REPORT. 
To the Senate and General Assembly of the State of New Jersey: 
The committee appointed under concurrent resolution of the One 
Hundred and Twelfth Legislature of New Jersey to inquire into and 
investigate the management, government and discipline of the State 
Asylum for the Insane, at Morristown, N. J., would respectfully sub- 
mit the following report: 
Your committee was appointed by virtue of the following resolu- 
tion : 
“Whereas, Charges directly affecting the management, govern- 
ment and discipline of the State Asylum for the Insane, at Morristown, 
New Jersey, are made in the public prints and otherwise; therefore, 
“Resolved, That a special committee, to consist of three members of 
the Senate and five members of the House of Assembly, be appointed 
to inquire concerning the management, government and discipline of 
the State Asylum for the Insane, at Morristown, N. J., and whether 
any, and if so what, action should be taken in the premises.” 
By a joint resolution passed subsequently to the passage of the reso- 
lution above quoted, your committee were authorized to sit during the 
recess of the Legislature. 
Eight entire days were consumed in taking, with the aid of a sten- 
ographer, the testimony of witnesses upon the matters involved in the 
inquiry. One hundred and twenty-four different persons were exam- 
ined as witnesses, and some of these were recalled and re-examined 
several times. The testimony so taken, as written out by the stenog- 
rapher, covers over 1,400 type-written pages. 
Your committee explored every quarter where it was suggested or 
seemed to them likely that information could be gained touching the 
matters under investigation. Every person suggested from any source 
as likely to be able to give testimony of importance, except where such 4 
REPORT OF INVESTIGATING 
testimony appeared to be unnecessarily cumulative, was sought out and 
examined, if his attendance before the committee could be procured. 
The charges referred to in the preamble of the resolution under 
which your committee was appointed, were found to be of two kinds— 
one affecting the official integrity of Martin B. Monroe, the Warden 
of the Asylum, and accusing him of dishonest conduct in making 
large sums of money by exacting bonuses and commissions from per- 
sons furnishing supplies to the Asylum, and also in using for the pri- 
vate supply of himself and his family articles bought and paid for by 
the State for Asylum uses. The second class of charges related to the 
business conduct and management of the institution under Mr. Mon- 
roe’s wardenship in various particulars that will be more fully stated 
hereafter. 
As to the first class of charges, your committee are happy, for the 
credit of the institution and of Mr. Monroe, to be able to report that 
they are unanimously of the opinion that these charges are entirely 
unfounded. 
Nearly all the principal dealers that have furnished supplies to the 
Asylum during Mr. Monroe’s term as Warden were called, and testi- 
fied that the houses they represent had never allowed to Mr. Monroe, 
or to any one for him, either directly or indirectly, any fee, bonus or 
commission whatever, for the custom given them by Mr. Monroe; 
that Mr. Monroe had never asked for or suggested any such compen- 
sation, and that as a matter of fact Mr. Monroe was so close and care- 
ful a buyer that they could not have afforded to take such a course, 
had they so desired. The firms whose representatives were examined 
with the result above reported, comprise such eminent and reputable 
names as Thurber, Whyland & Co., John S. Martin & Co., and H. 
D. Van Nostrand & Co., of New York city. Adding to this that 
Mr. Monroe denied under oath, in the most emphatic manner, ever 
having asked or received anything whatever in the way of bonus, 
commission or drawback from persons of whom he bought supplies 
for the Asylum, as well as his testimony that he had never saved 
above $500 in any one year since his connection with the Asylum, 
and the fact that neither from the evidence nor from the suggestions of 
his accusers could anything be discovered to show that he had amassed 
any property disproportionate to his salary and position, we have the 
most justifiable grounds for affirming his entire honesty and fidelity 
to his trust in these particulars. COMMITTEE ON MORRISTOWN ASYLUM. 
5 
The alleged instances of the procurement by the Warden of various 
articles of household and domestic use for his private needs out of the 
public supplies, are all entirely and satisfactorily refuted by the evi- 
dence and explanations produced on his behalf. These allegations 
were apparently due to misconstruction on the part of discharged 
employes of facts of which they had only very imperfect knowledge; 
and your committee are of the opinion that this misconstruction was 
not wholly devoid of a malicious and vindictive purpose towards 
Mr. Monroe. 
