OX THE BEST MODE OF PROV JECTS OF CHRONIC I FOR THE SUB- NITY, CHARLES II. NICHOLS, M. D., i \/£ LATE SUPERINTENDENT OF THE GOVERNMENT HOSPITAL FOR THE I^W^NK,^EAU WASHINGTON, 1). C, MEDICAL SUPERINTENDENT OF THE BLOOMING DALE ASV- ."=y^ LUM FOR THE INSANE, NKW TORE, PRESIDENT OF THE ASSOCIATION < >F MEDICAL SUPERINTENDENTS OF AMERICAN INSTITUTIONS FOR THE INSANE. ETC., REPRINTED FROM THE TRANSACTIONS OF THE INTERNATIONAL MEDI- CAL congress, Philadelphia, 1876, with a few explanatory notes, Man lives by reason ; the brute by instinct-. The greater size and com- plexity, and the higher organization, of the organs of reason, render them more susceptible to derangement than those of instinct; while the complex necessities, motives and struggles, which belong to a life of reason, evolve the numerous exciting causes of such derangement just in proportion a> the reasoning being develops his pre-eminent intellectual powers and put- his feeble instinct into abeyance. When reason or motive is perverted by cerebral disorder or defect, man is both a dependent and an aggressive being. The litter incapacity to provide for himself which causes him to be regarded ay an infant in the eye of the law, is more apparent because of its uk^t frequent occurrence at a time of life when he is most independent in bis normal powers, and when both his absolute and artificial wants are nio.-t numerous and pressing. Intensity of purpose and action is often in direct ratio to perversion of judgment or motive, and the insane man is not only disqualified for providing for his numerous want*, but has the inclination. and power if left to himself, to be exceedingly dangerous to life and pro- perty. Insanity is a term used to express the mental symptoms of a phy>ical disease or defect which generally admits of partial relief, and which often admits of entire cure. If cured, the subject of the disease regains all hi- inestimable, human prerogatives—the ability to mingle in society, and free- dom to will and do of his own good pleasure. If relieved, as far as each case admits of relief by the diligent and skilful use of the appliances <>f modern science and benevolence, a life of sickness and privation is rendered 0 comfortable and often measurably happy. Such a helpless, dangerous, priva- tive, and yet remediable when not curable, infirmity, appeals not only to the deepest sympathies, but to the self-interest of the whole race among which it prevails. Insanity is everywhere regarded as the chief ill to which flesh is heir; and it is the sentiment of enlightened Christendom, however imperfectly and variously that sentiment may be expressed, that the insane of all classes should have all their needs provided for, because they cannot provide for themselves; should have the medical and moral treatment that will alleviate, if not cure, their grievous disease; and should, as a rule, be restrained of their liberty, because it is unsafe for them to be at large. If not cured, the pathological conditions of the brain which give rise to mental derangement, rapidly pass into a chronic condition, whose average duration is about equal to one-half of the mean length of human life. The result of efforts to establish by observation and pathological research the relations between the duration of mental disease and its curability, is the practice of classifying cases of not more than one year's duration as recent and presumptively curable, and those of more than one year's standing as chronic and probably incurable. Experience shows that this generalization is useful in estimating the tendencies in respect to recovery, or duration of illness, of large masses of the insane, and the provisions required for their proper maintenance and treatment; but when it is considered that, under the circumstances most favorable to recovery, about fifty per cent, of all the cases of insanity that occur in a community pass this arbitrary boundarv- line which has been set to divide recent from chronic mental disease, while the rapidly diminishing probabilities of recovery are not found to be ex- tinct in individual cases until the expiration of the third or fourth vear after the invasion of the malady, it will be seen that such a generalization can be only an approximation to the truth, with many exceptions. As the re- cent insanity of a community imparts an increment of not far from fiftv per cent, of all the cases-that annually occur, to those of technically chronic mental disorder, while an uncertain period of several vears expires before individual cases become hopeless, the two classes are, for a considerable pe- riod at least, inseparably linked with each other, and either a philosophical or a practical consideration of "the best mode of providing for the subjects of chronic insanity," should obviously form a harmonious part of a com- prehensive scheme of providing for the treatment of insanity of every du- ration and form. In the year 1Sf window in each, communicating directly with the external atmosphere. (11) Xo chamber for the use of a single patient should ever be less than eight by ten feet, nor should the ceiling of any story occupied by patients be less than twelve feet in height. (12) The floors of patients' apartments should always be of wood. (13) The stairways should always be of iron, stone, or other indestructi- ble material, ample in size and number, and easy of ascent, to afford con- venient egress in case of .accident from fire. (14) A large hospital should consist of a main central building, wath wings. (15) The main central building should contain the offices, receiving rooms for company, and apartments, entirely private, for the supeiintending phy- sician and his family, in case that officer reside in the hospital building. (1(5) The wings should be so arranged that if rooms be placed on both sides of a corridor, the corridor should be furnished at both ends with movable, glazed sashes, for the free admission of both light and air. (IT) The lighting should be by gas, on account of its convenience, clean- liness, safety, and economy. (IS) The apartments for washing clothing, etc., should be detached from the hospital building. [19] The drainage should be under ground, and all the inlets to the sew- ers should lie properly secured, to prevent offensive emanations. [20] All hospitals should be warmed by passing an abundance of pure, fresh air, from the external atmosphere, over pipes or plates containing steam under low pressure, or hot water, the temperature of which at the boiler does not exceed 212 degrees Fahr., and which are placed in the basement or cellar of the building to be heated. [21] A complete system of forced ventilation, in connection with the heating, is indispensable to give purity to the air of a hospital for the in- sane, and no expense that is required to effect this object thoroughly, can l>e deemed either misplaced or injudicious. 