DISCUSSION. DISCUSSION. PRESIDENT MERRILL: This subject of county care for the chronic insane, as the members of this conference will remember, who were at St. Cloud last year, was very ably presented to the conference by Mr. Heg of Wisconsin, who was a member of the state board of control. As indicated by Governor Wakefield, he has personally visited Wisconsin, and looked through their plan, and has embodied their ideas in his paper. The question is now before the conference for discussion. PRESIDENT MERRILL: I see Dr. Tomlinson present, and we would be pleased to hear from him on the question. DR. TOMLINSON, St. Peter: Mr. Chairman: I do not know that I ought to take any part in this discussion, because the board by whom I am employed will recommend to the legislature a different system of care for the chronic insane, and as they are practically committed to that method, and I agree with them, I do not know that I ought to express an opinion one way or the other. At the meeting of the American Medico-Psychological Association in St. Louis, last spring, this question was gone over very thoroughly, and the only advocates of this system in the whole meeting were two men from Wisconsin, and they frankly confessed that they were not familiar with any other system of care. The experiment which was tried in Wisconsin was tried on the continent of Europe long ago. It was tried in New York and Massachusetts. It was tried, to a certain extent, in a modified way, in New Jersey. In every place in which it has been tried the result has always been the exploitation of the insane patient for the financial benefit of the county. Human nature is human nature the world over, and when you make it possible for any body of men representing the public to save money at the expense of somebody else who is defenseless, thy are almost sure to do it. And then, when you leave to laymen to determine what the medical care or treatment of a sick man shall be, there is always room for a wide difference of opinion, and you may be sure that nothing will be done that does not have to be done, and nothing will be done that costs money if such expenditure is for the medical treatment of the patient. I know nothing about the working of the Wisconsin system from the standpoint of personal observation, but I am willing to grant without question that it relieves overcrowding. There is no question about that. Whether it is applicable to the conditions existing in the State of Minnesota is another question. I believe the colony system, which has been adopted on the continent of Europe, and to some extent in this country, such as the state institution at Kalamazoo, Mich., offers the best means of meeting the conditions in this state; that is, a method by which the chronic insane can be cared for at the least expense and at the same time have proper medical supervision. I do not see any objection to the Wisconsin system as a system. The difficulty is in carrying it out. I do not want to be understood as opposing it as a system, but taking into consideration the conditions which exist in Minnesota, I do not think it is applicable to this state. The insane could be better provided for by increasing the amount of land around the present institutions and the establishment as they are needed of buildings for the classification of the chronic insane as the cases accumulate. And at the same time they can have what they have not under the Wisconsin systemproper medical supervision. The experience of those who have real practical knowledge on this subject such as is only obtained from every-day association with the insane, shows that they do need a great deal of medical treatment. Where the medical care of these people is to be determined by a lay superintendent, and he is the one authorized to decide whether or not such treatment is necessary, why, the wisdom of such provision is at least open to doubt. I can understand how the Wisconsin system appeals to people as a good method of relieving the overcrowded institutions, but I do claim that it is not the best system for Minnesota, nor is it the best or most economical for the care of the chronic insane under the conditions that exist in this 1 SEVENTH STATE CONFERENCE OF CHARITIES. state at this time. And further, so far as my personal experience is concerned, there has not been the same study in this state, by those interested, of the conditions as they exist at home as there has been of the conditions as they exist in other states, and there has been a tendency to go to work and from an improper. basis to adopt a system belonging somewhere else without having first a thorough knowledge of the conditions which exist at home. MR. RICH, Red Wing: Mr. President: I am unable to discuss this proposition from a scientific standpoint, but from observation and study of this Wisconsin system I am unable to agree with Dr. Tomlinson in his proposition. Now, the main point that I would draw from the doctor's remarks is the question of the medical treatment not being adequate in a county asylum. In our state, under the present system, we have from 1,000 to 1,200 inmates in each state hospital, with a very limited medical staff to look after so large a number. The result is the chronic insane cannot receive a very large amount of medical care, except as the necessity of that care may be brought to the attention of the superintendent through the attendant of the ward in which the patient is confined. Now, there is no question but what the medical skill is at hand in our state asylums to care for the chronic and other insane that could not be provided in a county asylum. The only medical care that can be provided in the county asylum is the employment of the best physician residing within a reasonable distance of such asylum to look after the medical requirements of the institution, which usually is physical instead of mental. Statistics show there are a larger percentage of chronic insane persons discharged from the county insane asylums in the State of Wisconsin than from the insane institutions of Minnesota; consequently, I do not believe that expert medical attention is so necessary for the benefiting of these unfortunate people as some other remedies. I am convinced, from careful observation, that it is much more beneficial to divide up this large body of chronic insane into small families of, say, 150, under the care of a superintendent who knows personally each patient under his charge, and all his peculiarities, together with the greater liberty that can be accorded them, that, of necessity, must be denied when crowded into one