic
institution should be built to provide  for them at once. I
labored to induce them to abandon that idea, and I think,
perhaps, that what little I may have done, may have had some 
20
weight  in  turning the current in  another direction.  Our
Legislature made provision for the enlargement of our north-
ern and southern institutions  to the  extent of double  their
present  capacity.   They have organized a commission to take
the census of the  State and ascertain the  number of insane
persons  unprovided for, with the idea in  view of building
another institution in a distant  portion of my own district,
and of dividing the district.  I am in hopes such a result will
take place, and indeed I  have very little doubt that another
institution will speedily be built upon the same general plan
of organization as that of the three existing State institutions.
We have all requisite  means for carrying on a system of hos-
pital labor, and  I cannot  conceive that any improvement
whatever  could be made by attempting the  experiment  of
separating the two classes in our State.  I wish, most emphati-
cally, to place myself on record in opposition to any proposi-
tion to provide for the chronic  insane in separate institutions.

   Dr. Ranney—I suppose that no one of the  States has ade-
quate provision for all the insane  within its limits.   The re-
sult is that our hospitals are crowded beyond their capacity—
so crowded that their usefulness is very much  impaired, and
one of their chief functions, as now organized, that of the
treatment  of  recent  curable  disorders,  is prevented  from
being realized.   It seems to me that a further  classification is
one of the ends to be desired, and that in that  further classifi-
cation the  principle of separation, to some  extent,  should be
adopted.  It cannot be absolute, I  suppose, but  to some  ex-
tent a separation  of the recent from the chronic cases is desi-
rable.   It  has  been my recent experience  more particularly
to observe  frequently unpleasant results, and often most inju-
rious  and  unfortunate results  from the  presence of  persons
with chronic and probably incurable disorders under the same
roof, and mingling with recent and  curable cases, and I have
felt latterly more  than ever before  the desirableness of the
.separation  of the two classes to some extent. Just  to what 
21
extent must be  determined by the peculiar  circumstances of
any particular case,  or  in  any particular region or locality.
Especially do I feel that it is very desirable in an institution
receiving recent cases that the supposed  incurable epileptics
should be removed.   Nothing, it  strikes me, can  be more un-
favorable to a person not accustomed to such exhibitions, than
the frightful convulsions liable at any moment to occur in an
institution containing a large number of patients in which no
such  separation is made.   That is the case,  to  a very great
extent, in the institution in Iowa, with which I am connected.
I may say that we have recently received more  cases of epi-
lepsy than I have  ever met before in  my experience.   I have
47 out of 315 patients subject to that disease.
  I should oppose the  aggregation of chronic and incurable
patients in one large institution.  The great distance from one
portion of the State  to another would, as has been expressed
by Dr. Brown, in  many cases work a final separation of fam-
ilies,  and do great injustice and almost  cruelty.  I  am not
aware of any patient under my care, however poor, who has
not some friends or persons interested in him to a sufficient
extent to induce frequent correspondence in respect to him,
and I know it is now felt to  be one of the greatest deprivations
where the distance is so great as  to prevent the friends of pa-
tients from visiting them.  It would be pleasant and generally
advantageous to both parties if  they were so near that occa-
sional visits  could be made by  friends.   I  should therefore
recommend, in the State where I live, and I presume it would
be the same in the adjoining States, that the chronic incura-
ble insane should be  collected  into small institutions in differ-
ent parts of the State, large enough, however, to have an or-
ganization that  will protect them from any cruelty or injus-
tice, and that would secure all  that their wants might require.
  It seems to me that the chronic  insane may be made, to a
considerable extent,  self-supporting.   It  is one  of the  great
wants of the institution with which I am  connected that 
22
greater opportunities and facilities for labor are not provided.
It is impossible, upon one farm of 170  acres, to give my pa-
tients all the opportunities  for work of  which they are capa-
ble and which they would be very glad  to perforin.  As it is.
the farm is very largely productive  and highly remunerative,
the chief work being performed by patients.  They take care
of the cows, twenty-five in number, three patients take nearly
the entire care of them, do the milking, feeding  and herding,
and it is well done.
   Dr.  Farle—Without the oversight of any hired persons?
   Dr.  Eanney—No.   With the usual oversight  of hired per-
sons.   The patients do  all the milking, and  pretty much all
the feeding, taking care not only of the  twenty-five cows, but
of twelve horses besides, and do  a great deal of  work on the
farm.  What I mean to say is, that three patients do as much
work as to take care of  the cows, and that much other work
is  done, and that  much more would be done if we had the
means  and opportunities.   For that  reason I proposed to the
Legislature of the State, at its last session, to purchase for us
an additional tract of land, and I have no doubt it would be
a remunerative investment for the State.
   Dr.  Peck—If I  may be allowed, I wish to make one addi-
tional remark.  I  desire to say that  the law regulating our
institution prohibits the admission of epileptics,  so that we
do not experience  the trouble mentioned by the  gentleman
who last spoke.   There should  be—and I have been labor-
ing to  that  end—an institution  for  their especial care and
treatment.
   Dr.  Yan Nostrand—Let me ask Dr. Peek what they do in
his State  with the violent  epileptics!1   Our most dangerous
patients are of that class.  In fact, the only injury I myself
have received was  from a violent epileptic.
   Dr.  Peck—If there are such, and I  have no doubt there are
in our  State, I suppose they are cared  for in the countv houses 
23
 and probably in jails.   I say they should  be cared for, but
 our laws prevent their being  admitted into the  asylums be-
 cause of their ill effects upon other patients.
   Dr.  Gray—Mr. President :  I feel  embarrassed in beino;
 called upon to speak at this period of the discussion, from the
 fact that I did  not hear  the paper of  Dr.  Cook, and further
 from the fact that I did  not hear the remarks of the member
 of the Committee (Dr. A\ralker) who presented the resolutions.
 I understand, however, that the subject before the Associa-
 tion embraces the report  or resolutions  of the Committee, and
 also the paper of Dr. Cook.   I inferred from the remarks of
 Dr. Brown that the resolutions and paper presented the same
 view of the  subject,  but the subsequent explanations of Dr.
 AValker, touching the intent of the resolutions, would seem to
 indicate a difference.  I judge from the discussion, so far as I
 have heard,  that the paper  of Dr.  Cook was in advocacy of
 institutions specially  for the  care of the chronic insane.
  Dr. Cook—I will call the attention of the members of the
 Association to the fact I stated distinctly in the paper read by
 me, that the  result would probably be  the erection  of build-
 ings more cheaply constructed in connection with State  asy-
 lums where these patients  would  be placed.  That was my
 impression.  I stated that in New York the condition of the
 insane  in the  county houses was  such that I believed the
 speediest practical relief  under the circumstances existing in
 our State would be afforded by the erection  ot asylums  spe-
 cially for their care;  not  that I would  recommend the estab-
 lishment of  separate institutions where  adequate  provision
 already exists for their care in hospitals  receiving recent cases.
  Dr. Gray—Then we have three  propositions under consid-
 eration.   We have the report  of  the  Committee,  declaring
 that a certain class of chronic  insane described as  " chronic
 and advanced  dementia," may properly be provided for in
institutions differing  from the asylums  now in existence,  and
yet adapted  to their pjeealiar condition, with a competent 
24
medical head, etc.  We next have the paper of Dr. Cook, ad-
vocating a special asylum for the chronic insane—its necessity
growing out of the peculiar circumstances existing in the State
of New York—which shall remain as an  institution for the
care of  those who are now in the poor-houses,  not having
passed through an ordinary hospital, and for the reception and
care of those who, under the operation of the Willard Asylum
law, shall be  discharged  from the ordinary  hospitals  when
advanced in dementia.  In fact the two propositions are sim-
ilar ; patients who have been treated in an  hospital for a long
time, and whose cases seem to be unfavorable, are to be pro-
vided for in special institutions contemplated by these gentle-
men. Dr. Cook, however, states as a third proposition, that
it would be  better to attach to  the ordinary hospitals cheaper
buildings for the care of the chronic insane.   Now I should
like to know to which of these propositions the discussion is
to be directed, or whether it is to apply to  all  of them {  Dr.
Brown,  in my view, has proposed to meet the difficulty which
lies before us in the  only true way, i. e., by the enlargement
of the institutions now in existence in the various States, to
the extent that each can be carried, and  yet be properly con-
trolled and taken care of; and if still further provision be re-
quired, then to erect other institutions of a similar  character,
and  enlarge them as necessity may demand  to the limit of
capacity or size that a single governing head, under a general
plan of  management, can control, and yet  give the necessary
care and attention to details.   This is a proposition, morever,
which the most eminent men in Europe,  who  have made this
a subject of special study, and  after the trial of various meth-
ods, have deemed to combine the most advantages of any plan
proposed to relieve the great pressure upon the institutions in
those countries;  and it  would seem to be the  only proper
mode of relief  for our  own.   If there  are   several ways of
accomplishing the same end, and those ways are equally  good,
it will remain simply a matter of taste  which is  to be cho-
sen ; but if one is better than the others,  let us make no com- 
25
promise, but adhere to that which is best.   The subject before
the Association is not a new one, yet it is one of the most vital
importance to the public, the profession, and the insane, and
grave questions are involved which are difficult to discuss ex-
temporaneously.  The real question, however,  is this: shall
we continue the present asylum  system  and extend and in-
crease  the  existing institutions, or engraft upon that system
some special plan for taking care of the chronic insane'(   I do
not propose, Mr. President, to discuss the  present system, but
shall direct my remarks to the propositions of the Committee
and of Dr. Cook,  which are, as  I  conceive,  essentially the
same.  And here let me say, the plan advanced proposes two
modes  of disposing  of the chronic insane, one by placing them
in separate institutions,  and  the  other, touched upon by Dr.
Ranney in his remarks, a separation of the two classes of in-
sane in the same institution, but  which separation shall not
be absolute.  This  plan,  Dr. Cook says, is the best; in other
words, that there should  be some  wards or connected build-
ing, in which certain individuals, whose  disease is chronic,
and others, as suggested by Dr. Ranney, whose insanity is of
such a character  as to produce unpleasant influences upon
other patients, should be placed.  Mr. President,  neither  of
these propositions  is  new.  Institutions for incurables, or as
these gentlemen would say, for the  chronic insane, in either
of  the forms proposed,  are  long  exploded experiments, and
nowhere have they been tested as faithfully as in  Germany,
and under the  most able medical men.  Ilayner gave great
attention to perfecting institutions  specially designed for in-
curables, and Dr. Damerow,  of Halle, while opposed to sepa-
rate asylums  for their care, instituted a system of relative
union, or as  Dr.  Ranney says, separation in the same estab-
lishment, but not absolute, which  was carried out in many of
the best hospitals of that country.  This was many  years ago,
and yet the system  has not been extended.   We have the his-
tory of those experiments, and why has the system not been
adopted in England or in this country ?  Because it was a fail- 
20
ure, and accomplished no results not  better attained  in the
ordinary asylums.   But we are told that the system has been
adopted in  England, Scotland and  France.  No, sir ;  most
distinguished gentlemen of these countries,  after having vis-
ited those institutions, utterly condemn them, and with them
the kindred institutions called u Agricultural Lunatic  Colo-
nies."   We have on this whole subject the opinion of medi-
cal men of sound judgment, of long experience, and of the
highest character as medical superintendents.   Dr. Bucknill
did not propose any of these plans when some years ago the
question of further provision for the  insane became so promi-
nent in England, and yet he was familiar with  their workings.
He then suggested the extension of asylums by the erection  of
cottages, and this plan was at once adopted in the institution
under his charge.

  Dr. Bucknill, after considerable experience,  has found that
this mode of extension can only be carried to a limited extent,
and Dr. Robertson  distinctly says  the same  thing' after
its  trial by many eminent  medical  men.   They, therefore,
propose the enlargement  of the existing asylums, and the
erection of  others.   Now,  if these gentlemen all  arrive  at the
same opinion, should it not be conclusive  with us that we
cannot  profitably enter  upon the same kind of  experiment i
We have the right  to infer this, as  they have by experience
and observation,  something more than theories and  vague
ideas on which to base their views.   But need we go to Eu-
rope to  test the cottage system'(  There is one gentleman, Dr.
Kirkbride, who has tried the same experiment in  this country,
and he has not recently extended the system,  for the reason
that he has not found the plan further beneficial.   He has,
instead, as we all know, duplicated the hospital.   Dr. Tyler,
of the McLean Asylum, in enlarging, did not erect a  cheap
building for those of his patients whose disease is chronic and
advanced dementia.   He  added a wing  under the ordinary
organization.  Dr. Buttolph, of the  Hospital for the State of 
27
New Jersey, has been obliged to  examine into this question,
as that institution was no longer able to meet the demands of
the insane  there, and did he propose relief by the establish-
ment of a special asylum for the chronic insane, or by build-
ings other  than hospitals, for those  advanced  in dementia'.
Did he say, " after  all, these persons can no longer appreciate
the blessings conferred upon them ;  they have sunk into de-
mentia and imbecility,  and now, when their voices  can no
longer go up, in pleading to God or man, let us place them
where they can be taken care of at less expense, and be made
to work for a living'?"  No, sir.  lie said to the Legislature,
"the counties have  no adequate provision for these people, in
their alms-house system, and I propose to enlarge this institu-
tion, and then receive all in the State."   Did  the people or
Legislature reply, " we are  poor, Doctor;  cannot you devise
some cheap method C  On  the contrary, they responded, by
an appropriation of §100,000, and said, "enlarge your build-
ings, and take all in."  New Jersey assumed the highest posi-
tion a State could assume — a position that every State, in its
organic lawT,  pledges its  citizens to assume, that, whenever a
citizen, by reason of misfortune beyond his control, is unable
to protect himself, the State will protect him and care for him.
Are the other States  poorer, less generous, less willing  than
New Jersey (  The State of Kentucky has increased her insti-
tutions, and  adopted  a  system of extension, instead of lower
class hospitals.  AVhen the State of Pennsylvania, a few years
ago, found its State asylums full, did the member of this com-
mittee from  that State  ask  for a change  of  system,  such as
is now  proposed? — ask for  the  separation  of the  helpless
chronic insane, and  for  cheaper accommodations  for them (
No, sir.  Pennsylvania enlarged her capacity of provision by
the erection of another institution of  the ordinary character.

  Mr. President: Have the people  or the Legislature of any
State arraigned the officers of their institutions for doing too
much for any class  of the insane under their  care?  Has any 
28
demand been made for hospitals of a low grade, and especially
for buildings other than hospitals?  Sir, we  have had enough
of alms-houses  for the insane,  and of buildings other than
hospitals, in which to care for these helpless, wretched people.
That is what we are suffering from now.  No people or Legis-
lature, understanding fully and  clearly the condition and
wants of these people, will turn  a deaf ear to them and say, " I
have been giving you bread, but you no longer appreciate it;  I
will now feed  you upon  husks."   If this whole subject was
brought to the  attention  of the  people and the Legislature,
earnestly, by men in earnest, all the insane would be provided
for.  The fault is with us, in you  and in me.  AAre have been
content to let these things take  their course.  We have satis-
fied ourselves with official  action by noticing the subject in our
reports; but have we given our personal efforts as we should
have done (  I, for  one,  have  not.  But we are  told, Mr.
President,  that New York is  an exception; that this great
State has refused to do more than establish a second class hos-
pital for  incurables.   Sir, the Legislature of New  York has
never refused a request properly presented.  It did not origi-
nate the scheme of incurable hospitals, and it would be a libel
upon the people and the Legislature to assert that they have
deliberately refused to provide  tor  the  insane, except in this
manner.   As to the county officers having charge of the insane,
I am prepared to say that they have never sanctioned the char-
acter or the abuses of the  system  of alms-house  care; but on
the contrary, have contended against  the system.   Why,  sir,
the very proposition of the committee has been  tried in New
York, and that trial  has been our curse.  The proposition  to
remove those advanced in dementia. '" the chronic insane," to
buildings other than hospitals, was engrafted in the  organic
law of the State Asylum,  and the plan  of Dr. Cook,  for hos-
pitals for  incurables, is but  the  aggregation of the  present
distributed  mass of  misery and wretchedness into  one great
receptacle.  Some of the existing county  receptacles have
reached the dimensions of asylums, having accumulated more 
29
than a hundred chronic insane; and yet what are they ?  They
have responsible persons in charge, and physicians who visit
and prescribe for their inmates; but these physicians say that
alms-houses are  not proper places for  the classification, care
and treatment of these people, and the county superintendents
of the poor say it is a disease for the  treatment of which we
have not the means under our control.  Sir, this is not  a ques-
tion as to further provision, for all demand this; but  a ques-
tion as to the character  of that provision.   Why, sir, as far
back as 1855, the Superintendents of  the Poor of the State of
New York met in Convention, and passed  a series of  resolu-
tions, which Dr. Chipley has proposed in this body to-day, as
presenting a higher standard for the  members of this associa-
tion than the resolutions of the committee, or the plan sug-
gested by Dr. Cook.  The chronic insane, as I have said, have
for years been returned to counties from the State Asylum —
cases well representing  the helpless  class  designated  by the
resolution of the committee—and placed in buildings  "other
than  hospitals,"  constructed especially for these insane, and
for the very reason urged by the committee, and the " friends "
of the Willard bill, to relieve the  State Asylum, and care for
them more cheaply.

