THE CHRONIC INSANE. EXTRACT FROM REPORT OF DR. WALTER KEMPSTER, MADE TO THE TRUSTEES OF THE Northern Hospital for the Insane. PRINTED BY ORDER OF THE BOARD. OSHKOSH : ALLEN & HICKS, Printers and Stationers. 1878. RESOLUTION, Passed by the Board of Trustees of the Northern Hospital for the Insane, at their Quarterly Meeting, held fanuary io, 1878. Resolved, That the Superintendent procure the printing of one thousand copies, in pamphlet form, of that portion of his Quarterly Report referring to the printed exti'act from the forthcoming report of the State Board of Charities and Reform. EXTRACT FROM REPORT OF DR. KEMPSTER. ( The statistical portions of the Report are omitted.) To the Board of Trustees of the Northern Hospitalfor Insane: Gentlemen—I have the honor herewith to present the Quar- terly Report of the Hospital. At this time it seems necessary to call your attention in an official manner to certain statements which are going the rounds of the press and which purport to be extracted from the forthcoming report of the State Board of Charities and Reform, relative to the cost of main- taining the insane, and with reference to the recommendations of cer- tain persons whose names are therein quoted as favoring a certain plan of providing for one class of the insane. The extract which was printed in The Milwaukee Sentinel of January T, 1878, is the one alluded to, and it is, in brief, incorrect in every statement made rela- tive to the subjects therein discussed; and the figures given relative to cost, etc., in each and every paiticular, are either stated through igno- rance or are willful perversions of the truth. To go back a little. It has been evident for some time that more room was needed for the treatment of the insane of this State, and you will recall that from the time the first annual report was issued from this institution until the present, this subject has been discussed in each, and the necessity for increased accommodation made a promi- nent topic. From first to last the same plan has been persistently adhered to, except that in the report for 1877, instead of asking for an appropriation sufficient to accommodate the insane in this district, you took a broader view, and asked for a sum sufficient, as you believed, to accommodate all the insane in the State not provided for, merely extending the same plan which for three years has been pre- sented to the State Board of Charities as economical, and endorsed by almost every person of experience on both continents, including Dr. 4 EXTRACT FROM REPORT OF DR. KEMPSTER. John B. Chapin, the superintendent of the Willard Asylum, at Wil- lard, New York. This plan, however, the Board did not think pru- dent to recommend, and each year the State Board has recommended a plan, each being so widely different from the other, that it is impos- sible to divest oneself of the thought that the subject must have been discussed by a new set of men each time. For instance, you will recall that in the report of the Board of State Charities for 1872, the statement was therein made that the north wing of the Northern Hos- pital being nearly completed and ready for occupancy, this would accommodate all the insane of the State then unprovided for, and fur- ther extension of this Hospital would not be necessary. When, how- over, you took steps to ascertain the number of insane then unpro- vided for, it became apparent that if the south wing had been ready for occupancy at that time, it would not have accommodated the insane of the state, and upon a proper representation of these facts to the Legislature of 1874, the first appropriation was made for the south wing, and in 1875 it was completed. The next year, there still being a large number of insane unpro- vided for, you recommended the erection of wings for their accom- modation. The State Board of Charities recommended that the State Prison be re-arranged and the chronic insane placed therein. Their next recommendation was to build a structure of some kind on the grounds of the State Hospital at Madison; this also fell through. Now they recommend that this hospital be transformed into a recep- tacle for chronic insane, and all acute cases to be sent to the hospital at Madison, “because that institution is large enough to accommodate all the acute cases of insanity in the State now, and thereby a great saving of money would be effected.” We shall examine this part of the subject further on. Without entering at length upon the discussion of a subject which has been worn threadbare — I mean the discussion of the question of separating the acute from the chronic cases and making provision for each class in separate institutions •—I will simply state that this plan meets with the unqualified disapproval of nearly every superintendent of long experience in this country and abroad, and is not recom- mended by Dr. Chapin, Superintendent of the Willard Asylum for Chronic Insane, as I will show directly by his own words, notwith- standing the State Board of Charities state that he does so recommend. The case is stated clearly and concisely by Dr. E. T. Wilkins, who EXTRACT FROM REPORT OF DR. KEMPSTER. 