The charges against the business management and conduct of the 
Asylum under Mr. Monroe’s wardenship, though not preferred in the 
first instance by Dr. E. C. Booth, the Medical Director of the Asylum, 
were first formally stated to the committee by that officer. They were 
presented in writing. We quote here so much thereof as is necessary 
to show the charges made : 
“ FOOD. 
“ The first abuse in the management of the Asylum to which we 
call attention relates to the food of the attendants and patients. We 
do not hesitate to say that in the last three years food has very fre- 
quently been supplied to feed our patients and their attendants which 
was unfit to be supplied to human beings in any institution whatsoever. 
The fault in the food begins in the purchase of supplies. Large 
deliveries have been made to the Asylum of meat unfit for use, which 
ought never to have been accepted from the seller. The quality of 
the butter supplied has been usually very poor. The milk, eggs, oat- 
meal and other sundries have varied from time to time, but have often 
been bad. The evils arising from poor supplies have been aggravated 
by negligence and incapacity in the kitchen department. The prepa- 
ration of food for so many people requires not only special skill and 
knowledge, but also intelligent and careful supervision. While there 
have been many faithful employes in the kitchen, who have done their 
best with the poor material furnished, yet the general management has 
been negligent and incompetent. The orders for special diet are among 
the most important duties of the physicians. If they are not obeyed, 
the physicians might as well be dispensed with. These orders can 
only be carried out through the kitchen. To carry them out requires, 
care and system, but no more than is found in every well-conducted 6 
REPORT OF INVESTIGATING 
hotel. Under the present system the physicians and attendants have 
found that they cannot rely on obedience to their directions, and this 
may be attributed partly to indifference to duty and partly to a willful 
disposition to show an independence of authority of the medical depart- 
ment. The instances of this character are very numerous and will be 
established by the supervisors and attendants. The negligence and 
lack of skill and system in the store-room and kitchen result in the 
sending to the wards of quantities of spoiled and wormy food, not 
only unfit, but dangerous to eat, which no sane person could eat. 
Details can be supplied by abundant evidence of the attendants, who 
have often refused to place before their charges the nauseous prepara- 
tion sent up from the kitchen under the name of food. The food sup- 
plied is also deficient in quantity. This complaint arises chiefly in 
the male department, and details can be established by abundant 
testimony. 
“the laundry, 
“ Next in importance to the food of the patients is their clothing. 
Cleanliness is simply vital. The mismanagement of the laundry is 
equally striking with that of the kitchen. The amount of clothing 
destroyed or lost, often the property of private patients who pay lib- 
erally for their support, is too great to be overlooked or explained. 
This grievance is particularly felt among the female patients, and will 
be shown by lists made by attendants of goods lost or injured in the 
laundry. It is a very common thing for patients to receive packages 
by mail or express. To prevent the introduction of improper articles 
sent by injudicious friends it is necessary to supervise the opening of 
these packages. This is a very delicate duty, which needs to be exer- 
cised with tact, and, as a rule, by means of the kind personal relations 
between patients and attendants or physicians, the supervision can be 
exercised by them without annoyance to patients; and this was long 
the practice. Under the present management the packages are opened 
by the Warden before they come to the attendants, and this often causes 
much excitement and anger among the patients. The reason given for 
the change is that a record should be made of the property brought in 
by patients, but in the opinion of the physicians, if there were no bet- 
ter ground than this to break open these packages, it would be no more 
justifiable than for the proprietor of a hotel to ransack the baggage of 
his guests. The physicians and their assistants alone can judge what COMMITTEE ON MORRISTOWN ASYLUM. 
