Rise and Progress of New York State Care of the Insane: 1901
by Goodwin Brown, Ex-State Commissioner in Lunacy
Editor’s Note: This 1901 article from the New York Times was copied with permission and derived from the blog researched and developed by Linda S. Stuhler at http://inmatesofwillard.com/
It is consonant with its destiny and greatness that the Empire State should have, of all States and countries in the world, the most complete, humane, and comprehensive system of caring for this most unfortunate class. This system, complete and harmonious as it is, like all successful organizations, was not the development of a day – practically it was the growth of half a century. It began in 1843 and was completed in 1890.
From 1843 to 1890 the care of the insane was regarded, not as a necessity required by the highest considerations of an enlightened economy. But rather as a form of charity grudgingly and often ignorantly bestowed at the caprice of unenlightened public authorities. It was not until the absolute safety and welfare of the State was dangerously threatened that the fruition of a method humane and economical was adopted. So long as ‘charity’ was the watchword all efforts toward the proper and humane care of this class were largely misdirected, with the inevitable result of cruelty and barbarism – which, by the way, were fearfully excessive – intermixed sometimes with something akin to humanity.
When public sentiment had become sufficiently enlightened on the subject it was seen that ultimate economy as well as humanity demanded a change which charity could not effect. It was seen that it would be actually cheaper to make adequate and suitable provision for the proper care and treatment of the insane than to permit them to be at large, committing acts of violence, destroying property, and breaking up families, thereby producing widespread misery and loss of productive energy.
Prior to 1843, when the first considerable effort to properly care for the insane by the opening of the New York State Lunatic Asylum at Utica was made, little had been done to alleviate the condition of the insane in New York State. It was the almost universal practice, so far as public care was provided, to place them in jails and poor houses. Toward the end of the first quarter of the last century the Hospital of the City of New York made a commendable beginning by the establishment of the institution which is now known as Bloomingdale, located at White Plains. For many years, however, the number which could be cared for was limited and the accommodations were inadequate. Obviously no private corporation, no matter how charitably disposed, could cope with what was even then a tremendous problem. During the next quarter of the century, through the efforts of various philanthropy and charity only – Miss Dorothea L. Dix being the most notable, the subject began to receive wider consideration.
About 1836 the first statute was enacted providing for the erection by the State of what became popularly known as the Utica Insane Asylum, which was opened for the reception of a small number of patients in 1843. The establishment of this institution by the State was the beginning of what eventually became known as ‘State Care of the Insane.’ For many long and weary years, however, the great mass of the insane remained in the poorhouses, for the Utica Asylum was only intended for a small number of supposedly curable cases. When a patient failed to recover after the lapse of a few months, or a year or two at most, if a public charge, he was returned to the poorhouse of the county whence he came, there to remain until his tormented spirit took its flight.
The success of the Utica asylum and similar institutions in other States was such as to stimulate those who, still actuated by motives of philanthropy only, desired to extend the system thus instituted by the State so as to include all the insane. In the meantime, with the great growth of population and consequent increasing numbers of insane in the poorhouses, an agitation was begun which culminated during the civil war in the passage by the Legislature of the second great act for the care of the insane by providing for the erection of the Willard Asylum for the Chronic Insane, which was opened in 1868 – an interval of a quarter of a century from the opening of the first institution at Utica.
The agitation which brought about the establishment of the Willard Asylum was a memorable one. The Legislature authorized the New York State Medical Society to investigate and report upon the question of the dependent insane, and this work devolved upon its Secretary, a young Southern physician lately located in Albany, under most romantic circumstances – Dr. Sylvester D. Willard. Dr. Willard proved himself both intelligent and humane. He entered into the work in a truly scientific spirit and with untiring zeal. His report produced a profound sensation – it revealed conditions which shocked the entire State. Among other things, he said:
‘In some of these buildings the insane are kept in cages and cells, dark and prison-like, as if they were convicts instead of the life-weary, deprived of reason. They are in numerous instances left to lie on straw, like animals, without other bedding, and there are scores who endure the piercing cold and frost of Winter without either shoes or stockings being provided for them: they are pauper lunatics and shut out from the charity of the world where they could at least beg shoes. Insane, in a narrow cell, perhaps without clothing, sleeping on straw or in a bunk, receiving air and light and warmth only through a diamond hole through a rough prison-like door, bereft of sympathy and of social life, except it be with a fellow-lunatic, without a cheering influence or a bright hope of the future…The violent have only to rave and become more violent, and pace in madness their miserable apartments. These institutions afford no possible means for the various grades of the insane: the old and the young; the timid and the brazen; the sick, the feeble, and the violent are herded together without distinction to the character or degree of their madness and the natural tendency is for all to become irretrievably worse…In some violent cases the clothing is torn and strewed about the apartments and the lunatics continue to exist in wretched nakedness, having no clothing, and sleeping upon straw, wet and filthy, and unchanged for several days…Can any picture be more dismal? And yet it is not overdrawn.’