   The superintendents  of the poor did  not propose, as a
 measure of relief,  the aggregation of this  mass of neglected
 humanity into  one great asylum.   On the contrary, they
 passed a resolution expressly against asylums for incurables.
 They  had learned, from wide experience, that such a measure
 could not afford the proper care, and that it would be unwise
 and unjust to demand that all the chronic insane from the east
 and the west of their broad State should be transported to one
 great  colony, where, from want of means, and time to make
 long journeys,  their friends  could  never visit them.  And
 here let me say, Dr. Ranney has  well  remarked that he has
 never met  a patient so poor or so wretched that he  had no
 person to visit him and inquire  as  to his welfare.   Such, I 
30
 doubt not, has been the experience of every member of this
 body.  Patients  may be utterly demented, their intellects
 darkened, so as not to recognize their friends, and yet, when
 sick, friends will visit them, and, dying, will desire their bodies
 that they may bury their own  dead.   Are we to encourage
 this humane feeling, or are we  to  disregard it?  Yvre should
 ask ourselves these questions, as men and as physicians.
   I have  said the people of New York never turned a deaf ear
 to  appeals made in  behalf of the  helpless.  AVhen the Su-
 perintendents of the Poor memorialized  the Legislature on
 the subject of further provision, a bill was introduced creat-
 ing two more asylums.   This bill was favorably reported, and
 was ordered to a  third reading, when the premature adjourn-
 ment of the  Legislature arrested its further progress.  The
 subject was not urged upon the next Legislature.   But several
 of the counties have since made provision, by the erection of
 buildings, " other than hospitals," for the " chronic insane."
 AVhen the  matter was  again  urged upon  the  Legislature,
 through the State Medical Society,  it was not  thrust aside;
 an investigation was at once ordered into the condition of the
 insane, the report to be made to the Legislature through the
 Secretary of the State Medical Society.   Dr. AATillard, as such
 officer, directed the  investigation, through a series  of inter-
 rogatories, and when his report was made it was followed by
 immediate action.
  I  infer  from the  remarks of Dr. Brown, that he was in-
formed that  the  Legislature were  unwilling to  create more
hospitals,  but would establish second class  institutions for in-
curables,  and that his  sympathy was  thus obtained for  the
principles  of  the Willard Asylum bill.  Now, sir, this is  not
the time or occasion to enter into the  discussion of the ques-
tion as to what that Legislature might have been  disposed to
do; but it is a significant fact, already alluded to by Dr.
Brown, that the next Legislature authorized the location of a
third institution, and  that too  without a dissenting voice in 
31
either house;  and the provision that it should be a building
for incurables was not attached to the bill, nor was there a
word said on that subject; and  at the same  time  an appro-
priation was made for the AVillard Asylum.  Now, Mr. Presi-
dent, this does not look like repudiating the care of the insane,
unless we are  willing to lower the standard  of public hospi-
tals ? And as Dr. Cook's paper is  especially on provision for
the insane of New York, I may dwell a moment more on the
history of recent legislation on the subject.   When Dr. AVil-
lard made his proposition to create hospitals  for incurables, as
a mode of  relief, the Governor  of the State transmitted the
question to the consideration of the Legislature.  I saw Dr.
AVillard  afterwards,  and I told him I was surprised at his
recommendation in view of the evidence of the failure of such
a scheme in Europe,  and from the experience we possessed of
the injury which such a  system would inflict  upon the insane
and the  community if adopted by tire State; that it  was a
retrograde step, unnecessary, and condemned by the profes-
sion ; that it would be only the continuance  of the  alms-house
svsteni disguised under another name, and I directed his atten-
tion to instances of failure in  counties which, in  good faith
and at great  expense,  had established such asylums.  The
Doctor said he had reflected very little on the subject, and had
received his ideas from  others.   AVhen, subsequently, he pre-
sented  the report before the State  Medical Society,  I  took
occasion to express my views,  and distinctly and  wholly dis-
sented from  the proposition to relieve the existing condition
of things, by the creation of  such  establishments.  At the
close of the session, Dr. Willard asked me to draw up such a
bill as I thought would meet the wants of our State, in respect
to the  insane.   This I  did,  simply  providing  for  two more
institutions,  one east, and the other west of Utica, and Dr.
Willard presented it to a  member  of the  committee of the
Legislature having  charge of the matter.   This bill was not
                                                   x»    1
rejected ; it was introduced by unanimous consent, referred to
 a committee, and reported  back favorably by that committee. 
32
Subsequently, and without discussion of its merits, and not by
the committee, that bill was transformed  into what we now
have  as  the Willard Asylum Act,  This  year, however, the
Legislature passed a bill for the location of another asylum,
which, we believe, will be on the plan of existing asylums.
These facts demonstrate that, had the subject been fully and
fairly presented to  the former  Legislature, the bill  for  two
additional institutions, would have become a law.
  This is all of the history it is here necessary to give;  and I
say thus  much to vindicate the assertion that the  people and
the Legislature of New York are sound on this subject, and
only wish to know what  is best to be done in  order to do it.
And  as  a beginning;  has been  made, and there  can be no
question  as  to the need of these institutions, I believe New
York will construct two additional asylums of  a character to
comport with her dignity and wealth and the highest interests
of her suffering children.  I need hardly say, Mr. President,
that I am opposed to the establishment of separate institutions
for  the care of the chronic insane.   If the whole subject of
the care of the chronic insane, as presented by the resolutions
of the committee and the paper of Dr. Cook, is open for dis-
cussion, I desire to say something on  the financial considera-
tions involved, and on the question of labor.
  The President—The whole subject is open.
  Dr. Gray-—The  demand for  a change  or modification of
policy has not been urged, on the ground that the institutions
in existence were unnecessary, and should be done  away with,
but that  those institutions, while necessarv for the treatment
of curable cases, might  be  dispensed with  for the care and
treatment of the disease  in the chronic stage.  This is  dis-
tinctly announced in the resolution of the committee, and is
the basis of the arguments brought forward by the advocates
of the separation of the curable and incurable, and the erec-
tion of cheap, second  class asylums.   The only reason urged,
and as far as I know that can be urged, for the  establishment 
33
of such institutions is, that they will provide for these people
at less expense,   It cannot be said that the intention is to take
better  care of thein—no  one  has proposed hospitals for the
chronic insane for that reason—it is to take care of them more
cheaply, and it is fair to ask their advocates how they are going
to cheapen  their care.  Let us have  the items.  So far, we
have only been  told  that they can  be cared for at less  cost.
You must have, I  suppose, an inferior physician !  He need
not know much in order to take care of an insane man in his
chronic state.  Let us  know the proportion of attendants to
patients,  and whether,  as a man becomes more helpless, he
will require fewer attendants and less care.  Let us know what
is to be the quantity and quality of food, and whether we are
going  to  have a repetition of what was deliberately paraded
a few years  ago, by a commission  in Canada, where the dis-
covery  was  made that men could  be supported on  a  diet
cheaper than bread and water—at about six cents a day—and
yet work be got out of  them.  Let us know whether it is pro-
posed to deal out medicines of inferior quality when  they are
sick; whether in anv or all these items of care, vou are going
to substitute something cheaper than at present.   We are not
informed, moreover, of  the character of the cheap buildings
the Committee propose for the care of the " advanced in de-
mentia,"  and the same remark will apply to the proposition
of Dr. Cook.  Economy,  cheapness, are the catch-words, and
with these we are to initiate reform!

  Mr. President: These are not novel words to the  profession.
AVe think we have been economizing, and we wTant  something
more definite  than  these vague generalities.  The intimation
these gentlemen would seem to convey is, that the insane are
not now as  cheaply housed and taken care of, in our public
institutions,  as they should be or  might be;  that too much is
expended on them in medication, attendance and food.   What,
then, if not these, let me ask, are the items  you wrould cut off
or cut down (  Is it in amusements  you would cheapen their 
34
care?  Perhaps it is in music—their ears are dull of hearing;
perhaps it is in the ministration of religion you would econo-
mize—they have no  longer kind and thankful hearts, and do
they need a preacher i   Perhaps you will allow them no longer
the visits of their friends, as they may not recognize them, and
a little might be saved in attention!  Is it  in these you would
cheapen'.  Perhaps it is proposed to cheapen in air ?  crowd-
ing into little space without ventilation—or will you cheapen
in warmth and clothing, or give them less  cleanliness, that
they may die off the sooner ?  Are you going to give them
less sunshine?  Oh, no! they may have an abundance of that,
for you  propose to turn  them into the fields and make them
earn their bread.   It is  said they are  to work for their own
advantage, and this labor will  be the element peculiar to  the
system.   Let  us examine this point a moment.  Is not labor
an element of treatment in institutions now ?  Is it something
new to introduce  labor ?  Is it not obtained already in our
institutions, to the last  extent consistent with the welfare of
the patient ?   One gentleman  says he  has not land enough;
let him get land.  Have these  institutions, in existence for so
many years, failed in obtaining from the  persons committed
to their care all the labor consistent with their health,  or have
they neglected their duty, and  allowed these men and  women
to sit in idleness and listlessness when they might have  been
contributing  to their own  support?  Have  the managers of
these institutions been unfaithful in their duties in this respect ?
AAre have made the experiment in Utica, during the past five
years, of recording the labor of  every man from day  to day.
We know what it is, and it is no more since we have gone into
this  detailed  record  than it was before, for we have  had to
hire  the same number of men to  carry on work.  We have
simply sought to obtain work from each, so far as it should be
for the benefit of his health and strength, looking only to his
own  good.  Dr. Ray,  who  would be  considered very good
authority on a question he had investigated, has, without con-
sultation with others, been making this question of  labor a 
35
special study.   And what does he say in his last report?  Does
he sanction the idea that this great element of labor has been
practically lost sight of,  and may now be made use of essen-
tially to  cheapen the cost of the care of these  people?  No,
sir; his report is a complete and perfect refutation of the whole
idea that you can extract from these helpless, sick people, the
sweat and blood that will contribute more largely to their
support.   Many of  them have barely the circulation to enable
them to  sustain a miserable physical  life, and others,  with all
the food  of the best quality you  can give them, have  scarcely
sufficient vitality infused into them to sit up during the hours
of the day, and walk about the wards and yards for exercise;
and yet these  are the people who, we are told by these bene-
volent gentlemen,  are to  be  provided  for in these separate
institutions cheaply, and who will  support themselves largely
by their own labor !  Dr. Ray has gone into the questions of
labor and of the proposed  asylums for the chronic insane, and
his report covers the whole subject, treating it upon the high-
est grounds which a dignified medical man, who understands
his relations to his profession and his duty to man and to God,
could take.  His report  is a complete and full document on
the subject; one that any professional man might well rest
upon.   It is the report of a man of great professional experi-
ence and ability—of one whose integrity could not be  swerved
by any consideration of  simple expediency;  and to the same
point and in the same direction are  the reports of Dr. Kirk-
bride and other members  of this Association.  These gentle-
men  have not been  silent lookers-on while, the attempt has
been made to undermine the very fabric which they have been
building for  years, and in  the construction of which their
heads have become whitened, and honors have been conferred
upon them.   Should they  stand still, or have they stood still,
while these things have  been attempted ?  No,  sir; they have
answered  the questions  that have been raised, and they have
the right to answer. 
36
  But we are told  that the people will not  provide  for the
insane, will not pay taxes to take care of them, unless we are
willing to lower the standard of the hospitals.   This I cannot
believe.  I have already remarked  upon this point, in reply
to Dr. Cook's remarks touching New York, but I will take
the liberty of recurring again to this assumption, which, though
honestly made, I think is  not true.  I have  spoken of New
Jersey and Kentucky.  Yermont takes care of all her insane.
But let me call your attention to further practical illustrations
of the benevolent.disposition of communities  when instructed
in regard  to  these things.   Take the case of  the President of
the Association whose experience has been far beyond that of
most  if not  all of us.   When the Pennsylvania Hospital
reached its full capacity, and patients had to be turned away.
unless more room was provided, did he say, " you have clone
well in erecting this building, but it cannot receive more, and
you are not able to  care in the  best manner for all; put up a
cheap building for those ' advanced in dementia,' the  ' chro-
nic insane,' and that will relieve us?"   He simply said, " The
institution is  full, and we need another," and gave himself to
the work of showing this fact.   And the reply of the people
was such as  it always is, and always will be, when they are
christianized  and properly informed as to that which is best.
They  did not wait and consider what less than their duty they
might do, but instantly poured into the coffers of the institu-
tion a fund more munificent than had before been dreamed of
in the annals of such charities, and ample provision was made
for all.  It is such a man  that communities delight to honor.
Such  men are the  true standard  bearers of the  profession.
Such  men are the Ben Adherns of the race.   And if it were
permitted us  to look into that book of gold wherein  are re-
corded by the angels the names of  those who have most fullv
discharged their duty to God and man, we should find their
names inscribed as  tk leading all the rest."  It is such men who
reflect the example  of him who gave to the world the parable
of the good Samaritan, as the example of Divine charity, that 
37
we are to follow, and to  such  the response hereafter is to be
given, " inasmuch as ye  have  done it unto one of the  least of
these, ye have done it unto me."  Has the public charged him
with  inducing them to  do too much?   No, sir; helms been
crowned with benedictions.   There is  another person in this
room who has gone through many States where no voice had
been raised in behalf of  these people, and has spoken a word
when it was needed in the ears of men—not a man of experi-
ence, but a woman;  and what has been the answer?   AVe all
know it  has  been the same in every place and at  all times.
She has but needed  to go to  the legislators and present the
cause.   She has but needed to tell them what she has seen:
'* Your father, your brother, your friend, he is  suffering, Ids
mind darkened, no one to care for him; if not your relative,
your  neighbor's—a  woman, a man, sick  and suffering.   In
every community the result  has been the same.   The  gentle-
man from Iowa holds his position to-day, because this  woman
went into  that State.  There  are others  also, and there are
thousands  of  helpless, wretched ones, and wretched only be-
cause they  are helpless, to whom she has been a benefactress.
AVhat does she say ?  She has not asked whether these are
poor or rich,  and  yet she has  always sought and obtained the
best  for them.  She  has  seen  the great alms-houses, and does
she commend them ?  But we  are told it is expedient to aban-
don the  idea of hospitals, and adopt these middle class recep-
tacles.  Sir, it is never expedient to do wrong, and this would
be wrong.  I tell you this is not a question of expediency, but
one of principle.   AVe are asked to lead the people to a lower
level  of duty, under the  disguise  of doing them good.   AVe
are to persuade them  that  the name Axylum  is all  that is
necessary;  that they can be just as well  taken care of in those
chronic establishments, at much  less cost,  if they will  but
think so.  If assertions were  arguments, we might consider
the question settled.  AVhy not give us  the secret of cheapen-
ing in the existing hospitals ?   If we have not done our duty,
let us know it; if these gentlemen have a plan by which we 
38
can do more and better than under the present system, which
has been adopted and carried forward so successfully for years,
let us have it.  Let us not have it, however, in vague asser-
tions and indefinite propositions, but in distinct, clear figures.
If the point is, that money is to be made or lost, if it is to be
a question simply of finance, we want it in  that form.   Sir,
we are not to be diverted from the duty and labor of pushing
the public asylum system forward  by these  specious cries of
cheap this and  cheap that  Colonies for the insane  are not
new.   How long has Gheel been in existence ?  More than a
thousand  years, and where is its repetition?   If it is so good
a thing, so wholesome a thing, why has it not been repeated ?
Esquirol visited and examined it as  far back as 1821, and why
did he not  adopt it ?  The institution of Fitz-James is a pri-
vate institution, a farm colony, where the insane are classified
into  rich  and workers, and why not recommend  this ?  Win-
is not this institution, its management and reputation brought
forward as an argument for the adoption of the farm system ?
This  subject of general provision has been discussed abroad
under three heads—social  advantages, economical results,  and
curative  results.  Let us  have  the testimony distinctly, that
shall  apply under each of these  heads, and then we shall be
prepared to ascertain the actual advantages to  be derived.
We say, and say with truth, that  the institutions of the coun-
try have vindicated their  character by success, and I  should
like to see the man rise upon  this floor and deny this proposi-
tion.  If there  is such a man, then I would ask him where are
the faults that you propose to remedy ?  Let  them be pointed
out in their practical bearings.  Let us have something more
than  " I suppose this," and  " I think that."  The social, eco-
nomical, and curative results are the results we have aimed at.
If you have anything new, we desire you to exhibit it.   If the
ideas  and practice of the  great body of medical superintend-
ents of America, France and England have been  based on
fallacious  principles, we trust we are not so  prejudiced as to
refuse to see the truth, if these gentlemen will but give us the 
39
 data.   One distinguished gentleman in England, Dr. Robert-
 son, has considered very maturely the advantages of the asylum
 system as contrasted with colonies.  He is a man of large ex-
 perience, and after making the most careful  investigation of
 the subject, his opinion is to be considered of some value.  He
 has the care of a large asylum, is a  man of learning and
 ability, a man  charged with great public duties—no mere
 theorist.  He says, in  respect to economical results, that an
 institution founded upon any other than the  asylum system,
 would be found utterly fallacious.   In Devon and in Cheshire
 they undertook  to  take care  of  these people, as a matter of
 economy, in cottages, and they found it cost more than to sup-
 port them in the asylum.  Dr. Robertson says that out of 250
 women he could hardly find six who wanted to be isolated,
 who wanted to  be  put off somewhere else.  Is it not marvel-
 lous that, after this experience, these gentlemen should want
 to repeat it here ?  If more asylums are required, let us build
 more.   I will read you some extracts  from Dr. Robertson's
 conclusions:  " If past success, unparalleled and unhoped-for,
 almost, were to  be  the test of the means most suitable to pro-
 vide for the future increase of pauper lunatics, the present
 public asylum system would stand without a rival.  The twenty
 years which have passed since 1844, have seen a progressive
 advancement  in  the treatment of the  insane of all classes—
 taking its rise under the fostering care of the commissioners—
 in the public asylums of England, of which the annals of me-
 dicine  offer  no  similar record.   It does,  therefore, appear
 unwise, rashly to abandon the  hope of providing, through
 means of the  public asylum system, for the care and treat-
 ment of the  increasing number  of pauper  lunatics, when
 already so much has been secured, and  when, comparatively
speaking, so little remains  to  be done.   Union houses [cheap
places  for the chronic insane] have  always  been found unfit
places for the  treatment of insanity; the private dwelling is,
from the nature of the disease—as Dr. Mitchell on his hobby
hardly sufficiently realizes—of only very limited application, 
40
 and agricultural lunatic  colonies are but the  day-dream of
 benevolent enthusiasts unversed in  the real life of the insane.
 In contrast stand the public asylums of England, rich with
 the practical fruits of twenty years' experience, trusted by the
 poor at home, and  known throughout the civilized world for
 their success in turning the house of cruelty and bondage into
 a quiet home of peace and rest."
   He  then  advocates the extension of the public asylum sys-
 tem, especially by enlarging the existing institutions, by  addi-
 tions " as far as its original structure will  admit,"  and when
 this plan will not avail in extending the establishment  to its
 requisite, ultimate capacity, he would add  detached blocks or
 supplemental asylums, as recommended by Dr. Bucknill, and
 also a limited number of cottages to be occupied by the per-
 sons employed who  shall  receive in them a few patients.  In
 summing up, under the three  heads—1st, social advantages,
 2nd, economical results, 3rd, curative results—Dr.  Robertson
 remarks on the first, "the advantages all lie on the  side of the
 public asylum system."
   Of economical results he maintains that in England  these
 would  be found also on the side of the public  asylums.  Of
 the comparative expense,  he says : " The cost  also was rather
 above that of the asylum."  On  the question of labor in this
 connection, he says: "I reply that no one  familiar with the
 real life of the insane would venture to promulgate so unlikely
 an idea as that there is any possibility of the product of  their
 labor sufficing to pay the  cost of the maintenance  and treat-
 ment of the insane poor.   I submit this opinion with confidence
 to the judgment of all men of experience."
  On the curative results he says: " These  results, I hold, are
 best attained in  a public  asylum for the insane."  He main-
tains that it is in the extension of the  public asylum  svstem
that the real advance is to be  sought and attained.  On the
 score of economy, I should like to  ask whether we are to ex-
 pect that we can have anything cheaper anywhere than four 
41
 brick walls and a bed ?   Yet I believe that is all asylums gen-
 erally furnish.   If the sleeping rooms are now too large, those
 gentlemen advocating change should say so.  If these helpless
 people in our institutions have too much general space to move
 in, they should signify the true amount.  If the food furnished
 is too good or too generously given, it is  easy to correct the
 error.
   The experiment of cheaper diet has been tried in Massachu-
 setts, at Worcester.  It was  found  that patients were more
 troublesome and difficult to get along with.  Why ?   Because
 they were  starving.   Because they were deprived of  that nu-
 trition necessary to keep their souls and  bodies together in
 their proper relations.  The experiment was abandoned, and
 the  patients soon came back again to their former condition.
 If that is not a sufficient  lesson upon  this subject, where  are
 we to seek it ?
   These gentlemen confine their efforts to the care of the poor
 and  indigent  in contradistinction to the system in existence
 which provides for all the insane.  They would send to these
 second class chronic asylums, as proposed in the Willard bill,
 only paupers.
  What provisions would here be made for those private pa-
 tients who have become chronic in private asylums, and have
 exhausted  their means  in these, it maybe said,  "in riotous
 living,"  for  they might  have been taken  care of  longer
 and  just as well in a public  asylum ?  Being  chronic, they
 have no  chance  of admission to the higher class hospital, and
 being now paupers they must descend to the lower class recep-
 tacle.  AVe have such cases at  Utica.   We have received them
 on public orders after they have been turned away " chronic"
 from private establishments.  These people may feel, but what
 of that; "only paupers,  whom  nobody owns!"  There are
those whose habits of life  would not make  them uncomforta-
ble, if  you were to give them much meaner  fare and poorer
beds to sleep on.  They have  been accustomed to very poor 
42
living in all respects.  But  this class does not form a large
element in our State asylums, and some of these have become
insane through poverty of living.  But side by side with these
poor, there is another class,  who have  fallen from a higher
estate, and who feel the least  depreciation in diet or com-
fort  in any respect.  "Will you make any distinction in  the
care of these poor, and if so, how will you draw the  line ?
Will you make  the distinction  at  the commencement of the
disease,  or only after it becomes  chronic?  Many  of  these
people, when they shall have passed into  the  chronic stage,
will  understand and realize the distinction you  propose to
make, and yet will you make a difference in  the treatment
of the various classes ?  Of course not.   There is no difference.
They are all poor  and sick, and in this they are on the same
level. If they had no friends you  might do so, and no ques-
tions would be asked, but they are the same people as though
they had a thousand friends, and their treatment must be the
same as it is now.  Mr. President: I think we  need rather to
elevate  our  institutions than lower their character.    Our
friend from Connecticut, Dr. Butler, must  not  ask the gener-
ous public for additional libraries, amusement halls, etc., for
one class of his patients, who are able to pay, and in the same
breath recommend to  the other class,  who have  nothing to
pay, and for whom the commonwealth has  wholly  to provide,
second class  accommodations and  no amusements.  Has he
lost all faith in the p eople ?  I understand he is quoted as in
favor of this scheme.