122] The boilers for generating steam for warming the building, should be in a detached structure, connected with which may be the engine for pumping water and for driving the washing apparatus and other machinery, [23] All water-closets should, as far as possible, be made of indestructi- ble materials, be simple in their arrangement, and have a strong downward ventilation connected with them. [24] The floors of bath-rooms, water-closets, and basement-stories, should, as far as possible, be made of materials that will not absorb moisture. | 25] The wards for the most excited class should be constructed with rooms on but ore side of a corridor not less than ten feet wide, and the ex- ternal windows shorn el be large, and should afford pleasant views. [2(5] AVherever practicable, the pleasure grounds of a hospital for the 0 several classes received by such institutions, whether these different condi- tions be mental or physical in their character. V. The enlargement 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 insane should be surrounded by a substantial wall, so placed as not to be un- pleasantly visible from the building. The following propositions, also offered by Dr. Kirkbride, were adopted at a meeting of the superintendents held in Baltimore, May 10, 1S53:— [1] The general controlling power of a Hospital for the Insane should be vested in a board of trustees or managers; if of a Stateinstitutiem,selected in such maimer as will be likely most ^effectually to protect it from all influ- ences connected Avith political measures or political changes ; if of a private corporation, by those properly authorised to vote. [2] The board of trustees should not exceed twelve in number, and should be composed of individuals possessing the public confidence ; distinguished for liberality, intelligence, and active benevolence; above all political influ- ence ; and able and willing faithfully to attend to the duties of their station. Their tenure of office should be so arrangeel, Avhere changes are deemed ad- visable* that the terms of not more than one-third of the whole number sliali expire in anyone yean [3] The board of trustees should appoint the physician, and, on his nomination, and not otherwise, the assistant physician, steward, and matron. It should, as a board or by committee, visit and examine every part e»f the institution, at frequent, stated intervals, not less than semi-monthly, and at such other times as it may deem expedient, and should exercise so careful a supervision over the expenditures and general operations of the hospital, as to give to the community a proper degree of confidence in the correct- ness <>f its management. [4] The physician should be the superintendent and chief executive of- ficer of the establishment. Besides being a well-eelucateel physician, he should possess the mental, physical, and social epialities to fit him for the post. He should serve during gooel behavior, and should reside on, or very near, the premises, and his compensation should be so liberal as to enable him to devote his whole time and energies to the welfare of the hospital. lie should nominate to the board suitable persons to act as assistant physi- cian, steward, and matron ; he should have the entire control of the medi- cal, moral, and dietetic treatment of the patients, and the unrestricted power of appointment and discharge of all persons engaged in their care ; and should exercise a general supervision and direction of every department of the institution;. [5] The assistant physician or physicians-, Where more than one are re- quired, shoulel be graduates of medicine, of such character and qualifica- tions as to be able to represent and to perform the ordinary duties of a phy pician during his absence. 6 carried, as required, to the extent of accommodating fiOO patients, embracing the usual proportions of curable and incurable insane in a particular com- munity. Xo one of these propositions has since been either repealed or modified, and the experience of the ten years which have elapsed since they were adopted, has fully established their soundness and practicability (except, pos- sibly, in respect to the last, which fixes an arbitrary maximum number of . patients that may be accommodated in one institution), not less than ten States and one Province, if not more, having proceeded to provide for their [6] The steward, under the direction of the superintending physician and by his order, should make all purchases for the institution; keep the ac- counts ; make engagements with, pay, and discharge those employed about the establishment; have a supervision of the farm, garden, and grounds; and perform such other duties as may be assigned him. [7] The matron, under the direction of the superintendent, should have a general supervision of the domestic arrangements of the house, and, under the same direction, do what she can to promote the comfort and restoration of the patients. [8] In institutions containing more than 200 patients, a second assistant physician and an apothecary should be employed, to the latter of whom, other duties, in the male wards, may be conveniently assigned. (9) If a chaplain be deemed advisable as a permanent officer, he should be selected by the superintendent, and, like all others engaged m the care of the patients, shoulel be entirely under his direction. (1.0) In every hospital for the insane, there shoulel be one supervisor for each sex, exercising a general oversight of all the attendants and patients. and forming a medium of communication between them and the officers. (11) In no institution should the number of persons in immeeliate attend- ance on the patients be in a lower ratio than one attendant for every ten patients ; and a much larger proportion of attendants will commonly be ele- sirable. (12) The fullest authority should be given to the superintendent to take every precaution that can guard against fire or accident within an institu- tion, and to secure this an efficient night-watch shoulel always be provided. (13) The situation and circumstances of different institutions may require a considerable number of persons to be employee! in various other positions ; but in every hospital, at least all those that have been referred to, are eleemecl not only desirable but absolutely necessary, to give all the advan- tages that may be lioped for from a liberal and enlightened treatment of the insane. (14) All persons employed in the care of the insane should be active, vigilant, cheerful, and in good health. They should be of a kind and be- nevolent disposition, should be educated, and"in all respects trustworthy, and their compensation should be sufficiently liberal to secure the services'of in- dividuals of this description. 7 insane upon the principles which they enunciate, and to embody them in their statutes. As I have intimated, the best provision for the subjects of chronic insanity should be embraced in a comprehensive plan of providing for the insane of all classes. The above propositions were intended to em- brace such a plan, and, as I prepared them, it will suit my convenience in the treatment of this question to attempt to reproduce the considerations that led to the views which they express; and perhaps this mode of pre- senting the matter will be more satisfactory to the Section, and more useful to the public, than any other. I propose to consider the propositions seria- tim, and to lay particular stress upon the bearing of each upon the care of the subjects of chronic insanity. The first proposition declares that "the large States shoulel be divided into geographical districts of such size that a hospital situated at or near the centre of each district, may be practically accessible to all the people living within its boundaries, and available for their benefit in case of men- tal disorder." The obvious purpose of this is to affirm that institutions for the insane must be within tlie reach of the people whom they are intended to accommodate, in order that their insane may be sent to them ; and it was frameel in view erf the fact that many hundreds of persons suffering from acute insanity had not received tlie hospital treatment that had been pro- vided for them, and had consequently run into the hopeless stages of the disease, because of the long, fatiguing and expensive journeys necessary to reach either the nearest hospitals, or those to which they were entitled to go. It is obvious that the principles of this proposition lie at tlie verv foundation of an adequate provision for the insane, whether the form of their disease be recent or chronic. In an article on " The Use of Insane Hospitals,1'' in the number of the Journal of Insanity for January, 1800, by Dr. Edward Jarvis, will be found a