THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 DR. ROY VAN WART
 
 THE TREATMENT AND 
 
 CARE OF THE INSANE 
 
 IN PENNSYLVANIA 
 
 BY 
 
 C. FLOYD /HAVILAND, M.D. 
 
 PUBLISHED BY 
 
 THE PUBLIC CHARITIES ASSOCIATION 
 
 OF PENNSYLVANIA 
 
 EMPIRE BUILDING, PHILADELPHIA 
 
 1915 
 
 PUBLICATION No. 15
 
 THE TREATMENT AND 
 
 CARE OF THE INSANE 
 
 IN PENNSYLVANIA 
 
 BEING 
 
 THE REPORT OF A SURVEY OF ALL THE 
 
 INSTITUTIONS IN PENNSYLVANIA CARING 
 
 FOR THE INSANE 
 
 MADE FOR 
 
 THE PUBLIC CHARITIES ASSOCIATION 
 OF PENNSYLVANIA 
 
 BY 
 C. FLOYD HAVILAND, M.D. 
 
 DURING 
 
 THE SIX MONTHS FROM 
 
 JUNE 1 TO DECEMBER 1 
 
 1914 
 
 PUBLICATION No. IS 
 
 PUBLISHED BY 
 
 THE PUBLIC CHARITIES ASSOCIATION 
 
 OF PENNSYLVANIA 
 
 EMPIRE BUILDING, PHILADELPHIA 
 
 1915
 
 fliomedieaJ 
 Library 
 
 \\x\t 
 
 Table of Contents 
 
 INTRODUCTION, BY CHARLES H. FRAZIER, M.D ........................ 4 
 
 RESOLUTION ADOPTED BY PENNSYLVANIA STATE BOARD OF CHARITIES IN 
 
 1870 ........................................................... 6 
 
 t, AUTHOR'S INTRODUCTORY STATEMENT ................................ 7 
 
 w MUNICIPAL INSTITUTIONS FOR THE INSANE ........................... 14 
 
 - SUMMARY OF MUNICIPAL INSTITUTIONS ............................... 20 
 
 I LICENSED COUNTY INSTITUTIONS FOR THE INSANE ..................... 22 
 
 GENERAL CONSIDERATIONS OF LICENSED COUNTY INSTITUTIONS ......... 68 
 
 UNLICENSED ALMSHOUSES CARING FOR THE INSANE .................... 69 
 
 SUMMARY OF UNLICENSED ALMSHOUSES .............................. 80 
 
 v GENERAL SUMMARY ............................................... 81 
 
 Relative Merits of State and County Care ..................... 82 
 
 635345
 
 Introduction 
 
 THERE are more than eighteen thousand indigent insane in 
 Pennsylvania. Less than eleven thousand of these unfortunates 
 are cared for in State Hospitals. Yet these State Hospitals 
 "afford practically the only opportunity in the State of Pennsyl- 
 vania for a public mental case to receive active medical treatment 
 directed to the alleviation or cure of mental disease." 
 
 In so many of the local hospitals and almshouses the insane 
 are accorded precisely the opposite of the remedial treatment 
 which they should receive. Instead of care they are neglected. 
 Instead of wholesome and varied food they receive ill prepared 
 and unfit diet, and often very scanty at that. Instead of the full 
 view of the sky they have the board fence, or worse, surrounding 
 the Exercise Yard. Instead of freedom they have the hand-cuff 
 or the strait-jacket. No class of persons, sick or well, more 
 need regulated occupation and exercise and open air work, such 
 as farm work and plenty of room, than the insane. 
 
 They need all that well people need to keep them well, plus the 
 best medical care and treatment. Locked up, out of sight, neg- 
 lected, forgotten, their misery cannot be told. The strongest in 
 physical health and mental vigor would break down if subjected 
 to the treatment which several thousand of our insane fellows in 
 the State of Pennsylvania continue to suffer needlessly. 
 
 As long ago as 1870 the late Mr. George L. Harrison, then 
 President of the State Board of Charities, advocated the "estab- 
 lishment by the State, within a reasonable time, of sufficient 
 accommodation for the maintenance and treatment of all the 
 insane who may not be cared for in private hospitals." 
 
 Forty-four years later Mr. Harrison's son, Mr. Charles Custis 
 Harrison, by his generosity made it possible for The Public Chari- 
 ties Association of Pennsylvania to employ Dr. C. Floyd Havi- 
 land, of the Kings Park State Hospital, Kings Park, Long Island, 
 
 Ul
 
 New York, to make a six months' study of all the institutions in 
 Pennsylvania caring for the insane. 
 
 The following pages contain a summarized report of Dr. 
 Haviland's survey. 
 
 This report demonstrates beyond peradventure that to-day, 
 as in 1870, the most advanced step possible on behalf of the in- 
 digent insane in Pennsylvania is the adoption of a plan by which 
 the State shall support and care for all its dependent insane in 
 institutions owned and controlled by it. Anything short of this 
 is a mere make-shift. 
 
 Is not a period of forty and more years a long enough time for 
 discussion? If so, has not the time now come for action? 
 
 CHARLES H. FRAZIER, M.D., 
 
 President 
 The Public Charities Association 
 
 of Pennsylvania. 
 April p, 1915. 
 
 [51
 
 Resolution Adopted 
 by 
 
 Pennsylvania State Board of 
 Public Charities in 1870 
 
 HON. GEORGE L. HARRISON, President 
 
 Resolved, That the Board of Public Charities, having 
 witnessed the evils which result from connection of 
 insane asylums with almshouses, and believing that a 
 wrong is done to the insane by classing them with 
 paupers, hindering the public from estimating aright 
 their claims to sympathy and remedial treatment, dis- 
 approve of such an alliance, and believe that the best 
 interest of this afflicted class of people and the duty 
 of the State concur in the establishment by the State, 
 within a reasonable time, of sufficient accommodation 
 for the maintenance and treatment of all the insane 
 who may not be cared for in private hospitals. 
 
 Resolved, That, in the judgment of the Board, all super- 
 intendents of hospitals for the insane should be mem- 
 bers of the medical profession.
 
 THE TREATMENT AND CARE OF THE IN- 
 SANE IN PENNSYLVANIA 
 
 BEING THE REPORT OF A SURVEY OF ALL THE INSTITU- 
 TIONS IN PENNSYLVANIA CARING FOR THE INSANE, 
 MADE TO THE MEMBERS OF THE COMMITTEE ON MEN- 
 TAL HYGIENE, OF THE PUBLIC CHARITIES ASSOCIATION 
 OF PENNSYLVANIA 
 
 GENTLEMEN: In accordance with the plan outlined by 
 you, and with the sanction of the Committee on Lunacy 
 of the Pennsylvania State Board of Public Charities, I have com- 
 pleted a survey of the State, as regards the conditions attending 
 the care of the insane and defectives, so far as they are confined 
 in public institutions. 
 
 It is unfortunate that there is little opportunity for the public 
 to learn about such conditions and hence public interest is apt 
 to be limited. The importance, however, of properly dealing 
 with the insane can scarcely be overestimated. The modern 
 conception of mental disease, as a condition resulting in defective 
 social adjustment, renders it easier to understand the intimate 
 relationship existing between abnormal mental states and such 
 social evils as vagrancy, intemperance, immorality, crime, etc. 
 Such relationship is now indisputable, and it reveals the necessity 
 of adequately dealing with the problem of the insane, not as an 
 academic question but as a practical issue involving numerous 
 social ills directly and indirectly dependent upon mental dis- 
 orders. To successfully combat such ills mental disease itself 
 must be first successfully combated. It is far more than a ques- 
 tion of mere custodial care for the insane ; what is needed is that 
 every known means be provided for the treatment and especially 
 for the prevention of insanity. 
 
 Mental disease not only vitally affects society as a whole but 
 either directly or indirectly it affects every individual member of 
 
 [71
 
 the community. The proper care and treatment of even the 
 dependent insane should, therefore, be regarded as a community 
 investment, a matter of self-preservation rather than as a charity. 
 The monetary cost of the social evils which depend in a large 
 measure upon mental disease is far greater than the cost of 
 adequately treating insanity and thus to a great extent removing 
 one of the fundamental causes of such evils. In so far as insane 
 patients fail of recovery, through a lack of proper care and treat- 
 ment, just so far does such lack mean unnecessary economic loss. 
 Charity implies giving without thought of return, but proper 
 facilities for the insane imply large returns not only in human 
 happiness but in economic advantage and, therefore, an insane 
 patient receiving treatment in a public institution should be con- 
 sidered no more a recipient of charity than is the farmer hauling 
 his produce to market over a State road. In each instance the 
 individual receives a direct benefit from a public utility, but 
 society's gain is no less real because indirect. Proper treatment 
 of the insane is merely a form of social insurance. 
 
 No system of care for the insane can be permanently successful 
 without a sustaining public opinion, and no method of moulding 
 public opinion is equal to the presentation of facts; hence in 
 making the survey every effort was made to insure such a state- 
 ment as would bear internal evidence of an impartial, unpreju- 
 diced attitude in collecting data and of the truth of every fact 
 stated. If any change in existing conditions is needed facts 
 alone should be used to determine the direction of such change. 
 
 With the kindly assistance of Mr. Bromley Wharton, General 
 Agent and Secretary of the State Board of Public Charities, and 
 Dr. Frank Woodbury, Secretary of the Committee on Lunacy, 
 of such Board, a list was prepared of all public institutions in 
 the State known to care for the insane, classifying them as to 
 type; it was thus shown there are 8 State hospitals, 19 County, or 
 Poor District, hospitals, and 4 Municipal hospitals, while in n 
 almshouses insane persons are kept for a greater or lesser period, 
 3 of the almshouses maintaining distinct insane departments, 
 although unlicensed to do so. With such widely varying types 
 of institutions a brief sketch of the manner in which the care of 
 the insane has developed in Pennsylvania may serve to render 
 more intelligible the present situation. 
 
 Originally the insane who had become dependent, by reason of 
 
 [8]
 
 their infirmity or otherwise, were cared for by poor districts in 
 the almshouses, together with all other dependent persons, sick 
 or well, thus following the early English custom. The concep- 
 tion of insanity as a sickness had not then become prevalent and 
 it was not until the notable memorial was presented to the State 
 Assembly in 1845, by Dorothea Dix, that the community awoke 
 to a realization of the need for a change. Then it was that the 
 State first took official action regarding the insane, who were 
 described, in the memorial mentioned, as being housed in build- 
 ings unfit for human habitation and receiving not only no medical 
 attention but only custodial care of the crudest sort. In an effort 
 to correct conditions laws were passed in 1845 and in 1848, pro- 
 viding for the first State institution for the "Care of the Insane 
 of this Commonwealth," which was then known as the Pennsyl- 
 vania State Lunatic Asylum, at Harrisburg. The counties were 
 granted the right to send a proportionate number of their insane 
 to it, remaining responsible, however, for such patients' main- 
 tenance, the State providing only the material plant. After 
 some years, a single institution proved inadequate, and there 
 followed the establishment, in 1853, of the semi-public institu- 
 tion known as Dixmont, located near Pittsburgh. Within a 
 few years such provisions were found insufficient and there was 
 established a State institution for the insane, in 1868, at Dan- 
 ville, but, even with such added accommodations, a large num- 
 ber of the insane still remained in almshouses, and we find in the 
 annual report of the State Board of Public Charities for 1870 
 reference to the matter as follows : 
 
 "More especially do we wish to denounce the cruel wrongs 
 which the insane suffer who are inmates of almshouses; these 
 institutions are generally wholly unsuited for their care or even 
 detention, or, if suitable, are presided over by persons who are 
 entirely ignorant of the needs of this class of the sick or infirm, 
 and whose administration is based on the crudest ideas of mental 
 diseases. * * * No hospital for the insane should remain 
 without the constant supervision of a medical superintendent. 
 The stewards of almshouses are never selected from any con- 
 sideration of the needs of the insane." 
 
 Accompanying the report above quoted was a copy of the reso- 
 lutions which follow the title-page of this report.
 
 In 1871, the General Agent of the Board of Public Charities 
 reported, with regard to the insane in almshouses, as follows: 
 
 "Indeed, without a total revolution of the system, it is impos- 
 sible to greatly improve it. There may be great faults in the 
 management of these poorhouses, some of which might be reme- 
 died, and others are probably incapable of remedy, but the great 
 cause, the fundamental cause of the evil, is the system itself. If 
 the administration was made as perfect as human infirmities 
 allow, if the best superintendents or wardens, and the most faith- 
 ful attendants were secured, while the evil might be mitigated, it 
 would remain substantially the same until the system itself is 
 changed. The remedy is not reform, but revolution." 
 
 Again, the following year, in 1872, Hon. George L. Harrison, 
 President of the Board of Public Charities, reported to the 
 Assembly, in reference to the same subject, as follows: 
 
 "For, at the best, they are merely confined in places of deten- 
 tion, under the guardianship of a respectable overseer, who is 
 wholly ignorant of their disease and of the means necessary for its 
 alleviation or its cure. We say at the best: we hesitate to de- 
 scribe the reverse of the picture; it would exhibit a scene of as 
 cheerless and uncomforted misery as the most bitter misanthrope 
 could desire to look upon. * * * The victims in this case 
 are a class of defenseless invalids, whose circumstances appeal 
 with a special urgency to every sense of humanity and justice. 
 Houses of detention, simply as such, misrepresent 
 the real demand of an enlightened public mind in relation to all 
 classes of unfortunates, they ignore the principle of the dignity 
 of the human person, which should govern the consideration of 
 these classes. This discrimination is lost where the thought pre- 
 vails that the chief good to be obtained is to restrain to save the 
 public in some sort from inconvenience, or damage, or depreda- 
 tion. This should surely be looked after and secured, but its 
 complete attainment may be better accomplished by considering 
 at the same time the duty of humanity in the care and custody of 
 every class of defectives. There are noble examples and expo- 
 nents of this theory in this age, in all parts of the civilized world, 
 and nowhere more devoted to its realization than in our own coun- 
 try, and in our own State, and we believe that a very large num- 
 ber of the insane in this Commonwealth are not only skillfully 
 but tenderly treated. But this is not so in many of the county 
 poorhouses; they have neither the accommodations nor the 
 medical care which are suited to their wants. * * * There 
 is nothing more true than that the State or county must pay for 
 the support of the sufferers during life, unless suitable provision 
 
 [10]
 
 for care and treatment induce timely restoration. It is therefore 
 no more than the common wisdom that is applied to the ordinary 
 business of life to take such measures as will give them the best 
 opportunity of restoration that the age affords." 
 
 It is remarkable that the enlightened words above quoted 
 should have been written over forty years ago, when, as this re- 
 port will show, they are as applicable to-day, so far as almshouse 
 care of the insane is concerned, as they were when written. 
 
 Largely due to the wisdom and effort of the State Board of 
 Public Charities, the situation was still further relieved when 
 there was established another State institution for insane at 
 Warren, in 1873, and still later there was established the State 
 Hospital at Norristown, in 1876. 
 
 But the number of the insane always exceeded the accommoda- 
 tions provided, and when, in 1883, a law was passed whereby the 
 State took half the burden of maintenance and made mandatory 
 the removal of all insane to the State hospitals, overcrowding 
 resulted from the first. With the passing years, it finally became 
 a physical impossibility to house all the insane in the State hos- 
 pitals and, in an effort to improve conditions, the County Care 
 Act of 1897 was passed, providing for county care. However, the 
 State agreed, under certain conditions, to pay $1.75 per capita, 
 per week, for each patient cared for in a county institution. The 
 conditions were rigorous requirements as to accommodations pro- 
 vided and treatment given, it evidently being feared that the 
 counties would not provide the same standard of care as obtained 
 in the State hospitals, and, as a matter of fact, the counties found 
 it impossible to satisfy all such requirements, so the law was 
 amended, rendering the requirements less exacting. To further 
 assist the counties, in 1899, the State increased the weekly per 
 capita allowance from $1.75 to $2.00. Thus it is seen that, while 
 the State has never assumed the full burden of maintenance of the 
 insane, it has for many years aided the counties in providing for 
 them, so that what now exists is a combined county and State 
 system, the counties paying a part of the maintenance of their 
 patients in the State hospitals, and the State paying a per capita 
 allowance for all patients in the county and Poor District institu- 
 tions. In each case the difference between the amount paid and 
 total cost of maintenance is made up by the political unit main- 
 taining the institution, although, in the case of the State institu-
 
 tions, such difference must not exceed $2.25 weekly per capita, 
 the State maintenance appropriation for these institutions being 
 based on such a fixed allowance. Such a rate contrasted with 
 the $2.00 weekly per capita allowance to county and Poor Dis- 
 trict institutions appears to imply a recognition by the State of a 
 higher standard of care in the State hospitals. 
 
 The existing system has now been in operation for a sufficient 
 length of time to warrant conclusions being drawn as to its effi- 
 ciency as determined by actual results, and it is to such end 
 that this inquiry has been directed. 
 
 Aside from visits to the 31 public institutions for the insane, 
 and to the n almshouses, with insane inmates, visits were also 
 made to three large private insane hospitals, and to three State 
 institutions for defectives, but this report will be confined to a 
 statement of conditions found in the 19 county and Poor District 
 hospitals, 4 municipal hospitals, and the n almshouses men- 
 tioned, the other institutions being considered in supplementary 
 reports I will submit to your committee. However, for the pur- 
 pose of comparison with other types of institutions, a few general 
 statements will be made regarding the State hospitals. 
 
 It was found that the combined census of the eight State hos- 
 pitals in Pennsylvania, with an official capacity of 9,457 beds, is 
 10,474, but 434 patients were found on parole from the hospitals, 
 and the actual excess of patients over capacity would therefore 
 be 583. This indicates but a moderate degree of overcrowding 
 but there are but few instances, either in State hospitals or 
 other institutions for the insane, of capacities having been 
 fixed in other than an arbitrary manner, depending upon the 
 exigencies of the situation. Hence in some hospitals there 
 is actual overcrowding which is not indicated by the official 
 figures. 
 
 The State hospitals embrace the best public institutions for the 
 care of the insane in the State, although facilities and standards 
 of care vary within rather wide limits. However, as will be later 
 shown, they afford practically the only opportunity in the State 
 of Pennsylvania for a public mental case to receive active medical 
 treatment directed to the alleviation or cure of mental disease. 
 
 In all the State hospitals physical conditions are fairly satis- 
 factory, and in some instances especially so. With numerous 
 buildings it is possible to classify patients, buildings with special 
 
 [12]
 
 facilities for special classes being found in most of these institu- 
 tions. There are infirmary buildings with modern surgical oper- 
 ating rooms, buildings for the tuberculous, reception buildings for 
 new acute cases, convalescent buildings, buildings for the dis- 
 turbed, and special buildings for hydrotherapeutic and electro- 
 therapeutic treatment, all of which are of importance in success- 
 fully treating the insane. 
 
 In the main, general hygienic conditions are excellent, especially 
 as regards the provision of modern sewage disposal plants. 
 Proper attention is generally given to fire protection, and for the 
 most part good service facilities are provided. 
 
 It is, however, in the actual care and treatment of patients 
 that these institutions excel. With but few exceptions food and 
 clothing are above criticism, while special attention is given to ex- 
 ercise, recreation and occupation. In most of these hospitals 
 occupation is under medical direction and, being regarded only 
 as a therapeutic agent, the need of the patient is paramount to the 
 need of the work. In several hospitals special occupational train- 
 ing is given for the correction of faulty habits, and intensive per- 
 sonal effort is made to awaken dormant interests. 
 
 Most of the hospitals maintain nurses' training schools, and in 
 one over 50 per cent, of the ward employees are graduate nurses. 
 As a result of the substitution of nursing care for custodial care, 
 restraint and seclusion have been greatly reduced, and in one 
 hospital entirely abolished ; in another hospital restraint has been 
 reduced 50 per cent, during the past year, and in still another 
 25 per cent, during a recent period. 
 
 In some of the hospitals the medical work is especially com- 
 mendable. Clinical and pathological laboratories are provided, 
 and that the latter have a distinct practical value is shown at one 
 State hospital, where formerly typhoid fever was rife every year; 
 however, it no longer occurs since general immunization by anti- 
 typhoid vaccine has been adopted, the vaccine being prepared in 
 the hospital laboratory. 
 
 In discussing the institutions, of which this report treats in 
 detail, it will, unfortunately, be necessary to criticize more freely 
 to accurately indicate the conditions found to exist. But that no 
 local authority may have ground for just complaint, that the 
 comments made are unjustly discriminatory, institutions will be 
 mentioned by number only. Unfortunately, however, those 
 
 [13]
 
 familiar with certain institutions will doubtless be able to identify 
 them, owing to the necessity of discussing conditions peculiar to 
 them alone, but as such discussion is necessary to a proper under- 
 standing of general conditions, the possibility of recognition of 
 identity of such institutions appears unavoidable. 
 
 Features worthy of commendation have been noted, as well as 
 those deserving of condemnation, that a true balance may be 
 reached, and from the facts given only such deductions are drawn 
 as are justified by actual conditions. 
 
 As it was found impossible to obtain accurate statistics for all 
 institutions for the same year, or the same date, owing to the 
 different hospital years in vogue, and also owing to defective 
 records, all statistical data has been taken for the last hospital 
 year available, while, as also representing more accurately present 
 conditions, all census data has been taken as of date of visit to the 
 respective institutions. Throughout the report statistics will in- 
 dicate census as the total number on the institution records, but 
 the number home on parole will also be indicated, so the actual 
 number in residence is the difference between such figures. 
 
 INSTITUTIONS FOR THE INSANE MAINTAINED BY 
 MUNICIPALITIES, NOS. 7-10 
 
 General Statistics. 
 
 Institution No. Capacity Census On Parole 
 
 7 1200 1804 24 
 
 8 555 475 
 
 9 650 724 18 
 
 10 300 324 15 
 
 Total 2705 3327 57 
 
 While, for the purpose of this report, No. 8 is regarded as a 
 separate institution, it is a branch of No. 7, but located at a dis- 
 tance from the main institution. 
 
 INSTITUTION No. 7 
 
 Physical Conditions. The ancient, monasterial structures in 
 which this hospital is housed are impossible. They form part of 
 a general plant, housing also an almshouse and a general hospital. 
 Light and air are deficient, and in some wards the day space is so 
 limited that benches are placed in rows across the room to pro- 
 
 [14]
 
 vide sufficient seating accommodations. The basement bath- 
 rooms are poorly lighted and ventilated. The old, unsanitary 
 and insufficient toilet facilities are now being replaced. The 
 service departments are all cramped for space. The fire pro- 
 tection could be improved, several iron fire-escapes having wooden 
 platforms. Some of the stone stairways are enclosed in wooden 
 towers and others lead to the cellar only. 
 
