THE STATE OF NEW HAMPSHIRE.

OFFICE OF THE STATE BOARD OF HEALTH.

CONCORD, March 8, 1893.

To the Honorable Senate and House of Representatives : In accordance with the instruction received from your honorable bodies, the State Board of Health submits herewith a partial report of the work authorized by the following concurrent resolution:

"Resolved, That the State Board of Health be directed to investigate the cause of the recent fire at the Strafford county almshouse and asylum, by which forty or more persons were burned to death; and, further, the said board shall investigate the management, construction, and condition of the said county buildings; the board shall also include in its investigation any other almshouse, or asylum for the insane, in this state that it deems necessary, and the board is empowered to send for persons and papers, and it shall report, at as early a day as practicable, all the particulars of its investigation, with such recommendations as it deems best for the public good."

The board finds it to be impossible to investigate in detail the construction, condition, and management of the asylums and almshouses in all of the counties, in season to make a report upon the same at this session of the legislature. The board purposes, unless otherwise instructed, to extend its investigations to all the institutions named in the concurrent resolution, and to report upon these at the next session of the legislature. We are of the opinion that the continuance of this investigation is necessary, in order to place before the proper authorities and the people the exact condition of these institutions. We are, however, emphatically of the opinion that it is the duty of the present legislature to take decided action in behalf of the pauper and indigent insane of the state.

In accordance with the terms of the resolution, the State Board of Health conducted a somewhat extended investigation into the cause of the fire at the Strafford County Asylum for the Insane, and into other matters connected with the management of that institution and the county almshouse. The entire investigation was conducted under the legal advice and presence of the attorney-general, together with other members of the board.

The coroner of the county was subpoenaed, with all the evidence presented to the coroner's jury, at the inquest held by the county. In addition, the board examined thirteen witnesses. For explicit information as to the basis of the conclusions and recommendations here with submitted, reference may be had to the testimony given at the coroner's inquest, and to 253 pages of type-written evidence taken by the board, all of which is on file in the office of the said board.

We find that on the night of February 9, 1893, the Strafford County Asylum for the Insane was destroyed by fire, and that by reason of said fire forty-one persons lost their lives.

We find, as also did the coroner's jury, that

"Said asylum was a two-story building, with two-story L with attic; first floor occupied by keeper and his family and seventeen inmates, second floor by nineteen inmates, attic by eight inmates. There were fifty-six cells or apartments in all,—twenty-one apartments or cells on first floor, twenty-three on second, and twelve in attic. The asylum was erected some twenty years ago, repaired and enlarged somewhat about ten years ago, constructed wholly of wooden materials, floorings, partitions, sheathing, and furnishings to all the cells of pine lumber, flooring and sheathing so dried and shrunken in portions of building as to enable persons to see each other between floors and cells, heated throughout by steam from boiler, by pipe hung from overhead. Its location was seventy feet west of the

almshouse and four miles from Dover and about six miles from Great Falls and Rochester. The out-door enclosure for the use of the inmates was surrounded by a wooden fence about ten or twelve feet high, windows to asylum barred with four or more bars; also some of the windows had heavy wire screening on the inside; building had four doors, one in main building, one in L, one leading into the out-door inclosure for women, and one leading into a like inclosure for men. Said building was supplied with two hundred feet of rubber hose, one hundred feet of which was kept coupled onto pipe leading to tank in the attic of almshouse; capacity of tank, twenty thousand or more gallons, that is always kept well filled by supply from pumping station. Another one hundred feet of hose hung on reel near stand-pipe; also supplied with four water-pails on first and four on second floor, which were always kept full."

At the time of the fire, and for several months previous, the management and control of the asylum was in the hands of the keeper, William P. Driscoll, with the exception that he had nothing to do with the food and clothing for the inmates, the same being supplied from the county almshouse under the direction of Chas. E. Demeritt, the superintendent. Mr. Driscoll was assisted at the asylum by his wife, who was matron of the institution. There were no other employés, the entire care of the forty-four inmates devolving upon Mr. and Mrs. Driscoll. Formerly Mr. Demeritt had entire charge of the almshouse and the asylum, but, owing to a personal difficulty which arose between himself and Mr. Driscoll, the county commissioners divided the authority, by giving Mr. Driscoll full control of the asylum, and thereby relieving Mr. Demeritt of that especial duty.

There was a night watchman, Wilbur Chesley, who received his orders solely from Mr. Demeritt, superintendent of the almshouse, and who was required to make six rounds each night, one of the stations, No. 4, being in the

asylum for the insane. In making his ten o'clock round on the night of February 9, he saw, upon entering the storm door at the main entrance of the asylum, through the glass of the inside door, a reflection from a fire in the cell of Mary LaFontaine. He entered the asylum as quickly as possible, and rushed to the apartment occupied by Mr. Driscoll and family at the further end of the corridor in the L, and informed him of the fire. Without waiting to dress, Keeper Driscoll rushed to the cell occupied by Mary LaFontaine and unlocked it, then turned and unlocked the cell of Jim Daly, near by, telling the watchman to "Get some water and open the doors; but while getting Daly out, Mrs. LaFontaine jumped upon Mr. Driscoll's back. Mr. Driscoll almost instantly disengaged himself from Mrs. LaFontaine, as he states himself, and the watchman also testified that Driscoll had freed himself from the woman before he had got the front door unlocked. The watchman, Chesley, left the asylum as quickly as possible, the spring lock effectually closing the door after him. Driscoll proceeded to unlock the other cells, and succeeded with those upon the first floor, barely escaping from the building in season to save himself and family. By this time, owing to the combustible nature of the building, it was so thoroughly on fire that further efforts proved unavailable. Two of the inmates whose rooms were unlocked by Mr. Driscoll escaped from the burning building, and one woman was rescued from the second story from outside. The remaining forty-one inmates were destroyed. Some points brought out in the evidence taken by the board are herewith submitted:

John S. Daniels, coroner of Strafford county, and formerly physician to the Strafford County Almshouse and Asylum, testified that he had remarked to the county commissioners and to the keeper that the building was a poor one, and that the county ought to have a better one; that it was impossible to keep it in a clean and healthy condi

tion; that the sheathing had shrunk so that one could look through the cracks; that some of the beds had no coverings on, because the patients tore them up; that a woman who was partially paralyzed had charge of the wards a good part of the time during his last term of service at the institution; that she was a pauper taken from the almshouse; that he made no recommendations in his report to the county as county physician regarding defects, but followed the course taken by other physicians.

Dwight E. Edgerly, chairman of the county commissioners, testified that he had held the office of county commissioner three years and eight months; the improvements in the asylum during that time were new floors and a few new cells in the attic; no appropriations for buildings during his term of service; no instructions had been received from the county delegation; not more than one half or two thirds of the delegation visited the institution; Demeritt had no control over the asylum after Driscoll was given authority; cooking for the asylum was done at the almshouse and furnished, but Driscoll had no authority to dictate what the food should be; he had thought of asking the county delegation to appropriate money for fire escapes; never tested fire hose and never saw it tested; no ladders at the asylum building; the unsafe character had been mentioned by the state board of health, and the county delegation had spoken of it; Driscoll could probably have done more effectual service with the hose than with the pails of water; the watchman received his orders from Demeritt; commissioners never looked at the watchman's dial; Demeritt had full control of the watchman; Driscoll could not order the diet of the patients; did not consider the building used for the insane fit for the purpose; it was about as bad a fire-trap as could be.

Winthrop S. Meserve, county commissioner, said he had never tested the hose; did not think the building suitable for the insane; did not think the county delegation com