XtLiNDIS. Bo -i f? 0 or State Commism- ri?s of Public Chr\mm ^M SPECIAL REPORT 23*S OF AN Investigation of the Management OF THE H BY THE State Commissioners of Public Charities, PRESENTED TO THE GOVERNOR, January 28, 1S86. / SPRINGFIELD, ILL.: H. W. Rokkeb, State Pbinteb and Bindeb, 1886. SPECIAL 'REPORT. s cr> r—I t I --------------- °Q Hon. Richard J. Oglesby, Governor of Illinois. *-*- Sir :—We have the honor to make to you the following special re- ,i port of an investigation recently made by us into the condition and management of the County Hospital for the Insane, of the county of Cook, situated at Dunning, near Jefferson. On the 19th of October, 1885, Dr. J. G. Kiernan, who was for one year the medical superintendent of this institution, read, before the Chicago Medical Society, a paper in which grave abuses in its man- agement were alleged to exist, to his personal knowledge. That paper was published. The statements contained in it were of such a charac- ter, that the State Commissioners of Public Charities were requested, by the Chicago Medical Society, the Citizens' Association of Chicago, and the Reform Committee of the Women's Club, to investigate their truth; in this request. Dr. John C. Spray, the present medical super- intendent of the hospital, united. We were naturally reluctant to undertake a task of such responsi- bility and delicacy; but, after deliberation, were of the opinion that the third and fifth sections of the act creating the State board, confer upon us the power to make such investigations when, in our judgment, they are necessary, and that it was our duty, under the circumstances, to exercise the powers given us, for the protection of the insane poor of Cook county. Having, therefore, notified the parties concerned, we met, on Tues- day, the 17th of November, at 2 o'clock, p. m., in Chicago, in parlor No. 1 of the Grand Pacific Hotel, and remained in session until the even- ing of Tuesday, the 24th, when we adjourned. The testimony taken was stenographic ally reported by Mr. John Ritchie, and we have it in our possession. The conclusions at which we have arrived, upon a careful study of the evidence, including the results of an examination, made by our secretary and his assistant, of the accounts of the institution for the past two years, (to which period of time we limited the investigation), will be presented, as briefly as possible, in the following order: (1) the facts; (2) the causes which are responsible for them ; and (3) the remedy. I. The Facts in the Case. Dr. John C. Spray, the present superintendent, was elected by the county board to that position, January 1, 1878; he retained it until the first of September, 1884, when he was succeeded by Dr. James G-. Kiernan; on the first of September, 1885, Dr. Kiernan was replaced by Dr. Spray, Dr. S. V. Clevenger was elected pathologist in 1883; he entered upon the discharge of his duties in June, and served until November, 1884. Dr. Delia E. Howe (at the instance of the Women's Club, seconded by Dr. Spray) was elected assistant physician May 1, 1884, and re- mained until February 1, 1885, when she was succeeded by Dr. Har- riet Alexander, .whose term expired September 1, 1885. . . .... 4 Dr. Charles Koller was elected male assistant physician September 1, 1884, and was discharged in November, when the vacancy thus cre- ated was filled by the appointment of Dr. Alexander Thuemmler, who was transferred, September 1, 1885, to the Infirmary. Up to the first of September, 1884, the institution had a single head, that is, Dr. Spray was in charge of the entire establishment, including the financial and domestic management; but during Dr. Kiernan's administration, the financial and domestic management was in the hands of a warden, Mr. H. A. Varnell, and Dr. Kiernan was sim- ply the medical officer, with very restricted powers. It will correct a great deal of misapprehension, to remark at the outset, that nearly all the testimony offered, related not to Dr. Spray's administration but to that of Dr. Kiernan. Its bearing and applica- tion were not personal, so much as against the system of organization and control of the institution, particularly against the division of au- thority between the medical superintendent and the warden, which did not exist while Dr. Spray was in charge. • System of Government. The government of this hospital is originally in the Board of County Commissioners, who name annually a Committee of Public Charities, who look after the affairs of the county infirmary or poorhouse, and .of the hospital, which, until a few years ago, was a department of the poorhouse and is now on the same ground with it, though it has a sepa- rate existence. The relations between the two are still very close. The committee on public charities is composed of five members of the county board. The board elects the medical superintendent, the war- den, the engineer and the druggist. The medical superintendent ap- points his assistant physicians, the supervisors and the attendants; the engineer appoints his own assistants ; all other employees are ap- pointed by the warden. The influence of the county commissioners in making the^e appointments is confessedly great. The committee on public charities makes the purchases on requisition of the officers, usually after asking and obtaining authority to do so from the full board, though this is by no means an invariable rule of action; the bills, except for building, etc., are sent to the warden, who compares the items charged with the goods received and checks them as correct —with the prices paid he has no concern; the duplicate is retained at the institution, but the original must have the affidavit of the party furnishing the goods attached to it and is submitted by the committee to the board, with a recommendation that it be paid, and it is paid after a vote approving the recommendation has been taken by the board, when it is placed on file in the office of the county clerk. This is in substance an outline of the organization, which varies in its details, at different times, according to the will of the board of county commissioners or of the committee on charities. Printed rules define more in detail the relations and duties of the officers and employees, but we need not discuss them at length. The results of this complicated system of divided authority were very clearly brought out by the testimony. It was shown that political considerations very largely govern the election of officers by the board, and to a less extent the appointment of employees by the officers; that 5 instead of entrusting the government to the superintendent, the com- missioners themselves spend an unnecessary amount of time at the hospital; that conflicts arise between the officers as to the limit of their respective powers ; that there is much insubordination on the part of employees; that the discipline is lax; that supplies, when needed, can not be easily and speedily procured; that the patients suffer various inconveniences, in consequence ; and that it is often difficult, if not impossible, to estimate the responsibility of individuals for the evils which are seen and admitted to exist. What makes it still more objectionable in its practical working is the fact that individual members of the committee claim to exercise and do exercise the powers which of right reside only in the committee as a whole, and that the com- mittee itself keeps no record of its proceedings, nor of its orders. Politics. Commissioner McDonald testified that, in his opinion, the appoint- ments in this institution are more apt to be made on account of their politics