7 
articles each particular patient may properly receive, and they can also 
be trusted to attend to the important duty of furnishing a list of prop- 
erty which needs to be accounted for without going into details. As 
to other departments, we charge generally that the clothing supplied 
is insufficient in quantity and of a poor quality and of a uniform cut, 
needlessly irritating and therefore injurious to indigent patients. The 
tailor-shop is managed without the good results shown in former years 
to be easily attainable. The garden and farm do not furnish to the 
table of the Asylum the fresh and abundant supplies available from 
these sources under proper management. Repairs in the wards are 
long neglected, and when made are made or sometimes carried on 
without due regard to the comfort and convenience of the patients. 
The proper requisitions of the medical department for drugs, furniture 
and supplies for wards and patients are habitually neglected. That 
many of the single items which go to establish the charges are petty 
is inevitable.” 
To ascertain the truth concerning these charges formulated by Dr. 
Booth, your committee examined Dr. Booth himself and all the medi- 
cal assistants then employed in the Asylum, together with almost all 
the supervisors, attendants and other employes in the medical branch 
of the institution, and many of the other persons either then or there- 
tofore employed there. As the result and a summary of the evidence 
upon these points, we would report that, while it is not true that such 
frequent or gross delinquencies occurred in the kitchen, store-room or 
laundry departments as would be inferred from the language of Dr. 
Booth’s charges, yet it is true that, dating principally from some time 
in the fall of 1887 and extending to a time near the commencement of 
our investigation, there were instances more numerous than is excus- 
able of improper articles of food served out from the store-room and 
meat-house to the kitchen, and prepared and served to the patients 
and employes. 
These articles include meat, oat-meal and eggs. To give an idea 
of the nature and frequency of such instances we refer to the evi- 
dence of Miss Julia Murphy, one of the supervisors. She kept a 
memorandum of occasions when improper food was served in her 
department. Her observations were begun to be noted down in June, 
1887. The instances noted by her from June 6th, 1887, to the date 
of her testifying, April 17th, 1888, were as follows : 8 
REPORT OF INVESTIGATING 
Jane 6th, hash condemned by Dr. Russell. 
June 9th, oat-meal had worms in it. 
June 9th, at dinner, milk was sour. 
February 9th, 1888, sour oat-meal, continuing to February 16tli. 
February 26th, apple-sauce had worms and bugs in it. 
March 6th, roast beef too rare to be eaten. 
April 13th, potatoes soggy. 
These are all the instances noted by her; though she says there 
were others she did not put down; that they only put down the un- 
usually bad instances. 
Dr. Andrew McFarlaue, an assistant physician, also took notes. 
As he was somewhat active in pressing the charges contained in Dr. 
Booth’s statement, we give here so much of his written testimony 
read to the committee as will show the instances that he deemed of 
enough importance to record : 
“On February 27th, 1888, the mutton in 1-2 hospital ward, 
where old, sick and feeble men are confined, was tainted and not 
eaten; it smelled badly and was thrown in the swill barrel. The 
mutton stew in 3-4, about twelve weeks ago, was so tainted and had 
such a bad odor that it was thrown away. On March 5th the corned 
beef on 3-4 was most of it fat and gristle, with a bad odor, and was 
most of it not eaten. The beef-steak is usually very much overdone, 
and so dried up that there is no nourishment in it. March 25th 
the patients on 2-1 could not eat the roast beef because it was im- 
properly prepared, being entirely too rare. The corned beef, if not 
tainted, is very uninviting, having much fat, gristle and bone, and 
often not near enough lean, good meat for the patients. This is 
almost always the case, and the meat has been very much complained 
of, especially about the mutton as being green and tainted. 
“Now, about the extra meats. The roast beef that is ordered is 
usually uninviting, and invariably it is not properly prepared. 
There is a great deal of fat and gristle about it, and the lean meat is 
very small in comparison with the amount of the beef sent up. Jan- 
uary 18th, 19th and 20th the roast beef that came up as extras for 
private patients on ward 3-1 north, was not fit to be eaten, over 
three-fourths of it was fat and gristle.” 
These records may be taken as affording a fair statement of the 
frequency of the instances when notably bad food was served. There COMMITTEE ON MORRISTOWN ASYLUM. 