 Overcrowding is of a serious degree. In some places beds ac- 
 tually touch. One ward is so completely filled with beds that 
 but a narrow space remains between them and the four side walls 
 for day space. In view of existing conditions, it is difficult to 
 understand how this hospital could have cared for several hun- 
 dred more patients, as is said to have been the case some years 
 ago. To accentuate the poor housing conditions, there is but 
 limited space for outdoor exercise and there are but limited facili- 
 ties for occupation. On occasion of visit but 28 per cent, of the 
 patients were occupied for even part of the time. 
 
 Despite these adverse conditions, the housekeeping is excel- 
 lent and commendable evidence of initiative was seen in the use 
 of sanitary bubbling drinking fountains, built by hospital labor 
 from old pipes. 
 
 Administration. The medical work appears fairly efficient and 
 the use of a social worker as an "after-care" agent is praise- 
 worthy. There is a large number of patients (an average of 77) 
 either restrained or secluded, as a result of an undue proportion of 
 disturbed patients and too small a proportion of attendants. 
 The number of attendants on duty on day of visit gave a propor- 
 tion of but one attendant to 15 patients, a proportion too small, 
 especially in view of existing material conditions. The small 
 number of attendants may partly account for an apparent failure 
 to use hydrotherapeutic facilities to capacity, especially the con- 
 tinuous baths. 
 
 That the large proportion of disturbed patients is directly due 
 to the faulty conditions appears evident in view of the result fol- 
 lowing a transfer of patients to one of the State hospitals (No. 17). 
 By special arrangement a large number of disturbed and destruc- 
 tive patients were included, yet, with improved housing condi- 
 tions and much outdoor exercise, the majority became quiet 
 within a few months and not a few became industrious. 
 
 The adverse conditions must also be held accountable, in a
 
 measure at least, for the abnormally high death rate of 9.9 per 
 cent, based on the total number of patients treated, and the ab- 
 normally low recovery rate of 7.3 per cent, based on the number 
 of persons admitted. 
 
 The business methods here in vogue are defective ; too small a 
 stock of supplies is carried ahead, with the result, for example, 
 that some months ago it was necessary to accept shoes said to be 
 worth at least a dollar less than the sample shoes on which the 
 contract had been awarded. The situation was such that either 
 the patients had to go without shoes or the delivery had to be 
 accepted, and the latter course was followed. 
 
 A non-medical superintendent is in charge of this hospital. 
 
 All the patients admitted pass through a psychopathic ward, 
 which at the time of visit was most crude and without facilities, 
 but changes have since been effected, improving the situation. 
 
 INSTITUTION No. 8 
 
 Physical Conditions. This is in a rural locality and somewhat 
 difficult of access. The patients' quarters are for the most part 
 in converted farmhouses, which, in the absence of equipment, 
 furnish rather crude accommodations, but permit a large measure 
 of freedom, with excellent opportunity for exercise and occupa- 
 tion, as is shown by the fact that 48 per cent, of the population 
 are regularly employed, the majority of the remainder being 
 tubercular and aged, decrepit patients. The chief defects are 
 the crude service accommodations, an insufficient water supply, 
 great fire risk, and an unsanitary method of sewage disposal, 
 cesspools being used which are too close to the buildings, one 
 being not far from the dairy barn. Water mains and sewer 
 mains are being laid, however, and if properly completed, will no 
 doubt provide an adequate water supply and a sanitary system 
 of sewage disposal. 
 
 Administration. Except for strictly medical matters, the head 
 farmer is in charge, reporting directly to the lay superintendent at 
 the mother institution, No. 7. There is evidence that more or 
 less friction exists between the medical and farm service. The 
 method of handling supplies does not appear to sufficiently safe- 
 guard the interests of the institution, for, while cost records are 
 kept, unit records of articles are not. 
 
 [161
 
 INSTITUTION No. 9 
 
 Physical Conditions. This institution forms one unit of a 
 plant composed also of a general hospital, almshouse, and tuber- 
 cular colony. The buildings are, in the main, satisfactory. 
 However, in the older buildings a number of archaic features are 
 to be noted. Several rooms are equipped with concrete floors, 
 with center drains, similar to a stable. They are also provided 
 with double, heavy, solid doors, thus providing for seclusion. For 
 the most part, the wards are bare, lack furniture, and are desolate 
 in appearance. Insufficient heat is provided, and last year it is 
 said to have been necessary for patients and attendants to wear 
 overcoats and shawls indoors. The exercise yards are objection- 
 able, being enclosed with high, whitewashed, board fences, so 
 closely fitted as to shut off any outside view. The grass has been 
 worn off, and during the absence of the women from their yard, 
 eighteen large rats were counted running about in it. 
 
 Administration. The patients have access to running hot 
 water, although no hot water safety devices are provided; as a 
 result a woman patient was so severely scalded a year ago that she 
 died following the burns. However, despite the subsequent 
 recommendation of the State Committee on Lunacy that a safety 
 device be installed, no action has ever been taken. On occasion 
 of visit, there were 23 patients either restrained or secluded, 12 
 of whom are constantly restrained. Even such a large number 
 is much less than a few years ago. In 1911, with a smaller 
 census than at present, the average number of patients re- 
 strained and secluded is given as from 40 to 50. There are but 
 20 per cent, of the patients regularly occupied, despite the fact 
 that there is a large farm and plenty of opportunity. However, 
 the policy heretofore has been to use the labor of the pauper in- 
 mates of the adjoining almshouse before endeavoring to provide 
 occupation for the insane. There has been a great lack of per- 
 sonal care and attention, as must necessarily be the case with 
 the unusually low proportion of attendants. On day of visit 
 there was but one attendant to 23 patients for day duty and one 
 to 90 for night duty. The medical work has heretofore been on a 
 low plane of efficiency, as could scarcely be otherwise, when dur- 
 ing the past year, except for a few weeks, but two physicians were 
 provided to care for from 1200 to 1400 patients, the physicians 
 attached to this institution being obliged to care not only for the 
 
 [17]
 
 insane, but also for over 50 tuberculous patients, over 200 general 
 hospital patients, and nearly 300 almshouse inmates, all housed 
 in adjoining buildings. 
 
 The future of this institution promises better things. A new 
 medical superintendent has recently been appointed, replacing a 
 non-medical superintendent. The new appointee fully appre- 
 ciates existing needs and has already instituted improvements, 
 while he plans many more. The dietary has been improved and a 
 departure has been made from the routine bread, molasses and 
 tea diet for breakfast and supper, formerly provided. Already 
 provision has been made for proper reception wards for new 
 patients, heretofore lacking, while hydrotherapy is to be installed, 
 the work of reeducational occupation is to be inaugurated, and 
 the lack of recreation to be supplied. The number of medical 
 men has been increased; a laboratory is to be started, and, in 
 general, it may be confidently expected that this institution will 
 enter upon a new era. It may likewise be expected that as a re- 
 sult of active curative treatment for insanity there will be a fair 
 percentage of recoveries, instead of no recoveries at all, as has 
 been the case since 1907. The latter condition has obtained, 
 despite the fact that during the past hospital year alone there 
 were 66 cases admitted suffering from such recoverable psychoses 
 as would under proper treatment yield a recovery rate of from 
 85 to 90 per cent. It is therefore to be most earnestly hoped that 
 the new medical spirit now in evidence may receive every possible 
 support. 
 
 INSTITUTION No. 10 
 
 Physical Conditions. The buildings are good, but are located 
 adjacent to a County Workhouse, the latter being but about 100 
 yards from the building for insane women, and just across a road- 
 way from their exercise yard. The two buildings for opposite 
 sexes are separated by an almshouse, in which are the administra- 
 tive offices of the hospital. The exercise yards are enclosed with 
 a high board fence, thus emphasizing the idea of restraint, so 
 pernicious in its effects upon insane patients. 
 
 Administration. The executive head is a non-medical man and 
 the usual objections apply with even more than usual force, owing 
 to the superintendent's lack of familiarity with the details of the 
 hospital, evidenced by supplying considerable information later 
 
 [18]
 
 found to be erroneous. The housekeeping of the wards is excel- 
 lent, but, aside from the farm and the engineer's department, all 
 the service departments were found in very poor order. There 
 are no formal amusements for the patients, and even those 
 patients fortunate enough not to be restrained lead a drab, color- 
 less existence, but the amount of restraint used appears unwar- 
 ranted. On the day of the visit there were thirty-one patients, or 
 10 per cent, of the total hospital population, either restrained or 
 secluded, while eighteen patients, or 5.8 per cent., are constantly 
 restrained or secluded. In making rounds most of such pa- 
 tients were found absolutely quiet, two only being moderately 
 restless. It was said that in most cases such treatment was used 
 because the patients had previously been disturbed. It cannot 
 be without significance that the lay superintendent occasionally 
 orders both restraint and seclusion, without consultation with 
 the physician. The amount of restraint, however, appears in a 
 measure due to the limited proportion of attendants, there being 
 on duty, on the day of the visit, but one attendant to fifteen 
 patients for day duty. Such lack was also given as the reason for 
 the limited amount of outdoor exercise, patients never being 
 out longer than two hours in any one day, even in good weather. 
 
 While, in the main, the separation of the sexes is good, there is 
 some opportunity for improper mingling of sexes, as was shown 
 when two working patients, a man and a woman, were found 
 eating together in a room off the kitchen, without an attendant 
 present. 
 
 The food service is poor and the dietary is stereotyped. All 
 kinds of food are heaped on a single plate for each patient. For 
 the meal inspected, after soup had been placed in deep plates, a 
 piece of meat and sliced green cucumbers were added, and it was 
 noticeable that as soon as the patients were seated a piece of 
 bread was used as an auxiliary plate. 
 
 The institution lacks any hydrotherapeutic equipment or pro- 
 visions for special medical treatment, and there is no treatment of 
 insanity as such. The result is seen in the remarkably low re- 
 covery rate of 2.8 per cent., based on admissions. During the 
 last hospital year, thirty-one cases were received suffering from a 
 certain recoverable form of mental disease, which, under proper 
 treatment, would have yielded a recovery rate of 85 to 90 per 
 cent., but among the cases discharged as recovered from this 
 
 [19]
 
 institution there was but a single patient discharged recovered 
 who had suffered from such type of mental trouble. Tubercular 
 patients mingle with the others until they become bedfast, when 
 they are cared for in the neighboring almshouse, which alone has 
 facilities for isolation. There were several insane patients resid- 
 ing in the almshouse on the occasion of the visit, including not 
 only tubercular cases, but a surgical case, the almshouse alone 
 possessing facilities for the treatment of surgical conditions. The 
 clinical records are poor, but the medical force is too small to 
 perform properly the medical work in this institution, with 324 
 insane patients, and also in the almshouse, with 201 inmates, as is 
 required, there being but two physicians. 
 
 One of the deplorable features of this institution is that there is 
 reason to believe that political influences have heretofore oper- 
 ated in the selection of employees, and the resulting inefficiency 
 of attendants thus selected is shown in the following instances : 
 One attendant caring for a sick patient reported a temperature of 
 1000 degrees; another, when told to get a bottle of ammonium 
 chloride tablets brought bichloride of mercury tablets instead, 
 believing all chlorides were the same. The superintendent him- 
 self admitted it was sometimes possible to find attendants on duty 
 partially intoxicated, but said it was no use to dismiss them, as it 
 would only mean replacing them with others of the same caliber. 
 During visit a death was reported to the office, but a few minutes 
 later it was reported to be a false alarm. It appeared that an 
 attendant had been deceived when, in cleaning the bed of a sick 
 patient, he had laid the patient on the cold concrete floor, where- 
 upon the shock of such treatment caused collapse. As a matter 
 of fact, however, the patient was actually in a dying condition 
 and expired later the same afternoon. 
 
 This institution is to be moved to and consolidated with No. 9 
 as soon as new buildings have been there erected, a change which 
 must necessarily result for the patients' good. 
 
 SUMMARY OF INSTITUTIONS MAINTAINED BY 
 MUNICIPALITIES 
 
 Institution No. 7 is so unsuited architecturally for the care and 
 treatment of insane patients that its use should be abandoned at 
 the earliest possible moment. The great overcrowding here 
 
 [20]
 
 existing only emphasizes structural defects. The abnormally 
 high death rate must, in part at least, be caused by structural 
 conditions, as the medical work appears fairly efficient. 
 
 Institution No. 8, a branch of No. 7, provides the great boon of 
 outdoor exercise and occupation lacking in the latter. Methods 
 of transportation are not yet adequate, the accommodations are 
 crude, the water supply is deficient, and the sewage disposal is 
 unsanitary, although the two defects last mentioned will ap- 
 parently be remedied by the completion of plans now under way. 
 The fire risk is considerable. The defects and disadvantages 
 indicated are all remediable, however, and there would seem to 
 be marked possibilities for this institution under State rather 
 than municipal control. 
 
 Institution No. 9 has heretofore provided only the most crude 
 custodial care. The fact that no patients have been discharged 
 as recovered for 7 years tells the whole tale; however, a new 
 administration has been inaugurated, and there is reason for 
 believing that not only will the material condition of patients be 
 improved, but that in the future they will receive active medical 
 treatment directed to the alleviation of their mental ills, some- 
 thing never before provided in this institution. 
 
 Institution No. 10 is poorly located, being in association not 
 only with an almshouse but with a County Workhouse. While 
 the buildings are good, there are no facilities for the medical 
 treatment of insanity and even in the treatment of physical ills 
 the baneful practice has arisen of treating surgical and advanced 
 tubercular cases in the almshouse, where no distinction is made 
 between them and the paupers. Under the circumstances, it 
 appears fortunate that this hospital is to be consolidated with 
 No. 9. 
 
 General Considerations. In reviewing the conditions found in 
 this group of institutions it would appear that none have been 
 properly performing their function as institutions for the treat- 
 ment and possible cure of insanity. Political and secular inter- 
 ests have apparently submerged the medical spirit, and as a result 
 it is certain that many unfortunate insane persons have failed of 
 recovery through lack of proper medical facilities and treatment. 
 The conviction appears irresistible that whatever may have been 
 past policies the welfare of the community would be best served 
 by removing these hospitals from municipal control. 
 
 [21]
 
 LICENSED COUNTY INSTITUTIONS FOR INSANE. 
 
 NOS. 19-37 
 General Statistics. 
 
 Institution 
 
 number Capacity Census On parole 
 
 19 42 43 2 
 
 20 800 886 93 
 
 21 203 286 24 
 
 22 None for 
 
 insane 8 o 
 
 23 305 294 6 
 
 24 107 89 9 
 
 25 50 26 o 
 
 26 25 29 i 
 
 27 48 44 2 
 
 28 50 46 o 
 
 29 64 69 o 
 
 30 530 517 9 
 
 31 300 364 42 
 
 32 600 621 17 
 
 33 132 114 i 
 
 34 40 39 
 
 35 5oo 481 25 
 
 36 229 240 9 
 
 37 96 IQ7 _5 
 
 Total 4121 4303 245 
 
 INSTITUTION No. 19 
 
 Physical Conditions. Building for insane at rear of alms- 
 house, with earth yard in front. It is in good repair. The halls, 
 however, are too narrow. There is no regular dining-room, a 
 short hall serving this purpose, in which both sexes eat at the 
 same table. The "cells" for seclusion have concrete floors and 
 are double-d cored, the inner door being iron-barred and the 
 outside one of heavy wood. One of these outside doors has 
 been removed, leaving only the iron-barred door in sight and thus 
 emphasizing the prison effect. Electric lights are used, but wiring 
 is attached to surface of walls in such a way as to be accessible to 
 patients. Wards are bare and without sufficient seating facili- 
 ties, so that when all patients are indoors it is necessary to use 
 backless benches from the dining-room. Much trouble is said 
 to have been experienced from patients sitting on the flat tops of 
 screened radiators, and local authorities have recommended that 
 a sloping top be substituted, but additional seating facilities do 
 not appear to have been suggested. 
 
 There are but two wards for each sex, so that little classifica- 
 tion of patients is possible. Fire protection is insufficient. 
 
 [22]
 
 Sewage flows untreated into an open ditch about 150 yards from 
 the main building; when seen this ditch was absolutely stag- 
 nant. Piggery is within 200 yards of building for insane, and 
 not overclean. 
 
 Small exercise yard for each sex is enclosed by high, white- 
 washed board fence, partly surmounted by barbed wire, the gate 
 to each yard being fastened with a padlock. 
 
 In many respects almshouse building is superior to that for 
 insane. 
 
 Administration. Women live on second floor, but stair doors 
 are left unlocked and separation of sexes is poor. Women pa- 
 tients were found doing housework in the male wards, without 
 any attendant, although male patients were present. There is 
 but a single married couple for day duty and another such couple 
 for night duty. Patients are left alone much of the time. Those 
 in the exercise yards when once locked in are left unattended. 
 In one of these yards five concentric rings have been beaten in 
 the earth about a tree by the ceaseless pacing of patients. 
 
 Dining-room service is crude. Food is brought in tin buckets 
 from the almshouse. In good weather some of patients eat on 
 the ground in the exercise yards. Most of dishes are of agate 
 ware. Food is sufficient in amount but of limited variety. 
 Bread, molasses, and tea or coffee are the staples for both morning 
 and evening meals, the dietary being the same as for the aims- 
 house. 
 
 The men's clothing is of overall material, suits being made in 
 almshouse and little attention paid to fit. A number of patients 
 were barefooted, and from appearance of feet, had been so for 
 many weeks. There are no recreations provided, and but three 
 or four patients attend the occasional religious services conducted 
 by volunteers in the almshouse. 
 
 The visiting physician calls once a week, but only physical 
 ills receive attention. The physician refuses to pull teeth, and 
 after hearing a woman patient weep all night with the toothache, 
 the "keeper" for the first time in his life pulled a tooth. He has 
 since pulled two more. "Keeper" was formerly a farmer; he 
 uses his own judgment in the matter of restraint and seclusion. 
 In his opinion, two days in a strait-jacket is enough "to make 
 them come down." Seclusion, however, is sometimes used from 
 six to eight weeks, or even longer. 
 
 [23]
 
 A woman patient has an open, undressed cancer, and another 
 woman patient has recurring ulcerations of the nose, apparently 
 of luetic origin. Neither these patients nor the single tuber- 
 cular patient here are isolated, but mingle freely with the others. 
 
 A particularly reprehensible practice in this community is the 
 custom of committing insane patients to the State Hospital only 
 if they belong to one of the "better families" or if they are par- 
 ticularly disturbed or troublesome. 
 
 The neighboring almshouse is crowded every winter, and the 
 present building for the insane could be used to advantage for 
 the paupers were the insane removed, as they should be. 
 
 INSTITUTION No. 20 
 
 Physical Conditions. The buildings are excellent, thoroughly 
 fire-proof, and the grounds ample. While some wards are bare, 
 others have decorative features. Sanitary bubbling drinking- 
 fountains are a commendable provision. The numerous wards 
 offer a good opportunity for classification. In general, service 
 departments are good, but the laundry is too small and some of 
 the departments are poorly located in basements. Farm build- 
 ings are excellent. Sewage flows untreated into a neighboring 
 creek. Fire protection could be improved, too much reliance 
 being placed on exterior fire-proof construction. For instance, 
 a third-floor dormitory with about 100 patients has but a single 
 exit to a stairway, although outside is an iron fire-escape which is 
 inaccessible, as the oval window leading to it is guarded by per- 
 manently fastened iron bars. 
 
 All exercise yards are enclosed, one with a high, whitewashed 
 board fence surmounted by barbed wire, while another is a court 
 covered with stone flagging and enclosed by an iron fence sur- 
 mounted by barbed wire. 
 
 The buildings of the neighboring almshouse are especially 
 good and well adapted for the care of the insane, one building 
 being so used. Were the almshouse and insane hospital consoli- 
 dated there would no longer exist the necessity for two laundries, 
 two direct refrigeration plants, two store rooms, two drug rooms, 
 two power plants, two carpenter shops, two paint shops, and two 
 plumbers' shops. 
 
 Administration. A fair grade of custodial care is here given, 
 but the non-medical character of the institution is shown in its 
 
 [24]
 
 annual report, the only medical feature of which is a table show- 
 ing causes of death. Physical ills receive proper treatment, but 
 there are no facilities nor treatment for insanity as such. 
 
 Owing to overcrowding and the comparatively small propor- 
 tion of attendants, restraint is much used, the overcrowding 
 being especially apparent in the disturbed wards. A particu- 
 larly objectionable form of restraint is a long-sleeved coat, by 
 means of which patients' arms are tied behind their back. 
 
 Tubercular cases are scattered throughout the various wards, 
 although it is proper to add that new construction now going on 
 will provide excellent facilities for the isolation of tubercular 
 patients. 
 
 With material facilities in general of an unusually good grade, 
 the whole plant could be utilized to the greatest advantage as 
 an institution solely for the insane. 
 
 INSTITUTION No. 21 
 
 Physical Conditions. A fairly satisfactory fire-proof building 
 is provided, many defects of which could be overcome by the 
 expenditure of small amounts of money. Hospital is over- 
 crowded, and as a direct result there is insufficient day space. 
 Fly-screens throughout constitute an excellent feature. Wom- 
 en's wards have some decorative features, but men's wards are 
 bare and have but few chairs, backless benches being substituted. 
 The outside entrances have iron-barred doors outside of wooden 
 ones, so when the latter are left open for ventilation an unpleasant 
 prison-like effect is produced. There are a few unprotected 
 radiators on the floor, but most are placed on the walls out of 
 reach. 
 
 There is a great lack of space for service departments, most of 
 them being crowded into small basement rooms. Another serious 
 lack is the want of land, the hospital having but a small plot set 
 apart for its use out of the entire county property, the remainder 
 being devoted to the use of the neighboring almshouse. 
 
 Sewage flows untreated into a river about a half mile distant. 
 There is a serious lack in the want of sufficient water supply. 
 During the past summer water pressure has been insufficient 
 to fill the service lines on the second floor, so water has had to 
 be carried upstairs by hand in pails for all purposes. Despite the 
 increased fire risk, authorities are said to have made no effort to 
 
 [25]
 
 remedy conditions although it would appear easily possible to do 
 so, and although the superintendent of the hospital has repeat- 
 edly urged it. There is already a well on the property giving an 
 abundant flow of good water, but, owing to a failure to provide a 
 sufficiently powerful pump, little relief is thus obtained. 
 
 The neighboring almshouse is in fair condition, and at an ex- 
 penditure of from five to six thousand dollars could be rendered 
 available for the care of the insane. The condition here presents 
 a striking contrast to that of the insane hospital, for instead of 
 being greatly overcrowded, as is the latter, less than half its 
 capacity is now utilized. 
 
 Administration. With but two wards for each sex, little classi- 
 fication is possible. There is an unusually good dietary. As 
 result of overcrowding and an insufficient number of attendants, 
 restraint and seclusion are frequently used. Despite efforts of 
 the medical superintendent, it has been impossible to secure hy- 
 drotherapeutic apparatus or any special medical equipment. 
 There are but two tubercular cases, who are allowed, however, 
 to mingle with the other patients. 
 