than on account of their qualifications for the position. Com- missioner Wren, when asked whether the commissioners do not have apportioned off to them a certain amount of patronage, replied: "I believe that is the way it is done." Dr. Spray said: "There is an element of politics in all those appointments." Conflict of Authority. On the subject of the conflict of authority between officers, during Dr. Kiernan's administration, the testimony was very full and explicit. All the commissioners seem to have known of it. Commissioner Klehm said that they were "always in a muddle;" Commissioner Wasserman, that the committee was continually called upon to come out and settle some difficulty, but could never find out what it was all about; Commissioner Lynn, that there were more complaints arising from jealousies between the physicians and the warden than from any other cause; and Commissioner Mattox, that "there was a great deal of confusion, so that it seemed almost impossible to reconcile the claims made by each." Insubordination. The natural effect of such conflict was insubordination—the division of the employees into parties, and obedience or disobedience, accord- ingto circumstances. Dr. Clevenger swore that "brawls and fights were the common order of things." On one occasion, there was a row be- tween a male attendant and the laundryman ; on another, the assist- ant engineer slapped a female attendant in the face. Dr Kiernan said that male employees should not go through the female wards; Mr. Kavanaugh, the engineer, said that they should. Dr. Koller was dis- charged and left his effects for a time in his room; they were thrown out into the hall by the housekeeper; and he swore that the warden threatened to shoot him. If Dr. Clevenger is to be believed, he was threatened with shooting by Dr. Spray, who. at another time, offered to fight a duel with the laundryman; but this Dr. Spray denies. Dr. Kiernan was knocked down by an attendant, struck by the engineer, 6 and choked by the night watchman, so that he had a hemorrhage and was confined for some time to his bed. Some unknown person fired a shot into Dr. Clevenger's room, on the night after the presidential election, and the ball was stopped by a book in the book-case a few feet from his wife. Certainly these events indicate a very bitter state of hostile feeling, in the highest degree prejudicial to discipline. Various instances of disobedience to orders were mentioned to us, some of which appear to have been followed by discharge and others not. Dr. Kiernan had power, for three months after his appointment, to discharge attendants; then it was taken from him. The house- keeper, Miss McAndrews, took a patient suffering from some female disorder out of her ward and set her to scrub in violation of orders; when Dr. Kiernan expostulated with her, she replied, "I do not pro- pose to have anything to do with you or your orders." The whole medical staff united in a request for her discharge, but it was refused ; Commissioner Leyden said that if Dr. Kiernan continued to insist up- on it, he would make it hot for him. On several occasions he found a female attendant—Miss Sheridan—asleep in her room, and the keys of the ward in possession of one of the patients ; he asked to have her discharged, but in vain. He tried to procure the discharge of John Covey, the cook, but failed. This cook had been heard, by Mrs. Kier- nan, to threaten that he would lay the doctor out. There was. a Miss Finerty, who had been cautioned that a certain patient was not to be left alone in the ward, but taken out when the rest were ; she disobey- ed, left her in her room, and while there she hung herself; in conse- quence of this suicide, there was an investigation by the committee on charities, when the warden and Commissioner Van Pelt said that she should be discharged, but Commissioner J. J. McCarthy said that she should not be, and she was not. According to the testimony of Dr. Alexander, the insubordination increased perceptibly during the latter part of Dr. Kiernan's connection with the hospital. Several of the employees testified that he was very unpopular, for various reasons ; they thought that he required too much of them, and that he was too ready to ask for their discharge. One special ground of complaint was that he did not allow the attendants every other afternoon off duty; it was commonly said that, at the expiration of his term of office, he would be "given the grand bounce." Dr. Clevenger stated that there were some attendants who were most excellent, who were con- scientious, and endeavored to mitigate the sufferings of the insane in every way possible, but that they were in a minority, and were over- awed by those who were not inclined to do their duty. Intemperance. It was further brought out in evidence that there was a good deal of intemperance in the use of ardent spirits in and about the institution. Ihe bills on file show an enormous quantity of spirituous and malt «? W4«£ur T '~im %e ??-ar 1884'Ullder Dr- sPrfty.not less tnan fQv' 1 ' T Un<\er !lr' Kiernan aiid Mr. Varnell, in 1885, a still nS JlTlYl ' naTly' $2'268;80- In order to judge of this expendi- ng £%l™ Lmay bi° comPared Wlth that of our State institutions, for TMtipnU in fi? Si f^.^T6 period- The averaSe number of patients, in four State hospitals for the insane, in Illinois in 1884 was m the aggregate, 2,246 ; in 1885 it was 2,923.' The total^xpendilure 7 for malt and spirituous liquors, in 1884, was $1,021.80; in 1885, it was $1,146. The testimony shows that the liquors at Dunning are kept in the drug-room, and that they are dispensed with great freedom to visitors, officers, and even to employees. The sub- ject is an unpleasant one, and we will not pursue it far. There was not a male officer of the hospital who was not charged, under oath, with having been at times intoxicated; precisely how much of this evidence to believe we do not know; we certainly do not believe it of all of them, but some drunkenness was admitted, particularly by Drs. Clevenger and Thuemmler, both of whom are now total abstainers. Intemperance on the part of the employees, in numerous instances, was clearly proved, and some of them have been discharged for this reason: among the rest, a male night-watch, an assistant engineer, and several attendants. Miss Lowell swore that she had seen two female attendants intoxicated, and gave their names. Dr. Alexander went into the drug-room one night, and found female attendants drink- ing beer there. Mr. Magee, the druggist, stated that it was Dr. Kier- nan's custom to send beer up to the wards in pitchers, and that the amount consumed in that way was about two kegs a day; this testi- mony was confirmed, and a lady patient said, in reply to a question, that the attendants helped themselves to it, which we think not im- probable. There are two drinking-houses, licensed by the county board, in the immediate vicinity of the hospital and infirmary, which are places of resort for the employees of both institutions, and it was shown that a female attendant had taken two female patients, at dif- ferent times, and treated them there ; she is still in the employ of the hospital. Other improprieties of conduct on the part of employees were alluded to, among which we may mention the practice, on the part of male employees, of poker-playing in a room in the basement, where cigars are sold by an ex-patient; and the practice, on the part of both male and female employees, of sitting on the stairs in a dark passage at night,which Mrs. Clevenger characterized as an imprudence, to say the least. Male employees have also been in