  Can Dr. Butler go through his  institution and point  his
finger at this and that patient whom he would elect to be sent
away to this cheaper institution ?   No,  sir; no man  can do
that;  he would desire somebody else to do it.  The Commit-
tee  propose  a commission,  composed of men who have no
knowledge of these patients, to designate these unfortunates.
I have looked over the Asylum at Utica again and again, and
asked which shall I send away ?  There is a poor woman who 
43
 bas three or four children, whose husband makes a pilgrimage
 from year to year to visit her.  She may not feel as much as
 some others ; shall I send her ?  No ;  she is a mother.   Send
 that young girl; she  is demented.  Alas !  what has she clone
 to merit this distinction?  There is a man paralyzed;  send
 him ?  No ; he requires too much medical care and nursing.
 And so I go through the list, and  the  result is,  I am unable
 to Select any one. And I apprehend this would be the  expe-
 rience of Dr. Butler or any other member  of the Association
 who should look through the wards of his hospital with the
 view of determining which of his patients he should assign to
 inferior quarters.  I do send persons to poor-houses, but I am
 opposed to  it, and only do so because the law so commands
 me,  when it  is necessary to make  vacancies for recent cases,
 and  I have  permitted one hundred to  be crowded upon us
 rather than send the helpless away.

  I have seen men nourishing and in power, robust  in health,
 imperious in their manners, and I have seen the same men
 again in the  asylum, under the order of a superintendent of
 the poor, helpless and wretched.  It is not for you or for me
 to say we may  not be so ourselves.  Sir,  I wouid demand for
 these persons,  even though they have no friends to care for
 them, the same  comforts I should  desire to be  provided for
 myself if I were in their condition, and when I cease to main-
 tain  this position, I shall no longer desire to be a member of
 the medical  profession.  AAThen we fall  below this, we  sink
 beneath the sacred pledge we have taken in entering upon our
 profession, to  say nothing of  the  christian rule to do  unto
 others as we would that they should do unto us.  These are
 the great  principles upon  which these  institutions were
 founded, and by the maintenance  of which alone they may be
 assured of success.  Men  who  adopt a lower standard must
school themselves to do  injustice to others,  and that injustice
will  certainly  recoil upon themselves.   Now, if we  are  to
adopt the rule of expediency hereafter and lay aside the great 
44
principles by which we have hitherto  been governed, let us
not act under the guise of love to the poor in so doing.  Let
us say to  them  frankly that we are too  poor to  do better.
While, however, the means are afforded us by a generous and
willing public, let us act up to the measure  of our duty, and
not endeavor to deceive ourselves and the helpless, whose inter-
ests we represent, by declaring beforehand that the burden of
charity is too great to bear.  Let us whisper no such false plea
into the ears of those who know better and  who would soon tell
us so.  Let us do  now what is right, and let the future take
care of itself.   Our business is with to-day.  Let us take no
step backwards, and above all, let us not turn our backs upon
what we have heretofore advocated in order to adopt a lower
standard of professional duty, but seek rather to go still higher,
at least until the people, to whom Ave  are responsible, shall
say to us,  " You are doing  too much."  Let  us  pursue the
course Ave have already trod, striving  rather to do where Ave
have left undone ;  to be more efficient Avhere Ave haA-e hitherto
failed, and endeavor to enlighten  the  communities in  which
Ave live as to the nature and Avants of the great work that has
been placed in  our charge.  For myself,  I cannot adopt any
other course.  The doctrine typified  by the parable of the
Good Samaritan is the  doctrine of the fathers, and are Ave the
degenerate sons to degrade it to a mere doctrine of expediency  ?
The Good Samaritan is the  seal of one of  the oldest  medical
hospitals of our country.  " Take care  of him, and what thou
spendest more I will repay thee on the morrow."  Shall Ave dis-
criminate in charity, and add to the Aveight of the burden of
disease the ignominy of separation on such grounds  as some
gentlemen propose ?
  I propose to say a word in reference  to a  remark  I  made
relative to Dr. Butler.  I do not know that Dr. Butler adopts
the chronic scheme at all.  If he does, I can  only sav. " IIoav
are the  mighty fallen!"  I  have no  direct evidence of his
holding such a position, and  I therefore withdraw what I have
said touching him. 
45
  I have detained this  Association longer than 1 ought to
have done,  but  this is a subject in Avhich I have been inter-
ested  for years, and I have  seen  enough suffering,  enough
tears, and have heard enough pleading, and have looked into
the faces of afflicted men and sorrowing broken-hearted avo-
men long enough to feel that they are not all dead when they
seem to be.   I  have knoAvn men  and Avomen. after vears of
apparent hopelessness, get well; persons whom, I am ashamed
to say, I have said Avould not get Avell.   I am  more careful
hoav how I pronounce  a case to  be incurable.   AVhen such
men and women have emerged from the darkness that had so
long overshadoAved  them,  they have told us Avhat Ave have
said and done, and that they have felt the good  and ill.  I
recall now  a boy avIio, for months did not speak a word, but
sat Avith his head  down, his eyes dull, and Ave called  him de-
mented. He became thin and wasted, but still he spoke not.
His mother came to see him, and Avept bitterly.  I listened to
her, and told her as  gently as I could that I did not think he
Avould  get  Avell.  She  Avent aAvay  and  came  again Avith a
breaking heart, but she Avas unable to take him home.  She
had not the means  to nurse him,  though he seemed to be
gradually sinking  into the  grave.  What Avould  you  do Avith
that boy ?   Would you send him off to a distant place, Avhere
his mother could no longer visit him, Avith the stamp of incu-
rability written upon him, and brand him as a pauper ?  That
boy suddenly emerged from darkness of mind.  He had heard
every Avord that had been said  in  his presence.   Dr. Brown
remarked the other day that Ave could not tell the operations
of  the  mind.   It  Avas Avell said ;  Ave cannot tell.  No man
could pierce into  that mind and say of what  that boy Avas
thinking.  Among other things, after he recovered  he said,
" When you came in Avith  Judge----you pointed me out to
him, put your hand on my head, and said so and so."  I had
pointed him out as a marked case of dementia.   He did not
seem, at that time, to  know enough to  go to his  meals, and
was led to the  table.   He said,  when I  asked him on this 
46
 matter, he thought he had no right to eat;  that the food Avas
 not his ; that he Avas Avaiting to go home.  Think of it, Avait-
 ing, silently and patiently, to go home for all those months !
 AATe did not seem to do much for him.   We gaA-e him a little
 room, 8x10, to sleep  in, had  him washed and  dressed and
 taken to his meals, and took general care of him, and he got
 well.   There is not a Superintendent here avIio could not re-
 cite cases of the recovery of patients pronounced by himself
 incurable.
   The President of the  Association has  truthfully said, in a
 recent annual report, in respect to persons pronounced incura-
 bly insane, that " only Omniscience can tell."  And Avhen God
 gives us something more than the fallible judgment of men, it
 will be time enough for  us  to  pronounce a  person  incurable.
 I, for one, have  ceased  to pronounce  any such judgment,
 as  disease is only complete at  death.   The past  that was
 wrong, I cannot make  right, but with more experience I can
 do better in the future.
  Dr. Nichols—After the  forcible  remarks of Dr. Gray, it
 does not  seem  to me that anything  more need be said Avith
 the design of affecting our sensibilities touching the question
 or questions now before us.   At any rate, I  shall concede in
 the views I propose to submit that Ave are all disposed to do
 all that we consider practicable for the benefit of the insane.
 Xot to take up the time of the Association, I have simply
 sketched certain propositions, which it seems to me are appli-
 cable  to the subject under consideration; a::d  I  propose to
 submit them in lieu of  any further remarks other  than to sav
 that the familiarity of most if not all the members of the As-
 sociation, with all questions touching the wants and claims of
 the insane, the character of the provisions that should be made
for  them, the question  of their support, the disadvantages of
their  removal in an unnecessary distance from their homes
when they are  taken insane, or in any subsequent  stage of
the disorder, is  such that  the reasons which have led me to 
47
the conclusion  I propose to submit, although  they may not
have the same force in the minds of other members they have
had in  mine, will  probably occur  to  each member.  There-
fore, I do not propose to elaborate my views, but  simply to
submit, as I now do, in brief form, the following propositions,*
which I will now read to  the Association, and  offer for con-
sideration at a later hour in the session.

  Dr. Earle—This is not a subject that I have studied very
much of late years, and I shall be to some extent forced to
fall back, as politicians often do, upon my formerly expressed
opinions.   I think, in my notices of the Reports of Hospitals
for insane in this country for the last twenty years, I haA-e met
the question more  than once.   I knoAV that at  least fourteen
years ago I  expressed my opinion A-ery clearly and distinctly in
print, and that  opinion may be found in the American Jour-
nal of Insanita-.
   When I was last in Europe, and Avent through the German
countries, I was very much surprised, and  I may say aston-
ished, to learn the extent to which the subject of insanity had
claimed the attention of the physicians of that country.  AVe
are at least, I Avas  going  to say fifty years, at  any rate, far
behind the  Germans  upon this subject, as Ave are upon many
questions connected  Avith  the  general subject of insanity.
This subject of the treatment of the  chronic insane Avas Arery
fully discussed in the countries in Europe, in which the people
speak the German language, from twenty to twenty-five years
ago,  and they came apparently,  certainly practically, to  a
pretty definite conclusion.   It seems to be the general  opinion
in  all the Germanic countries that the chronic  insane should
be separated from  the acute;  but then came up  the second
question, where will you place your different institutions ; Avill
vou have them near together, or Avill you haA-e them  as sepa-
rate institutions at different points ?  This subject of the loca-
  * These propositions will be found  near the close of the Discussion. 
4S
 tion of hospitals for the curable and incurable runs through
 an amount of published matter in  Germany very great in ex-
 tent.  Some of the most eminent German writers have taken
 one side, and some the other.  I am  sorry to say that  one of
 the ablest  superintendents of hospitals in one of the Germanic
 countries has always advocated  the  entire separation  of the
 two kinds of hospitals.   A large  majority, however,  of the
 Avriters upon the subject have advocated Avhat they call  a rela-
 tively connected  system,  where  the two  institutions, one for
 curables and the other for incurables, shall be near each other
 and under the  same plan of management  as  Dr. Kirkbride's
 institutions for the tAvo sexes.  Practically, indeed, they have
 come  back essentially to  just Avhat Ave iioav have.   At the
 time  I Avas there, in 1841), the  large  establishment at  Halle,
 Prussia, and  a large one Avhich  had not then gone  into
 operation,  on  the Rhine,  near the  city  of  Johannesberg,
 and another  at  Vienna,  Avere  all  on the  relatiAely  con-
 nected plan.   All these institutions realize, almost preciselv,
 one actual  practical plan.  For instance, at Halle the institu-
 tion is built like that at Utica, round a square.   In the  centre
 of that square is the kitchen.  In the centre of the court are
 two sheds,  cutting the interior square into four  equal  parts,
 these sheds running parallel Avith the building, and the food
 is carried through  them to all parts  of the house.   Tavo  of the
 wings are deA-oted to  the curable and tAvo  to  the incurable.
 Noav, in my hospital, our separation  is almost  as distinct as
 that.
  I mention this  as the result of a very thorough and pro-
 tracted discussion of  this  question  among that wonderful
people, from whom we derive the Saxon element of our  blood
and of our character.
  Dr. Walker—How many curable cases haA-e you in your
institution ?
  Dr. Earle—I do not know; very feAv, howeA^er.
  Dr. Walker—Have you twenty \ 
19
   Du. Earle—I  should think Ave haA-e  twenty curable cases
out of three hundred and fifty.  Let me say just here, that in
the account I gave of the hospitals in Germany, I made a re-
mark in which I proved myself a true prophet, as I hope I
shall in what I said  a day or two ago on moral insanity, that
the time would come when this subject would attain a promi-
nence in this  country that would require the question to be
definitely settled.  I therefore  gave  a brief account of what
had been done in the Germanic countries, and then remarked,
in substance, that after all I had heard and read on the sub-
ject, and after all I could conceive could be said or written,
my opinion would remain as it then was, and now is, that the
best way, the true way, the most humane way to treat the in-
sane is to district your State, put your hospitals each as nearly
in the centre  of its  district as possible, and  receive all the
insane of each district into  its hospital.  I repeat that I am
fully convinced that is the most humane way and the true way
of treatment, and I believe it will be found as cheap a way as
can be devised.  If we had a hundred insane people in Mas-
sachusetts demanding  to  be  taken care of,  I  do not believe
they could  be properly anywhere else, or in  any new estab-
lishment any cheaper than I  could take care of them in North-
ampton.   .Xoav, there is one objection to the last resolution
reported by the Committee.   "Demented persons,  in whose
cases the disease is  chronic and advanced, may with propri-
ety," etc.  Now, with my interpretation of that language, I
seriously object to it.  If I could be the one to select the per-
sons, that would be  a consideration, but even then I do not
see how Ave are going to take care of them  any cheaper, and
that is the  only  ground  on  Avhich separate institutions are
proposed.  The State of Massachusetts  is uoav  preparing  a
place for one  hundred patients at the State Alms House  at
Tewksbury.  Can they provide for or treat these one hundred
demented patients any cheaper than Ave could at one of the
hospitals already established, by making a little addition ?   I
u 
50
do not believe they can, if they are properly provided for and
properly treated.   With my interpretation of this resolution,
I should seriously  object to  it, and I do not think it wise for
the Association to  adopt it.  Mark the latitude which could
be given to it  by other people—" When the disease is chronic
and advanced."  There is no definiteness in that.  After one
year the  "disease is chronic and advanced."  Under that
resolution, with the latitude  always taken in such things, 300
patients could be taken from our hospital.
  Dr. Walker—Are there 300 cases in your hospital a phy-
sician would pronounce in an adA-anced stage of dementia ?
  Dr. Earle—Do you not knoAv, Dr. Walker, that you might
call one person demented, and I not?  Do we  not know that
a patient  might be brought into this room, at this moment,
and if each member of the Association Avas asked to classify
his disease, some would place  him under the head of demen-
tia, and others under the head of chronic mania ?