 An excellent feature of this institution is the degree to which 
 occupation for patients has been developed under adverse con- 
 ditions. Those who work on the farm do so under the direction 
 of the almshouse steward, so that the hospital superintendent has 
 to exercise care as to the patients sent out for such work, having 
 no knowledge of what tasks they will have to do. The superin- 
 tendent is probably correct in believing that more patients could 
 be allowed the benefit of farm work if he had the authority to 
 regulate tasks to their varying capacities. It is unfortunate 
 that so many of the patients working in the service departments 
 are obliged to work in the basement where light and air are de- 
 ficient. 
 
 Unusually close accounts are kept. The hospital is obliged 
 to pay the almshouse for bread, milk and pork, although it re- 
 ceives no compensation in return for the labor of patients and 
 attendants. A large number of reimbursing patients makes 
 this institution self-supporting, aside from State aid. 
 
 Although the superintendent is a physician, he has no medical 
 assistants, and but little help in business matters, so it would 
 appear impossible for him to give as much attention to medical 
 matters as would seem desirable. 
 
 [26]
 
 The material conditions of the plant, as a whole, including 
 almshouse, are such that it could be rendered available for the 
 care of the insane at comparatively small expense, as most de- 
 fects noted are removable ones. 
 
 INSTITUTION No. 22 
 
 Physical Conditions. The insane are kept in the almshouse 
 proper, separate corridors being reserved for them, although in 
 practice they freely mingle with the paupers and with a consider- 
 able number of defectives; the only discernible difference in 
 treatment is that they are allowed less freedom. Rooms for the 
 insane have iron bars over windows, while the doors are heavy 
 wood with iron braces ; in the center of each door is an aperture 
 covered by an iron grating, with a wooden slide for a peek hole, 
 while lower down in the door is an open aperture through which 
 food is introduced when an excited patient is secluded. Doors 
 are fastened with heavy padlocks. 
 
 Although exercise yards are enclosed, they are unusually pleas- 
 ant for such type of yards. A philanthropic neighbor has built 
 an excellent small chapel divided for Protestant and Catholic ser- 
 vices. There is an excellent farm with good farm buildings. 
 
 Fire risk appears especially great. The illumination is by 
 open flame, gasoline gas-jets. Water pressure is sufficient onl^ 
 to carry water to the second floor. Buildings are old, and it 
 appears doubtful whether inmates on the third and fourth floors 
 could escape in case of fire, despite the fact that there are a few 
 fire-escapes provided. 
 
 Administration. Separation of sexes is poor; they occupy 
 different floors, but the stairs are open during the day. But 
 limited paid help is provided, and in practice the paupers do con- 
 siderable of the work in caring for the insane. 
 
 A humane atmosphere exists in this institution, and restraint 
 and seclusion are little used; however, both may be used at the 
 discretion of the woman nurse or the almshouse steward, and 
 shortly prior to visit a male patient was said to have been se- 
 cluded for a week. There is, of course, no medical treatment for 
 insanity as such, and even provision for the treatment of physical 
 ills is limited, the visiting physician making regular visits once a 
 week only. 
 
 The donor of the chapel above mentioned had engaged an in- 
 
 [27]
 
 structor in raffia and reed basketry, who was found teaching such 
 craft to a number of the pauper inmates and to one insane patient, 
 but in general the insane are little occupied. 
 
 INSTITUTION No. 23 
 
 Physical Conditions. The building provided is excellent; 
 it is fire-proof and well arranged. There is also an excellent farm, 
 but it is conducted by the steward of the neighboring almshouse. 
 This almshouse building, while old, is remarkably well preserved. 
 Institution has a good modern sewage disposal plant. Fire pro- 
 tection is fair, but hose is not tested, matters of this kind being 
 in charge of the almshouse steward. The hospital superintendent 
 is said to have repeatedly requested such tests. 
 
 Hospital lacks space for service departments, most of them 
 being located in the basement. There is an excellent detached 
 building provided as a home for women attendants. This in- 
 stitution is notable in that although it is a county institution it 
 possesses no enclosed exercise yard. 
 
 Administration. The hospital superintendent is a physician, 
 and all business matters are under the direction of the almshouse 
 steward, who has authority t revise superintendent's requests 
 for supplies. 
 
 There is no laboratory, hydrotherapeutic equipment, nor 
 medical treatment, except that directed to the alleviation of 
 physical ills only. 
 
 Except in the severest winter weather heat is said to be shut 
 off from 9.00 P. M. to 5.00 A. M.; it was admitted that patients 
 often complain of the cold, when they are supplied with extra 
 blankets. Patients are for the most part locked in their rooms 
 at night. Several were also found locked in their rooms during 
 the day. A tubercular girl was found locked in her room on the 
 second floor with no attendant on the floor. Patient was weak, 
 confined to bed, and there appeared no apparent justification 
 for her seclusion, unless it was to prevent her from wandering 
 about the ward, although in her weak condition she showed no 
 such tendency; moreover, two ambulatory tubercular cases 
 mingle with the other patients without restriction. An elderly 
 woman, moaning and protesting loudly, was found secluded; 
 when her room was entered and she was addressed, she became 
 somewhat quieter and there appeared no doubt that could she 
 
 [28]
 
 have received adequate personal attention her agitated depres- 
 sion would have been much lessened. Another secluded woman 
 was said to have been homicidal; but when addressed, she ex- 
 plained, with a smile, that sometimes the voices called her such 
 bad names she could not help but get angry, although she did not 
 mean harm to anybody. Two women were found locked in a 
 bathroom, but for what reason did not appear, as both were quiet. 
 Both restraint and seclusion are ordered by the matron, who then 
 reports to the superintendent. 
 
 Recreation is given some attention in this institution, and in 
 many respects the custodial care provided is of a fair type. 
 
 Material conditions both at the insane hospital and the alms- 
 house are such that the whole plant could be well devoted to the 
 exclusive care of the insane. It would then be possible to provide 
 some degree of classification, and the present lack of the hospital 
 as to space for service departments would be supplied. 
 
 INSTITUTION No. 24 
 
 Physical Conditions. Building for the insane is at the rear of 
 the almshouse, with a shed containing an outdoor toilet in the 
 foreground. It is in a poor state of repair, side walls being 
 cracked, woodwork worn, and paint generally needed. While 
 lighting is by electricity, wiring is attached to the surface of the 
 walls and is easily accessible. Despite the fact that kerosene 
 lamps are kept on the wards for emergency use, an attendant 
 was found smoking in the ward. Room doors are locked with 
 numerous different kinds of locks, although most are secured with 
 a small padlock and a hasp and staple. There is little day space, 
 except on dark halls. But few chairs are provided, benches 
 without backs being substituted. Men's wards are particularly 
 bare and desolate in appearance. On a single ward there is one 
 stationary wash-basin, but elsewhere patients are obliged to use 
 the single bathtub faucet found on each ward. As patients eat 
 breakfast at 5.30 A. M., it appears questionable whether they all 
 have a chance to wash before breakfast. 
 
 Ward dining-rooms are narrow, the two tables in each almost 
 completely filling the space ; only backless benches are here pro- 
 vided. There is a zinc sink in each dining-room for dish-washing, 
 but water has to be carried in a pail the length of the ward, the 
 bathtub being the only source of water supply. Food service is 
 
 [29]
 
 haphazard, patients entering and leaving dining-room at will. 
 In one instance the attendant had gone to the almshouse build- 
 ing for his own meal, although patients were found still eating, 
 while thus left alone. 
 
 Ventilation is defective and deodorizing fixtures were seen not 
 only in toilets but in wards. Sewage disposal is by cesspools, 
 and one in use is but a few hundred feet from the almshouse 
 building. It should be added, however, that plans have been 
 made for more sanitary sewage disposal. There is a good exer- 
 cise yard, except that it is enclosed by a high board fence, com- 
 pletely shutting off the patients' view, while it is undivided for 
 the sexes. However, the matter of exercise fails to receive proper 
 attention, many patients going outdoors but rarely. 
 
 Administration. Sexes are poorly separated and the quiet 
 patients of each sex are allowed to mingle in going in and out of 
 the exercise yard, the doors of the two quiet wards leading to 
 the yard being left open much of the time. Patients fail to re- 
 ceive proper personal attention. In the men's wards clothing 
 was found generally disordered, unbuttoned, and in a few in- 
 stances torn. When last-mentioned condition existed, there 
 was no evidence of underwear. One male patient was seen in 
 the morning with clothing unbuttoned and much disordered, and 
 when again seen late in the afternoon he was in exactly the same 
 condition, being a stupid, inactive patient. Several men were 
 seen barefooted ; some had shoes but no socks, while others had 
 socks but no shoes. In general, the condition of women was 
 better than that of the men. 
 
 Dietary appears too scanty, practically no food being left on 
 the tables after the meal inspected. The same menu is served 
 the corresponding days each week, varying only as the seasons 
 render different supplies available. Butter is served but once or 
 twice a week. Molasses, bread and coffee are the staples for 
 breakfast and supper, although occasionally a potato, some oat- 
 meal, or crackers are added. 
 
 The punitive idea is here prominent; two women were found 
 strapped to the chair with a leather strap, and a third was so 
 strapped to a toilet chair. It was readily explained that in one 
 case at least the patient was strapped "as a little punishment"; 
 it was added, "You have to punish them a little sometimes, it 
 does them good." Later, a male attendant remarked in reference 
 
 [30]
 
 to restraint, "We use it simply to conquer them; it is to punish 
 them a little when words are not enough." The institution has 
 several cells in the cellar for violent cases, but none was occupied 
 at time of visit, their last occupant having been transferred to a 
 State hospital some weeks prior to visit. Such cells are provided 
 with inside doors of iron grating, with heavy wooden doors out- 
 side. Side walls are finished in wood. Each possesses but a 
 single high basement window, so both light and air are deficient ; 
 there is an open toilet hopper in one corner ; they are heated only 
 from cellar passageway. 
 
 A visiting physician attends to the physical ills of patients, 
 but there are no medical facilities nor treatment for insanity as 
 such. There is no recreation, and patients lead a confined and 
 monotonous existence, a number being noted lying about on the 
 floor asleep, there being no effort to keep any occupied except as 
 they may work willingly. 
 
 A vicious practice exists whereby four pauper inmates of the 
 almshouse live with the insane and one of the latter lives in the 
 almshouse. It should be added, however, that two of such pau- 
 pers present mental symptoms and are to be shortly committed, 
 but in the other cases they live as they do simply because they 
 assist with the work. There is also in the insane department the 
 infant child of one of the women patients, no consideration having 
 as yet been given to the matter of its ultimate disposition. 
 
 Particularly objectionable as the conditions are for the care of 
 the insane, it would be likewise desirable to remove the insane 
 from this institution for the reason that the almshouse is over- 
 crowded and every winter it is necessary to house almshouse 
 inmates in the attic, so good use could be made of the present 
 building for the insane to relieve this condition. 
 
 The objectionable practice is here followed of deciding as to 
 whether a patient shall be committed to a State hospital or to the 
 county hospital by the degree of troublesomeness manifested by 
 the patient, regardless of prognosis. 
 
 INSTITUTION No. 25 
 
 Physical Conditions. A single story extension at each end of 
 the almshouse provides accommodation for the insane of each 
 sex; there being a single covered connecting corridor to each 
 closed by doors of iron grating placed at the entrance. Outside 
 
 [31]
 
 such doors hose and stand pipes are found, but they constitute 
 the only fire protection for the insane wards. There are no out- 
 side exits from the latter, the only approach being through the 
 corridors mentioned. On the men's side is a small basement 
 dormitory with two small high basement windows from which 
 there is but a single exit by means of inside winding, wooden 
 stairs to the ward above. The men's ward is bare and cheerless, 
 but on the women's side ornamental wall-paper has been cut 
 out and pasted in sections on the wall, so as to give the effect of 
 pictures. Windows are guarded by inside iron bars, producing 
 a prison-like effect. Chairs are permanently fastened to the 
 floor, and as a result patients were found lying prone on the floor 
 not only in the ward, but in the toilet sections; while patients 
 have access to hot water, there are no hot water safety devices. 
 
 Sewage flows untreated into a swamp about a mile distant. 
 Water supply is limited. Service departments were found in 
 excellent condition and housekeeping generally is above the usual 
 almshouse standard. A particularly good feature, showing ini- 
 tiative on the part of local authorities, is a home-made refriger- 
 ator, which is divided into compartments, and which is most 
 satisfactory. 
 
 There are no porches on the wings for the insane, although the 
 almshouse proper is so equipped. Women's exercise yard is 
 unused for the purpose, but men's yard is covered with paths 
 worn in the earth by the pacing back and forth of patients. It 
 is enclosed on three sides by buildings and on the fourth side by 
 a heavy masonry wall of distinctively prison-like appearance. 
 
 Administration. One of the most serious faults is the substitu- 
 tion of close confinement for personal attention. There is but a 
 single male attendant and no women attendants. Women pa- 
 tients are "looked after" by the woman cook, when she can spare 
 time from her other duties; but she was not in evidence during 
 visit. As she sleeps near the women patients and the man at- 
 tendant sleeps in the male ward, there is thought to exist no neces- 
 sity for night attendants. Patients are admittedly left alone 
 much of the time. One result is that patients' clothing was 
 found disordered, in some instances torn, and in a few cases much 
 soiled ; such condition being more marked on the men's than on 
 the women's side. In the almshouse proper the inmates of both 
 sexes presented a much better appearance. 
 
 [32]
 
 Women patients never exercise out-of-doors, it being said "we 
 can't get them out" and their exercise yard is therefore utilized 
 for clothes-lines. Although the weather was favorable, men were 
 not out for exercise on day of visit. Only willing workers are 
 employed, the majority of the patients sitting or lying about in a 
 dull, listless fashion. There are neither recreations nor religious 
 services. 
 
 Patients eat in the same dining-room with the paupers, al- 
 though at separate tables. In accordance with the general ex- 
 cellence of the service departments, the garbage is well handled. 
 
 Medical treatment even for physical ills is limited. Visiting 
 physician visits regularly but once or twice a month. He is 
 said to give no attention to the insane, except as indicated by the 
 lay superintendent. As it was expressed in referring to the mat- 
 ter, " He doesn't even know how many we have got in the Insane 
 Department." The lay superintendent and his son dispense 
 medicines, and during visit the latter filled a bottle with eye-wash 
 . and one with a cough mixture at the request of two pauper in- 
 mates. He expressed the opinion that he could give out most of 
 the medicines needed as well as the doctor. A trusty patient 
 who has a room to himself is charged with the duty of keeping the 
 ward disinfectants. 
 
 Institution is provided with handcuffs, which, however, are 
 said to be but rarely used except in transporting patients to and 
 from the institution. Two patients were found in seclusion on 
 occasion of visit. The opinion was expressed that seclusion was 
 a good practice in certain cases, for if patients got troublesome it 
 was only necessary to shut them up and allow them to go without 
 a meal or two, at the same time giving them plenty of water to 
 drink, when, "They will follow the point of your finger around 
 like a dog." Despite the above statement, there is evidence 
 that the local administration is kindly disposed toward the pa- 
 tients, and the attitude indicated appears the result of ignorance 
 rather than intent. 
 
 The County Commissioners determine whether in a given case 
 an insane patient is to be committed to the State Hospital or the 
 County Hospital. They usually consult with the visiting physi- 
 cian and the superintendent of the almshouse. In practice it 
 appears that it is the latter's opinion which usually prevails, but 
 it should be added that he is said always to recommend commit- 
 
 3 [331
 
 ment to a State hospital if in his judgment a patient can be im- 
 proved by treatment. While some alleged cases of insanity are 
 placed in jail pending commitment, others are brought to this 
 institution and confined in the insane ward with the committed 
 patients, it having happened that patients have been so confined 
 for three to four weeks without commitment. 
 
 It has been proposed to enlarge the capacity of the insane 
 ward, the County supporting a considerable number of patients 
 in the State hospitals, whom it is thought can be supported more 
 cheaply here, the question of expense evidently being the only 
 factor considered. 
 
 A deplorable feature of this institution is the presence of nine 
 children in the almshouse, it being remembered that paupers and 
 insane eat in the same dining-room. The almshouse is over- 
 crowded, especially in winter, and it was recently necessary to 
 convert part of the chapel into bed space, so good use could be 
 made of the insane wards if the insane were removed, as would 
 seem most desirable. 
 
 INSTITUTION No. 26 
 
 Physical Conditions. Insane women occupy the second floor 
 of a wing of the almshouse, entrance to which is had only through 
 the almshouse wards. Men insane live in a detached building 
 at the rear, which has been properly condemned by the State 
 Committee on Lunacy. This building has a central narrow dark 
 hallway, with such small bed-rooms on either side that beds 
 occupy most of the space. There is no day space at all ; because 
 of these and other conditions, male patients are no longer ad- 
 mitted. Women's ward also lacks day space, owing to the neces- 
 sity of using part of ward for a dining-room. Both wards have 
 inside vertical iron bars at the windows, while most of doors to 
 rooms have similar bars in the upper half. Wards are bare and 
 unattractive. One room on women's ward is lined with tin on 
 side walls for disturbed patients. With but a single ward for 
 each sex, no classification is possible. Ventilation is defective, 
 especially in toilet sections, where deodorizing fixtures were noted. 
 
 Service departments are in good condition, save in meat- 
 cutting room, where several beef hearts were seen covered with 
 mold, and where the meat cutting block was in an uncleanly 
 condition. Fire protection is inadequate. Water pressure is 
 
 (34)
 
 insufficient to throw water over the building, as it is obtained from 
 water tanks in the attic. Sewage disposal is unsatisfactory; 
 sewage flows from a cesspool into trenches, the earth from which 
 is used as a fertilizer. 
 
 An unpleasant spectacle was afforded by a number of coffins 
 piled one on top of the other in a small storeroom just outside the 
 entrance to one of the almshouse wards, the door of which was 
 left open throughout day of visit. 
 
 Administration. Male patients are all parole patients, and 
 hence no attendant is provided. There is but one woman at- 
 tendant, who also works in the almshouse department, so pa- 
 tients are left alone much of the time. Owing to the lack of 
 day space, most of the patients were found in their rooms, where 
 they were idly sitting, only willing workers being occupied. 
 Dietary here is better than is usual in almshouses. Male insane 
 eat with the male paupers at the same table. There is no en- 
 closed exercise yard and such of the patients as exercise do so with 
 the paupers, but a large proportion of the women never go out- 
 of-doors, being decrepit and unable to go up and down stairs 
 from the second floor. 
 
 Few patients now in institution ever require restraint or 
 seclusion, but either may be used at the discretion of the at- 
 tendant or lay superintendent, the physician not being consulted. 
 The use of morphine to quiet excited cases is regulated in the 
 same way, a "practical" nurse from the almshouse department 
 administering it if thought necessary. Institution is equipped 
 with leather belt, strait-jacket and leather handcuffs, should 
 restraint ever be deemed necessary. 
 
 It was formerly the practice to commit acute cases of insanity 
 to this institution, but the present practice is to commit such 
 cases to a State hospital, the change in practice resulting from the 
 death of a patient, while at home on parole, from starvation. 
 It was said the patient refused to eat because of delusions, and 
 the relatives not knowing how to deal with the situation allowed 
 the patient to starve to death. Alleged cases pending commit- 
 ment are placed either in jail or with the committed insane here. 
 
 INSTITUTION No. 27 
 
 Physical Conditions. There are but two wards, in the form of 
 narrow halls, the men living one floor above the women, so no 
 
 l35l
 
 classification is possible. Light and air are both deficient. 
 Windows are but the width of two small old-fashioned window- 
 panes. As halls furnish most of the day space, the patients re- 
 main in their rooms most of the time, and the practice of keeping 
 the doors closed renders the halls darker than would otherwise be 
 the case even with the small windows. Both wards open into 
 the almshouse proper. 
 
 A dark storage basement under the building is in part used for 
 a tramp room; being dark and unsanitary, it has been properly 
 condemned by the Committee on Lunacy. General service 
 departments are poor. Kitchen in basement of almshouse has a 
 broken concrete floor, is dark and poorly ventilated, and was 
 found in an uncleanly condition, only pauper help being here 
 employed. A barrel sunk in a spring is the only cold storage 
 provision. The laundry, situated in part of the slaughter house, 
 is equipped with wooden tubs only and hand wringers. The 
 clothes are dried on out-of-door lines or in the attic, and are ironed 
 in the almshouse basement. The boiler room for heating is 
 situated below the surface of the ground, so that the ashes have to 
 be carried by hand up a flight of steps. 
 
 Sewage disposal is unsanitary. There are two cesspools, each 
 about 200 feet from the building. At times these overflow and 
 formerly would then flow into a neighboring creek, but owing to 
 objection on the part of the State Board of Health, when over- 
 flow occurs it is now carried by ditches to waste land about one 
 quarter of a mile distant. 
 
 Fire protection is extremely poor. The only water pressure 
 is obtained from a small attic reservoir, with a capacity of 150 
 barrels; there is a second such reservoir which has never been 
 used owing to the expense of making connections. A single 
 screw nozle faucet for garden hose is placed outside, some dis- 
 tance from the building, and this furnishes the only means of 
 fighting fire, there being no inside provisions whatever. There 
 are two unenclosed outside iron fire-escapes. There is a single 
 inside wooden stairway at the junction of the building for insane 
 with the almshouse proper, there being no outside exits at other 
 end of building, except through windows, to the fire-escape. A 
 recent addition supplied by the steward's initiative is an outside 
 wooden stairway to the second floor at almshouse end. That 
 the fire risk from lack of water has been appreciated is evinced 
 
 [36]
 
 by the statement that plans have been considered for connection 
 with the water mains of the neighboring city, which pass directly 
 in front of the property. As yet, however, no action has been 
 taken owing to the expense involved. 
 
 The wards are provided with outside iron-barred window 
 guards, and in so-called "strong rooms" such guards are also 
 placed inside the windows. There is a short hall on each ward, 
 at one end of which is the dining-room and at the other end the 
 toilet section. The toilet facilities are all in one open room. 
 There are no hot water safety devices, although patients have free 
 access to faucets. The hot water supply is limited, however, 
 being obtained only from a heater on the kitchen stove. It 
 was admitted that the supply frequently becomes exhausted 
 before bathing is completed. Plumbing is old, worn, and much 
 of it is concealed in the walls. It was said that on one occasion 
 it was necessary to tear up an entire floor in order to make neces- 
 sary plumbing repairs. Each so-called "strong room," aside 
 from extra window guards, is provided with an extra door of open 
 iron grating inside the wooden door. Ore such room has side 
 walls lined with tin, a disturbed patient having destroyed the 
 plaster. Benches and chairs are both provided, the quiet stupid 
 patients being kept on the former, ranged along the side walls. 
 As it was expressed in pointing out one such patient, "She usually 
 stays right there where she is put all day long." 
 