the habit of visit- ing female attendants socially, in their wards, in the evening after the patients had retired. Keys to these wards were given to the mechanics employed about the building. All of these practices were positively sworn to, and not contradicted, nor the character of the witnesses im- peached. We do not wish to condemn them too severely, but we do not approve of them, nor regard them as consistent with the discipline of a well-regulated institution. Dances. In connection with this subject, we must speak of the entertainments given in the amusement hall, to outside parties. Possibly too much has been made of these in the public press, which has denounced them in unmeasured terms. A dance is given to the patients once a week, which lasts for an hour, and afterward the attendants and employees are allowed to dance for a while; this is usual in most institutions for the insane, and there is no impropriety in it. But the evidence went to show that the dancing had, on some occasions, been of a boisterous character and kept up to an unreasonably late hour, so as to disturb the rest of officers and patients alike. Commissioner Ochs put a stop 8 to these dances from January to July, 1885, but on the evening of the fourth of July, a picnic party from the vicinity assembled on the lawn, to witness a display of fireworks; a shower about nine o'clock drove them into the house ; they brought beer with them into the hall^and when most of the party had left, those who remained danced the ^"fire- man's quadrille," at one point in which they all cried, "Fire! Fire !,r In view of the possible effect it might have upon the patients—it was a warm night and the windows were all open—this was very thoughtless. It was not shown that parties from the city were in the habit of coming out to the asylum to dance. That they were attended by disreputable women, as one of the witnesses suspected, we do not at all believe. Twice, only, so far as we know, were evening excursions to Jefferson organized by any of the commissioners, and in both instances they brought singers with them for the entertainment of the patients. Food. We come now to the question of the treatment accorded to the patients, both in respect of the material conditions of health and com- fort, and of the care taken to soothe their wounded sensibilities. To begin with the food, we should conclude, from the bills on file for provisions, that the supply must have been ample, if not excessive. The total expenditure on this account in 1884 (after deducting the amount charged to the infirmary for bread furnished by the hospital) was, under Dr. Spray, for 592 patients, $40,904.73 ; under Mr. Varnell, for 568 patients, $53,873.38. In other words, the per capita cost of food at this institution in 1884 was $68.74, but in 1885 it was $94.84. The per capita cost of food'in our State hospitals for the insane in 1884, with 2,246 patients, was $56.24; in 1885, with 2,923 patients, it was $52.65. The excess in the cost of food, as compared with State institu- tions, for these two years, therefore, is $31,578.83, or fifty percent., to be accounted for by extra diet, extra cost of provisions, waste or theft. How to reconcile these figures with the testimony as to the quantity and quality of the food furnished to patients, we do not know. The actual fare provided upon the wards was as follows: Breakfast, coffee, corn or oat meal mush, stewed prunes or dried apples, and bread, with or without butter, but generally without; Dinner, soup (consisting of the liquor in which the meat was boiled, thickened with rice, barley or vegetables), boiled meats, beans or hominy, vegetables in their season, and bread; Supper, tea, bread and butter, and some- times a hash of the meat left from dinner. Commissioner Klehm con- sidered that the fare was too meagre, that the supper especially was not sufficient, that the only full meal given was dinner, and that there was a lack of vegetables, to which he drew the attention of the warden and of the chairman of the committee. Dr. Alexander said that per- sons in ordinary health might have supported life on the food given, but that it was poorly cooked, and, for insane people, unwholesome and insufficent in nutritive value,. Dr. Kiernan had the same medical opinion of it, and made persistent but ineffectual efforts to have a diet list established, more in conformity with what it should have been. Commissioner Wasserman moved, in committee, on the 12th of Dec- ember, 1884, that the list proposed by Dr. Kiernan be adopted, and the warden instructed to see that it be conformed to by the cook; the motion carried, but nothing came of it. As to the quality of food' the 9 bread was undoubtedly good; the coffee, in the opinion of Commis- sioner Ochs, was not bad, but "light"—one witness swore that it was difficult to distinguish the tea and coffee apart, and another that it was sweetened in the kitchen, and she sometimes could not tell whether there was sugar in it or not; the milk was pronounced to be inferior, on all hands, and when tested by Dr. Clevenger, it exhibited ah inferior specific gravity and an acid re-action; there was often a dearth of fresh vegetables, even of potatoes, in consequence of which there was more than one epidemic of scurvy, of which we will speak presently; the meat certainly was not what it should have been. The cooking, we are convinced, was bad ; the cook, Mr. Edward Anstead, swore that the facilities for cooking, for the number of patients fed, are wholly insuf- ficient ; and this opinion was confirmed by the engineer, as well as by our own inspection of the kitchen. It is not possible to serve anything but a boiled dinner, which, in Mr. Anstead's quaint language, is not properly cooked, but "coddled." The service was also bad; there was a failure to distribute the food properly, so that some wards received too much, and others not enough; the table furniture generally is un- inviting ; in many of the wards tin plates and cups are used, and the ladies of the Women's Club who appeared before us had repeatedly seen them when they were black and dirty; the conduct of the patients at their meals was disorderly; the attendants do not eat with them, but in the officers' dining-room in the centre building. A great deal of evidence was submitted on the subject of pigs' heads as an article of diet. It seems that meat is furnished, under a contract, by a butcher named Bipper, on State street; his bills for 1884 (for the hospital only—he also supplies the infirmary) were $15,763.04, and for 1885 they were $18,934.11. His bills on file contain items for hog's heads, which are charged and were paid for, at nine cents a pound —the price of good pork. Mr. Anstead, the cook, testified that he had never seen joints of pork brought in for the patients, and when asked in what condition the heads were when brought to the kitchen, replied, emphatically, "brought into the kitchen a disgrace to the butcher who sent them." Being asked to explain his meaning more fully, he said that the hair had not been properly scraped, when scalded, and that it was imbedded in the skin, so that it could not be removed by the knife nor by fire. Various persons testified to the condition of these heads when they came upon the table. Dr. Alex- ander said that they never were inviting—the bristles were very long. Dr. Howe mentioned having seen black dirt on the ears, which the cooks had not succeeded in boiling off. One day in June, 1884, a patient, Mrs. Wilker, found in her plate a snout with an iron ring in it, which led to an investigation by the committee, and the snout and ring were exhibited to Commissioners Lynn and Van Pelt, in the warden's parlor. Commissioner Van Pelt directed the discharge of Mr. Covey, the cook, but his order was disregarded. Scurvy. The lack of fruit and fresh vegetables in the latter part of the winter and early spring led to a serious epidemic of scurvy, which lasted from February, 1885, until June or July. According to the evidence of Dr. Koller, who left in November, 1884, and had seen about a dozen case3 of scurvy in the course of two or three months, we should judge that there was at all times a scorbutic tendency among the patients. 