table which shows that, in the course of a series of years, twenty-two institutions in the United States and the Dominion of Canada received annually an average of one patient to 3,974 of the population of the districts in which they were situated, and that the ratio of patients to population constantly and rapidly diminished in every case as the distances from the institutions increased, until an average of only one patient in 18,978 of the population of the fourth tier or belt of counties from the hospital centres, was sent to them. It is not reasonable to suppose that institutions for the insane breed insanity in the populations immediately surrounding them, nor that insanity is of more frequent occur- rence in their near neighborhood than in more remote districts, and hence the only reasonable conclusion is that the remote districts were, solely on ac- count of their remoteness, to a gaeat extent deprived of the use of hospl- 8 tals. This less use of hospitals by distant districts, is eloubtlcss in some part elue to the less acquaintance with their management and benefits than is acquired by people situated nearer to them, but in greater part to the dis- inclination of public authorities, and the inability of friends, to incur the expenses of transporting patients long distances with the neees-ary escorts, and to the apprehended danger to the lives erf delicate persons from the ex- posures and fatigues erf a protracted journey. It follows, as Dr. Jarvis says, that hospitals are somewhat local in their operation, and that, in order that their benefits may be enjoyed in case of need, they must be, in the language of the proposition, practically arrrssi- 11 e to all the poe>ple residing within the boundaries of the district which each is intended to accommodate. A necessity so vital to the urfare of the jierple, hecomes the hounden duty of the State. Xo rule limiting hospital districts to an exact and uniform area, can be laid down. Indeed, it would not be possible to divide the States and Provinces in such a way that a cen- tral institution should not be more or less difficult of access from one or more remote corners erf the district which it was intended to accommodate, but intelligent legislators will in most cases be able to approximately meet the requirements of the proposition, if they are imbued with a sense erf its vital importance to the needs of, an. afflicted class of their constituents. In districting States and Provinces having large areas erf unsettled, or partially settled territory, reference should be had to tlie probable elirection and ex- tent erf tlie growth erf their populations, lest a sufficient number erf institu- tions for the whole area erf the State or Province should be so placed in the original centres of population as not to accommodate the subsequent settle^ ments. Indisputable facts show that tlie remote inhabitants of a district must be able to reach its hospital by a journey that can be made during the waking hours of a single day, or they will not avail themselves of its bene- fits. Such a generalization will aid in the practical solution of this problem, for it will readily be seen that insane persons can be conveyeel to a hospital by railroad from a distance erf 'Seventy-five or a hundred miles with more convenience and less expense than they can be conveyed half that distance by ordinary car'riag>roaeb, and that the number and directions of the rail- roads and the character of the carriage-roads of a proposed district, shoulel have much influence in determining its si/,e and shape, and the situation erf its hospital. The practicability of the early treatment erf acute insanitv will increase the number of recoveries, and proportionately diminish the number erf cases erf chronic insanity to be provided for. This brief discus- sion of this first and fundamental element of all adeepiate public provision 9 for the insane, is, therefore, pertinent to the particular question, under con- sideration. I now come to the second proposition of the series. It is, that all State, county, and\ city hospitals for the insane, should receive all persons that hdong to the vicinage designed to he accommodated by each hospital, who are affected with insanity proper, whatever he the form or nature of the hodily disease accompanying the mental disorder. Except in some of the Xew England States, the ordinary poor of tlie United States are generally maintained in county alms-houses, and, in liarmony with that practice, and mainly from mistaken motives of economy, most county authorities are dis- posed to provide for their insane poor as well as for their other dependent classes. The populous and wealthy counties, whose insane are numbered by hundreds, and are sufficient to fill one or more institutions of suitable size, may properly establish and maintain hospitals of their own, and thus save the cost of transportation, and secure the benefits of local employment and trade, and of easy access. It may with reason be maintained that as State legislators and officials are from their position, if not from their per- sonal character, likely to entertain broader and more liberal views of their duty to tlie sick and unfortunate, and to be less under the influence of petty local strifes and parsimonies, than the officials of the subordinate munici- palities, the States and Provinces should take direct charge of this class of their dependents, so peculiar in its wants and in its liability to suffer from neglect or abuse. There are several county and city institutions the mate- rial appointments and management of which are equal to those of the aver- age State and Provincial asylums, and it is due to truth and professional character to declare, in this public manner, that the unsatisfactory condition of others is attributable to defective means and organization, and not to the very respectable medical gentlemen who now have, or have had, charge of them. Without exception, these gentlemen appear to have discharged their duties with humanity and ability, and with very remarkable industry an el perseverance, in view of the difficulties and discouragaments that have at- tended their work. City institutions for the insane are subject to the same objections as those of the county, and to the adelitional objection that a city will seldom, if ever, be able to afford within its limits the area erf ground necessary for salubrity, privacy, anel cultivation ; and,rather than that a city should go outside erf its territory to establish and maintain an institution for its own exclusive benefit, it would be more feasible for the common au- thority over the city anel neighboring municipalities, to take charge of this sacreel function of government and administer it for their equal benefit.