.^:^^% IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I tiiilM 12.5 IIIM ilM |||Z2 1 2.0 1.8 1.25 1.4 1 6 zr—. i == 4 6" ► v: / I III-: l'i:.\ .\s) lA lA/.l l/nsl'l I II , /'////. Ilii:i.flll I. •I THE INS'VNrr' HE l-NniiD STATLS ANU \ N ADA. i-.v "xw'i-; V'i-iS •; TincK. v.\y, LL.D., ' IBii .oriWAl. or MJtSlAl. SCJKNCK." /I .;.\7./ i 1 ^ >// ^r if r-,a^«^< /■ no ' ■ //"SI/ r u , />////. I />/■ /./>(//.!. THE INS IN THE UNITED STATES AND CANADA. m J BY D. HACK TUKE, M.D., LL.D., FKLLOW OF THE KOYAL COLLEGK OF rHYSlCIAXS, LOXDOX. CO-EBITOll OF " TUE JOUKNAL OF MENTAL SCIEXCK." \7. LONDON : H. K. LEWIS, 136, GOWER STREET, W.C. 1885. [All Itiglits Jlcscrvcd.] ( 1 If T? 'i. J 204563 T-ot^c .1>.H tHINTED BY H, WOLFF, 04, IIIUII BTHliLT. $0 THE MANY FRIENDS On toe Am ku I can Contini. nt WHO AIDED HIM IN CAIIKV1X(» Ul'T THE PUKPOSli OF 'IIS VI IT TO THU United States and C a n a i a , THIS small contkibution TO A GREAT OBJECT IS GRATEKULLy DEDICATED BY THE AUTUOll. 1 J CONTENTS. CHAPTER I. -m EARLY LUNACY PRACTICE IN AMERICA. BENJAMIN RUSH, M.D. ;ctch of Rush's Life— His Medical Practice — His Death. Medical Works — Observations on Old Age — On the Duties of a Thysician — Eush in Eolation to the Insane — Moral Treatment — Stratagem — Erect Posturo — Terror and Pain — The Gyrator— Prolonged Fasting — Importance of Labour — Enlightened Views — Dipsomaniacs — Medical Treatment- Baths, etc. — Blood-lotting — Defence of it by Eush — Opposite Practice at York Eetreat — lllooding in Mania — Directions for Bleeding — Kirk- bride andEarle on Bleeding— Pargeter—Crowther — Haslam — Monro — Esquirol — Sir Alexander Morison — Burrows — Prichard — Bell — Todd — Brigham — White — Ray — Curwen — Eush on Moral Insanity — Case of Servin — Genius and Moral Depravity — Doubtful Irresponsibility — Rush, the American Fothergill — Reflections on the Death of Rush. CHAPTER II. PROVISION FOR THE INSANE IN THE UNITED STATES, 1752 TO 1870. Pennsylvania Leads the Way— Williamsburg, Virginia— Frankford Asylum — Misa Dix — Loathsome Crazy-hou.: I'tout a nil e, plus inso- ail]l Witness is duly pub- that such a nd the shot which iiud e hurriedly J' remaiiieJ and inhu- the paper introduced g Lunatic if passed, .tisfactorilv em is pev- ; will alone ns on the Its in the •een abuii- TUKE. THE INSANE IN THE UNITED STATES AND CANADA. CHAPTER I. Eatily Lunacy Practice in America. Benjamin Rush, M.D. IIaving for many years held this celebrated American tohysician in the highest esteem, and taken occasion more than once to express my appreciation of his admirable writings in relation to mental affections and also the in- ^uence of the mind upon tlie body, I made a point of inquiring- when in Philadelphia last September whether a portrait of him existed, I ascertained at the General Hospital that they possessed an oil painting, by Sully, which pourtrayed the Philadelphia physician. I was cour- teously shoAvn it, and although it did not exactly corres- pond with the mental image I had formed of the man, it tad every appearance of being a life-like portrait. I could not ascertain that it had been copied, but the physician ,who sliowed me the painting promised to obtain a copy for me if it existed. He, however, failed. Dr. Ricliardson has told the readers of his '^ Asclepiad " for January last how, on meeting Dr. Weir Mitchell in Lon- don last year, he conversed with him about Dr. Benjamin Rush, and how Dr. Mitchell promised to supply him with a portrait. He succeeded, and an excellent impres- sion executed by the Autotype Company, London, appeared in the January number of the above-mentioned journal, B 2 Shitch of Rush's Life. which quarter by quarter bears witness to the extra-l ordinary mental energy and ability of the editor. To] my request for permission to malce use of it, Dr.l Richardson generously responded, and I am sure mj| readers will thank him for granting me this favour. I proceed to give a brief enumeration of the principal] events of Dr. Rush's useful and active life.^ He was born near Philadelphia, December 24, 1745.] He was educated at the academy of an uncle, the Rev.j Samuel Finley, in Nottingham, IMaryland, where hel resided eight years. He graduated as B.A. at Princetown,] New Jersey, in 1700 ; he tlien studied medicine under two] American physicians, and subsequently, from 176G to 17G8,] at Edinburgh, where he obtained his degree of M.D.j After spending a week in London he returned to Phila- delphia, and was elected Professor of Chemistry in the] College there. He was 40 years of age before he filled the! chair of medicine in the University of Pennsylvania, into] which the College merged. His name is found among the! signatories to the Declaration of Independence in 1776,] when he was a member of Congress. 7n the following year he was appointed physician to the Military Department of the hospital. That he was not so absorbed in his profes- sion as to be unable to devote some time to public matter? is shown by his acting as a member of the Convention for adopting the Constitution of the United States, and hj fulfilling the duties of treasurer to the United States Mint during the last fourteen years of his life. Pie was presi- dent of the Society for the Abolition of Slavery, and lie was connected with a number of charitable, religious, and literary societies. He wrote strongly against the use of tobacco on account of its deleterious effect uj)on the health and morals. He was among the first to advocate temperance. He was the patron of education, and devised the establishment of free schools. * The particulars which follow are mostly given on the authority of the] " American Hiogi'aphical Dicticjiiaiy," by Allen, 1S")7. His Medical Practice. ) the extra-) editor. To] J of it, Dr. -ra sure myj tavour. he principal! er 24, 1745. [!le, the Rev. 1, where he| Princetown, ne under twoj 1766 to 17G^.' •ee of M.D, ed to Phila- istrj in tlie I he "filled tlit ylvania, into d among the ice in 177G, i\ ' Jin- lowing year >- partment of I his jDrofesj- blic matter ivention for -tes, and by States Mint was presi- eiy, and he igious, and the use of upon the advocate md devised : ithoritv of the i It is stated that on conimuncing practice in Phihidelphia )r. Rush found the system of Boerhaave paramount in Imedicine, and that he publicly taught that of Cullen fen opposition to it. After a while, however, he threw /uUen entirely aside, and refusing to be shackled by any )ne master, became an original observer and teacher. He simplified the interminable list of diseases which the Edinburgh Professor had invented, and with which he had jewildored the medical student. To Rush, names were of little importance; the reality — the essential nature — of the jilisease was what he strove to grasp and teach. While the system of Cullen demanded theoretical nosologies and )urdened the memory, that of Rush appealed to clinical facts and common sense. Dr. Thacker, who knew both systems from practical experience, feelingly observes that it is no exaggeration to say that in three years, the one, the American, prepared the student for the art of healing, nore thoroughly than the other, the Scotch, did in live. lush so mastered the indications of the pulse that instead )f being " fallacissima res," it was to his subtle and 3ractised touch, the "nosometerof the system.'^ That Rush bled and purged and used calomel (which le designated the Samson of the Materia Medica) to a legree which we have come to regard as deadly, cannot be lenied. Whether, like the Hebrew hero, mercury has, as ^ts enemies allege, slain its thousands, will always be a natter of debate ; but looking at the marvellous success uid popularity of the Philadelphian physician, one finds it lard to believe that this, or any of the heroic remedies which he employed, had the same effect upon the human system that they have at the present day. Rush always maintained that a treatment which even then might be ^granted to be unsafe in Europe was required in America. Lt any rate, when the yellow fever raged in Philadelphia lin 1793, and every other remedy (including bark, wine land cold baths), failed, his favourite remedies, which in (this disease he tried with hesitation and fear, succeeded. His Death. Medical Works. 1 1 Even when the pulse was scarcely perceptible, pury;ation! by calomel restored the patient. When the tide thus turned he wrote in his note-book, "Thank God, out of one hundred j^atieiits whom I have visited or prescribed for this day, I have lost ncnie ! " He himself nearly fell n victim to the incessant labour which his success entailed upon him, but after free bleeding and purging he re- covered. The mouth of criticism is stopped. For close upon half a century Dr. Rush gave the results of his experience and meditations to the world. His style, however, bears no marks of haste, notwithstanding his constant occupation. Ho held that our ideas, whether original or acquired, produce a mental plethora, whieli depletion by the pen oi* tongue can alone relieve. The pen, therefore, was to him in his literary work what the lancet was in his practice. His admirable devotion to his profession is expressed with his usual felicity in a letter, ' ■ thus — "Medicine is my wife; science is my mistress; books my companions; my study is my grave. There I;,.': lie buried, 'the world forgetting, by the world forgot."' Medicine was not, however, ti' bo his only wife. Fur- getting or disregarding his philosophic resolutions, ut , the age of 32 he married Julia, daughter of Judge Stock- ton, and had a large family. He hold that no female should marry before 10, and no male before 21, and that : the longer they put off "perpetrating matrimony" the '^ better, so long as the former do not delay beyond 21 andj the latter beyond 30. Rush died of pleurisy after a few days' illness on the ^ 19th of April, 1813, aged 07. He had been bled, but the scythe of death vanquished the lancet of the physician. The principal works of Dr. Rush are contained in seven volumes. Of these the first four consist of Medical Inquiries and Observations. The first edition was ^\xh- lislied from 1789-98, and appeared in five volumes. The second edition was published in four volumes in 1804. The fifth volume, entitled " Medical Inquiries and )l>sor Observationn on Old Aye. 5 e, pur^'atioii le tide thus God, out of r prescribed nearlv fell a ;ess entailed ffinnf lie re- iiserv.itions upon the Diseases of the ^[iud," appeared rst in 1812, and passed throu<^h several editions, a iifth einij published in 1835. A sixth volume contains sixteen introductory lectures to oarses on Mcnlicine, with two lectures on the Pleasures f the Senses and of the Mind, and bears the date of 811. The seventh volume consists of Assays, " Literary, oral, and Philosophical.'^ The first edition was published n 1798. In 1800, Dr. llnsh edited '' SydtMiham's Works" as well s those of other medical authors, and to these works he <)ntributed valuable notes, dieve. Tho | [ should have stated that his Latin Thesis, written k what the ibubon he graduated in 1708, was entitled '' Dissertatio hysica de Ooctione Ciboruni in Ventriculo."' In his "Medical Inquiries and ()bsc;rvations," the liapter entitled " An Account of the State of the Body nd Mind in Old Age, with Observations on its Diseases nd Remedies," possesses lasting- value, and exhibits that cute observation of the small as well as the large circum- stances of life in health and disease which so strikingly haracterizes this physician. In it he observes that he has ot met Avith a single instance of an octogenarian whose oscendants were not also long-lived. He only knew ne instance of an unmarried person living beyond the ge of eighty. He records the case of one Avonian in ngland in the hundredth year of her age who had borne child at sixty, and frequently suckled two of her chil- ren at the same time. Most of her life was spent ov(,'r a ashing-tub. He pointed out the influence of emigration n the decline of life in imparting fresh vigour and npparently prolonging life for many years. lie had only |not with one person beyond eighty who had ever been ft'ected by a disease of the stomach, and he was struck rvith the circumstance that a gentleman Avho died in the e the results . His style, tanding his as, wht'ther hora, whicli otion to his ■ in a letter^ '| y mistress; e. There li Id forgot.'" wife. For- olutions, at idge Stock- no female 1, and tliat nony" the ond 21 and ess on the ed, but the ysician. 3d in seven Medical was pub- |mes. The 1804. liries and LOOth year of his age had never vomited in his life. 6 On the Ditfie.s off VliijxictiDi, lilt fl( crli nvit^ lire u;;-l 11 id In It' ii(j ect, ory 01 iilili(tiiH'li lio liiul hocii iit soa sovonil yoar^! wlion yuimp, This niiiirs inotlirr livcil to 01, and liis prandlatlior to 101. It is stid(Ml tliiit lie had a j^Tcat disliko to spirits, and (hut his constant drinks wore water, beer, and cider. Jn re- t'eronce to the nioinory of old persons, after niakin|:i^ iW coiiinioii observation in re<:fard to recent events and thosi ' occurring' loiijj^ a^o, IJiish records the case of a GeniKiii woman who had learned to sjx'ak English after she was' forty and had foi'ijfotten it entirely after the age of eighty, 1 while she spoke her native tongue as fluently as ever, ^' He conmients on the increase of appetite in old people, and the recurrence of the desire for articles enjoyoil in childhood, especially sweet substances, as cake, Ikv. Again, the circiunstiince did not escape his observatidi, that the aged resemble children in a tendency to detiii' immediately to others all they see and hear. Many othci striking observations are made in this essay, but I havt adduced enough for my present purpose, which is to indi- cate to the reader unacquainted with the -writings of Dr Hush the acuteness of observation and the many-sidednes; which characterize them. The address on the Duties o; a Physician, delivered in 1789, is replete with practica advice. In it he says : " Permit me to recommend toyor,;||^^''^'' ^ the study of the anatomy of the mind, commonly callct metaphysics. The reciprocal influence of the body aiu mind upon each other can only be ascertained by ai accurate knowledge of the faculties of the mind and c: their various modes of combination and action. It is tlit duty of physicians to assert their prerogative, and t rescue the mental science from the usurpations of sclioo]| men and divines. It can only be perfected by the aid ancj discoveries of medicine." He particularly recommends ii-l the way of medicinal treatment the indigenous mecli-.