RECOMMENDATIONS

AS TO THE FUTURE POLICY OF THE STATE IN THE MANAGEMENT OF

THE INSANE.

The present number in hospital is about 1,040, of which Independence hospital has 580, that at Mt. Pleasant 460. We have in this State one insane person in every 639, according to the last United States census, and we have the lowest percentage of insane of any State in the Union. There were, in 1880, in this State, 2,544 insane persons, of whom 913 were in hospital, 69 in other institutions, 323 in county poor-houses, 7 in jails, and 1,232 at home; and it is thus shown that only 36 per cent of our insane are cared for in hospitals, while Illinois has 43 per cent, New York 57, and Massachusetts 60. On an average in the whole Union, 44 per cent are under treatment in hospitals. The design of our present hospitals being mainly for the cure of insanity, it is manifest that more hospital room must be provided for the relief of this afflicted class of our fellow citizens; the present hospitals being constantly crowded with the chronic cases, we regard it as an imperative duty of the coming legislature to make an appropriation for locating and building a new hospital in the western part of the State; the location, in our opinion, should be to accommodate the southwestern and central western part of the State, and the institution should be of the same general character as the present ones; it should be a first class brick building, and not built as expensively as the present hospital structures. This should be the third of our series of hospitals, and will necessarily be followed by a fourth, eventually, of about the same kind, located in the northwestern part of the State. As the population of the State increases the percentage of insane will undoubtedly continue at least as large as at the present time; and our State does not, in the opinion of your committee, desire to be behind other States in its provision for these unfor

tunates.

After our State has been well supplied with curative institutions, other structures may be provided on the hospital farms, where, under the same general supervision, the chronic cases can be cared for more cheaply and in a better manner than they could be in county institutions for the same purpose. Your committee, in their report at the end of the biennial period two years since, inclined to the belief, for special reasons given at that time, that a state institution for the care

of what are styled "chronic and incurable cases of insanity" would be the better mode; but, after further investigation and further thought on the subject, we think it simply better than sending them back to their counties; and our opinion is now firmly fixed that there should be no separate institution for such a class, but that they should be provided for in and about our hospitals on the plan indicated above. The following opinions on this subject are given by some of the most distinguished alienists in this country:

Dr. Brigham says: "No one can determine with much accuracy which patients are, and which are not, incurable. Of this asylum (Utica), we cannot say of at least one third, to which of these classes they belong. We still indulge hopes of their restoration, but will probably be disappointed in a majority of them. But the hope we have, and which encourages us in our efforts to cure them, would be destroyed by sending them to an 'incurable' establishment. The fact that the chances of recovery would be diminished to even but a few is enough to make us hesitate before we establish such asylums. Many who are incurable are deranged on but one or two subjects, and sane on others. Such, surely, should not be deprived of comforts that are offered the curable class, among the greatest any of which is the hope of again being restored to society, which would be destroyed if they were sent to an asylum for incurables. Among the incurable insane there would be no certain means of ascertaining the neglect or abuse of them. In all, the fact that some are well and soon to leave the asylum is the greatest safeguard against abuse. 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 poor-houses? There are no facts in favor of such estab lishments. We hope never to see such institutions in this country. On the contrary, let no asylum be established but for the curable, and to this, the incurable, the rich and the poor, should be admitted; let all have the same kind of care, and let all indulge the same hope, even if delusive to many, of ultimate recovery; but do not drive any to despair, and destroy the little mind they still possess, by consigning them them to a house, over the entrance of which Dante's lines on the gates of hell might well be inscribed: Leave hope behind, all who enter here."

Dr. Gray, the present distinguished superintendent of Utica asylum, says these opinions are as sound and comprehensive as ever, and embrace the whole philosophy of the subject.

Dr. Bell, so eminent by reason of his investigations into the organization and management of insane hospitals in Europe, declares as the fruit of his experience: "The principle is, there is no such thing as a just and proper and curative or ameliorating treatment of the insane in cheaply constructed and cheaply managed institutions. If it is worth while to have any institutions beyond these receptacles in which the worst patients, or rather the worst sufferers, can be crowded together at the least charge, it is worth while to establish such as will accomplish all of cure or relief which is practicable."