* -There is at this time a conspicuous movement in this direction. During the progress of the construction of the buildings of a State hospital for the 10 To effectively prevent the peculiar abuses that are liable to creep into in- stitutions for the insane governed by local authorities, State and Provincial statutes, with heavy penalties for their violation, should require them to be constructed, organized and conducted substantially as the State and Provin- cial liospitals or asylums are usually appointed and maintained ; and should especially require them to receive, whenever the friends may desire it, the insane of the favored classes in respect to "property, either as pay patients, or as free patients supported, like all others, from the common fund of tlie municipality. One of these courses is pursued by all the State institutions, anel there is no one feature of their organization that is as effective as this in preventing their management from falling below a liberal, curative stand- ard. The poor will generally be well taken care of when they receive such treatment as the middle classes in respect to fortune are willing to pay for, or are satisfied with without payment, except indirectly as taxpayers. The rich will generally be sent to the corporate or private institutions, all the inmates of which are independent, and can more conveniently receive in them such indigencies as their habits and tastes require and their means allow, than they can in large institutions, most or all of the inmates of which are a public charge. The second proposition, in theory at least, solves the question before the Section. The reception and care by every public hos- pital for the insane of all persons belonging to the vicinage—that is, within the hospital district—who are affected with insanity proper, includes, of course, the reception of those whose insanity is chronic, and this is believed to be the best of all the provisions for their care which have been, or are, or possibly can be made, or which have been suggested or advocated. The movement of the insane, under this scheme, will be simply as fob ' lows: The recent insane are promptly placed in district hospitals, and there receive the treatment most conducive to their comfort and recovery. About one-half of them recover, and return to their homes and emplov- insane in Danvers, Mass., which are about to be opened for the reception of patients, it has generally been understood that the Boston (city) Lunatic Ilospitcd would be discontinued and that all the dependent insane of the north-eastern counties of that State would be accommodated in the State institution, but I believe it is yet undecided whether Boston will continue to maintain its own separate provision for its insane or not. Xew York i^ c ecting in or near Buffalo large buildings for the care of the insane of the western comities of that State, including, I believe, the cities of Buffalo and hochester and several other populous towns. Pennsylvania bv appropria- ting at once the whole amount thought to be necessary for the completion of the work, will promptly establish a much-needed hospital for the insane of' tlie south-eastern counties of that Commonwealth, including the <>-reat citv of Philadelphia. & (v"~>i[''Y ' 11 ments, or die, in the course of tlie year that s folio ws their admission; the other half remain where they are Avithout additional expense for transpor- tation, anel continue to receive care and treatment adapteel to the condition erf each case. Those who still give promise erf improvement, are treateel with that enel in view, anel occasionally reward persevering efforts in their behalf by entire recovery of reason ; those who continue to be actively ma- niacal, or melancholic, or who exhibit suicidal, homicidal, or other specially dangerous propensities, anel the paroxysmal cases, whether simple or epilep- tic, receive the care that secures to each case the highest elegree of comfort anel safety of which it is susceptible, and that is as necessary note as in the acute stage of the diseaxe. A few, perhaps ten per cent., of the annual ad- elitions to the chronic members erf the hospital family, pass early into the mechanical, but not always unhappy, life of passive elements, whose bodily habits are regulated, anel whose comforts are ministered to, by the order anel appliances of the institution, while they engage, with more or less interest in its character anel results, in such labor as they are capable of, in the wards, kitchens, laundry and stables, and in the gardens and fields, when the sun is not too hot for their weak brains, nor the air too cold for their feeble cir- eulatiems. The subjects of chronic insanity render considerable assistance in the wards occupieel in part by the recent cases, anel somewhat reduce the number of attendants that need to be employed; while the labor of the in- sane is mostly performed by the chronic patients, the recovery of those who have been recently affected is occasionally much promoted by industrial ex- ercise, and they will here and there fall into a party of regular workers with more facility than they will work either by themselves, or in company with others whose cases are entirely erf their own class. The habitual employ- ment of a large number of patients is calculated to suggest and justify a variety of occupations, among which the recently affected may find those adapteel to their respective capacities. The insane may be much benefited bv labor and may also be greatly injured by it, for compulsory labor would cause the rapid and cruel sacrifice erf many erf the insane, both of the acute and chronic classes. 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 as carefully watched. The medical juehmieiit 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 laro-e number of subjects erf both recent and chronic insanity may labor without detriment, if not with advantage, will become more acute and just in its discriminations, and less liable to fall into injurious errors, 12 than a staff of less experience in this particular. The extreme vicissitudes of the American climate, with its fierce summer heats and depressing win- ter-colds, seem to admit of less labor by the insane in the open air than the more equable climate of Europe. If the disease be more active here than there, as many represent, our insane cannot advantageously work as much, either in-doors or out, as theirs, and yet, if such a sense of the importance of labor as a sanitary measure in treating the insane, especially of the work- ing classes, prevailed here as appears to prevail abroad, the systematic em- ployment of our patients would probably become a constant feature in the administration of our liospitals, with an improvement in the health, con- tentment, quietude, cheerfulness and happiness of their inmates. The scheme of providing for the insane of all classes in institutions situ- ated at or near the centres of limited districts, renders it practicable for the kindred of the chronic patients to visit them occasionally, and, in addition to the immediate happiness which such visits confer, they may open the way to the return of a portion of the snbjects of passive, settled dementia to the care and support of their families. The practice of furloughing pa- tients, which obtains among the English asylums, has been resorted to, to a limitent extent, in this country and the Provinces, If it should here be- come an approved measure, either of treatment or of relief of over-crowdeel institutions, it will be practicable anel frequently resorted to only under the district system. A patient's return on furlough to his home one or two hundred miles from the hospital, must in practice prove equivalent to a final discharge, both from the eustoely and from the oversight of the institution.