| cines of America. " Who knows," he says, " but it majl be reserved for America to furnish the world, from heij productions, with cures for some of those diseases whict now elude the jtower of medicine? Who knows bii:! [State lis an inadt tate ells fPliila Ipast \ in tli( he v: ued, vogut distil: hatt s a d noral essio nenti Wl he e differ^ Rush in Relation io the Inmnc. wlion yoiinp. at her to UH. rits, and tli;it der. In in- ■ iiuilxinpf ill. its and tlids. of a Gorniiin it'tor she Av;b ijife of (.'i'^litv. ntly as ovir, 11 old people, icles eiijoyci'; as cake, Ac 3 observatidi ncy to dot II i Many otlic y, but I liiiv. icli is to indi- itings of Dr iny-sidedncs> he Duties c: dth practica nmend toyoi monly callc he body ani tained by lu mind and c: )n. It is tk itive, and t ns of school' y the aid an commends ii enous medi- " but it ma; 1(], from hi seases "whici. knows bii that, at the foot of the Allc^linny INFountain, there blooms flower that is an infallible euro for the epilepsy? (U'haps on the ]\lonon;^Mliela or the I'otomac, there may '^grow a root that shall supply by its tonic powers the ,invif,'orutin^ effects of tlio savay;o or military hfo in the jtcure of consumptions." $i I shall now endeavour to determine the position which ||ou;,'ht to bo accorded to liush in relation to the insane .'land their treatment. In his writin^rs, so far as they bear directly ni)on insanity, le not only dwells upon tlie theoretical aspect of the sub- ect, but supports his views by a frequent reference to very interesting cases. '"^ Ut the condition of the insane, or their claims on the •State, he makes little mention. L am not aware that there ii'is anything' which shows that he was struck with the inadefpiate provision made for them or their miserable Estate at that time in <^aols and almshouses, and even in the ^#cells of the basement of the Pennsylvania Hospital in "Irhiladelphia. These receptacles survive as relics of the jpast to indicate the wretched provision made for maniacs ■in those days. Coercion in some form of personal restraint |was rejj^arded by everyone as absolutely necessary ; and |tlie views entertained by Hush, and the practice he pur- |sued, differed little in this respect from those then in I'voyue.* What I should claim for him would be that he ',|distinctly recognised the corporeal nature of insanity ; Sthat to his students and in his writings he taught that it kis a disease that must be submitted to medical as ■well as moral treatment ; and, further, that he gave to the pro- -i'ession and to the world an able exposition of the forms of ^mental disorder. I When, in 1812, he wrote his classic work on the Mind the experiment of the treatment of the insane by very (litferent methods from those in fashion had been in opera- > * As will bo auL'U, lu; objeclcd to cliaiiLs iiiid sti'iiJt's. I 8 Moral Treatment. tion at the York Eetreat for some years ; liacl, in fact,! ceased to be an experiment. A few passages from his work will indicate his opinionsj on the moral treatment of the insane. In mania he re- commended the following modes of coercion when milderS means had been employed without success : — First, the strait-waistcoat or a chair called the " tranqnillizer," which is another name for the well-known restraint! chair ; secondly, privation of the patient's customarjl food ; thirdly, pouring cold water into the coat-sleeves so| that it might descend down the trunk and body general lj;| fourthly, the shower-bath continued for 15 or 20 minutes,! which one would wish to believe a misprint for seconds.^ Dr. Eush adds that " if all these modes of punishment fail^ of their intended effects, it will be proper to resort to the | fear of death." He gives an edifying example of the| success of this dernier ressort. A certain Sarah T. dis-l turbed the whole hospital by her loud vociferations.! Light punishments and threats had failed to put a stop to j them. The gentleman in charge of the case, Mr. Higgins, at last went to her cell and conducted her, loudly oiS vociferating, to a large bathing-tub, in which he placed! her. "Now," said he, "prepare for death. I will give! you time enough to say your prayers, after which I intend ^ to drown you by plunging your head under this water."- The patient immediately uttered a prayer, such, we are | told, as became a dying person ; then Mr. Higgins, satis- fied with this sign of penitence, extorted from her a pro-; mise of amendment. We are assured that from that' time no vociferations or maledictions proceeded from the | cell of Sarah T. I think I ought to add that within the memory' of living man a similar experiment was tried in j St. Liike's Hospital upon a male patient with the plunge- bath, and with a like satisfactory result ! Dr. Rush's commentary must be added : " By the proper application of these mild and terrifying modes of punishment, chains will seldom and the whip never be required to govern mad )eop jases )hys 7hip We these Stratagem. Erect Posture. d )eople. I except only from the use of the latter those jases in which a sudden and unprovoked assault on their )hysicians or keepers may render a stroke or two of the kvhip^ or of the hand a necessary measure of self-defence." We are sure that Dr. Ensli would have exercised any of these coercive measures with the greatest reluctance, and, Iwhen he deemed them necessary, with the greatest lossible gentleness ; but the observations which he ^nakes throw a curious light upon the ideas and prac- tices of his day, from which even so enlightened and idmirable a man as Dr. Kush could not entirely free limselt". In passing, it may be remarked that Rush felt mch confidence in relieving patients of their delusions 3y stratagem, for he says that " cures of patients who suppose themselves to be glass may easily be performed )y pulling a chair upon which they are about to sit from mder them, and afterwards showing them a large collec- tion of pieces of glass as the fragments of their bodies." There is a curious passage in Rush's work in which he speaks of treating refractory patients by forcing them to retain the erect position of the hotly. To many it will sound barbarous, but it was certainly not intended to be 30. He says, " There is a method of taming refractory lorses in England by first impounding them, and then ceeping them from lying down or sleeping, by thrusting sharp pointed nails into their bodies for two or three days md nights. The same advantages, I have no doubt, might De derived from keeping madmen in a standing posture, land awake, for four-and-twenty hours, but by different and Imore lenient means. Besides producing several of the letfects of the tranquillizing chair, it would tend to reduce lexcitement by the expenditure of excitability from the con- Istant exertion of the muscles that support the body. The [debility thus induced in these muscles would attract morbid [excitement from the brain and thereby relieve the disease. It is clear from this that the whip was considered at tfint time an lessential part of the furniture of an asylum-ward. 10 Terror and Pain. The Gyrator. 1 I That benefit would be derived from preventing sleep, I infer from its salutary effects in preventing delirium, andi from delirium being always increased by it in fevers of | great morbid excitement." Dr. Eush recognised the influence of ter7'or. *'It| should be employed in the cure of madness." He was I struck with its effect upon a lady who was deranged, andj for whom he bad advised riding. One day the horse rani away with her, but was stopped in its course by a gate.! When the attendants came up to her they found her restored to reason, and she had no return of her malady. .He relates the case of a madman who was suddenly cured by the breaking of the rope to which he was attached for the purpose of bathing him in a well. The poor fellow was nearly drowned, but was cured of his insanity. The com-l ment Eush makes upon this recovery is, that the new action induced in the brain by the powerful stimulant of Sj terror brought about the cure. P When Dr. Eush refers to instances in which flagella- tion appeared to produce a salutary effect upon the insane, he is careful to say that " in mentioning the cures per- formed by the whip, let it not be supposed that I ami recommending it in this state of madness ; " and he adds, p " Fear, pain, and a sense of shame maybe excited in manyl other ways that shall not leave upon the memory of theil patient the distressing recollection that he owes bis re- if covery to such a degrading remedy." Here lie was dis-|| tinctly in advance of CuUen. We cannot be surprised that Dr. Eush was fascinated, i like so many others, with the famous rotatory machine ofl Dr. Cox. The former contrived one himself for use at the p hospital, and called it the Gyrator. He also suggested a| cheap contrivance, by which a patient was placed upon ai board, moved at its centre ui)on a pivot, with his head towards one of its extremities. A rotduory motion was] then to be given to the machine. Among the remedies for madness, Dr. Eush enumerates! Prolomjed Fasting. Importance of Labour. 11 <( enumerates | great pain/' and records the fact of a transient gleam of reason having been induced in several idiots in Italy by means of torture inflicted by priests. It is hai'dly neces- spry to say that the humane physician of the Pennsyl- vania Hospital would not have followed the examples of the Italian ecclesiastics. "NVhat he says is that " should this remedy be resorted to it should be induced by means that are not of a degrading nature, and which are cal- culated at the same time to excite violent passion or emotion of the mind." It is surprising to find Rush disposed to treat some cases of insanity by prolonged abstinence. He suggested tasting for two or three days, and he bases this treatment upon the fact that in India wild elephants, when taken, are always tamed by dei^riving them of food until they dis- cover signs of great emaciation. But let us turn to his more enlightened views. Dr. Eush fully recognised the importance of labour. He mentions the case of an insane gentleman whom he attended, but failed to cure by his prescriptions. After his return, however, to his family in Maryland, at the time of hay-making, he was induced to take a rake into his hands and assist. He occupied himself for some time in the hay- field and recovered. Dr. Rush attributes this result to profuse perspiration. I think that it is due to the doctor to quote the following passage. '' I have often wished," he writes, " and lately advised that the mad people in our hospital should be provided with the tools of a number of mechanical arts. Some of them should be laborious and employ the body chiefly ; others ingenious and of a nature to exercise and divert the mind more than the body. None of them should be carried on by instru- ments with which it would be easy to hurt themselves or others. . . . The advantages of thus producing a current of new action, both corporeal and mental, which should continue for weeks and months, and perhaps years, could not fail of being accompanied with great advantages.^' ^ III 12 'Enlightened Views. Dipsomaniacs. Dr. Rush observes that the inadequate means employedl for ameliorating the condition of the insane leads us toj lament the slow progress of humanity in their case mcrej than in any other of the afflicted children of men. He| expresses his satisfaction that the period of cruelty and in- sensibility to their sufferings is passing away. He refers i to the " humane revolution " that had recently taken place in the receptacles for the insane in Great Britain J and he states that a similar change had occurred in tbe Pennsylvania Hospital. " The clanging of chains and the! noise of the whip are no longer heard in their cells. Theyj now taste of the blessings of air and light and motion inj pleasant and shaded walks in summer, and in spacious] entries warmed by stoves in winter." He admits that much remains to be done for their comfort and relief, and bids those whom he addresses to recollect the greatness of J the object, for it is not to cure a common disease, but "to restore the disjointed ov debilitated faculties of the mind I to their natural order and offices, and to revive in the! patient the knowledge of himself, his family, and his God." It should be stated that, even in his day. Dr. Rush I pleaded for the establishment of curative institutions fori dipsomaniacs. He says, " To the account of physicall remedies for drunkenness I shall add one more, and thatj is the establishment of a hospital in every city and town in the United States for'the exclusive reception of hard drinkers. They are as much objects of public humanity and charity as mad people. . . . Let it not be said tliati confining such persons in a hospital would be an infringe- ment upon personal liberty, incompatible with the freedomi of our governments. . . . To prevent injustice or oppres- sion, no person should be sent to the contemplated hospital! or sober-house without being examined and committed by a Court, consisting of a physician and two or three magis-j trates, or commissioners appointed for that purpose'' (p. 2GG). In these institutions he would not allow the nsc Medical Treatment. Batlasy etc. 13 f tobacco or ardent spirits. What the substitutes for hese should be we are not