 Exercise yards are enclosed by a high, whitewashed board fence, 
 in part surmounted by barbed wire. 
 
 Administration. Food service is very poor, it being necessary 
 to carry all food by hand from the almshouse through the length 
 of the wards to the dining-rooms. The food served is the same 
 as for paupers, and it lacks variety. The same meals are served 
 on corresponding days each week, except only as the seasons 
 change. Bread, butter, molasses, and coffee are served for prac- 
 tically every breakfast and supper. For the latter meal, how- 
 ever, an onion, tomato, or apple is occasionally added. Each 
 patient receives a glassful of butter weekly, the whole amount 
 being left in charge of the individual patient. It is said that some 
 consume their allotment within a day or so, while others, more 
 economically inclined, keep the butter in their rooms and make 
 it last the entire week. Patients are also allowed to take meat 
 from the table to their rooms after the noonday meal, so that 
 
 [371
 
 they can save it for supper. A woman patient was pointed out as 
 being able to go for long periods without food, it being said that 
 she had gone as long as sixteen days without apparent injury. 
 It was added, with a smile, "She soon makes up for lost time when 
 she again starts to eat." 
 
 Patients can necessarily receive but little personal attention, 
 the only attendants being one married couple. In lieu of a night 
 attendant, a colored pauper is used as an outside night watch- 
 man. He is not allowed to enter the buildings. The male 
 attendant was formerly a farmer, and neither he nor his wife 
 ever had previous experience with insane. It should be added 
 that they both appear to be doing their duty as well as possible 
 under defective conditions, and according to their lights, this 
 being evinced by the good housekeeping and the unusually good 
 condition of patients' clothing. 
 
 The practice exists of keeping untidy patients in the toilet 
 sections, and on day of visit four male patients were found there 
 seated on a bench and restrained, it being necessary to leave them 
 alone most of the time, as the single attendant performed his 
 duties elsewhere. One such patient was said to be constantly 
 restrained; two of them were fastened to the bench by leather 
 straps about the waist, and one had his hands secured by a leather 
 muff. The latter also had a wire screen cage over his head rest- 
 ing on his shoulders, it being explained that even when restrained 
 he tore his clothing with his teeth. These patients, together with 
 an unrestrained stupid patient sitting with them, were bare- 
 footed, their feet resting on the concrete floor. While it was said 
 they were not used in the institution, steel handcuffs are used in 
 transporting patients either to or from it. A disturbed patient 
 who died during the past year was, in the opinion of the local 
 authorities, "worried to death." This patient was so violently 
 disturbed that even when handcuffed with his hands behind his 
 back, or beneath his knees, and being meanwhile strapped to the 
 bed, he could free himself. On one occasion after being locked in 
 his room when restrained in the manner described, he not only 
 freed himself but tore the screen from the radiator and sustained 
 severe burns, which appear to have been at least a complicating 
 factor in causing death. It was stated that even when this 
 patient was in one of his wildest moods, he could be quieted when 
 the steward talked to him, as it was expressed, "in a sensible 
 
 [38]
 
 manner." At such times the patient declared he was not insane 
 but simply was unable to control himself. The facts as given 
 would indicate that had patient received proper personal at- 
 tention, and had proper medical treatment been instituted for 
 the relief of his mental condition, the case would have had a very 
 different termination, as the symptoms described indicate that 
 he was suffering from a recoverable form of insanity. 
 
 The visiting physician regularly calls but three times a week, and 
 although it was admitted that the State Committee on Lunacy 
 had spoken about the matter, no clinical records are kept. There 
 are, of course, no medical facilities or treatment for mental disease. 
 
 The separation of the sexes is poor, on which account the pres- 
 ence of several erotic girl imbeciles constitutes a menace. 
 
 Owing to the fact that the almshouse only is provided with 
 dormitories, and the building for the insane only with single 
 rooms, the custom prevails of caring for certain of the insane in 
 the almshouse proper, and for certain of the pauper inmates of 
 the almshouse with the insane. 
 
 Alleged cases of insanity if quiet are cared for in the almshouse, 
 but if disturbed are placed in the "strong rooms" of the insane 
 department. Commitment is by the Commission process, the 
 Commission recommending whether commitment shall be to a 
 State hospital or the county institution. It was freely admitted 
 that the issue was determined by the degree of troublesomeness 
 manifested by the patient, or should the patient belong to one 
 of the "better families," the recommendation is always for com- 
 mitment to a State hospital. 
 
 The almshouse is utilized to capacity, is overcrowded every 
 winter, and it could well use the building now occupied by the 
 insane, especially as they would supplement one another as re- 
 gards single rooms and dormitories. There thus appears an 
 added reason, apart from the deplorable conditions, why the in- 
 sane should be removed from this institution at the earliest pos- 
 sible moment. 
 
 INSTITUTION No. 28 
 
 Physical Conditions. An extension from either end of the 
 almshouse provides a single story ward for the insane of each sex, 
 each ward being connected with the almshouse proper by a cov- 
 ered corridor, at the entrance to which are doors of heavy iron 
 
 l39l
 
 grating. A similar iron door shuts off a short hall on which single 
 rooms open, such door being regarded as necessary when patients 
 are secluded in their rooms, although the latter are locked. 
 There is a single day room on each side where all types of cases 
 mingle. Wards are bare and in some places plaster has fallen, 
 although on day of visit repairs were in progress where such 
 damage was most extensive. Toilet facilities are fairly satis- 
 factory, except that the single bathtub for each sex is placed in a 
 small room, which, with but a single small window, is dark and 
 poorly ventilated, while no hot water safety devices are provided. 
 
 Single rooms have no lights and are locked at night. Several 
 such rooms, used for seclusion, have adjoining toilets which have 
 no opening aside from the door. 
 
 There is an exercise yard for each sex, enclosed by a high iron 
 picket fence; neither has any shelter. Although the almshouse 
 has porches, there are none for the insane. 
 
 Only fire protection is provided by a hose and standpipe out- 
 side the iron doors*^at the entrance to the corridors connecting 
 the almshouse with the insane wards. The only outside exits 
 from the latter are into the exercise yards, and there is no gate 
 in the surrounding iron fence. But part of the steam radiators 
 are protected. Sewage disposal is most unsanitary; sewage 
 flows untreated into a small creek about 200 yards from the front 
 of the building; when seen, the creek had little water, sewage 
 was stagnant, and there was considerable odor. 
 
 Administration. Patients receive little personal attention, as 
 would be expected under the conditions, there being but a single 
 male and a single female attendant. The former is termed assistant 
 superintendent, works on the farm, and admittedly spends little 
 time in the wards, which are left in charge of a trusty patient in 
 his absence. The woman attendant spends the greater portion 
 of her time in the sick ward of the almshouse, being the only 
 woman employee aside from the matron and cook. The insane 
 patients are, therefore, left to their own devices much of the time. 
 There is no night employee not even a watchman. 
 
 The housekeeping is generally poor dust and cobwebs being 
 much in evidence. Toilet sections were in particular disorder. 
 A number of beds were seen in the afternoon just as they had been 
 left by patients on arising in the morning. Patients are allowed 
 to collect worthless trinkets and rubbish in their rooms, and in 
 
 [40]
 
 one room a large piece of broken glass was noted. A patient 
 was found smoking in the ward without exciting comment. 
 
 Although clothing is of fair quality, it is poorly cared for 
 in the majority of cases buttons were found off and clothing 
 open; much of clothing was soiled and some torn. One young 
 girl's dress was so torn as to expose her person. Many patients 
 were seen without shoestrings, and a number of both sexes seen 
 barefooted; in the latter instances, from the appearance of the 
 feet, patients had not worn shoes and stockings for a long time; 
 it would have been impossible for one man to have done so, 
 because of the extreme length of his toe-nails. 
 
 Sufficient food is apparently supplied, but there is little va- 
 riety. Meat is served but three or four times a week. 
 
 Only willing workers are occupied, and they constitute a com- 
 paratively small percentage of the total number. Idle patients 
 have no regular exercise, and on day of visit, although weather 
 was favorable, no men were out. On the women's side, however, 
 the door from the ward to the exercise yard stood open, and some 
 of the women were found in the yard, one lying prone on her 
 back with the sun shining full in her face, without anyone giving 
 heed. Several of the women in the yard were talking loudly, 
 while on the other side of the open iron picket fence children 
 from the almshouse were playing. 
 
 There are no recreations. Only occasionally do a few of the 
 insane attend religious services in the almshouse, and for the 
 most part patients lead a mechanical and monotonous existence. 
 
 With such a limited amount of personal attention, restraint 
 and seclusion are both necessarily used; the forms of restraint 
 used include leather wrist cuffs and muffs and the strait-jacket. 
 One woman patient is constantly restrained with leather muffs, 
 so she has to be fed and undressed by others. It was ex- 
 plained that "She tears her clothing and is very bad." When 
 patient was questioned, she said, " I would be good if they would 
 take this off," indicating the muffs. As to seclusion, the at- 
 tendant remarked that it was rarely necessary to keep them 
 locked up more than half a day, as "That is usually enough to 
 tone them down." A paralyzed man was found locked in his 
 room with both the bed and floor in a foul condition, but the door 
 was again locked, the condition found causing no comment. 
 
 There are no special medical facilities except that a seriously 
 
 [41]
 
 sick patient is removed to the sick ward in the almshouse, which 
 is an ordinary dormitory set apart for the purpose. The visiting 
 physician calls regularly but once a week, and that patients do 
 not receive sufficient medical attention is evinced by the condition 
 in which a stupid male patient was found. He had a large abscess 
 on the side of his neck, evidently of some duration, as the pus had 
 burrowed a considerable distance through the tissues. Although 
 the superintendent inquired of other patients how long the condi- 
 tion had existed, nobody was found who knew anything about it. 
 
 An unfortunate feature of the situation is that the visiting 
 physician believes that acute cases of insanity can be cared for 
 here without difficulty, his idea of the treatment of mental disease 
 being summed up in the phrase, "Build them up." 
 
 Alleged cases of insanity are sent here pending commitment, 
 and they often remain several weeks, no distinction being made 
 between them and the committed cases. One male case at pres- 
 ent in the institution has been here for several months, the ex- 
 amining physicians having refused to commit him, and his rela- 
 tives having refused to allow him to return home. 
 
 An unfortunate tendency was observed here as in several other 
 county institutions in reference to general visitors. On day of 
 visit, there were three parties of general visitors, whose interest 
 in seeing the insane was quite evidently one of morbid curiosity, 
 as they did not fail to make audible comments about the women 
 patients as they stared at the latter through the iron fence sur- 
 rounding the exercise yard. 
 
 All positions in both insane department and almshouse are 
 regarded as political assets, even the male attendant receiving his 
 appointment as a reward for political service. The superin- 
 tendent is a former farmer, who frankly admits he knows nothing 
 about the insane. 
 
 Were the insane removed from this institution, as existing 
 conditions render most advisable, the two wards could be used to 
 advantage by the almshouse, where every winter there exists much 
 overcrowding. 
 
 INSTITUTION No. 29 
 
 Physical Conditions. The institution is inaccessible, except 
 by private conveyance; it is located six miles from the nearest 
 railroad, over poor highways. The almshouse adjoins a recently 
 erected, substantial, fireproof building for the insane which has 
 
 [42]
 
 but a single ward for each sex, men occupying the first floor and 
 women the second. A prison effect is produced by heavy iron 
 bars at the windows and iron grating doors outside wooden ones 
 at the outside entrance. Toilet facilities are modern, but there 
 is an insufficient number of wash-basins. Dormitories are excel- 
 lent, but there is only one, single room for each sex. There is a 
 lack of day room space, considering the number of patients cared 
 for. As a result of the impossibility of classification and the 
 close physical contact, two discolored eyes were noted among the 
 women patients. Some overcrowding was evident, and a few 
 mattresses on the floor indicated lack of sufficient bed space. 
 
 Service departments are in basement, where the dining-room 
 also is located. Decrepit patients eat in the ward, and two cases 
 were noted of patients eating from the top of a screened radiator. 
 Food is apparently satisfactory. 
 
 Service departments are generally well conducted, particularly 
 the outside departments, under the direction of the almshouse 
 steward. Farm work especially appears to be done in an effi- 
 cient manner. 
 
 There is no provision for fire fighting, except water lines, the 
 pressure in which is obtained only from tanks in the neighboring 
 almshouse attic, and which are therefore unreliable and insuf- 
 ficient. Dependence is admittedly placed on fireproof construc- 
 tion of building, although it has the usual interior wooden trim. 
 Kerosene is kept in the basement. 
 
 Raw sewage flows into a neighboring creek, but plans have 
 been formulated for two settling tanks. 
 
 Exercise yard is enclosed with wire netting, but exercise is 
 irregular, and is only possible when resident physician is present 
 to act as an attendant, owing to the limited number of attendants 
 employed. In his absence on day of visit patients were not out 
 for exercise. 
 
 A so-called "cell" in the basement is used for seclusion. It 
 is an unfurnished room with a single high basement window, so 
 light and air are deficient; it has a concrete floor with a drain in 
 the center, in lieu of toilet facilities, and is provided with a heavy 
 wooden door of double timbers. While patients in seclusion are 
 taken to the toilet during the day, they are not at night, the room 
 being flushed with a hose in the morning. It had been vacated 
 day prior to visit and an odor was still perceptible. 
 
 [43]
 
 While the main almshouse building was fairly acceptable, 
 two detached buildings for male paupers were in a dilapidated 
 condition; one has been condemned by State authorities, and 
 it would appear that both should be. Plans have been formu- 
 lated for a building to replace the condemned almshouse build- 
 ing, but such necessity would not exist could the insane be re- 
 moved from this institution, as the lack of facilities, especially 
 regrettable in a new building, renders desirable. 
 
 Administration. Existing conditions are held responsible for 
 the free use of restraint, although they do not seem to offer an 
 excuse for the forms employed. On day of visit a man was re- 
 strained with steel handcuffs, fastened tightly about his wrists, 
 because, as it was explained, "If they were loose, he would free 
 himself." Both wrists were abraded, evidently as a result of his 
 struggles. He repeatedly asked to be freed, and when he was 
 asked why he did not conduct himself properly, he inquired in 
 turn how could he with the handcuffs on. When seen, he was 
 sitting on a chair talking in a moderate tone, and showing no 
 great unrest. Comment being made on the form of the restraint 
 when the ward was first visited, it was noted when passing through 
 the ward later that the handcuffs had been removed. The 
 patient was moving rather restlessly about, but was smiling and 
 less talkative than when first seen, making no trouble whatever. 
 He was said to be a recurrent maniacal case and able to tell 
 the day before when an attack is impending. He will then 
 spend considerable time dashing cold water over his head, but 
 such efforts on the part of the patient do not appear to have ever 
 caused his caretakers to think of using showers, wet packs, or 
 such forms of hydrotherapy as are possible without special ap- 
 paratus. The forms of restraint, aside from steel handcuffs, 
 include the strait-jacket, leather cuffs and anklets, the latter 
 being exhibited in a broken condition, a male patient having 
 succeeded in freeing himself from them. 
 
 A fair proportion of the patients are occupied, but occupation 
 is unregulated except in accord with the demands of the Board 
 of Directors, who are said to be constantly complaining that an 
 insufficient amount of work is obtained from the patients. 
 
 Medical facilities are limited, even for the treatment of physi- 
 cal disease, which is admittedly the only medical treatment. 
 The resident physician was recently appointed, after answering an 
 
 [44]
 
 advertisement, and so far as known has never had any experience 
 with the insane. He is allowed to engage in general practice. 
 Nobody knew the cause of his absence on day of visit, or when he 
 was apt to return. A single tubercular patient mingles with the 
 others without restriction. 
 
 There is a general atmosphere of depression pervading the 
 institution, and the punitive idea prevails. Attendants were 
 heard ordering patients in a most peremptory manner to perform 
 various tasks. 
 
 Business affairs and the matter of supplies are in charge of the 
 almshouse superintendent. The latter is of progressive ten- 
 dencies, and has made numerous changes during his tenure of 
 office tending to a more business-like administration. 
 
 INSTITUTION No. 30 
 
 Physical Conditions. Main building for insane is of an old 
 type, but fairly satisfactory. A detached building, however, 
 used by untidy patients, is dilapidated and unfit for occupancy. 
 The neighboring almshouse building is of recent construction, 
 and is much superior to any other building of the entire plant. 
 Aside from wards in detached building, insane wards are well 
 furnished and comfortable. Toilet facilities, however, are in- 
 sufficient in number and in part of an old, antiquated type. 
 Steam radiators are but partly protected, although work is in 
 progress to screen them all, following recommendation of State 
 Committee on Lunacy made nearly two years ago. 
 
 Kitchen is too small, but is well equipped. A new building is 
 in process of erection to replace present unsatisfactory laundry; 
 it will likewise provide an amusement hall, the present one on the 
 fourth floor furnishing an undue fire risk. Cold storage facilities 
 are inadequate, but otherwise, except as noted, service depart- 
 ments are satisfactory. 
 
 Fire protection is fair, but no fire drills are held, being regarded 
 as undesirable. 
 
 Exercise yard is enclosed by a high iron picket fence, and 
 divided by a brick wall for the sexes. However, the practice 
 of allowing patients to exercise on the open lawn is increasing. 
 
 There is a modern hydrotherapeutic plant, including continu- 
 ous baths, but it is poorly located. Disturbed patients, for whom 
 such treatment is mostly indicated, are kept on the floor above 
 
 [45]
 
 and it is necessary not only to bring them downstairs but through 
 a hallway and the main dining-room to receive hydrotherapeutic 
 treatment, so its use must necessarily be restricted. 
 
 While two wards are set apart for the reception of new cases, 
 neither have any special facilities. There is no provision for the 
 isolation of tubercular cases, except that advanced cases are kept 
 in single rooms. 
 
 Administration. Formerly the superintendent of the alms- 
 house was the executive head of the whole plant, but in recent 
 months a change was made whereby the resident physician be- 
 came chief executive of the insane hospital; he has no voice as 
 to supplies, however, other than strictly medical ones, and cloth- 
 ing, food, etc., are not regarded in the latter category. An even 
 more serious administrative defect is that while the physician may 
 indicate which patients may go outdoors for work, they are under 
 the direction of the almshouse superintendent as soon as they 
 leave the ward, so the physician has no voice as to the tasks 
 assigned individual patients, and there is considerable evidence 
 that the needs of the work are considered before the needs of the 
 patients. There are no occupational classes. 
 
 A good result following the administrative change is the re- 
 duction of restraint and seclusion. On day of visit but a single 
 patient was restrained, being a homicidal woman who had one 
 hand only, secured by a leather cuff and fastened to a leather belt 
 about her waist. 
 
 There is an insufficient number of attendants and but a single 
 graduate nurse to care for the sick, not only in the insane hospi- 
 tal but in the almshouse. It is said, however, that a training 
 school for nurses is planned. There are but two physicians to 
 care for over 500 insane patients and the sick in the almshouse, 
 but it is said another physician is to be added to the staff. There 
 is no provision for dental work. 
 
 There is no reason to doubt but that patients' material comfort 
 receives proper attention, although the care given is but custo- 
 dial. There is a lack of facilities, not only for the treatment of 
 acute insanity, but for the treatment of physical ills. There is no 
 pathologic work and but a meager amount of clinical laboratory 
 work, the facilities for which are limited and crude. Medical 
 records are poor, but improvements in this respect are planned. 
 
 Defective discipline prevails; an attendant was found smoking 
 in the ward without exciting comment. 
 
 [46]
 
 Business methods are defective and do not provide for the 
 rejection of unsatisfactory deliveries of supplies. There is in- 
 sufficient checking of the latter, so that the interests of the in- 
 stitution are not sufficiently safeguarded. 
 
 There is evidence that political influences have frequently 
 asserted themselves in regard to hospital matters, especially con- 
 cerning appointments to the higher positions. 
 
 In view of the fact that the excellent almshouse building has 
 never yet been occupied to capacity, while part of the insane 
 are occupying a building unfit for habitation, it would seem de- 
 sirable that the whole plant be converted to the use of the insane 
 alone. Could such a plan be adopted, this institution would 
 form the nucleus of a good State hospital, material facilities being 
 in the main satisfactory. The comparatively large acreage here 
 available would permit of future development. 
 
 INSTITUTION No. 31 
 
 Physical Conditions. The insane occupy two buildings, situ- 
 ated between the main almshouse building on one side and the 
 almshouse hospital building on the other, all being connected by 
 covered passageways. One building for the insane is of com- 
 paratively recent construction and fairly satisfactory; it lacks 
 sufficient toilet and bath facilities, however, and some of the 
 plumbing is placed so low as to afford opportunity for suicidal 
 attempts. Heating facilities are insufficient. In the old build- 
 ing the floors are badly worn, walls are smoked, cracked and 
 broken, woodwork is worn, and paint is generally needed. The 
 ceilings are low, there are numerous dark, narrow passageways, 
 and its dilapidated condition renders it unfit for human occu- 
 pancy. Some of the patients' rooms in this building have iron 
 grating doors inside of solid wooden ones, and have, in addition 
 to the usual outside iron-barred window guards, heavy wire 
 screens placed inside the windows. On one of the women's 
 wards a heavy iron-barred partition extends from the floor to the 
 ceiling, shutting off one end of the hall, so that patients cannot 
 reach the windows. Part of toilet sections have wooden floors, 
 and toilet accommodations are not only insufficient but anti- 
 quated, worn, and unsanitary. Numerous small, dark closets 
 are found and, in general, light and ventilation are extremely 
 poor. Benches provide the only seating facilities, and being 
 
 [47]
 
 devoid of any decorative features, the interior of the old build- 
 ing presents a most dismal and desolate appearance. 
 
 The dining-rooms in the old building are particularly objec- 
 tionable, there being no service facilities. Food appears satis- 
 factory, although a stereotyped menu is repeated weekly. 
 
 Lighting is by electricity, but in the old building wiring is 
 attached to the surface of walls and ceilings, and is easily acces- 
 sible to patients. Although steam radiators are unprotected, it 
 was said a contract has been let to install protecting screens. 
 
 Sewage flows untreated into a creek about 500 feet from the 
 rear of the buildings. Fire protection is defective, especially in 
 the old building. Water pressure is variable and is not always 
 sufficient to reach the upper floors. 
 
 Exercise yard is below the ground level on one side, being dug 
 out of a hillside, so that it is at the ground-floor level of the ad- 
 joining building, which stands on the slope. The yard is sur- 
 rounded by whitewashed stone walls and is divided in the middle 
 for the sexes. Patients exercising here can be heard easily on 
 the street in front, the institution being located in a residential 
 suburb, and it is admitted that neighbors occasionally complain. 
 