Unfortunately, while the step gained was exceedingly important, the act of incorporation of the Willard Asylum provided that it was to care only for the chronic insane. This institution was designed to care for all the insane in the county poorhouses, except in the counties of New York and Kings.
Dr. John P. Gray of the Utica Asylum, with a wisdom and foresight far in advance of his time, opposed the establishment of the Willard Asylum in the lines proposed and finally adopted; namely, to care for the chronic insane. From various causes, principally the opposition of the county officials, who were loath to give up the patronage and profit of caring for their chronic insane – the institution was not enlarged sufficiently to provide for all the insane remaining in the poorhouses. The Superintendents of the Poor argued – and their argument had a certain plausibility – that inasmuch as custodial care was to be provided at Willard without reference to the curative treatment of its inmates, they, the Superintendents of the Poor, might, as well be intrusted with the care of the chronic insane. This argument to some extent prevailed, and the Legislature was induced to grant exemption from the operation of the Willard act to certain counties – the number ultimately reached twenty – under conditions which contemplated humane custodial care.
Experience soon showed that the conditions could not be enforced, and thus the old inhumanities and barbarities were restored. Renewed agitation to at once and forever blot out this one of the greatest disgraces which ever sullied the fair fame of a State, was begun by the State Charities Aid Association, a voluntary society which, in its visitation of county poorhouses by local committees, because thoroughly convinced of the unfitness of these institutions for receptacles of the insane. This reform movement was uncompromisingly pursued by the Association under the able leadership of the Chairman of its Committee on Legislation for the insane, Miss Louisa Lee Schuyler, eminent as a philanthropist and friend of the insane, and to whose unremitting efforts the successful outcome of this final effort in behalf of State care for the insane was largely due.
The principal difficulty encountered in previous agitations to improve conditions of the insane lay in the fact that the State had no adequate machinery to enforce its statutes – there were statutes in plenty but no adequate executive power was given to anyone. In 1889 the condition of the insane in the poor houses had become intolerable. The conditions, while perhaps not as bad as those so vividly and truthfully described by Dr. Willard a quarter of a century before, were such as to call for immediate action. The number of the insane in poor houses had by this time reached more than two thousand – a number twice as large as existed there at the time the Willard Asylum was created. It was already seen that if the evil were to be completely abated heroic measures must be adopted.
The efforts of the State Charities Aid Association in 1888 and 1889 to secure the enactment of a law to wipe out the disgraceful blot had been threatened by a combination of greed and patronage which had rarely been witnessed in the halls of the Legislature. The officials having supervision of the dependent poor and insane were marshaled in solid array against a movement which threatened to destroy their immense power and to take from them the sources of great and constantly increasing revenue. In the preceding twenty-five years the number of state institutions had greatly increased, but the accommodations for the insane had not nearly kept pace with the demand for space. Each institution was separately governed by a board responsible to no adequate central authority. So far as unity of action was concerned, they might as well have been located in so many separate States. These institutions had largely been built and were managed on the plan of ‘doing something for the district.’ In consequence, scandals and gross inefficiency were frequently charged with results of many acrimonions: Legislative investigations. No doubt many of these charges were not sustained nevertheless they gave occasion to the enemies of State care to point to undeniable extravagances
and frequent mismanagement. Millions had already been expended with inadequate accommodations, and it was said that the assumption by the State of the care of all of the insane would be followed by State bankruptcy. These arguments found many attentive listeners in the Legislature and elsewhere.
In conformity with the suggestions and recommendations of many Legislative investigating committees, the Legislature of 1889, after a prolonged struggle lasting more than three months, and at the very end of the session, passed a bill creating a State Commission in Lunacy with far more extensive powers and duties than had been devolved upon any executive body theretofore having jurisdiction over the insane. Governor Hill appointed as members of the Commission, Dr. Carlos F. MacDonald, Goodwin Brown and Henry Reeves. Dr. MacDonald had for years been regarded as one of the leading alienists in the country, and his practical knowledge of the management of institutions for the insane had covered a period of more than twenty years, as he had been superintendent of three hospitals for the insane in succession. Moreover, his ideas in regard to the treatment and care of the insane were known to be of the most advanced order. He was a most pronounced believer in State care for all the dependent insane and opposed to the Willard system of caring for the chronic insane in separate institutions. The wisdom of this appointment was at once universally recognized, and there is little doubt that to his genius and energy is largely due the magnificent system of State care that prevails to-day in the State of New York.