5 was sent out by the State of California to examine and report upon the conditions of the insane in the several countries of the world, as well as in the United States. In his report made after his return, he states that he visited 149 insane asylums in complete working order: 45 in the United States; 1 in Canada; 15 in Italy; 3 in Bavaria; 7 in Austria; 11 in the German states; 2 in Switzerland; 13 in France; 8 in Belgium; 3 in Holland; 24 in England; 10 in Scotland and 7 in Ireland, a larger number, probably, than has been visited by any other single person. He took full notes of what he saw, and his con- clusions have, with those whose experience entitles their opinion to any consideration, the weight of authority. In speaking of separation he says, (Page 164 of his Report)'. “ Candor compels us to say that our observations of the results of the two systems forces us to the conclusion that separation is wrong in principle, and detrimental to the best interest of the insane.” He says further, (Page 165), relative to the institutions for chronic insane which he visited: “That at Ovid, on Lake Seneca, in the State of New York, with its splendid location and beautiful and picturesque surroundings, especially impressed us most favorably;” but “we failed to discover, however, even the shadow of a reason why a per- son becoming insane in the neighborhood of this beautiful asylum, should be sent to Utica because he was considered curable, and that one in Utica should be sent to Ovid, because the reverse of this was true. * * * They should be as successfully treated at one asylum as the other; while it is too plain a proposition to require argument, that economy of transportation and convenience to family and friends would be best subserved by keeping them at the asylum nearest their homes. * * * With regard to the results of treatment, the facts elicited are altogether in favor of non-separation: the percentage ot cures being less, and that of deaths greatest, in those countries where the system of separation is most generally pursued.” — (See Report Dr. E. T. Wilkins to Gov. Haight, of California, December, iS’yi.) Again, Dr. Pliny Earl, Superintendent of the Northampton Asy- lum, in Massachusetts, who has never been accused of extravagance in the management of his hospital, and whose reports are a thorn in the flesh of those persons who advocate expensive structures, who has twice been abroad for the express purpose of visiting institutions, the last visits having been made subsequent to those of Dr. Wilkins, says after an exhaustive review of the whole subject: “The brief limit of 6 EXTRACT FROM REPORT OF DR. KEMPSTER. time forbids any further development of the objections to separate establishments for incurables, further than to ask if we may not learn something from the Germans, who, after this matter had been sub- jected to exhaustive discussion, came to the practical result of construct- ing nearly all their largest and most recently erected institutions upon the plan of treatment of both classes under one roof.” Dr. John B. Chapin, the accomplished Superintendent of the Wil- lard Asylum for Chronic Insane, says in his sixth annual report to the Board of Managers of that Asylum for the year ending 1S74, on page 34, after discussing the subject of further provision, as follows: “ Again the practice of discharging the chronic and incurable insane poor should be changed. We believe it is entirely practicable to attach to all asylums supplemental departments, in which the tranquil and harmless cases can he made comfortable, made much more so than in any almshouse organization, and on economical plans.” Again, if I can read language aright, Dr. Chapin maintains and defends the position which all other superintendents of this country contend for, in the very quotation made by the State Board in their extract; for, says Dr. Chapin, in this very extract, that institutions should be “organized [I quote] and managed under the same laws, to secure efficiency, as are found best adapted to the successful working of the existing asylums and hospitals, and should also be divested of all the influences and associations which attach to an alms-house. An adherence to these principles will secure the successful admitiistra- tion of an asylum, whether designed for the reception of recent or chronic cases, and a departure fro?n them will as surely result in low- ering the standard of careP What are we to understand by such language? If it does not mean what it says, then we must get the State Board to translate the English language, and tell us what Dr. Chapin does mean. As it stands it appears to me to be perfectly plain. Without quoting further from the annual reports of Dr. Chapin, we find that, running through each of his annual reports, he reiterates the ideas presented in the quotation above given. He insists that in every essential particular the asylum at Willard, so far as cubic space is concerned, must be made to conform to existing institutions else- where — the only departure, according to the doctor’s statement, being in cost of construction and in cost of maintenance. Further on EXTRACT FROM REPORT OF DR. KEMPSTER. 7 we shall see how it compares in that respect with the cost of con- struction and maintenance here. Following up this subject a little further, we find that the State Board of Charities in New York, in their report for 1874, after hav- ing watched the operations of the Willard Asylum for eight years, and being thoroughly and practically familiar with all its details, rec- ommend as follows. I quote from the Eighth Annual Report of the Board of State Charities of New York, Page 27: “It is shown by experience that most of the counties cannot be expected to make suit- able provision for the care of their chronic insane. This does not grow out of any feeling of inhumanity or disregard of the claims of this unfortunate class, on the part of the county authorities. The small number of the chronic insane in a majority of the counties ren- ders it very expensive to furnish suitable buildings and employ proper attendants. The Board, therefore, does not deem it advisable to encourage the county authorities, generally, to provide for the chronic insane, but on the contrary, rather to discourage the undertaking. It is believed that it will be found much better and less expensive to give this class proper treatment and care in State institutions, where the number of inmates accommodated may be so large as to reduce the maintenance to the minimum per capita rate. This result may be obtained by the establishment of two or three additional asylums, in different parts of the State on the plan and character of the Willard Asylum, or by engrafting the principles of