told. I think that he would ot have forbidden beer or claret. Let us now turn to his medical treatment. Dr. Rush ecommended the application of cold water to the body, n cases of mania. He observes that the whole body hould be immersed in it for several hours to prevent the eaction of the system. The same end, he adds, would be ttained by pumping water on a patient for an hour or wo, but this he thinks undesirable, as it might be re- arded in the light of a punishment, inasmuch as it was niployed in cases of drunkenness. He recommended the cold shower-bath in succession to he warm bath, which was to be heated above the natural emperature of the body. He kept a " torpid patient " in he latter for an hour o)' two, and then led him, " smoking ith vapour," to the shower-bath^ which, he observes, ave the most powerful shock to the system. He adds, It extorted cries and groans from persons that had been umb for years." Eush records one case in which this lode of treatment relieved, and another in which it estored the patient. It is a sad commentary upon the liserable receptacles then in use in the Pennsylvania luspital, that the latter patient died some time after is recovery, from the damp cell in which he was on fined. No reference to Dr. Rush would be complete without welling at some length upon his strong opinions and qually strong practice in regard to bleeding the insane in lany forms of their disorder. It is a remarkable fact that the treatment he pursued and tliat adopted contempora- eously at the York Retreat were in this most important articular diametrically opjiosed to one another. While {ush used the lancet freely, it was almost, if not wholly, aid aside at the Retreat, nourishing food and stimulants eing administered in its place. A London medical journal xpressed, not only its astonishment at this daring innova- 14 Blood-letting. I ■ ■( tion on a time-lionoured practice, but its hearty approval iu consequence of the satisfactory results which so manifestly followed its adoption. But was not Rush equally successful? It is diflScult, as I have said when speakinj^ of his general practice, to believe, considering his popularity, that he was unsuccess- ful. Would not his own acute mind and quick observa- tion have soon led him to the conclusion that bleeding and low diet tended to induce dementia or death, if they really led to these results in America ? That there succeeded a reaction against his treatment, in his own land, it will be our purpose shortly to prove, and there are those who hold that (as has been said in regard to old-fashioned medical treatment in general) many a weeping Martha might have addressed the Doctor when he lost his patient with— " Sir, if thou hadst not been here, my brother had not died ; " but we must not too hastily conclude that while the treatment adopted at the York Retreat was right, as no one now disputes. Rush's treatment was wrong at that time, in the country in which he practised. Those who main- tain that there has been a change in the type of disease may have truth on their side, and may be correct in their j opinion that insanity was no exception in those days to the general rule which, as they believe, holds good, namely, that disease at that period presented a sthenic form, and con- sequently required depletion. The most serious objections to this theory, when applied to England, are that deple- tion was thought to be necessary at Bethlem and St. Luke's, at the same time (a fact tliat was doubtless well known to Dr. Rush when residing in London in 1/ '8), and that its non-necessity, nay, its absolute harmfulness, was demon- strated by the success of the opposite course of treatment pursued at York. The question thus raised is, it must be admitted, a diificult one to answer ; fortunately it is one of historical interest, not practical importance, at the present moment, for all are agreed, whether in Europe or America, that mental disorders are associated with low nutrition, Defence of it by Rush. 16 i quick observa- ;hat bleeding and I ith, if they really I here succeeded a n land, it will be! '6 those who hold I ishioned medical irtha might have patient with — brother had not elude that while lose who main- type of disease correct in their lose days to the )od, namely, that form, and con- ious objections are that deple- and St. Luke's, well known to S), and that its 1, was demon- se of treatment d is, it must be itelyitisoneof at the present >pe or America, low nutrition, Ind do not call for venesection, however useful local deple- |ion may occasionally be. Fully to appreciate Eush's treatment of the insane by [)hlebotomy, it should be remembered that, after rejecting [he prevalent notion that madness is situated in the mind Itself, or in the abdominal viscera or the nerves, he held that the primary seat of insanity is in the blood-vessels of brain, and that it depends upon the same kind of lorbid and irregular action that accompanies other arterial liseases. " There is," he adds, " nothing specific in these ictions. They are a part of the unity of disease, particu- larly of fever, of which madness is a chronic form, affecting that part of the brain which is the seat of the mind." He lupports his views by many reasons, among which are — the frequency of the pulse in mania ; the influence of digitalis [n reducing its frequency, and at the same time mental jxcitement; the alternation of insanity with several dis- eases evidently (to him) seated in the blood-vessels, as jonsumption, rheumatism, &c. ; the blending of the Bymptoms of insanity and fever ; the occurrence of a brm of mania attended with feeble pulse, muttering lelirium, &c., recognised at that time as typhomania; the character of the blood in maniacs ; the appearance of the brain on post-mortem examination ; and lastly, the iflPects of treatment, which, according to Rush, were iden- tical with those successfully pursued in fever. He did not restrict the seat of madness, however, to the cerebral blood- r'essels, but admitted that it extended to the brain itself mdthe nerves. Rush fully recognised Avhat he called the jhrenitic predisposition ; it consisted, he held, in a preter- Inatural irritability of that part of the brain which is the Iseat of the mind and of the nerves. In consequence of Ithis, a deranged action was more promptly communicated Ito the blood-vessels of the brain. The presence of this predisposition accounts for some persons being delirious in fever; its absence explains why others have disease of the brain or fever without becoming mentally deranged. i((T^ IG Opposite Practice at York Retreat. I may here mention a circumstance of interest as bearing directly upon the present subject. In the spring of 181 1| one year before the publication of Rush's work on the Mindl my father addressed a letter to the governors of the Ner| York Hospital in reply to an inquiry regarding tlitl treatment pursued at the York Retreat. In this letter k] writes:—" General bleeding and other evacuants have beeJ found injurious at the Retreat, and are therefore not useJ except where their necessity is indicated by the state of tlitfl bodily habit; cupping, however, is not unfrequentlri resorted to." In the " Description of the Retreat," tLt| preparation of which was suggested by the composition am the above letter, the author writes much to the same eftectl In both he dwells upon the success attending the feedincl of maniacal patients " freely with meat, or cheese anl bread, and good porter."* In the "Review of the Earlj! History of the Retreat," the same writer observes, " Froii the history of patients brought under care at an earlJ period, it was evident that the reducing system had beeif extensively used; low diet as well as active depletonj means had generally been resorted to. To the abandouJ ment of this system must, we believe, be attributed, ill no inconsiderable degree, the mental recovery of mami patients, as well as the preservation of life and the inj crease of its comfort " (p. 34). Let us see, now, how consistently Dr. Rush carried out| his theories in regard to the seat of insanity in the cerebrail vessels, in his treatment of those labouring under thtj disease. Among the remedies for hypochondriasis or| tristimania, he observes in the work just referred to, that! should the disease continue after its causes have been re-l moved, "recourse should be had to bloodletting if tbei pulse be tense or full, or depressed without either f ulnessi » " Description of the Retreat," by S, Tuke, 1813, p. 118. The author, inj preparing the work for a new edition, wrote, "'J'his plan of treatmeml (depletion) appears to be founded on the supposition that irritation or vio-l lence proceeds universally from a plethoric habit, wlicrcas I think experience! clearly contradicts this opinion." Bleeding in Mania. 17 |r tension. I have prescribed this remedy with success, Ind thereby in several instances suddenly prepared the ?ay for its being cured in a few days by other medicines.'* If this he gives a remarkable illustration. He also pre- 3ribes in some, if not most cases, blisters, issues, saliva- Son, emetics, purges, and a reduced diet. Then, " after jducing the action of the blood vessels to a par of lebility with the nervous system, or to borrow an allusion rem a mechanical art, after ^flii^bing those two systems," allows stimulating aliment, drinks, and medicines, Le observes that warm tea and coffee made weak are [enerally grateful to the stomacli, and that Burke often ?]ieved the low spirits fi-om which he suffered by sipping a ;a-cup full of hot water. He extols opium as " that noble ledicine which has been happily called the medicine of le mind," and holds that it has many advantages over rdent spirits as a cordial. He approves of wine in the )ndition just described as resulting from reduction by [epletion, and says he had once known the disease cured the liberal use of Madeira. Under the head of Ameno- ania, " which is a higher grade of hypochondriasis, and characterised by exaltation instead of despondency," Dr. tush advises nearly the same remedies as in tristimania, id "particularly bleeding, purging, emetics, and low iet, in an excited state of the blood vessels, and after they re reduced, stimulating diet, drinks and medicines, and a lange of company, pursuits, and climate.'* As might be expected, Rush prescribes blood-letting as le first remedy in mania, which he observes is indicated all the facts in favour of mania " being an arterial isease of great morbid excitement or inflammation in the rain," and " by the importance and delicate structure of lis organ which forbid its bearing violent morbid action )r a length of time without undergoing permanent ob- [iruction or disorganization." He also held that vene- jction was necessary in consequence of there being *' no itlet from the brain to receive the usual results of c 18 Directiontf for Bleedinrf. i!l I I disease or in flam m a ti on, particularly the discharge on serum from the blood-vessels/' He appealed to the acci| dental cures of insanity followin:^ the loss of large quuiv| tities of blood, and it must be granted that this hasi occasionally occurred in the case of patients who have cui-^| their throats. He likewise pointed to the morbid condi- tion of the blood in mania, and says he never saw a siufrle. instance in which it presented a natural appearance. IJni the (inal truth of his darling remedy was " the extraor- ij dinary success which has attended its artificial use in tlif a United Stales, and particularly in the Pennsylvania^ Hospital." It is interesting, now-a-days, to recall his special direc-^ tions for bleeding in mania. It must be copious. Fromf 20 to 40 ounces of blooi are to be taken at once, unless| syncope occurs before it is drawn. He asserts tliat"tlie| effects of this early and copious bleeding are wonder- ful " in calming mad people. It often obviates thef necessity of using any other remedy, and sometimes curesl in a few hours. Dr. Rush even adds that bleeding must] be continued, not only when there are the obvious in-a dica tions referred to, but " in the absence of them all,! provided great wakefulness, redness in the eyes, a ferocious countenance, and noisy and refractory be- haviour continue, all of which indicate," he adds, "a] highly morbid state of the brain." It is noteworthy that our author insisted that the quantity of blood drawn in mania should be greater than in any other organic] disease. He selects from his successful cases of profuse bleeding a man of 68 from whom he abstracted between December 20th, 1806, and February 14th, 1807, nearly 200 ounces of blood ; and another man who lost in 47 bleed- insrs about 470 ounces. In a third case of recent madness with cool skin and natural pulse, but with insomnia and eyes suffused with blood, Rush bled him copiously, after which the pulse became frequent and tense. He repeated the bleeding, and gave him several purges, with the result I Kirkhride and Earle on Bleeding. 