  Dr. Walker—I should differ with you there.  Some might
place him under the head of melancholia and others dementia,
but between mania and dementia I doubt if there Avould be  a
difference of  opinion.
  Dr. Earle—Very well.  Let me say that from all  the ob-
servations I have  made upon  this subject, I think there is  a
very great difference in the minds of superintendents of our
various  institutions in regard  to classification.  Examine the
reports, and  see how many more  one  superintendent  places
under the head of mania than another in  proportion  to  the
aggregate number, and so of the other classes.   I believe there
is nothing like uniformity in  that respect.  On the stand in
courts, I have several times, as a Avitness, differed with  other
medical witnesses on the classification of the disease.   And  I
seriously think that, allowing for the stretch that all such acts
receive, that 300 patients could be taken out of my hospital,
and 150 out of either of the other hospitals in Massachusetts. 
51
  Dr. Walker—It ought, perhaps, to be stated that most of
your patients have already been through some of the other
hospitals.
  Dr. Earle—Xot most of them.   I do not know the propor-
tion.  I  should think perhaps half.
  The President—Do you constantly receive recent cases?
  Dr. Earle—We have  done  so,  and hope to continue to
receive them.
  The President—My object in asking  this question was to
illustrate the fact that incurable cases require the advantages
of a first class hospital.  Here is a  hospital in Avhich a very
large majority of the cases are incurable.
  Dr. Earle—Certainly.  Everybody who  knows  anything
about the hospital at Northampton knows that a very large
proportion of the patients are incurable cases.
  Dr. CuirLEY—I wish to ask Dr. Earle Avhether, if his twenty
or  twenty-five curable patients were removed, it Avould be
possible  to reduce the number  of attendants and reduce the
cost of  food and clothing, consistently Avith proper  care of
the patients?
  Dr. Earle—Not one  iota.  It  Avould not cheapen  their
food or clothing  at all.
  Now,  in regard to  the institutions for the chronic insane: I
visited scweral of these in Germany, and I could describe their
condition.  I remember one  particularly, at Dusseldorf,  that
Avas reasonably neat; but everywhere, almost, there Avas just
what you might  expect—neglect and filth.
  Noav,  there are so many to speak on this subject, that I do
not intend to  dwell upon any particular point, but to state
conclusions rather than arguments.   I Avas  going to  say that
one of the strongest arguments I haA-e heard mentioned by
airy one, for keeping the  chronic insane with the curable in-
sane, is  that their labor cannot be turned to so good purpose 
52
anywhere else.  In the  State of  Massachusetts, Dr. Wheel-
wright, Superintendent of State Charities, who has the power
to go to our asylums and remove any patient he pleases, and
who will be the man to make the selections for this new insti-
tution, at Tewksbury, may take a ^ery large  number of those
able to labor.  But if he takes away my patients, who are
useful as laborers, I shall haA-e to hire other people.  It seems
to me that is really one of the strongest arguments in favor of
continuing the present system, and that, if properly presented,
it should have particular value with  those avIio attempt to de-
cide this question, simply upon  its pecuniary relations.  I
ought to sav, there is a strong feeling in the minds of some in
office, in Massachusetts,  and men  of influence and power, to
some extent, to have the question tried.  They are disposed
to belieA-e that the proper way is to haA-e separate institutions
for the incurable.
  Dr.  Gray-—Are they  men who  have had experience in the
management of the affairs of the insane ?
  Dr.  Earle—Xot generally.
   Dr. Yan  Nostkaxd—I Avould like*to ask Dr. Earle Avhether,
if they were to take away the tAventy curables from his insti-
tution, and  attempt to lower the  standard of the institution,
he would remain in the institution ?
  Dr. Earle—I Avould not.
   Dr. Yan Nostrand-—Parties in our State haA-ebeen talking
upon the subject a little.  I took the position, in my report,
that no man who is fit to take charge of these helpless, insane
people, would  stay in such  an institution.   They  might be
able to  get along  a  little cheaper, but such an institution
could not be kept up on  a basis creditable to the humanity of
the people.
   Dr. Earle—I ought to add a single sentence more, to Avhat
I said of the German institutions.  The institutions for the
incurable, which I visited, were all old institutions, established 
53
many years before.  All  the  new institutions had their incu-
rable department connected with the curable.
   Dr. Gray—It has been remarked that these persons may be
provided for in Massachusetts a little cheaper at this new in-
stitution.   I should like  to inquire whether brick  and other
building materials are much cheaper in Tewksbury than they
are at Northampton ?
   Dr. Banxey—I take it that the building at TeAvksbury will
cost less than  an addition capable of accommodating an equal
number at Northampton, Worcester,  or Boston, Avould cost.

   Dr. Earle—I do not know.  I have not  investigated  the
subject.  I think  the  building  at TeAvksbury will probably
cost less than one at Northampton, but it will be very differ-
ent from the building we have.  I have no doubt that building
Avill cost less  than  one with  accommodations for the same
number Avould  at  either hospital;  but a common barn or
stable Avould cost less than that building.
   Dr. Yan Nostkand—And would be just as Avell A-entilated.
   Dr. Earle—I know nothing about  it, and, therefore, am not
competent  to speak on the subject.  I presume the sole object
in erecting that building, however, is to support  the insane
cheaper.  I perhaps ought to  state, and I do it as a matter of
explanation, merely, that  some tAvo or three years  ago, Dr.
Hills, in his report, recommended a plan for a hospital for in-
curables.   Some correspondence followed, between Dr. Hills
and myself, in respect to the plan being inserted in  the Joar-
nal of Medical Science.  I informed him, in  the  course of
that correspondence, Avhat I should do in regard to  it, and I
afterwards  did it.  I made a fair exposition of his plan.  I do
not recollect how much I quoted from his report, but sufficient
to make it  understood.   I then distinctly stated it had always
been my opinion that hospitals should be constructed as I have
here stated. I thought they should;  but that under the then
condition of things—in the midst of war—I thought the pros- 
54
 pect Avas that it would be impossible for us ever to  have our
 number of hospitals sufficiently increased to accommodate all
 the insane upon the present  plan, and  that for that reason
 alone I would be in favor of the next best thing, i. e., having
 establishments for the incurables, and that I thought the plan
 of Dr. Hills was  a  good one—something to that effect.  But
 the war has ended,  and, although we have all got to be taxed,
 yet things do not look so dark as they did when I wrote that,
 and I shall, therefore, resume  my old opinion,  and cling to it
just as long  as I can.   I  shall not  yield until  I find it abso-
 lutely necessary.

  Dr. Tyler—I have nothing new to offer upon this question.
 Whenever it has been under discussion,  as it has been before
 the Association two or three times, I have fully giA-en my
 views upon the  subject.  I do not believe Ave  ought ever to
think of separating  the curable from the incurable insane, and
 I do not think it would be any more safe to divide  the  acute
from the chronic insane.  There  is no mode of classification
that I Avould adA-ise for separation.   I think the test given in
the resolutions that  have been offered for division, is liable to
less objection  than  any other.  I think  the arguments that
have been  adduced here, against it, are, to a great  degree—
though  I  do not say how far—fallacious.  The same  argu-
ments that have  been presented, on the score of humanity,
Against  placing  demented persons in separate  institutions,
would apply with equal force against placing them in hospital
at all.   Still, I think  our present hospital system is the best
and the only one we, as an Association, ought to recommend.
  I merely Avish  to  say, in regard to Massachusetts, referring
to what Dr. Earle has said  here, that something would  una-
\-oidably be done in the Avay of taking care of the  chronic
insane, outside of the regular organized hospitals of the State.
This suggestion came through  the Board of State Charities, or
members of that  board; and my argument is—though  I can
only speak concerning  those  gentlemen  of that board  with 
55
whom I have conversed—that they have recommended  this,
not as the best measure, but as a measure they feel themselves
forced to adopt, because  they have  no faith that  the State of
Massachusetts will build another large hospital.   It is merely
with  them a  financial question, and  I am inclined to think
that the voice of this Convention, coming strongly, as I judge
from  the discussion  so far as  it has  progressed, it will come
strongly enunciated in favor of the hospital system, as best for
the insane, will have great weight with those gentlemen, and
enable them to take stronger ground than they have done, and
give them more courage.
  On the score of  humanity, if I found the  choice Avas to be
between  some establishment for  the  care  of the  insane, hu-
manely organized and so managed in every respect as to secure
a degree of comfort to the class of  demented persons referred
to, Avhich institution, whatever it might be, would draw these
people from their different localities in the poor-houses, Avhere
Ave know they are not properly taken care of—I say, if the
choice Avas between  such an institution, and alloAving these
people to remain Avhere they are, it seems to me, on the score
of humanity, I should very much prefer to see the idea carried
out, for Avant  of something  better, simply as the best thing
that could  be done.
  The President—But you Avould, however, think it impor-
tant that the Association should express their preference for
the existing class of hospitals ?
  Dr. Taler—Yes, sir;  I think I  gave my  views clearly on
that question.
  The President—I beg leaA-e to  ask Dr. Tyler Avhether he
does not think the adoption  of this  intermediate  class of insti-
tutions would haA-e a tendency to prevent the building of first
class  hospitals?
   Dr. Tyler—As a general thing, I should think it Avould.
If I thought it would prevent the erection of regularly organ- 
56
ized hospitals, or that this class of institutions would be  sub-
stituted for hospitals which would otherwise be built  if  they
were not, I should certainly oppose them with all my ability.
I have no doubt at all that our hospitals, as at present organ-
ized, are the best for the care of all classes  of  insane, and  that
anything else would be a  mere expedient.   What I  said re-
ferred simply to the fact that, in even such institutions, these
people Avould haA-e better care than many  at present have in
our poor-houses.
  Dr. Peck—AVhen the matter  Avas being discussed last win-
ter, in the Ohio Legislature, Avith respect to making provision
for the  insane who are  uoav in  our alms-houses, a  gentleman
said to me, Avhen advocating strongly, as I Avas, the erection
of more regular hospitals, and the enlargement  of our present
ones, that in NeAV York they Avere  about putting up one for
this very class, upon a  cheaper  plan.   I  told him, my Avord
for it, I did  not believe the State of  New York would  ever
build a  hospital of that sort.  He said they Avould ;  that the
Legislature of NeAV York had already acted upon the matter.
I told him I did not care if they had; my Avord   for it,  they
would never build such  an institution.   Noav, the point I  Avish
to make is, that if New York had actually commenced a build-
ing of that kind, I do not believe our Legislature Avould haA-e
provided one dollar  for the enlargement of our present insti-
tutions, or the building  of new ones; but, inasmuch as it Avas
not a fixed fact, I succeeded in getting an appropriation for
enlarging the Northern and Southern institutions,  with a fair
prospect of another new hospital at no distant day.
  Dr.  Bancroft—I propose to  say  but very feAV words upon
this subject, although I  have been deeply interested in all that
has been read  or said,  and  I  am especially so, for the reason
that it is a question  which  interests my State at  the present
time.   Our hospital is full and overcrowded,  and this ques-
tion, in a different form from that it has taken in other States,
is now before our people, and some action  is expected at thfe 
57
next session of our Legislature.  The  form it seems about to
take is this : A proposition is to be made to change  our  poor
system from town to county, making all our town poor county
poor, and to erect county establishments.  The idea connected
with this, although the proposition has not come up directly,
is to establish, in connection  with  each ' of these county
poor-houses, a department for the insane also.   This has  been
done in one county already, and I think that it can work only
evil with  us, even if it should operate Avell on a larger scale.
These will, of  course,  be only small establishments, perhaps
sufficient  to accommodate twenty-five or  tiiirty patients,  in
each county,  and Ave have no right to expect  that any build-
ings or arrangements  will be fitted up on that small  scale,
which will be at all suited to  the Avants of this class of per-
sons.
  In regard to the general question, I hold this  view:  Our
present system of caring for the insane has been proved.  It
is one which  is Avell established, and we know that it works
for  the advantage of  the insane.  If this system should  be
changed for another, it Avill be  under the sole consideration
already named—of keeping them at less expense—and I, for
one, should look with some degree of fear upon any plan hav-
ing such an element and motive.   I do not believe that, under
our present system, Ave do too much for any class of the insane;
and, as has been remarked to-night, all that Ave  gain in the
item of expense Avill be in the way of subtraction from Avhat
Ave do for the patients.  If we do not do it  in respect to medi-
cal care or in  food, clothing, or other necessaries of life, it
still must  be in taking something from the benefits we  noAV
bestow upon them.  I  should be reluctant to see the demented
class  of patients  deprived of even  the moral and  religious
privileges which they enjoy  in our  hospitals.  Again:  It
Avould be exceedingly difficult ever to make  any division of
the insane, in filling up these  new  receptacles, which would
n'ot do injustice to some  of them.  I can  readily see there 
58
might be  some  patients Avho  could be Avell cared for in an
institution which  should gather  around it fewer comforts or
privileges than our present hospitals provide;  but in making
our  diA-ision we should be pretty sure to exclude some in
whose cases it would  be a great  deprivation to  lose  these
things.  I know that in our OAvn hospital there are many of
those who are incurable, many avIio Avould be considered de-
mented and in an " advanced stage  of dementia," Avhom I can
still  see derive  much  satisfaction and real good from these
moral appliances, who derive  much gratification and advan-
tage from the privileges they enjoy.

  As to the question of labor. I haAre not much faith, under
whatever  management, that their labor will eA-er become pro-
fitable, per  se.  I have  great  confidence in the value to the
patient  of labor,  carried to a certain extent, and  I should
make the  greatest exertions in organizing any hospital to pro-
vide a system of well regulated labor.  I encourage the offi-
cers  and attendants of my institution  to employ the labor of
the patients in  as great a variety of Avays as possible ; but it
is not in accordance with my observations to  belieA-e that la-
bor  is productive in any other sense than beneficial to the
patient.   There is much of it which it is very expensiA^e to pro-
vide for, and the testimony of those who have made this sub-
ject  a matter of careful  experiment, is against  its productiAe-
ness.  I may be  allowed to say that,  Avithin  the last  few
months, I have had the opportunity of making some inquiries
upon the  subject, in  the English  hospitals, and AvhereA-er I
had  the opportunity to visit a hospital, I made that particular
a point of special inquiry,  and received, in nearly every in-
stance,  very  definite  statements from  superintendents and
others.  I found A-ery  feAV avIio  were ready to  say they had
ever made labor pecuniarily productive.  Out of a large num-
ber  of  places I visited,  there were not more than three in
Avhich it Avas  confidently stated that labor had been produc-
tive ; and even in some of these,  qualifications Avere  added. 
59
Dr. Hill holds that he makes labor productive in a pecuniary
point of Anew;  and yet one of the prominent members of the
Commission of Lunacy told  me, in private conversation, he
did not think the statistics showed that, and he had no confi-
dence  that it  was really  so.  And that is the institution at
Avhich labor is acknoAvledged to be carried on to better advan-
tage than in any other hospital in England.  In every place
which I visited, the  superintendent advocated  labor, in the
strongest terms, as  a curative influence.  I  think it is secured
to a larger extent,  and  under a better organized system in
that country, than I have supposed it to be in this.