9 
were doubtless other instances not recorded by these witnesses, per- 
haps not occurring in their departments. Taken in connection with 
the other evidence, too voluminous to be quoted, they go to show that 
there was a lack of care or supervision in the kitchen and store-room 
that resulted in the serving of improper food more frequently than is 
excusable. We believe that on at least two occasions meat was 
received at the Asylum that should have been rejected and returned 
to the seller. One was the lot of veal received in October, 1887, and 
the other was the lot of mutton received and used in February, 1888. 
That any of it was used in an unfit state we think is due to the 
butcher and to the cook. It appears that Mr. Monroe’s orders to the 
butcher were never to send any meat to the kitchen which was not in 
first-rate condition. It is hardly credible that Mr. Monroe would 
knowingly permit spoiled meat to be served; and the evidence of all 
the reliable witnesses goes to prove that he was not informed of these 
two specific instances. 
We believe, also, that on several occasions worms may have been 
bred in oat-meal or flour, and served up to the patients in that 
condition. Also, that water bugs found their way into the food ; 
that spoiled or stale eggs were sometimes given out; and that other 
articles of diet were sometimes spoiled or infested with foreign bodies. 
All these things will happen even in the best-regulated families, as 
every housekeeper knows. It is the* frequency or infrequency of 
such things that determines the good or bad quality of the house- 
keeping. 
From the fact that all the witnesses agree that the service and food 
had much improved in these particulars since the charges under ex- 
amination had been made public, it is safe to infer that there was 
culpable fault theretofore in the kitchen management. 
The quality of the cooking was also greatly complained of, and we 
think it very likely that i*» that matter there has been a good deal of 
just ground of complaint. During the period covered by the com- 
plaints which are in evidence, the kitchen was never under the charge 
either of a really competent cook or of a Steward. Had there been 
a competent cook, the complaints of overdone and underdone meats, 
poor beef-tea, &c., would not have been so frequent. Had there been 
a Steward to supervise and inspect all articles of food before they were 
cooked as well as after, there would have been little chance for the 
occurrence of those instances of complaint that have been referred to; REPORT OF INVESTIGATING 
10 
and had they occurred, the responsibility could have been fixed at 
once on the cook or Steward, and the recurrence of the complaint 
avoided. 
During the progress of this investigation, and as soon as practicable 
after these complaints of bad food and bad cooking were brought out 
before the committee, the Board of Managers secured the services of 
a first-class cook and superintendent in the kitchen, and appointed a 
qualified store-keeper ; and we are glad to be able to assure the Legis- 
lature, that under these arrangements, the food is now prepared in a 
manner that is beyond criticism. 
The inquiry naturally arises, why was not all this remedied before ? 
The Board of Managers are charged by law with the employment of 
proper officers and servants, as well as with the management and con- 
trol of the whole institution. Prior to the year 1885, the Medical 
Director had the charge (of course under the control of the Managers) 
of the whole institution; both the medical and the business department. 
In 1885, by act of the Legislature, it was provided that the Managers 
should appoint both a Medical Director and a Steward or Warden. 
The Medical Director was to have charge, direction and control of all 
the patients and of all persons engaged in the care of patients in the 
Asylum ; the Steward or Warden was to be the General Manager of 
the Asylum buildings, grounds, and farm, with the furniture, fixtures 
and stock thereto belonging, and to perform such other duties as 
should be assigned to him by the Managers, subject to the by-laws, 
rules and regulation prescribed by the Managers. This is what is 
known as the dual system. The management of the institution in 
both departments was vested in the Board of Managers, gentlemen 
appointed on account of their business capacity and high standing in 
the State, who serve without compensation. Both the medical and 
business departments were completely under their control. The Board 
has always comprised among its members, a large proportion of phy- 
sicians, ranking among the most eminent in the medical profession of 
the State. The Legislature and the people of the State expected, and 
had a right to expect, that with the ample powers given them by law, 
these Managers would do whatever was necessary to make this insti- 
tution a model among Asylums, and a source of pride, as it is an 
ornament, to the State. If reform was necessary in the kitchen, or 
laundry or anywhere else, the Managers were the agents of the State 
to make the reform, and it was the duty of any officer in the institu- COMMITTEE ON MORRISTOWN ASYLUM. 