10 lat the patient recovered in a few days. Well may he }.y that the attention of the pupils of the hospital was ttractcd to this case in a more than ordinary degree, iven in " iJerangenient in the jMemory," indicated by its [eakiics3 or loss, he recommends " depleting remedies, if ^etliora attend, and the pulse be tense or oppressed." After 16 reduction of the system by bleeding, purges, and low fet, the remedies proscribed were blisters, issues in the rms, errhines, the cold bath, and exercise. I now proceed to note the practice of Rush's contem- 3raries and successors in respect to depletion in insanity, llthough I shall refer especially to alienists in America, shall cite some leading authorities in Europe. In this iquiry I am under great obligations to Dr. Pliny Earle, [ho some years ago carefully collected the opinions of kany mental physicians in reference to bleeding. I have leely availed myself of his valuable production, " Ex- lination of the Practice of Blood-letting in Mental Dis- rders," written in 1854. In it the author says, " Few puths in pathology are better established than that active khenic inflammation is of very rare occurrence in those pms of disease ordinarily included under the general ^rm of insanity." He also observes " "What might then ive been the success of a practical adherence to the thera- }utics of Dr. Eush cannot now be determined except by iference. The intelligent, judicious, and successful iperintendent, Dr. Kirkbride, in the early part of his ireer, took occasion to caution physicians against pur- ling a course of treatment proper for the inflammation the brain, and there is good authority for the sup- )sition that in cases of mania, unaccompanied by )ilepsy, paralysis, or apoplexy, or by some adventitious 1" accidental disease, he has never during his management that institution* practised venesection " (p. 98). Take the treatment recommended by an English phy- ■i' * The reniisylvaiiia Hospital for the Insane, Philadelphia* 20 Vanjrtcr. Cnmihcr. HaHhim. i''. Hician of some ropnto in his day who wrote in 1792, Dr I'll rgoU' !•.■'<■ He observes that as the coiiclition present iijj acute mania nnmifestly depends on an undue and iiJ creased excitement, the object should bo '* to derive bloo^j ' from the brain." He prescribes "abstinence to a veHjg considerable de^a'ce," and says that " maniacs canabstabj from food with wonderful perseverance." " Bleed iiicj copious and repeated, in the jugular vein, wonderfnll-| miti;^-ates," we are assured, " morbid heat, proves hi<,'liH anti-spasmodic, lessens the tone of the Jihr reverse tli' madness i; ain.' in incipient iuperintendciit- isanity led young practitioners into the fatal error of •eating by bold depletion irritation for inflammation, than hich, as a general rule, nothing is more prejudicial to ihe radical cure of the patient.'^ I will next take the testimony of Dr. Ray, v^ho, in the Jliird Annual Report of the Maine Hospital for the Insane 1(1843), observes :— " I trust that I may be allowed without offence to call ;he attention of my professional brethren, who are so lartial to the depletory treatment advocated by Rush and certain English writers, to the important fact that in no ospital for the insane in New England — and the same iniay be the case in many other institutions in our country '§ — is this treatment now used. I cannot but think that if •this fact were generally knoAvn, it would lead to a thorough frevision of the ground of their treatment, or, at least, would render them more cautious how they practise those lenornious abstractions of blood which so often lay the ff oundation of hopeless fatuity or a tedious convalescence." Lastly, I would quote Dr. Curwen, for many years the Superintendent of the State Lunatic Hospital at Harris- jburg, and now occupying the same position at Warren, mho, in his Report of 1852, observes : — " I feel I am discharging a part of my duty towards the ivinsane in calling attention to an error which is very ex- ttensively prevalent, and consists in the almost invariable resort to blood-letting in all cases of insanity." This is a very remarkable statement, and would, per- haps, rather tend to show that the change in the treat- ment of the insane by blood-letting, which marked the jiractiee of some physicians, was the result of a change jiof opinion rather th^'n of the type of disease from -sthenic to asthenic, for here we have the majority of those engaged in that branch of medicine following, in 1852, the practice of Dr. Rush in as full a belief in its officacy as was entertained by Dr. Rush in 1812. And it may be observed that neither Dr. Ray nor others who ipp 26 Rush on Moral Insanity. protested against the sanguinary treatment pursued bji their fellow-practitioners, contended that such change iEi the form of disease had taken place. They appear to havel thought that depletion was, and always had been bad, notf only when they wrote, but when Rush practised it. I will now refer to the position taken by Eush in re-i gard to Moral Insanity. "I once knew a man," says he, "who discovered! no one mark of reason, who possessed the moral sense or| faculty in so high a degree that he spent his whole life inl acts of benevolence. He was not only inoffensive (whichl is not always the case with idiots) but he was kind audi affectionate to everybody. He had no ideas of time but! what were suggested to him by the retiirns of the statedi periods for public worship, in which he appeared to take! great delight. He spent several hours of every day iiil devotion, in which he was so careful to be private that he! was once found in the most improbable place in the worldj for that purpose, viz., in an oven." This case is from an essay written by Dr. Rush exactly! a century ago, entitled, " An Inquiry into the Influencel of Physical Causes upon the Moral Faculty;" and I| confess as I read it and a chapter of his work on the Mind in which he speaks of " moral derangement and of innate preternatural moral depravity, the result of original defective organization," I am driven to ask myself whether we do not even now require to be taught the truths which its author enforces with so much power and originality. Is it that in the study of the minute shades of difference between the various forms of insanity and the multitu- dinous questions which have presented themselves fori solution since his day, we are unable to recognise the broad character and bold outline so lucidly sketched by I the hand of this great master? Have we become unable to see the forest fur the trees? What should we think of j the physician who, when shown a case of congenital alopecia, should, after examining it with minute ac- cura |ther( Sure case then how( are us n( [teac It jwhi of mc lesioi Case of Servin. 27 [curacy, discover one or two stray hairs on the scalp and [thereupon declare that it was no case of alopecia at all ? I Surely this would be to miss the essential feature of the case in noting a mere trifling exception. Let us discover, then, if we can, whatever intellectual flaw there may he — Ihowever slight — in every instance in which the emotions [are primarily and essentially the seat of disorder, but let jus not, in doing so, lose the lesson which the case really Iteaches. It has often seemed to me strangely inconsistent that, ^ while we demur, on psychological grounds, to the separation If of mental functions which is imp)lied in the doctrine of the I lesion of the emotions without disorder of the intellect, we H accept as nothing at all extraordinary the converse con- dition of healthy affections with morbid derangement of I some intellectual function. Wliat stickler for the unity and solidaritv of the mind hesitates to believe that our memory may fail, and yet our love remain the same ; that our power of attention may become extremely weak, while " ■ there is no increased tendency to depravity 9 I have known V a man lose his knowledge of several languages in a railway . accident, but he kept the Ten Commandments just as well [alter as before this intellectual loss. This will not bedis- I puted. Then why should it bo thought metaphysically hete- j rodox to believe that an injury to the head can alter the moral character without a perceptible weakening of the memory, the attention, or any other intellectual faculty ? Some years ago I was struck with the r(Mnarkable case of Servin, described in Sully's " M.-moirs of Henry IV. jof France," as possibly one of moral insanity or moral imbecility, and was not aware that Itusli had made use jof this extraordinary character to illustrate his theme. The chief question which arises in this class of cases is not — Was there any intellectual aberration, but rather — Are we justified in regarding such moral monsters as anything more than horribly vicious and responsible for their acts ? Rush reLrarded Servin as a case of " universal moral 28 Genius and Moral Depravity. derangement." Sully saya : "Just before my departure for Calais, old Servin came and presented his son to me, and begged I would use my endeavours to make him a man of some worth and honesty ; but he confessed it was | what he dared not hope, not through any want of under- standing or capacity in the young man, but from his I natural inclination to all kinds of vice. The old man was in the right ; for what he told me having excited my curiosity to gain a thorough knowledge of young Servin,! found him to be at once both a wonder and a monster ; for I I can give no other idea of that assemblage of the most excellent and most pernicious qualities. Let the reader! represent to himself a man of a genius so lively, and an ■nuerstanding so extensive, as rendered him acquainted rr-I'"' almost everything that could be known ; of so vast and -erdy a comprehension, that he immediately made| L^mseij' -ster of whatever he attempted, and of so pro- di '/ ju.' H . "uo.'y that he never forgot what he had once] learned. Ti'.- j^ossessed all parts of philosophy and the mathematics, particularly fortification and drawing; even in theology he was so well skilled that he was an excellent preacher whenever he had a mind to exert that talent, and an able disputant for and against the reformed religion indifferently. He not only understood Greek, Hebrew, and all the languages whicli we call learned, but also all the different jargons or modern dialects ; he accented and pronounced them so naturally, and so perfectly imitated the gestures and manners both of the several nations of Europe and the particular provinces of France, that he might have been taken for a native of all or any of these countries ; and this quality he applied to counterfeit all sorts of persons, wherein he succeeded wonderfully ; he was moreover the best comedian and greatest droll that perhaps ever appeared ; he had a genius for poetry, and had written many verses ; he played upon almost all in- struments, was a perfect master of music, and sang most agreeably and justly; he likewise could say mass, for he Do uhtfu I Ii'i'ei^}wus lb ilitij . 29 was of a disposition to do as well as to know all things ; his body was perfectly well suited to his mind, he was lio-ht, nimble, dexterous, and fit for all exercises ; he could ride well, and in dancing-, wrestling, and leaping, he was admired ; there are no games of recreation that he did not [know ; and ho was skilled in almost all mechanic arts. " But now for the reverse of the medal. Here it appeared [that he was treacherous, cruel, cowardly, deceitful ; a liar, a cheat, a drunkard, and glutton ; a sharper in i)lay, im- mersed in every species of vice, a blasphemer, an atheist; jin a word, in him might be found all the vices contrary to nature, honour, religion, and society ; the truth of which I he himself evinced with his latest breath, for he died in the flower of his age, in a low house, perfectly corrupted by his debaucheries, and expired with a glass in his hand, cursing and denying God." * It may well, I say, be a question in this instance whether controllable vice, or uncontrollable impulses, would the more properly characterize the case of this young man. I think we may reasonably conclude that there was some I constitutional peculiarity, while I should hesitate to pro- I nounce him wholly irresponsible. We ma}', however, agree with Rush, that " such persons are, in a pre-eminent degree, objects of compassion, and that it is the business of medicine to aid both religion and law in preventing and curing their moral alienation of mind." {0}). cit., p. 358.) Rush could hardly be expected to write with com- plete perspicuity in all he says, when he treats on this subject. He seems to contradict his own principleg to some extent when he discusses moral responsibility. His use of the words "vice" and "wickedness" is consequently loose and undefined. The wonder, however, is, not that he allowed himself to be betrayed into ijiconsistencies of expression, but that he saw so far in advance of the age in which he lived, and addressed himself so forcibly to it. * "The Memoirs of tho Duke of Sully, Prime Minister to Henry the Great," Vol. iii., p. 35. Ir'i 30 Rush, the American Fothergill. Eush has been styled the Ainerican Syclenliam. 