10 Dr. Alexander had about fifty well-marked cases. Dr. Kiernan esti- mated the entire number at two hundred. He thought that all of them were permanently injured by it, and that several died from its indirect influence; in one case, he entered "scurvy" as the cause of death. To combat it, he ordered lemons in large quantities and sent lemonade to the wards ; the books show 82 boxes purchased, at a cost of $464. There had been scurvy the year before, under Dr. Spray, as sworn to by both Dr. Clevenger and Dr. Howe. Dr. Clevenger said that he was satisfied that patients died from innutrition, owing partly to their own indisposition to take food and the neglect of attendants to feed them. Dietary. The Reform Committee of the Women's Club, of which Mrs. Helen S. Shedd is chairman, has taken a great interest in the county insane, and, at its instance, the warden did, in June, 1885, adopt a special diet-list for the sick and infirm; and it succeeded in having a hospital ward established, in which a gas-stove and an ice-chest were placed, and this ward was made, in various ways, more comfortable and attractive than the other wards. Since the return of Dr. Spray to the superintendency, a general diet-list has been printed and copies of it hang upon the walls of all dining rooms in the wards, throughout the institution; it is an improvement, but it can not be what it ought to be, so long as all the meat supplied to patients has to be boiled, as is the case at present. Ciothiny and Beddiny. In the matter of clothing and bedding, we are again compelled to re- fer to the State institutions as a standard of comparison. The amount expended by the four State hospitals for the insane, for dry goods of all sorts, in 1884, was $30,194.42, or $13.44 per capita ; in 1885, it was $39,834.34, or $13.63 per capita. The amount expended, in 1884, by the Cook county hospital for the insane, for the same purpose, was $12,503.61, or $21.12; in 1885, after deducting cost of clothing furnished, from the infirmary,to laborers employed in excavation for the new building, it was $15,507.71, or $27.30 per capita, which was just double the amount paid by the State hospitals. Part of this excess of cost may possibly be accounted for by the larger number of patients, relatively, in the State institutions, who receive clothing directly from their friends; how this may be we are not prepared to say, though we do not believe that in any event it fully explains it. But an exam- ination of the items contained in the bills on file at the county institu- tion reveals the fact that, notwithstanding the high per capita cost of clothing and bedding there, certain items, which we would expect to find, do not appear upon the bills at all; for instance, collars and neck-ties for the men, corsets for the women, handkerchiefs, ready- made underclothing, woolen dress-goods, and woolen shirts and drawers. On turning to see how much flannel was bought, for winter use, we discover that the entire purchase, in two years, was only 1,410 yards, namely, 770 yards in 1884, and 640 yards in 1885, or an average amount of less than one and a quarter yards a year, for each patient. Even without the testimony of witnesses to the fact, it must be appar- ent that the patients were so thinly clad in winter as to prevent their taking any exercise in the open air, and to occasion great suffering 11 inside the house, whenever, for any reason, the supply of heat was inadequate. It was in evidence that, before the introduction of direct radiation, in 1884, it was impossible to heat the building properly; and, even after that improvement, the thermometer, on some of the wards, has been, at times, as low as 55° Fahrenheit; the heating is unequal, being sometimes insufficient and at other times excessive; and the engineer stated that there are four rooms in the west wing into which it is impossible to force hot air. If, as seems probable, the tempera- ture is lower through the night than by day, the question of bedding becomes important. Straw beds are the rule, hair mattresses the ex- ception ; and one witness remarked that the hair mattresses now in use are to. be replaced by straw beds. Great difficulty has been experienced in the past in obtaining straw, and hay has sometimes been used instead. We take it for granted that, under these circum- stances, the straw can not have been renewed as often as desirable. The number of pairs of blankets bought, in 1884, was 500; in 1885, it was 396; or about four pairs, during the two years, to every three patients. Considering the destructive habits of the insane, and the want of a sufficient stock on hand, this was a scant allowance; it should have been at least one pair a year to each patient. The number of quilts purchased, during the two years, wras only 178. We can readily believe the statement of Dr. Howe, that she took the cover- ing from her own bed and gave it to some patients who were suffering, and covered herself with shawls and blankets of her own. As to towels, we think it clearly proved that the supply was inadequate. The intimate connection between insanity and phthisis is well known; the existence of a tendency in the insane to pulmonary diseases may be suspected in advance, and its occurrence should be guarded against by proper precautions, of which an ample supply of clothing is one of the most important. Ventilation. Reference has been made to the heating; it should be added, that the engineer condemns the system of ventilation, and declares that it is absolutely impossible to ventilate the building as constructed,. Furniture. That there was a deficiency of suitable furniture in the wards appears from the testimony of Dr. Spray and others. There are no pianos on the women's side, nor billiard-tables for the men ; no carriage in which to take patients out in the open air; few pictures; no books; and Dr. Howe, Mrs. Shedd and Dr. Florence Hunt testified to the absence of a sufficient number of seats, so that in the demented wards the insane women were compelled to sit or lie upon the floor. Administration of Medicines. The system of admistering medicines in hse under Dr. Spray was, in our judgment, objectionable. The usual practice in hospitals for the insane is to have the doses for individual patients put up by the druggist, in medicine glasses, marked with the patient's names for whom they are intended, and to require the attendants from the sev- eral wards, at stated hours each day, to come to the drug-room for the 12 ward-trays in which these glasses are carried, and after the adminis- tration of the remedies, the empty glasses are returned to the drug- room. Prior to September 1, 1884, Dr. Spray's plan was to have a medicine-closet in each ward, and to send up from the drug-room bot- tles marked with the names of the patients, on which directions as to the quantity and, possibly, the frequency of the dose were written, for the instruction of attendants. Certain remedies, such as whiskey and a sedative mixture containing bromide of potash, cannabis mdica, choral-hydrate