that institution upon all the State asylums now having the care of acute cases only. The lat- ter flan is recommended by the Board as being much more economi- calfor the State, and well designed to meet the wants of this class of insane. It will require the erection of no expensive buildings for offices, and for the separate treatment of violent cases, as the asylums referred to already have those accommodations. It will insure to the chronic insane the best medical skill without additional expense, and also save large sums now paid for the transfer of this class from the asylums for acute cases to the counties, or the asylums for chronic cases.” Unb'ke the State Board of Charities in Wisconsin, the New York board seemed to have determined upon a definite plan, and to have adhered to it year after year, for in the next report, the ninth annual report of that board I find (Page 26) that they reiterate the same opinion expressed in the eighth annual report, and quote the language 8 EXTRACT FROM REPORT OF DR. KEMPSTER. used in the eighth report, which I have given above, re-affirming their opinion that it would be better to provide for the chronic insane by making suitable provision for them in all State institutions, erect- ing suitable buildings in connection with the hospitals for their care and maintenance; and this scheme meets with mv approval. The erection of separate institutions, especially for the care of the chronic insane, is objectionable on many grounds, which it is not necessary to repeat here, but when persons are thus treated in groups or classes, the individuals themselves are lost sight of, an unhealth}' moral atmos- phei'e is created — a sort of mental epedemic induced, where delus- ion and debility and extravagant insane ideas are propagated from individual to individual, and the intellect is dwarfed and enfeebled by monotony, routine and subjection, and when to these evils we super- add the double stigma of pauperism and bicurability, all hope is extinguished in the breast of the patient, his self-respect is impaired, and his irretrievable degeneration secured. Truly, over the gateway to such an institution, should Dante’s inscription to the portals of hell be written, “ All hope abandon, ye who enter here ! ” All are aware of the powerful influence of hope in recovery from any disease, and the disastrous consequences of its opposite, despair. In no class of maladies are the beneficial effects of desire, joined to the expectation of recovery, more manifest than in insanity. Deprived of auspicious hope, branded with incurability, under the two-fold burden of disease and despair, the sufferer from chronic insanity drags through his miserable life, and as if this were not enough, the stigma of pau- perism is to be affixed, forgetting the fact that pauperism is generally the result, and not the cause of insanity. The great majority of patients in all asylums come from the industrial producing classes. Rendered unserviceable by no fault of their own, stricken in God’s providence by disease, it is deliberately proposed to add to this burden the load of pauperism, and stamp his brow with the brand of incura- bility; and then, with a deliberation that even Shylock might envy, coolly calculate how little money it will take to eke out a miserable existence — and this to be done in the name of charity and humanity. A fair inference to draw from such logic would be, that it would cost the State less to dispose of them altogether than to keep them at all; and it would then be a question as to the difference in cost of gun- powder, strychnine or hemp rope. 9 EXTRACT FROM REPORT OF DR. KEMPSTER. The people of the State of Wisconsin have wisely concluded to make the insane the wards of the State, that there might be no traffic- ing in the misfortunes of men, no bartering about the cure of disease. The State Board of Charities were impressed with the same view in 1876, for I find in there Sixth Annual Report, {Page id), these words: “The question of wealth or poverty in the case of lunatics should not, therefore, enter into consideration in the least. The mere fact of the pressure of mental disease in any citizen, should make him the ward of the State, so far as his person is concerned, until the disease is removed. He should be made comfortable and receive intelligent treatment at the public expense, without regard to his previous social position.” Again they say: “The incident of insanity is one against which science offers no certain guarantee to anyone. The busy classes are most liable to it, but leisure even does not offer perfect immunity. Once in its power, the most vigorous person is more helpless than the weakest of those who have the full use of their minds. The helpless- ness of insanity is such that the victim is often ignorant of his own wants, and even when knowing them is frequently unable co make them understood by others. * * He walks about under the impres- sion of a waking nightmare, and if not under proper care he has his burden made greater by the ignorance or carelessness of those with whom he comes in contact. Even if he comprehends a wrong done to him, and can tell it, his story will generally be considered as the off- spring of a delusion, and no attention will be given to it. * * * So far as his own welfare is concerned, he is utterly helpless, alike in the hands of nature, and in those of his fellow men.” Judging from the recommendations of the Board as made in the extract referred to, we should infer that the chronic lunatic, being in this wretched, helpless and most forlorn condition which they have so graphically described in the report for 1876, they can now relegate him to such an institution as they picture, without fear that he will ever find fault with it, or if he does its no matter, because what he says is delusion, and will not be believed. It is virtually saying to you, to me, to every citizen of this State: “ Have no care; should