Reprinted from The Journal of Nervous and Mental Disease, November, 1597. 
Report of the Committee of the American 
Neurological Association on 
THE AFTER-CARE OF THE INSANE. 
HENRY R. STEDMAN, 
CHAS. L. DANA, 
F. X. DERCUM, 
Committee. 
Submitted on May sth, 1897, at the 23d Annual Meeting of the 
Association. Reprinted from The Journal of Nervous and Mental Disease, November, 1897. 
Report of the Committee of the American 
Neurological Association on 
THE AFTER-CARE OF THE INSANE. 
HENRY R. STEDMAN, 
CHAS. L. DANA, 
F. X. DERCUM, 
Committee. 
Submit ted on May sth, fSgj, at the 2jd Annual Meeting of the 
dissociation. REPORT OF THE COMMITTEE OF THE AMERICAN 
NEUROLOGICAL ASSOCIATION UPON THE 
AFTER-CARE OF THE INSANE. 
This Committee was appointed upon the motion of Dr, 
C. L. Dana, of New York, at the meeting- of this Association 
which was held in Washington, at the time of the last (1894) 
Congress of American Physicians and Surgeons. It wras the 
outcome of a paper which was read and discussed at that meet- 
ing on the management of convalescence and the after-care 
of the insane.1 
The work of the Committee was begun by issuing a circu- 
lar letter to certain prominent alienists and neurologists in the 
States of Massachusetts, New York and Pennsylvania. This 
number was afterwards increased in order to ascertain the 
sentiment of authorities on the subject in other parts of the 
country. 
The letter ran as follows 
My dear Doctor;— 
At a meeting of the American Neurological Association, 
held at the last Congress of Physicians and Surgeons in Wash- 
ington, in 1894, a Committee on the After-care of the Insane, 
consisting of Dr. H. R. Stedman, of Boston; Dr. C. L. Dana, 
of New York; and Dr. F. X. Dercum, of Philadelphia, was 
appointed. Its purpose is to investigate and to report to the 
Association upon some feasible plan for the aid and supervision 
during the first month or two after their return from asylums 
to public life, of discharged pauper insane patients, who are 
recovered or improved. 
Asylum physicians often hesitate, you are aware, to set at 
liberty certain patients whose condition seems to have so far 
improved as to make it useless to keep them longer under 
treatment, for fear that, thus thrown suddenly upon their own 
resources without oversight or perhaps means of support, they 
will fall back into the old habits of life which gave rise to their 
insanity. This applies also to patients who have recovered. 
These unfortunates are also distrusted and prevented from ob- 
taining employment, simply because they have been inmates 
of an asylum. 
These considerations led, in France, to the founding by Dr. 
journal of Nervous and Mental Disease, Dec., 1894. 2 
THE AFTER-CARE OF THE INSANE. 
Falret, in 1841, of an association for providing protection,, 
assistance and homes for this class. It was, however, restricted 
to the department of the Seine. Its efficient operation has led 
to the recent establishment throughout that country, under the 
auspices of the French government, of sueieth de patronage 
(aid societies) for such discharged patients. Similar systems 
are in operation in England and Switzerland. 
The office of an after-care society is to find for such dis- 
charged patients, according to their individual needs, suitable 
homes and places of employment; to provide gifts of moneyy 
clothing or tools.; to redeem articles in pawn; to advance pay- 
ment for rent, etc., etc., and finally to have them under super- 
vision for the first month or two after their discharge. 
We are of the opinion that the same need exists in this coun- 
try, and that the work within our institutions for the insane 
should be supplemented by the same measures of outdoor re- 
lief on their discharge that have proved, advantageous else- 
where. As this is an undertaking which has for its object the 
diminution of insanity by delaying or possibly preventing re- 
lapses, it seems to be called for both in the interest of human- 
ity and of public economy. 
The Committee would value your opinion on the subject and 
respectfully asks replies to the enclosed questions; 
I. What are your views as to the practical utility of such an 
undertaking, generally speaking? 
11. In your opinion should such an association be entirely a 
private charity, or would the co-operation of the State in its 
work be practicable? 
111. Do you think it probable that benefit to a sufficient 
number of patients would result from the establishment of 
convalescent homes as departments of, but at a distance from 
our State hospitals for the insane? This inquiry is suggested 
by the proved usefulness of convalescent homes as adjuncts to 
general hospitals, and of summer cottages in connection with 
private institutions for the insane. 
IV. (For superintendents of hospitals for the insane). Will 
you kindly give a rough estimate of the probable number of pa- 
tients who have been discharged during the past year from 
the hospital under your charge, whom you would consider de- 
serving of, and likely to be benefited, by such a charity, men- 
tioning any special instances that may occur to you. 
Yours very truly, 
CHAS. L. DANA, 
F. X. DERCUM, 
HENRY R. STEDMAN, 
Committee. THE AFTER-CARE OF THE INSANE. 
3 
The result of this inquiry is as follows: Fifty replies were 
received; scarcely half a dozen.less than the number of letters 
sent; a remarkable showing for a circular letter. Thirty of 
these are from superintendents of hospitals for the insane. 
They are for the most part full and comprehensive and, as 
might be expected from the practical experience of the writers, 
throw much light on the question. Thirteen only are from neu- 
rologists, as, in view of the apparently unanimous sentiment at 
the meeting in favor of the general adoption of after-care pro- 
visions for the insane, it seemed unnecessary to extend the 
canvass further in this direction. The remaining six replies 
are from members of boards of lunacy and charity. 
Of the entire number of correspondents but six are either 
doubtful of the desirability and practicability of after-care 
associations for the dependent insane, or are decidedly op- 
posed to such a step. The reasons given by them are that the 
number of cases which are likely to be benefited by such aid is 
too small to make it advisable; that while such a project might 
be desirable, it is inexpedient; that while excellent in theory 
it would be impossible in practice, etc. By far the most forcible 
argument on this side of the question will be found in the ap 
pended letter of Dr. Thos. G. Morton, Chairman of the Com- 
mittee on Lunacy, of the Board of Lunacy and Charity of 
Pennsylvania. 
On the other hand, the overwhelming majority of forty-four 
in fifty (or forty-seven in fifty-three, if the Committee be in- 
cluded) express, and in not a few instances, in the strongest 
terms, their decided belief in the great advantages to result 
from properly organized and conducted aid societies of this 
kind for discharged insane patients who are recovered, con- 
valescent or improved. It is impossible within the limits of a 
committee report to give even a summary of the experience 
and arguments offered by these observers. The published re- 
plies, which are appended,2 must be read to adequately ap- 
preciate the strength of the sentiment in this direction. 
Regarding the number likely to be benefited in this way, 
the experience of superintendents of hospitals for the insane, 
as indicated in these replies, is not of much assistance, as 
the few who replied found it difficult to properly estimate the 
number of deserving patients. It would seem as though spe- 
cial inquiry of the individual patient when he leaves the hos- 
pital as to his circumstances and future surroundings is not 
customary in many institutions, although in some States he is 
provided with a sum of money or clothing. Fourteen only 
of those superintendents, who had charge of the class of pa- 
tients to whom such a charity would be applicable, answer this 
question. Of these, nine think that there were “many” ap- 
propriate cases among patients who had been discharged from 
* Hee Appendix. THE AFTER-CARE OF THE INSANE. 
4 
the hospitals with which they are or have been connected. 
Some of them say “great numbers” or “a great many,” and one 
“nearly all discharged.” Of the remaining five, three think 
that a few patients a year from each hospital might, perhaps, 
derive benefit from such an organization, while two think that 
no benefit at all would result. 
As to the auspices under which such associations should be 
conducted, it is the general opinion of both the alienists and 
neurologists that they should by all means be begun as private 
organizations, and so continued until their utility be demon- 
strated. If successful, State aid could probably then be ob- 
tained. 
In reply to the question regarding the advisability of estab- 
lishing State homes for convalescent patients as a part of the 
general policy of States toward their insane, there is more 
diversity of opinion but the same degree of interest and careful 
consideration of the subject. Scarcely a member of this Asso- 
ciation has written in opposition, and of twenty-nine hospital 
superintendents and other alienists nineteen were warmly in 
favor of such an accessory provision, five were doubtful of its 
expediency and five were decidedly opposed to the project. Of 
four members of lunacy and charity boards, one is in doubt 
as to its utility and the rest think it would be an unnecessary 
and useless experiment. 
As the result, therefore, of their inquiries on the subject of 
the after-care of the insane, your Committee reports the follow- 
ing conclusions: 
First. It is the general and well-nigh unanimous sentiment 
of those who are the most conversant with the needs of the 
insane in this country that measures should speedily be in- 
augurated for the temporary relief of discharged recovered 
convalescent and improved insane patients of the dependent 
class by organized outside assistance. 
Second. As a preliminary step, inquiry should be made of 
all such patients before they leave the hospital, regarding the 
mode of life, surroundings and occupation to which they are 
returning, and appropriate advice given by a medical officer 
of the hospital. This precautionary measure is, we believe, too 
often neglected in large institutions for the insane. 
Third. The legal provision, whereby an allowance of money 
and clothing is made in some States to each patient on his dis- 
charge, should be adopted by all. 
Fourth. Outside assistance can best be provided, we be- 
lieve, through the medium of an after-care association which,, 
until its utility be proven, should be entirely a private under- 
taking, and should be organized like most existing charitable 
associations depending upon voluntary contributions. Ob- 
viously, a large city offers the best field for starting and devel- 
oping such a system. THE AFTER-CARE OF THE INSANE. 