large asylum. The management of one of our large asylums, with from 1,000 to 1,200 patients and 200 or 300 attendants, requires a man of unusual business ability, and so largely occupies his time that, necessarily, the time which be can devote to the medical end of the institution is limited. One great question of humanity that appeals to me in the county asylum plan is this: In selecting the patients for one of these county asylums, first, they send all of the insane from that county; the balance are from counties located nearest, not having asylums of their own. near to their homes and friends, when, on certain days, their friends are alThis takes them back lowed to visit them, and the expense of doing so is a trifle compared to visiting our state hospitals, and the management and care of these poor unfortunates is always under the interested observation of their friends. We found in Wisconsin that this visiting feature was very general and beneficial, both to the patient and careful management of the institution. The economical part of this proposition, which, in my opinion, is secondary to the humane, cannot be lost sight of, but fortunately, in this case, it is in favor of the county asylum. The cost per capita of all the insane as compared between Wisconsin and Minnesota is practically the same, but the difference lies in this, that out of the $3.25 per week which the county asylums in Wisconsin get, the county gains enough in twelve or fifteen years to pay for its asylum. Hence the incentive for the counties to always stand ready to construct an asylum as soon as another is needed, making the system so elastic as to guard against any possible overcrowding of the asylums. In this manner no appropriations of state money is needed to build asylums, and the disgraceful fight in our state as to the location of any further state insane hospitals would be relegated to the past. The great majority of the chronic insane are able and willing to work, and it would be the greatest benefit to them that they should be employed to the fullest extent. This cannot be accomplished in our large hospitals, as It is not practicable to work on land adjacent to our institutions the labor to be had among 1,000 to 1,200 insane people, but by dividing them up into families of 150, scattered through the state, their labor can be so successfully utilized as to make the farms so profitable that, in addition to everything used in the hospital, $1,000 and $2,000 of surplus is sold by the older asylums in Wisconsin each year. My theory of the adoption of the Wisconsin system into this state, under our present conditions, is to only adopt the county asylum features, making of our present hospitals hospitals in fact, where everything known to science shall be done for new and acute cases, and, if possible, return a larger portion of them to society capable of caring for themselves. This would be the humane and economical plan to pursue. The "board of control" feature, as practiced in Wisconsin, I would omit in this state, as the danger of creating a salaried board would place the management of all our state institutions in the hands of a board created by political appointments, and, in my judgment, would not result in the selection of men with any view to their ability to filling the position. These positions would be continually changed with successive administrations, and changes in administration of all the institutions would follow for political reasons, much to the detriment of the institutions, in my opinion. This is the experience of every state allowing political appointments to creep into their penal, charitable and correctional institutions. Minnesota, to-day, stands in the very front rank in its care of the insane, and if adequate appropriations could be had to prepare sufficient accommodations without overcrowding, I should hesitate to advocate any change, but we have demonstrated in this state that that cannot be done, and the experience of other states has demonstrated the same thing, and, without any fear of successful contradiction, I assert that the most economical, most humane, most businesslike proposition is for this state to adopt the county asylum in conjunction with our present state hospitals, which will, for all time, provide without overcrowding for the increase of the insane population of this state. DR. TOMLINSON: I do not want to be understood as opposing the Wisconsin system at all. I appreciate all its benefits and advantages. The question simply is whether it is adapted to this state under existing conditions. WHY SHOULD THE PLACING OF A MAN IN A HOSPITAL FOR It is my object in this paper to try to make plain the fact that, although insanity is now looked upon by the public as disease theoretically, practially the insane are regarded as criminals both by the law and public opinion. This difference between the sentimental and real status of the insane I believe to be due to the nature of the legislation governing the commitment of these unfortunate people to the state institutions provided for their care. I shall take, therefore, as my thesis, the following statement of what I believe to be true: The statutes governing the commitment of the insane and their care are based upon a legal fiction, having its origin in superstition and prejudice, without foundation in fact or experience. Herbert Spencer, in his "Data of Ethics," beginning Chapter XI., says: "If insistence on them tends to unsettle established systems of belief, self-evident truths are, by most people, silently passed over; or else there is a tacit refusal to draw from them the most obvious inferences." I know of nothing within my experience to which this statement is more applicable than to the current beliefs with regard to insanity, and the attitude of the law and public opinion toward any discussion of these beliefs. When the law first began to take cognizance of insanity, its administration was only concerned with the poor, because the wealthy took care of their defective relatives at home. In consequence of the fact of the insane being a public charge, an individual was looked upon either as a criminal or a pauper, according to the nature of his conduct. If he was simply demented, quiet but unable to support himself, and demanding personal care, he was a pauper; but on the contrary, if his conduct was such as to interfere with his welfare, or the comfort and convenience of his neighbors, he was looked upon as a criminal. In the one case he was confined in jail, while in the other he was taken to the almshouse. In spite of the changes which have taken