and fluid extract of hops, were sent up in larger bottles marked "for ward use," and a certain amount of latitude seems to have been allowed to the attendants in their administration, or, if not allowed, sometimes exercised by them. Dr. Howe saw attendants hir- ing patients to do work by promising them a dose of sleeping medicine as a reward. Dr. Kiernan changed the system, but it has now been restored in part; that is, there are medicine-closets on the wards, but trained nurses have been employed to administer the remedies, instead of leaving their administration to the discretion of attendants. There are two such nurses on the pay roll, both of them women, who serve on the male as well as on the female side of the house. If the bills for drugs purchased are a test of the amount of sedative medicine administered, there can have been little difference in this re- gard, between the practice of Dr. Spray and that of Dr. Kiernan. In 1884, the institution paid $209.30 for chloral-hydrate and bromo-chlo- ral, for example, and in 1885, for the same drugs, $177.46. While we are speaking of the drug bills, it may be mentioned that the amount paid for tobacco, under Dr. Spray, in one year, was $607.92, under Mr. Varnell it was $1,471.48. Restraint and Abuse. We made special inquiry as to the use of restraint and the abuse of patients by attendants. Insane people are, from the nature of their malady, unreasonable, and often exacting and irritating, sometimes dangerous ; attendants often feel a contempt for them, especially if they belong to the pauper class ; and we may assume, that, in an institu- tion like that at Dunning, there will always be more or less unkind- ness on the part of certain attendants, which will be heightened, if the discipline is lax. A large part of the duty of every physician of an insane hospital consists in watching the attendants, weeding out the incompetent and unfaithful among them, and supplying their places with new ones. If the physician has not the power of appointment and discharge, his authority is weakened, and the strength of his purpose to protect the patients under his care is of necessity impaired, since he has not the ability to do so. We did not think, from the evidence, that there was an undue disposition on the part of either Dr. Spray or Dr. Kiernan to resort to mechanical restraints, as a means of deal- ing with refractory patients, though perhaps too much discretion was allowed to attendants in its application. Without facilities for exercise in the open air, through the winter, and with little or no occupation in the house, and few if any means of recreation and diversion, it ap- pears to us, that the occasions for the employment of restraint and se- clusion must have been more 'frequent than they otherwise would have been. 13 Not many instances of positive abuse were brought to our notice; though*the attendants were sometimes very rough, as in the case of a patient named Herzberg, who was, however, dangerous, and had the keys of the ward in his posession at the time of the difficulty with him. Dr. Koller once saw an attendant strike a patient in the face, because he would not go to dinner. Mrs. Wilker, a former pa- tient, saw a female attendant kneel on a patient's stomach and try to pour a dose of medicine down her throat; at another time she saw an attendant slap a patient, who had on a straight-jacket, in the face, because she persisted in calling for Dr. Spray; sue also saw an attend- ant pull a patient out of the dining-room by the hair, slap her and strap her to a bench, for breaking a plate. A Mr. Hughes, who ap- peared to be a very respectable mechanic, testified that he had been employed to oversee the demolition of the old poorhouse, and that he had a room in the hospital and had opportunity to observe the treat- ment of the patients there, as well as on the outside, when at work. It was a common thing for the attendants to threaten patients who would not work, with the straight-jacket. On one occasion a patient at work with Mr Hughes complained of being ill, and was continually going for water. The attendant said to him, "Come, Jack, if you won't work, I will put the jacket on you." "I can't work." "Well, I will put the jacket on you." "Well, I'll take it, sooner than work." "Come with me." They went into the ward together, and Mr. Hughes follow- ed after them, in a few minutes, when he saw Jack with the jacket on. The next day Jack came out again to work, but was unable to do so. The third day he staid in the house ; and the fourth day he was dead. The clinical clerk informed Mr. Hughes, in answer to his inquiries, that he had died of typhoid fever. We think that instances of neglect, arising from indifference or incompetence on the part of attendants, were more common than actual abuse. Mr. Anstead, in his examina- tion, admitted that there were times, in hot weather, when the meat "might have been a little sweeter." Mr. Hughes observed it one day, when its appearance led him to ask the butcher, "What do you do with that?" "That's for the cranks." "In the name of goodness, you don't cook that for them ?" "Oh, that's good," he replied, "they don't know the difference." Dr. Howe said that she had often seen patients seated at the table for their meals in a straight-jacket. One she saw, jacketed, with a por- tion of her food before her, eating it as a dog would. She spoke to the attendant about it, and the attendant replied, "she always does so; even if she was not jacketed she would not eat any other way." But that very patient was afterward taught to eat differently. Several patients in a detached ward had varicose ulcers, and through the neglect of the attendants, maggots bred in the sores. On the same ward, one of the attendants administered iodine internally by mistake. Requisitions. We learned, from the testimony submitted, that the officers of the hospital, when any article is needed, have to file a requisition for it with the committee on public charities, and that such requisitions are not always honored; and, when granted, there is sometimes considera- ble delay in procuring the articles required. Dr. Kiernan asked for 300 overcoats and 300 shawls; the recollection of the committee was 14 that they had allowed him 100 or 150; but the bills paid show that the actual number furnished of each was fifty. He wanted fine combs, and could not get them; nor could he procure fresh vegetables. This sys- tem has three injurious consequences in practice. If the requisitions of the medical officer are not complied with, he becomes discouraged and will not ask for what is really needed. If they are granted, since he has no personal responsibility for the financial management, he is tempted to become extravagant in his demands, and the cost of main- tenance is increased. In an emergency, which may often arise, and should be promptly met, the comfort of the patients has to wait on the convenience of a committee, which may not meet for some time, or may fail to act, when it meets, or may have to submit the whole ques- tion to the county board. It would be better to give the superintend- ent power to make purchases, when needed, and to restrict him in the total amount to be expended by him, which would make him careful to use all due economy, without subjecting the inmates to liability to suffering, on account of any error of judgment on the part of the coun- ty board or its committee of charities. Reform is Necessary. lu what we have said, we have endeavored to present, in the briefest possible way, an abstract or summary of what appear to us to have been the most important parts of the testimony. We