Fifth. The special methods of after-care relief by such an 
association should be those employed by similar organiza- 
tions in other countries: England, France, Switzerland, or a 
selection of the best methods of each; these may be modified 
later to meet special conditions. 
Such relief should, at first at least, be extended only to the 
class mentioned, and be understood as temporary, covering 
only the first month or two following the patient’s discharge. 
The work may be best done by associates or agents appointed 
for the purpose, who shall find suitable homes and situations 
lor all proper cases. There should also be systematic super- 
vision of the homes by agents for the time specified or until the 
patient seems to be under good conditions for taking up life 
and work again. This applies also to patients returning to 
bad surroundings in their own homes. Reports should be 
made and records kept of each case. 
Sixth. We believe it a duty that is especially incumbent 
upon this Association to take up in this way the work of the 
hospital physicians, and to see that the good accomplished in 
institutions be supplemented by proper outside supervision in 
appropriate cases; and we would urge its members to actively 
engage in the formation in their respective States, of relief as- 
sociations for the after-care of insane patients of this class on 
their discharge from hospitals, and to endeavor to enlist in the 
work of co-operation all friends of the insane so far as 
practicable. To facilitate this, your Committee would sug- 
gest that a brief compilation from all available sources of the 
methods employed by such organizations abroad, be author- 
ized and published by the Association for distribution to all 
who are interested in furthering this work. 
Seventh. Regarding State convalescent homes, there is 
abundant evidence of the most authoritative kind of the ad- 
vantages to follow from their establishment, but, in our opin- 
ion, the first reform in the order of precedence should be 
the general recognition of the necessity of separate hospital 
treatment of insanity in its early and active stage, and the ac- 
tual adoption of special provision for, the “acute” insane as an 
indispensable step in the hospital treatment of public insane 
patients. Only when this result is reached should separate 
establishments exclusively for convalescents be added to the 
already large burden of expense for our dependent insane. 
The Committee acknowledge with gratitude the assistance 
given them by the numerous and full replies to their circular 
letter. 
HENRY R. STEDMAN, 
C. L. DANA. 
F. X. DERCUM, 
Committee. APPENDIX. 
REPLIES TO THE CIRCULAR LETTER OF THE 
COMMITTEE OF THE AMERICAN NEUROLOG- 
ICAL ASSOCIATION UPON THE AFTERCARE 
OF THE INSANE. 
From Dr. H. E. Allison, Medical Superintendent of the Mat- 
teawan State Hospital (for Criminal Insane), New York, 
N. Y.; 
“I think the held is open for the operation of a large and 
wise charity in this direction of after-care for the insane; as by 
helping patients at a time when they most need help, many of 
them could be made independent and self-supporting. Such a 
plan of organized relief, if placed in competent hands, would 
do much to benefit and alleviate the condition of the individ- 
ual, and ultimately result in economy to the.State. 
“An after-care society would find a field for work that would 
be decidedly practical and helpful to discharged inmates of the 
class mentioned, namely, the friendless insane who are with- 
out money and seeking employment. Many such patients 
are anxious to secure positions in order to support themselves 
and have no means and no one to whom they can look for as- 
sistance. Assistance is extended to the criminal and should 
be to the insane. Charitable societies are formed and are in 
operation, whose purpose it is to aid such inmates of our penal 
institutions as may be released from custody. The State, by 
furnishing money, as well as other aids through official agents 
appointed for that purpose, recognizes this duty. It also pro- 
vides that the convict may retain a percentage of hL earnings 
in prison to be used towards the ultimate end of self-sup- 
port, and also endeavors to educate him and to teach him a 
trade, and often refuses to discharge the inmate until assur- 
ance is given that some position is waiting for him, to which 
he may go upon his release. Reformatories and prisons are ii 
APPENDIX. 
conducted upon this plan. The insane, who are also in a large 
measure dependent, should be equally protected until able to 
care for themselves. Reports to the reformatory and to the 
prison in certain cases are required to be made for a definite 
period until the paroled inmate has become self-supporting 
and established. 
“I believe the State should co-operate in providing for the 
after-care of its insane by charitable organizations for that pur- 
pose. 
“Regarding State homes, I think it probable that more good 
would come from furnishing to the patient, upon discharge, 
some individual home or place where he could enter the world 
again with the assurance of there being able to provide for 
himself. No doubt the convalescent home would benefit. 
Such adjuncts at present are useful in connection writh many 
hospitals for the insane. Detached cottages, summer homes, 
convalescent departments in the country are undoubtedly of 
great service, and contribute to the successful care of the in- 
sane. Several years ago at the Willard State Hospital a large 
farm house was occupied for one summer by women patients 
while several wards were undergoing extensive repairs, and 
the change effected surprisingly good results and contributed 
much to the health and comfort of the occupants. I believe 
in convalescent homes connected with hospitals for the insane 
as an adjunct to treatment, and they should be supplemented 
by out-patient relief. 
“Nearly all patients who are absolutely released from this 
institution require some assistance, and we endeavor so far 
as possible to ascertain their destination and prospects before 
discharging them from custody. Several men have been as- 
sisted by various charitable societies for a time, and afterwards 
have become self-supporting. We are in receipt of letters oc- 
casionally from such cases who struggle, and with temporary 
help succeed in getting on. Several patients have written to 
this hospital asking to be taken back, and have offered their 
gratuitous services for a home. One patient walked about 
seventy-five miles and asked for re-admission, saying he could 
not get work. He was furnished a position with a family in 
the neighborhood and remained^well, but ultimately became 
intemperate and has now drifted out of notice. Several have 
succeeded well in similar circumstances with a little aid from 
others. The criminal, the insane, and the insane criminal, all 
need help, support and intelligent direction until able to 
provide for themselves. Any effort to this end is a move in 
the right direction. APPENDIX. 
iii 
From Dr. J.B. Andrews, the late Superintendent of the Buffalo 
State Hospital, New York: 
“I am inclined to think that such an undertaking- for the 
after-care of the insane is one of practical utility. It would 
seem to me more practicable to have it as an adjunct to some 
private charity, which would not only find employment for, 
but also exercise supervision over, such discharged patients, 
and leave to the State the establishment of convalescent 
homes at a distance from the State hospitals. 
“I think it would be more practicable, at least until the work 
is established, that this work be done by private associa- 
tions; with provision that they have State financial aid in cer- 
tain cases, if necessary. 
“Yes; I believe that not only comfort and happiness, but 
recovery in some cases could be hastened or determined by 
the judicious use of State convalescent homes at a distance 
from the parent institution, where those patients who had 
reached a point where change, different occupation, interest, 
etc., would be beneficial, could be sent. 
“A rough estimate would place the number of patients who 
would be deserving, or likely to be benefited by such a charity 
[after-care associations], as about twenty out of the hundred 
and two recovered patients discharged from this hospital last 
year; most of them young men and women who needed friends, 
encouragement and employment.” 
From Dr. C. P. Bancroft, Medical Superintendent of the New 
Hampshire Asylum for the Insane; 
“In States where State care prevails, the State assuming the 
custody and support, as well as treatment of its patients, I 
should think that the after-care of the insane in the manner 
outlined in your letter would be of great practical utility. 
“In my opinion it would be preferable for the State to co- 
operate in this work, if not to assume the entire control of it. 
“I think it very probable also that benefit to a sufficient num- 
ber of patients would result from the establishment of convales- 
cent homes at a distance from our State hospitals. Such small 
establishments not only favor convalescence, but also furnish 
a very good test as to the mental capacity of the patient. The 
convalescent accommodations connected with this institution 
have enabled us oftentimes to demonstrate whether a person 
is able to be thrown upon his own responsibility, and one of 
the most valuable features of this system, as,practiced here, 
has been the preliminary test of the capacity of the patient 
for self-support outside of an institution. 
“ In the New Hampshire Asylum there are manv patients APPENDIX. 
who are, by the assistance of certain charitable funds, sup- 
ported by their relatives. Consequently, in the New Hamp- 
shire asylum there are many patients who are practically 
private, and have homes to go to when they are discharged, 
but out of the number of dismissals of public charges during 
the year there were at least as many as twenty-four patients 
who would have been materially benefited by such a charity. 
I think there is no question that in every year there would be 
a number of patients, who, if assisted in this way and not 
allowed to drift about unaided, might continue self-sustain- 
ing.” 
From Dr. H. M. Bannister, of Chicago: 
“I believe that the idea is an excellent one and that the plan, 
if carried out, will be of great benefit to such patients as have 
no homes or friends to go to on their discharge. 
“I believe there are some advantages in having any estab- 
lishments apart from the asylums as a private charity, as the 
French societes de patronage are, at least to a great ex- 
tent. The State, however, should provide, as is done in some, 
if not in all, a small sum of money to patients on their dis- 
charge, which might be put under the control of this society. It 
might be of advantage to have a fund for the temporary em- 
ployment, at small wages in the hospital, for a portion of the 
recovered, but friendless. 
“That is the plan that suggests itself to me as advantageous. 
As to a State convalescent home, I think it might be located to 
advantage in a city that supplies a large number of indigent 
patients to the hospital. It would be an advantage to have 
it for a home for the discharged patient while looking for 
employment, and it might be managed So as to supply some 
slight amount of remunerative work for a time, if this be 
thought best.” 