misfortune overtake you, the broad charity of this great State will take such good care of you that you need not go abroad to find shelter in a pri- vate institution, where you may be subjected to outrages and cruel wrongs, and where your substance will be wasted. Our public insti- tutions shall be so conducted that every comfort, every care that can 10 EXTRACT FROM REPORT OF DR. KEMPSTER. be procured for you, regardless of your previous social standing, or wealth or poverty, shall be provided for you; but then, having got you into our power, $2.83 per week, or less, if we can wring it out of less, must furnish you with all the aforesaid luxuries and comfortable maintenance, and you must not find fault, either, or if you do it don’t make any difference, for ‘ You are only a pauper, whom nobody owns,’ and if you do make complaints they are to be regarded as delusions and emanations from a weak brain.” Indeed, putting the statements of the Board in their Sixth Annual Report alongside of the recommendations made in the forthcoming report, and it is difficult to conceive that both recommendations should have emanated from the same body; but on turning to the title page, we find the same names. In a certain class of minds, we find that the standard of cheapness is the standard of excellence, and this same spirit seems, at present, to imbue the State Board of Charities of Wisconsin. Had they extended their investigations they could have found one institution in this country where the insane were kept for nine cents a day, and as this method seems to be the one they are in search of, this particular institution to which I refer would probably have become the standard instead of the Willard Asylum. To be sure, the death rate in the institution referred to was more than 200 per cent, greater than in any other institution in the country, but then, this, I suppose, must be regarded as another economical measure which would relieve the tax- payers. In discussing this question of economy, it is well enough for us to ask who it is that complains of the cost of caring for the insane, whether acute or chronic. Where do the complaints arise, and who are the persons making them? In all my experience, now extending over a period of twelve years, I have never heard one of the patients complain that too much had been done for them. I have never heard a person who had been a patient complain that too much had been done for him, that too much money had been expended upon him; and I have never heard the friend, or father or mother, or sister or brother complain that too much had been done for the sick one. I have never heard a member of the community from which the patient came, complain that too much had been done in behalf of the extract from report of dr. kempster. 11 sick one, or that too much money had been expended upon him. On the contrary, in one of the State institutions in this country with which I was formerly connected, which deservedly stands at the head of sim- ilar institutions in this country, and where the cost of maintenance is nearly double what it has been here, the constant cry was, on the part of friends, “spare no expense, do eyerything that money can com- mand; let no effort be untried.” And my experience in this institution has been precisely similar. No father or mother, no husband or wife, when pleading with me to use my every effort to restore the afflicted one, has ever suggested that I could possibly get along with a smaller sum than the usual price, although the patient might be chronic. I do not find that hope dies from the heart of a mother, because her child is called “chronic.” That word means nothing to her. She sees somewhere beyond a restored child — the wife, a restored husband — and relies upon the bounty of the State, under providence, to bring about the restoration. The complaint that we do hear most frequently is, that there is not enough done for the insane, that they are not fed well enough, that they are too cold, that there are not a sufficient number of attendants to permit that liberty of movement which is of so much importance in maintaining the health of the individual. I repeat, that it is not from the patients nor from their relatives or friends, that we hear com- plaints that it costs too much; and in all my experience, the only per- sons who have complained, have been the members of the State Board of Charities. And I am confident that if a member of the family of either of the gentlemen composing that Board should be so unfortun- ate as to be afflicted with this dread disease, the last thought would be, “ what will it cost to get them well.” I am confident, that no money, no expense of time or labor would be taken into account, so long as resloration was in view; and if, forsooth, disease had fastened too deeply upon the sufferer for mortal man to aid, that fact alone would not deter them from demanding the utmost that could be compassed to insure the welfare of the afflicted one, whether the disease was acute or chronic. It is one thing to figure out, in cold blood, to the farthing, just how little it will cost to keep some one else’ father or mother, or brother, wife or husband, and another to figure for your own; and we dont find that the father or mother, or husband or wife complain of the taxes they pay to support these institution, especially as it costs only 12 EXTRACT FROM REPORT OF DR. KEMPSTER. three-fifths of one mill on the dollar of the taxable property of the State to support them all, at the full rate of $4.50 per week; and to keep all in the State, assuming that there are 1500, it would cost only fourteen-fifteenths of a mill, at the same rate of $4.50 per week. In the report of the State Board of Charities of Wisconsin for 1871,1 find the following: “No one complains that the inmates of our State Hospital fcr the Insane are too well taken care of, or are made too com- fortable. No good citizen of our State can visit this