In reference to this subject, Dr. Kirkbride, for forty years superintendent of the Pennsylvania hospital for the insane, at Philadelphia, says: "I have been trying for years how we are to keep the chronic insane more cheaply in separate institutions than we have been keeping them where all classes were received. Why, they have got to have the same amount of air, fresh air I mean, and warmth; the same amount of clothing and the same amount of food. How, then, are you to keep them cheaper? I have never seen any mode suggested by which you are to reduce the expense, except by lowering the scale of treatment. You must give them room; what is necessary in one institution is necessary in another. I do not know that it is necessary to say one word more, only to remark that I do not believe it can ever be economical to do wrong. And to revoke the decision of the association, or to put up institutions for incurables would be a wrong step. It is better and cheaper to cure a man at any cost than to support him as an incurable."

The Association of Superintendents, after years of effort to obtain the most reliable data, and after full and free discussion, resolved: "That insane persons considered curable, and those supposed incurable, should not be provided for in separate institutions or establishments."

In the Medical Record of the 23d of December last, Dr. C. R. Agnew, of New York, in an article upon the care of the chronic insane, says: "The idea at present in full operation in this State, of gathering the acute insane in one institution and the balance in another, is both unscientific and inhuman, as bad as it can be in an economic point of view. An asylum for chronic cases comes to be considered

by the popular mind as a place for incurables, a place on which may be inscribed, no hope enters here,' and the influence of that consideration, sooner or later, pervades the asylum itself, and scientific interest in the scrutiny of the inmates case by case dies out, and you have a mere poor-house, with scarcely a vestige of a hospital or sanitarium about it."

INVESTIGATIONS.

The investigations made by your committee during the biennial period are now in the executive office, and to be printed as a part of this report.

Your committee are much pleased to see an effort made in both hospitals to do away with mechanical restraints as far as possible in the management of violent cases of insanity; and as one means of accomplishing this purpose they encourage all male patients who are able to go out to work on the farm; these patients perform a large amount of labor, to their own benefit and that of the hospitals, when under proper management; many help do the ward work; in the female wards a large number do ward work; others go to the sewing and ironing rooms, and are benefitted by such labor; all work off their nervous disturbances, and rest better at night, and like to do such labor as is assigned them. We recommend the establishment of such shops as are asked for by the superintendents in their reports, so as to have a diversity of labor as needed.

Your committee have carefully looked over the list of appropriations asked for, and find that what the boards of trustees and superintendents of both hospitals have asked for are of vital necessity to the successful management of the hospitals; especially would we recommend the addition of the "Gray farm" to the hospital grounds, for reasons given in reports from Independence hospital; and we think it economy to add to the farms of each hospital as opportunity offers; each of the present hospitals could work one section of land with a very small increase of expense in labor above what they now have.

In the Mt. Pleasant report, the following items asked for should have the necessary appropriations, being absolutely needed for the successful working of the Institution and safety of the property, viz.: Heating and ventilating, including the same changes in the west wing already nearly completed in the east wing and front center; this im

provement is a very valuable one, and has made a great change for the better in the heating and ventilation of the parts already completed. In fact, there is no single item asked for which can be left out without damage to the building or diminishing the capacity of the management to take good and efficient care of the inmates. We call attention especially to the superintendent's plan for adding to the capacity of Mt. Pleasant hospital, and think that it is the most feasi ble and rapid method of increasing our accommodations for the insane, but it should not interfere with appropriations for a new hospi tal; both objects should be provided for at the coming session of the legislature. A plan should be adopted for increasing our number of hospitals until all our insane are cared for in State institutions, and appropriations should be made at every session of the legislature until the system is complete.

Your committee again call your attention to the criminal insane, and protest against their admission to our hospitals; and as there is a good opportunity for the State to provide hospital accommodations for this class within the penitentiary walls, we most earnestly recommend that such provision be made for them with as little delay as practicable.

We ask your attention to the call from both hospitals for new steam mains and radiators, and recommend that the appropriations be made for larger mains, so that what is called the "low pressure" plan of heating can be adopted, which is both the best and the most economical.

We also recommend that the appropriations asked for from both hospitals for woven wire mattresses, and bedsteads, be continued from year to year until a full supply is obtained.

The appropriation desired at Mt. Pleasant for the continuance of the work on sub-basement walls is absolutely necessary to the safety of the building.

The improvements in the wash, drying and ironing rooms, in both hospitals, are positive necessities in each.

We need not particularize further, for there is not one item asked for either hospital which can be omitted without damage.

At the close of the last biennial period your committee regarded the water supply at each hospital as uncertain and inadequate; since that time the arrangements made at Independence Hospital will render the supply of water abundant and certain, we believe, if the