From Dr. G. Alder Blumer, Medical Superintendent of the 
Utica State Hospital, New York: 
“Everyone who is familiar with the history of the insane in 
Great Britain and knows what has been accomplished in that 
country by the intelligent initiative and tireless energy of the 
Rev. H. Hawkins, chaplain of Colonel Hatch Asylum, cannot 
question the practical utility of an after-care association for 
the United States. While it is no doubt less difficult for the 
discharged patient to procure employment in this country than 
in the crowded labor markets of Europe, all experienced alien- 
ists must recall cases where discharge might have occurred 
earlier if they had been able to occupy a middle ground of care APPENDIX. 
and shelter pending the renewal of bread-winning outside, un- 
der conditions most favorable to continuous health and in- 
dependence. New York State, however, has always treated 
her dependent insane humanely, and for many years there has 
been on the statute books a provision permitting—indeed re- 
quiring—the patient to be properly clothed on discharge and 
furnished with money ‘not exceeding $25.00/ to defray his 
immediate expenses until he shall ‘find employment to earn a 
subsistence.’ But it is not clothing and money alone that are 
required. The patient who has been clothed and fed and 
cared for by the State sometimes suffers by that bounty, is 
enervated by it, and shrinks, from a lack of self-confidence, 
both natural and thus acquired, from putting forth an effort 
in his own behalf. The patient, loath to leave the State hos- 
pital and face the world of stress and struggle, is by no means 
a rare phenomenon, and he is not necessarily a shiftless, lazy 
man. For him the association would be useful. Especially 
in the case of the friendless and homeless, and for the men 
who have an unfortunate taste for strong drink the beneficence 
of the scheme would make itself felt. 
“It should be entirely a private charity. The State already 
does all that can be reasonably expected of her in the treat- 
ment of the dependent insane. A little private philanthropy 
in their behalf might be encouraged with advantage. And 
would not the co-operation of the State in such a scheme es- 
tablish a dangerous precedent in so far as it might give rise to 
other enterprises, pseudo-philanthropic and less worthy, for 
which the substantial aid of the State exchequer would be 
sought? 
“ I have never felt the need of a convalescent home as an 
adjunct to the Utica State Hospital. Farm houses at sofne of 
our institutions, where the patients enjoy a large liberty, 
answer an equally good purpose, and the open wards of others, 
together with the shops, offer an opportunity for the conva- 
lescent equal to that of the home. 
“During the past year, at a rough estimate, I should say 
that about half a dozen patients might have been benefited by 
the provisions of an after-care association.” 
From Dr. Charles H. Brown, of New York; 
“There undoubtedly should be some means to accomplish 
this end [establishment of after-care associations] either 
through the aid of philanthropy or legislative action. 
“Philanthropy should govern such an institution. Political 
supervision undoubtedly would ruin the object sought in many 
ways. 
“This point [the desirability of State convalescent homes for vi 
insane], like many other medical improvements, should have 
suggested itself to our present (New York) State Lunacy 
Board, and in some way been experimented with. There 
certainly should be a State convalescent home away from the 
general hospitals. There should be really two, one for the 
borderland and greatly improved type, and the other for the 
fully recovered.” 
APPENDIX. 
From Dr. J. P. Brown, Medical Superintendent of the Taun- 
ton Lunatic Hospital, Massachusetts: 
“I should think such an agency or association as your cir- 
cular suggests might be very helpful to- many patients who 
have no relatives or friends to give them a home or assist them 
to employment after they are discharged from the hospital. It 
would result in earlier discharges in those cases which need 
assistance than would otherwise be wise, and might prevent 
relapses in some cases. I highly approve of the general idea 
as stated in the circular. 
T am of the opinion that it should first be organized and 
put on a thoroughly practical basis, as a private charity, and 
then after its usefulness is demonstrated it would be compar- 
atively easy to induce the State to render such aid as it may 
need. 
"A convalescent home for each hospital might be very use- 
ful, and would be a very practical way of rendering aid in 
many cases. 
'Thirteen, and perhaps a few more than that number, have 
been discharged during the past year, who might have been 
aided by such an association.” 
From Dr. Edward N. Brush, Physician in Chief and Superin- 
tendent of the Sheppard Asylum, Maryland; 
"Such an undertaking as is in successful operation in Eng- 
land and France, as I have had occasion to observe, would, 
I think, be in many cases of great value to the convalescent 
insane, wbo have no suitable homes or whose ‘after-care’ is 
apt to be of the worst possible character. It should be a pri- 
vate organization, certainly until its utility is demonstrated. 
"The very large majority of our patients pay something; all 
have homes and friends, and none depend upon public aid. 
"lalways advise friends as to after-care, occupation, etc., and 
quite commonly advise a patient’s going to the sea shore, 
mountains, or similar places, rather than directly home. 
“The benefit to resu.lt from State convalescent homes is 
doubtful, and the attempt to organize such a system might, by 
the growth of expense which it would foreshadow, be a stum- 
bling block in the way of better care for the insane.” -APPENDIX. 
From F>r. C. B. ikvrr, Superintendent of Oak Grove Hospital, 
■Hint, Michigan, (formerly Superintendent of the Eastern. 
-Michigan Asylum,); 
“Desirable as an organized system of after-care for the im- 
sane undoubtedly would be, I question its expediency. 
“Private charities are so numerous, and popular subscrip- 
tions so unreliable and so dependent upon temporary busi- 
ness conditions that the outlook for a new charity is not hope- 
ful. Before organization there should be a previous endow- 
ment (permanent). State aid (I speak from experience in 
Michigan) cannot be looked for. 
“A convalescent house in connection with any State hos- 
pital would be desirable. lam satisfied that great good would 
result from ltd’ 
From Miss Rosalie Butler, of the State Charities Aid Asso 
ciation of New York: 
“I have really no direct knowledge of the condition of per- 
sons discharged from the New York City Asylum, now Man- 
hattan State Hospital, the only asylum with which I am 
personally acquainted. In looking over the statistics of 
the asylum it has appeared to me that the number discharged 
cured was very small in comparison with the proportion given 
elsewhere (in other institutions); so far as I have had oppor- 
tunity to compare them, and on a priori grounds, I should 
think that efficient oversight and assistance of those discharged 
would tend to facilitate discharges. Further, my observation 
of the general hospitals of the city, and what I hear of the pri- 
vate hospitals leads me to believe that care for the convalescent 
is one of the crying needs of the community; on a priori grounds 
I should suppose that the same thing would apply the in- 
sane. 
“I am not properly qualified to pronounce an opinion on' 
such a point, without previous study. My prepossessions are 
in favor of private charity rather than State action. In the 
present condition of public affairs public institutions tend to 
become more or less political machines, and it appears to me 
that a well-managed private institution can maintain a higher 
standard. I doubt the wisdom of extending the limits now set 
to the care of individuals by means of money raised by taxa- 
tion. 
“I should suppose that every asylum ought to have a con- 
valescent department, where recovering patients might be 
tested by being taken out of the society of lunatics and the re- 
straints of an insane ward. But only those who are practically 
familiar with the management of the insane can properlv an- 
swer such a question.” From Dr. Walter Charming, Medical Superintendent of the 
Private Hospital for Mental Diseases, Brookline, Mass.; 
APPENDIX. 
“I should endorse after-care associations in the strongest 
way as a much-needed reform. Each State would have an 
association of its own, I suppose, and there would probably be 
a national association. 
“Probably this should be at first a private undertaking— 
later, mixed; ultimately, wholly State. This allies to Mas- 
sachusetts; other States might follow a different plan. 
“Regarding the advisability of’State convalescent homes, I 
should answer, ‘ Probably yes.’ They could be at first simple 
farm buildings, and could do considerable good at a small 
cost.” 
From Dr. J. B. Chapin, Physician and Superintendent of the 
Pennsylvania Hospital for the Insane, Philadelphia, Pa.: 
“The question of the disposition of a convalescent or re- 
covered patient is one that exercises the thought of a hospital 
physician. As a rule of experience, if the patient is convales- 
cent or has recovered, and has a home to go to, the sooner the 
patient resumes normal environments the better for him. 1 
cannot speak of the practical utility of such an undertaking, 
as you propose, as I have had no opportunity to observe any 
results. Patients admitted to this hospital [ Pennsylvania 
Hospital for the Insane] usually have homes. I can understand 
that patients may convalesce or even recover at a State 
hospital, and that the question of their disposition may then 
come up and be a subject of embarrassment. 
“It is partly true that many recovering patients reach what 
may be called a convalescent stage, and then become station- 
ary; and that quite as maity in that stage are improved by a re- 
moval from all institution influences: and that a continuance 
in a hospital, or any annex, is often deleterious. It is part of 
my practice to advise the removal of patients, who have the 
means to pay the cost, to private homes or quiet hotels, where 
a certain time may be passed during this transitional stage. 
Such persons, under the care of a judicious companion, often 
make more rapid changes for the better than might be ex- 
pected in any organized institution. But I doubt very much 
the practical utility of establishing an after-care institution for 
patients of the public class remote from the parent hospital. 
“An after-care association should be preferably a private 
charity if disassociated from a hospital. 