hospital, pass through its clean, well-regulated wards, witness the care and kind treatment received by its inmates, and see the evidence of their comfort and well-being, without feeling thankful that he is a resident of a State that has made such noble provision for this unfortunate class of its inhabitants; and although he may be a large tax-payer, instead of com- plaining that so much has been done, the predominant feeling in his heart is a desire that, if possible, still more may be done for their com- fort and restoration.” Again, “We hope that when the hospital at Oshkosh is completed, that sufficient accommodation may be found for them all, but if not, that the State will not stop building and enlarg- ing until this end shall be fully secured.” This differs somewhat from the Report of the present year. Thus fiir I have spoken only in a general way about separation of the classes, that is, the acute and chronic cases from each other, and have endeavored to determine from whom complaints arise as to cost of maintenance, and in concluding this part of the subject, I can not withhold the conviction that the people of the State of Wisconsin always have been, and are now, ready and willing to make good, thor- ough provision for all classes of insane; they have assumed the care of them, by making them the wards of the State, and I have yet to learn that this assumed guardianship has become a burden grievious to be borne, and when it does so appear, doubtless the State will so inform the friends of the insane, that they may provide suitable places for them elsewhere, and thus throw off or rather give up the moral responsibility that now attaches to their care — a step not likely to be taken yet. It now remains to look into some of the assertions made by the State Board of Charities, to determine whether they are corrector not. I have stated above that Dr. Chapin does not recommend the exten- sion of the plan of the Willard Asylum beyond its present magnitude, EXTRACT FROM REPORT OF DR. KEMPSTER. 13 but does recommend that the asylums of New York be enlarged by adding to them suitable structures in which to care for chronic cases. And this recommendation is iterated and re-iterated in the reports of the Board of State Charities of New York, for the years 1874 and i875- The extract already alluded to states that Dr. Nichols, the Super- intendent of the National Asylum at Washington, D. C., had aban- doned the theory “ that associated treatment of recent and chronic cases is necessary, and has begun the separation in the institution under his charge.” The Board of State Charities would evidently have us believe that Dr. Nichols advocated separate establishments for the care of the chronic insane. This is not the fact, and the Board of Charities know, or at least ought to know, that the statement made by them, to say the least, is incorrect. Dr. Nichols has never advocated the construction of separate institutions for the care of the chronic insane. His voice and pen have always and everywhere denounced this plan in no measured terms, as the file of reports of the institution with which he was for so many years connected will show. And when this subject was under discussion in the Association of Medical Superintendents, Dr. Nichols said: “This subject was so fully consid- ered in my last report that I am sure the gentlemen will know what were mv opinions at that time. If I were to write it again, I can only say, I should use a little stronger language than I did then, on the same side of the question. * * * If the chronic insane are going to require about as much food, about as much clothing, about as much warmth in winter, about as much fresh air, and all these things, as the curable insane, I think when we are treating the curable insane we can take care of the chronic insane with more economy, really, than they could be cared for in a separate institution. I speak for myself, when I say that our expenses for the supposed curable insane, and for the chronic insane treated in connection with each other, are less than it would be possible to provide for them separately. * * * Then in regard to the Willard Asylum, about which so much has been said, I should like very much to understand whether it is to be a cheaper institution than the ones already existing in New Hampshire and Vermont. If I am correctly informed, it is likely to be more costly. I understand that more money has been expended for the site than has been paid for that of any other asylum in the United States.” Again, “ My opinion is very decided that all our insane should be 14 EXTRACT FKOM REPORT OF Dli. KEMPSTER. provided for in regular asylums, as many of the chronic insane require more warmth and ventilation because their condition is such, with less vigor of circulation, that more warmth and more fresh air is abso- lutely necessary than for curable patients. * * * I only desire to put myself on record as not having changed my opinion upon this sub- ject.” And in order to put himself more fully on record in reference to this subject, he offered a series of resolutions, drafted by himself, which were adopted by the Association, one of which reads as follows: “All State, county and city hospitals for the insane should receive all persons belonging to the vicinage, designed to be accommodated by each hospital, who are affected with insanity proper, whatever may be the form or nature of the bodily disease accompanying the mental dis- order.” Another is as follows: “ The enlargment of a city, county or state institution for the insane, which, in the extent and character of the district in which it is situated, is conveniently accessible to all the people of such district, may be properly carried, as required, to the extent of accommodating 600 patients, embracing the usual propor- tions of curable and incurable insane in a particular community.” From this it does not appear that Dr. Nichols is at all equivocal in