11 should rather call him the American Fothergill. Ue resembles this physician (whom he personally knew and! admired) in the independence of his medical practice ; in acutencss of observation ; in an enthusiastic love of the art of healing ; in his incessant labour; in popularity as | the leading physician of the day in a great city ; but above all, in uniting with the functions of a physician the phil- anthropy which manifested itself in innumerable practical I suggestions for the benefit of his kind, and in the daily exemplification of Terence's immortal axiom. Like Fother- gill he did not practise to live, but he lived to practise. Like Fothergill, also, he might have said in relation | to diseases w^iat the Roman said in relation to battles: *' In the midst of them I have always found time to con- template the stars, the tracts of heaven, and the realms above." Such men serve to raise the character of the] profession above all mercenary considerations ; they recog- nise that their calling is divine ; and they afresh illustrate the truth of Cicero^s proposition, ^'Homines ad deos mdl& re propius acc^dunt (juavi salutem hominihvs dando." I must now draw this somewhat desultory notice of a remarkable physician and excellent man to a close. I am conscious that the citations from his writings fail to do him justice. I had almost said they do him injustice, because it requires a study of the whole of his writings to convey a faithful picture of his opinions. It is true that, if we take isolated passages from his work on Insanity, lie appears to disadvantage ; but a perusal of the whole, while it shows that he was not free from some of the strange notions then prevalent in regard to the treatment of the insane, leaves the conviction upon the mind of the reader that he was an original observer, a humanely in- tentioncd, and in many instances a successful, physician of the insane. It cannot, I think, be denied that those who contemporaneously with him were endeavouring in Paris and in York to ameliorate the condition of the in- Reflections on the Death of Rush. 31 lane, saw further than ho did as to what could and ought \o be done ; and that it would be easy to illustrate this by a Beries of parallel passages from the works which describe ^hc moral and medical treatment pursued at the Bicetre ind the York Retreat. Still we cannot withhold our admi- ration from the lancet-loving physician of Philadelphia, dio, amidst his incessant engagements and varied practice, fetudied mental disorders profoundly, advanced in this track far beyond his teacher, Cullen, and found time to compose monograph on derangement of the mind, which, had he written nothing else, would have given him an enduring nime in the republic of medical letters. The reflections on the death of Prichard made by a ^indred soul, Dr. Symonds of Bristol, are so applicable to that of Rush, that I offer no tipology for citing them IS an appropriate conclusion to this brief sketch : — "Though he bad not ceased from his labours, nay, the sickle was in his hand when it droj)pedj few could so well lave said, though he would have been the last to say it, I have not lived in vain.' If one could venture in imajxi- lation to follow the mnsingsof that dei)arting spirit, one light conceive the satisfaction with which he looked 3ack upon his well-spent life. . . . Youth had found him issiduous in acquiring truth and knowledge; manhood ind advancing age had witnessed untiring exertions in a jrofession which, whatever it may produce to the prac- titioner, is, if grounded on adequate knowledge, an em- 3loyment pre-eminently useful to his fellow-creatures, aid the intervals in those avocations, instead of haviiig )een set apart, as they might innocently have been, for recreation and amusement, had been filled up with labour which, had he done nothing else, would have enabled him [to bequeath honour to his family, as the inheritors of his [renown, and lasting benefits to mankind of the highest [order, for I know not what gifts can surpass those of truth [and wisdom. . . . And one fancies that, with such re- [membrances, he might well say, Nunc dimittis. . . . But 82 ReJlecUons on the Death of Rush. I doubt not that the deeds of his life, which to us look hirge and brilliant, before his failing sight shrank small and dim, and that his soul, which no earthly vision could] content, much less the contemplation of his own doings,, turned towards that Parent Source from which pH his light had been drawn, and longed to be absorbed into its divine and immortal essence. Though, however, he would have depreciated rather than magnified himself, we who| look at him from without, and estimate him by the stan- dards that enable men not only to recognise moral excel- 1 lence, but to mete out the degrees of their approval, cannot refrain from declaring that no spirit could pass more blameless and unstained from its mortal trial, none more fitted for the communion of the great and good, none more ready to appear ' Before the Juclj^e who henceforth bade bim rest, And drink bis iill of pure immortal streams.' " * * Meeting of the Bath and Bristol Branch of the Provincial Medical and] Surgical Association, March, ISid. I to us look irank small v'ision could I 3\vn doings,! lich pU his bed into its' 31', lie would elf, we will I •y the staii- tioral excel- )val, cannot pass more , none more good, none al Medical and CHAPTEE II. Provision for the Insane in the United States FKOM 1752 TO 187G. ]t may not be uninteresting to the readers of this book ^to have a slight historical sketch of what may be called the past asylum movement in the States. I am not aware that this has been given before in any journal or work [)ublished in Gi'eat Britain. The peculiar difficulties of a new country, peopled by different races, and the constantly jdisturbing intluence of immigration, ought to be borne in mind in this narrative. These difficulties are too trequently overlooked. Jn a letter I received from Miss )ix ill 1874, she wrote — "We have an amazing burden ill all our charitable institutions of every class of disabled foreigners of all ages and in all stages of feeble or quite )roken-dowii conditions of health." As in England, so, no doubt, in America, frightful {abuses have existed — more than that, much remains to )c done.* The insane have been subjected to the same )arbai'ous neglect and treatment as with us. Puritanism, fn the first instance, was only too likely to treat some forms of madness as instances of witchcraft, and their subjects would be punished or put to death accordingly. )ther cases would be simply referred to the cruel action [of Satan upon the mind, and proper medical treatment Iwould be the last thing thought of. A good illustration )f the belief in such diabolical influence in mental depres- jsion occurs in Cotton Mather's " Life of William Thomp- son." " Satan," he says, "■ who had been often in an [extraordinary manner irritated by the evangelic labours * That is, at the closo of the period to which this chapter refers, namely |18Vi'i — the date al wliich this Kivotch was writton. U 34 Vennsi/lvanla Lcadu the Watj. 1 1 of this lioly man, obfniiuMl tlic liliorly to silt liim ; iuu! honc'o, lifter this worthy inaii had serviMl tho Lord Josus Christ in the? chnrch ol'our^'t'w Kn;,dish Jhaintn-o, ho fell into that, lidlneum dtaboll — n bUudc melancholy, which fuif divers }ears almost wholly disabled him fur tho exercisf of his ministry." .... " >.'ew Enj^-land, ii conntn where splenetic maladies are prevailing ""d pornicions— perhaps, above any otlier — hath atic . numberless! instances of even pions people, who have contracted thosi' mclanchohj indinposUioNH, which have nidiin^ed them fruml all service or comfort. Yea, not a few persons have been hunied thereby to hiy violent hands upon themselves lit the last. These are amon^- tho unsearchable jud^'inentd of God." AVhen they were really re<^'arded as madmen, the care and treatment of the insane were probably neitluT better nor worse than in tho mother countries from which j the early settlers came. Humanity and Science, however, attacked and at last broke throuLjh tho stron<4'holds of superstition, i<^-norance, and prejudice; hI benevolent! men (and women, too) exerted themselv mitigate tlic unhappy condition of those who weroconiined as lunatics, and to provide for them suitable accommodation and kinder treatment. It appears that it Avas from tho Province of renn- sylvania that the iirst humane impulse proceeded. It was fitting that tho State founded by the humane and en- lightened Penn, should take tho lead in this work ofj mercy. From Philadelphia there went a petition to the House of Kepresentatives, in which it is stated that, with the increase of the population, the number of tho insane lias greatly increased ; " that some of them going at large are a terror to their neighbours, who are daily apprehen- sive of the violence they may commit ; and others are continually wasting their substance, to the great injury of themselves and families — ill-disposed persons wickedly taking advantage of their unhappy condition, and draw- ing them into unreasonable bargains — that few of them are WUliatnsbimjy Virtjinia. 35 so son^iblo of tlioir condition us to subiuit voiiintiirily to the troatinent tlieir rcspoctivo cfiaos roquiro, unci tluM'eforo contiimu in the samo dcploniblo statu diiriiij,' their livoa." Tho Jlonse in rcquostod to aid iii fouiidini^^ a small pro- Ivincial hospital lor these and other persons labouring [under disease; for it stjcnis that in the first instanco it was not desi<,nied oxclnsively for the insane. This, tho 'petitioners athrni, will bo "a ^-ood work acceptable to God and to all tho y'ood people they represent." This was in 17ol. The consecinenco was that the LoL^islature passed the necessary Act ; a sum of money was voted, subject to an ('(pial amount beinj^ raised by private means, and the now hospital was opened at Philadelphia in tho |foll()win;4 year. Although anticipating" the course of events, it should be added that in 1811 the insane patients were transferreil to the new "Pennsylvania, Hospital for the Insane," near Philadeli)hia, of which Dr. Kirkbride was appointed Supiu-intendent. it is pointed out by Dr. liay* (to whom I am indebled [for these and other partiouhirs) that this Pennsylvania jllospital has an additiomil !aim on our gratitude, inas- much as it was hero that Dr. Jiush obtained the materials jfor his work on "■ Diseases of tho Mind," published in 11812. ^ Twenty-one years later (177;J) Virginia estati^olied at iWillianisburg- an asylum, or, as the Americans very pro- perly call such institutions, a " hospital,'^ which provided for the insane only. "Many years elapsed," Dr. Hay states, "before this worthy example was followed; nor was the great want supplied by associations like that hvhich founded the Pennsylvania Hosi>ital, nor by indi- jviduals, as in the private asylums of England. The latter class of enterprises was almost unknown in this country until the beginning of the present century; for they [required a knowledge of insanity not easily obtained by our * Address on tho occasini) of liiyinp: the foundation stone of the Danville llJospiiiil for tilt! Insiino (IV-iin.), in I Mil). 36 VrankJ'ord Aaylum. physicians, an outlay of capital which few of thcni pos- sessed, auJ a rate of prices greatly beyond the n)eans of our people. In process of time they made their appear- ance, few and far between, but their benefits were confined to the affluent classes."' In 1817 the Friends established an asylum at Franlrinted in the Journals of both Houses as worthy of perpetuation in the governmental history of New Hampshire. (Shortly after," he was appointed physician-superintendent of the McLean Asylum, Boston, Mass.) The New Hampshire Asylum * " American Journal of Insanity." Ra)j. Brigham. Jarvis. 41 was opened in 1842, Dr. Chandler being appointed Superintendent. In 1845, Bell visited Europe, and foand, as he said he had expected to find, that much progress had been made in the construction of asyhinis in Great Britain. Of this he availed himself, and prepared plans for the erection of tbe Butler Hospital for the Insane, at Providence, Rhode Island ; of which institution Dr. Ray Avas appointed the first superintendent. He had previously superintended the Maine Asylum, opened in 1840. The New York fctate Lunatic Asylum, Utica, was opened in 1843. The well-luiown Dr. Brigham was superintendent from its opening until his death in 1849. Dr. Gray now (1870) fills that office. In 1 844 Miss Dix induced the Legis- lature of New Jersey to take up the question of provision for the insane in that State, and to appoint a committee to select a suitable site for a building. Dr. Buttolph was appointed medical superintendent. On reference to the admirable Report on the insane in Massachusetts, drawn up by Dr. Jarvis, and pre- sented in 1855, we learn that there was at that time 1 lunatic in every 427, and 1 idiot in every 1034 of the population, or 1 of either class in 302. There were 2G32 lunatics, 1087 idiots; of the former, 1284 were at their homes or in town or city poorhouses ; 1141 in hospitals; 2(>7 in receptacles for the insane, in houses of correction, jails, and State almshouses. Of the latter, G70 were sup- ported by friends, and 417 by the public treasury. The pauper class of lunatics, it is stated, furnished in ratio of its numbers sixty-four times as many cases of insanity as the independent class. In 1850 Dr. Bell said in his Report, "The number of Hospitals for the Insane in the United States has increased during the last 19 years from G to between 40 and 50, and the accommodation for patients has risen from about 500 to between 10 and 11,000. Even the four larger British provinces adjoining us have caught the influence of our zeal, and each of them has, during that period, pro- 42 Dr. Woodward. Dr. Horvc. Dr. Wilbur. vided itself with a large and well-f urnislied institution, essentially upon our models." (Dr. Bell wrote very strongly, I may remark in paren- thesis against the association of the sexes in asylums, against the frequent visits of relatives to patients, and against giving up all mechanical restraint.) I must not, however, enter into further detail. Suflice it to say that sooner or later buildings were erected in the States, ada[)ted for the purpose, and what is still more im- portant, were provided with medical superintendents, devoted to their work. Amono- these are not a few who have distinguished themselves in this specialty, and have exerted an important influence upon medical psycholopfy and the jurisprudence of insanity, beyond their own immediate circle. There have been features of the American asylums, I do not hesitate to say, which have been well-deserving of the attention of Knglish physicians. The Reports of their superintendents have been and are valued by alienists in the mother country. Dr. Woodward, so long ago as 1800, urged that, with many, intem^ierance was a disease recjuiring special caro, and the American psychologists worked at this subject until an Act was passed in 1855 by the New York Legis- lature incorporating an association wnth powers to carry out this view in a deHnite forni.^' They have also taken a prominent place in the education of idiots. The late Dr. How^e, known everywhere as the enlightened friend of the idiot, was a member of a commission appointed by the Legislature, in 18 10, to enquire into the condition of the idiots of Massachusetts, and to ascertain whether anything- could be done for their relief. Dr. Wilbur's labours in the education of idiots are also well known. He was appointed superintendent of the New York State Institu- tion for Idiots, in 1852. * Vide "American .Tounml of Insanity,'' Jul\-, ISoiI. When this was written I was not aware that lon^ before, i)r. Kush had ailvocatod separate iurilitutions for dipsoniiiuiac^. v^oo paico VI.) Memorial of Pennsyhania Medical Society. 