 The outside departments belong to the almshouse and patients 
 working in them are under the direction of the almshouse su- 
 perintendent. The rear yards and those about the farm build- 
 ings were found littered with considerable rubbish and flies were 
 numerous. But a short distance from the springhouse, where 
 milk is handled, at a point about 500 yards from the patients' 
 buildings, is a frame piggery found in a most unsanitary state, 
 rubbish and garbage being scattered over the ground about it. 
 It was remarked: "This condition probably accounts for the 
 many flies throughout the institution." 
 
 The new building contains practically all dormitories and the 
 old one practically all single rooms, hence classification is dif- 
 ficult. The official capacity has been increased as patients have 
 increased, although without additional accommodations, and a 
 serious degree of overcrowding exists, as is shown by local calcu- 
 lations, which, including both bedroom space and dayroom space, 
 give but 350 cubic feet of air space per patient. 
 
 There is no hydrotherapeutic apparatus and no special medical 
 facilities, aside from a small, but well-equipped clinical labora- 
 tory, established by a former physician, but the present resident 
 
 [48]
 
 physician has no opportunity to use it, having no assistant, and 
 being charged with the care of over 300 insane patients, besides 
 the physically sick in the almshouse. 
 
 There is a detached building for contagious diseases which 
 stands idle most of the time. In view of the fact that tubercular 
 cases have to be kept with other patients, it would seem that 
 such a building should be utilized for their care. New tubercu- 
 lar cases not infrequently develop in the wards, in the majority 
 of instances the disease resulting fatally, and of the total number 
 of deaths occurring the last hospital year, 27 per cent, were from 
 tuberculosis. It was said that the State Committee on Lunacy 
 directed that the insane hospital should use the above-mentioned 
 building, but the Board of Directors adopted a resolution oppos- 
 ing such suggestion and no further action has been taken. It 
 was said that such building when erected was approved by the 
 State Board of Charities with the understanding that it should be 
 used only for cases of contagious diseases occurring in the in- 
 stitution, but the Board of Poor Directors have used it only for 
 cases of contagious disease occurring outside the institution. 
 
 The almshouse hospital building is much less objectionable 
 than the old building for the insane, and hence the practice of 
 caring for occasional sick insane patients in it is less inhumane 
 than might appear at first sight. 
 
 Administration. There is reason to believe that the custodial 
 care given is as good as could be expected under the conditions, 
 but it is, of course, custodial care only. Patients' clothing is 
 above the average and they apparently receive as much personal 
 attention as is possible with a meager number of attendants. 
 Strict rules are enforced as to ill-treatment of patients, and dur- 
 ing the past year two attendants were placed under arrest on 
 evidence that they had ill-treated a patient. 
 
 Restraint and seclusion have been reduced to a minimum, 
 although it is unfortunate that some of the attendants regard the 
 latter as "just for punishment." The more objectionable forms 
 of restraint have been abolished, including leather muffs, wrist- 
 lets, and straps. 
 
 A fair percentage of the patients are occupied, but there are 
 no occupational classes and work is unsystematized. There are 
 but limited facilities for recreation. 
 
 Both sexes occupy both buildings, and separation of sexes is 
 4 [49]
 
 poor. While communicating doors between their respective 
 wards are supposed to be kept locked, it was admitted that such 
 a condition is only obtained with difficulty. This is the more 
 serious by reason of the large number of defectives cared for, who 
 present no evidence of insanity. No effort is at present made to 
 discharge them, as in the past, when discharged, they have 
 either been recommitted as insane or been returned to the alms- 
 house, in which circumstance it is the policy of the Directors to 
 have them committed as insane, although admittedly without 
 mental symptoms, apart from defectiveness. 
 
 As one of the insane buildings should be at once abandoned 
 and as the almshouse is overcrowded every winter, it would 
 appear desirable that the insane be removed from this institu- 
 tion and the almshouse given the use of the more recently con- 
 structed building for the insane. 
 
 INSTITUTION No. 32 
 
 Physical Conditions. The insane hospital with the adjoining 
 almshouse is maintained by a specially created Poor District, 
 but the two institutions are independently administered, except 
 as supplies for both are purchased together. The building for 
 the insane is not unsatisfactory, except for such defects as poor 
 natural lighting in places, defective ventilation, and certain other 
 less important defects, all of which could be improved by altera- 
 tions. The main almshouse building is the superior structure, 
 and so far as structural conditions are concerned is better adapted 
 for the insane than is the building now used for them. 
 
 There are two separate laundries, two storerooms, two kitchens, 
 etc., but space is lacking for adequate service facilities for the 
 hospital, several such departments being in the basement with 
 especially poor light and ventilation. 
 
 The upper sashes in the hospital are permanently fastened, 
 the lower ones being guarded by outside straight iron bars. 
 Varying sized dormitories provide fair classification at night, but 
 day classification is unsatisfactory. Excellent porches for de- 
 crepit patients constitute a good feature. On all wards there is 
 a lack of chairs and benches, patients lying on the floor, even in 
 the passages to the water sections. 
 
 Ventilation is generally defective, a distinct odor being ob- 
 served throughout the institution, but it is especially marked in 
 
 [50]
 
 the infirmary. There is a system of ventilating flues, but the 
 fact that the openings to them were in several instances stuffed 
 with socks and old rags may have had some relation to the con- 
 dition found. 
 
 There are no special reception wards, while the infirmaries for 
 the sick lack special facilities. There is no provision for isola- 
 tion of tubercular or contagious cases. There are no hydro- 
 therapeutic apparati, no facilities for pathological work, and 
 but crude facilities for the meager amount of clinical laboratory 
 work done. 
 
 The toilet facilities are insufficient, despite which two toilet 
 sections were found unused, it being explained, "It's hard to 
 watch them in here and they're apt to hurt themselves." Some 
 toilets were out of order and emitting an odor. The plumbing 
 is old and some leaks were observed. Hot water safety devices 
 were lacking and it was admitted that at least one patient has 
 been seriously scalded by hot water. 
 
 Two basement dining-rooms are particularly objectionable, 
 being dark and ill-ventilated as well as devoid of furniture 
 except bare tables and chairs. Old dented tinware is used. 
 The two main dining-rooms have windows on but one side, so 
 light and air are also deficient in them. The food elevators are 
 lined with wood, and although the local authorities recommended 
 that they be replaced over two years ago, no action was ever 
 taken. The basement kitchen is also poorly lighted and ven- 
 tilated. While there is a direct refrigerating plant, it is badly 
 located at the rear of the dynamo room, which in turn is at the 
 rear of the kitchen and laundry. The entrance to the plant is 
 at the side farthest from the kitchen, and here considerable 
 refuse was noted. 
 
 The water supply is limited, but could be improved by addi- 
 tional wells, the single well now used in conjunction with other 
 supply having a good flow. The sewage flows untreated into a 
 neighboring river. Fire protection is fair, but could be improved. 
 A considerable quantity of rags and some refuse, including a pile 
 of mouldy shoes, were found in the basement, although a trusty 
 patient was seen here smoking a pipe. 
 
 Administration. The housekeeping is generally poor; in the 
 male infirmary sputum was seen on the floor with flies clustering 
 about. Here also soiled linen was found stored in a bathtub. 
 
 [51]
 
 All the toilet sections were in disorder; water was splashed about 
 and in one bathroom the central floor drain was obstructed by 
 the contents of a cuspidor emptied over it. 
 
 The food service was unusually poor; patients straggle in a 
 few at a time and immediately proceed to seize the food placed 
 on the tables before their entrance. The food, however, is satis- 
 factory, but a bad feature is the practice of allowing some pa- 
 tients extra food supplies at the discretion of attendants. There 
 appears to be an unnecessary amount of food waste, but it is not 
 locally regarded as waste, as the hospital sells garbage to the 
 almshouse for the privilege of buying pork under the market 
 price. 
 
 Occupation receives some attention, but there are no special 
 occupational classes or re-educational work, as such. Patients 
 working on the farm are under the direction of the almshouse 
 superintendent after leaving the ward. The matter of exercise 
 receives attention, and a good feature is the absence of an enclosed 
 exercise yard. There are some recreations, but their employment 
 is unsystematized. There is an assembly hall on the fourth floor, 
 and while there are outside fire-escapes, these do not obviate the 
 danger of panic in case of fire. 
 
 The patients' clothing is of fair quality, but receives little 
 attention, being disordered in the majority of cases and not in- 
 frequently torn. Even with the women, when clothing was so 
 torn as to expose patients' limbs and bodies, the matter appa- 
 rently was regarded with indifference. Although there is an 
 insufficient force of attendants, discipline appears poor and per- 
 sonal attention seems even less than would be possible with the 
 number of attendants provided. For instance, a male patient 
 was found locked in his room, both bed and floor being in a foul 
 condition, as well as the patient's person, but the door to the 
 room was again locked without comment being made. Another 
 man locked in his room was found nude on a mattress, the only 
 article in the room; he was said to be dangerous and the door 
 was opened with caution, but he responded to greeting with a 
 smile and made no hostile move. Another secluded man was 
 noisy and pounding on the window-sill with a tin cup, no effort 
 being made to take it from him. A secluded woman had bits 
 of food on the bed and smeared on her person, and every patient 
 found secluded was either nude or partially so, while such cloth - 
 
 [52]
 
 ing as they possessed was in most cases soiled. On all wards 
 patients were allowed to roam about in a disorderly manner, 
 attendants giving no heed, unless an altercation between them 
 occurred. Many patients were barefooted, especially in the 
 infirmaries, where bed patients wandered about in their night 
 clothes, which in some instances were soiled. In the women's 
 infirmary, with thirty beds, no attendant was seen for five minutes 
 after entering the ward. 
 
 The boast is made that abuse of patients has been abolished 
 here and it is true there appears no evidence of physical abuse, 
 but the above clearly indicates neglect. It was said that re- 
 straint was rarely used and that half a dozen cases were a fair 
 daily average for the number in seclusion. However, twenty- 
 one patients were counted who were locked in their rooms, and 
 when this fact was mentioned it was explained that to merely 
 lock a patient in his room was not seclusion unless it was against 
 the patient's will. 
 
 The clinical records are worthless from a psychiatrical stand- 
 point. Emphasis is laid on the physical findings, which, excel- 
 lent though they be, do not render any the less regrettable the 
 fact that in many instances no mental notes at all are deemed 
 necessary. The modern classification of insanity is deemed 
 undesirable. It is explained that the practicing physicians in 
 the neighborhood are unfamiliar with it, and there is evidently 
 no conception of the institution as a disseminator of psychiatrical 
 knowledge. 
 
 As contrasted with the conditions in the hospital, the alms- 
 house is administered on a much higher plane. There is evidence 
 that the inmates receive good personal attention, the general 
 housekeeping is excellent, and the service departments are not 
 only better arranged but better conducted. As the almshouse 
 has never yet been filled to capacity, and in view of the excellent 
 material conditions there obtaining, it would appear entirely 
 feasible to provide accommodations elsewhere for the almshouse 
 inmates, taking over this whole plant for the care of the insane. 
 The defects of the institution as a whole are administrative 
 rather than material. The more serious of the material defects, 
 moreover, are remediable without undue expenditure. 
 
 53
 
 INSTITUTION No. 33 
 
 Physical Conditions. The insane live in the main almshouse 
 building. The women occupy the second floor of one wing, with 
 a few beds on the third floor, where some patients live with the 
 pauper women. The men occupy the second and third floors of 
 the opposite wing and have wards to themselves. The women's 
 wards are provided with plants. The women are allowed to 
 decorate their rooms with their personal possessions and they 
 are not unattractive in appearance. The men's wards, however, 
 are bare and bleak, possessing no decorative features whatso- 
 ever. Chairs and benches are both provided, but the latter 
 predominate on the men's side. Throughout the building, in- 
 terior repairs are needed, side walls and floors being broken in 
 numerous places and paint generally is lacking. There is in- 
 sufficient day space and the patients were generally found in their 
 rooms. Toilet accommodations are insufficient, the plumbing 
 is old, and much of it is concealed in the walls, but it is kept in 
 good repair. While iron beds are used, they are poorly con- 
 structed and several were noticed with parts loose. Straw ticks 
 are used, but the bedding is clean and the housekeeping generally 
 good, especially on the women's side. 
 
 Although the pauper inmates and the insane have separate 
 tables, they eat in the same dining-rooms, the children eating 
 with the women. The dining-room appointments are crude, the 
 dietary is stereotyped and bread and molasses with either tea 
 or coffee form the staples for breakfast and supper; the food is 
 apparently sufficient, however. The kitchen has little equip- 
 ment. There is a general lack of fly-screens and flies were 
 numerous on the occasion of the visit. Most of the service 
 departments are in the basement, where light and air are 
 deficient. 
 
 Raw sewage flows into a neighboring creek. There is fair 
 fire protection, but there are no outside hydrants. Water 
 pressure is obtained from an elevated water tower, filled by a 
 single pump in the power-house, and the risk of depending on a 
 single pump has caused the Directors to consider another pump 
 near the water tower. An unnecessary fire risk arises from 
 naked, natural gas flames in the men's toilet sections and in some 
 of the basement service rooms. 
 
 The farm buildings are in fair condition, except a more or less 
 
 [541
 
 dilapidated piggery, which is too close to the main buildings. 
 A new one is planned, however. 
 
 A good feature is a small frame structure for contagious dis- 
 eases, erected largely by inmate labor at small expense. At the 
 time of the visit no insane patients were here, but it was occupied 
 by two tubercular and one syphilitic pauper. There are no other 
 special medical facilities, however, and, of course, under the 
 conditions, proper classification of the insane is impossible. 
 
 Administration. There is an atmosphere of kindness here; 
 the patients appear to receive an unusual amount of personal 
 attention, and the care given, considered as custodial care only, 
 is good. No seclusion is employed, as it is deemed worse than 
 restraint. The latter has been reduced to a minimum, although 
 it is occasionally employed at the discretion of the lay superin- 
 tendent. The forms used include leather muffs, wristlets, and 
 straps. 
 
 The visiting physician calls but three times a week, or as his 
 presence may be deemed necessary by the superintendent. The 
 medical work is limited to the alleviation of physical ills. No 
 medical records are kept, the visiting physician frankly admitting 
 that he cannot afford to keep any for the salary paid. While he 
 passes on the patients' condition for discharge, the initiative 
 proceeds from the superintendent. 
 
 A feature of unusual excellence is the manner in which occu- 
 pation has been developed, the value of work as a therapeutic 
 agent being here recognized and employed as such. 
 
 The matter of exercise for idle patients is emphasized, although 
 unfortunately the exercise yards have the usual fence about 
 them. The lack of recreation has evidently appealed to one of 
 the Directors, as he is said to have agreed to furnish at his own 
 expense several entertainments during the coming winter. 
 
 Alleged cases of insanity are brought here pending commit- 
 ment, if they are not taken to jail. If brought here they are 
 cared for with the committed cases without discrimination being 
 made. The issue as to where commitment shall be made is de- 
 termined by the Board of Poor Directors, although the lay 
 superintendent's recommendation is often taken; the decision 
 is not determined by medical considerations, the troublesomeness 
 of the patient being the main feature considered. 
 
 While this institution must be ranked as one of the better 
 
 [551
 
 ones of its class, so far as administration is concerned this is 
 untrue as to material conditions. Moreover, the insane receive 
 no medical treatment directed to the cure or improvement of 
 their mental condition, and the care given is pauper care. It 
 would therefore appear desirable to remove the insane to a cura- 
 tive institution. The quarters now occupied by them could be 
 well used by pauper inmates, some of whom now occupy a small 
 detached building at the rear of the main building, which is much 
 less desirable than the main building, even considering the lat- 
 ter's defects. 
 
 INSTITUTION No. 34 
 
 Physical Conditions. The insane occupy wings extending at 
 right angles from either end of the almshouse building ; there is a 
 ward on each of two floors for each sex. The wards are in the 
 form of narrow hallways with rooms on either side, and apart 
 from a small day room on the ground floor, the only day space is 
 in the halls and is, therefore, insufficient. In several of the pa- 
 tients' rooms the plaster has fallen. The windows have heavy, 
 prison-like iron guards. The bed-rooms have no lights, although 
 the doors are locked at night. The only toilet facilities provided 
 at night are tin pots. Most of the doors to the patients' rooms 
 are lined on the inside with tin and in several instances the side 
 walls are so lined to prevent the patients from damaging the 
 plaster. The wards are bare of decorative features and are un- 
 attractive in appearance. 
 
 The toilet facilities and the single bathtub provided for each 
 sex are apparently sufficient for the small number of patients 
 cared for, but the two tubs are also used by the pauper inmates of 
 the almshouse, although on different days. There is but a single 
 day-attendant for each sex, and on the occasion of the visit 
 women patients were bathing without an attendant. No hot 
 water safety device is provided. 
 
 The dining-rooms have windows on one side only and hence 
 the light and ventilation are defective. The insane and pauper 
 inmates eat in the same rooms, but at different tables. The food 
 service is poor, although it is directed as well as possible by the 
 single day-attendant on each side. The food is abundant, but 
 lacks variety. Considerable food waste results from poor ser- 
 vice and lack of proper supervision. 
 
 [56]
 
 Natural gas burners are used, and while they are protected in 
 the insane wards, naked flames were seen in the almshouse and 
 in the basement beneath. This is supposed not to be dangerous, 
 it being said: "Nothing is allowed to come near them that will 
 burn." The steam radiators are in part protected, but those in 
 the women's toilet section and in the dining-rooms are un- 
 screened. 
 
 In general, the service departments are well conducted, their 
 chief defect being lack of space and equipment. 
 
 The water supply is excellent and abundant. The sewage 
 disposal is unsanitary, with raw sewage flowing into a neighbor- 
 ing creek. 
 
 A high iron picket fence surmounted by barbed wire encloses 
 the exercise yard. A bare path worn in the earth about a tree in 
 the yard where a patient mechanically trots day after day is an 
 instance of misdirected energy, which under proper conditions 
 could be rendered productive, again illustrating the futility of 
 the attitude, which regards chronic cases as unworthy of special 
 attention. 
 
 Aside from a crude operating room in the almshouse there are 
 no special medical facilities. There is a sick dormitory for each 
 sex, where the sick insane are taken, but these are no different 
 from the other almshouse dormitories. The visiting physician 
 calls regularly but once a week and medical treatment is directed 
 only to the relief of physical ills. 
 
 Administration. In addition to the single day-attendant for 
 each sex, there is a male night-attendant who makes rounds 
 through both the male and the female wards, the propriety of 
 which is certainly open to question. Under the conditions 
 patients are necessarily left alone much of the time, and it was 
 during the absence from the ward of the attendant that a male 
 patient committed suicide on April 4, 1913. 
 
 It was said there were no patients restrained or secluded on 
 the day of the visit, the explanation being that troublesome 
 patients were transferred to a State hospital. However, on 
 making rounds a number of men were found locked in a small 
 day room, while the attendant was shaving the other patients in 
 another room at the opposite end of the ward. On the women's 
 side, a woman was found locked in the day room, the attendant 
 being busy elsewhere and it being regarded as unsafe to trust 
 
 (571
 
 such patient on the ward alone. It appears that the term 
 seclusion is reserved for seclusion in patients' rooms only. The 
 latter is at the discretion of the lay superintendent. Despite the 
 present lack of restraint, the male attendant spoke of a violent 
 case who last year succeeded in doing considerable damage, even 
 after steel handcuffs had been put on him. 
 
 A patient's condition on discharge is determined by the lay 
 superintendent, although it was said that he occasionally advises 
 with the visiting physician. 
 
 The patients are committed here by the commission process; 
 but the issue as to whether a patient shall be committed to a 
 State hospital or to this institution is determined by the County 
 Commissioners. While they assume to decide the question on 
 the possibility of improvement and the need of active treatment, 
 they, as laymen, receive no medical advice, except incidentally; 
 and as a matter of practice there is reason to believe that the de- 
 gree of troublesomeness manifested by the patients is a deter- 
 mining factor. The lay superintendent of this institution makes 
 recommendation when such alleged cases are confined here and 
 it was admitted that such recommendation was usually followed, 
 as it is in the transfer of any committed case to a State hospital. 
 
 One County Commissioner asserted that all the insane patients 
 at present in the institution had been returned from State hos- 
 pitals as chronic, but it was learned from another source that 
 this statement was true of but twelve patients out of the thirty- 
 nine in residence. There is every reason to believe that there 
 are at least several patients now here who could have been im- 
 proved, if not cured, had they received active medical treatment. 
 
 The almshouse is overcrowded every winter and could use the 
 insane wards to advantage, were the insane patients moved else- 
 where, as conditions seem to render advisable. 
 
 INSTITUTION No. 35 
 
 Physical Conditions. This, in most respects, is the best 
 County hospital in the State, and it is significant that it is con- 
 trolled by an independent, unsalaried Board of Trustees. There 
 is but a single building, recently constructed, which, while pre- 
 senting excellent features, also has some architectural defects. 
 It more closely approaches actual fireproofing than is usual, and 
 as features of unusual excellence may be mentioned: Sanitary 
 
 [58]
 
 bubbling drinking fountains, a system of vacuum cleaning, vacu- 
 um tubes leading from every part of the building to the base- 
 ment, plaster-lined linen shutes on every ward and drying closets 
 of most modern character. The most serious architectural de- 
 fect is the want of sufficient natural lighting, a large number of 
 electric lights being necessary during the day. 
 
 An objectionable feature of the site is the almshouse in the 
 foreground, while the hospital approach passes the almshouse 
 out-buildings, including the hennery and the piggery. A serious 
 lack is the want of acreage, hospital being allowed only the land 
 immediately about the building, which has been set apart for 
 its use out of the entire County property, the remainder of which 
 is regarded as belonging to the almshouse. 
 
 There are but two wards for each sex, so little classification is 
 possible. The patients mingle in the single large day room found 
 on each ward. A modern feature is the heavy wire window- 
 screens used in place of the usual heavy iron bars. Porch space 
 is provided, including enclosed porches, which afford partial iso- 
 lation for tubercular cases. 
 
 The result of housing disturbed patients in a single day room 
 was seen on the day of the visit; although on entering the 
 disturbed ward it was found comparatively quiet, one patient 
 suddenly began to scream and in a moment the whole ward was 
 in an uproar. An effort is made to overcome this difficulty by 
 placing benches in a hollow square, so that the more disturbed 
 patients can be kept apart. 
 
 The toilet facilities are excellent, the plumbing being of the 
 most modern type. However there are no hot-water safety 
 devices. In general, the ventilation is good, a special venti- 
 lating system being provided. It is, nevertheless, deficient in 
 the dining-rooms, where the natural lighting is also poor. 
 
 The dining-rooms possess an archaic feature in permanently 
 fastened revolving chairs, although the other facilities are ex- 
 cellent. It was admitted that such chairs occasioned difficulty 
 in sweeping and cleaning the room and also when it became neces- 
 sary to remove an epileptic seized with a convulsion. 
 
 The kitchen is excellent except for its location in the base- 
 ment. The grooves in the concrete floor render cleaning some- 
 what difficult. For the want of other available space, the service 
 departments generally are likewise in the basement, where the 
 
 [59l
 
 light and air are deficient. An unnecessary fire risk is involved 
 in the storage of lubricating oil and kerosene in the carpenter 
 shop. 
 