** The subjects of chronic insanity, to whom the habits of the hospital have become a seconel nature, are efficient aids in maintaining its discipline. Most of the recent patients, admitted one by one, unconsciemsly imitate the companions with whom they are thrown, and readily fall into the order of the hospital, witliout friction, and witliout special instruction e>r exercise of authority which many would excitedly, if not violently, repel. In America, the insane of every elegree of culture and refinement, and of ignorance and rudeness, as well as of every nationality, are received into all our institutions. The character of the institution to which a patient is sent, is mainly eletermined by his mean*, or those of his near friends who may aid him in his extremity. Each class has it* conditiems of happiness : The first for every class, is se»ciety after its kind ; after that, the cultivated -The furlough would not, of course, be likely to be resorted to if the pa- tient's home were 'at such a distance from the hospital that he could not readily be returned to it, should the necessity arise* (\ II. X, 13 demand articles of taste and delicacy, which may be an inconvenienec to the ignorant; the ignorant demand the substantial conditions erf physical com- fort and health, which, by themselves, are bare, deficient and depressing to the refined. After insanity has been under treatment for a year, those cases that are complicated with paralysis and Other indubitable evidences erf or- ganic cerebral disease, may be classed with the cases of four or more years' duration, while cases which exhibit no evidences of organic disease may still be classed among the hopeful, and should be treated as such ; but be- yond tlie rule, which shoulel be inflexibly adhered to, that the violent and turbulent shoulel be entirely separated from the quiet and orderly, all rules of classification in American institutions are, and should be. regarded as generalizations which afford much aid in a proper distribution of the in- mates of each establishment, but from which there must be constant depar- tures in every effort to secure the highest comfort and the utmost allevia- tion of which individual cases are susceptible. As a general rule, epileptics should be placed in one or more wards by themselves, but it would be an unnecessary cruelty to subject a person erf refined sensibilities whose par- oxysms are light and infrequent, to the constant observation of the painful scenes of an epileptic ward. Such a patient may often be an agreeable and useful associate of the convalescents. On the other hand, culture is some- times brutalized by dissipation and disease, and, though not physically vio- lent, the possessor erf early social and educational advantages is sometimes a most unfit associate for real gentlemen and ladies. It must be obvious, and this is the lesson of experience, that sueh a critical classification can be carried into more satisfactory details in the treatment of the collected insane of a community, than in the exclusive treatment of either class, or of a sin- gle division." In estimating the necessary conditions of the best provision for the sub- jects of chronic insanity, it should be borne in mind that this is precisely the same disease in its nature and phenomena as recent insanity. They dif- fer only in duration, in the proportion of cases of passive dementia, and in the prospect of restoration. It follows that the active forms of chronic, mental disease require precisely the same treatment as the recent. The pro- tection of society and of the individual, and the mitigation of the pains and privations erf 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 ":<"By "either class" the great subdivision into acute and chronic cases is referred to. By a " single division " is meant such a sub-class as the epi- leptics, parolyties, passive done ids, and the like* 14 accustomed to treat recent insanity with the expectation of curing it, is likely to be better prepared, 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 institutions should re- ceive the subjects of both recent anel chronic insanity, are sustained by the crucial test of experience. Nearly every institution for the insane in Christ- endom is to-day occupied by cases of every variety, duration, and manifes- tation ; from the last admitted, in which the enitbreak occurred but a short time ago, to the most hopeless case of fatuity. The exceptions are a very few—not, I think, as many as half a dozen altogether—which are occupied exclusively by chronic and presumptively incurable inmates. I know erf none which receives only recent cases and discharges them as soon as they become chronic. The presence of recent anel chronic cases in all institu- tions is, of course, due in part to the retention of cases which were admit- ted when recent, and which have passed to the chronic state ; but it is by no means wholly due to a circumstance so natural and purpe>seless. Not e>nly was the subject of the care and treatment of the victims of chronic insanity fully discussed, both m Great Britain anel on the continent of Europe, long before the question became an urgent one in this country, but, after trying various experiments in separating, to a greater or less degree anel in various ways, the acute from the chronic cases, the Europeans have all, I understand, come back to what in England is called the puhlic-asyhrin, and here the State-asylum, or hospital, system. In fact, if the public in- stitutions for the insane in the United States and the Provinces of the Do- minion were to be distinguished by the character of their inmates in the respect under consideration, they sho\ild be styled asylums for the suhjects of chronic or incur ahle insanity, and if the recent and chronic cases were to be separated, the most numerous class (the chronic) would naturally take the present institutions, which are much too large for the recent, and the pertinent and pressing question of the day would then be the hest provision for the recent or acute insane. Estimates kindly furnished me by 21 super- intendents of the United States, show that, on an average, 12i per cent, of the cases of insanity in 22 States are of less than one year's duration, and the remainder chronic. Five of their superintendents estimate the average ratio of recent to chronic cases of insanity in the Provinces erf Canada to be T.S per cent. As only five of the States maka full provision for all their insane, in institutions having a resident medical head, it may be that the ratio of recent to chronic cases, under treatment in them, is a little greater than in the whole insane population of those States ; but I am more 15 inclined to think that the estimates of recent cases are too high, and will not be borne out by tlie results of treatment. The proposition is not only sustained by the practice of the institutions of both the old and new worlds. but by the authority of the ablest and most experienced men in the spe- cialty. Among readers of the English language the names erf Dr. Buck- nill and Dr. Eobertson, of England, and Dr. Earle, erf this countiy, are best known in this connection. Perhaps a full consideration of the plan for providing for the subjects of chronic insanity, now as fully set forth as the time allowed me will permit, should embrace answers to the objectiems that have been, or may be, made to it. It has been said that the retention of chronic cases in the liospitals in which they have been placed, brings no direct relief to the wretched luna- tics in the county alms-house receptacles. It does not, except by arresting all additions to their number, which would certainly be a great and happy achievement; but the objection is answered by a simple declaration of the obvious truth, that it is less expensive and in every way more feasible to provide for the alms-house insane in district institutions than in any other proper way. It will cost less for the necessary enlargement of buildings and their appointments, and for transportation. If a sufficient number erf district institutions already exist, they can be enlargeel both so as to retain all the patients whom they do not cure, until they die, if their conelition require it, and to receive the alms-house patients at less expense than woulel be incurred by providing for them either 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 cases of the vicinage. It has been said that the States (I do not recollect that it has been said of the Canadian Provinces) will not incur the outlay necessary to provide in- stitutions with such appointments and management as are deemed neces- sary for recent cases; but this declaration is shown to be unfounded-by the activity and liberality which are displayed at this moment by the greater number of the leading States, in establishing excellent district institutions for all their insane, erf both the