“In my opinion it is practicable to establish in connection 
with every State hospital a department for convalescing pa- 
tients, within reasonable proximity to the parent institution, 
and under the direction and management of its officers. The APPENDIX. 
advantage of such an arrangement obviously is that the hos- 
pital physician ought to know best what the patient may be 
able to bear, and where he should be best placed. The prox- 
imity of such an annex would render transfer back to the hos- 
pital, if necessary, comparatively easy. 1 can well understand 
that there may be objections even to this plan. It is not to be 
assumed because homes or annexes have been established in 
connection with a parent hospital, or in connection with pri- 
vate institutions for the insane, that they are devoted to the 
convalescing class. In my observation they are not; but they 
form a means of relaxation and change, which are recognized 
as very valuable even to patients of the chronic class, who are 
yet quiet, and have an appreciation of change. In several of 
the institutions of this class with annexes I have known 
convalescing patients to improve very much by the change, 
yet the majority have not been of the convalescing class. 
“ This is a private hospital. All patients discharged, re- 
covered or improved, are removed by relatives to homes. A 
few patients in indigent circumstances would have been sur- 
rendered to an after-care institution by their friends, but the 
number is limited. Probably two or three might, or might 
not, have sought a convalescent home, if it had been offered.” 
From Dr. Robert H. Chase, Medical Superintendent of the 
Friends Asylum, Frankford, Pa.: 
“I am in full sympathy with such measures as you suggest, 
to render aid and protection to discharged patients from the 
State hospitals, according to their individual needs. 
“ I think the project would be of great practical utility. 
“Regarding the auspices under which it should be con- 
ducted, it would depend much on the scope of the undertak- 
ing. I see no objection to State aid, if obtained under proper 
conditions. 
“ It seems to me probable that much benefit would result 
from State convalescent homes, as it has in the two instances 
you cite. 
“ As all of the patients in this institution are of the pri- 
vate class, your inquiry hardly applies to them, although with 
them even a suitable case now and then occurs. But in my 
former service at the State hospital at Norristown there would 
be no difficulty in selecting many appropriate cases each 
year.” 
From Dr. Edward Cowles, Medical Superintendent of the Mc- 
Lean Hospital, Waverly, Mass.: 
“I should think that the organization of an after-care so- 
ciety, with successful examples for guides, would be likely to APPENDIX. 
do good work. My attention not having been especially di- 
rected to this subject before, I should think it might require 
considerable time and patience to put the undertaking on a 
working basis, but its practical utility seems to me very prob- 
able. 
‘‘l should think it likely that it would have to be started as 
a private charity, and some demonstration be made of its es- 
sential usefulness before practical legislators would believe in 
it. It is in the line of the good things that might be developed 
under the fostering influence that ought to be exerted by a 
good lunacy commission. 
"The suggestion [State convalescent homes] seems to me 
an eminently sound one. It is in line with the modern ex- 
cellent idea of truly ‘hospital wards’ as adjuncts of the great 
State hospitals. Such detached departments should promote 
most logically the recovery of the acutely insane of any social 
grade, as they do in the Massachusetts General, and Boston 
City Hospital. 
"Patients of the McLean Hospital, who are of the self-sup- 
porting class, get precisely the effects of after-care in their own 
homes. It is always a matter of careful study to consider the 
surroundings into which a patient shall pass, and we almost 
always have patients go on a visit for a time before discharge; 
but there would sometimes be cases that could be aided by 
after-care.” 
From Dr. John Curwen, Medical Superintendent of the State 
Hospital for the Insane, Warren, Pa.; 
“There can be no doubt of the great benefit of after-care as- 
sociations if they could be conducted in the true spirit. 
“I very much doubt if the co-operation of the Common- 
wealth could be secured for the establishment and mainten- 
ance of such an organization. The demands on the Treasury 
for purposes, which should be maintained entirely by private 
parties, are such that no money could be secured for such an 
object continuously year by year. It is doubtful, also, in the 
great demand for objects of a charitable character,whether add- 
ing another to the long list could meet with such favor as to 
secure a steady and continuous supply of the needed funds. 
“If arrangements could be made, such as are in operation 
in France, great good might be obtained from State convales- 
cent homes, but in this country the diverse interests in differ- 
ent States would, I fear, be a serious drawback to the success- 
ful maintenance of an institution as it should be kept up. 
“ The people are not yet educated up to the necessity of such 
a measure, so that they would willingly and regularly contrib- 
ute to the proper support of such an institution, and without a 
generous and hearty support no such institution could be APPENDIX. 
maintained at a standard which would meet the emergencies 
daily arising. 
"It is the practice of this hospital to keep all cases which have 
a reasonable prospect of restoration until such restoration has 
been effected, and the authorities of the different districts are 
in full accord with the practice, and as the patients are restored, 
they are able to take their places in the positions they have 
previously held, and maintain them successfully. Relatives 
will sometimes insists on removing their friends before they 
are entirely restored, but they are generally able to look after 
and provide for them.” 
From Dr. Richard Dewey, Medical Superintendent of the 
Milwaukee Sanitarium, Wauwatosa, Wis., formerly Su- 
perintendent of the Illinois Eastern Flospital for the In- 
sane, and President of the American Medico-Psychologi- 
cal Association; 
"In my experience of fourteen years at Kankakee, I was 
more and more impressed with the importance of after-care 
from both humanitarian and economic standpoints, as set 
forth in your admirable circular. No small part of my time 
and energy was devoted to this very business of endeavoring 
to secure conditions whereby cured, convalescent or proba- 
tionary patients might be favorably surrounded on leaving the 
hospital, believing this to be a duty appertaining to some- 
body, if the work of the hospital for the insane was to meet its 
full measure of success. 
“ Would it not further the work of your Committee to dis- 
seminate information concerning the "Patronage” society of 
Paris and the work done in the same line in London? The 
former is described by Victor Parant in the July or October 
issue for ’94 of the American Journal of Insanity. 
“ Wherever and whenever the co-operation of the State can 
be secured it ought to be. It seems probable that private and 
voluntary work of after-care will form the nucleus around 
which State aid will grow, but a preliminary work of education 
will be required. The higher the civilization and culture of the 
community, the more certain will be the general appreciation 
of the necessity of after-care. Yet it would seem that any com- 
munity which recognizes the need of after-care for convicts 
would equally see the necessity of the same for the insane; the 
latter are innocent and even more helpless than the convict. 
“The institutions are moving in the direction of convalescent 
homes, and will continue to enlarge the work by means of 
convalescent cottages and wards. If these were entirely sep- 
arated from the institutions (and at the same time properly 
equipped and supervised), they would do their work far bet- 
ter. For this purpose the aid of right sentiment and individ- APPENDIX. 
ual effort is exceedingly important on the part of those outside 
who co-operate. 
“ In my experience in a State hospital the number which 
might be benefited by an aid association was large. I cannot 
now give figures; perhaps to per cent, at Kankakee. 
“ I have known patients in great number, whose own people 
would not have them at home, who only needed an opportu- 
nity to go out in order to do well permanently, and I have more 
than once secured places for such people where they labored 
with mutual satisfaction for many years. * I often required 
when a patient recovered that the relatives should come and 
see him or her at the hospital, and thus sometimes the pre- 
judice against the return home could be overcome.” 
From Dr. W. Brown Ewing, Physician-in-Chief of the State 
Asylum for the Chronic Insane, Wernersville, Pa.: 
“I think that such a scheme would be not only humane but 
practical, and I feel that it would be of great service to those 
for whom it is intended. 
“ Patients should be as far as possible removed from the 
causes of their attack, and the liability to its return decreased 
as far as possible. Former associations, if renewed, will often 
produce the same results as previously on a mind just recover- 
ing. 
“As the State has to support the patient after he becomes 
insane, anything that would lessen the liability to an attack 
would certainly be a direct benefit to the State, and the ex- 
penses should, in part at least, be borne by it. 
“I will go even further than that and say that the State should 
bear all the expense. 
“I believe in the practicability of State convalescent homes 
near hospitals for acute diseases. 
“Formerly I knew of many cases who were discharged, with 
fear and trembling, and returned to their homes and to old 
surroundings and associations, and relapsed. Here, in this 
asylum, I have known of only one case which relapsed, but I 
have had only two discharged as recovered. 
From Dr. Charles F. Folsom, of Boston: 
“ The establishment of after-care associations seems to me 
exceedingly worth while, and the co-operation of the State 
seems to me desirable in such an undertaking.” 
From Dr. Edward French, Superintendent of the Medfield In- 
sane Asylum, Medfield, Mass.: 
“I think that an after-care association would be a useful 
and a very excellent charity for both patients and the general 
public. APPENDIX. 
“ I think it would be more successful if it were an entirely 
private organization. There would be less publicity, and con- 
sequently the feelings and pride of the patients would have 
more protection. There is also more interest taken in private 
enterprises by the rich benevolent. 
“ Regarding State convalescent homes, I do not believe in 
taking a patient from one institution to place him in another. 
His surroundings should begin to approach those of his future 
life as much as possible. Convalescent homes are generally 
managed on the institutional plan, and the departure from the 
management of the parent institution is not enough to seem 
the greatest good. 
“ This institution, Medfield Insane Asylum, is too new to 
have a record of discharges.” 
From Dr. William A. Gorton, Superintendent and Physician 
of the Butler Hospital for the Insane, Providence, R. I. 
“I have always thought that such after-care societies for the 
middle and lower classes would be of great value.' 
“In the present temper of the public, I should think a small 
beginning, as a private charity, would be advisable. If suc- 
cessful, public aid could probably be obtained. I should 
hardly expect much aid from the State for some time. 
“I should not personally favor such [State convalescent] 
homes as departments of public hospitals. They would soon 
be utilized by chronic cases who could never go out into the 
world, and their true aspect be defeated thereby. A central 
industrial establishment might be of service, the able-bodied 
being paid something for their labor for a limited period. But 
the character of such an establishment would necessarily be 
gradually evolved in my opinion from the practical experience 
of original charity experiments. 
