Care of the Filthy Cases of Insane

by Stephen Smith, M.D., State Commissioner of Lunacy, New York City

Editor’s Note: This 1885 reprint  was copied with permission and derived from the blog researched and developed by Linda S. Stuhler at http://inmatesofwillard.com/

“In all of the institutions for the insane in the State of New York there is a considerable number who are very properly classed as ‘filthy.’ They are found in largest numbers in the asylums for the chronic insane, in county asylums, and in the poorhouses. But, wherever they are found, they are a source of perpetual annoyance to attendants, and of disgust to the more intelligent and refined inmates. One filthy patient on a hall, or ward, will often require more of the time and work of the attendants than the remaining fifty. I have seen patients in the asylums of this State who were thoroughly bathed, and had a complete change of under-clothing, and two or three times of their external clothing, eighteen times in a single day. And this occurred in spite of constant watchfulness to anticipate their wants. The filthy constitute, therefore, a separate and independent class of insane, so peculiar and repulsive in their habits, and requiring such special care, that they should have suitable provision made for their accommodation and treatment.

During the past year, I have made a special examination of this class in the institutions for insane in the State, with a view to determine the kind of care which these helpless insane receive and what additional accommodations they require. In every institution, I have personally examined the individual patients pointed out as filthy, as to the cleanliness of their persons and clothing, and have opened and examined all of their beds with reference to the cleanliness of the bed-clothing and their freedom from foul odors. I have also made night inspections in all of the State asylums, and have made the operations of the night service in each a subject of special observation.
It is unnecessary, for the purposes which I have in view, to divide the filthy insane into grades according to their intelligence or their mental or physical condition. It is true that many insane persons are filthy at intervals, and then recover for a time; while others remain filthy during life, and are called the ‘habitually filthy.’ In either case, this special feature of their insanity demands that kind of care which will insure cleanliness; and during the period of relapse there is no reason for not classifying and associating this class together – namely, the occasionally filthy with the habitually filthy – for the purposes of convenience in their care.
In the hospitals for the acute insane in the State of New York, the number of habitually filthy is small, and very variable. This is due to the fact that the chronic insane, as a rule, are early removed from these institutions to those devoted especially to that class. The filthy in the hospitals for the acute insane are usually found in the wards of the disturbed and violent, where there is always the greater number of attendants. In these wards, they occupy rooms or portions of the wards farthest removed from the other patients.

The care of these patients is all that can be desired. Each of these hospitals has a regular day and night service, so organized that the filthy are trained, if possible, to habits of personal care and cleanliness. They are not only promptly changed when found to be soiled; but, as far as practicable, their necessities are anticipated, and they are required to protect and care for themselves. At night, the attendants raise them at given fixed hours, and thus endeavor to form habits of cleanliness. The rule in those hospitals is that the night attendants must turn over to the day attendants all the filthy cases in a cleanly condition, and every infraction of the rule is at once reported. The result is that a soiled patient is rarely found in these hospitals, either at night or during the day; and when found, the investigation shows, with rare exception, that the patient has but just become soiled.

The result of this extreme care is most happy. Large numbers of patients who fall into habits of uncleanliness are restored to good and regular habits. Others, who would be made uncomfortable, and at night would be greatly disturbed, are rendered comparatively quiet, and sleep well. The wards are also free from the foul and repulsive odors so common in the dormitories of the filthy, where there is no organized system of care at night as well as day. There is also a great saving in the washing of clothes, and in their destruction by the effects of filth on the texture of the cloth.

In the State asylums for the chronic insane, the great mass of filthy cases necessarily congregate. Many of them enter these asylums thoroughly confirmed in habits of uncleanliness, and are, therefore, already beyond the curative influences which care and discipline are likely to exert. In my early experience as visitor to these institutions there was no organized night service for the filthy, as in the hospitals for the acute insane. As a consequence, I had opportunities of observing the habits of the filthy insane, when there was no special night service for their care, and contrast them with the same class in hospitals for the acute insane, where the night service was as perfect as that of the day.

On entering the dormitories of the halls where the filthy were confined, at the rising hour of the morning, the sight was most repulsive, and the odors intolerably sickening. The day attendants at once began their task of placing their halls in order, preparatory to taking breakfast. It was a matter of astonishment to me that men and women attendants could be found who, for any wages, would undertake to perform such a disagreeable task. Some of the patients were literally wallowing in their own excrements. They had besmeared their beds, their heads and faces, and even the floors and walls of their rooms. In some instances, the patients resisted being bathed by fixing their limbs and bodies in such rigid positions that it required three or four attendants properly to wash them, and put on their clothes. When the patient was finally prepared to be dressed or returned to bed, the bed had to be more or less completely changed, the floors scrubbed, and the walls washed, if soiled. This was the regular morning work in many wards, the year through, and had to be performed before breakfast.