acute and chronic classes. Five States have provided for every case within their borders not preferably provided for by friends, and others will soon have discharged the same duty. An editorial table in a recent number of tlie American Journal of Insanity shows that the total present and prospective capacity of the institutions for the insane in the United States is for 35.325 inmates, at a cost, according to a table prepared by Dr. Conrad, of the Maryland Hospital, of at least £35,000,00(1, 16 with an annual expenditure, at this time, for maintenance, of &5,n or three of the rules which use arbitrary numbers in expressing their requirements. The increased numbers of the insane to be provided for, anel the larger ratio erf the chronic to the curable inmate's erf our institutiems at the present time, as compared with that of twenty-live years ago, have rendered it ne- cessary and admissible to treat a much larger number of patients in one in- stitution than was then considered proper. Like many institutions of gov- ernment, education and business, those for providing for the insane have grown upon our hands until they have become much larger than was antici- *Miss D, L. Dix, 17 pated when those propositions were framed and adopted. Other things being equal, the evidence of experience anel authority shows that hospitals having 500 patients are managed as advantageously to their inmates, anel quite as economically, as those having half that number; and there is no- thing in experience, nor, to my mind, in theory to show that hospitals con- taining a still larger number of inmates, " embracing," in the language of the fifth proposition of the series of ISM, "the natal proportions of cura- ble anel incurable insane in a particular community," are not equally well managed. Of course it is necessary, anel, I believe, conducive to the wel- fare of patients and the advancement of the specialty, that the ratio of staff- physicians should not only be proportionate to the number and character of the patients, but that the physicians should be charged with more authority and responsibility than they usually possessed twenty-five or more years ago. That they should be men of ability, liberal education, and sound principles, no one will deny. It does not appear to me that the number of assistant physicians required in large institutions for the insane can be determined by a rule of universal applicability, but I think that a proportion of one to one hundred cases of active disease, whether acute or chronic, and one to two hundred chronic cases that are ordinarily quiet and orderly, will, on the one hand, afford no opportunity for the rust and vices of idleness, and will, on the other, be sufficient for the performance of every useful professional office in the medical and moral treatment of the patients, with time for the relaxation necessary to the maintenance of cheerful health, and for profes- sional and general improvement. The prevalent overcrenvding of institutions for the insane, is highly pre- judicial to the welfare of their inmates. Xot only should this be avoided by the provision of ample room for the number of cases under treatment, but the facilities of classification or warel separation possessed by institu- tions which receive all the insane of a community, should considerably ex- ceed those ordinarily provided, in order that, in addition to the usual classi- fication based mainly on conduct and the activity of disease, there she nlel be sub-classes of epileptics, erf dipsomaniacs, of regularly Working patients. and of patients who are too demented, or who, though able, are too indo- lent to work—each of these classes reepiiring some special provision and treatment- In enlarging district institutions, in addition to extending the original structure as far as it will admit, I think that one or more detached build- ings or wards may be desirable in effecting all useful proposes of subdi- vision. I certainly see no objection to them for the use of the epriet classes of agricultural patients, if not placed too far from the main structure, if 18 the topography of the grounds favor the erection of such wards, and if it be thought otherwise desirable; but I should always consider it an indis- pensable condition of good management, that the assistant physician having immediate charge of the inmates of a block or group of blocks, should have such a residence that he could not only conveniently see his patients often, but that lie could be readily consulted at all hours of the day and night. In some cases, the fitness of accommodations might be most economically and conveniently secured by the erection erf new and improved buildings e>n the same grounds with old and imperfect ones, anel the devotion of the former to tlie recent cases and their suitable associates among the chronic, and of the latter to the most hopeless cases or to those belonging to the col- lateral classification which I have recommended. When a district institution contains as many as 000 patients of both sexes, and the number is likely to considerably increase, a second complete set of hospital builelings should be prOvideel in the same neighborhood, and, if practicable, on continuous grounds, and the sexes separatee! by retaining one in the old buildings and placing the other in the new. The buildings for each sex should be separately inclosed, and not much less than half a mile distant from each other, unless a hill or wooel should present a natural barrier to the view and hearing of one from the other. The two sets of buildings being in the same neighborhood, patients of both sexes can at the same time be accompanied to and from thorn by the same friends or officers, anel the same relatives can visit patients of both sexes by one journey, which will not mifreepiently be both a convenience and a saving erf expense. The employment of each sex will conveniently and economically supple- ment that of the other. The men will raise vegetables, milk, etc., for both establishments, and the women may do the washing, mending, etc., for the men as well as for themselves. The separate care of each sex will render admissible many relaxations of the restraints to personal liberty that pru- dence requires when both sexes occupy connecting wings of the same con- tinuous structure. After the separation, the superintendent may remain in charge of both establishments, with an adjunct in immediate charge of each, or there may be an independent superintendent of each, under the same board of management, as circumstances may render most expedient. All public buildings, particularly those belonging to a government of the power and dignity of a State or Province, should present just claims to architectural fitness anel taste. Edifices occupied by the insane should be at least neat and cheerful in their appearance; anil their construction of durable materials, in the most enduring manner, will prove most economical in the end. Cost should be held subordinate to every essential sanitary pre)- 19 vision, as drainage, ventilation, the supply of light, heat and water, and abundant room and means -of classification ; and just in 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 hospital treatment. There is, how- ever, some incongruity in providing highly ornamental and costly structures mainly for the treatment of the insane poor, most of whom have little or no jesthetic capacity to appreciate and be benefited Ivy the extra outlay for that purpose; anel it may be feared that the taste and ambition of legislatures that at one period authorizes the high embellishment, of hospital structures at considerable cost, will at another be accused of extravagance, and that, in the strifes of political parties, such expenditures will be made the pre- text, if not the real reason, for withholding