11 
tion, having knowledge of faults or deficiencies, to report them to 
the Board for correction. 
Your committee, upon receiving Dr. Booth’s written presentment 
of delinquencies in the business department of the institution, very 
quickly, therefore, desired to find out why the Board of Managers 
had not corrected the evils complained of. They asked Dr. Booth if 
he had ever complained to the Board respecting the matters contained 
in his written charges, and detailed in his testimony. We copy here 
his evidence on that point: 
“ Q. Did you ever complain to the Board of Managers on this sub- 
ject? 
“A. I have complained to the Board of Managers of this. 
“ Q. Well, have you ever made formal complaint to the Managers? 
11 A. I did make formal complaint in, I think, October, 1886, a 
few months 
“ Q. Was there any improvement after that? 
“A. For a short time things were better; I think that they gave 
directions; that they endeavored to ameliorate matters, I am satisfied. 
“ Q. Have you never complained since then ? 
“A. Not to them as a Board, but I have told individual members 
from time to time, things were going about the same; I told Dr. Var- 
ick and Mr. Lewis about it; I often told Dr. Varick, who is now 
dead, and I have, I think, told other members. 
“ Q. There have been three or four physicians on the Board of 
Managers all the time, have there not ? 
“A. I should say so; yes, there have been several. 
“ Q. Dr. Jackson, Dr. Green, Dr. Varick, Dr. Clark? 
“A. And Dr. Hendry. 
“ Q. Well, these matters are such as would be easily appreciated by 
a physician, are they not ? 
“A. I think so. 
“ Q. Why did not you present the matters formally to the Board, 
as often as you had occasion to complain ? 
((A. The Managers told me that matters would be remedied after 
making these formal charges—set charges. 
u Q. The last formal complaint you made to the Board, was 
in October, 1886 ? 
“A. Yes, sir. 12 
REPORT OF INVESTIGATING 
“ Q. Has there been any understanding between you and the Board 
of Managers, that you should make a report to them, when anything 
was in trouble ? 
“A. The Board of Managers have inquired how things were going 
on in the house, had not inquired otherwise, and I have never told 
the Board of Managers, in any one instance, things were going on 
well in the house; they would ask how things were going, and I have 
told them they were going just about the same; that, I think the 
gentlemen will say, has been my habitual and general remark; they 
have not asked me particularly about it, and I have not gone on to 
explain what was the state of things; I have a great many letters 
from friends, imploring me to let the patients themselves open their 
parcels. 
“ Q. Have you laid that matter before the management ? 
“A. Yes, sir; I laid that matter before Dr. Yarick. 
“ Q. But not before the Board of Management ? 
“A. Not as a Board of Management; I have felt a little diffident 
in bringing frequent charges to the Board of Managers, since the 
failure of my charges in 1886 ; I felt the management would think 
I was captious and fault-finding, and I have endeavored to get along 
without, for that reason, and I believe it has been the only reason I 
have been able to stay for the time I have; I have put up with a 
great many things in that and other respects.” 
Mr. George A. Halsey, President of the Board of Managers, and 
Judge Banta and Dr. Green, members of the Board, testify that they 
never knew or heard of the complaints of bad food until the charges 
appeared in the newspapers just prior to the appointment of this 
committee. 
We understand Dr. Booth to testify substantially that he never 
brought these complaints of bad food and cooking to the attention of 
the Board. He says something in an indefinite way about having 
told Dr. Yarick, a former Manager, now deceased, about ‘‘these 
charges,” but it is scarcely credible, and hardly in keeping with the 
high sense of public duty we know Dr. Yarick to have possessed, to 
believe that Dr. Booth could have told him “that in the last three 
years food was frequently supplied to feed the patients and their 
attendants which was unfit to be supplied to human beings,” and 
that Dr. Yarick should not have taken prompt action to investigate COMMITTEE ON MORRISTOWN ASYLUM. 