Dr. MacDonald’s associate Commissioners, while having had no experience in the care and treatment of the insane, had long been in the public service and had the opportunities of learning much about the management of public institutions. Mr. Reeves had served with ability and fidelity both in Congress and the Legislature and enjoyed the very highest reputation as a public officer and a public spirited citizen. The Commission was required to visit periodically all institutions and places where the insane were in custody and to report to the Legislature and suggest such changes as might in their judgment be necessary. During the first year of its existence the Commission visited all the institutions where the insane were in custody, including twenty poorhouses, which had received special permission to care for the insane. Its report, which was submitted to the Legislature at the beginning of the session of 1890, revealed a condition of things in these so-called county asylums even worse than the State Charities Aid Association had previously reported. It was unanimous in recommending the immediate abolition of the poorhouse system, the enlargement of the present
State hospitals so as to provide for the insane in the poorhouses, and the placing of all the State institutions on a curative basis by the wiping out of the statutory classification of the insane. The Legislature of that year, in conformity with the recommendations of the Commission, after a severe struggle, passed the so-called State Care Act, providing practically the third and last in the series of acts passed at the end of half a century – the first in 1843, the second in 1865, and the third in 1890. The following year the Commission requested an appropriation of approximately half a million of dollars, which was granted without opposition, to provide additional buildings for housing the insane then in the poorhouses.
The State Care Act provided that when sufficient accommodations had been provided, the Commission should so declare, and from that time all of the dependent insane should be a State charge and the counties relieved of all charges whatsoever. The act provided that the counties of New York, Monroe, and Kings should be exempted from the provision of the act on the ground that they had provided suitable institutions for the purpose, but that they might avail themselves of the privilege of coming into the State system. In 1891 Monroe, in 1895 Kings, and in 1896 New York came into the State hospital system. The poorhouse system ceased to exist October 1, 1893, when the State care system proper went into effect. From that date no insane person has been an inmate in any poorhouse in the State, and thus ended, after an agitation of more than fifty years, one of the greatest evils that has ever disgraced the State. All of the public insane in New York are now supported in institutions owned and absolutely controlled by the State with moneys appropriated by the Legislature. All are given that medical care and attention which their condition requires – the food, clothing and general care do not in the least depend on anything but their physical necessity.
In 1891 the Commission in Lunacy secured the application for the competitive system of civil service examinations for the medical service, and in 1895 it adopted a uniform rate of officers’ salaries and employes’ wages for all the hospitals in the State. It also established a training school for nurses in each of the State Hospitals, and the graduates of these schools obtain increased wages. An allowance is especially made for amusements and diversion, and from this fund a band of music is provided for concerts and dances. In fact, everything consistent with proper care and treatment is provided for by the state in the discretion of the Commission, which has the power to pass upon all items of expenditure. The element of charity is altogether eliminated in dealing with this class – the sole question is what amount of money will restore the greatest number of relatives and friends recovered or improved sufficiently to live at home. It is now a matter of the highest ultimate economy. A low diet, insufficient clothing, insufficient medical attendance and nursing would reduce the recovery and thus prolong the time of detention, and consequently increased expense to the State. A proper standard of care and treatment is consonant with humanity and economy.
On October 1, 1893, the Commission was given supervision over expenditures. By the use of this power and unification of the system of management, a great saving was not only effected, but the standard of care and treatment was greatly improved. The average expenditure per patient was in round numbers previous to 1893, $222; the Commission reduced this to $184 – a savings of hundreds of thousand of dollars. The power of revision of expenses was extended in 1895 to cover expenditures for buildings and extraordinary improvements.
The State hospitals are now operated as a unit – one charter covers all. A change in the statute which would affect one institution would affect all, and, therefore, the lawmaking power is not likely to make a change for the benefit of a locality which might injuriously affect the whole system. There are twelve State hospitals containing a total population of 23,000. One hundred and twenty-five physicians and nearly 4,500 employes are required. The fixed charges or yearly running expenses amount to about $4,000,000. There are approximately 4,500 commitments of insane each year – in some instances the same individual may be discharged and readmitted more than once. One thousand are discharged as recovered each year, while the actual annual increase in numbers over discharges and deaths averages about 600. Apparently there is an increase in the number of the insane greater than the increase in population. It is doubtful, however, if there is an actual increase in the ratio of insanity to the same population, for friends and relatives are less likely to care for patients at home than formerly, owing to the better management of institutions. This view is held by the Lunacy Commissioners of Great Britain. There is nothing to indicate from a careful study of the statistics that people are more subject to mental disease than formerly – in fact, the contrary would seem to be true, as the general health of the people is improving owing to the great advance in medical and sanitary science.
With the assumption by the State of the care of all the dependent insane, the following are some of the great and lasting advantages that were secured: Absolute security against abuse and neglect. A proper standard of care and medical treatment, including sufficient food and clothing, good nursing, amusements, and diversion. Providing for the appointment and promotion of officers and employes in accordance with civil service rules, thus minimizing the danger of partisan influences in the State hospital service. Economy in management and the adoption of the best methods resulting from unity of action. Giving all the insane proper care and treatment, and giving all a chance for recovery so long as life lasts. A higher recovery rate, which must inevitably result from the application of the methods outlined.”
Source: Reprinted from “The New York Times” Published: November 10, 1901, Copyright @ The New York Times.