  This idea has occurred to me during the  discussion to-day.
I should fear that if  Ave should admit a form of organization
of institutions, based on the idea of supporting them by the
labor of the insane, the  desire for light taxation and the dis-
position upon  the  part  of public officers   who have  charge
of the poor,  to sIioav a good bill of economy, would induce
them to seize upon  that as a ground of introducing institutions
in AA-hich the insane Avould not be properly cared for.  Now,
it is within my constant experience at home to have  the in-
quiry put to  me in reference to cases  that have  been some
time in the hospital, " What is to be the result of this case ? is
this patient curable ?   Because if there is no good prospect of
recovery, Ave should Avish to  keep him cheaper."  That is es-
pecially the case Avith paupers.  I see a constant tendency in
that direction,  a constant  pressure for information, Avhich is
adverse to the  recovery of the patients.  As soon as you are
obliged, by the delay of favorable symptoms in a case, to ex-
press a cautious opinion of the future, there is a pressure to
take the patient away, and it is one of the most embarrassing
things with me in  regard  to that class of patients  to keep
them long enough  to  give them a  fair trial  or to settle the
question of possible recovery.   It seems to me if we should
give any encouragement to the idea by adopting any modified
system of hospitals,  this  pressure  Avould  increase,  and Ave 
60
should not be able to keep  any case  long before the officers
would be urging us to a decision as to whether it Avas curable
or not.  It is possible that 'cheaper institutions  may be con-
structed, where this class of people  may be cared for with
some degree of comfort, but I should myself rather be on the
safe  side,  and if  any modification  of our present system is
called for, I should rather it wrould  be accomplished by a sys-
tem of classification under Avhich these people should be pro-
A-ided for in buildings attached to regular hospitals, under the
care of the  regular superintendents.  I should regard the
adoption of any other system, hoAvever, as incurring a serious
risk of depriving  these persons of proper care and treatment.
I have already learned, as others who have spoken, never to
despair of the recovery of the patient.   I do not believe we
are authorized to  pronounce any case  incurable.   I do not be-
lieve it is right for those in charge of a hospital to give up any
case; but on the  other hand, that it  is our  duty to continue
our care and Avait Avith patience for the result, and I should
be sorry to give my A-ote for any plan that should incur this
very great risk.
  Dr. Gray—I should like to make a single remark in  rela-
tion to the statement of Dr. Bancroft in  regard to county in-
stitutions.  A feAv years ago one of the large  counties in New
York established a county asylum, and erected a special build-
ing for the  accommodation  of  insane patients.   Last Avinter
they had 120 inmates, and from the report made to the Legis-
lature, it was one of the Avorst conducted establishments to be
found in the Avhole State.  I give  this as an instance of the
manner in which  such institutions invariably degenerate in a
short time.
  Dr. Bancroft—I Avill just add to what I said in relation to
a particular county in New Hampshire, Avhere this policy of
caring for their own insane has  been  adopted, that since that
Avas established there has been a disposition to withdraw the
insane of that county from the asylum, and at  present Ave 
61
have hardly a patient from that county.   Another fact occurs
to me  in connection Avith the same  matter.  I discoA-ered in
the progress of this thing that there Avas  an itching on the
part of the Superintendents having that county establishment
in charge, not only to take charge of the  patients for whom
it Avas designed, but to get as many into  it as  they possibly
could, urging the Commissioners to take them from the asylum
and place them there.
   It Avas  now moved to adjourn  till to-morroA\- at 9 A. M.,
but the motion Avas AvithdraAvn at the request of Dr. Curwen,
to enable him  to offer the folloAving:
  Resolved,  That a committee be appointed to take into consideration the
proper treatment and care of the epileptic insane, and report at the  next
meeting of the Association.

   Dr. CVrwen—I offer this  resolution because I really think
these patients have less care, and require more attention than
any class of patients Ave have.

   Dr. Tyler—I second the  resolution, and am very glad it
has been  offered.
   The President—The Chair fully concurs with Dr. Curwen
that there is no class now deserving our sympathy so fully as
that of the epileptic insane.
   The resolution  Avas adopted,  and the Association adjourned
till to-morrow at 9 A. M.

                        fourth hay.
   Friday, April 2*, 1866, the Association met at 9 .V. M., and
resumed the consideration of the report and paper on the care
 and treatment of the chronic insane.
   Dr. Abbott—I  did not  think of  expressing any views on
 this subject at all.  I came to the meeting Avith my mind set-
 tled, having formed  my  opinions  from A-ery much the  same
 facts as liaAre been presented by others, and have iioav no dis- 
62
 position to protract the discussion.  I presume  cwery gentle-
 men has made up his mind  Iioav  he will vote upon the ques-
 tion.   There  is,  however, one aspect that has not, to my
 knowledge, been presented.   It is this :  In the remote dis-
 tricts particularly, the workings  of our  asylums are not so
 well understood as in  their neighborhood, and  a great preju-
 dice exists  against asylums  altogether for the custody  and
 treatment of the insane.   With many  the prominent idea is,
 that asylums  are mad houses; they do not visit them or see
 their beneficent workings.   This prejudice operates very much
 to the disadvantage of those who ultimately reach the asylum.
 It often protracts their stay at home until the disease becomes
 more or less chronic or past its curable stage.
 *  Whatever fosters these  prejudices operates to the great det-
 riment of those avIio, through the providence of God, have
 been brought to the deplorable condition of insanity.
   Now, the proposition to change  the  mode of  treatment for
 those who  are incurable,  and proAdde a cheap plan for their
 care and employment,  will strengthen these prejudices of the
 community.  It cannot be denied  that the plan of treating
 the insane in a cheap manner, and  of getting from them Avhat-
 ever amount  of work it  is possible to obtain,  if once com-
 menced as a system,  Avill go on from bad to Averse until such
 institutions become subjects of investigation by grand juries.
 I have no doubt that such Avould be the result, and that the
public exposure of evils incident to such a  system Avould cast
a dark shadoAv over our existing institutions, now  so benefi-
cent in their operations and in their objects, and thus the insti-
tutions which we represent will suffer materially.   I see no
redeeming feature about the proposed neAy system, but, on the
other hand, it seems to me to be frought with incalculable
mischief.  I am ready, so  far as I  am  concerned, to  vote at
any time upon the question.
  Dr. Lomax—I have  not much to say on the subject under
consideration.   While I  am  free  to admit that those  who 
63
advocate the proposed new system are just as anxious about
the care of the insane  as  I am myself,  yet I think the propo-
sition brought forward in the paper which was read, Avill have
a very bad tendency.  Kensselaer county, I think, has a right
to speak on that  subject, because that county has provided
very generously for that class of patients, and in doing so, they
have not established a county alms-house, but a regular insane
asylum, with corridors, wards, dining rooms, and every feature
of such an institution, with a proper number  of attendants, a
regular organization, etc.  The  Marshall  Infirmary receives
both the acute and chronic insane.  It was opened, I believe
in  1859,  and  since that nearly 400 patients of both classes
have been received; and about  100 of these have been dis-
c-barged, cured, showing  that the operations of the institution
have been very successful.  The institution is largely indebted
to the benefaction of one individual, from Avhom it takes its
name.  The county also contributed $12,000  or §13,000 to its
original funds.  It has been largely patronized by liberal peo-
ple in donations, etc.  And at this very time the endeavor is
being made to relieve the institution of a debt of $20,000, by
subscriptions, and I think it will succeed.
   I speak of this institution because I think  it is an honor to
the county.   Instead of trying  to  build  a  cheap institution
they have tried to build one upon the old recognized plan.   I
think I can safely say that the County officers would not favor
the kind of institutions Dr. Willard's Avas intended to be.
   Dr. Cabaniss—My mind is fully made up on the subject^
and I shall not vote to  sustain the views  expressed in the
report of  the  Committee.  I  think Dr. Gray has expressed
my views so much better than I  could myself, that I feel indis-
posed to make any remarks.  I should regret if in Mississippi
such institutions as proposed by the paper read or by the Com-
mittee were to be established.   I regard  the present institu-
tions  as the true inheritance left for incurables, and I am not
inclined to take it away  from them.  I shall vote to let mat- 
64
ters stand as they are,  and if Ave are not able to take care of
the insane of . our  State  in the present  hospital,  I  shall
endeaA^or to have it extended or another Asylum built.

  Dr. Chipley—I suppose it is scarcely necessary for me to
say much.  I expressed myself so fully in the last annual
report of mv Asylum, that I have very little to add upon the
subject.  In  this  connection, from  a hint contained in the
paper read by Dr.  Cook, it may be necessary to make  some
apology, understanding him  as I did, very distinctly to inti-
mate that it Avas rather indelicate for members of the Associ-
ation to anticipate a subject upon Avhich a committee had been
appointed.  If the Association take  this view of the matter,
so far as I am concerned,  all I have to say is, that as nearly
all the other Superintendents noticed the same subject in their
reports,  I Avas not singular in taking the  vieAv I did.  I did
not suppose the  appointment of a committee precluded Super-
intendents from expressing  their opinions in their annual
reports.   So  far as I am concerned,  I have endeavored to dis-
charge my duty under the law of Kentucky, which requires
absolutely of the  Superintendent to communicate certain sta-
tistical information.   I do  not think  it  a  matter  of any
moment, and yet  I annually give these statistics because they
are required by laAv.   The laAV also declares that Superintend-
ents shall annually communicate upon any subject Avhich they
may deem of importance to the insane.  I  conscientiously
believed this subject Avas an  exceedingly important one.  We
Avere just about to enter upon the extension of an Asvlum  or
the adoption of some other system.  This idea of a  cheap
institution for incurable  patients, had even crossed the Ohio
River and had  begun to  penetrate the minds of gentlemen,
 conscientious in their desire to benefit  the insane,  and avIio
 might have been induced to believe a change of svstem would
 accomplish good,  and Avhen I saA\- that danger, believing that
 it would be the Avorst evil that could  be fastened upon the
 insane,  I deemed it a matter of importance, and  therefore 
65
complied with  the  laAv of my State,  by communicating mv
views upon the subject,  I hope the committee does not take
the same view of the subject which was expressed by the gen-
tleman avIio read the paper.  At  any rate, at least  a  half a
dozen of other  members of the Association also deemed  it a
matter of sufficient importance to dwell upon at some  length
in their reports, and are therefore under the same condemna-
tion.

   The question for us to  decide  is not what any particular
State shall do.   It is not for us to settle a  great question here
as a matter of policy.   Our duty is one rather of an abstract
character, although looking to practical action.  The question
for us to determine is, what is the best  means of taking care
of the insane, and Avhen Ave decide upon  the means that are
proper and Avhich ought to be adopted,  Ave shall have accom-
plished our duty.  There may be exceptions.  What Ave  con-
ceive to be the  best means of taking care  of the insane, may
not be the most practicable  in certain localities.   I do not
think Ave are determining here Iioav the insane shall be taken
care of in the  State of New York, or in Kentucky ; but as a
body of gentlemen avIio have had  charge of the insane, and
who are supposed to have had some  experience  upon the
subject, the question comes up Avhat is the best plan for taking
care of this unfortunate class of people ?  That is the question
Ave have to determine, and Avhen  you bring it  doAvn to  that
plain abstract  question, there seems to be  no  difference of
opinion.   The  gentleman who read the paper  admitted that
to continue our present system Avould be the best course, but
his Avhole  paper Avas  based  upon  the  assumption  that  that
could not be accomplished in  the  State  of NeAV York, and
that the next best thing would be to gather the  insane out of
their county alms houses and put them into a State alms house.
I do not know  whether he is right or Avrong.  I do not under-
take to determine what New York  can do.  I do not pretend
to understand Avhat her financial policy may be.  I have been
             D 
m
impressed Avith the fact  that  there  Avas great wealth  in  the
State, and a large class of wealthy people who Avere ready to
perforin their duties to all classes of society, no matter Avhat
it might cost.  But the question for me, as a member  of this
body, is, Avhat is the best means for  providing for the insane (
If it is impracticable, as a matter  of course, the  next best
means must be adopted, and finally it may come doAvn even to
the alms house.
  The paper throughout Avas  based  upon the assumption that
what Ave conceiAre to be the best plan, that is, coiribining  the
asylum and hospital principle  together, is, in NeAV York,  im-
practicable, and that, therefore, they must fall back upon this
other  plan.   I repeat that Ave have nothing to  do Avith the
exceptions that may exist in  the different  States.   I  Avas  a
little surprised that the author of this  exceedingly interesting
paper, a paper Avhich has said  all that can be said  on that side
of the question, should haA-e reported  Dr. Brigham  as being
in favor of establishments of this kind, for I do not kiiOAV of
any one a\-1io has expressed his opinions more decidedly in op9
position to such institutions.   I happen to haA'e in my posses-
sion a single  paragraph from Dr. Brigham, Avhich is certainly
entirely in opposition to the idea that he had at any time ever
giA-en support to that class of  institutions.
  Dr. Brigham says he never  saAV but one of these  establish-
ments  for  supposed  incurables.   Of  the  inmates  he  savs:
"They Avere confined in badly ventilated apartments, from
which they Avere never released except by death.  The quiet,
the noisy, and the violent, Avere all congregated too-ether and
a majority Avere chained to  their  beds  by their Avrists and
ankles.  No  contemplation of human misery ever affected me
so much;  the hoAvlings,  execrations, and clanking of chains,
gave to the place the appearance of the infernal reoions.  Little
or no medical treatment  Avas adopted.   We hope  never to see
such institutions in this country.v
  Knowing that this Avas the language of  Dr. Brigham  I sav 
 L Avas surprised to bear his name mentioned as being in favor
 <>f the establishment of institutions  of this kind.   I do not
 think his opinion could have been  expressed more  clearly or
 decidedly than in that paragraph.
  The whole idea of this classification of the insane by separate
 establishments rests upon a single plea—that is economy.  It
 gives to my mind the most prominent objection that lies against
 institutions of that  sort,   If you start out with a certain prin-
 ciple as the basis of action, that principle will permeate every-
 thing connected with the institution you are to establish.  The
 one grand idea  in  this proposed scheme is cheapness.  The
 gentleman who may be placed at its  head will, from the mo-
 ment of his connection with it, understand that this institution
 is established for the purpose of saving money, and that his
 credit will rise just in proportion as he diminishes the expenses.
 Now, any one avIio will reflect  for a moment must see how
 such  an organization will work the utter  destruction of those
 placed in its charge.

  We have sometimes expressed our  surprise at certain insti-
 tutions maintaining their patients at ten or fifteen cents a day;
 but that  can  easily be done if you can find men  heartless
 enough to take charge of such  institutions  and govern them
 by such a principle.  You may give a man a pound and a half
 of corn meal, in the shape of mush, corn bread, in some form,
and it will not only maintain life, but  a  very considerable
amount of labor may be obtained from a person so fed.  That
Avould be at a cost of only about three cents a day.   But you
may be a little liberal, and alloAv three or four ounces of meat
a clay in addition, and  it Avill  only bring  it  up to five or six
cents  a day; so that, in the mere matter of the reduction of
expenses  and of saving money, I am ready to concede that the
object can be accomplished.   You may build a house that will
contain four or  five  hundred persons  at  very little  cost.
Suppose you erect a four story building, 100 feet long and 30
feet Avide.   You may  put 100 persons on each floor.  You 
6S
may arrange their bunks, four and five high, along the centre,
and then leaA-e fifteen or eighteen feet on each side.  You may
put into a building of that sort, four or five hundred persons.
and feed them as I have indicated—on the principle of saving
money—and there is no doubt  you can save  a  great deal of
money.   But  Avould it be humane?   Would it be  proper?
Would it be right to  treat individuals, avIio  are not  able to
take care of themselves, in that manner?   If you desire to
treat them Avith humanity, I  suppose no  one Avill  claim that
too much is done for the  insane in our  present institutions.
Then there Avill  be  no humanity in  separating the  classes;
and, Avith the  same treatment,  it is my firm  belief that the
cost of the maintenance of the Avhole  number will be greater
in separate institutions than when you  treat them altogether.
For example:  In an institution  accommodating 250 patients,
150  are  supposed to be  incurable.  We have  an incurable
establishment  to Avhich Ave remove 15<»,  leaving 100  acute
cases, or cases  supposed to be curable.  Noav, does any gentle-
man suppose that, having  removed the 150 chronic cases,  you
can reduce  the  number  of employes  required  for the other
100'.   I >oes not  every one knoAV, from his oavii experience,
that absolutely  fewer employes are required with  the  250
patients, of chronic and acute cases, than for 100 cases simply
under treatment I You Avill  have  absolutely to  enlarge  your
pay-roll.  Of course, you will not require as extensive supplies
for the 100 as  for the 250; but  that does not matter, for the
150 must be supported elsewhere.   The paid labor for the 100
will be greater than for the 250, because of the  chronic  cases
included in the 150, there will be a very  considerable number
who will actually prove a benefit to the  institution—doing a
very considerable amount of work, and saAang a very consid-
erable amount of expense.  Every  one here knows that there
are a large number of little things which are constantly being-
done about an institution, by the chronic insane, which would
have to be paid for in an establishment from Avhich thev had
been removed. 
69
  I need not recur to the matter, which has been mentioned
by  Dr. Gray, as to the utter impossibility of determining
Avhen cases are incurable.  I recollect, Avhen I took  charge of
the institution at Lexington, there Avas a case represented to
me to have been one of mania, finally terminating in deinen-
tia; that there Avas no one in the institution avIio had known
the individual to speak, and  some of them had knoAvn him for
a period of nearly tAvo years.   He Avas a quiet patient.   I did
not suppose he Avould be in any Avay affected by attending the
social gatherings or the chapel meetings, though he was every
Sunday taken to the chapel;  but he came to me one morning
and said very politely, kl Doctor, I would be  A-ery much obliged
to you for a sheet of paper; I Avish  to Avrite  a letter/'  I could
not  haA-e  been  more astounded.   Of course, the paper was
immediately furnished.   I saAV from the condition of his  mind
that there ay as a A-ery considerable germ left, and a possibility
of restoration.  Noav, there  Avas a case, AAdiich, if I  had  been
called upon to give an opinion, I should have pronounced in-
curable.   He stated, in his letter to  his  friends, that he had
been in the  habit of attending church for some time, since I
had taken charge of the institution, and that he had heard so
much of the heavens and the  angels, he Avas disposed to  try
and do as Avell as he could so as to  go to them and be happy.
There  Avas  a A-ein of insanity running  through  his letter,
certainly,  but evidently his mind Avas not in a hopeless  case.
I had a conversation Avith him, changed his Avard, and placed
him Avith another class  of patients, Avhere he Avould  have  all
the advantages the institution  could  possibly give him.  The
result Avas that,  after the lapse of a considerable period of time,
he completely recoArered.   lie  is a  married  man ;  and for the
last seA-en years has been doing exceedingly Avell—as A\-ell as
any of his neighbors.  Noav, take  that case, and suppose he
had been sent to an  institution for incurables; is it likely that
anything Avould have occurred in an institution of that sort to
have aroused  him, and even if  he had sIioavii some symptoms
of improvement, Avould it have been  possible in such an  insti- 
TO
 tution to give him the best, chance of recovery (   Could  you
 have put him in a better condition, especially in an institution
 the prime  object  in  the management of which is to make  it
 self-supporting (