43 It is admitted that the provision made for the insane, in I at least some of the States of America, was recently and probably still is (187(5) far from complete. We have referred !to Massachusetts. In 1800 it was estimated that there jwere in this State about 2000 insane or idiotic persons un- provided for. The number of lunatics unprovided for in the State of New York some years ag-o, and placed in work- houses and gaols, in a deplorable condition, attracted iiiiuch attention and just criticism. In 185G there were 1)00 insane poor in the poorhouses and gaols of this State, ;JliO of whom were in cells and mechanical restraint, from one end of the year to the other. My authority is the " American Journal of Insanity." In 18G8 the Pennsylvania Medical Society memorialised the General Assembly, alleging ilie insufficient ac- Icoinmodation which existed in that State, and asserting that " a large proportion of insane persons are kept I under conditions shocking to the dullest sense of propriety, or even of common humanity, suftering from cold or heat, from bad air, or indecent exposure; chained to the floor, perhaps deprived of every means of recreation or employ- nnent, and dying by that process of decay which i)hysicians call dementia." They urged the immediate establishment ()f a hospital for the district, composed of the counties of Wayne, Susquehanna, Wyoming, Luzerne, Columbia, plontour, Sullivan, Bradford, Lycoming, Tioga, Clinton, Centre, Clearfield, Elk, Cameron, M'Kean, Potter, and Forest; and nine others, should the finances of Penn- isylvania allow of it. The result was the erection of the Hospital for the Insane at Danville, Penn., the corner stone of which was laid in 18G9, on which occasion Dr. Ray delivered the excellent address, from which jwe have quoted. The proper persons, we would here remark, deserving of blame for the deplorable condition of the insane, wherever it has existed or still exists in America, are not the body of alienist physicians, but the mass of the people themselves. 44 Board of Public Charities, In 1873 were published a "Report of Public Charities | in Penn.," " A Plea for the Insane in Prisons and Poor- houses in Penn.," and subsequently "Addenda," wherein] evidence is given, apparently conclusive, that some at] least of the insane inmates (thou^jh the ])roportion to tlie whole number may be small) were often greatly neglected] and ill-treated. The condition of these, in fact, recalls that of the insane before any reforms wore introdncocl, One old man is described as starved to death, medicine] being forced into him, but food thought unnecessary ; aj young lady, for the last two years occupying a filthy cell, resting like a beast upon her haunches, and so per- manently cramped as to be only capable of frog-like I movements; a "splendid old man" in chains for 4(1 years, Ac, &c. The Report of the Board of Public Charities gives many deplorable cases of a similar or even worse character. In one almshouse we read, " We found the female insane department in a shocking condition ; so bad that it wouUl be impossible to give a description of the place on paper. In some cells there were two oi| more women confined; some without any clothing, lyiiii. on the Hoor without mattress, carpet, or anything elso, ] except an old Government blanket. The place had a horrible putrid odour." Of another establishment, the I report is made, " Insane totally neglected, morally, physically, and medically ; less attention is given to them than would be given to the lowest aiunials." \Ve re- produce the above descriptions, not from any wish to throw odium upon the people of Pennsylvania for past errors, but as historical facts which we are bound tul chronicle; and also as forming an instructive lesson for the future, showing, as it does, how possible it is in the 1 midst of an enlightened community for a fearful state of] things like this to remain for so long unremedied, in spite of the protests of medical men and others, and how abso- lutely necessary is unremitting attention to the condition of a class unable to make 1 heir own wants and sutferinu's Petition from rhiladclphia. 45 known. We doubt not that much remains to be done, for at ihc time of •which we speak (1878) it was stated that there wt'iv twice as many of the insane poor ]an<^uishing in the poorhonses and prisons of Pennsylvania, as there were wlicn Miss Dix mandered Pennsylvania slower than she otherwise would have been to reco^-nise her duties to the insane. Many of the citizens of Philadelphia (including Dr. Ray and Dr. Kirkbride) petitioned the Legislature in l871, that " hospitals enough for the care and treatment of all the insane in Pennsylvania be prepared at the earliest possible time," and represented that " the course proposed will relieve the Commonwealth of the reproach of having insane men and women confined in almhouses, gaols, penitentiaries, or, what is worse oiten than either, put out of observation, neglected and inhumanly treated at their own homes, or in detached buildings near them." I regret that in the observations of the I'oard of Public Charities this is not insisted upon. If, indeed, the hospitals already in existence were built for the indigent insane alone, they are right in their complaint that they are now partly oecupied by those whose friends can pay for Ihem, 40 Phijsiciayis and Board of Charity. howevGi- moderately ; or if, built for both classes, the State designed the poor to have the first claim for admission. irrespective of curahilUij, the complaint is just. The law on this point is vague; for while it provides that the poor are to have precedence of the rich, it requires also that recent | cases shall have precedence over those of long standing, That it admits of the construction put upon it — that a I recent case, although not a pauper, shall be admitted before a chronic pauper case — seems clear from the fact| that the Board of Public Charities urges upon the Legis- lature a more definite law on the subject. The mixture of I different classes, hoAvever, in the same building would] seem to be, so far, a recognised plan with the Americans ; and granting tliis, we imagine that the question the I Medical Superintendent has supposed himself bound to consider is — Which of two cases who apply for admission is the more likely to be benefited by treatment? The Medical Superintendents would seem the last persons to blame; yet, unfortunately, the tendency on the part of the Board of Public Charities appears to be to cast the odium of the state of things we have described upon them. And, further, is not some weight to be allowed] to the consideration that many who are admitted ou moderate terms would become paupers in a short time if I not so admitted ? If the Medical Superintendents are to be blamed, should not some blame be attached also to the Board of Public Charities for allowing the poorhouses to be in so bad a condition ? Could not their visitation have been made more effective sooner ? Ought not the Board to have done long tigo what they did in 1873 ? Be this, however, as it may, as their proceedings have in the end been productive of good, we rejoice, although they may in some respects have erred in judgment. In a letter I received from Dr. Ray in the summer of 1873, he states that at that time every State in the Union, excepting Delaware, and one or two of the newest States, had one or more hospitals for the insane, and they were all incrcane of Ast/hims. 47 y ■>-l- lilnMiilly siipportoil iti most, rospoots. " Some of tho (itHcers tliink they themselves are meanly paid ; and I suppose they are, in some Western and in all tho Southern States. Tho Western — Ohio, lowii, Illinois, Indiana — are steadily increasin"- their hospital capacity by bnildinj;^ new hospitals, or addin^,' to the old ones. In them tho essential objects of such institutions, I think, are pretty well obtained, thon^-h an EnLJ'lishnuin would probably observe some laxity in the service. In the Atlantic States, exoeptiii^' New England, it is impossible to obtain good attendants, and this evil seems to bo increasing every year, and the ^ onsequenccs are an increase of suicides, icloiienients, and other casualties." A year later the same correspondent informed me that another asylum had been commenced at Warren,* in the niirth-west part of Pennsylvania ; that in New England tho ho^pital capacity was Jiearly up to the demand, and Avhen hospitals in building were completed, no patient need be left in the poorhonse; that New York, hitherto (h'lintiueut, had live hospitals in course of construction, [which, with additions to old asylums then projected, would [provide for all ])auper insane; New Jersey had added to iior hospital at Trenton, making provision for between five land six hundred, and was building one of equal capacity at ]\Iorris I'lains. Maryland had hospital capacity enough. I "In the hospital at Washington, planned by Dr. Nichols, the national government provides for about live hundred insane from the army, navy, and the district. All the Western States have, at least, one hospital; many of them more. One of the first things provided by tho new [States, after coming into the Union, has been a hospital for the insane. All the Southern States have at least lone hospital, but they became so impoverished by the war that they are hardly able to maintain them, much less to meet the increasing demands for new ones." f On » * Now (lS>J.'i) iiiiilor tlip rlmrtro of Dr. Ciirwen, I Leitci' written IST-J. 48 Admitted Duty of the States. the whole, thoreforo, there is an onward movement, and it looks as if public opinion, enlightened by the writings of American psychologists— especially the Annmil Re- ports of the Hospitals for the Insane, and the man!- festoes of the " Association " — would demand, and | bo willing to support the further extension of hos- pital accommodation which doubtless is called for, I although it may be only gradually effociod. "I can] state two facts," writes Miss Dix to mo (187G), concern- ing the state of communities in Ihe United States, *'an| acknowledged obligation to iirovide suitably for all insaiit. persons, whether chronic or recent cases — for the former! permanently y for the latter, till cure is advanced, or recovery established. Much is said on the supposed rapid increase o^ insanity in the United States. I do not think this a sound proposition. Of course, the number of insane persons is vastly larger than ten years since, but the ania/ing increase of population by a continually inflowing emigration from Europe, with the natural] increase of native inhabitants, will create imperative need for a multiplication of hospitals for care and treatment " I cannot conclude without a brief reference to an I article which appeared in the " Lancet," Nov. 13, 1870, in which the wi'iter brought very serious charges against the customary treatment of the inmates of the American asylums by their medical superintendents. I deeply regret that so unqualified an attack should have been made upon a body of honourable and humane men, and I am sure that the members of the Medico-Psychological Association in this country share in the regret. If the writer had spoken strongly in refers j condition of the insane in workhouses and >'o»ne of the asylums, the case would ha ely ferent; the language in regard to such not to strong X dare say; but surely the only justification for wholesale onslaught on the medical superintendents oi the asylums in the] United States would have been conclusive evidence o\ T/ic Jiancci and Dr. lii'rhilt/. 10 allocrod facts as ji fi;(>iioriil rule in ihoso iii.stitutions. On Itlic contniry, T)r. liuckiiill,"'^ in roj^^ard to the several par- [ticiiliirs specially mentioned by the " Lancet,'* entin-ly klt'iiit'S the correctness of the statements. To those familiar ^vitIl the names, writin<,'s, or deeds of Butler, Earle, iriiy, Nichols, Curwen, and others among living, and Briiiham, Woodward, Bell, Ray, and Kirkbrido, among |(loiid medical psychologists, it sounds strange to read that we iire almost forced to the conclusion tiiat our friends icross the Atlantic have not yet mastered the fundamental irinciples of the remedial system." And stranger still (so \\v as regards the men of the first class), to hear that they adhere to the old terrorism, tempered by petty rynmny." Can we be surprised that the feelings of men ?iii;aged in a noble and arduous work— the work of their jives — should be hurt when they read such charges made by members of the same profession ? With what feelings, HiidiifiH mutandis, should ivc read them P In the rejoinder iiade in the " Lancet " to Dr. Bucknill's letter, it is said, I' Wo do not say all American asylums are bad/' It is cer- [aiiily to bo regretted that this qualification, or rather a iHU'h lariior and more wiierous one, was not made in the Jrii^iiial article. Neither, on the other hand, do we say hut all American asylums are good. We simply maintain lliat the sins of some asylum authorities — and these, as a [ule, municipal rather than medical — should not be visited luliscriminately upon the whole body of medical superin- [ondonts of hospitals for the insane. An American )liysician, visiting St. Luke's subsecpiently to 1840, found Chains in use. Had he in consequence stigmatized tlie 5nj,'lish superintendents of asyhims, as a body, as being In the habit of employing manacles, he would have tonnuitted a gross injustice, which they would have listantly resented. In the same way the American " Lancet," Feb. 12, 187l». Dr. Bncknill's impressions of American isyliiiii'j will be fonnd in liis little liock, iinbli>li('(i by Miiciiiillun in lS"ti, 'Ncii'S on A^yiuuis for liie Insane in AuiericH,'" 50 Hospitals for the Jvsa^w. superintendents naturally feel aggrieved when a leadirg medical journal represents them, without (in the first j instance) any exception whatever heing made, as adhering; to the old terrorism, &c.; resorting to contrivances of com pulsion ; using the shower-bath as a hideous torture ; and, leaving their patients to the care of attendants, while they devote their own energies to beautifying their asylums. Let us give credit where credit is due, and not involve I in indiscriminate censure, worthy and unworthy superin- tendents, good and bad asylums ; but if we denounce at all, let us confine our denunciation to those institu- tions in which ill-treatment is known to prevail. The following is a list of the principal Hospitals for the Insane in the United States, with their dates of| opening : — 1773. Williamsburg, Virginia. 