 The power-house is the only service facility used in conjunc- 
 tion with the almshouse, it being under the direction of the alms- 
 house steward. When the hospital was built an addition was 
 constructed to the power-house, but it is too small, it being neces- 
 sary to place the air compressors and pumps so close to the boil- 
 ers that the bearings of the former must necessarily be injured. 
 The lack of proper natural lighting renders the electrical load 
 heavier than would otherwise be necessary. 
 
 Continuous baths are provided, but they are poorly located 
 in that a single one is on each ward, so a single attendant has to be 
 detailed to each, and hence it is never possible to use more than 
 one or two at a time. There is no other hydrotherapeutic ap- 
 paratus. A modern operating room is provided, adjoining which 
 a small clinical laboratory has recently been fitted up; it is un- 
 fortunate that the sterilizing apparatus was not placed in an 
 available anteroom instead of in the operating room itself. Ad- 
 joining are two excellent modern hospital wards intended for the 
 respective sexes, but as yet unused except for sick attendants. 
 At present, special dormitories on the wards proper are reserved 
 for sick cases and for new patients. 
 
 There is an excellent amusement hall and chapel with a grand 
 piano purchased by the Board of Trustees, and the attention 
 paid to recreation is most commendable. 
 
 Administration. An atmosphere of kindness prevails. The 
 patients receive good personal attention, and for the most part 
 were found in a neat and tidy condition. 
 
 Restraint and seclusion can only be used on the physician's 
 order, the amount employed is larger than will ultimately be 
 the case, as there is at present an undue proportion of disturbed 
 cases, due to transfers from other institutions, when the hospital 
 was opened less than a year ago. Another factor is the inex- 
 perience of the attendants, likewise due to the youth of the in- 
 stitution. 
 
 A fair percentage of the patients are employed, especially when 
 the great lack of occupational opportunity is considered. There 
 are as yet no occupational classes, but it is planned to establish 
 some in the near future. Special attention is given the matter 
 
 [60]
 
 of exercise, and this is one of the few County institutions where 
 an enclosed exercise yard is deemed unnecessary. Special op- 
 portunity is given for exercise of the indoor workers. 
 
 The medical work is satisfactory, so far as the facilities permit, 
 and this is the only County hospital for the insane where there is 
 any medical treatment for the relief of mental diseases as such. 
 The medical records are above the average. While there is no 
 pathological work as yet, it is to be undertaken shortly. 
 
 In general, a progressive spirit is manifest, and it is very evi- 
 dent that the local officers and the Board of Trustees work in 
 harmony, with the best interests of the patients and of the in- 
 stitution as their sole aim. 
 
 The proximity of the almshouse to the hospital is objection- 
 able, as under similar circumstances elsewhere. Most of the 
 buildings of the former could be remodeled at comparatively 
 small expense, for certain classes of the insane, and could this 
 whole plant be utilized as an insane hospital, the chief defects 
 of the present hospital would be at once eliminated, i. e., lack of 
 opportunity for classification and occupation, especially outdoor 
 work. The best of the almshouse buildings, the almshouse 
 hospital building, is unusually well arranged for an infirmary 
 unit and would require no alterations except minor repairs. 
 The other almshouse buildings, while less satisfactory, present 
 no unsurmountable obstacles preventing their use for the insane. 
 As this institution is located near a center of population, it would 
 appear most desirable to provide accommodations for the aims- 
 house elsewhere and utilize the entire plant for the insane. 
 
 INSTITUTION No. 36 
 
 Physical Conditions. Separate buildings are provided for the 
 male and the female insane, respectively, both located at the 
 rear of the almshouse. The men's building is of recent con- 
 struction and is practically fireproof, but is poorly designed for its 
 purpose. There is but a single ward on each of the two floors, 
 so little opportunity is afforded for classification. It is provided 
 with inside stone stairways in lieu of fire escapes, which, however, 
 lead to the basement only. In the original plan, no provisions 
 were made for a dining-room, so a basement room is used, where 
 the light and air are both defective. To reach this dining-room 
 food is carried in tin wash-boilers across an open yard to a base- 
 
 [61]
 
 ment passageway. No provision originally made for employees 
 and hence makeshift arrangements are now necessary. The halls 
 are narrow ; inside iron-barred window guards emphasize the idea 
 of restraint, and despite the fact that the building is compara- 
 tively new, the side walls are cracked to some extent and in sev- 
 eral places the ceiling plaster has fallen; the toilet facilities are 
 insufficient for the number of patients, especially wash-basins. 
 
 The women's building is older and even less satisfactory, 
 save that it has a better dining-room. There are numerous 
 narrow dark passageways, the walls are still more cracked, and 
 paint is generally needed. The toilet accommodations are also 
 less satisfactory than in the men's building, being limited in 
 amount, while the plumbing is old and unsanitary. Despite 
 adverse conditions, the housekeeping is excellent throughout the 
 institution. 
 
 The fire protection is defective, especially in the women's 
 building; there is an elevated water tank to afford gravity 
 water pressure, but it is filled by a single pump, so, in case of 
 accident to the latter, the institution would be without water 
 protection. There is no fire fighting apparatus of any descrip- 
 tion in the men's building. In the women's building there is a 
 small hose with standpipes, but as the latter connect only with 
 small attic tanks filled by rain-water, they afford meager protec- 
 tion. There are three outside fire-escapes, but the approach to 
 one from the third floor is by a window shut off by permanently 
 fastened iron window guards. 
 
 The service departments are well conducted, but in most in- 
 stances space and proper equipment are lacking. The laundry 
 is poorly located in a detached building, in front of the building 
 for women patients. 
 
 The farm buildings are old and generally dilapidated. An 
 old, unsanitary, frame piggery is located within three hundred 
 yards of the women's building. It was said that the Board of 
 Poor Directors at one time planned to build a new piggery, fol- 
 lowing the condemnation of the present one by the Grand Jury, 
 but it was finally determined to defer the matter for another year. 
 
 An exercise yard is provided for each sex. The one for men is 
 enclosed with wire screening and is of good size but lacks any 
 seating facilities. The one for women is too small, there are no 
 shade trees, the most of the grass has been worn off, and it is a 
 
 162]
 
 most desolate appearing spot; it is enclosed by an old, unpainted, 
 high board fence, which completely shuts off the view. This 
 yard also lacks seating facilities, and when seen patients were 
 crowded together on the ground or were restlessly pacing back 
 and forth. The local authorities plan a larger exercise yard for 
 the women, but unfortunately they consider it necessary to 
 erect a high concrete wall about it. 
 
 There is a surgical operating room, poorly located at one side 
 of the entrance to the administrative office in the men's building, 
 but otherwise there is an entire lack of special medical facilities. 
 
 Administration. The superintendent, who is a physician, has 
 charge of the adjoining almshouse, and there being no steward, 
 his time is largely occupied with business and administrative 
 details, so the medical work is directed only to the relief of physi- 
 cal conditions. During his tenure of office he has made a con- 
 siderable number of material improvements, and has more 
 planned. He has also introduced greatly improved business 
 methods, especially in the matter of purchases and the checking 
 of supplies. 
 
 With but few exceptions, the patients present a tidy appear- 
 ance, and they apparently receive as much personal attention as 
 is possible with the limited number of attendants. As evidence 
 of this may be cited the excellent results attending the effort 
 made to reduce restraint and seclusion to a minimum, especially 
 commendable in view of the absence of hydrotherapy. One 
 patient admitted here from another hospital is said to have been 
 restrained for several months prior to the transfer, but by means 
 of special personal attention such patient has never been re- 
 strained here and has recently been induced to do some work. 
 
 There is a fair percentage of the patients occupied, but there 
 are no special occupational classes. There is little opportunity 
 for recreation, but emphasis is placed on the matter of exercise. 
 
 Two of the women patients have with them their illegitimate 
 children, one fourteen months old and the other eighteen months 
 old. Both children accompanied the mothers when the latter 
 were admitted, although nothing was said about the children in 
 the commitment papers. In one case the infant's maternal 
 grandmother is also a patient, and although considerably de- 
 mented, was seen holding the child as she sat on the steps leading 
 to the exercise yard, while all about were the other women pa- 
 
 [63]
 
 tients, some of whom were restless and talkative. The local 
 authorities have no idea as to what disposition will be made of 
 the children, although they hope to make other arrangements 
 soon. 
 
 One woman patient was described as a moral imbecile, and 
 certain it is she fails to present any evidence of insanity ; she has 
 had five illegitimate children, and is regarded as utterly incorri- 
 gible, which appears to be the only basis upon which her commit- 
 ment as insane rests. 
 
 The Board of Poor Directors are perhaps too economically 
 inclined, and it was only with much difficulty that they were 
 finally convinced of the necessity of painting the women's build- 
 ing, although it had not been painted for fourteen years. How- 
 ever, the Board is said to be of a higher caliber than former 
 Boards. It is said that a former Director once vigorously pro- 
 tested against any expenditure for bathtubs, arguing that as he 
 had none in his own house he did not see why the County institu- 
 tion should be so equipped. 
 
 The care given is necessarily custodial care only, and as the 
 buildings here are so unsatisfactory for the insane, it would seem 
 desirable to remove such patients to a medical institution. 
 Should such course be followed, the almshouse inmates could use 
 the new building occupied by the male insane, as neither the 
 building for the women insane nor the almshouse building is 
 worth the extensive and expensive repairs required to render them 
 satisfactory. 
 
 INSTITUTION No. 37 
 
 Physical Conditions. A wing extends at right angles from 
 either end of the almshouse for the respective sexes of the insane ; 
 however, the insane occupy only the first and second floors, the 
 third being used by paupers. The wards are short halls with 
 rooms on either side and a small day room at one end. None 
 of the patients' rooms are sufficiently large to properly accommo- 
 date more than two beds, but some contain three and four. 
 The side walls are cracked and broken, the bare board floors are 
 worn, paint is everywhere needed, and in the absence of any 
 decorative features whatever, the wards present a most bare and 
 desolate appearance. There is little furniture, a ward for twenty 
 patients having only three benches and a table, while another 
 ward has benches, but no table. 
 
 [64]
 
 Most of the beds are of iron, but there are a few wooden ones, 
 which it is hoped to replace when funds are available. There 
 are no service or supply closets, the ones in the almshouse proper 
 alone being available. All the toilet facilities are in a large open 
 room ; there should be at least twice as many toilet hoppers pro- 
 vided and four times as many wash-basins, considering the num- 
 ber of patients using them. Dependence is placed on natural 
 ventilation only, and it is particularly poor in the toilet sections. 
 
 The steam radiators are about to be covered with protecting 
 screens. Such protection was first recommended by the State 
 Committee on Lunacy eight years ago. 
 
 The pauper inmates and the insane eat in the same dining- 
 rooms and at the same tables; stools without backs are used 
 and the dining-room appointments are meager and crude. The 
 dining-rooms are as cheerless in appearance as the wards. The 
 kitchen has a board floor broken in at least one place, while 
 the walls and ceilings are smoked, stained, and scratched. A 
 limited equipment renders it impossible to cook the whole of a 
 single meal at once, and as both meat and soup were served for the 
 meal inspected, the meat was placed on the table while the soup 
 was being prepared in the same kettle in which the meat had been 
 cooked, so the latter was cold by the time the patients entered. 
 Although the food appears sufficient in amount, it is of the usual 
 stereotyped variety; breakfasts and suppers are practically the 
 same, the staples being bread, either with or without butter, 
 molasses, and coffee. In summer, however, it is sometimes pos- 
 sible to add for supper only, a tomato, a potato, beans or ginger 
 bread. 
 
 The service departments are for the most part in the base- 
 ment, and considering the character of the institution have a fair 
 equipment and appear well conducted. 
 
 The sewage flows untreated into a creek about five hundred 
 feet from the main entrance. 
 
 The fire protection is poor, there being practically none for 
 the insane wards, as the single entrance to each ward is from an 
 almshouse hallway and while the hose in the almshouse is suffi- 
 cient to reach such entrances, it reaches no further. Even this 
 hose was found in disorder, being uncoiled, and it was admitted it 
 had not been tested "for a long while." There are only inside 
 
 s [65]
 
 wooden stairways in the almshouse, and but a single outside fire- 
 escape at one end. There are no outside hydrants. 
 
 There is, of course, no proper classification, with but two wards 
 for each sex. 
 
 An exercise yard for each sex is provided, each being enclosed 
 by a plain high board fence. But a single bench was seen in the 
 women's yard and none in the men's yard, so most of the patients 
 sit or lie about on the ground. There is but a single shade tree 
 in the women's yard, and neither shade nor shelter in the men's 
 yard. In the latter are numerous paths worn in the earth by the 
 pacing back and forth of the patients. 
 
 Administration. Personal attention is necessarily limited, 
 there never being more than a single attendant on day duty for 
 each ward. With regular time allowance off duty, and with the 
 necessity of the attendants for the insane assisting with the alms- 
 house work, the wards are left alone much of the time. The 
 patients are locked in their rooms at night, but only since July, 
 1914, has there been a male and a female night-attendant em- 
 ployed. They now make rounds at intervals during the night 
 through both the insane wards and the almshouse, but they do 
 not open the doors of the patients' rooms except in special cases. 
 The cause of the recent employment of the night-attend- 
 ants was a suicide during the month mentioned. It appears a 
 woman patient was admitted in a disturbed state, and was not 
 only locked in her room at night, but was left in restraint. When 
 her room was entered in the morning, it was found that she had 
 succeeded in freeing herself from the restraint and had hung 
 herself with the bed sheet. She was still alive when found, but 
 died a few hours later. 
 
 Another instance which can justly be attributed to the lack of 
 a sufficient number of attendants was the suicide in January, 
 1914, of a woman inmate of the almshouse who jumped from a 
 third -story window. 
 
 In most instances, especially on the male side, the patients' 
 clothing was found disordered, unbuttoned, and in some instances 
 torn, although it should be added it was in the majority of in- 
 stances clean. In three instances observed on the male wards, 
 the patients' flesh showed through the torn garment, there being 
 no evidence of underwear. Several instances were noted of 
 patients with shoes, but without stockings or socks: some men 
 
 [661
 
 wore socks, but had no shoes. One woman was seen eating din- 
 ner in the dining-room while barefooted, and later six male pa- 
 tients were seen in the exercise yard in a similar condition. 
 Here also was found a patient admitted on the day of the visit 
 seated alone on the ground in his shirt-sleeves, having received 
 no special attention. 
 
 On the occasion of the visit, two women were constantly 
 secluded because of their restless and untidy tendencies. Both 
 cases are defectives without evidence of insanity. No cases 
 were in restraint, it being explained that disturbed patients are 
 at once transferred to other institutions. Should a new case 
 become violent it is the practice to strap the patient to the bed 
 with leather straps about the arms and legs, or in the discretion 
 of the lay superintendent, a strait-jacket may be employed. 
 
 While the superintendent is active and apparently anxious to 
 do the best possible for the patients, his idea of the care of the 
 insane is evinced by the question: "What is the best form of 
 restraint?" It appears unfortunate that he should be regarded 
 as specially qualified for the care of the insane by reason of 
 experience obtained as turnkey in the County jail, where he was 
 obliged to care for a certain number of insane persons. 
 
 The practice exists here of employing paupers in preference to 
 the insane and such of the latter as are occupied are the willing 
 workers only, there being no occupational training. There is a 
 lack of recreation and the patients lead a drab, colorless existence. 
 
 There is an entire lack of special medical facilities, an ordinary 
 dormitory being set apart in the almshouse for sick cases; here 
 the physically sick among the insane are cared for, while the 
 practice also exists of placing uncommitted paupers in the insane 
 wards, if, in the judgment of the local authorities, special cir- 
 cumstances render it advisable. Throughout the institution 
 there is no distinction made in the care of the almshouse inmates 
 and the insane. They eat together, wear the same clothes, and 
 receive the same limited amount of personal attention. As was 
 stated: " There is no favoritism here ; everybody, whether insane 
 or a pauper, is treated alike." 
 
 This institution has evidently suffered from being subjected 
 to political influences, although it was said such influences are 
 now less active than formerly. That there has been some local 
 recognition of defective conditions is evinced by the plans made 
 
 [67]
 
 for a new County insane hospital, but a dispute having arisen 
 among the local authorities, no action is considered probable in 
 the near future. 
 
 The custodial care here given is below even the usual standard 
 of County institutions, and as a mere matter of humanity the 
 insane patients should be removed at the earliest possible mo- 
 ment. In recognition of existing conditions State aid has been 
 withheld for the time being by recommendation of the State Board 
 of Charities. 
 
 GENERAL CONSIDERATIONS OF COUNTY INSTITU- 
 TIONS FOR THE INSANE 
 
 In reviewing this group of institutions, the most striking fea- 
 ture is the close association maintained between the institutions 
 for the insane and almshouses, in some instances both the in- 
 sane and paupers being cared for in the same building, and in a 
 few cases in the same ward : the inevitable result is that the care 
 of the insane tends to the almshouse standard, and, indeed, in 
 some places an effort is made to provide exactly the same type 
 of care for both. Hence it is not surprising that one finds the 
 practice common of caring for the insane in the almshouses 
 proper or the uncommitted almshouse inmates in the insane de- 
 partments, when in the judgment of local authorities circum- 
 stances appear to render it advisable. 
 
 In numerous instances the material conditions should be rem- 
 edied for the care of any class of dependents, insane or other- 
 wise, especially as regards unsanitary sewage disposal and the 
 woefully inadequate fire protection so often found. 
 
 As a result of the existing system, in these institutions custodial 
 care is generally substituted for active remedial treatment di- 
 rected to the improvement or the recovery of the insane as such. 
 As a rule, the medical treatment for physical ills is satisfactory, 
 although such is not invariably the case. With but few excep- 
 tions, the County institutions have no special medical facilities, 
 nor can it be expected that such facilities can be provided under 
 present conditions, for, with the comparatively small number of 
 patients treated in the respective institutions, such provisions 
 would require a prohibitive per capita expense; but as a result 
 of such lack of facilities, mechanical means of restraint and con- 
 finement are substituted for proper personal treatment and 
 
 [68]
 
 attention. With but a limited number of attendants, enclosed 
 exercise yards and personal restraint and seclusion must inevi- 
 tably result. Under existing conditions, one cannot blame the 
 caretakers of the insane for resorting to such means, for while 
 restraint and seclusion can and should be abolished, they can- 
 not be successfully abolished without the substitution of other 
 means of dealing with the disturbed insane, such as hydrother- 
 apy, occupational training, and close personal supervision. In 
 this connection it is agreeable to note that little evidence was ob- 
 tained of actual physical abuse, but that gross neglect exists is 
 indisputable. 
 
 That the theory of County hospitals for the chronic insane 
 only does not obtain in actual practice is but a necessary result 
 of the prevailing custom of determining the question as to whether 
 a patient shall be committed to a State hospital or to a County 
 hospital, regardless of prognosis or medical issues, in many 
 instances the decision being made by local lay authorities with- 
 out medical advice. It is certain that many acute cases have 
 lapsed into chronicity in the County hospitals simply for lack of 
 proper treatment. Dreary, desolate wards, lack of recreation, 
 or other means of exciting or maintaining active interest are alone 
 sufficient not only to hinder improvement or recovery, but must 
 necessarily result in actually hastening the terminal process of 
 deterioration. 
 
 UNLICENSED ALMSHOUSES CARING FOR THE INSANE 
 
 NOS. 38-48 
 General Statistics. 
 
 Institution No. Insane Inmates 
 
 38 36 (34 committed) 
 
 39 2 
 
 40 9 
 
 4i 2 
 
 42 I 
 
 43 3 
 
 44 6 
 
 45 6 
 
 46 8 
 
 47 2 
 
 48 7 
 
 Total insane 82 
 
 None of these institutions is apparently deemed worthy by the 
 State Board of Charities to receive State aid and, accordingly, 
 
 [69]
 
 none is licensed, yet three have locally recognized insane depart- 
 ments, while in the others the number of inmates above indicated 
 were found actually insane, although cared for without discrimi- 
 nation with the other paupers. Excepting only the thirty-four 
 inmates indicated, none has ever been committed. In addition 
 to the insane, one hundred and ninety-six defectives were found, 
 ranging from the lowest grade idiots to high-grade imbeciles. 
 There are also a large number of dotards; thirty-three children 
 were found ; while in one almshouse the conglomerate mass of 
 humanity was found increased by the practice of the courts in 
 committing thereto incorrigible girls. 
 
 INSTITUTION No. 38 
 
 There is a separate building for the insane located at the rear 
 of the almshouse proper. It is partly brick and partly frame; 
 the sexes are divided by central partitions, and while the com- 
 municating doors are said to be kept locked, one at least was found 
 open. The ceilings are low; the floors and in some instances the 
 side walls need repair. Dark, narrow passageways are numer- 
 ous. The stairs are dark, winding, and of wooden construction. 
 The windows are guarded outside by heavy iron bars set in the 
 brickwork and inside by closely woven, heavy wire screens. 
 The ventilation is poor, especially in the small, dark toilet sec- 
 tions, all crude in the extreme and in a most unsanitary state. 
 Bathing facilities likewise are primitive. All the rooms are bare, 
 desolate, and with a prison-like appearance, produced by the iron 
 bars at the windows and in the doors of the so-called "strong 
 rooms." Straw or husk bed-ticks are used, but the bed- 
 ding, while coarse, is fairly clean. The fire risk is great and 
 fire, at night especially, would inevitably mean loss of life. 
 Lighting is by kerosene lamps; there are no fire-escapes, hose or 
 standpipes. One of the inside stairways has been removed and 
 the stair well used for stores, while a wooden ventilating flue 
 extends to the roof from the second floor, and both would act 
 as flues in case of fire. With windows guarded with iron bars, 
 the patients are locked in their rooms at night, and left without 
 any night-attendant, while the day-attendants sleep in an ad- 
 joining building, it being explained that after the patients are 
 locked in their rooms at night "they can't make any trouble." 
 A year ago a barn was burned, resulting in total loss, although an 
 
 [70]
 
 outside hydrant stands much nearer to its site than to the building 
 for the insane. The radiators are unprotected; an epileptic girl 
 was seriously burned on one some time ago, but no action was 
 taken to correct this condition. 
 
 The basement dining-room is dark, ill ventilated, and with a 
 broken concrete floor. The men and women eat together, al- 
 though at separate tables. There are but a few agateware dishes, 
 and the food service is crude and haphazard. All the service 
 departments are in extremely poor condition. The sewage 
 flows untreated into a neighboring creek, but below the point 
 where part of the water supply is obtained. Litigation is said to 
 have resulted from the County Commissioners' failure to adopt 
 the recommendation of the State Board of Health regarding the 
 sewage disposal. 
 
 In many respects the farm buildings are in better condition 
 than the interior of the building for the insane. 
 