what he has to say on this subject. These remarks were uttered some years ago, but the Doctor has not changed his views in the least, except as to the size of the institution, for in an address “ On the best mode of providing for the subjects of chronic insanity,” which was delivered by Dr. Nichols at the International Medical Congress, held in Philadelphia in September, 1876, he says, in reference to the cure of the insane, and with particular reference to their labor: “ The insane may be much, benefitted by labor, and may be also greatly injured by it. Compulsory labor would cause the rapid and cruel sac- rifice of many of the insane, both of the acute and chronic class. The condition of the brain, and the probable effects of labor upon it, should be carefully considered before each patient is put to work, and the effects of his work carefully watched. The medical judgment that prescribes and regulates the labor of the insane, should be as able and critical as that which prescribes the drugs that are administered to them; and a medical staff accustomed to consider the conditions under which a large number of subjects of both recent and chronic insanity may labor without detriment, if not svith advantage, will become more acute and just in its discriminations and less liable to fall into injurious errors, than a staff of less experience in this particular,” Again, “ In EXTRACT FROM REPORT OF DR. KEMPSTER. 15 estimating the necessary conditions of the best provision for the sub- jects of chronic insanity, it should be borne in mind that this is pre- cisely the same disease, in its nature and phenomena, as recent insan- ity : they differ only in duration. In the proportion of cases of pas- sive dementia, and in the prospect of restoration, it follows that the active forms of chronic mental disease require precisely the same treat- ment as the recent, The protection of society and the individual, and the mitigation of the pains and privations of disease, are as much demanded in the case of the chronic maniac, whether his mania be constant, recurrent, periodical or epileptic, as in that of the recent; and it stands to reason that a medical staff constantly accustomed to treat insanity with the expectation of curing it, is likely to be better pre- pared, both by knowledge and habit, to treat chronic disease for its alleviation, than one whose professional efforts in the exclusive treat- ment of chronic disease are very rarely rewarded by a full restoration. * * * The theoretical grounds of the rule that all public institu- tions should receive the subjects of both recent and chronic insanity' are sustained by the crucial test of experience. Nearly every institu- tion in Christendom is to-day occupied by cases of every variety, dura- tion and manifestation; from the last admitted, in which the outbreak occurred but a short time ago, to the most hopeless case of fatuity.” I know of none which receive only recent cases and discharge them when they become chronic. “ Not only was the subject of the care and treatment of the victims of chronic insanity fully discussed, both in Great Britian and on the continent of Europe, long before the question became an urgent one in this country, but, after trying vari- ous experiments in separating, to a greater or less degree, and in vari- ous ways, the acute from the chronic cases, the Europeans have, as I understand, come back to what in England is called the 'public asylum, and here the state asylum or hospital systemP This proposition (of caring for all classes of insane in one institution,) is not only sustained by the practice of the institutions of both the old and new world?, but by the authority of the ablest and most experienced men in the speci- alty. Among readers of the English language, the names of Dr. Buck- nell and Dr. Robertson, of England, and Dr. Earle, of this country, are best known in this connection. To these opinions may be added also the weight of the combined European and continental observers; for we find in the Blue Books of England, Scot- land and Ireland, that the commissioners of lunacy appointed by the 16 EXTRACT FROM REPORT OF DR. KEMPSTER. home government for the special purpose of looking into this, and all other subjects connected with the economical and humane administra- tion of the elemosynary institutions, advise against the separation of the two classes of cases, and recommend the erection of new, or the enlargement of old district asylums, which are similar to the State hospitals in America, and under the same general form of manage- ment. Surely if time and long experience are guides of any value, we have both here. The result, it appears however, does not accord with the experience of our State Board of Charities. Again he says: “ If a sufficient number of district institutions already exist, they can be enlarged both so as to retain all the patients whom they do not cure, until they die, if their condition require it, and to receive the alms-house patients at less expense than would be incurred by providing for them other independent central or district asylums of a proper kind, and if there are not enough district institutions to make them practically accessible to all acute cases, they certainly should for reasons that have been given, be provided as rapidly as possible with accommodations for all the chronic insane cases of the vicinage.” He says again: “ It has been said that the States will not incur the outlay necessary to provide institutions with such appointments and management as are deemed necessary for recent cases: but this dec- laration is shown to be unfounded, by the activity and liberality which is displayed at this moment by the greater number of the leading States, in establishing excellent district institutions for all their insane, of both the acute and chronic classes.” Again he says: “ When a district institution contains as many as 600 patients of both sexes, and the number is likely to be considerably increased, a second complete set of hospital buildings should be pro- vided in the same neighborhood, and if practicable on continuous grounds, and the sexes separated by retaining one in the old buildings and placing the other in the new.” And this is the only kind of sep- aration that Dr. Nichols does favor. Again he says: “Edifices occupied by the insane should be, at least, neat and cheerful in appearance: and their construction of dura- ble materials in the most enduring manner will prove most economi- cal in the end. Cost should be held subordinate to every essential sanitary provision, as drainage, ventilation, the supply of light, heat and water, and abundant room and means of classification; and just in EXTRACT FROM REPORT OF DR. KEMPSTER. 