have omitted some minor details, and have not thought it necessary to quote the opinions of employees or friends of patients who were satisfied with the existing condition of affairs. Very little of what we have quoted was denied; we have brought into the narrative very little which was matter of controversy. If the picture is a dark one, we can not help it; the only way to make it light would have been to suppress the evi- dence. We do not attribute deliberate or wilful unkindness to any of the county commissioners or of the officers or employees of the hospital. Whatever want of consideration and care was manifest was due, first, to the want of knowledge, and then to the want of efficient organi- zation. We are aware that in any investigation of this character, the worst side of the case is brought into full relief, under a strong light, while the better side remains in shadow, and that the public may con- clude that the condition of the patients was worse, upon the average, than it really was. But the necessity for a thorough reform in the present methods of caring for them is beyond dispute, and we com- mend the courage and fidelity of the witnesses who have dared to speak plainly of the wrongs which have come under their observation. With the question of their motives we have no concern; their motives may fairly be presumed to have been not unworthy, and do not change the facts, which the public is desirous to know, and can not ascertain by casual visits to an institution of such magnitude, remote from observa- tion. The only security of any institution from scandal lies in the utmost possible publicity. We are glad, if, by this investigation, the truth has in any measure been brought to light, since we have con- fidence in the power of the truth to correct every error and right every wrong. 15 ^ II. The Cause—Faulty Organization. It remains to speak of the remedy for the evils complained of. To tma this we must first search out the cause, in order that it may be, if possible, removed. It is impossible to affix or apportion to indi- viduals the blame of any irregularities or defects which may exist. Ine entire system of organization and control is at fault. With the present system m force, no other result can rationally be expected. Under that system, there can be no adequate personal responsibility, tor there is no responsibility where there is no power. The power which should be concentrated in a single, responsible head, is scatter- wv. .dl¥used' untl1 ]t 1S no longer possible to trace its ramifications. Where is it ? It is not in the medical officer, for he can make neither appointments nor purchases. It is not in the warden, for he, though he can appoint and discharge employees, has no control of the finan- cial management, further than as a steward in charge of the stores and other property. The committee of public charities holds in its own hands that power of the purse, which is greater than the power of the sword. The full board of county commissioners retains the right to elect officers, whom, by such election, it makes virtually, though not nominally, independent of each other. Said the engineer: "It takes as many votes in the board to make an engineer as a warden or a physician. I have read and know enough of life to know, or at least think, that one of these institutions ought to be exclusively in the hands of one man. I do not assume that the engineer should be a bigger man than anybody else, but only that, in the present instance, the engineer is as good as anybody else ; he is elected, and on a per- fect equality with everybody in the building." The druggist, when asked who appointed him, replied: "Commissioner Wren ;" and in reply to the question, what he would do if discharged by the warden, said: "I would see Commissioner Wren." The county board is, of course, a political body; it is elected by popular vote, and it is only natural to conclude that the positions within its gift will be bestowed in part with a view to the political effect of such appointments upon the persona!fortunes of the commissioners. How can it be otherwise ? It is equally natural' to suppose that those who have successfully labored to secure an election by the board will be more or less sub- servient to the wishes of the commissioners, in making subordinate ap- pointments. A striking illustration of this was afforded in the case of Mrs. Phillips, formerly supervisoress in the institution, who shed tears when asked to tell the reason of her discharge, but swore that Mr. Varnell called her into the parlor, to speak to her in private, when he said: "I would rather part with my right arm, than tell you what I have got to say to you. I shall have to ask you for your resig- nation. You have fulfilled your duty here in every respect. There is no cause for your dismissal, but you are not popular—the simple fact is, you are too much of a lady to be here. It is either you or me ; you will have to go, or I will have to go. You are not popular with the commissioners; they do not know you, and the plain truth of the business is, you are not in the ring." We have never had faith in the ability of any county board to care properly for the insane—certainly not without State supervision—and we wonder that legislatures will devolve upon them a responsibility for whose discharge their very con- stitution unfits them, rather than make the necessary provision for the care of all the insane by the State itself. 16 The county board, it is true, after electing as many officers as it may think expedient, turns the management of the asylum ove^ to a committee; but the relations of this committee are very different from those of a board of trustees, since the members of the committee which has to account for the management, are also members of the board to which the committee must account. As commissioners, they necessarily form a part of every combination, political or otherwise, in the larger body to which they belong, and their action as trustees or committeemen is controlled by the exigencies which grow out of such combinations, rather than by a disinterested regard for the welfare of the inmates of the institution of which they have charge. What powers they do possess, should, under the law, be exercised by the committee as a unit, and their acts should be made a matter of record; but they have no secretary, keep no records, and each mem- ber of the committee assumes, or may assume, to exercise, individual- ly, the power which in fact is vested only in the full committee, regu- larly convened. The county board is, as was well remarked by Commissioner Ochs, a changing body; it has no opportunity to inform itself as to the nature of insanity, the needs of the insane, the princi- ples of organization, or the practical methods of work best adapted to the successful management of a public institution; experience has demonstrated that it does not even know what a public institution ought to cost for maintenance, nor how the items of expenditure should be apportioned. The folly of substituting, for a single executive head, the present divided authority, is best shown by the financial result, which will be clear to every business man, from the simple statement that, under Dr- Spray, in 1884, the cost of maintaining 592 patients, exclusive of moneys spent for machinery, building and repairs, was sll7,611 53 or $198 66 per head ; under Warden Varnell and Dr. Kiernan, in 1885, with 568 patients, it was $153,500.55, or $270.39 per head, an increase of over 36 per cent. Excluding the same items, the per capita cost of the State hospitals was $181.37, in 1884, and $174.20 in 18d5. The following tabular statement will make clear the main points of comparison of cost between the State hospitals and the county hospi- tal for the insane, in the past two years. Moneys paid for building, machinery, improvements and repairs are not included in it. The figures given are per capita. It will be observed that the State has more to pay for freight, etc., and for farm and garden expenses, than the county. The item for food in the county hospital would be larger than it is, were it not that all the flour bought both for the hospital and infirmary is delivered to the hospital and there baked, when the bread required for the use of the infirmary is sent over and charged to it, at a price sufficient to cover not only the original cost of the flour but also the estimated cost of baking it. Item. Attendance.......... Food............;....... Clothing, bedding, etc . ... Laundry supplies........ Fuel.................... Light.................... Medicine, etc............ Freight and transportation Household expenses....... Furniture................ Farm, garden, stock, etc.. . All other expenses........ Total There seems to have been no increased comfort proportionate to the increased cost; if the condition of the patients was in some respects improved by the change, in others, notably in the character of the discipline, there was a deterioration, due to the division of authority in question. We repeat the remark which we have already made, in substance, that the investigation by this board had no relation to the personal differences between Drs. Spray and Kiernan, and that very little testimony was offered, relating to Dr. Spray's term of office. The results arrived at by us were mainly the results of the double- headed management, in Dr. Kiernan's time; and it was an- extra- ordinary sight, to witness his willingness, at the risk of censure which might be visited upon him personally, to reveal the defects and failures of his own administration. We give him credit for both courage and public spirit in the course pursued by him. III. The Remedy. The remedy suggested by some of the county commissioners, upon the stand and in private conversation, is to place the institution out of their hands and in charge of the State. Transfer to the State. This would be a remedy, but it is, in our judgment, impracticable. There was, perhaps, a time when this might have been done, but it was before the erection of the new infirmary building. In our report for 1877-78, we said: "The State, for a series of years, tried the experi- ment of divided responsibility, and was forced, as the county of Cook will be forced sooner or later to do, to abandon it forever." We advised the building of a new almshouse in some other portion of the county, thus completely separating the almshouse and the insane asylum. Part of our advice was taken, and part rejected. The county authori- ties subsequently endeavored to sell the institution to the State; had —2 17 State, 1884. $66 73 56 24 13 44 1 29 14 16 3 67 2 68, 9 41; 1 86 4 01 6 34 1 54' $181 37! Spray. $55 14 68 74 21 12 3 62 22 51 2 79 6 50 27, 1 70 5 70 1 13 9 44 State, 1885. $62 38 52 65 13 63 1 04 14 72 3 21 2 77 6 76 1 72 3 85: 6 48 5 00 $174 21 Varnell and Kiernan. $69 82 94 84 27 30 4 76 31 35 2 69 12 84 3 51 3 16 11 95 2 92 5 25 $270 39 18 they offered it as a gift, we do not know whether or not it would have been accepted by the legislature. The building is poorly planned and constructed; to bring it to the grade of our State institutions, would require the outlay of a large sum of money. The proximity of the poorhouse is a fatal objection to this scheme. It would be difficult, if not impossible, to infuse into the organization the spirit which per- vades the State institutions. Even if there were no other evils likely to ensue from the previous close relations of the two establishments, there is not land enough connected with the infirmary for the use of the hospital alone, and more land could not be bought in that neighborhood at .a reasonable price. In our judgment, if the State wrere to undertake to relieve Cook county of the burden, it would, in the end be cheaper, and assuredly it would in every way be far better, to build up a new institution from the foundation, in some other por- tion of the State, presumably in the northwest. Under any circumstances, what is demanded is an immediate, not a remote and contingent remedy. We are not sanguine that our suggestions will be adopted by the county board; yet we think it our duty to offer them, for its considera- tion. An Independent Board of Trustees. The hospital, under the present system, is costing for its support, from one-third to one-half more than it should. Two hundred dollars per patient per annum, would be a liberal allowance for the proper care of an institution with an average population of six hundred * patients, which would be $120,000 annually, instead of its costing $150,000 as it did in 1885, with inferior care. If the board would do as the State does, make an appropriation of this amount, payable quarterly in advance, put it in the hands of trustees—not membeis of the board, but to be selected from among the best citizens of Chicago, of business experience and of known integrity, competent and humane, to serve without compensation—and give these trustees absolute con- trol over the expenditure of the fund thus created, with power to appoint the medical superinttndent, the annual cost would not exceed the figure which we have named, and an improvement in the condition of the inmates would be immediately visible. This is what we would advise as the best thing which the board can do; but we fancy that it is scarcely prepared for so radical a change of policy. A Single Executive Head. Our next suggestion would be, that the board should make this ap- propriation, and give to the committee on public charities the control of the funds, but only in the same sense and to the same extent that such control would be exercised by the trustees of a state institution. The committee should have power to make rules and regulations for the government of the institution; to appoint a single executive head, who should be a medical man ; and to audit his accounts, and observe and report upon his official conduct as superintendent. This should be the limit of the powers vested in the committee. All executive power should be vested in the superintendent, who should be required to appoint and discharge every subordinate officer and employee, to 19 make all needed purchases at his own discretion, and to administer the affairs of the institution. All power retained and exercised by the board relieves the committee from responsibility; all power retained and exercised by the committee relieves the superintendent from re- sponsibility. The responsibility should rest upon him alone, unshared with any other person above or below him; then he can be held to a strict account for whatever happens or is left undone ; in order to do this he must have power. If he is not fit to be trusted with it, he is unfit for his place. The chronic trouble with this institution has been the want of power in the superintendent. The attempt to cure that difficulty by still further depriving him of power has failed. If, now, the board will take the opposite course, and confer upon him un- limited power, subject, only, to be discharged from his position if he should prove unequal to the task assigned him, the practical wisdom of our counsel will speedily be apparent. There is no other remedy. Beyond this he must also be sustained in the lawful exercise of his power. The reason