   I do not kiiOAV that it Avas scarcely necessary for me to have
 said even as much as I have.  There is nothing in connection
 with the management of  the insane,  of Avhich  I am more
 thoroughly convinced, than of the  impropriety of the separa-
 tion proposed.   I cannot see anything, in any aspect of it, not
 productive of unmixed evil.  You may look back  to the Avliole
 history of the world,  so far as the insane are concerned, and it
 is, without exception, that, Avhenever you place the  supposed
 incurable in an institution  by themseh-es, Avhatever may be its
 original  character, it degenerates  from  day to day until  it
 becomes—as has been expressed—a perfect u hell upon earth."
 Place eA-en a good man in  charge of such an institution, Avith
 the idea that his main object must be to saA-e money, and then
 Avith the disposition to save ourselves trouble, it Avill ineA-itably
 fall into  the  condition in Avhich these institutions haA-e been
 found in eA-ery part of the  world.  It may be asked why this
 does not occur in the  asylums  as they uoav  exist'.  If there
 Avere no  other reasons, the  fact that there is a constant stream
 of visitors to them, that the friends of the patients are look-
 ing into their condition, the knoA\-ledge there is on the part of
 all the officers and employes, that persons are recovering and
 going out into the Avorld to report the condition of the institu-
 tion and the treatment they receive, is sufficient to explain the
 difference.   It may be said that the sense of duty, Avhich every
 man ought to feel, should  lead him to  do right, Avhether  his
 conduct is exposed to the Avorld  or not.  That is quite true—
 entirely  correct  in principle—but Ave have,  in these institu-
 tions, to  deal Avith all classes of people, and it Avill not do to
rely upon the conscientiousness Avith which men ought to per-
form their duties.   It is a great deal better, in  addition to
whatever principle and Avhatever amount of faith  Ave may 
71
have, that there should be a little watching.  The knowledge
that there are persons passing from the institution, and that
there are persons in the institution who are able and will look
into their interests, will go very far to  keep these  institutions
in proper condition.   Nothing of this kind  occurs in institu-
tions exclusively for the chronic insane.   There are very few
persons who will suffer  their friends to go  there  if they can
avoid it; and persons sent there, as a matter of necessity, will
not be likely to receive great attention from their friends.   I
repeat, in conclusion, that it is only necessary to look into the
character of institutions which have been established for incu-
rables, to show their utter destructiveness, and I hope no such
system will ever be adopted in this country.

  Dk. Walker—Mr.  President: I do not stand  here to-day
as the advocate of the separation of the chronic from the acute
cases of  insanity, or, in other words, the separation of the cu-
rable from the incurable.   Whenever that question is pre-
sented by itself alone, I shall always be found on  one  side of
the line.  I cannot conceive any other position which  an en-
lightened, experienced superintendent  of an asylum for  the
insane can possibly take.  We liaA-e, in every hospital, a large
class of chronic cases who  require, for their own  best estate,
all the appliances Avhich Ave are apt to regard  as absolutely
necessary for  the  highest success  in  curative treatment.   I
cannot  concei\-e it possible  that any one can, for a moment,
entertain the idea of proA-idi ng for them elsewhere  than in the
same institutions and  under the same treatment provided for
curative  cases.  At the  same time there is, in every hospital,
a class of cases in an advanced stage of dementia, and, hu-
manely speaking, in a hopeless state of dementia.  I use the
term "hopeless*"1 understandingly, having learned as Avell  as
others to  be very careful  Iioav I pronounce  any given case ut-
terly incurable.  But  there is  a large class,  in  all our larger
hospitals, of Avhom it may be said they are beyond doubt in a
hopeless stage of dementia ;  and they form the least desirable 
72
class of patients.  They are those who give most trouble to
the superintendents, and are most annoying to their fellow-
patients, and yet who, beyond all question, require the utmost
care and  constant  attention.  But, filling up  our wards, as
they do, they are  to-day keeping  aAvay from curative treat-
ment numbers of those avIio  might othenvise be subjected at
once to its benefits,  and possibly, in  many cases,  be saved.
The question comes up in some of our States.  It has come up
in Massachusetts, in NeAV York,  in NeAV  Hampshire, and in
Pennsylvania, I think, Avhat shall be done for the  groAving
Avants of the community in regard to the insane'(   I honestly
belieA-e that it is utterly hopeless to go before our legislative
bodies and ask for  further appropriations for institutions for
the insane,  so long as Ave  insist  in declaring that this class
must haA^e all the accommodations the best class require.   It
has become a question of practical utility,  and Ave must meet
it as practical men.  We cannot avoid the responsibility.   It
is useless for us to  fortify ourselves behind theories, and say
to our communities. " you may go thus far and no further ;
we cannot help you, and will not go beyond it."'  It has come
to this:  that, in many of  our communities, unless Ave take
hold of this subject, as practical men,  and guide our commu-
nities in a safe and proper direction, they Avill take the matter
in their own  hands  and go on  Avithout us.   I venture the as-
sertion that it is utterly  hopeless to attempt to provide imme-
diate hospital accommodations for all  the insane in the State
of  Massachusetts.    As  the  superintendent of  an asylum I
Avould be glad to see it done.  As a practical man, if a mem-
ber of the Legislature, I could  not honestly vote for  it.  Our
communities are Aveighed  doAvn and  overburdened  Avith  ex-
penses.   They hold out  their hands to us  to-dav, liberal  as
they have been  in  every requirement  heretofore,  and ask us,
can you not devise  some means of relief for us here  '.  If Ave
fold our hands and  shut our  mouths against them, Avhat Avill
be the result'.  In my judgment, Ave shall be told by our peo-
ple that they cannot incur the expense of the additional hos- 
73
pitals required, and that they will take  the  matter into their
own hands if we refuse to guide them.

   Such were  the reasons Avhich  induced the  committee to
draw up the resolutions presented to the Association—not in
all respects Avhat they desired,  yet intended as a  practical
compromise of the  question.  When we cannot do what we
will, let us do the next best thing and save the  worst.  I ap-
peal to you if that is not the part of practical men, and wise
men '.   It is useless  to  stand in this Association  and make
use of poetic terms in describing the misery and  despair of
this unfortunate  class  of human  beings.   There  is  no man
avIio feels it more than I.   But it is useless to tell me of  the
extreme sensitiveness of the man so perfectly demented as  not
to know enough to go to his meals.  It is not so, and it is  not
Avise in us to make such appeals to our  sensibilities.  I think
we can do for that degraded class of our patients all  they re-
quire to have done in that  condition, and having done that,
I believe Ave haAre responded fully to the call upon our sensi-
bilities.
   With this question  so  fully determined-before the discus-
sion Avas entered upon, it matters very little Avhat resolutions
are presented.  The A-ery first member avIio spoke upon them,
utterly ignored the signification of the resolutions, and declared
that they  in effect, yielded the Avliole question, and advocated
the separation of the curable and incurable.  And so through-
out this discussion,  hardly  an allusion  has been made to  the
resolutions presented.   My friend, Dr.  Earle, did  allude  to
them, and both Dr. Tyler and  Dr. Earle  said in  relation to
resolution  No. 5, that if  the selections  could be made Avith
judgment and safety, they would be in favor of it.   Yet from
the outset no member has offered  a suggestion  to  make that
resolution perfect.   There is, in  parts of our country, an  ex-
treme Avant in regard to this matter, and members  have cho-
sen utterly to disregard that Avant.  The committee have re-
ported what  seemed to them a  Avise, careful and  judicious 
71
means of meeting the difficulty.  But no one has attempted
to suggest improvements of the plan Ave have proposed, in or-
der to make it acceptable to the  Association and profitable to
the community.   Your  Committee say that  " demented per-
sons in Avhose cases the disease is chronic and advanced, may.
Avith propriety, be proA'ided for in institutions other than hos-
pitals ; but ahvays in buildings constructed expressly to meet
the requirements of their peculiar condition,  Avith such ar-
rangements and  proA-ision for their care and custody as shall
effectually secure them from the danger of abuse and neglect,
to Avhich, as a class, they would  otherwise  be specially liable,
and under the entire control  of a resident  physician.  The
persons to be provided for as  above, should  be  selected by a
commission composed in part, at least, of experienced Super-
intendents of hospitals for the insane, and no one should be
thus provided for who has not previously enjoyed the benefit
of hospital treatment.-"  Noav if there is not sufficient protec-
tion in a commission composed in part of experienced Super-
intendents, then  Avhy is  the motion not made to amend so that
the commission shall be composed wholly of experienced Su-
perintendents, a  majority of Avhom could hardly mistake any
giA-en case (
   It has  also been  intimated  by some of the speakers, inad-
vertently, no doubt, that the  committee have advocated the
building of separate institutions as an economical moAement,
Avhereas the declaration they really made was,  " it is unwise
and opposed  to pure humanity as Avell as to economy, to at-
tempt to make the labor of  the  insane remunerative, or even
as a primary object, contributive  to their support.*"    These
are my present sentiments in that respect ; that in no  hospi-
tal is  it Avise to attempt to make the labor of the insane con-
tributive to their support as the object of  their  labor,  (live
them  all the labor you can, for their OAvn personal benefit and
improvement, and if the result  shall be remunerative, let it
go towards their support; but never  make that the object  of
furnishing them  Avith labor. 
75
   Having thus explained the motives of the committee, and
called your attention renewedly to the point they have made
in their resolutions, I have  only to say again,  that  the com-
mittee felt that they Avere  actuated by the highest motives of
benevolence and kindness to the  insane, and also by a sense
of duty to the community.   The Superintendents a\-1io object
to putting this class of patients aAvay in a building provided
expressly for  them, under all the safeguards  you choose to
throw around them, are, as Ave all know, from the want  of ca-
pacity and room in their  institutions, compelled, Aveek after
AA-eek, to  send out this very class of patients into the  poor-
houses, jails and county receptacles throughout  the State.   If
it is such a Avrong to do Avhat Ave propose, is it not a positive,
terrible wrong  to do Avhat  they  are doing constantly year
after  year, Avithout in their annual reports protesting loudly
and earnestly against it?   Yet they are silent, and the  thing
goes on increasing in its extent and misery.  I do not believe
in the separation of the tAvo classes,  the  incurable from the
curable.   I do belieA-e, hoAvever, as  a practical measure,  in
taking this matter into ouroAvn hands, and indicating in some
Avay our willingness to cooperate in some practical measure  of
relief.  Those avIio are uoav turned adrift into cages, jails and
poor-houses, Avill not suffer from being transferred into com-
fortable homes.   And Avhen  Ave undertake to say to the com-
munity that persons in our hospitals, so utterly demented that
they do not know enough to  go to the table to eat; that they
do not kiiOAV enough to obey the ordinary calls of nature ; are
so sensiti\'e as to be miserable if they are deprived of the moral
and social, and intellectual advantages of our highest institu-
tions, it is my deliberate judgment that Ave outrage the enlight-
ened  common sense of the community, and  destroy our own
influence as practical men.

   Dk. Beoavn—Before Dr. Walker leaves the  subject,  I beg
to ask him a question.  I may say that I can sympathize from
the experience I haA-e  had, Avith  the  vieAvs of Dr. Walker  in 
                            76

this  matter, having occupied  a position  identical with  his
when I Avas in  connection with  the Asylum at  BlackAvelFs
Island, and I would like  to ask his views upon the practical
question, what he would recommend in reference to the insti-
tutions of the large cities like Boston  and New York*   The
population of such cities, of course, forms a concentrated com-
munity, differing only from the  rural population in the fact
that a very large number is collected Avithin a small territory.
Noav, the Avliole theory of this question  may be tested by de-
ciding Avhat Avould  be  proper accommodations for the insane
of all classes in  such a community, and then applying the re-
sult, Avith such modifications  as circumstances may require, to
larger and more sparsely settled  areas.   I would, therefore,
like to ask Dr. Walker Avhether, for the large cities, he would
separate  the tA\-o classes in distinct  institutions, or Avhether he
Avould object to  the annexation of a department for the chronic
insane to his oavii institution, to be under his general super-
A-ision, Avith competent assistants to have their immediate care i
The advantage of such an arrangement, in a large  city, OA-er
the same arrangement in the rural  districts, would be that the
incurable  would still  be in  the immediate  neighborhood of
their oavh  acquaintances  and friends.  If Dr. Walker thinks
there would be  no  objection  to such an appendix, to our ordi-
nary hospitals, it seems to me that is all that could be desired
anywhere.  As  I said before, any A-ieAvs upon  this  subject
have ahvays been someAvhat latitudiiiariaii.  I see no such ob-
jection to such an establishment in connection Avith and under
the  same general supervision of our ordinary asylums, and it
seems to me the Avhole object could be obtained  by the exten-
sion of our asylums to a reasonable limit,  better than by sep-
arate asylums for the chronic insane or hopeless  cases.

   Dr. Walkek—In  ansAver to  Dr. BroAvifs question, I Avill
say, that the resolution offered by the committee did not go
in to that  part of the subject at all, for the reason that every-
thing could not be provided for in a single resolution.  I see 
                             I 1

no objection to appending these buildings to any of the State
hospitals.  In our oavh  case, in Boston, Avhenever the number
of that class becomes so  large as not to be able to properly
accommodate  them; Avhenever, for  instance, more than 300
accumulate, Avhich  is  the number  Ave  can accommodate, I
should  advocate the erection of a contiguous  building, espe-
cially for this  class of chronic insane, to be under the same
direction.  This very question came up on a small scale  in
our institution, within the last year, and without  reference to
any general plan, Ave settled it upon its own merits, with prob-
ably not more than  lso patients on  the  average;  still,  Ave are
overcrowded at  times.  A member of the Board of Trustees
applied to  me for  a list  of persons, who, in  my judgment,
could be comfortably provided  for  in the alms-house  of  the
State.   At his  request I  made out a list of about twelve, I
think,  out of the ISO, who, for anything I could see, might be
comfortably provided for  in  our  alms-house at  Boston.  At
the same time I Avas compelled, on sending the list to him, to
send also a note utterly disclaiming  any responsibility for that
disposal of them.  I did not belieA-e there Avas anything in the
condition of our hospital, at that time, to Avarrant the separa-
tion proposed.   If  such separation Avere eA-er to take place, I
should adA-ocate the erection of an additional building, con-
tiguous to our OAvn, for the care of this  class of patients.  In
the State of Massachusetts, as in  other  States, there is a A-ery
large class of these people; enough, if  congregated together,
to occupy a hospital, and a very large one,  too, and I see no
objection AA-hatever to their being  divided among the different
State hospitals,  and accommodations provided for them.

   The President—AIIoav me to inquire of Dr. Walker,  in
AAdiat Avay he proposes to  economize  in the institutions he pro-
poses to establish over the care of these people in our present
hospitals, which are provided  A\-ith every  convenience and
comfort'{ 
7S
    Dr. Walker—I should think a good deal of economy might
 be practiced, both in the building and in the diet afforded.  I
 do not refer uoav to  the quantity or quality of the food; but
 to the Aariety of it.  I think a saving may also be effected  in
 the number of attendants  provided.  These persons, many of
 them Avill  not  participate in, and care  nothing  about the
 amusements of the institution, and so in respect to riding and
 walking.  I can see a good many ways in which quite a saA-ing
 of expense  may  be affected.  Any Superintendent avIio has
 not given his attention to the subject, Avill  be surprised to find
 how much,  in the aggregate, Avill be saAred  by the reduction  of
 the cost to  each patient  of a single cent for each  meal.  At
 the end of the year, you Avill  find the amount saved, in a large
 institution,  is very considerable.  I knoAv that in some of our
 State institutions, those AArho  have given  most attention to the
 subject, have been surprised at the amount  of saving they have
 effected in  the aggregate, Avithout depriving their  patients
 either of  a single comfort.

   Dk. Earle—I should like to ask Dr. Walker, whether, upon
 reflection, he really thinks  the number of attendants could be
 reduced?  It strikes  me the number Avould be much more
 likely to be  increased, if  all the really chronic, demented, ad-
 vanced cases were taken out of the hospital and put into a
 separate building.  I really think a larger  number of attend-
 ants would be required for their care, than under the present
 system.

   Dr. Walker—That is not my impression.   I think more
 could be taken care of in one ward, and if  so, of course there
 would be a  saving in the number of attendants, while they
 Avould be  just as Avell taken care of as now.

