from the woman; did not think the fire could have been extinguished with the hose if it had been used; an inmate might have made a great deal of noise through sickness or distress and he would not have known the cause; did not know how many pails of water there were in the asylum; had never seen any; there was a Yale spring lock on door; at first was told to look after the woman with broken hip in making his rounds, but after one or two nights no attention was paid to her; never gave attention to any other patients.

The above synopsis of the more salient points brought out by the principal witnesses, is presented for the purpose of giving a more general knowledge of the case than otherwise would have been obtained except by reference to the quite voluminous stenographic report of the hearings.

The board has carefully reviewed all the evidence presented in this case, and has arrived at the following

CONCLUSIONS:

First. That the fire originated in the room occupied by Mary LaFontaine, and was, probably, ignited with a match in her possession. It was shown that matches were furnished those inmates who smoked. She smoked occasionally, therefore it would not be difficult for her to obtain matches herself or from other inmates. That the attendant of the asylum, William P. Driscoll, in a manner inexcusably careless, furnished matches to the aforesaid inmates when called for.

Second. That the fire might have been extinguished immediately after its discovery, had the watchman, Mr. Chesley, and the keeper, Mr. Driscoll, promptly made the attempt, inasmuch as at the time of its discovery the fire was small, being, according to Mr. Driscoll's testimony, "no larger than a bushel basket," and there was a fire hose ready for instant use, within a few feet of the fire, which was not used at all.

Third. That Mr. Wilbur S. Chesley, upon his own testimony, is shown to be totally unfit for a watchman, by reason of his defective eyesight, and also in not knowing, after having made the rounds of that institution for several months, that there was a fire hose and fire-buckets in the asylum.

Fourth. That the superintendent, Mr. Charles E. Demeritt, while having many commendable qualities, was inefficient in his administration of the affairs of the institution in the following particulars: Neglect in not having given specific instructions to his employés (and especially the watchman) as to what should be done in case a fire was discovered; in not disciplining or reprimanding the watchman for failure to perform his required duties, as shown by the register dial of the watchman's clock; in not having a properly organized and drilled fire squad, consisting of his employés and such inmates as might be available.

Fifth. That the attendant, Wm. P. Driscoll, was guilty of faulty management in not having instructed the watchman regarding the means available for extinguishing fire at the asylum, even though the testimony shows that he had no authority over the watchman.

Sixth. That the county commissioners were negligent of their duties in the following particulars: In not giving explicit instructions as to the management of the institution, both the almshouse and the asylum; in not examining carefully and fully into all the details of the management of both of these departments, and remedying the defects that might have been readily ascertained by them; in not providing fire escapes, which they might have done, to a greater or less extent, without a special appropriation for that purpose; in not furnishing suitable means for promptly liberating the inmates from their cells, the testimony showing that several different keys were required to unlock the doors; in dividing the responsibility of the management of the institution, on account of personal differ

ences between Mr. Demeritt and Mr. Driscoll, instead of discharging one or both and employing one competent man to take their places.

Seventh. That prior boards of county commissioners were guilty of official negligence, in not recommending to the county delegation such improvements and changes as were necessary to the best interests of the institution, and for not taking action themselves as far as their authority extended under the law.

Eighth. That all previous county delegations have been guilty of allowing to exist, and of maintaining, after having been officially warned of its condition in 1883, a building for the use of the insane which was totally unfit for the purpose, and at which has existed, at all times, the terrible danger from fire, which finally destroyed it, with an appalling loss of life.

Ninth. In investigating the rumors of intoxication connected with the institution, the board found that Mr. Demeritt has, for a short period, been addicted to the use of chloral; and that, in consequence of the use of that drug, his efficiency was perhaps somewhat impaired, but this had no bearing upon the question of the fire; that, so far as Mr. Driscoll is concerned, it appears, from his own testimony and that of others, that several times within a year he has been given to the excessive use of intoxicating liquor, and on one occasion, at least, was gone from the institution two and a half or three days, leaving nobody, except his wife, in charge of the asylum during that time. There was no evidence showing that he ever drank at the institution. The evidence further shows that two of the employés of the institution had been seen in a condition of partial intoxication.

The system of caring for the county insane is the same in all counties, differing only in some minor details. It was not originated through carefully matured plans, after due consideration of the requirements of the insane, but it

was the outgrowth of a forced necessity, the guiding principle of which has been to house, clothe, and feed this unfortunate class at the smallest possible expense to the county. To this end, few provisions have been made for anything beyond the brute necessity of life. The principle that the insane should always be regarded as sick persons, who require expert medical treatment and special care with reference to surrounding influences, has not been taken into consideration in caring for our insane poor. Insanity is now recognized by the highest medical authorities as a disease, possessing an infinite variety of symptoms and manifestations, and requiring the most scientific, competent, considerate, and careful treatment and management. This more humane and logical method of treating the insane has been so frequently demonstrated to be the best and most successful, even among the so called chronic class, that the most skeptical have only to search the records to be convinced. It is through failure of legislative bodies to recognize the fundamental fact, that insane persons are sick persons, that no better treatment has heretofore been provided.

The system under which the county insane are now cared for is lamentably defective, inasmuch as the only authority legally qualified to make these institutions what they ought to be has little or no knowledge of the requirements necessary to the most modern and humane methods of providing for this class. The county delegation, upon which rests the power to appropriate money for these institutions, and to fully equip them in accordance with modern methods of managing the insane, too often-in fact, generally-fail to study and to understand the needs of our asylums.

Among the defects which may be mentioned under the present county system are,

First. Lack of suitable buildings. In several of the counties of the state this statement admits of no qualifica

tion, the buildings used being unfit in toto. In other counties this criticism may not be so forceful, so far as the buildings themselves are concerned; but when the matter of classification is taken into account, proper and ample facilities are not to be found at any of the county institutions.

Second. No classification of patients. This is a radical defect in every county of the state. The custom of grouping together in one ward all the different classes of the insane, from the simplest case of delusional insanity to the most violent case of acute or chronic mania, is in itself a sufficient condemnation of the method.

Third. Lack of skilled attendants. For the proper care of the insane it is necessary that attendants more or less skilled in the care of, and possessing a knowledge of the characteristics of, this class of patients is essential. Moreover, insane persons should at all times be under the watchful supervision of some attendant, a requirement not fulfilled at our county almshouses.

Fourth. Lack of expert medical and surgical treatment, which cannot be readily obtained at our county institutions.

Fifth. Lack of occupation and entertainment for the patients-features highly essential in the treatment of the

insane.

In this same category many other defective conditions pertaining to our county asylums might be mentioned.

RECOMMENDATIONS.

First. That the state assume entire support, control, and management of the insane, and that county asylums for the insane be abolished.

Second. That all buildings hereafter constructed, to be occupied as almshouses, asylums for the insane, jails, and orphans' homes, shall be built of brick, iron, or stone, with partitions of fire-proof or slow-burning material, the plans