“When I was in a State hospital I saw quite a number of 
cases who could have gone away earlier from the institution, 
had there been an intermediate station for their care, than they 
could have under present conditions. Here, with private cases 
mostly, the need is not so apparent.” 
From Dr. William D. Granger, Superintendent of “Vernon 
House,” Bronxville, N. Y.: 
“After all objections that can be raised, I think well of such 
a society as is suggested. The agents would, however, have 
to be very tactful, and the society would have to work in, 
harmony with the asylum authorities. It must be remem- 
bered, however, that the recovered insane in most cases look 
lightly upon their insanity and fail to appreciate the gravity 
of their past illness, and regard the future with either uncoil- cern or are unreasonably hopeful, while advice is often re- 
ceived with studied indifference. This is also frequently true 
of families and friends. The patient is anxious “to take up 
the burden of life again'5; to return to his old ways of living, 
his old habits, and is extremely restless during the period of en- 
forced convalescence. It is also true that most patients wish 
to have it unknown, or at least not spoken of, that they have 
been inmates of an asylum. They are suspicious if visited by 
their old asylum physician, and in most cases social inter- 
course is discontinued, although friendly feelings on both 
sides remain. 
APPENDIX. 
“I think that an entirely private society not connected in any- 
way with asylums is preferable, and for the reasons just given. 
“In my experience in the Buffalo State Asylum there were 
few persons recovering whol were not taken away by their 
immediate family. The exceptions were mostly cared for by 
the Superintendents of the Poor; a few were able to care for 
themselves. An early discharge sometime during the period 
of convalescence was recognized as desirable in many, perhaps 
in the majority of cases. A minority were unsuited to receive 
such liberty, and some few had, by nature of disease, to be re- 
tained a long time after full convalescence was established. Of 
those we wished discharged we could discharge but few, be- 
cause of the undesirable homes awaiting them, and we were 
obliged to detain them for a full and unquestioned recovery. 
Such patients as were discharged during convalescence gener- 
ally did well; as a rule better, we thought, than if they had 
remained longer. The need of direct pecuniary help has not 
been great in my experience. The public authorities have 
given all that was pressingly needed. 
“A [State] convalescent home for the insane is most de- 
sirable, and would prove extremely beneficial. It would, I 
think, require legal provisions for necessary detention, other- 
wise patients would not remain. Such a home must also be 
near the family and friends of the patient. To be useful in 
New York State, one would be needed in the central part of 
the State and one near New York City. The surroundings 
should be most cheerful, and there should be an entire absence 
of institutional features. The trouble with all our asylums is 
they are too institutional. The true cottage and village plan 
has never been tried in this country. Even the most acute 
cases among the public insane can be well cared for in a frame 
homelike looking house when proper medical supervision and 
good nursing is employed. 
“But the greatest usefulness of such a home would come by 
the removal of the convalescent from the asylum and by the 
influence of an anticipation based upon such a change as 
would give the hope of speedy recovery, of freedom and APPENDIX. 
restoration to friends. The practical results of such a home 
would be found in its earlier and earlier use in the stage of 
convalescence. Under such conditions I believe the recovery 
ratio would be decidedly increased. 
“I believe a convalescent home would be a step of enlight- 
enment and tend to destroy the present illogical and false 
ideas of asylum structure and asylum care, and would help to 
promote the true hospital spirit. 
“I believe also that restricted ‘boarding out' is most bene- 
ficial for many of the chronic cases, and is practical under suit- 
able State supervision. I also believe it can be made prac- 
ticable in this country.” 
From Dr. Graeme M. Hammond, of New' York: 
“The plan is eminently useful, and under proper safeguards 
would be practicable. Why not make such an institution em- 
brace the convalescents of all hospitals and not merely of in- 
sane asylums? 
“An after-care association should be a private society prop- 
erly incorporated.” 
From Dr. John L. Hildreth, Cambridge, Mass., of the Mas- 
sachusetts State Board of Lunacy and Charity: 
“I think some plan should at once be devised for taking 
care of the convalescent pauper insane. 
“At present I have not given the subject sufficient thought 
so that I could advise either a private charity or convalescent 
hospital, under the care of the State.” 
From Dr. Herbert B. Howard, Medical Superintendent of 
the Asylum for Chronic Insane, Tewksbury, Mass.: 
“ I think that an after-care plan would work well if the men 
who have charge of it are sufficiently interested in it. 
“ It could be conducted satisfactorily either as a public or 
private charity. 
“Any method that takes the insane by easy stages back to 
normal life is a move in the right direction. 
“Six, perhaps eight, of the patients discharged during the 
past year from this asylum would have been benefited by an 
after-care association.” 
From Dr. Henry M. Hurd. President of the American Medico- 
Psychological Association (formerly Medical Superin- 
tendent of the Eastern Michigan Asylum) and Superin- 
tendent of the Johns Hopkins Hospital: 
“I believe the movement to be most humane and useful. “It should be managed as a private charity by being wholly 
divorced from politics or political control. The State should 
be asked for aid. 
APPENDIX. 
“I am of the opinion that it would be practicable to estab- 
lish convalescent houses in connection with State hospitals for 
the insane.” 
From Dr. Henry A. Hutchinson, Superintendent of the West- 
ern Pennsylvania Hospital for the Insane; 
“I believe the object is a very worthy one, and I think that 
when placed upon a business basis and managed in a system- 
atic manner, in capable hands, it would result in great good to 
tills class of people. It is a great pity, in this enlightened age, 
that the general public points the finger of scorn at those who 
have once lost their reason, but such is the case in my ex- 
perience. Ido not believe that superintendents of large hos- 
pitals can give this charitable work much attention, as their 
time is too much taken up with the management of their own 
institutions.” 
From Dr. Philip Coombs Knapp, of Bostog: 
“I believe that such a plan would be of distinct benefit to 
many patients, and I see no reason why .it could not be made 
practical in this country as well as elsewhere. The success 
of similar undertakings for the benefit of discharged criminals 
would confirm this view. 
“If such a society could be established as a private charity 
I think greater success might be attained. 
“I see no reason why State convalescent homes should not 
be of as much benefit as convalescent homes for general hos- 
pitals.” 
From Dr. Edward B. Lane, Superintendent of the Boston Lu- 
natic FTospital, Austin Farm, Mass.: 
“ I believe that where the need exists as clearly as this 
does, there must be a method for its relief, which, if properly 
managed, will prove practically useful. lam not sufficiently 
familiar with the workings of such societies to criticise in de- 
tail. 
“I think the State should assist with financial support, but 
that the control should rest with a private society. 
“I am a firm believer in the benefit of such a State convales- 
cent home for a small number of cases, especially women. A 
slight change of surroundings I have repeatedly observed to 
act as the initial stimulus of rapid improvement or recovery. 
“I have seen mostly chronic asylum cases the past vear. I APPENDIX. 
do not recall a case which would have been helped by such a 
charity.” 
From Dr. James Hendrie Lloyd, of Philadelphia: 
“I should think that if such a plan has been found prac- 
ticable in France, England and Switzerland, it would be 
equally so in America. Of the desirability of such aid to the 
convalescent insane there can be no doubt. 
“A private charity would probably be more zealous and ef- 
ficient than a purely public body. There would be no reason 
why a private charity should not receive recognition, and- even 
aid from the State, after it had once proved its usefulness. 
“While in State convalescent homes, the patients would still 
feel themselves under restraint; hence such homes would not 
supply the place of societies, which would be instrumental in 
giving aid after the patient was removed from the shelter and 
support furnished by the asylum. 
“Still, such convalescent homes, as furnishing change of air 
and scene (as at the seaside or mountians) would be a distinct 
benefit and gain in many cases, and would tend to expedite re- 
covery.” 
From Dr. Samuel B. Lyon, Medical Superintendent of the 
Bloomingdale Hospital for the Insane at White Plains, 
N. Y.: 
“In reply to your first enquiry, I may say that there is no 
question that the patient convalescing or recovered from in- 
sanity labors under a disadvantage in pursuing his former em- 
ployment or career; and the realization of this disadvantage 
must often retard entire recovery. If he can be helped or bol- 
stered up for a time it might be a decided advantage to him. 
“Second. As the great majority of insane patients under 
treatment are in the direct custody of the State authorities, 
any provision for the further care of discharged patients, it 
would seem to me, ought to be under the authority of the 
State or, certainly, its close supervision, in order that a uni- 
form and judicious system might be followed, and that the 
State institutions might regard it under these conditions as in 
some sense adjunct to their hospitals, and might occasionally, 
in doubtful cases, transfer their responsibility for the safety of 
patients to a new responsible authority. The homes should 
not bear the stigma of insane homes; and this might raise a 
legal difficulty in regard to- State jurisdiction over them. 
“Third. I am fully convinced of the advantage of separate 
convalescent buildings in connection with hospitals for the in- 
sane, which can be used in the treatment of patients to pro- 
duce change of feeling with a change of environment, and to APPENDIX. 
hasten or confirm the convalescence begun in the parent in- 
stitution. 
“Fourth. In every case the patients in the institution with 
which I am connected, are put here by responsible friends, 
who continue their watchful interest in them while here, and 
the moral and pecuniary support which they need during the 
period of their dependence. But in the public institutions, 
there must be a great number of patients who have no personal 
friends or acquaintances capable of rendering this assistance, 
over whom the State might very properly exercise a temporary 
guardianship, after they cease to be obviously suitable inmates 
of a hospital for the insane.” 