   Dr. Gray—I  Avish to make a  single remark.   I  do  not
knoAv whether the gentleman alluded to me, as one of those
who had shut my mouth and  kept it shut,  instead of remon-
strating against the inhuman practice of caring for these people 
70
in the jails and alms-houses.  I may say here, that if the re-
mark applied to me, it Avas hardly Avith a full recollection  of
Avhat has occurred.   I haA-e remonstrated in my annual reports,
year after year, against this practice, and have taken  every
occasion to call the attention of the community to it.
  ()ne other remark :  The member of the Committee report-
ing these resolutions, has  touched upon the actual mode of
cheapening he proposes to adopt.   I haA-e nothing in addition
to say, in regard to the question of diet, to A\diich  he alludes;
but he Avould cut off walking.

   Dr. Walker—Xot at all.  I said the Avalks and rides might
be lessened, but not dispensed Avith.
   Dr. (tray—Then he would limit the privilege  of walking,
 on the part of these patients, and his  institution Avould gradu-
 ally sink into the institution Dr. Brigham has so  graphically
 described.   I  am  glad  Dr. Chipley has  quoted from  Dr.
 Brigham.
   Dr. Lockhart—No  subject discussed before the Association
 has so much interested me as this one, because our people are
 very much interested in it.   In Indiana, as in  Massachusetts
 and other States, the subject of  establishing  separate institu-
 tions for the chronic insane  has  been mooted, and I may say
 that, if the question is to  be presented in the shape of Avhether
 it is better to establish public alms-houses or  second rate asy-
 lums, in place of alloAving these people to remain in the county
 poor-houses  and in the jails,  AA-hich are still  used  to some
 extent for the confinement of the insane, I should be in favor
 of such places of refuge  as those uoav proposed,  if Ave could
 not obtain better.
    We have in the  State of Indiana more than 1,000 incurable
  insane.  That estimate is within bounds, according to our cen-
  sus reports, and referring also to  a  special census taken  by
  mv predecessor.   The hospital of AAdiich  I am Superintendent,
  when full, will accommodate only about 300 patients.   Noav, 
80
what shall be done for the other TOO or H00 patients ?  Shall avc
try to urge up our Legislature to the erection, of three new hos-
pitals now, commodious, Avell-appointed hospitals, or shall avc
adopt a system like the Willard Asylum, or on the plan we are
uoav discussing ?  I confess that I hesitate very much in consent-
ing to recommend the establishment of an institution of aloAver
grade  than that  of the hospitals in the  country generally.
There  are abuses even in our hospitals, as well  regulated  as
they are.   In  the State of Indiana, 17 years ago, our hospital
Avas enlarged  into an institution creditable to the  State, and
to the  people  of the  State, at  that period, and our Commis-
sioners and law makers rested entirely satisfied Avith what had
been done.  And I feel sure that if we were to adopt asylums
of a lower grade, in the different quarters  of the  State,  to
accommodate  these 1,000 insane, our people would again  be-
came self-satisfied, and leave us Avith  second  rate institutions
for the insane, which, in the end, would become disreputable
and disgraceful.   I fear this would be  the  tendency of the
adoption of such a system.  From my knowledge of the asy-
lums and hospitals we have, I know how difficult it is for us
to keep up an institution, proper and  creditable in its  charac-
ter, and efficient in its operations, as  a  refuge for the  insane.
With all the safeguards throAvn  around our institutions, with
all  the reports Ave are required  to make to  Governors and
Legislatures, Avith all the appliances at our command, with all
the inducements held out to us, to keep our institutions in the
best condition possible, I knoAv that  we do not do too much
for the insane  as it is.  And if we are  to  establish  new asy-
lums, Avith fewer advantages and capabilities, much  less Avill
of course, be expected from them, and  the result will  almost
inevitably be a great deal of deprivation, suffering and misery.

  Our  Legislature, at its  last session, I am happy to say, made
an appropriation for the enlargement  of our  present hospital
for the insane.   We hope, at the next session of the Legisla-
ture, greatly to increase the amount of the appropriation and 
81
the Commissioners and myself haA-e  purposed, and still  pur-
pose, that the money appropriated shall be used in building
an addition to our hospital, as complete, as perfect, and eA-en
more so, in  all its parts, than the old building; but in respect
as to Avhat shall be done in future, I am satisfied much depends
upon the decision  that Ave make here to-day.   If the Willard
Asylum shall be decided to embody a plan that ought to be
fostered, other  States Avill  imitate it, and perhaps  our  OAvn
State Avill build an asylum of this sort.   This question, as  I
said, is  forcing itself  upon the communities; Ave haA-e to meet
it in some Avay.   Even in  the avell-regulated State of Massa-
chusetts—a model in all these enterprises—Ave knoAv that the
Asylum at  Xorthampton is practically a resort for the incura-
ble insane.   This  thing is unavoidable; you  cannot help it.
In  our  institution, we are from  year to  year turning  aAvay
these chronic patients to make room for neAv cases, and Ave
think Ave do right; for, after a case has been under treatment
tAvo or three years, the probabilities of recovery have, of course,
very much  lessened,  and a greater  amount of good may be
done, as avc cannot  accommodate all, by requiring them to
give place to cases of perhaps a feAv  days' or Aveeks' standing,
of which the hope  of being able to benefit is greater.  I learn
from Dr. Kirkbride,  that  the number of insane now in the
alms-house  of  Philadelphia is  near 600.   So  that, in  the
wealthy State of Pennsylvania, Avith its Avell-appointed hospi-
tals and asylums, capable of accommodating great numbers of
patients, the chronic insane,  in  large numbers, are, after  a
time, forced into the alms-houses.  Perhaps, if  we consented to
the erection of  these institutions,  and gave them the designa-
tion of alms-houses,  instead of calling them asylums or hospi-
tals, Ave should  find the use of that term less objectionable.

   Dr. Nichols—If the Doctor will alloAv me to interrupt him,
Avithout wishing to impair the force of his  argument at  all,  I
would like  to have a proper impression made in respect to the
character of the Philadelphia Alms-House Hospital for the
            E 
S2
insane, or rather insane department of the alms-house, because
the effort is being made, and in a good  degree successfully, to
make that an hospital for the curable, organized  as  our State
institutions are, and carried on with the same degree  of effi-
ciency.   If it has not improved as rapidly as its friends desired,
it has still greatly and  steadily improved.   It has a medical
Superintendent avIio has no other duties, and aa-1io is endea\'or-
ing to make it  a desirable hospital, substantially like our other
institutions.  I think it is due, not only to the Superintendent
and medical officers, but to the general issue in question also,
that the true character of that institution should be stated.
  Dr. Lock hart—The  fact Dr. Nichols has expressed, I was
about to  state.  I have  visited  the Philadelphia  Alms-IIouse,
and Avas pleased with its  management  as such.  I Avas  about
saying that, in  consideration of having regular medical attend-
ance and  officers, and in consideration of  its being so Avell
regulated an establishment, although  called an alms-house,
would it  not be better to establish in the States, institutions
for the incurable insane, giving them the designation of alms-
houses '.  Now, take the Philadelphia Alms-IIouse as  an ex-
ample.  The result Avould certainly be  good in  sending such
persons there, in comparison with our county poor-houses and
jails.
  The President—The Chair Avill remark, in respect  to the
Alms-IIouse at Philadelphia, that the insane department is
entirely distinct from the alms-house,  although  in the same
general building.   We regard it as a  hospital for the insane ;
but its present  position  is not regarded as satisfactory, and the
proposition uoav is to remove the insane department entirely
from the alms-house, and erect a separate institution for that
purpose.
  Dr. Lockhart—The  proposition I am discussing is, to estab-
lish an alms-house hospital, Avith a regularly paid superintend-
ent and medical corps to care for the insane, avIio are now
inmates of our jails and poor-houses. 
83
   The President—Then you make a regular hospital.

   Dr. Lockhart—Yes ; but I propose to call it an alms-house.

   Dr. Nichols—What is the benefit to accrue from calling it
an alms-house (

   Dr. Lockhart—There has been, since this discussion com-
menced, an expression on the  part of almost every one, that
the establishment of asylums, on the Willard plan, would have
the effect of degrading the business of taking care  of the in-
sane.  If,  therefore,  institutions,  having a loAver standard as
hospitals, are to be established, the idea  I suggest Avould be to
change the name, rather  than  to change the reality; for,  I
believe it is a fact—I knoAv it  is Avith our  people—that  our
communities are now so burdened Avith taxation as not to  feel
able, at the present time, to provide ample, commodious hos-
pitals for the insane, regulated in every respect as they ought to
be for recent cases, sufficient for the accommodation of all these
unfortunate people avIio ought to  be cared for.  It Avould re-
quire the expenditure of a million and a half dollars to do it
in Indiana, and if the appropriation cannot be obtained, will
it not be better—although I am opposed to anything less than
a Avell-regulated hospital—to provide some intermediate estab-
lishment, under Avhich  these people can be better cared for
than at present  (  The fact cannot be ignored, that the neces-
- sity for something to be done is  very great.   Our jails and
poor-houses contain many epileptics, dangerous  in their char-
acter, and there is no  proper place to provide for them;  and,
unless Ave agree to have something of this sort for their benefit,
they will not be provided for.   I say, therefore, the question
is Avhether, under these  circumstances, it is not better to have
second class hospitals, Avhich shall provide, in a measure, for
our immediate  Avants?  But, at the same time, I  shall Arote
against any proposition  of this sort, as a general proposition,
and shall try my utmost to urge our people up to the point of
providing four hospitals for the four quarters of  our State. 
si
  Dr. Nichols—It has long been an  impression  on my mind
that, in many of the States of the  Union, Avhich have at least
one first class hospital for the insane, the wants of the commu-
nity are not  entirely accommodated by that institution, even
in the care of recent cases.  And I think that view is demon-
strated by the paper which Dr. Jarvis has  recently prepared
and published in the Journal of Insanity.  The first reason
why I desire hospitals for the insane to be multiplied in a
State  is, to afford better facilities for the treatment  of recent
and probably curable  cases.   Noav, suppose we  get such a
number in each State as Avill  make them accessible to all the
people of the State, the thought  has  been uttered by Dr.
Chipley and perhaps other members of the Association, but it
seems to me has not "been sufficiently considered, that it is of
the first importance to  have a certain proportion  of curable
cases in every hospital  for the insane, in order to keep them
up to  the curable standard, and in order  to keep them up to a
humane standard.   I do  not believe it can be done in an hospi-
tal in Avhich  all minds  are impressed Avith the idea that there
is nobody in  that hospital avIio is  ever going to  be cured.  I
do not believe it can be kept up to a humane standard, or that
the people Avill be made comfortable in it.

  Another idea I Avish to express in this  connection,  and it
strikes me, a valuable one, in  reaching the  proper conclusion
in relation to this A'ery important  question noAV before us, is
this:  Suppose Ave  get, as in  Massachusetts, and perhaps  in
Ohio, such a number of AA-hat Ave call curative  institutions  as
Avill accommodate the  people of those States, and that they
are accessible each to the people of its district.   Then  comes
up the question, Avhieli is uoav pressing in  Massachusetts, for
example, of taking proper care of the incurable insane.   It is,
as Dr. Walker justly remarks, a question of economy with the
public.  Noav,  it seems  to me  as  demonstrable as anything
perhaps can be, because it is arithmetically  demonstrable that
it Avill cost less to  add suitable accommodations for the incu- 
85
rable insane to the institutions already existing, and have that
class of insane taken care of in  connection Avith  the  curable
cases, than it Avill be to erect and conduct  such separate insti-
tutions for the incurable insane, as any one  member of this
Association AA-ould be satisfied Avith.  I do not propose to go
into a demonstration of this proposition.   It seems to  me it is
self-evident.   I throAv out the suggestion because it is  to me a
very important one.   All these provisions for  the insane of all
classes Avere had in vieAv, in submitting the propositions which
I submitted, yesterday, in lieu of any extended remarks on the
subject.
  Noav, I do not knoAv as it has been insisted by any member
AAdio has addressed the Association, that the  incurable insane
shall be kept largely, or even  at all, in Avards Avith the curable.
If you have curable insane enough to fill the present hospitals,
when you come to enlarge  these hospitals, I'see no objection
to erecting separate buildings in  connection with them for the
incurable. Dr. Kirkbride has demonstrated  that such a plan
can be pursued successfully, and I think it a Avise course, cer-
tainly, in  the Doctor's case, and  I have no doubt it Avould be
in perhaps most others.   But I see no objection to putting a
curable insane person in that  building, provided it  is a good
one, or of taking the present  building for  the incurable, and
erecting another for the curable.   The  thought I wish to im-
press upon the members of this  Association  is, that you are
not going to cheapen the care of these people  by erecting and
conducting such separate hospitals, of a character such as anv
member of this Association would be satisfied Avith.   And as
the question is one of economy,  as is conceded on all hands,
so far as the community is concerned, it is of the utmost con-
sequence to the welfare of the insane, that Ave should take the
vieAV, if it be a correct one, that  it really is not an economical
measure to build these separate institutions.

  Dr. Chipley—I belieA-e it is a fact that some of the States
have made ample provision for all their insane.  The State of 
so
Yermont, for instance, has made provision for the accommoda-
tion of one for every 720 of its population, and  I  take it for
granted that is all Avhich would be required.   Noav, the ques-
tion occurs to me Avhether insanity is more prevalent in other
States than in Yermont.  Massachusetts has not made so large
a provision proportionately.   The capacity of  the institutions
in that State, I believe, amounts, in the aggregate, to one for
every 1,025 or 1,030 of its population.
   In my own  State, the people have ahvays been ready, and
have urged the  Legislature to  make more ample  provision.
The people never have  objected to any provision that has been
made for the insane.  The only class by Avhom Ave  have been
met Avith opposition in  these matters, have  been  those in offi-
cial position.  I do not knoAv  that I haA-e ever heard an intel-
ligent person,  outside of the  Legislature, express opposition ;
but, on the contrary, the people have been constantly urging
every Legislature to make more ample provision for the in-
sane.  Before the Avar,  provision was made for the erection  of
another asylum, costing a quarter of a million of  dollars.
That, unfortunately, Avas burned in 1860.   Since that period,
another quarter of a million of dollars has  been  appropriated
for the  reerection  of that  building, and the Avork Avas prose-
cuted even during the Avar, Avhen Avagons and teams had to be
guarded by the military, for five or six miles from the institu-
tion, against the depredations of  guerrillas.  I believe our
Legislature Avill be induced soon, and I hope at its next session,
to make further provision for  other institutions, not. of a lower
standard, but, if possible, of a higher standard than those Ave
uoav have,  so as to provide for all the best means of recovery,
and to provide for those avIio  do not recover, all the care and
comforts such  institutions are  capable of affording.

  The question has been asked, and there has been no satis-
factory  answer to it, Iioav Avill  these institutions be made more
economical than if this  class of patients is retained in our reg-
ular asylums  and  sufficient  accommodations provided for 
S7
them?   For instance: Ave have a large Avard A\-ith  perhaps
forty men in it.   Every morning, after breakfast, every man
in that ward has the same occupation.   Two or three remain
to attend to matters about the Avard ; some assist in the kitch-
en, some in  the boiler house, some in  the  laundry, some on
the farm, and  some in the garden.  The two men avIio have
charge  of that Avard going  with certain parties,  and others
with other attendants.  At 12 o'clock the bell rings;  they all
reassemble, take dinner,  take their proper rest,  and go  out
again in the afternoon.  Will any one tell me Iioav those forty
men  can be more  economically supported in an institution
professedly for incurables than in an hospital  so organized'( To
save my life, I cannot conceive Iioav they can be more cheaply
supported in such an institution than  in a regular organized
hospital, receiving curable patients as Avell as incurable.