13 
and remedy the evil, or at least to impart the information to his asso- 
ciates on the Board. 
Dr. Booth gives as a reason for his failure to make complaint to 
the Board, a statement of the history of a complaint against the 
Warden, made in October, 1886, which he alleges was not properly 
investigated or considered. Remarking in passing, that nothing in 
that complaint related in any way to improper food or cooking, we 
give here the complaint of 1886, as then submitted in writing: 
“ (1) I charge the Warden with a disposition to carry on the affairs 
of the Asylum as if he were the only head, which, indeed, he has 
declared himself to be. 
“(2) With encroaching upon the department of the Medical Di- 
rector, and with contempt for his authority. 
“ (3) With discourtesy and insult towards the medical officers. 
“ (4) With breeding insubordination among the attendants and dis- 
affection among the patients. 
“(5) With hindering the successful operation of the institution by 
inefficient management of his own department, as regards supply of 
special diet to patients on physicians’ orders, care of clothing while 
in the laundry and its return to the wards, attention to requisitions 
and orders from the Medical Director. 
“ (6) With unwarrantable interference of his subordinates in the 
management and discipline of the wards.” 
It will be observed that five out of six of these specifications 
relate to matters of alleged encroachment and interference by the 
Warden in and upon the domain of the Medical Department. These 
charges were referred to a special committee consisting of Judge 
Banta, Dr. Varick, Dr. Jackson and Messrs. Halsey and Meeker. 
The action of the committee is thus detailed by Judge Banta in his 
testimony : 
“ On the 22d of October the committee met; Dr. Varick and Mr. 
Meeker were absent. Dr. Varick wrote me that he would not come, 
that he had an engagement which prevented him from coming. On 
that day the committee had before them Dr. Booth and Mr. Monroe; 
they heard the statements of both of those gentlemen, and I think 
that ended their investigation for that day. The next meeting of 
this committee was on the 27th of October. Dr. Varick was then 14 
REPORT OF INVESTIGATING 
here; Mr. Meeker was absent on account of sickness in his family. 
Dr. Varick had been informed of what had been done, and I think 
Dr. Varick sent for Dr. Booth and Mr. Monroe, and in the presence 
of both of them, Dr. Varick, in his short and emphatic way, asked 
them if there was any difficulty in getting along in the future, and 
both of them said they thought there was no difficulty at all, and 
that ended the whole thing, and we supposed that they would in the 
future get along very nicely; we supposed that it was a mere matter 
of misunderstanding, or something of that kind, and there was really 
no report made by the committee of investigation; they supposed 
they were both men of sense and would use their sense in getting 
along pleasantly. 
“ From that time until the 7th of July, 1887, not a word of complaint 
was ever heard by any member of this Board, or, at any rate, not 
officially, not as a Board. Dr. Booth then made some complaint 
before the Board, the nature of which I do not understand, because I 
was not present at the time; but I know that a resolution was offered 
(I was then present) by Dr. Green that the Warden and Dr. Booth 
should confer, I think the resolution said, on the morning of each day, 
with regard to their duties and work. I think that resolution is on 
July 7th, and that was the last we ever heard of any complaints. No 
other complaints were ever made to the Managers. The Managers 
never heard of any bad food being furnished the institution. Offi- 
cially, at any time, not one single word concerning bad food, or rotten 
eggs, or tainted beef, or wormy flour, or bad cooking, ever came before 
this Board. The Board simply understood the difficulty between the 
Warden and Dr. Booth to be one of conflict of authority or jurisdic- 
tion, and they supposed by smoothing over the rough edges, there 
would be no difficulty in their getting along. 
“ I read from the minutes of the meeting of the Board of Managers 
of July 7th : 
“ On motion, the following resolutions, by Dr. Green, were acted 
upon separately, and each passed by a unanimous vote: 
“Resolved, That it shall be the duty of the Medical Director and 
the Warden to meet each other daily, at some regularly-appointed 
place and hour, to arrange and consult about the business and interests 
of the Asylum, in order that their separate departments may be har- 
moniously conducted.