From Dr. Carlos F. Mac Donald, recently Chairman of the 
State Commission in Lunacy, of New York: 
“The question of providing for the class of persons referred 
to, after their discharge from asylums, is a very difficult one, 
indeed; first, for the reason that such persons are impatient of 
control, even in an institution which does not involve their 
legal restraint, and having been discharged as recovered, they 
cannot legally be compelled to remain; second, in view of the 
large numbers of insane persons for which public provision 
must be made, and the heavy burden which such provision 
lays upon the tax payers, it would be difficult to induce State 
Legislatures or municipal authorities to appropriate sufficient 
funds for the establishment of institutions or homes for this 
class. I doubt, also, if such institutions, in view of the large 
expense which their establishment and operation would in- 
volve, could be permanently maintained as private charities, 
and while it is undoubtedly true that cases are to be found in 
every public hospital for the insane, whose insanity is of such 
a mild and harmless type as to enable them to live comfort- 
ably outside of the hospital, it seems necessary to detain them 
for the reason that, being unable to maintain themselves out- 
side unaided, and being friendless and homeless, they cannot 
be turned loose upon the community. Furthermore, many 
such cases are liable to undergo a change as to the form of 
their insanity, which would render them dangerous, or at least 
unfit to be at large; hence, the necessity, for the reasons stated, 
of their retention in the hospital. 
“I can readily conceive that a society such as you propose,, 
and composed of practical men and women, with time and 
means at their disposal, who would give personal attention to 
the disposition of such cases in suitable private families, and 
who would maintain an effective supervision of their care and APPENDIX. 
treatment, might accomplish a most valuable work, both as 
regards humanity and the public interest. 
“In my opinion, such a society should be entirely a private 
charity and organized somewhat on the lines of our State 
Charities Aid Association, which is a most worthy voluntary 
organization. It is sustained entirely by private subscription 
and has accomplished more practical results in behalf of the 
dependent classes than any similar organization of which I 
have knowledge. In fact, it occurs to me that if the Commit- 
tee on Insane of the State Charities Aid Association could be 
induced to take up this work, it would be better, in view of 
their familiarity with the subject, than to undertake to organ- 
ize a new society for the purpose. 
“I do not believe it would be feasible to establish and main- 
tain convalescent homes as departments of our State hos- 
pitals.” 
From Dr. Charles K. Mills, of Philadelphia: 
“I believe that after-care associations might be made a suc- 
cess. 
“ The State should co-operate in the work of such an asso- 
ciation. 
“State convalescent homes for the insane would, I believe, 
probably prove useful.” 
From Dr. S. Weir Mitchell, of Philadelphia 
“After-care of the insane by associations is needed for every 
reason you mention. Even as regards ordinary hospital insane 
patients, it is shameful that they go out without such help as 
you mention, while every released convict in my State, at least, 
is amply aided. I have often seen the necessity for care of the 
insane when released. 
“Such associations should be at first private, later they may 
claim State aid. 
“Years ago I urged the establishment of State convalescent 
homes for the insane, but could get no hearing.” 
From Dr. Thomas G. Morton, Chairman of the Committee on 
Lunacy of the Board of Lunacy and Charity of Pennsyl- 
vania: 
“ The question appears to be, not whether such a plan as 
you suggest is feasible, but rather if there is a necessity for 
such a charity. In the first place, I think that there would be 
few, very few, of the recovered patients who would seek, ac- 
cept or require, either aid or supervision after leaving the hos- APPENDIX. 
pital. The number of the wholly ‘ cured ’ discharged patients 
from our State hospitals is very small, possibly not three per 
cent. These are generally young persons who have been sud- 
denly stricken with insanity and who recover more or less 
promptly, and who, as soon as convalescent, are eager to get 
their discharge and to return to their homes and to work. 
They early seek to be at liberty, or their friends plead for their 
discharge, and few, if any, of this class would require further 
supervising care. Work of some sort or other in the hospital 
wards or about the farm has been a part of their treatment, so 
that when discharged by the Medical Superintendent they are 
supposed to be cured and ready and well enough to resume 
their usual occupations. 
“In regard to the ‘improved,’ etc., there might be some who 
would accept further assistance, for there are always appli- 
cants to any and every sort of charity, but even these patients 
have homes and friends who are just as anxious to have them 
back in their keeping. As you well know, there are no free 
patients in any of our State institutions. The cost of mainte- 
nance in every case is made up in part by the State and in part 
by the county sending the patient. Security is also required 
for furnishing clothing, etc., and some responsible party must 
enter into agreement to remove the patient when directed to 
do so. Thus no patient can be discharged from any hospital 
friendless, alone or without suitable protection. 
“ At this moment, and after many years’ experience as one 
of the Commissioners of Public Charities, I cannot call to mind 
an instance where any patient of the class you refer to required 
further aid and supervision after being discharged. Yet I am 
quite willing to believe that there may be such instances. 
“ I notice that our indigent insane are referred to in your 
circular as ‘ pauper insane.’ Pennsylvania does not recognize 
this class as paupers, nor should our poor insane be compared 
with the pauper class of Europe, for the conditions are very 
different. Our poor insane very commonly have become in- 
digent in the effort of the family to care for the insane relative 
at home, and reluctantly hospital care is sought when the like- 
lihood of poverty presents itself, or when the insane person be- 
comes dangerous or unmanageable, and it is not verv unusual 
for a part of the cost of the maintenance to be voluntarily paid 
by the family in order to avoid the patient’s being considered 
even as indigent. Our poor are not by any means so destitute 
as the term ‘ pauper ’ would imply. They are workers with fair 
wages, have homes and often something in reserve, so that on 
leaving the hospital the patient has more or less favorable sur- 
roundings. The statement that ‘ these unfortunates are also 
distrusted and prevented from obtaining employment simply 
because they have been inmates of an asylum,’ I am well satis- APPENDIX. 
fied is not well founded. It is said to be so in regard to those 
leaving our penitentiaries and jails, but not so in regard to pa- 
tients discharged from our hospitals for the insane. 
“ At all events the plan you have proposed might be under 
taken, but it should be supported as a purely private charity, 
and I should question the advisability of any congregate care. 
A country home or place suited to the individual would be 
preferable, and the State should not be expected to give any 
assistance unless after thorough experience it can be conclu- 
sively demonstrated that the discharged cured or improved pa- 
tients require further aid than the hospital can afford. But 
such assistance, if required, might be afforded in permitting 
such patients who would be recommended by the Medical Su- 
perintendent of the hospital to reside in small cottages upon 
the grounds of the hospital, built for this special purpose, apart 
from the main hospital building, and provided only with such 
supervision as would be needed to secure the general comfort 
and well-being of the inmates, but without custodial care or 
restraint. 
“ I am, as you see, not in favor of increasing our already too 
numerous charitable institutions, but believe rather in carefully 
directed individual assistance, which might be given without 
publicity and in an inexpensive manner.” 
From Dr. Charles W. Page, Medical Superintendent of the 
Danvers Lunatic Hospital, Danvers, Mass.: 
“Such an organization would serve a good end in a few 
cases. 
“It should be entirely a private charity. 
“I should not think it probable from the experience I have 
had that State convalescent homes are needed. It would 
be an excellent device for a few cases, but comparatively few 
patients from this hospital would patronize such an institution 
if established. 
“I do not recall any special case of the sort described with- 
in a year. Perhaps half a dozen cases each year might be 
persuaded to go to such a temporary home.” 
From Dr. Frederick Peterson, of New York: 
“I believe that an after-care society of this character would 
be very useful and beneficent. 
“It should be a private charity, as it is improbable that the 
State would contribute anything to its support. 
“There is no doubt that convalescent homes at the seashore 
or in the mountains would be of great value when in conjunc- 
tion with our large asylums. This is a not uncommon thing 
abroad and there are asylums in this country that have put the 
same plan into successful operation.” APPENDIX. 
From Dr. Charles W. Pilgrim, Medical Superintendent of the 
Hudson River State Hospital, Poughkeepsie, N. Y.: 
“I do not think I can better answer your question than by 
quoting from a paper which I recently wrote: 
“ ‘ There should then be established in connection with each 
large State plant a small detached hospital and a convalescent 
cottage for each sex. 
“The convalescent homes it would be well to mave some dis- 
tance from the parent institution, and far enough away to in- 
sure a complete change of scene and mode of living. My ex- 
perience leads me to believe that it is exceedingly difficult to 
tell just when a patient should be discharged and returned to 
his old life, and I believe the difficulty would be overcome if 
we had cottages for convalescents where doubtful cases, es- 
pecially friendless ones, could be sent for a time to be prepared 
for renewing the struggles of outside life. It is true that we 
have a partial solution of the difficulty in the system of parole 
by which we are enabled to permit patients to go home on a 
trial visit of thirty days before final discharge. This practice, 
however, cannot be put in force where the patient is without 
home and friends, and it is such cases that occasion us the most 
anxiety. In England and France they recognize the fact that 
’Tis not enough to help the feeble up, 
But to support him after, 
and in the former country they have what is known as an after- 
care association, and in the latter convalescent homes, where 
suitable cases are provided for for a period of from four to six 
weeks. Friendless ones are helped to obtain employment, and 
assistance is rendered in many ways. 