 There is little personal attention, the only attendants being a 
 married couple, who care for the respective sexes. One patient 
 was seen with finger-nails half an inch long. The clothing was 
 generally disordered and, in some instances, torn. In one case 
 bed-ticking was used as suiting. While no patients were re- 
 strained or secluded on the day of the visit, a woman had been 
 shortly released from a strait-jacket after three months' con- 
 finement, her poor physical condition suggesting that this might 
 account for the fact that she was fairly quiet when seen. The 
 institution is provided with handcuffs and leather wristlets, but 
 seclusion is more used. The "strong rooms" are inside, have 
 but a single window opening on an inside passage, and are so 
 dark that it is impossible to see across them when looking through 
 the iron bars of the doors. Medical treatment of even physical 
 ills is limited, the visiting physician calling but twice a week, or 
 when the male attendant, who was formerly a driver, deems his 
 presence necessary. The attendant has full authority to dis- 
 charge any insane patient that he deems fit. 
 
 It is considered necessary here that the exercise yards be en- 
 closed, and from $1300 to $1400 is to be spent for a steel fence, 
 replacing an old fence recently blown down, and for a concrete 
 floor for the yard; meanwhile the patients are not allowed to 
 exercise out-of-doors unless they are paroled patients. No 
 opportunity is afforded for classification, all types mingling to- 
 
 [71!
 
 gather and the two sexes mingling in going to and from the din- 
 ing-room. There are no recreations, no religious services, and 
 the patients lead a dull, monotonous, mechanical existence. 
 
 INSTITUTION No. 39 
 
 Most defective material conditions exist here, even for an 
 almshouse. The main building is four stories high, and although 
 kerosene lamps are the only illuminant there is no fire protection. 
 The only water supply is from an outdoor hand-pump, an attic 
 tank and a ground cistern, the latter two being filled only by 
 rain and both dry at time of visit, so that the weekly washing had 
 been postponed for lack of water. The heating facilities are 
 insufficient. The only toilet facilities are crude ground vaults 
 in outside sheds. Bathing facilities are equally primitive. 
 Several old portable iron tubs were seen in various parts of the 
 institution; one partly filled with rubbish, one turned upside 
 down, and none showing evidence of recent use; if used, the 
 water must be carried by hand, all hot water being obtained from 
 the kitchen stove. Under the circumstances, it is perhaps not 
 surprising that there was reason to believe that at least some of 
 the inmates had not been recently bathed. Straw or chaff bed- 
 ticks are used, but though coarse, the bedding was clean. Empty 
 tin cans are used beneath the bed legs to protect the floor. 
 
 A small, single-story, detached building is known as the "mad- 
 house," and is in charge of an imbecile inmate. The yard about 
 this building is enclosed by a rough, whitewashed board fence, 
 and contains the usual ground vault toilet, with an old rusted 
 iron bathtub, in an old shed of unpainted boards. This building 
 is in worse condition than the main one and rubbish was every- 
 where in evidence, papers, sticks and boxes being scattered in- 
 doors and outdoors, while the beds and bedding were dirty and 
 disordered. It is heated by an old battered coal stove. A few 
 broken chairs and a bare table constitute the only furniture. 
 There are several small cell-like rooms, with no outside windows, 
 formed by whitewashed board partitions and with the upper half 
 of the doors set with whitewashed, wooden slats. 
 
 The steward and his wife, the matron, are the only inside em- 
 ployees, so that the inmates can receive little personal attention. 
 In the "mad-house," aside from the imbecile in charge, two male 
 idiots were found, an epileptic dement, and an advanced paretic; 
 
 [72]
 
 the latter two were in bed, although fully dressed, even to their 
 shoes. The paretic was found in one of the small, unlighted rooms, 
 because, it was said, of his untidy habits, and he was in a state of 
 personal uncleanliness when seen. 
 
 While primarily for men, the "mad-house," being the only 
 available place in which to segregate mental cases, it was neces- 
 sary recently to confine an epileptic girl there when she became 
 excited following convulsions. She was restrained with hand- 
 cuffs and locked in one of the small rooms, despite the presence 
 of male inmates in the adjoining small rooms, it being remembered 
 that the upper halves of the doors are provided with open slats. 
 Her cries and screams are said to have been so constant and so 
 loud that she disturbed not only everybody in the "mad-house," 
 but in the main building, some distance away. Her hands be- 
 came much swollen in her effort to break down the door, and 
 scars from the handcuffs were perceptible at the time of the visit. 
 
 The separation of the sexes is poor. While the male and the 
 female inmates live on opposite sides of the main building, the 
 doors open directly from one side to the other and women in- 
 mates were found doing the housework on the male side, with some 
 of the men still on the ward, although no employee was present. 
 
 An hallucinatory woman lives with the other inmates, receiving 
 no special attention. There is little medical attention, the visit- 
 ing physician only responding as the steward, a former tanner, 
 deems necessary. The practice of the County of purchasing 
 morphine for two morphine habitues is at least of questionable 
 propriety. 
 
 INSTITUTION No. 40 
 
 This institution is housed in two old buildings, one erected in 
 1800 and the other in 1855. The board floors are worn and 
 broken, the plaster is cracked, smoked, and has fallen off in places, 
 while the woodwork is almost devoid of paint and the buildings 
 generally are in a dilapidated condition. They have been con- 
 demned by several grand juries, but only recently was an option 
 obtained on a site for a new institution. However, a factional, 
 political fight has developed, and it appears probable that no 
 improvement in conditions can be expected in the near future. 
 
 Part of two dark hallways, with rooms on either side, are each 
 reserved as a so-called "insane ward." They are shut off from 
 
 [73]
 
 the remainder of the halls by partitions of turned wood bars. 
 On one side of each hall is a bare room with a board table and 
 backless wooden benches which serves for a dining-room. All 
 the appointments are meager and crude. Opposite each such 
 dining-room is a toilet section, with a slop sink in lieu of a wash- 
 basin. All the toilet facilities are old, worn, and unsanitary, 
 and they are insufficient in number. 
 
 The fire protection is especially poor, and loss of life appears 
 inevitable in case of fire. The sewage flows untreated into a 
 creek less than three hundred yards from the buildings. 
 
 In spite of these distressing material conditions, it is a pleasure 
 to note the prevalence of a spirit of kindness and as much per- 
 sonal attention as is possible with a single attendant for each of 
 the two "insane wards." Nevertheless, it would be difficult to 
 imagine a picture more dismal than is presented by the poorly 
 lighted, bare, and dilapidated wards with patients sitting idly 
 on benches ranged on either side, where they spend most of their 
 waking hours. Aside from the actual insane inmates in the 
 "insane wards," there are twenty-one idiots and imbeciles 
 confined there. There is poor separation of the sexes whenever 
 inmates leave the wards, and on such account the presence of a 
 sixteen-year-old girl imbecile, who is extremely erotic, and who 
 has had a child following incestuous relations, is a distinct menace. 
 
 This institution is wholly unfit for the care of any class of de- 
 pendent human beings. 
 
 INSTITUTION No. 41 
 
 The material conditions here are defective, even for sane 
 paupers. A so-called "bull pen" is a locked dormitory where 
 eight inmates were found, one nude, and all in a state of personal 
 uncleanliness. The air was heavy with the odor of a deodorizing 
 agent, it being said that otherwise it would be impossible to re- 
 main in the room. The fire risk is great, despite which inmates 
 are allowed to smoke on the second floor. 
 
 Cases of alleged insanity are brought here pending commit- 
 ment, but the two cases now here have never been committed 
 and as they are quiet are treated as the other inmates. 
 
 The only provisions for the insane are so-called "cells," three 
 of which are located in the basement and are no longer used. 
 The latter are heavily barred with iron bars over a single high base- 
 
 [741
 
 merit window; are provided with heavy double doors which open 
 into the cellar, while the walls are of stone construction. A 
 single winding wooden stairway leads from the cellar to the floor 
 above, so it would appear that the fire risk alone should have pre- 
 vented their construction. 
 
 The cells now used for the insane are rooms set apart in the 
 almshouse proper; each has a single window, heavily guarded 
 by inside iron bars, while a "strong cell" has also iron bars out- 
 side the window. Heavy double doors are provided, the inner 
 one being heavily bound with iron braces ; they have an aperture 
 in the center with an inside shelf, where food is placed by the 
 pauper inmate, who alone cares for the insane patients. The 
 cells have no furnishings except a mattress and a blanket thrown 
 on the floor, except in a single instance, where a small cot is pro- 
 vided. A tin bucket is the only toilet convenience. As there is 
 but one cell on the women's side, it occasionally happens that 
 women are placed in the men's cells, and it was said that male 
 paupers have used the door aperture to inspect the insane women. 
 
 The pauper assigned to care for the male insane is a cripple, 
 and is physically unable to cope with an excited case, but if he 
 deems it necessary to enter the cell of an excited patient he calls 
 to his aid a sufficient number of other inmates to subdue the 
 patient by force of numbers. There are no bathing facilities, 
 and while it was not admitted that insane patients never bathe, 
 the informant remarked : "You can form your own conclusions." 
 He added: "If they are not insane when they come here, this 
 place will make them so." 
 
 All alleged cases of insanity are locked in cells, because the 
 local authorities do not feel that they can afford to take chances, 
 since a case committed suicide several years ago and there have 
 been several attempts since. While cases are sometimes com- 
 mitted and removed within a week, it was said that if they have 
 no friends to secure a lawyer to hasten proceedings, "They lay 
 here the limit," and have been locked in a cell for as long as two 
 months without once leaving it. 
 
 The visiting physician has no responsibility for the insane, 
 except as his attention may be called to them by the steward for 
 the care of physical ills. 
 
 The situation is made worse by the fact that within less than 
 fifteen miles is a State hospital, where, with excellent natural 
 
 I 751
 
 advantages and good material conditions, only such insane can 
 be received as are regarded as chronic and who are transferred 
 from other institutions for the insane. If the State hospital 
 were allowed to receive new admissions from the surrounding 
 community, the above conditions would soon cease to exist, 
 simply from lack of necessity. A better illustration could not 
 be presented of the results attending the lack of a general policy 
 governing the State as a whole than the existence side by side, 
 within a few miles of each other of such extremes in standards 
 of care. 
 
 INSTITUTION No. 42 
 
 This is an almshouse of the better type and, in general, for an 
 almshouse, the physical conditions are satisfactory. But a 
 single insane patient was found among the inmates and only rarely 
 are patients brought here pending commitment. There is a 
 single cell provided in the basement for the violent insane, which, 
 however, is said not to have been used for about a year. It 
 has a single, small, high, basement window, with a small grated 
 aperture in the center of a solid wooden door. It is so dark that 
 one cannot see across it through the open doorway. It is padded, 
 both as to floor and side walls, and is devoid of furnishings of 
 any kind. The reason for alleged cases not having been brought 
 here recently is that they are more frequently taken to the County 
 jail. 
 
 INSTITUTION No. 43 
 
 This is the smallest almshouse visited, being maintained by a 
 special, small Poor District. No cases of insanity, as such, are 
 ever brought here, but three women inmates were found present- 
 ing definite evidence of insanity. All were unattended in their 
 rooms. One was restless, walking up and down, talking to her- 
 self, and rubbing her face and neck, upon which were numerous 
 abraded areas thus produced. 
 
 INSTITUTION No. 44 
 
 This is one of the better almshouses, and except that the build- 
 ings show age, the physical conditions are satisfactory for aims- 
 house inmates. Few cases of alleged insanity are brought here 
 and none are supposed to be here at present, although six cases 
 were found presenting definite evidence of insanity. The prac- 
 
 [76]
 
 tice of keeping the alleged insane here has only ceased since the 
 opening of a State hospital in the vicinity, since which time direct 
 commitments from homes are usual. Thus is shown the benefit 
 to a community of a modern hospital for the insane. 
 
 There are four so-called cells for the insane, which, since the 
 practice of bringing insane patients here has largely ceased, are 
 used for the punishment of inmates. They are ordinary rooms 
 with iron-barred windows, and an open toilet hopper in one 
 corner, and while two have ordinary wooden doors, substituted 
 at the steward's initiative for the original open iron-barred doors, 
 the latter still remain on the other two cells. When occupied, 
 the doors are kept locked, food being passed through an opening 
 in the iron grating. 
 
 INSTITUTION No. 45 
 
 This is another almshouse with fairly good physical conditions 
 for the care of paupers. No cases of insanity are supposed to be 
 kept here, nor have any alleged cases been sent here for observa- 
 tion for some years. However, six cases were found presenting 
 definite evidence of insanity, aside from deterioration, which 
 is present in a large number; most of these cases have persecu- 
 tory ideas, thus rendering them a source of annoyance to the 
 other inmates. One involutional case remains mute for days, 
 when she breaks forth into loud waitings and meanings, which 
 she keeps up incessantly for long periods. At such times she is 
 locked in a cell, and although such treatment is said to quiet her 
 within twenty-four hours, it is difficult to understand how this 
 result is effected, except by exhaustion. 
 
 The cell mentioned is located in a basement against a hillside ; 
 there is a single, small, high window about 10 x 18 inches opening 
 on a narrow shaft and hence both light and ventilation are very 
 poor. It is so dark that little of the interior can be seen by look- 
 ing through the iron-barred door which opens on a narrow pas- 
 sageway. There are no toilet facilities and the cell is bare of 
 furnishings. As it was remarked: "They dread the locked 
 door." A further remark illustrates the prevailing punitive 
 idea: "You have to show them who is boss." 
 
 Tubercular cases are received here, as in most of the other 
 almshouses, none of which have proper facilities for isolation. 
 
 I 771
 
 INSTITUTION No. 46 
 
 For the most part, the material conditions are fairly good for 
 almshouse purposes, in many respects being above the usual 
 almshouse standard. This applies especially to the service de- 
 partments, farm, etc. 
 
 Alleged cases of insanity are brought here pending commit- 
 ment, but the insane inmates now here are regarded and treated 
 like all the other inmates. Up to a year ago disturbed insane 
 patients were confined in a steel cage formed of flat steel bars 
 arranged in a lattice-work. This, located in the basement, is 
 divided into two compartments by a blank partition, so that two 
 persons can be confined at once, and in the past even patients of 
 the opposite sex are said to have thus been confined together. 
 The use of the cage is now deemed inhumane, it being used now 
 only to punish refractory pauper inmates. The disturbed in- 
 sane are now confined in a cell, which is merely a cellar room with 
 whitewashed brick walls on three sides and a board partition on 
 the fourth side. It is at least two-thirds below the ground level, 
 with a single, small, high, basement window covered with heavy 
 wire grating. The room is of good size, but is damp, and there 
 is no ventilation, with the door and window closed. It is pro- 
 vided with a single exposed electric-light globe, which can be 
 reached by a patient standing on the bed, and when this fact 
 was pointed out the superintendent remarked that it was fortu- 
 nate a suicidal patient confined here last winter had not used the 
 globe in a suicidal effort. A bed and a bucket for toilet facilities 
 constitute the only furnishings. There is a door of iron grating, 
 with a heavy, solid, wooden door outside. Both doors are locked 
 when the cell is occupied "to shut out the noise." While it does 
 appear that the cell is slightly less objectionable than the steel 
 cage, yet it is anomalous that it should be regarded as an advance 
 in the humane treatment of the insane. 
 
 One of the insane women now here becomes talkative and dis- 
 turbed at intervals, so it is thought it will eventually be necessary 
 to commit her; but the others are quiet and no such action is 
 probable in their cases. One of the women defectives has a child, 
 the father of whom is a vagrant, formerly an inmate.
 
 INSTITUTION No. 47 
 
 This almshouse is satisfactory for the care of pauper inmates. 
 No insane are supposed to be kept here and but two insane 
 cases were found. Through the efforts of a progressive visiting 
 physician cases of alleged insanity are rarely brought here pend- 
 ing commitment, although two women were committed from here 
 during the past year, one after a month and the other after two 
 months' residence; as they were quiet they were allowed to 
 mingle with the other inmates, receiving no special attention. 
 
 Formerly when it has been necessary to care for disturbed 
 insane, the women have been locked in a narrow hallway outside 
 the bath and toilet rooms, all doors opening on which are of 
 heavy, solid, wooden construction. This hallway is short, has 
 a single window, with an inside, heavy, solid wooden shutter, 
 which it has been customary to close when patients were placed 
 here. Although artificial light is provided, no ventilation is 
 possible under such conditions. This hallway, being the only 
 means of reaching the toilet and bathroom, has had to be tra- 
 versed when patients wish to reach the latter, thus disturbing the 
 insane inmate here confined. 
 
 On the men's side there is a special room for insane cases, which 
 has been finished off with wooden boards covering the entire side 
 walls. It has a single window, inside of which is a solid, heavy, 
 wooden shutter. The door is constructed of wire grating, covered 
 on the outside with a layer of boards. With the door and shutter 
 shut, there is no ventilation. It is a pleasure to note that the 
 steward stated he would only use this room and the hallway in 
 case of extreme necessity. 
 
 INSTITUTION No. 48 
 
 The material conditions here are satisfactory for an alms- 
 house. Although this institution is supposed to have no insane, 
 the local authorities recognize the insanity of the insane persons 
 found among the inmates, it being explained that so long as the 
 insane are quiet and inoffensive it is customary to keep them 
 here, regardless of mental symptoms, as the County thereby 
 saves the extra expense involved in their maintenance in a State 
 hospital. However, when one becomes noisy or troublesome, 
 commitment follows. One such case had an incised wound, the 
 result of striking his head on a washbowl, when, in a fit of anger, 
 
 l79l
 
 he declared he would kill himself, and it is felt that this individual 
 may shortly have to be committed. 
 
 Five of the defective women inmates have borne children, 
 although but two are married, and their husbands have deserted. 
 One has her child with her. A male sane inmate was seen bring- 
 ing in a basket of potatoes, although his nose was partly eaten 
 away with carcinoma and there was no dressing upon it. 
 
 Alleged cases of insanity are brought here pending commit- 
 ment. When disturbed they are kept in so-called cell rooms, 
 there being four for the men and three for the women. The men's 
 rooms are ordinary rooms, but have tile floors; each has an 
 outside window covered with a close iron-bar mesh-work, with 
 an inside door of similar construction, outside of which is a heavy, 
 solid, wooden door. Both doors are kept locked when the rooms 
 are in use. The women's cell rooms are inside, with no opening 
 other than the door, and hence are dark and poorly ventilated. 
 The side walls are finished with boards ; the doors are of heavy, 
 wooden construction, with a central aperture covered with 
 straight, heavy, iron bars. The rooms are heated only from 
 the hallways. The only toilet facilities provided are small 
 vessels. On the day of the visit but one cell was occupied and 
 that by a male, restless, deteriorated epileptic. 
 
 While unused, two so-called "standing cells" are an interesting 
 relic of the past; they are merely two small closets, just large 
 enough for an adult to stand erect in with the door closed. If 
 a person once sank down, it would thus be impossible to again 
 assume an erect posture ; it was admitted that the quieting effect 
 of such confinement could only have resulted from exhaustion, 
 and it was said that their manifest barbarity caused their aban- 
 donment. 
 
 SUMMARY OF UNLICENSED ALMSHOUSES 
 
 In reviewing this group of almshouses it may be said that, while 
 the majority provide fair material conditions for paupers, even 
 that is not true of all of them, and none have any proper means 
 of caring for the insane. Despite this fact, three of them have 
 locally recognized insane departments. None of the local au- 
 thorities have any idea as to what constitutes proper treatment 
 for the insane, and there can be no doubt that many insane 
 patients have failed of recovery, even if some alleged cases of 
 
 [80]
 
 insanity have not been rendered actually insane, by the barbarous 
 treatment to which they have been subjected. In such category 
 may be mentioned seclusion for long periods in dark and un- 
 wholesome cells, in some instances cared for only by pauper in- 
 mates, and often deprived of even the most common and most 
 necessary conveniences of life. Treated more as wild animals 
 than as unfortunate human beings entitled to every considera- 
 tion and sympathy, they constitute a class of individuals for 
 whom no possible future misfortune can have any terrors. 
 
 Fortunately the number of the insane in the almshouses is 
 comparatively small, but so long as Counties act independently 
 in caring for this dependent class, so long will there be some Coun- 
 ties in which a patient must be either "noisy or troublesome" to 
 receive the benefit of treatment in a State hospital, the matter of 
 cost outweighing the possibility of cure in quiet, inoffensive cases. 
 
 GENERAL SUMMARY 
 
 In reviewing the State as a whole, as to the care of the insane, 
 a striking feature is the great variability in the standard of care 
 and treatment maintained in different types of institutions, and 
 in some instances in different institutions of the same type. In 
 some places patients receive every care and attention that is indi- 
 cated by modern science as beneficial, while in others, although 
 there appears no evidence of any degree of actual physical abuse, 
 yet, what may be even worse, there is the most utter neglect. 
 
 It appears to be largely a question of the geographical location 
 of a patient's residence whether such patient receives the benefit 
 of active, curative treatment, or is allowed to lapse into chronicity 
 in some custodial institution without an effort made to stay the 
 course of the disease. Just how our boasted political equality 
 can be reconciled with such a vital inequality of opportunity does 
 not appear. There is no greater necessity to "the pursuit of 
 happiness" than mental health, and so far as public provisions 
 are made for the insane it would appear as though one citizen had 
 as much right to receive good treatment and a chance for mental 
 restoration when stricken with mental disease as another. 
 
 The un-American and un-democratic practice prevailing in some 
 communities (Institutions Nos. 19 and 27) of sending patients " be- 
 longing to the better families " to a State hospital and others to the 
 6 [8iJ
 
 county custodial institution should no longer be tolerated. But 
 it is in no way worse than determining the question as to where a 
 patient shall be committed by the degree of troublesomeness 
 manifested, regardless of prognosis. It is impossible that the 
 latter can be adequately taken into account when the matter is 
 determined by County Commissioners, Poor Directors and non- 
 medical stewards and superintendents of county institutions, as 
 is now the prevailing practice, even in communities where the 
 loud boast is heard that only chronic cases are sent to the county 
 institutions. 
 
 That varying standards should exist is not surprising in view 
 of the varying methods of dealing with the insane. There can 
 not be more than one best system, and but a single policy can be 
 successfully followed. The only results obtained in the State of 
 Pennsylvania, which have been even approximately satisfactory, 
 have been in the State hospitals. The fact that the State has 
 never yet assumed full responsibility for the insane is no reason 
 why advantage should not be taken of experience. The mere 
 fact that treatment of insanity implies deprivation of liberty 
 suggests the propriety of general laws governing all details of the 
 matter applicable in exactly the same manner to all individuals 
 affected throughout the State. 
 