17 proportion as such provisions are subordinated to necessary cost in the construction and fitting up of buildings for the insane, do these become custodial receptacles, which deny to their inmates the benefits of hos- pital treatment.” This does not seem to be an abandonment of a “ theory ” held by Dr. Nichols. Dr. Nichols built two wings connected with the National Hospital while he was superintendent, in which to provide for chronic insane, but they are in strict conformity to the plans he mentions above, and are just such wings as you recommend in your last report to be added to this hospital. I have visited and inspected the wings, and Dr. Nichols fully coincided in my views respecting the enlargement of out State hospitals, as expressed in my former reports, and made these statements, and gave the cost of construction of the wings at Washington to one of the members of this Board of Trustees, who visited that institution with me. So far as Dr. Nichols is concerned, the Board of State Charities have either been grossly misinformed, and upon a subject of this im- portance there can be no excuse for so direct a misstatement as they make, or else, for some purpose the Board is attempting to mislead the public, by putting into the mouths of public men the words they would like to have them use. It is not worth while to discuss the opinions of Dr. Wilbur, to whom the Board refer in their report, for he has never been connected officially or in any other way, with any hospital for the insane in the United States or abroad, and is now, as he has been for many years, at the head of an idiot asylum in the State of New York. Dr. Cha- pin’s opinion has been quoted above. I come now to speak upon that part of the subject which the State Board of Charities have misrepresented in nearly every particular, and the misrepresentations they make can not be excused upon the score of ignorance, because the source from which they have derived their information must be either the Report of the Board of Trustees and Superintendent of Willard Asylum, or else the Report of the Board of State Charities of New York, and in both these documents, from which I propose to quote presently, I find that the per capita cost of main- tenance as given both in text and figures, is altogether different from the amount stated in the extract from the Report of the Board of State Charities of Wisconsin. 18 EXTRACT FROM REPORT OF DR. KEMPSTER. But, first of all, as we propose to briefly examine the whole subject, let us look for one moment at the cost of construction of the Willard Asylum as compared with the cost of construction of other institutions for the care of both acute and chronic cases in other paits of the Union, and let us see on which side the economical features appear. As it will not be necessary to burden you with a long list of figures, as to the cost of a number of institutions in the country, I will here name the institution, the number of patients and the per capita cost of construction, the figures being taken from a schedule prepared by Dr. J. S. Conrad, superintendent of the Maryland hospital for the insane. Patients. Per capita. Vermont Asylum for Insane, . 450 Brick. $666 00 Worcester Lunatic Hospital, 365 “ 721 00 Boston Lunatic Hospital, 200 “ 500 00 Taunton Lunatic Hospital, 5°° “ 820 00 Kings County Lunatic Asylum, N. Y., 650 “ 923 00 Willard Asylum 900 “ 942 00 New Jersey State Lunatic Asylum, 500 Sand Stone. 556 00 Pennsylvania State Lunatic Asylum, 400 Brick. 750 00 Western Lunatic Asylum, Virginia, 376 “ 583 00 Indiana Hospital for Insane 600 “ 833 00 Minnesota Hospital for Insane, 500 Stone. 960 00 Northern Hospital for Insane, 550 Brick. 900 88 Many other institutions might be taken from this list, some less in per capita cost than those quoted above, and some more, but I have taken the average, and from different sections of the country. In reference to the cost of the Northern Hospital, the figures do not quite agree with those given by Dr. Conrad, but as this hospital was not completed when he made his schedule, and has been completed since, I have taken the liberty to give the figures just as they are. It will be observed that of those hospitals quoted above, with but one exception, they have cost less per capita to build them than it had cost at Willard up to that time. But it will be said that Willard Asylum was not complete when this schedule of Dr. Conrad’s was made out, Granted, but we will examine this more closely directly, and see if it alters the facts. Without going into details further, I find the average cost of forty- seven institutions for the insane in the United States, including Wil- lard and our own hospital, was $925 per capita; this figure excludes those very expensive hospital structures in New York, New Jersey, EXTRACT FROM REPORT OF DR. KEMPSTER. 