“There is also a provision of law in this State permitting su- 
perintendents to furnish suitable clothing and money to an 
amount not exceeding $2O whenever it is thought advisable to 
do so. 
“I think probably it would be more satisfactory to have the 
State undertake the work. One home could be made to an- 
swer for all the State hospitals. 
“I think that in a State like New York the entire population 
of the State hospitals would be able to furnish a sufficient num- 
ber of patients to warrant the establishment of at least one 
home. 
“There were quite a number discharged from this hospital 
during the past year to whom such a home would have been 
beneficial, but there were not more than a half dozen cases APPENDIX. 
who were entirely without friends to manifest interest in 
them.’ ” 
From Dr. James J. Putnam, of Boston; 
“I am heartily in sympathy with the plan as outlined in the 
circular. 
“I think it would be much better that the arrangement 
should start as a private charity. Its promoters would be 
much more free at first to work out their plans in this way. 
Later, the State might properly assume the supervision and 
the expense.” 
From Dr. A. B. Richardson, Medical Superintendent of the 
Columbus State Hospital, Columbus, Ohio: 
“If a system of supervision could generally enlist the co- 
operation of a few people in every community, I believe much 
could be done to disarm the prejudice that exists against con- 
valescents from insanity, and something could doubtless be 
accomplished to secure them employment and homes in fam- 
ilies. It seems to me this should be done as a branch of char- 
itable work by private means entirely. 
“I can scarcely see how the State could undertake the ex- 
pense which a successful operation of such a plan would en- 
tail. It would require the co-operation of many individuals. 
Most patients in our hospitals are so closely connected to fam- 
ily and relatives that their cases must be supervised in the 
neighborhood from which they came. Possibly the State 
might be the leader or organizer and maintain the patient. 
“For a State institution, I fear it will be found difficult to 
provide anything practicable at State expense that will not 
be itself simply another form of hospital or institution, and not 
have much of the home life for which it is sought to make it a 
preparation. A longer stay in the parent hospital would prob- 
ably accomplish almost as much, at least as much as is prac- 
ticable, as a State charity. 
“I do not believe that the number with us that would be 
benefited by such homes is sufficient to justify their expense. 
They might be more practicable than I now think, but it 
to me their utility would be comparatively limited. Danger 
from recurrence is not limited to the first eolith or two after 
leaving the hospital, but exists for many months. Convales- 
cence after mental disease is n-Aoriously uncertain in the con- 
ditions that will encourage it. Sometimes, indeed often, I 
have found a return to home life the very best promoter of 
convalescence I could employ. I, for my part, must confess 
that I know of no reliable way of anticipating in which cases 
such influence is to be expected. “I do not believe any estimate I can make would be re- 
liable. Two hundred and one patients were discharged as re- 
covered or improved. Probably ten per cent, of these is a 
liberal estimate of the number which would be really benefited 
in a practical way by such an association.” 
APPENDIX. 
From Miss Louisa Lee Schuyler, Chairman of the Committee 
on Legislation for the Insane of the State Charities Aid 
Association: 
“There is great need of the establishment of some system 
of assisting the insane, who are convalescent, in the way sug- 
gested. lam inclined to favor the plan of boarding in families 
at the expense of the State such discharged patients as need 
this temporary assistance. The assistance of private charities 
should be enlisted for the purposes of visitation and for what- 
ever friendly assistance they may be able to give, but I would 
place the actual control, the entire responsibility, and the en- 
tire support, in the hands of the State. 
“I am not inclined to favor, upon first consideration, the es- 
tablishment of State convalescent homes, feeling that it would 
be better for the recovered patients to share the ordinary life 
of the family and the community.” 
From Dr. E. V. Scribner, Medical Superintendent of the Wor- 
cester Insane Asylum, Worcester, Mass.: 
“I regard the undertaking as both practicable and desir- 
able. 
“My present thought would favor a private undertaking. 
“I think also that State convalescent homes would accom- 
plish a useful purpose. 
“No patients have been discharged during the past year 
from this institution |for the chronic insane] who would pro- 
perly come in this class, though in many former years there 
have been a few cases.” 
From Dr. Wharton Sinkler, of Philadelphia: 
“I believe that it is of the utmost importance that some pro- 
vision should be made for the after-treatment of patients who 
have been in insane asylums. I believe that many relapses oc- 
cur because no suitable care has been taken of convalescent 
patients, not only in the care of pauper insane patients, but 
quite as much so in regard to patients in the better classes of 
life. The society, such as is proposed by your Committee, 
would be of the greatest value to the community. 
“As the cases which the society is intended to reach are 
mainly paupers, I believe that the co-operation of the State in 
this work would add greatly to its usefulness. I believe that APPENDIX. 
there will be no difficulty in obtaining aid from the State for 
such an institution. 
“Probably the best plan for obtaining beneficial results from 
the work of such a society would be to establish State con- 
valescent homes for the insane. This would enable the au- 
thorities to have a more thorough knowledge of the patients 
whom they are admitting than in any other way. By having 
convalescent homes, occupation could be given the patients at 
an earlier period than if they were given public work to do.” 
From Dr. M. Allen Starr, of New York: 
“There can be no question as to the utility of such an un- 
dertaking (after-care associations), and it is evidently one 
which should commend itself not only to physicians, but also 
to the State. 
“The co-operation of the State by the establishment of con- 
valescent homes to which State patients could be sent is most 
desirable, but private societies should also be established for 
the same purpose.” 
From Dr. H. P. Stearns, Medical Superintendent of the Re- 
treat for the Insane, Hartford, Conn.: 
“I think such a transitional home as is referred to would 
be practical, and it might be most useful for a large number of 
patients who are discharged yearly from the State hospitals. 
With such a provision many patients might be discharged 
sooner than they can be under present conditions, and would 
certainly be much more likely to remain well after their re- 
turn to their homes. 
“I think they should be supported by the State, whether the 
homes are connected with hospitals directly or not. Certainly 
the great majority of patients who would need to be bene- 
fited by such a home are under State care and supervision, 
and should remain so until they can be restored so far as to be 
able to properly care for themselves, or be cared for by friends, 
without danger of relapse from such weakness of the nervous 
system as usually follows attacks of insanity. 
“I also think it probable that benefit to a sufficient number of 
patients would result from the establishment of convalescent 
homes, as departments of, but at a distance from, our State 
hospitals for the insane. 
“As I usually have comparatively few patients who are sup- 
ported by the State or towns where their homes are, any state- 
ment I could make on this point of inquiry would be of little 
value in a practical way.” 
From Dr. Selden H. Talcott, Medical Superintendent of the 
Middletown State Homeopathic Hospital, New York: APPENDIX. 
“About five years ago I wrote a few lines concerning the es- 
tablishment of country homes for convalescent patients, and 
protracted cases. I send you a copy of our twenty-first an- 
nual report, and in it, on pages 63, 64, 65 and 66, you will 
find a description of the plan which we outlined at that time. 
If we could have such convalescent homes established and 
maintained by the State, then we could place therein certain 
patients whose condition seems to have so far improved as to 
make it useless to keep them longer under treatment in a gen- 
eral hospital. If an improved, quiet and harmless patient has 
no means of his own, and no friends and no home to go to, and 
no employment, then it is certainly unwise to thrust such a 
patient back into the community. If a homeless and friendless 
insane person recovers in full, then he might be returned 
to a county almshouse for care and protection until he is able 
to care for himself, or until some one else is ready to take care 
of him. If a private association could be organized for the 
purpose of helping those who are discharged from our State 
hospitals as recovered, that would b.e a wise and beneficent 
thing to do. Ido not see how the State could venture to pro- 
vide for those who are sane in mind and sound in body. 
If the State could do this for a recovered lunatic, then it could 
properly take care of everyone in the community. But pri- 
vate enterprise seeks now to engage in all kinds of home mis- 
sionary work, and the care of recently discharged patients 
from our public hospitals is a task to which home mis- 
sionaries might well direct their attention and their ener- 
gies. If the State would establish convalescent homes for 
patients who are recovering, but who are not yet fully re- 
stored to health, then quiet and harmless patients might find 
a safe and comfortable retreat in such places until they could 
properly and wisely be discharged from the wardship of the 
State. 
“In conclusion, therefore, I will endeavor to answer your 
questions seriatim: 
“ (1) Help for rcovered persons recently discharged from 
public or private hospitals is most positively of “practical util- 
ity,” especially when these persons are poor and trying to 
make a new start in life. Recently discharged patients often 
need as much care, protection, help and support as children 
or young persons who are just beginning a career in education 
or in toil. 
“(2) It seems to me that after the State has finished its work 
of caring for a patient in a hospital, and has returned that 
patient, furnished with good clothing and a fair amount of 
money, to' his home, then private charity should conclude the 
work of restoring the recovered patient to his normal position 
as a worker and self-supporter in the community. The State APPENDIX. 
should not cease from caring for a patient until that patient 
is fully restored to health, and thus rendered capable of self- 
care. 
“(3) With regard to the establishment of convalescent homes 
at a distance from each State hospital for the insane, I will re- 
fer you to the twenty-first annual report of this hospital, page 
63. I believe that the establishment of such homes would re- 
sult in great benefit to many of our patients who- become tired 
of living year after year in one place, and consequently dis- 
couraged and dispirited. 
“(4) It is not our custom to allow unrecovered and help- 
less patients to return to their homes unless the friends have 
sufficient means to properly care for them. 