1817. Frankford, Penn. (Society of Friends). 1818. McLean Asylum, Somerville, Mass. 1821. Bloomingdale, New York. (Hospital, 1797.) 1824. Hartford, Connecticut. 1824. Lexington, Kentucky. 1827. Columbia, South Carolina. 1828. Staunton, Virginia. 1832. Worcester (Chronic Insane), Mass. 183G. Brattlt'boro, Vermont. 1838. Columbus, Ohio. 1839. Boston Lunatic Hospital, Mass. 1839. New York City Lunatic Asylum (Women), Black- well's Island. 1840. Augusta, Maine. 1840. Nashville, Tennessee. 1841. Philadelphia, Penn. (Hospital, 1752-1841.; 1842. Milledgeville, Georgia. 1842. Concord, New Hampshire. 1842. Mount Hope Retreat, Baltimore, Maryland. 1843. Utica, New York. 1845. Almshouse, Philadelphia, Penn. Hospitals for the Insane. 51 a leading ■■ 1847. Indianapolis, Indiana. the first Bj 1847. Providence, Rhode Island. 3 adhering; H^ 1848. Jacksonville, Illinois. es of com ^| 1848. Jackson, Louisiana. ture ; and, H 1848. Trenton, New Jersey. while they H 1851. Harrisburg, Penn. isylums. ^1 1851. Fulton, Missouri. ot involve ^| 1853. Taunton, Mass. y superin- ^| 1853. Stockton, California. denounce ^| 1854. Hopkinsville, Kentucky. se institu-^H 1855. Dayton, Ohio. ^^^^H 1855. Jackson, Mississippi. jpitals for ^B 1855. Washington, District of Columbia. dates of ■■ 1855. Flatbush, King's Co., Long Island, N.Y H 1855. Newburgh, Ohio. H 1856. Raleigh, North Carolina. H 1857. Austin, Texas. ■ 1857. Dixmont, Penn. \ ^H 1857. Northampton, Mass. ^H 1859. Criminal Asylum, Auburn, New York. H 1859. Kalamazoo, Michigan. H 1859. Mendota, Wisconsin. H 1860. Burn Brae, Kelly ville, Penn. H 1N60. Longview, Carthage, Ohio. H 1861. Tuscaloosa, Alabama. H 1861. Mount Pleasant, Iowa. H 1862. East Portland, Oregon (Closed 1883;. i), Black- ^1 1866. 1866. Middletown, Connecticut. Osawatomie, Kansas. 1 1866. St. Peter, Minnesota. 1 1866. Weston, West Virginia. 1 1867. St. Louis, Missouri. 1867. Bellevue Place, Batavia, Illinois. 1 1868. Danville, Penn. 1 1869. Willard, Seneca Lake, New York. 1870. Cranston (State Farm), Rhode Island. ■ 1870. Richmond, Virginia. 52 Hospitals for the Insane. 1871. 1871. 1871. 1871. 1871. 1872. 1872. 1872. 1872. 1873. 1873. 1873. 1873. 1874. 1874. 1875. 1875. 1876. El^n, Illinois. Poughkeepsie, New York. Wootlbridge, California (To Stockton in 1877). Lincoln, Nebraska. New York City Asylum (Men), Ward's Island, N.Y. Winnebago, Wisconsin. Catonsville, Baltimore, Maryland, (Hospital 1797). Jacksonville (Oak Lawn Retreat), Illinois. Athens, Ohio. Anna, Illinois. Independence, Iowa. Frankford, Kentucky, (now for feeble-minded children). Anchorage, Kentucky. St. Joseph's, Missouri. Middletown (Homoeopathic), New York. Cincinnati Sanitarium, College Hill, Ohio. Napa, California. Morris Plains, New Jerse}'. Hospitals opened after 1870. 1877. Worcester (New Hospital), Mass. 1878. Pontiac, Michigan. 1878. Danvers, Mass. 1871). Rochester, Minnesota. 1879. Topeka, Kansas. 1879. Kankakee, Illinois. 1879. Norristown, Pennsylvania. 1880. Warren, Pennsylvania. 1880. Goldsboro', North Carolina. 1880. Buflalo, New York. 1881. Binghampton, Now York. 1882. Little Rock, Arkansas. 1883. Salem, Oregon. Such is a brief sketch of the history of the insane in the United States in former years. The following pages will describe their present condition, so far as the author's visit in 1884 enabled him to judge of it. 1877). land,N.Y. ital 1797). s. )le-inin{le(l 10. hsane in |g pages lauthor's CHAPTER III. Present Condition of the Insane in the United States. I, General Management and Treatment. In my recent visit to the asylums of the States of New Hampshire, Vermont, Massachusetts, New York, Connecti- cut, Ehode Island, Pennsylvania, New Jersey, the District of Cohimbia, Illinois, Wisconsin, and Maryland, I found that, with some exceptions, their condition was satisfac- tory, many bein^j admirably managed, and reflecting great credit upon all engaged in their administration. As a class, the American Asylum Superintendents are excellent men, devoted to their work, and as honour- able, intelligent, and humane as those in any other country. I can, of course, speak only of the asylums and physicians I know. Judging from report, I believe there are institutions in some localities which are not in a very creditable state.^ In fact, it is quite recently that the treatment of patients in one of the asylums in a Western State was admittedly most disgraceful. And in several of the institutions I visited, the rooms occupied by patients were quite unsuitable, and the amount of mechani- cal restraint indefensible. I may go a step further, and say that in regard to the latter point the number of * The insufficiency of tJie provision for tiio insane is indicated by tlie Btateuient made by an American physician, Dr. Uana, two years ago, that the condition of the insane in Kome of the Southern Stales "is particularly • listressinp ;" and that in South Carolina hardly one-third can be cared for in the single State Uospital there. The asylum in Texas holds only ono- tifth of the State insane. " The importunities of the few Medical Superintendents in tlie Soutli show how negligent these States are." Ho nssertB ihat the conili'ion of the non-asylum insane in the Southern and Western States has little altered from what it was 10 years ago. " They lup miserably kept, in jails, almshouses, aud on poor farms, &e.'' 54 Number in Restraint in 1 880. asylums is considerable, in which there is more resort to restraint than superintendents in England would approve, although I am by no means sure that in all these cases disapproval would be warranted. In many other American asylums there is either no restraint whatever, or it is so slight and manifestly necessary for surgical reasons, that hyper-criticism alone would find fault. I have been favoured with certain unpublished returns of restraint made in 1880, but before giving them I must premise that it would be unfair to take these figures as giving a correct representation of the amount of restraint at the present time, because I am certain, from informa- tion received, and from my own observation, that the number restrained in asylums has within the last few years been greatly reduced. One is glad to know, also, that many who were then in almshouses, and were in restraint, have been removed to institutions for the insane in which little or no restraint is employed. The number of patients in asylums in 1880 was 40,902, and the number reported to be under restraint 2,242, or 5'4 per cent. The mode of restraint was as follows : — Camisole . . . ... 887 Muff ... 526 Strap to bench ... 439 Handcuff ... ... 147 Ball and chain ... 21 Crib-bed ... ... Ill Form of restraint not stated ... Ill 2,242* I should suppose the number returned under "crib- bed *' is below the mark. Its incomplete return may be accounted for y the circumstance that it is scarcely regarded as mechanical restraint by some superintendents, inasmuch as it does not actually confine the limbs in one * AIho reHtraint by " personal attetidancti only/' 1444. The Covered or Crib-Bed. 55 position. Outside asylums a return is given of the use of crib-beds, but I wish now to restrict myself to asylums proper, not almshouses or private care. The " ball and chain" reported as in use in 21 cases in asylums sounds strange to our ears. There were none in any asylums I visited ; probably they are to be found in some Southern or far Western institution. Returning to the crib-bed, which has caused so much acrimonious discussion, it would be disingeuuous to deny that there are patients who are constantly getting out of bed, sometimes feeble elderly people; and others, restless, excited patients, who persist in standing up, and become very much exhausted; for whom it is an ingenious and sometimes effective device. I make this admission, as I do not believe in that definition of travellers which defines them as persons who go abroad in order to lie for their country ; or, as the immoral Scotch proverb expresses it, " A travelled man hath leave to lie." At the same time, the crib-bed is to me an unpleasing object, and inevitably suggests, when occupied, that you are looking at an animal in a cage. Moreover, it is so temptingly facile a mode of restraint, and is on that account so certain to be abused, that I hope it will not be introduced into this country among the useful American inventions we are so glad to possess. That whatever its occasional utility may be, it may be abused, will be admitted when I say I counted 50 in use in a sinsrle asylum, and that a very good institution in most respects. At the celebrated Utica Asylum, under Dr. Gray, where a suicidal woman was preserved from harm by this wooden enclosure, my companion. Dr. Baker,^ of the York Retreat, allowed himself to be shut up in one of these beds, but preferred not remaining there. On examining the journal of the Bloomingdale Asylum, New York, of which Dr. Nichols is the Superintendent (there being 247 patients), I found that from the 1st of * Dr. Baker and myself visited ten of the United States AsylaiUB together. Includiug thuse iu Canada, I iubpectcd furty. 50 Complaint of American Alienist a. January, 1884, to the date of my visit, in the third week of October, 1884, two men had at times required restraint to prevent self-mutihition. I think no one will bu disposed to criticise the resort to restraint in these cases, On tlie women's side of the house there had been no mechanical restraint for two years, and no seclusion durinjjf the year. I may add that durin*^- the several days I was at the Bloomino-dale Asylum there was one individual, and only one, to whom it was necessary to apply mechanical restraint, namely, the doctor's collie, which it was needful to muzzle for a snapping propensity which suddenly developed ! I would here say that in visiting the American asylums I carefully refrained from making non-restraint the measure by which I estimated them, but lotdced rather at the general comfort of the house and the patients as a whole, and had regard to the evident character and inten- tion of those in authority. I had, of course, a great deal of conversation with superintendents on this inflamma- tory topic, and I should say that they feel they have not always been fairly treated in the criticisms made upon them in this country. What the American alienists complain of is this : thev say that the British superintendents proclaim themselves the disciples of Hill and ConoUy ; that they protest in their writings against mechanical restraint as never necessary and always injurious ; and yet when they (the Americans) visit our institutions they find some patients in restraint even in the best conducted asylums, often for the same reasons for which they themselves resort to it, and for which they have been so severely criticised. More- over, in conversation with some of the superintendents of British asylums, they meet again and again, they say, with the frank admission, that the absolute disuse of mechanical restraint in accordance with the teachings of Hill and Conolly is not really held 1 y them in theory, but is nither a '' pious opinion." Seclusion. Padded Rooms. o1 Perliajis there has hardly been that public outspoken avowal of the occasional resort to restraint which the rare examples which do occur would seem to demand, whenever ('onollyisni is proclaimed as the adopted faith, and, by iitiplication, tiic constant practice, of the medical super- intendents of British asylums. Thus the difference between American and Enatients 801 are reported to be able and willing to engage in some kind of occupation. Again, at the new asylum .at Worcester, Massachusetts, where there are 780 patients, 38 per cent., namely 102 men and 218 women, were occupied. At the Northampton Asylum, the laundry work for an average of 530 persons is done with only two assistants (women), whose aggregate wage is £7 a month. For the last fifteen years, nearly or quite three-fourths (Dr. Earle thinks it may safely be placed at two-thirds) of all the necessary manual labour upon the premises have been per- formed by the patients. With an average number of over r.mpht/iiient of Patients. 