19 Massachusetts and California, about which so much has been said and written, and which are not likely to be duplicated at present. l ean not procure definite data as to the exact cost of the Willard Asylum proper. I mean the main structure, consisting of the center building, lateral wings and rear building, somewhat similar to this structure, and which has accommodation for 500 patients. The appropriations from time to time have been made in the aggre- gate, for putting up main building and putting up detached buildings, but near as I can ascertain, the Willard Asylum proper, i. e. the main building, cost about $1,400.00 per capita. The subordinate struc- tures, call them by what name we choose, have all cost more than $500.00 per capita—some have cost more than this without the item of furniture, and some a little less. We are to remember also that when the State took possession of the grounds, there was then already built upon the premises what was known as the agricultural college building, which provided accommodation for 200 patients, by simply furnishing the college building, and this fact must be taken into the account in reckoning the per capita cost. Now, the main building at Willard, cost from three to four hund- red dollars per capita more than the institution here; and the subor- dinate buildings, excepting the college, have each cost from five to six hundred dollars per capita to finish, and this does not include the large items of expenditure necessary to put bakery, gas works, pumping apparatus, laundry, engine and boiler room into such a condition as to fit them for supplying the various wings and subordinate structures with heat, light, laundry work, &c., &c., and which have been made from year to year, to meet the demands. The fact then is, that it has cost about $350 per head more to con- struct the main building at Willard, than it has cost at this institution, and about $475 per head more than the average cost of forty-seven institutions in this country, and that the cost of the subsequent struc- tures has been considerably larger than the estimates made by a skilled architect, for the proposed wings here. Let us look at it in another way: The total cast to the State, per head, of all treated at the Willard Asylum from its opening until the close of 1876, has been $662.28. The figures are taken from the Report of the State Board of Charities of New York for 1877. The total cost to the State of Wisconsin for all treated in this institution, 20 EXTRACT FROM REPORT OF DR. KEMPSTER. including buildings of every description, fences, furniture, and in short the entire expenditure for all purposes, has been but $661.37, and this is in the face of the fact that the Willard Asylum has been in operation twice as long as this institution, and of the further fact that each year reduces the expense in accordance with the whole number treated. Let us look at it in another light: Taking the total amount of money received for all purposes at the Willard Asylum lor the year ending 1876, less the balance on hand, and we find the weekly per capita to be $4.97. The total amount of money expended here at this institution for all purposes, during the year ending 1876, shows the per capita cost to be $4.35. We come now to that part of the extract of our State Board of Charities which can not be characterized in any other terms than as a flagrant perversion of truth. The Board of Charities, in the extract alluded to, state that the “ Willard Asylum in western New York supported more than a thousand chronic cases during the year 1876, at an average weekly cost of $2.83 per capita.” Neither the State Board of Charities of New York, nor the Board of Trustees of the Willard Asylum, nor the Superintendent of the Willard Asylum, make any such statement, and I challenge the State Board of Charities of Wisconsin to furnish the proof of their asser- tion, correct their error, or stand branded with a word easily spelled, quickly written, but which would sully the pages of this report. Neither in 1876 nor in any other year since the Willard Asylum has been founded, have the inmates of that institution been kept upon the amount named by the Board of State Charities of Wisconsin,- which they must know full well, if they have ever read the docu- ments emanating from that asylum or its officers, or the report of the New York Board of Charities. As the Board quote from the Report of the Willard Asylum for the year 1876, it is to be presumed that they have read it, and there- fore have wilfully perverted the facts and figures contained therein, the amount named ($2.83) being taken from the middle of a sentence, the balance of which explains the fact that the patients were not kept for the sum they name. On Page 24 of the Eighth Annual Report of the Trustees of the Willard Asylum, for the year 1876, there are these words: “The average weekly cost of maintenance, exclusive of clothing, which is EXTRACT FROM REPORT OF DR. KEMPSTER. 21 charged to each patient as issued, and exclusive of salaries of resident officers which are provided by legislative appropriation, was $2.8354, and including salaries and clothing, $3.20.” An item of $21,962.60 per annum over and above the amount stated by the Board of Chari- ties, being nearly one-third of the amount asked for to run this hospi- tal for the ensuing year. On the same basis, the per capita cost per week in this institution has been, for the same year, excluding the amount spent for perma- nent improvements, which is not included in the Willard report, only $2.66; and including officers’ salaries and clothing, the per capita cost in this institution for the same time has been $3.13 per week, as against $3.20 at the Willard Asylum. In the Seventh Annual Report of the Willard Asylum, for the year 1875, the weekly cost per head, per patient, was $3.48; at this institution, on the same basis, the weekly per capita was $3.26. Now if the State Board of Charities of Wisconsin obtained their information from the Report of the State Board of Charities of New York, they would have seen there, also, had they chosen to see it, that the cost of caring for the chronic insane at Willard, was greater than they state in the extract from their forthcoming report, both for the year 1875 an