place both in our knowledge of insanity and the improvement in the care of these unfortunate people which the establishment of special institutions for their treatment has brought about, the conception of what constitutes insanity is practically unchanged; and even at this day, with its more general enlightenment, the public look upon the insane man with fear and dread and the law deals with him as a criminal. This fear and dread can be explained by the survival of the superstition that a man who is insane is possessed by the devil, or in some way under demoniacal influence. This feeling has not only prompted those who had no personal interest in the patient to shrink from having anything to do with him, but also makes his relatives want to hide the fact of his condition from everyone. This anxiety is so great, as a rule, that it results in the insane man's friends mistaking their feelings for his welfare; so that it becomes more important to hide the fact of his insanity than to provide the proper treatment of his condition. Out of the fiction involved in the idea of criminality has grown the method of dealing with the insane when it becomes necessary to place them under treatment, and we therefore have invoked, in this country and in England, the constitutional provision which guards against the violation of the liberty of the subject. We are constantly told of the great danger and harm of depriving the insane man of his liberty, by commitment to an institution for treatment, and yet this same man may have been confined to a room in his own house, or in a general hospital, for an indefinite period, without any such thought or fear with regard to his welfare; and if he is demented, and not so violent as to require restraint, he may be, and often has been, kept his whole life long secluded from the public without any thought about violation of the constitution and the rights of the individual. And besides, the insane man may be confined in an establishment called a sanitarium for years, without any complaint on the part of his relatives or friends, or any fear on the part of the general public for his rights; this fear and anxiety only arising when the fact of his insanity has to be publicly acknowledged. If the presentment I have made is a true one, and I do not believe that anyone familiar with the subject will deny its truth, it can be readily understood that, in order that the insane may be properly cared for, their condition recognized and treated early enough to make recovery probable, more rational methods must he devised for dealing with them, and an effort made toward practical recognition that insanity is a disease, or one of the manifestations of a general diseased condition. It would be just as consistent to employ a legal process for the commitment of a case of typhoid fever, consumption or small pox to a hospital for treatment as a person suffering from insanity. During the progress of the disease an individual suffering under any one of the conditions described must naturally be deprived of his liberty and kept under restraint. Not only that, but he is, in the average case, during a large portion of this time, mentally incapacitated, and often as much so as the man committed to the hospital for the insane. A man is not insane because of the conduct manifested by him which interferes with his welfare and relation to those around him, but his conduct is such because he is insane. Insanity is something apart from the conduct by which it is manifested, as is witnessed by the fact that there is no difference between the behavior and actions of the sane and the insane. The difference lies in the relation of the conduct to the environment of the individual, It is this perverted conception that is the basis of the wrong belief with regard to insanity that is recognized in law and public opinion. They do not admit the existence of mental alienation except it be manifested in criminal conduct. The individual may be insane, but so long as there is nothing in his behavior to attract attention or interfere with the welfare of his neighbors, his insanity is neither recognized nor considered. However, if steps are taken to provide for his care and treatment in an institution adapted to the purpose, then the law steps in, and determines the disposition of the individual, not on the ground of his insanity, but by the evidence of criminality or vagrancy furnished by his conduct. The statutes governing the commitment of the insane in this country are based on those in force in England at the beginning of the present century, and they vary in complexity from the comparatively simple procedure in Rhode Island to the complicated absurdity now in force in New York. Except in Rhode Island and in one or two of the Southern States, these statutes have been formulated by men absolutely without knowledge or experience of the nature of insanity or significance of its manifestations. The language and form of these statutes indicate that they are based on the belief that insanity is a condition of criminality, to be established by a trial, practically in accordance with criminal procedure, in which witnesses are to be examined to establish the fact of insanity by evidence of criminal conduct or vagrancy. The trial is given a quasi-medical aspect by the appearance of one or more physicians, who occupy an anomalous position, something between a prosecuting attorney and juror, the value of whose verdict is to be determined by the presiding judge. Furthermore, the language of these statutes is criminal. The suspected person is complained of by his family or neighbors, and a warrant is issued for his arrest on the charge of insanity (sic). He is taken into custody by an officer of the law, lodged in jail, or placed under surveillance. At his trial the evidence given is estimated as to the extent to which the behavior of the alleged insane person indicates criminality or vagrancy. I quote from section 17, chapter 5, of the Laws of 1893, as follows: "No person shall be deprived of his liberty in this state, by being committed to custody as insane, unless his insanity be established in manner and form as prescribed in this act, and his commitment to custody be recommended, either because (1) he has perpetrated acts dangerous to himself or to others, or to property; or (2) it is reasonably certain, by his threats or otherwise, that he has dangerous tendencies or uncontrollable propensities towards crime; or (3) he wanders about and is exposed to want of food or shelter, or to accidents; or (4) he is ill-treated by his relatives or friends; or |