why a medical man should be at the head of this hospital, rather than a business man, is, that in a medical institution every question to be decided has a medical bearing, which a non-medical man may not perceive, and the final word on every subject should be spoken by the physician, from which there should be no appeal. There are physicians of experience, good judgment and business capacity, to be had for a sufficient salary; and the county can afford to pay the highest salary for the services of such a man. Other Suggestions. We offer the following additional suggestions, for the consideration of the county board : (1) The protection of the building, and consequently, of the lives of the inmates, against the perils of fire, is not sufficient, and ad- ditional safe-guards should be provided. (2) We would advise the board to secure the services of a sanitary engineer of established reputation for skill and experience, and have a thorough sanitary inspection made of the premises, with a view to improving the heating, ventilation, plumbing and drainage. (3) In our opinion, the first necessity of the institution is a spacious, airy kitchen, with every approved facility for the preparation of food, so as to make it palatable, and to secure greater variety in the diet. (-4) Much of the furniture in the wards should be renewed and ex- tensive additions made to it. There ought to be pictures on the wards; a billiard table in the convalescent ward on the male side; and one or two good pianos or cabinet organs in the best female wards. The beds and bedding should be of better quality, and for patients not filthy in their habits, it would be economy to purchase woven-wire and hair mattresses; the use of so much straw is objectionable, for a great variety of reasons. (5) The dark, forbidding aspect of the wards might be relieved by knocking out partitions and converting two of the single dormitories in front on each floor, in each wing, where needed, into alcoves, which would let in light and afford a cheerful day-room in each ward at slight expense. 20 (6) We recommend that the attendants be required to take their meals on the wards with the patients, instead of in the centre building, as at present. This is the universal rule in all well-regulated institu- tions, of which we have any knowledge, and the rule suggested would insure complaint, on their part, in case the food furnished to the patients should at any time prove to be insufficient in quantity or of an inferior quality or improperly cooked and served. Food which is not good enough for an attendant is not good enough for a patient. (7) All apparatus for physical restraint should, we think, be kept in the office of the physician, and not on the wards ; and attendants should be required to come to his office for it in every instance where it has to be applied, and secure his approval or permission before applying it. A refractory patient can be secluded, in an emergency, during the attendant's absence from the ward on this errand. (8) In case of the appointment of a lady physician, the salary paid her, the provision made for her comfort, and the support given her, should be such as to command for her the respect and obedience of the female employees and patients, and she should not be subjected tb the humiliation of being mistaken for a head nurse, but should be on an equality in every respect with the male assistant physician. (9) We think that a library of books suited to general readers should be provided for the use of the patients. Legislation Needed. The necessity for a revision of the lunacy laws of this State has been pressed upon the attention of the legislature for a long series of years. They are defective in many particulars. We do not pro- pose here to discuss them, further than to remark that, under a strict construction of the statute, it might be a question whether power has been conferred upon the county court of any county to commit insane persons to the care of a county institution for the insane. The lan- guage of the law is: "Upon the return of the verdict, etc., it shall be the duty of the clerk of the court to make application to the superin- tendent of some one of the State hospitals for the insane." Four out of five of the patients at Dunning are sent there directly from the county court. In the chapter on counties, power is granted to the county boards "to cause to be erected, or otherwise provided, suitable buldings for, and maintain, a county insane asylum, and provide for the management of the same." But the presumption is, that the legislature had in mind, when this power was conferred, the care of the chronic insane discharged from the State hospitals, to which it intended that all acute or recent cases should, in the first instance, be sent. If, as we are informed, application for the admission of recent cases is made to a State hospital, and admission of the patient refused, on the ground of want of room, or for any other reason, either the spirit of the law is not complied with, or it should be so amended as to prevent the possibility of such an occurrence. It must be evident, we think, that if county boards are to be allowed to own and man- age institutions for the insane, some additional legislation is necessary, in order to secure, on behalf of the inmates, independence and stability in the medical staff, and a more effective oversight and control on the part of the State. 21 The conduct of this investigation also revealed the necessity of fur- ther legislation as to the powers of the State commissioners of public- charities. The act creating the board recites that "the said commis- sioners, or any one of them, are hereby authorized to administer oaths, and examine any person or persons in relation to any matters con- nected with the inquiries authorized by this act;" but it does not make provision for the issue of subpoenas or of compulsory process in case of neglect or refusal on the part of any witness summoned to appear and give testimony. The expense of this investigation has been very considerable, and is not covered by our appropriation. We presume that the language of the twelfth section of the act is sufficiently explicit: "Any actual out- lay for any actual aid and assistance required in examinations and investigations, on being made out and verified by the affidavit of the commissioners making the charge, and approved by the governor. shall be paid by the treasurer, on the warrant of the auditor of public accounts, out of any moneys in the treasury not otherwise appro- priated." We supposed, without examining the law, that the evidence in this investigation would be printed in full, and that the governor had power to order its publication. We are informed that there is no law under which it is possible to print it. Acknowledgments. In conclusion, we desire to acknowledge the courtesy with which we were treated by the county commissioners and the officers of the asy- lum, who placed at our disposal every possible facility for the fullest and freest examination of the accounts and management of the insti- tution; also to the county attorney, for his presence and assistance; and to the Citizens' Association, the Chicago Medical Society and the Women's Club, for their presence and co-operation in the investigation. Mr. Beach represented the Citizens' Association and rendered us valu- able aid. We have the honor to be, Very respectfully, Your obedient servants, W. A. Grimshaw, President, J. C. Corhus, M. D., John M. Gould, Charles G. Trusdell, F. B. Haller, M. D., Fred H. Wines, Secretary. Commissioners. Springfield, Illinois, January 28, 1886. —3