“P. S.—lf a society for the aid of recently discharged pa- 
tients from hospitals for the insane could be organized, and a 
suitable fund raised, the interest on this fund might be ap- 
plied toward procuring temporary boarding places for those 
who have no homes, and who are out of employment, until 
work can be obtained, and consequent self-support insured. 
Under our present method, not more than three or four per 
year would require aid from such a society as you have men- 
tioned.” 
From Dr. J. Madison Taylor, of Philadelphia; 
“After-care associations would be most valuable and most 
important. I have often felt the need of such aid for the dis- 
charged insane, and would welcome any measures directed to 
that end. 
“Such associations should be private for the present, later 
the State might be drawn upon. 
“I am not capable of differentiating, but incline to the an- 
alogy of the convalescent home which has proved so valuable.” 
From Dr. FI. A. Tomlinson, Superintendent of the St. Peter 
State Hospital of Minnesota: 
“I believe that such an undertaking would be practicable 
and of inestimable advantage to the class of patients in our 
State hospitals who are now compelled to take up immediately, 
and commonly under very adverse circumstances, the cares 
and responsibilities of bread-winning and the care of a family. 
“It would probably have to be begun as a private charity, 
but after it is once established and its advantages shown, 
public aid would be forthcoming and could be advantageously 
combined with private interest. The private interest should 
always be kept up, however, as it serves to stimulate and en- 
courage the convalescent to face the world again after resi- 
dence in a hospital. APPENDIX. 
“ Of the two hundred and eighty recovered and improved 
patients discharged during the past biennial period, all of the 
women and most of the men would have been much more 
certain of remaining permanently well mentally, if they could 
have spent a month or two in a convalescent home. 
‘'Among the unintelligent and illiterate, the desire to leave 
the hospital as soon as possible is very strong, and this is 
shared and often exceeded by the anxiety of the family or 
relatives. A convalescent home, therefore, as a half-way house, 
would act as a check upon this eagerness to get away from 
the restraint of hospital life, and which, on account of lack of 
room and facilities, bears unnecessarily hard sometimes on 
convalescents. 
“For the same reason that they are useful for patients suf- 
fering from general disease (State) convalescent homes or 
cottages would be advantageous for the insane, • and they 
should be under the control of the hospital in order to keep up 
the necessary regime, as convalescent patients do not have 
much self-control and need constant stimulation to engage in 
useful occupation and activity to prepare them to again take 
up the responsibilities of life.” 
From Dr. John W. Ward, Medical Director of the New Jersey 
State Flospital for the Insane, Trenton, N. J.: 
“Such an undertaking is most commendable, and excellent 
in theory, but I much fear would be attended with almost in- 
superable difficulties in being carried out in this country. It 
is worth a trial, however, for its object is humane, and I will 
gladly render any assistance in my power to further the object. 
“As a private charity, I fear that the results would not be 
as successful as we should wish them to be. It might, how- 
ever, be successfully carried out if the State assumed the 
charge and cost of the work. As a matter of fact, it would be 
economical to the counties from which such patients are sent 
and to the State as well, in those States that give State aid in 
the maintenance of the insane. 
“A State convalescent home should not be a department 
of the State hospital, but should be under a separate manage- 
ment. Hospitals could and should co-operate, but not have 
any part in the control. This should not be located in the 
immediate vicinity of the hospitals, and others than the of- 
ficials of the hospitals should be made responsible for the man- 
agement. 
“It is difficult to give a specific, definite answer as to num- 
bers; possibly eight or ten patients were discharged from this 
hospital in the past year who might have been benefited by an 
after-care association.” APPENDIX. 
From Dr. Henry M. Wetherill, Secretary of the Committee on 
Lunacy of the Board of Public Charities of Pennsylvania: 
“I consider the plan to extend relief or after-care to indigent 
insane, who have been discharged from institutions, an excel- 
lent one for any community which contains a considerable 
number of persons requirnig it. 
“ As a rule, the indigent insane of Pennsylvania have homes 
to which they return after residence as patients in hospitals or 
other places, or they are admitted to the institutions at the re- 
quest or instance of Boards of Directors of the Poor, or County 
Commissioners, to- whose care they return when discharged 
from institutions, so that for the State at large I feel that, as a 
generally applied charity, this plan would operate in favor of a 
relativey small number. Ido think, however, that this plan of 
relief would apply with considerable benefit if tried in such 
large and crowded centres of population as Philadelphia, Pitts- 
burg and, possibly, Scranton and Erie, the two latter because 
one is the centre of an immense floating, foreign, mining and 
laboring population, and the other touches the lake traffic. It 
would seem, also, as though Pottsville, the centre of hard coal 
production south of the Lehigh, might also afford a useful relief 
station. For a beginning, the localities offering the best fields 
for trial would be Philadelphia and Pittsburg. I am free to say, 
however, that this relief would apply even in these to a relatively 
moderate number in any year, if the benefit were to be re- 
stricted to the absolutely needy and homeless. As in dispen- 
sary work, there would be a rush for relief on the part of the 
friends of some discharged subjects whose after-care should be 
a home and family duty, and discrimination and selection of 
cases would involve much time and trouble, yet this should 
deter no one from extending relief to proper subjects. 
“I believe that the plan, if tried, should be started in the most 
favorable locality—Philadelphia—and as a private charity, be- 
cause the work is, so far, entirely experimental and might be 
considered by some to be rather Utopian. Ido not think that 
State aid should be invoked to start such a work. The indi- 
gent insane of this State require very much at this time, both 
as to increased accommodations and facilities for thorough 
classification—questions of State aid which touch their well- 
being far more closely than the subject of their after-care. 
“ In Usitine our public institutions for the insane I see a 
moderate number of uncured, indigent patients who might 
leave the hospital if there were any home or place for them to 
go, but most of these are near the large cities. As to such 
chronic insane, it must be remembered that the State Asylum 
for the Chronic Insane, at South Mountain, Berks County, 
contains man? such cases, as I have taken care, in selecting its APPENDIX. 
population, to place homeless, friendless, chronic, working pa- 
tients therein. The capacity of the asylum is eight hundred. 
‘T hope that what I have said here may be of some ser/ice to 
you in the question under discussion, but I cannot help feeling 
that, except in one or two cities, this plan would have but a 
limited application. I believe that, in twenty-five years more, 
it would have a much more extended one, unless the broken- 
down, defective and insane poor from other countries are pre- 
vented from landing on our shores.” 
From Dr. Peter M. Wise, Chairman of the State Commission 
in Lunacy and formerly Superintendent of the St. Law- 
rence State Hospital, Ogdensburg, N. Y.: 
“I think your questions are all answered in the little paper 
I enclose, as far as lam able to answer them. My opinions 
have not changed materially since writing it. 
“I sincerely believe, however, that any attempt on the part 
of the State, or municipalities to do this work, would result 
in failure. It calls for a personal effort that only comes with 
a volunteer service.” 
“ ‘The desideratum would be the combined and harmonious 
efforts of science and benevolence in the direction of attempt- 
ed work, and in a gratifying measure successfully accom- 
plished in the Parisian after-care institution. After-care must 
necessarily be free from the jurisdiction of government, either 
State or municipal; hence it must be voluntarily accepted .by 
the patient. Conditional discharges from asylums could be 
made for periods varying with the requirements of each case, 
such periods to be determined by the opinion of the psychia- 
ter, and hence free of sentiment and based entirely upon the 
history of the attack and its exciting cause, and also upon, a 
required knowledge of home conditions. The latter can gen- 
erally be measured with considerable accuracy during earlier 
convalescence, provided the confidence of the patient is in- 
vited. A change of residence that might be considered as 
upon the road towards home, providing discharge were condi- 
tional upon it, would not be difficult, I apprehend, of receiving 
the approval of the patient. Friends would necessarily be 
treated as they deserved, and in the larger number of cases 
could be reasonably apoealed to upon the argument of future 
health and mental stability. It is, however, the home need 
for the patients’ labor that at once establishes both the ur- 
gency of the call for them in the earliest days of convalescence, 
and the greatest danger of relapse in the dependent insane that 
form the mass of our insane population. The strain of living, 
working and worrying for others is taken up at that period in 
the healing process when any strain is dangerous. A hus- APPENDIX. 
XXXI 
band, upon whose labors depend the family living, and a wife 
whose household ministrations seem an absolute necessity, 
are oft-told tales for us. These form, I believe, the com- 
moner instances of relapse in otherwise hopeful cases. Then, 
too, there is a considerable proportion of cases that have 
broken down under bread-winning efforts; that are wholly 
dependent upon labor for subsistence, and that have no* home 
or refuge to serve as a medium between the hospital and re- 
newed struggle. These are the cases for which our London 
brethren have enlisted their sympathies and have given their 
aid, and are especially the subjects for charitable cognizance. 
“ ‘But it has not been my intent to either propose methods or 
make a charitable appeal. I want to impress my belief that a 
large proportion of relapses are the result of premature dis- 
charges, and are avoidable by some means of care interposed 
between the asylum and the home, or the irritation—whatever 
it may be—in order to permit organic recovery and renewed 
evolution of psychical integrity and “resistance.” I believe 
this need is as absolute as the tender care required for the ul- 
cerated insulse Peyeri in typhoid convalescents after the re- 
turn of the appetite and the healthful feeling. It cannot be 
ignored and until we lend our countenance to reform in after- 
treatment by “after-care,” we cannot expect any reduction in 
the proportion of those who relapse after first recoveries.’ ” Press of Raff & Co 
512 TO 516 WEST 41ar STREET, 
NEWYORK.