  The President—With the permission of the Association, I
Avill say a Avord or two upon this subject, merely to indicate
that I have  not changed  my sentiments in  reference to this
(piestion, in consequence  of the argument  to  which I haA-e
listened, in this discussion.   The subject Avas so fully consid-
ered in my last report, that  I am sure  gentlemen will knoAv
Avhat Avere  my opinions at that time.   If I were to write it
again, I can only say, I should use a little stronger language
than  I did then, on the same side of the question.  I  have
really been  anxious  to learn from  some of  our friends, avIio
take a different vieAV, Avhere  anything is to be gained.  If Ave
belieAre, and  are able to convince our legislatures and our citi-
zens,  that there is  to be no economy in  it, they  will certainly
haAre no  disposition to carry out this system of separate institu-
tions, for the so-called incurable.   It was for that reason, that
I asked the  question of my friend, Dr. Walker,  whose ability
on the subject  of  political economy Ave all  know, and I will
confess that  his reply to my question  was not  entirely satis-
factory.  If  the chronic insane are going to require about as
much food;  about as much clothing; about as much Avarmth 
s.s
 in winter;  about as much fresh air, and all these things, as
 the curable insane, I think, Avhen Ave are treating the curable
 insane, Ave  can take care of the chronic insane with more econ-
 omy really than they could be  cared for in a separate institu-
 tion.  I  speak for myself, when I say that our expenses, for
 the supposed curable insane, and for the chronic insane, treat-
 ed in connection with  each other, are less than it would  be
 possible to provide for  them separately.  Then  again, in our
 institution,  some of the most useful people about the hospital,
 are those who  are  really incurable, and have come to spend
 their lives with us.  That has been my experience during my
 whole connection Avith  the Hospital.
   In regard to further provisions for the accommodation of a
 large number  of patients, I think my friend, Dr.  Lockhart,
 has given the true  principle on which  a solution of all these
 difficulties is practicable.   The  trouble is, we haAre not faith.
 If we have  faith in our legislatures, and in the people they
 will not disappoint us.  I haA7e faith in the people of PennsA'l-
 vania, as I haA-e reason to haA-e faith in the people of Phila-
 delphia.  If we have asked for means to provide neAV hospitals,
 which have not been granted, the reason has been, that the
 people haA-e not had the importance of it shown to them.   I
 venture to say, there is  not  a  community in this land, Avhich,
 if properly informed and educated, in respect to the Avants and
 requirements of these people, that Avill not  be ready to meet
 those requirements.  There are some communities, in reference
 to this subject,  AA-hich are  like taking  children who.have not
 been cultivated into cultivated families.  You have to educate
 them, before they Avill understand even A\-hat they Avant.   Get
 our people to understand Avhat  is wanted, and they will do it.
 The annual  expense required for this purpose, from any indi-
 vidual tax-payer, is so  small, that  I say  to my friend, Dr.
Lockhart, he can hardly find an individual in his State who
would not be ashamed to say he would not be Avilling to con-
tribute his portion for  the  four institutions required in the
State of  Indiana. 
8{l
  Then, in regard to the Willard Asylum, about AA-hich so
much has been said, I should like very  much  to understand
whether it is to be a cheaper institution than the ones already
existing in Vermont or in NeAV Hampshire.  If I am correctly
informed, it is likely to  be more costly.  I understand that
more money has been expended for the site than has been paid
for that of any other asylum in the  United States, and that
by the time it shall have been completed, instead of being the
cheapest, it will be the most  costly institution in the Union.
I may be in error.   I speak from Avhat I suppose to be good
authority, and if I am Avrong, will thank any gentleman to
correct me.  My oavh opinion is very decided that, all our in-
sane should be provided  for in regular asylums.  I can under-
stand  Iioav  certain classes of patients may be provided for,
more cheaply than others, in our regular institutions.  It is
entirely practicable, to place in certain wards, a class of sup-
posed incurable patients, aa-1io need not haA-e mirrors, parlors,
billiard-tables, or anything of that kind.  But  in many other
things, they cannot properly be deprived of any of the advan-
tages required for the curable, and many of the chronic insane
require even more warmth and ventilation, because  their con-
dition  is such, Avith less A'igor of circulation, that more Avarmth
and  more fresh air  is absolutely necessary, than  for curable
patients.   It is the safest, most humane, and in my judgment,
the most economical plan to provide for all this unfortunate
class of people, in the manner that shall giA-e them the great-
est  amount of comfort, and the best  chance  of recovery.  I
Avill not detain  the Association longer.   I only desire to put
myself on record, as not having changed my opinion upon this
subject.   There is one thing that, perhaps I ought to say before
I sit doAvn, that my information, in regard to  the cost of the
Willard Asylum site, did not come from any  member of this
Association.

  Dr. Earle—I should like  to ask  Dr. Lockhart, Avhat evi-
dence  he has that the people  of Indiana Avill  not erect more
asylums'( 
90
  Dr. Lockhart—Dr.  Athon, my  immediate  predecessor,
for a period of ten years, annually appealed to the people, to
the Governor, and to the Legislature, for " more room, more
room," until the appeal has become chronic in the State of
Indiana, so that I did not even mention it in my report of last
year.   These reports were very widely circulated.
  We are about making another  effort.  I am getting out
blanks to  send into each county, asking petitions to be signed
by the doctors, lawyers, ministers,  and other influential men,
in the community, for this purpose.  Miss  Dix has consented
to visit  us next Avinter,  and I hope  that, through  all these
agencies, Ave shall succeed in obtaining a liberal appropriation.

  Dr. Jones—It is demanded  at our hands, that Ave should
consider a system of economyj under Avhich the insane, in our
respective States, may be cared for at less  expense than here-
tofore.  The gentleman from Indiana, is, I think, an exception
to the general rule.  As often as I have seen reports of Super-
intendents, especially those haA-ing charge of State institutions,
I ha\-e seen that they had cause to  felicitate themselves, that
all their requests in  regard  to supplies and appropriations of
every description, needed for their institution, haA^e been cheer-
fully granted upon the  part of the legislatures.   Gentlemen
here,  all knoAv how liberally their people have contributed,
and Iioav  cheerfully, whateA^er they have said, Avas needed.
The Superintendent  of the Government Asylum congratulates
himself, from  time to time, that the Congress  of  the  United
States responds to every request made by him, and until Ave
are really appealed to,  for a system  under which the insane
may be  cared for more cheaply, the Superintendents of these
institutions should be the last to volunteer suggestions  on that
subject, to the public.   Let  us, at  least,  exert such  influence
as we are  permitted  to  haA-e, to accomplish the provision of
whatever  accommodations are necessary for all the insane, and
Avhen  we fail, it will  then be time  enough to consider some
other  system. 
91
   Dr. Walker—The observations of Dr. Jones, in respect to
 the liberality of  the people, are  certainly Avell  merited.   The
 disposition of the members of our legislature, has ahvays been
 to provide all that is asked for to meet our  current  expenses.
 But Avhen Ave have asked them to appropriate $250,000  for a
 new Asylum, they have hesitated before granting it.*

   Dr. Cook had  no desire to prolong the discussion.   The pa-
 per he had read, contained a full expression of his views, and
 he thanked the Association for the kind and courteous manner,
 in which the  subject had been  received.  But it seemed to
 him, that the discussion had taken a very Avide range, and that
 much had been said,  which had  little bearing upon the  (pies-
 tion presented.   And he would  here ask the attention of the
 Association, for a moment, to the main question discussed in
 the paper he had read.   It is therein stated, that if all the in-
 sane poor in the  State  of NeAV  York, Avere now pro Added for
 in State Hospitals, he Avould not come forward  as an advocate
 for a separate asylum for the chronic insane.  But the practi-
 cal application of the laAvs, under the hospital  system in our
 State, has placed hundreds of them in the county house recep-
 tacles, and he did not believe that any human poAver could put
 them back into hospitals.   And  the practical question is, Avill
 you continue to uphold this hospital system, under Avhich  these
 poor house receptacles  haA'e so  rapidly come into favor and
 poAver, as the only proper  provision '.  Will you leave   these
 chronic insane in their present misery and degradation, or Avill
 you give them something better, even though it be something
 cheaper than  hospitals?  We have  heard the word "cheap"
 denounced here in no gentle terms.   He cared not Iioav others
 might sneer at " cheap11 asylums and u cheap11 men.   He ear-
 nestly desired the  adoption of some system of proA'ision for

  * At this point of the discussion the Stenographic Reporter left the  room.
 The remarks of Dr. Cook, which follow, have been written out by this gen-
tleman, since the adjournment  of the Association, and kindly forwarded
 for publication. 
!*2
the insane poor, which shall be economical enough, or, if you
please, " cheap" enough to include them all, recent and chronic,
within its provisions.   He could not perceive the justice of a
system, which in its practical application, leaves the greater
number uncared for, and AA-hich would then attempt to bar the
way by its theoretical propositions, to those  who  would  help
this unfortunate class thus left to suffer.

  He had not desired to differ from the majority of the Asso-
ciation on this question, but events unforeseen, and  beyond
his control, made it necessary for him to defend the action of
the legislature in creating the Willard  Asylum.   An experi-
ence and observation of eighteen years,  had convinced him,
that the hospital system alone, as administered in the State of
NeAV York, is not adequate to meet the wants of all the insane
poor.  We have one State hospital and many poor house re-
ceptacles.  Other States have increased the  number of their
hospitals.  Ohio and Massachusetts each  have three, and yet
the great mass of the chronic insane, in those States, continue
to be insufficiently provided for in alms houses.   The same re-
sults will folloAv in the State of NeAV York.  The erection of
two more hospitals will not abolish a single  county house re-
ceptacle.  No community in the Avorld has ever yet made hos-
pital proA-ision for all its insane.  He Avould  not ask the Asso-
ciation to receive this fact upon his assertion.   Dr. Bay is good
authority for this statement, and he further  tells us that  such
provision is less likely than ever to be made in  this country,
while Ave are staggering  under the  burdens  imposed upon us
by the great national struggle.   Noav, he would ask the Asso-
ciation, as a body of practical men, if hospital provision has
never yet been made in this or any other country for all the
insane, and if we are less likely than eA-er to make such pro-
A-ision noAV,  Avhat probability is there  that  hospitals on the
present plan of construction and organization, as presented by
the propositions of this Association,  will ever be erected for
the chronic insane that now fill  our county  poor  houses,  and 
93
are yearly increasing in number (   By theoretically adhering,
exclusively, to the hospital plan, do you not, in  effect, help to
perpetuate the county house receptacles '.   No other conclusion
seems legitimate.
   Our esteemed President tells- us that avc should have more
faith.  But faith must have a foundation upon Avhich to rest,
and here is no foundation, except a theory AA-hich has failed in
practice.
   He desired to call the attention of the Association to the re-
marks Avhich had been made in regard to the neAV asylum bill,
passed at the late session  of the Ncav York State Legislature.
It has been said that the  Legislature, in  this bill, had righted
itself, and Ave were left to infer, that a hospital on the plan of
our present State hospital had been created.
   The bill consists of two sections.   The first  section pro-
vides for the appointment of commissioners.  The second sec-
tion provides that  the commissioners may accept a site as a
gift, or contract for the purchase of  one, and  report their
action to the next legislature for approval.  That is all;  there
is no appropriation and no asylum even, of any kind created.
It is a mere assumption  to say that it  is to  be an  hospital
according to the Association's propositions.  It may be or it
may  not;  upon that question he  Avould express no opinion
here.
   AVhen the paper Avas  read  upon  pro\ision for the insane
poor, in the State  of NeAV York, Dr. Gray was absent.   In
the remarks which he made upon the subject, he took occasion
to say, that he did not knoAv what personal allusions had been
made in  that  paper.   It seemed proper, therefore, that  he
(Dr. C.) should now read the extract which he made from one
of Dr. Gray's reports.   He read from page thirty-one, of the
Eighteenth Annual Keport.  Dr. Gray has there written, that
" hospitals, with all the varied appliances for the treatment of
acute diseases,  must still be demanded; but  for the care of
chronic  insanity,  more  simple  and less expensive arrange- 
91
ments will be required and adopted."  Thus it  appears  that
he, (Dr.  C.)  is not the only one in the State of New York,
avIio asserts that more simple and less expensive arrangements
are required  for the care of the  chronic  insane  in our State.
He Avould leave the association to place its oavh estimate upon
the denunciation Avhich had been heaped upon him,  (Dr.  C.,)
and other  friends of the Willard  Asylum,  as   advocates  of
"cheapness"  and ''inhumanity.11
  In reply to a remark made by the President, about the  cost
of the Willard Asylum, he Avould  say, that  this Avas  neither
the time nor  place to enter upon that  subject.  It could  not
be entered upon, without personal allusions, Avhich he Avas un-
willing to make here.  He Avould simply say, that if the plan
of the Willard AsA-lum Avas not, oriorinalh-,  as economical as
it should have been, some  one, other than the friends of the
measure  were responsible for it.
  He desired to thank the gentleman from KentuckA',  Dr.
Chipley, for the illustration he had given of Avhat  may be done
by proper classification and organization of labor in the care
of the insane poor.  Dr.  Chipley, says that he  has forty-one
patients in one ward, under  the care of tAvo  attendants,  and
that all those patients, with their attendants,  go  out to labor.
Here are forty-one patients cared for by tAvo attendants,and their
labor made aA-ailable, without extra cost for supervision.  This is
a practical  illustration of Avhat maybe accomplished, on a more
extended scale, by the Willard Asylum.   If all our State  asv-
lums had been managed according to the practice of the gen-
tleman  from  Kentucky, there would  not exist to-day  the
urgent necessity for more simple and economical  provision for
the hundreds of chronic insane  now left unprovided for in
county alms-houses.  With these  remarks he would  leave the
subject, content to let future events decide the truth or fallacy
of his vieAvs.

  Dr. Kirkbride—The gentleman who has  just spoken,  as
the advocate  of separate institutions for the  chronic  insane, 
95
fails to ansAver the  important question  put to him, Iioav these
institutions are to be constructed and carried on Avith  greater
economy than obtains under the present system.   If the pro-
posed substitute is to cost as much as the present system, why
introduce it at all {

   The Association  here took up the consideration of  the Re-
port or Resolutions of the Committee, and the  seA-eral substi-
tutes presented therefor.

   Dr.  Cook presented the folloAving substitute, Avhich received
but one vote in the affirmative, Adz: that of the moAer of the
resolution :

  The subject of provision for the insane poor, especially for the chronic in-
s ane poor, having been brought before the Association and discussed at some
length, and the question*raised as to whether some modification of the pro-
positions heretofore adopted, in regard to the construction and organization
of hospitals, was not required to meet  the necessities of this class,  the Asso-
ciation would take the opportunity to  record its decided preference for hos-
pital provision for all the insane, whether in the acute or chronic stage of the
disease.  But it is willing 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 poor-houses, or shall provision  be made
for them in special asylums at a less cost than in hospitals ?  On this ques-
tion, the Association would accept the special provision, if hospitals were
not attainable, and abolish the  county poor-house receptacles.

   Dr. Chipley offered the following propositions,  as a substi-
tute for the Report of the Committee, which were unanimous-
ly adopted:

  1.  Every State should make ample and suitable provision for  all its in-
sane.

  2. That insane persons considered curable, and those supposed incurable,
should not be provided for in separate establishments.

   Dr. Nichols stated that he desired to offer, for the consider-
ation and action  of the Association, the series  of resolutions
Avhich  he had  read at a previous period of the discussion, in 
96
lieu of extended  remarks, and  as expressive of  the vicAvs  he
entertained.   The passage of the resolutions, offered by Dr.
Chipley as a  substitute for the report  of the Committee, of
course, ended the discussion of  the subject of the care of the
chronic insane.   But  he (Dr. Nichols) desired  to offer these
resolutions as independent propositions; and, at this late hour
of the session, he hoped the Association  Avould act upon them
AA-ithout discussion.  The  principles they enunciated Avere  fa-
miliar to the  members.  The resolutions Avere  then  read  by
Dr. Nichols, as folloAvs :

  1. The large  States should be divided into geographical districts of such
size that a hospital, situated at  or near the  centre of each district, will be
practically accessible to all the  people living within its boundaries,  and
available for their benefit in case of mental disorder.

  2. All State, county, and city hospitals for the insane should  receive all
persons  belonging to the vicinage, designed to be* accommodated by each
hospital, who are affected with  insanity proper, whatever may be the form
or nature of the  bodily disease accompanying the mental disorder.
  3. All hospitals for  the insane should  be constructed,  organized,  and
managed substantially in accordance with the propositions adopted by the
Association in 1851 and 1852, and still  in force.
  4. The facilities of classification or ward separation,  possessed by each
institution, should equal the requirements of the different conditions of  the
several classes received by such  institution, whether these  different condi-
tions are mental or physical in their character.
  5. The enlargement of a city, county, or  State institution for the insane)
which, in the extent and character of  the district in which it is situated, is
conveniently accessible to  all the people of such district, may be properly
carried, as required,  to the extent of accommodating 600 patients, embra-
cing the  usual proportions of curable and incurable insane in a particular
community.

    The President remarked that one of the propositions of Dr.
Nichols was opposed to one that had already been adopted by
the Association, limiting the  number of patients in  hospitals
for the  insane to 259.  He thought two-thirds  of the Avliole
number of Superintendents  should be present when such a
change wTas contemplated. 
9T
  Dr. Curwen moved a  postponement  of  these  resolutions;,
which, after some discussion, was carried.

  Dr. Earle then moved a reconsideration of the vote on post-
ponement, which, after some debate, prevailed.

  Dr. Chipley suggested that the President of the Association
had practically violated that proposition, by increasing his in-
stitution to about 500, by establishing hospitals for the two
sexes under the same organization.

  The President begged to deny this.  The  two establish-
ments, though under his charge,  were separately conducted;
and he felt it his duty to add that his Board of Trustees would,
on his resignation, appoint a medical Superintendent for  each*.
He held this position now, only for the reason  that his Board
urged it upon him.

  Dr. Curwen here remarked that several members  had left
the room, being compelled to return home, and he hoped  these
resolutions would not be pressed to vote.

  Dr. Nichols stated that several of  the  absentees  had left
their votes with him.

  Dr. Gray remarked that  Drs. Peck and  Stanton, of Ohio,
on leaving, requested him to cast their votes in the affirmative
on the resolutions of Dr. Nichols.

  Dr. Chipley moved to vote upon the propositions separately.
which was agreed  to, and  the first four propositions passed
unanimously.  On  the fifth proposition, the  ayes  and noes
were called, with the following result:

  A.yes—Abbott. Cabanis, Chipley, Earle, Gray,  Lomax, Nichols and Van
Nostrand—8.
  X.ws—Cook, Curwen, Jones, Kirkbride, Lockhart and Walker.—U. 
98
   Dr. Nichols then Said that the absent members would have
voted in the affirmative, but as this proposition  had received
a majority of those present, it  was not Avorth while to  record
the votes of  the members aa-1io had left, particiilarlV, as the
Association Avere aware of their views.

   The Association next voted on the propositions, as a whole:

  Yeas—Abbott, Cabanis, Chipley, Earle, Gray, Lockhart,  Lorriax, Nichols
and Van Nostrand—9.
  Nays—Cook, Curwen, Jones, Kirkbride and  Walker—5.

   Drs. Kirkbride and Jones desired to say that they fully con-
curred in all the propositions of Dr. Nichols but the last.

   Dr. Jones  thought 250 to 300 were  as many as one institu-
tion should receive.

   Dr. Kirkbride observed that, although it might be practi-
cable to cafe for a larger  number in one institution than  the
Association propositions established, he thotight, at the same
time,  that, until  this  proposition,  which  had  received  the
unanimous Aote  of the Association, Avas  repealed by a  vote
taken when two-thirds of all the members of the Association
were present, no change should haA-e been made.- 
 
 
 

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