appropriations for the most ne- cessary purposes. Happily, the first cost of the essential provisions for the most humane and beneficial treatment of the insane of the dependent classes, has now been determined by a wide and varied experience, anel is found to be much less than has been sometimes expended for the purpose, and not to exceed the means of any State. What the States and Provinces have already accomplished in this direction, and most of it in the short pe- riod of less than fifty years, while they have been at the same time not only providing their capitols, court-houses, penitentiaries, and other build- ilia's that directly appertain to the necessary functions of government, and also making considerable outlays for institutions for the blind, for the deaf and dumb, and for feeble-minded youth, affords as positive a guaranty as anything that lies in the future can, that at no distant day all of them will adequately care for all their insane poor, as well as no little excuse for what appears to impatient benevolence and sometimes unpractical science, to be inexcusable tardiness in the discharge of their imperative duty. Diseussiox ox Dr. Xiciiols's Pafek. After the reading of the preceding paper, Dr. Isaac1 Ray, of Philadel- phia, said:—The increase of insanity among us has led to much inquiry as to tlie best means of caring for its subjects, who are mostly of the indigent class, with the greatest degree of economy compatible with a proper regard to their comfort and cure. One of the conclusions arrived at by many in- telligent men, some of them superintendents of our hospitals for the insane, is that the larger our liospitals, the more cheaply they may be built and maintained. This conclusion I have always regarded as unsound, and the more the experiment has been tried, the more it has confirmed me in this opinion. True, an institution for 200 patients would, undoubtedly, cost 20 less, proportionately, than one for -10 or 50 patients, other things being equal. But the rule is not absolute. There coines a point where the eco- nomical result is reversed, so that the larger the hospital, the more expex- sive it will prove. Indeed, It would be hard to show how increase in r how the cost erf maintenance is diminished, is not very obvious. True, the cost of one superintendent is supposed to be saved, but, unquestionably, the larger the establishment the larger would be the salary of the superintendent, and as more care and responsibility would be thrown on the assistants, their com- pensation would naturally be increased. So that little, if anything, could be saved in that direction. l^sides, I believe, it is generally understood among those who have had some experience in the financial history erf in- stitutions requiring the expenditure of more e»r less money, that the prac- tice of economy is much affected by the amount of money disbursed. Tlie smaller it is, the more frugally it is spent. In the daily handling of large sums, there conies, as a result of such familiarity, a sort of contempt for small sums not likely to produce the strictest economy. This is human na- ture, and implies no lack of honesty or sagacity. Though not very familiar with the reports of our hospitals, of late years, yet I have the impression that our largest hospitals show no decided advantage over the smaller, in the cost of maintenance. Any little difference in their favor may be, very likely, the result erf other causes. According to the report erf the Willard Hospital, for the year 1S74, the average cost was S3.17 per week, if I re- collect rightly, wheih is little less than it is in some of our smaller State hospitals. And yet it is supposed that in the former the patients are all of the kind that can be properly maintained at the least expense. And this figure is likely to be increased in future years, by the repairs and renewals. always a formidable item in the expenditures, and none the less, certainly'. Where the buildings are cheaply constructed, and all the appointments erf'a makeshift kind. Xor do I see how the expense of construction can be diminished by the plan much favored just now, of having the hospital consist of several builelings, separate anel independent, scattered over the premises, instead of 21 a single structure receiving all the patients under its' roof. The idea that anything is gained by this mode of construction is such an obvious fallacy that one hardly knows how to meet it. It certainly has always been sup- posed that, in building, the less you have erf wall anel roof, the less will be the first cost ; and if that be so, it is self-evident that 20 or 30 patients can be more cheaply provided for in a hall, in the usual way, than in a build- ing designed only for them. Nor does it need any special proof to shew that the expense of warming and Ventilating several detached buildings must be far greater than would be needed for a single one of equal capacity. The fact is obvious at sight. In short, the clamor against •' palatial" struc- tures, to use the popular phrase, is little better than claptrap, thoughtlessly used by people supremely ignorant of the cost of building at the present day. as well as of the peculiar requirements of a hospital for the insane. As the result erf my own observation and experience, I am convinced that four hospitals for 300 patients each, can be both built and maintained at a less cost than one for 1,2()0 patients, equal provision being made in both cases for the kind of care to which the insane, even in the lowest grades of the disease, are entitleel. I doubt-, however, whether it is possible to have, in these mammoth es- tablishments, certain qualities of administration indispensable to their highest purposes-. The animating spirit} the close and thoreuigh supervision, inspir- ing, guiding, correcting every movement, and essential to our highest [idea of hospital management, will be but feebly manifested under such condi- tions. The patient is but an atom in the great mass around him, losing the attributes of humanity, sane ami insane, in the technical character of patient. Conteneling as I now tlo, and as I always have done, against the estab- lishment of large hospitals, I cannot give an unqualified approval to Dr. Nichols's paper; With this exception, however, I heartily concur in all his conclusions. Dr. TiiomAs S. Kikkbkide, of Philadelphia^ said ;•—I am sure that we must all appreciate the value and importance of the excellent paper which we have just heard read-. There is little in it with which I do not agree entirely. On one point, however, I must confess that my views differ from the.se expressed by my excellent friend, and that is, in regard to the best size for liospitals for the insane. We all know that this is a point On which there has, erf late years at least, been a difference of opinion in the Asso- ciation of Medical Superintendents. As it now stands, indeed, it is the only one of our many propositions that has not received an unanimous, or very nearly unanimous, approval by the members: I still believe that the original proposition was right. I believe that the size then recommended 0 0 is really better than any other, but I am also fully aware of all the argu- ments that can be brought to justify much larger hospitals, especially those of expediency anel even pos,sihility. It is fully shown by reliable statistics, as I believe, that the people of the State will derive more benefit from seve- ral small liospitals in different parts of the State, than from one large one at a central point; and I think that it will also be found that the former can be provided with quite as small an expenditure of money, and.can be carried em at no greater cost per patient. Dr. Nichols has recommended the plan, which has now been fully tested, and which, even by the first decision erf