The effect was unfavorable in every respect. The patients were made uncomfortable during the night, and were thereby greatly disturbed. Those who could be trained to better habits, by careful attention to their wants, were neglected, and allowed to lapse into habits of uncleanliness. The attendants were burdened in the morning hours with a most repulsive task, which could but disturb their digestion, and thus gradually impair health. The dormitories were foul with the disgusting odors which neither scrubbing, ventilation, nor disinfectants could wholly remove. The waste of bed-clothing and the night clothing of patients by washing was immense.
Within the past year or two, these two asylums have instituted each a night service for the care of the filthy; and now this class is turned over each morning to the day attendants, in the same cleanly condition in which they were received from the day attendants on the previous evening. A visit to the same wards now, whether during the night or in the early morning, gives the visitor an altogether different impression from that formerly made. As a rule, the patients are quiet and asleep at night. If one is found soiled, it is evident that the soiling has just occurred. There are no longer any of the offensive odors which characterized long-continued saturation with urine and excrements. Attendants are themselves free from the contact with filth, and perform their duties cheerfully and without disgust and annoyance. The universal testimony of attendants who have witnessed the change, and who have taken part in carrying out the reform, is that the habits of the more intelligent are greatly improved; and many become clean, and some even scrupulously particular about being soiled. Many of the more demented have gradually impressed upon them habits of rising at given periods, which the attendants quickly recognize and improve so promptly as to prevent soiling. Finally, cleanliness is found to be powerfully promotive of sound sleep of all grades of insane classed as filthy. Those who were noisy much of the night now fall into a heavy sleep as soon as they are raised, or, if soiled, are cleaned, and have a change of clothes.
In the large county asylums of the State, as those of New York, the care of the filthy is reduced to a very perfect system. The night service is organized with the greatest attention to details; and, as a result, no patient is allowed to soil himself, if watchfulness can prevent it. The hospital for men on Ward’s Island has large numbers of habitually filthy; and yet a visit to their dormitories shows a remarkable freedom from offensive odors, though these dormitories are poorly arranged for ventilation and cleanliness. The asylum for women, on Blackwell’s Island, has a pavilion set apart for the filthy, and in that respect is in advance of any other hospital or asylum in the State.

In this building, the habitually filthy are congregated; and the service is organized for their special care and treatment. The attendants are selected with special reference to their interest in their work; and here, for the first time, an attendant professed that she preferred to have charge of the filthy to any other class of the insane.
The asylums of other counties have, with rare exceptions, no night service for the filthy. As a consequence, this class is neglected at night; but, during the day, I have always found them clean, and their dormitories in good condition. In a very careful search through these institutions, I found but two soiled beds in the daytime; and these were left unchanged by the assistants of the matron, who did not regard them as sufficiently soiled to require a change. The rules enforcing cleanliness during the day are quite as stringent in the county as in the State asylums. Rubber sheets are used over the ticking. These are washed, and dried in the sun when practicable, whenever soiled; and I have never found them foul or filthy.

If the patient remove the rubber cloth, and soil the ticking or the straw, both are removed, the ticking washed, and the entire body of straw removed, unless the soiling is very slight, and can be thoroughly remedied by cleansing and the removal of a very little straw.

In the poorhouses, as a rule, no adequate measures are taken to protect the filthy from the consequences of their habits. They were usually found in the most deplorable condition. Neither the person, the body clothing, nor the beds receive any special attention.

It may be stated as a conclusion based on this investigation that the filthy classes of insane in this State in State asylums are under such special care as insures cleanliness of the person, clothing, and bedding. In the metropolitan county asylums, the care of this class is equally efficient. In other county asylums there is no night service designed to protect the filthy from the evil effects of their habits; but, in general, the day service is well organized, and both the patients and their dormitories are kept in good condition. In the poorhouses, as a rule, the filthy insane receive no special care, either day or night, and as a consequence have often been found in a most deplorable state of filthiness.

In many instances, the stock on the farm were more carefully secured against filth than the insane.

In private asylums, the night service is usually well organized, and the filthy are well cared for. The number of this class is, however, small in these institutions; and those who are habitually filthy generally have means adequate to meet any special expenses required for their care. Two suggestions occur to me as important, in the light of my investigation, with reference to the care of the filthy class of insane.

1. State asylums should have separate buildings constructed with special reference to the isolation and care of this class. In no asylum is it possible now to remove the filthy from that contact with the wards of the main building, or with other patients, that is desirable. Wherever they are grouped in a part of a hall, or in separate halls, they so contaminate the atmosphere, through the walls and floors, the beds and bedding, that the dormitories remain, in spite of cleaning, disinfection, and ventilation, so foul and offensive as to be quite uninhabitable by other patients. I have visited single sleeping-rooms of the filthy at mid-day, in summer, which, though scrupulously clean and fully exposed to the external air and strong sunlight, still had an extremely offensive atmosphere. The very presence of these inmates tends, therefore, permanently to damage wards, and render them unfit for future occupation, unless walls and floors are frequently scraped, and thus comparatively renewed.

Every State asylum has ample grounds and appropriate sites for the construction of detached buildings for this class. These buildings need not be elaborate or expensive, but certain conditions and conveniences should be supplied. They might be one story in height, with a few single rooms for the more disturbed and an associated dormitory for the quiet. The walls and floors should be impermeable, and susceptible of being thoroughly washed and disinfected daily. There could be a wide veranda constructed completely around the building, where patients could sit or lie in the summer, and, when enclosed, could be so warmed as to be comfortable in winter. The facilities for bathing and cleansing the patients should be immediately at hand, and of the most approved kind. The service should be so organized as to be continuous, day and night, in the raising and bathing of patients.

While every State asylum should have its separate building for the filthy classes, the necessity of such provision in the State asylums for the chronic insane is imperative. There is no want of provision for the insane in this State that is to-day so urgent, and that should appeal with greater force to the legislature for suitable appropriations.

2. County asylums should organize, each, a night service for the filthy, and maintain it with well qualified attendants. Already, this service has been instituted in some of the larger and better managed asylums of the counties, with great and immediate benefit to the inmates.
In regard to the poorhouses, it is sufficient to state that the filthy insane should never be sent to them, and when found in them should be removed to State asylums for the chronic insane.”

Source: Reprinted from “Care of the Filthy Cases of Insane,” Stephen Smith, M.D., State Commissioner of Lunacy, New York City. Proceedings of the National Conference of Charities and Correction, at the Twelfth Annual Session Held in Washington, D.C., June 4 – 10, 1885, Edited by Isabel C. Barrows, Official Reporter of the Conference, Boston: Press of George H. Ellis, 141 Franklin Street, 1885, Pages 148-153.