 But apart from the desirability of securing a uniform and satis- 
 factory standard of care is the imperative necessity of taking 
 some action to provide for the excess number of insane in the 
 State for whom there are now no accommodations in any kind of 
 an institution. When, as has happened, a city and a State hos- 
 pital have to resort to the courts to determine the right of each to 
 refuse to accept more patients because of dangerous overcrowding 
 it would seem as though a definite, well-planned policy should at 
 once be substituted for the present temporizing method, especially 
 as in the dispute mentioned the fact of overcrowding was indis- 
 putable, and hence both institutions were justified in their atti- 
 tude. 
 
 RELATIVE MERITS OF STATE AND COUNTY CARE 
 
 In discussing the relative merits of State and county care, it 
 must be admitted that the latter system has had numerous argu- 
 ments urged in its favor, the main ones being as follows: 
 
 1. Possibility of patients remaining near home and receiving 
 visitors. 
 
 [82]
 
 2. Greater opportunity for occupation. 
 
 3. More individual care and avoidance of so-called "massing 
 
 together" in large institutions. 
 
 4. More homelike surroundings and avoidance of institu- 
 
 tional atmosphere. 
 
 5. Greater numbers of recoveries. 
 
 6. Lower maintenance cost, especially for chronic insane. 
 The above arguments will be discussed separately and in order. 
 
 1. POSSIBILITY OF PATIENTS REMAINING NEAR HOME 
 AND RECEIVING VISITORS 
 
 While theoretically visits from friends may be more readily 
 possible in county institutions, as a matter of fact they are not. 
 Including only such institutions as keep records of visits and 
 those in which the local authorities felt it was possible to make an 
 accurate estimate, it was found that in six State hospitals, with a 
 census of 7275, there were 2942 patients who had not been visited 
 within a year, while in 21 city and county institutions, with a 
 census of 6476, there were 2583 patients who had not been visited 
 within a year. In figuring the percentage of unvisited patients, 
 the surprising result is that the proportion of visited patients 
 remains practically constant, regardless of the type of institution 
 the percentage for the State hospitals being 40.43 per cent un- 
 visited and for the city and county institutions 39.88 per cent 
 unvisited. 
 
 It is contrary to ordinary experience to believe deprivation 
 of liberty amid familiar scenes is less irritating than the loss of 
 liberty amid strange ones. Under the latter circumstance new 
 surroundings and interests are often found to so occupy even a 
 diseased mind that such deprivation of liberty as is necessary 
 is obscured and unrealized by the patient. Such result cannot 
 be expected when confinement occurs amid familiar surround- 
 ings, where all objects recall former habits of unrestricted move- 
 ment. But aside from the above consideration, if a well balanced 
 State Hospital system were established, with due regard to the 
 distribution of population, no hardship regarding visits need 
 
 result. 
 
 2. GREATER OPPORTUNITY FOR OCCUPATION 
 
 The matter of occupation is undeniably of first importance. 
 But this, like all other features, must be judged by general results 
 
 [83]
 
 and not by isolated instances. The degree to which occupation 
 is developed in any institution, regardless of type, depends upon 
 personal initiative and material conditions. 
 
 The actual findings respecting this matter are as follows: 
 8 State hospitals have percentages ranging from 39.1 per cent to 
 64.3 per cent of the total hospital population regularly occupied. 
 
 Institution No. 1 1 43.2 per cent 
 
 12 48.2 
 
 13 42.1 
 
 H 48.4 
 
 15 39-i 
 
 16 64.3 
 
 17 61.8 
 
 18 48.5 
 
 The hospital (No. 15) in which the lowest percentage obtains is 
 termed a State hospital by courtesy only, for, while supported for 
 the most part by State funds, it is under private control. While, 
 as is to be expected, the above percentages show some variation, 
 and the number of patients occupied in some institutions could 
 undoubtedly be increased, the general average is good. 
 
 As for the 19 county institutions, the following indicates the 
 percentage of the total number of patients regularly employed : 
 
 Institution No. 19 29.2 per cent 
 
 20 28.8 ' 
 
 21 50.7 ' 
 
 22 " I or 2 patients" has cen- 
 sus of but 8 patients 
 
 23 57.4 per cent 
 
 24 26.8 ' 
 
 25 46.1 ' 
 
 26 " About 50 per cent 
 
 27 40.9 per cent 
 
 28 36.9 ' 
 
 29 52.1 ' 
 
 30 49-9 ' 
 
 31 50-3 ' 
 
 32 " About 50 per cent 
 
 33 67.2 per cent 
 
 34 43-5 ' 
 
 35 25.6 " " 
 
 36 32.0 ' 
 
 37 39-2 ' 
 
 The percentages given show a much wider range of variability 
 in the number of patients occupied in the county institutions 
 than in the State hospitals, suggesting that when good results are 
 obtained in the former it is because of special local conditions or 
 special initiative. The latter is especially true in Institutions Nos. 
 
 [84]
 
 21, 23, 29 and 33, where has occupation been developed in an 
 excellent manner, although in the first mentioned under most ad- 
 verse circumstances. The lesson to be drawn is not that either 
 State or county institutions, as such, offer superior opportunity 
 for occupational work, but rather that opportunity can be offered 
 in any type of an institution if properly equipped and provided 
 with sufficient acreage. The two factors mentioned material 
 conditions and personal initiative, are alone essential to success, 
 and the mere fact that fairly uniform results are obtained in the 
 State hospitals, whereas county institutions show a wide vari- 
 ability, seems to indicate that such factors are more apt to exist 
 in State hospitals. 
 
 3. MORE INDIVIDUAL CARE AND AVOIDANCE OF SO-CALLED 
 "MASSING TOGETHER" IN LARGE INSTITUTIONS 
 
 The lack of individual care in the State hospitals has not, at 
 the present time at least, assumed the proportions of such lack 
 in county institutions. This fact is demonstrated by the num- 
 ber of attendants found on duty in the various institutions in 
 proportion to the number of patients treated therein. The 
 number actually on duty is, of course, less than the number 
 assigned, as there are always a certain number of absences by 
 reason of sickness, regular time allowance off duty, special de- 
 tails, etc. 
 
 In the State hospitals the proportion of day -attendants was 
 as follows: 
 
 Institution No. n I attendant to 14 patients 
 
 12. 
 
 13 
 14. 
 
 15- 
 16. 
 
 17 
 
 18. 
 
 13 
 12 
 
 13 
 II 
 16 
 13 
 19 
 
 The last institution is for criminal insane only and the propor- 
 tion of attendants is there less because of the closer confinement 
 of patients and the necessity for a large night force, the latter 
 being in the proportion of I attendant to 17 patients. 
 
 The proportion of day-attendants in the county hospitals was 
 as follows: 
 
 [85]
 
 19 
 
 i 
 
 2O 
 
 i 
 
 21 
 
 i 
 
 22 
 
 IN 
 
 23 
 
 i 
 
 24 
 
 i 
 
 25 
 
 i 
 
 26 
 
 i 
 
 27 
 
 i 
 
 28 
 
 i 
 
 29 
 
 , i 
 
 30 
 
 i 
 
 31 
 
 i 
 
 32 
 
 i 
 
 33 
 
 i 
 
 34 
 
 i 
 
 35 
 
 i 
 
 36 
 
 i 
 
 37 
 
 i 
 
 24 
 
 16 
 
 None, solely for 8 insane 
 here confined 
 
 21 p 
 22 
 26 
 14 
 
 22 
 23 
 17 
 22 
 
 16 
 
 15 
 18 
 
 19 
 13 
 
 21 
 
 32 
 
 'In some instances the difference in proportion between the 
 State hospitals and county institutions is not large, but as seen 
 from the details of the care given, as set forth in this report, the 
 type of care in the county institutions, considering the whole 
 system, is so decidedly inferior to that in the State hospitals as 
 to admit of no comparison. In general, it is the substitution of 
 mechanical means of restraint and confinement for personal care 
 and attention, the lesser cost of the former no doubt being a factor. 
 
 The difference between the State hospitals and County institu- 
 tions is still more marked as regards medical care and attention. 
 While all State hospitals have staffs of resident physicians, the 
 number of physicians being in fair proportion to the number of 
 patients treated, in but 8 of the 19 County hospitals are there 
 resident physicians. In 4 County hospitals, or half of those 
 having resident physicians, there is but a single physician in the 
 person of a medical superintendent, or a physician in charge, who 
 in every instance is obliged to devote so much of his time to 
 executive duties that it is impossible for him to give as much 
 attention to strictly medical matters as would appear desirable. 
 In the remaining 4 County institutions with resident physicians, 
 in no instance are there more than two assistant physicians in 
 addition to the physician in charge, although such institutions 
 have the number of patients indicated below : 
 
 No. 20, census 886 
 No. 30, 517 
 
 No. 32, 621 
 
 No. 35, " 456 
 [86]
 
 In the II County hospitals without a resident physician, the 
 only medical attention is that given by visiting physicians who 
 regularly visit only at intervals of varying length. It is thus not 
 surprising to find that the medical work is devoted solely to the 
 treatment of physical ills. 
 
 As to "massing together," no properly equipped hospital of 
 any character allows such conditions to exist. A large institu- 
 tion does not necessarily mean such a single, monasterial structure 
 as was formerly in vogue, but a collection of numerous building 
 units, sometimes widely separated. With the modern cottage 
 system, a large institution alone is able to provide proper classi- 
 fication, a general lack of which is one of the serious faults of the 
 county institutions. Indeed, the only classification attempted in 
 the vast majority of them is to separate the disturbed from the 
 quiet as well as may be, but that such result is not always ob- 
 tained is shown in the main body of this report. It is likewise 
 there shown that the close physical contact between patients 
 of many different types could not be exceeded under any possible 
 condition of "massing together" in a State hospital. 
 
 4. MORE HOME-LIKE SURROUNDINGS AND AVOIDANCE OF THE 
 
 INSTITUTIONAL ATMOSPHERE 
 
 The less said about the home-like surroundings the better, 
 so far as the average county institution is concerned, for it may be 
 again repeated that average conditions must be considered and 
 not specific instances. And the prevailing custom of erecting the 
 buildings for the insane at the rear of the almshouse buildings 
 is certainly not calculated to remove institutional atmosphere. 
 Neither is the practice peculiar to county institutions for the 
 insane of providing only enclosed exercise yards, most of which 
 are surrounded by high fences, completely cutting off the pa- 
 tients' view. 
 
 5. GREATER NUMBER OF RECOVERIES 
 
 It has been argued that the county hospitals cure more pa- 
 tients than do the State hospitals. If such were the case, it 
 would seem that all progress has been made under false im- 
 pressions. If poor facilities and lack of facilities produce better 
 results than do proper provisions, then, indeed, should present 
 conditions prevail. 
 
 [87]
 
 It would be possible to present statistics as to recoveries which, 
 as in the statistics given, would show individual county institu- 
 tions making a good showing, but as the manner by which re- 
 coveries have been determined leaves much to be desired, such 
 statistics would prove nothing. For instance, even in such 
 county institutions as have a physician to determine the ques- 
 tion of recovery, it was found that patients were discharged as 
 recovered when diagnosed as suffering from incurable disorders, 
 such as paranoia, and even the fatal disease of paresis. In one 
 institution with a high recovery rate it was found that 33 per 
 cent of the recoveries were alcoholic cases, some of whom were 
 admitted and discharged several times within the year, each time 
 counting as a recovery, one such case repeating on four different 
 occasions. Recovery rates prepared in such a manner are not to 
 be considered seriously. Nor can it be thought that in such 
 institutions as provide a layman to pass on the question of re- 
 covery, recovery statistics are any more accurate. 
 
 The question of recovery is ofttimes most difficult to deter- 
 mine. Insanity is, after all, a social maladjustment, and, unless 
 a patient has had an opportunity to prove recovery by proper 
 social adjustment outside an institution, statistics bearing on the 
 subject are more apt to lead to erroneous conclusions than correct 
 ones. Hence the desirability of a parole period with subsequent 
 examination prior to discharge. Despite all the above, 7 of the 
 19 county institutions discharged no cases as recovered during 
 their last hospital year, 5 institutions discharged in the aggre- 
 gate 1 8 cases as recovered, while in but 7 were there fair re- 
 covery rates, assuming, for the sake of argument, that statistics 
 were accurately prepared. In the State hospitals, on the con- 
 trary, normal recovery rates everywhere obtained, except only 
 as they were influenced by their special character, as in the State 
 hospital for chronic insane and the State hospital for criminal 
 insane. 
 
 6. LOWER MAINTENANCE COST, ESPECIALLY FOR CHRONIC INSANE 
 It cannot be denied that cost of maintenance is less in county 
 hospitals, as proper facilities cost more than does their lack. 
 Mere custodial care costs less than does remedial medical treat- 
 ment. An article of poor quality can always be purchased for 
 less than a superior one. It is cheaper to die without medical 
 
 f881
 
 attendance than with it. But because these facts are true, no 
 one suffering from even a fatal illness, or with a near relative so 
 suffering, would feel that the question of cost should prevent the 
 sufferer from receiving every possible medical aid and atten- 
 tion. Therefore, it appears strange that mental death, in many 
 respects worse than physical death, should be differently re- 
 garded. 
 
 But it is argued that chronic insane require only custodial 
 care. The first difficulty is to find the person competent to 
 determine chronicity; while, of course, it is possible to do so in 
 many cases, there are still many others in which present knowl- 
 edge does not allow a definite statement. No better proof of 
 this is needed than the fact that there were, during the last hos- 
 pital year of the various institutions, 117 patients discharged as 
 recovered who had been under treatment longer than a year. 
 After making due allowance for such inaccuracies in the sta- 
 tistics as have been pointed out, the above renders striking con- 
 firmation of the fact, repeatedly demonstrated by experience, that 
 in some forms of insanity improvement and even recovery may 
 occur after several years' duration. It is therefore not creditable 
 that the question of cost should be allowed to weigh against 
 every possible chance being offered every insane person for mental 
 restoration. 
 
 It is, however, unfortunately true that large numbers of the in- 
 sane cannot be restored by any known means of treatment, but 
 that does not argue that they are not entitled to the best grade 
 of custodial care consistent with a properly economical ad- 
 ministration. The details already presented relative to indi- 
 vidual institutions indicate that even custodial care, as such, 
 is best given in the State hospitals, for, with detached groups of 
 buildings, no need arises whereby such patients come in contact 
 with acute patients. Furthermore, it is not often that so-called 
 "chronic cases" present the distressing scenes of great excitement 
 or extreme depression and agitation, so feared by some for their 
 injurious effect upon the acute cases. It is rather among the 
 acute insane themselves that such scenes occur, and hence the 
 necessity of acute hospital buildings for the treatment of such 
 conditions, that fine classification may be possible. 
 
 There are, however, chronic cases which occasionally suffer 
 from acute exacerbations which require the same treatment as 
 
 [89]
 
 similar phases of disease in acute cases, and only when such 
 chronic patients are cared for in a well-equipped, large hospital 
 can they be transferred to the acute hospital department and 
 receive proper treatment. 
 
 In addition to all the above we now know that infinite possi- 
 bilities exist in the occupational reeducation of even the most 
 chronic insane patients. But not only do the county institutions 
 fail to provide such work, as such, but in most of them there is no 
 knowledge whatever of the subject. That work is good for the 
 chronic insane is, of course, universally conceded, but that oc- 
 cupation should be fitted to special needs, that dormant interests 
 can thus be awakened, and that practically new mental life is 
 often the result of intensive personal reeducational effort applied 
 with regard to individual needs, there is no conception. But 
 such is the fact and it alone would seem sufficient to render forever 
 obnoxious the idea that ordinary custodial care is good enough 
 for the chronic insane, however less the cost. 
 
 The fact that county institutions do not and cannot supply 
 the demand of modern psychiatric progress is evident from a 
 brief consideration of their organization. Controlled as they are 
 by Poor Directors, whose thought is not the cure of insanity, 
 many even expressing an open incredulousness as to its possi- 
 bility, such institutions are conducted in conjunction with 
 almshouses towards whose standard they inevitably tend. 
 Indeed, as has been noted, in some instances the insane and the 
 paupers occupy the same building, and in but few instances is 
 there any appreciable difference in the character of the care given 
 the two classes of individuals. It should not, however, be as- 
 sumed that the faults of the county institutions are wilful faults 
 of the local administrations ; in most instances the local stewards 
 and superintendents of county institutions were found to be men 
 doing their duty as best they knew and as best they could under 
 woefully inadequate conditions. As a class, they were found to 
 be kindly, humane men, who in the vast majority of instances 
 appreciate the faults of the existing system and would welcome 
 State care of the insane. 
 
 Aside from material conditions, the most universal and the 
 most serious lack is the want of medical treatment directed to the 
 
 [90]
 
 cure of mental disease, as such, but under the existing organiza- 
 tion of county institutions such lack is not surprising. The 
 Poor Directors must necessarily be chiefly interested in the matter 
 of expense; should the poor tax be raised, their chances of re- 
 election are of course jeopardized, and it is not without signifi- 
 cance that Institution No. 35 is the only county institution in the 
 State, with a single exception, provided with continuous baths and 
 other modern equipment when one learns that it alone of all 
 the county institutions is governed by an independent, unsalaried 
 Board of Trustees. 
 
 It is contrary to ordinary experience to expect that all counties 
 can ever be induced to spend sufficient funds to properly equip 
 their institutions. In fact, it would appear unjustified to expect 
 it, for it would mean a prohibitive per capita cost. It is only in 
 large institutions, where the cost is distributed over a large num- 
 ber of patients, that the expense of proper equipment assumes 
 reasonable per capita proportions, and when adequate facilities 
 are provided, it is but common sense to expect the fullest use 
 to be made of them, which is, of course, impossible in small 
 institutions. 
 
 It has been argued that a large institution is undesirable, 
 because the superintendent is unable to personally know and 
 direct the treatment of individual patients. But such a view 
 of the matter appears superficial. It matters little to the patient 
 who the individual is who treats him, providing that individual 
 be competent and adequate material facilities be provided. It 
 would appear that a superintendent fulfils his function when he 
 sees that proper facilities and treatment are provided, retaining, 
 of course, such personal supervision as is possible. It is more 
 important that adequate material facilities be provided to sup- 
 plement skilled medical treatment than that the latter should be 
 administered by any one person; the above, of course, implies 
 a well-organized and competent staff, as none could successfully 
 decry the importance of personal treatment. 
 
 To remove the insane from almshouse association, with all that 
 it implies, to provide proper facilities for the treatment of mental 
 disease, as such, including chronic as well as acute conditions, to 
 remove the whole subject of the care of the insane from the realm 
 of partisan politics and at the same time accomplish such result 
 at a minimum expenditure of money is a problem which appears
 
 in no way possible of accomplishment except by the adoption of 
 State care. 
 
 As a necessary corollary there should be a State Civil Service 
 for officers and employees, wherein merit alone will win promotion 
 and where like salaries will be paid for like service in all parts of 
 the State there now existing great inequality in this regard. 
 The successful operation of a State Care system likewise implies 
 a central coordinating or supervisory bureau or commission 
 empowered to maintain proper standards and to recommend the 
 distribution of funds where the greatest needs exist, with regard 
 to the interest of the State as a whole, all, of course, under proper 
 checks. In such connection, the budget system is worthy of 
 consideration. 
 
 Such an organization should not displace the local boards of 
 managers, for local initiative and local pride should be stimulated 
 in every proper way and the details of hospital management 
 should be left to them and the superintendent. So it would, of 
 course, be necessary that the exact balance of power between the 
 central and local authorities be very carefully worked out. 
 
 Such a definite State-wide scheme is as much in the interest 
 of true economy as humanity, for only thus can uniformity of 
 method be obtained, with resulting economies peculiar to large 
 organizations. The present lack of uniformity in both business 
 and medical methods is a necessary result of the independent 
 manner in which each institution has developed. It follows that 
 experience gained in one institution has been lost in another, 
 while records are worthless for purpose of comparison. By 
 uniting all institutions in one system, the experience of one will 
 become the property of all. Records, both business and medical, 
 being prepared alike throughout the State, will be thereby en- 
 hanced in value. And thus alone can medical records be rendered 
 available for scientific study, which is merely the formation of 
 conclusions based on exact data. 
 
 There are numerous matters in connection with the care of the 
 insane in Pennsylvania which merit discussion, but which can but 
 be mentioned within the limits of this report. Among them is 
 the need for codification of the insanity law, with the elimination 
 of such an inconsistency as is seen in the provision whereby a vol- 
 untary patient must be financially able to provide maintenance, 
 when, in another section, the law reads that indigent patients 
 
 [92]
 
 shall have the preference in securing admission to hospitals for the 
 insane. It is by the treatment of voluntary patients that later 
 commitments can be avoided, as the importance of early treat- 
 ment cannot be overemphasized. But under the law an indigent 
 patient must first progress in his mental disease until commitable 
 before he is permitted to receive treatment, although at such 
 point he is given preference. 
 
 In connection with the need of early treatment, the matter of 
 psychopathic wards in general hospitals should receive attention. 
 Despite the excellent law passed at the last session of the As- 
 sembly relative to such wards, but two have been established, 
 and the practice is still well-nigh universal of placing the alleged 
 insane in jails. Indeed, the plans of a jail about to be erected 
 call for a padded cell for the insane. Insanity being a matter of 
 public health, would seem to more properly belong to the realm of 
 health officers than peace officers, or even poor officials. 
 
 A uniform method of commitment should be provided. As at 
 present constituted, the law appears more concerned with an 
 alleged insane person's right of freedom than right of treatment. 
 Provide all legal safeguards thought necessary to prevent wrong- 
 ful commitment, but do not make them mandatory, except on 
 appeal. If a person knows he needs treatment and desires to 
 receive it, make the way easy. There is far more danger of a 
 mental case failing to receive proper treatment than there is of a 
 sane person being committed as insane. Experience shows the 
 latter but rarely happens, and it is safe to say that whenever it 
 has happened such person has at once been discharged. 
 
 The question of after-care following a patient's discharge from 
 the hospital and the subject of public mental hygiene are of vast 
 importance. As in all the ills to which human flesh is heir pro- 
 phylaxis offers more hope than treatment after the development 
 of disease. The statistics prepared by the National Committee 
 for Mental Hygiene show that at least 50 per cent of the insanity 
 in this country arises from preventable causes a startling fact, 
 but one offering encouragement for work in this field. It is in 
 such connection that there should be closer reciprocal relations 
 between the general practitioner and the mental specialist. 
 
 In bringing this report to a close, it is unnecessary to make 
 further comments on the conditions found to exist throughout 
 the State. The results in no way justify the existing system or 
 
 l93l
 
 rather lack of system. A remedy is demanded and it is hoped 
 that in some measure this report has pointed the way to com- 
 plete State care as the remedy needed. 
 
 In conclusion, I wish to express to the members of your com- 
 mittee my sincere appreciation of the many courtesies extended 
 me, and to your Executive Secretary, Mr. Robert D. Dripps, my 
 gratitude for his ever-ready assistance and kindly encouragement. 
 
 Respectfully submitted, 
 (Signed) C. FLOYD HAVILAND. 
 
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