the Association, allows as many as 500 patients being collected in e>ne vicinity; anel this is by having separate hospitals for the sexes. This plan I feel that I have a right to say is no longer an experiment. .V trial of sixteen years uneler my own observation has shown that, in every respect, it is a most valuable arrangement, having many advantages and no disadvantages. It has also received unqualified approbation from many other distinguished psychologists in aeldition to Dr. Nichols. I am aware that it has been said that, while I argue in favor erf hospitals for 250 patients, practically, I have been providing one to accom- modate twice that number. This, however, is a mistake. The Pennsyl- vania Hospital for the Insane, at Philadelphia, is really made up of two en- tirely distinct hospitals, one for each sex, and it has been so, as already said, for more than sixteen years. Poth hospitals has the same board of man- agers, and, for reasons not necessary to detail here, have always had the same physician-in-chief anel superintendent. It is anticipated, however, that ultimately each will have its own separate superintendent, and that the only connection between them will be the board erf managers. Now, what we have done, is exactly what I would propose for any hos- pital. First build your hospital for 25(> patients. This will commonly be occupied by both sexes. When this is filled, or nearly so, build another for a similar number of patients. Separate the sexes ; have distinct organiza- tions—all on the same tract of land, but with entirely separate pleasure- grounds. There may be the same water-works, gas-works, bakery, machine- shop, and other common arrangements, that will add to the economy of the institution. This provides for 500 patients in one locality, and vet conforms to the original proposition of the Association. I do not propose entering into an extended discussion of the reasons why I believe that these smallJr hospitals have advantages, but there is one that I cannot avoid referring to, and that is the personal intercourse which a superintendent is able to »ive to his patients, when their number is not so great as to prevent his pavim*- daily, or very nearly daily, visits to each. Tbelieve this to be one of the 23 most important of all his duties, and one which generally, if he is rightly constituted for his position, no one can do for him. It is true that an as- sistant may be superior to his chief in this respect, but this is not to be an- ticipated, and if it is so, the assistant ought to have charge of a hospital himself. Two hundred and fifty patients, or about that number, are as many as any superintendent can visit daily, with tolerable satisfaction te» himself anel to them. Now, I do not wish to be misunderstood in this matter. I still think, as the Association at first thought, that this size of 250 is the very best, but I do not mean to say that no other is admissible. I am well aware how much easier it is to get an appropriation for the extension of a hospital, than for the building erf a new one. What I mean to say is this :—Build your hos- pitals, in different parts of a State, erf a capacity for 250 patients, anel in sufficient numbers to accommodate all your insane, //' you can do so. If you cannot do this, anel yet can build single hospitals for 500, 700, or even 1,000 patients at one point, by all means elo so. The liospitals you must have at all hazards. If vou cannot get what I regard as the best arrange- ment. come as near to it as you can, let the size be what it may. The Presielent, Dr. John P. Gray, of Utica, said:—I should object to putting buildings half a mile apart, if for no other reason, because such an arrangement would render it elifficult, if not impossible, for the superinten- dent to consult constantly with his subordinate officers. I was chairman of the commission which located the Willard Asylum. We found the point on the lake the most desirable place for the main hospital building; the building now called the " branch," and more than half a mile away, was then erected; it was the old State Agricultural College, and was subse- epiently remodeled to receive patients. But there is a resident physician in the " branch,"' as there are in other separate buildings, since constructed, anel these physicians, for all practical purposes, exercise the power and con- trol of resident superintenelents, for the communication between these dis- tant structures anel the main hospital-building is by telegraph. Although that is an institution for the subjects of chronic insanity, there are five medi- cal men, a superintendent and four assistants, for a thousand patients—and thev are needed. Though as a commissioner I voted to place the main building on the lake, I did not like the feature of having buildings half a mile or more apart. In this instance it seemed a necessity, though unde- sirable. As to the other question, as to the number to be recommended in a sin- gle institution, or under erne superintendent, there is great difference in opinion. Semie think it just as practicable to have 2,on0 as 1,000, or less. 24 I think that 000, the maximum of the proposition of the Association of Superintendents, passed a few years ago, is as many as should be under one superintendent, even if the buildings be separated, and each have a resident physician. In England, some of the best public institutions are larger than those in this country, and} according to Dr. Buckniil, in his recent letters on American Asylums, published in the Lancet, are not .as well supplied with medical officers. That at Wakefield, the West-Riding Asylum, stand- ing at the head, has l,SO<> patients. In reply to the criticisms of Dr. Ivirkbriele on the qualifications of assis- tant physicians, I think it important to. have assistants who have had hos- pital experience. I shemld object to taking young men just out erf a medi- cal college, and without medical experience, and putting them in such esponsible places. Df. Ivirkbride's remarks as to qualifications would ap- ply with double force in an asylum where the buildings were separated. Note.—As the foregoing paper is reprinted and will be circulated solely with the hope that it may throw a welcome light upon the paths of those enlightened and benevolent men who, With special difficulties in almost every case, are striving to extend the provisions for the dependent insane^ of their respective States and Provinces, until all classes phall receive the care to which they are entitled, I think it proper to append to it the dis- cussion which followed its reading, as reported in The Transactions of the Centennial J fed icu I Congress, in order that parties interested mavhave the benefit of two or three shades of opinion in respect to the best size of State and Provincial institutions for the insane. I am by no means a special advocate of very large institutions for the insane* ^ The history of existing provisions for the insane in America shows conclusively, to my mind, that neither the States ne>r Provinces will pro- vide hospitals or asylums of a maximum capacity for 250 patients, suffi- cient for all the poor oi dependent insane, simply because the cost erf con- struction and maintenance is less per patient in large liospitals than in small ones. ^ I am, therefore^ strongly in favor of accepting large hospitals as the essential conditieni of properly providing for all the insane, acute and chronic; especially as 1 feel sure that no one who will put the question to the crucial test of critical observation will deny that among the institu- tions in charge of members erf the Association of Superintendents that are /// all re .pert s managed as well as any others, are several that contain from 450 to 75o patients. 0. II. Nichols. BnoeiMixonAi.K, Xi;w York, Jan'y. 1STS. Asylum Press.