68 30 cows, the milking is all done by patients— an employe over-seeing them. The poultry-house is uniler the sole ('hiirj,'e of a patient. And, as eh)sely connected with em- ployment, may bo nnMitionod the reinarkable extent to which, fit this institution, in-door recreation in some form is carried out, mimely every evenin<^ durin^; the }'ear. It is creditable to the Norristown Asylum (Penn.) that (if oK) male patients 1()7 were employed out ot doors. Sixty-four were engaged in the brush-shop alone. At the New York City Asylum for males (VVai'd'a Island), under Dr. MacDonald, a printing press is in con- stant use, and there were four patients at work on the day of my visit, bookbinding being done as well as print- ing,'. Of the total number of patients (1,494) 34 percent, were employed, 219 in outside and 298 in inside work. As many as 1,154 go out for exercise. Although I can hardly adduce bathing as an example of work, I may mention, as a praiseworthy attempt to occupy the patients, that salt water has been brought into the grounds so as to form a large bath 220 feet long by IJO feet broad, and from 4^ to 5^ in depth, where a number of patients bathe in the open air to their heart's content. From 500 to GOO patients bathe every day. There were as many as 200 in the water when I was there, and they evidently enjoyed their immersion immensely. There is a large slied under which they dry themselves. This is the second year the bath has been in operation, and it has proved a great success. As a useful mode in which to employ patients T may here mention that, at the Pennsylvania Hospital for the insane, till recently under Dr. Kirkbride's charge, a con- siderable number are engaged in pottery work, the clay being moulded by them into various useful and orna- mental forms, specimens of which are collected in a room in the institution. At the Middletown Asylum, Connecticut, superintended by Dr. Shew, 45 per cent, of the 892 patients were em- 61 Less in Amtricrt than FmylamL Vr ployed, 20 being engaged on the farm, o7 on the grounds, and 18 in the stables. When I come to speak of the system of providini; for the chronic insane in the State of Wisconsin, it will be shown that a very considerable amoun! of work is done by them in the small county asylums. It must be admitted that the above percentages arc somewhat low, even for mixed asylums (as some of thoiii are) and contrast strongly with our Sussex asylum, wliciv GO per cent, of the men are omjiloycd, exclusive nf ward cleaners, 11(3 being engaged on the land; or with Brook- wo( d (Surrey), where, of -US men, 1G;J are engaged on the farm and garden, and GO at various trades. There are two reasons assigned for this difference. Tho one is the greater independence of the people in America, the other the character of the climate. ^Vheu I observed one day to an American doctor that, on such a sunnv day as that, our patients would be nearly all out of doors, " f should think they would in Em/hivd,^' he rejdied, iron- ically, for ho knew sf)mething of this sun'jss island of ours, and was not surprised to hear that when th(> sun does shine everyone turns out to see it. But, joking apart. I should hold that the English are in advance of tln' Americans in this very important matter of out-of-door occupation; and this is the more to be regretted wluii one considers the liberal supply of land which is attaclH'd to many State as}lums. There is already a movement in this direction, and I am inclined to think it will he found that neither independence of character nor pecu- liarities of clinnite will ultimately prevent the system being carried out to a greater extent than it is at present. Dr. Dana refers, in an article in the " Journal of Nervttus and Mental Dis< ase,''* to the lack of sufficient work ami amusement as I'n evil still existi";; in a large number of the asylums in his country, but adds that in some States tlie asylums are '"'> niiserably jtrovided with nkoney and * Vol. ix, No. •_', April, \HH'2. Lunncy Legislation. 65 even grounds that reallj little can bo done. Among other State asylums, those of New York and Maryland appeal to the authorities for power to give their patients more work, exercise, and amusement. It must, in this connection, be remembered, in justice to American asylums when compared with our own, that while iu Eiit,-land men can work out of doors during the greater part of the year, there is little or nothing to bo (lone in many of the American States from November to April. Very much is certainly done in the way of providing instructive amusements for the patients. T have already referred to the systematic manner to which this is carried out at NortJKimpton. Dr. Curwen, at the Warren Hospital for the insane, in common with many other superinten- dents, keeps up frecpient magic lantern exhibitions during the week, taking a certain number of pictures and ex- plaining them each evening. He informs me that he has imported from London more than ;")(•() photographic views in Ureat Britain and Ireland. These readily atfortl an op- portunity for observations on ]i()ints of hi>tory, biography, and geography. One evening is given to natural historj, with photographs of aninuils, birds, structure of plants, kc. The assistant medical officer takes one night for iiuisic or theatricals, and on the sixth night Dr. Curwen himself reads on various subjects, poetry, Ac. In this way every evening in the Avinter has something to occu2)y the patients. Dr. Curwen thinks that too little attention, as anile, has been given to the matter "f instruction and diversiun, which, while they involve much time and labour, prove of corresponding benefit to the patients. II. .Lunacy Lctjislatiou. I i.'owpasson to the qnestloii of Lunacy Legislation, and as this exciti's so much interest in England at the present time, I will mention the practice jausued in several of the Auiorican States, the result of laws which have been 66 A flmission- Papers. enacted for the protection of the insane. As these laws vary with every State (nearly 50), it is impossible to do more than single out three or four as examples of the diiferent plans which have been adopted, including those ot the most drastic kind. It is as thoy bear upon admis- sion into asylums, involving, as this docs, the deprivation of liberty, and the inspection of asylums, that we are most concerned with these enactments, and the practice pursued. A. Aihnission. — {a.) I will first take the simplest possible form of admission as it is found in the State of Connecticut. The retpiest for admission of a private patient, signed by a guardian, near relative, or friend, simply desires that A. JJ., of C. D., may be admitted as a patient into the hospital for the insane. The certificate of one physician is sufficient, and runs thus : — " I hereby certify that T have, within one week of this date, made jiersonal examination of A. B., of C. D., and believe him to be insane.'* This is subscribed and sworn to by the physician before an rtfficer authorized to administer oaths, who certities to the respectability of the physician and the genuineness of the signature. (6.) If wo now go to P< ftnKi/Ir((via, we find a consider- able advance made in the wtiingency of the checks on improper admis.si-tm into asylums, although I should observe that the law «»f Pfiinsylvaniii aUows persons to place themselves voluntarily in an asylum "-'a period not exceeding seven days, on signing an agreement giving authority to detain them, which may be renewed from time to time tV>r the same period. In ordinar)^ ca.ses, in accordance with, an Act of 1883, passed in consequence of a Commission appointed by the Governor of the State to report upon the Luiuu-y Laws, it is necessary that the medical certitieate should be signed by at least two physicians in actual practice for five years, Practice m Different States. 67 who shall certify that they have separately examined the patient, and believe him to bo insane and requiring the care of an asylum. Tlioy must not be related by blood or marriage to the patient, nor connected medically or other- wise with the institution. This certificate must be made within one week after the examination of the patient, and within two weeks of his admission. Further, it must be sworn to or affirmed before a judge or a magistrate, who must certify the genuineness of the signature, and the standing and good repute of the signers. It is not, how- ever, necessary that the judge or magistrate should examine the patient, or express any opinion in regard to his insanity. The order and statement arc signed by the person at whose instance the patient is received. The statement comprises the chief points of importance, but is not so full as our own. Copies of the admission-papers are forwarded to the Conunittee on Lunacy, which is a section of the Board of Charities, within seven days of admission. (('.) 1 will now give an example of a more stringent pnjcedure, and for this piirpose draw my illustration from the iState of MasKdchusclts. Here, not only are the certi- ficates of two physicians required (the facts upon which their opinions are founded being specified), but the Lunacy Act of this iState recpiires that no person shall bo committed to a lunatic hospital, asylum, or other reoe[)taele for the insane, public or private, without an order signed by a judge of one of the various courts eiuunerated, certifying that he finds that the person com- mitted is insane, and jit for treatment in an, ysi/lnm. Some discretionary pc»wer is, however, permitted, for if the judge thinks it undesirable to see the patient, he may certify to tliat effect, and still commit him. Again, if he is in doubt, lie may sunnnon a jury of six to his aid. To obviate the difficulties which might arise from re- quiring a judge's order and examination in urgent cases 68 Insane Thursday. (difficulties to whieli we are just now so much alive), an emergency certificate is allowed, upon which the Superintendent may receive and detain a patient for five days. This document, signed by two physicians, certifies that the patient is labouring under violent and dangerous insanity, and it is accompanied by an application for admission from the Mayor or one of the Aldermen of the place in which the patient resides. The permitting this exceptional action in cases of emergency must certainly materially lessen the inconvenience of the Massachusetts Act. {(I.) The last example, and the most stringent of all which I have to give, is in operation in the State of lUhiois, where the law requires that no one shall be de- prived of his liberty by being placed in an asylum without trial by jury. Instead of giving the details of the Act which requires this proceeding, I will briefly descrihe wliat I myself saw of triul by jury of the insane in Illinois, when I was at Chicago last October. I went, accom- panied by a solicitor (Mr. McCagg), on what is called " insane Thursday," to the County Court, where the trials are held, presided over by Judge Prendergast. Below the Court were some rooms occupied by insane persons await- ing their trial. In ilie Court there were about forty specti: "s. In one corner of the room sat the jury of six, the foreman being a doctor. When the patient wiis brought in for trial, a physician (Dr. IJluthardt) employed by the Court, gave the result of his examination. A friend of the patient also gave evidence, and the judge asked a few questions. The jury then retired into an adjoining room to consider their verdict, and another case was tried. The consideration of each case did not occupy much time, but there was no unseemly haste. One ]iatient v»as too acutely maniacal to bo examined in the Court, out of which he was quickly con- veyed, restrained by a U-atheru muff, into another room, where the jury and the official docior went and Jury- Trial, ()9 examined him. I followed. The jury, very properly, made short work of tlie case. la one instance, after a careful inquiry into all the circumstances, the man was not found insane, althouf,'h lie was evidently not quite right, and it was agreed that he should go and reside with a farmer who was a friend of his. I had an opportunity of conversing with the judge, who told me that he regarded the law under which these trials are conducted as (piite satisfactoiy. " Insane Thursday " is likely, I was told by others, to remain an institution in Illinois, as popular feeling demands trial by jury as a right. The publicity, how- ever, is a serious objection ; and I was informed that people often keep their friends at home rather thun nuiko their insanity known. The circumstance is almost sure to come out, although they often bribe the newspaper reporters not to report their friend's case, and though the judge, as he told mo, sometimes considerately defers the trial of those cases in which he knows there is a droad of publicity until all the others have been disposed of, and the reporters have left the room. In regard to jury-trial of the insane. Dr. McFarland, of Jacksonville, 111., thus writes to another American physician. Dr. Parsons: ''The Illinois law of which you iiupiire is injurious, odious, barbarous, damnable, and you may add as many more expletives to it as you please, and still not say the truth in regard to its evils. . . . Every superintendent of an asylum in the State is most eloquently pleading for a change in this detestable system ; the Board of State Charities urges the change most tV^rcibly ; a 15111 is before the Legislature, reported favourably upon ; the Chairman of the Judiciary Ccnjimittee is a true champion of the reform; but all, as I fear, will amount to nothing, because there are a few fanatics who raise the hue and cry ever an imaginary bugbear." Dr. Parsons himself objects to the jury-triiil of the insane on the grounds that as the removal from home to an asylum necessitates publicity, to an odious extent, 70 Its Disadvantages. hospital treatinont must be clelayed in many cases until prospects of recovery have been seriously lessened ; that the transfer to a Court and the incidents of the trial often endanger the life of a patient; and that, in not a few instances, patients become dan<,'erously excited by having to appear in Court as defendants. Dr. Jewell, of Chica,'iiol8 over nij,'lit, in order that tlio jinli,'!' may sao tlii.'ni. Notwiilistamliiif? tiiid objoelion Dr. Earlo writea to mo — " In my opinion the exi.sliiif? h-iw in .Masaachiisetts in i'efj;ard to tho coniinittnciit of luiiatiL'a is none too Btrinj,'rnt. It occasionally HccniH sonicwliat Iniiili'nsomo to tlio I'rirnils of tho patient; but that is a small conjiidcrat iuii when com- pari'il wiiii the di'fectn in fornu'i- laws whicli it has rcpaii'i'il, and the de- ticionciea it luis suiiplied, ll !iot only furnishes far j^reater safe-guards a^,'uinst improper commitments, and consetpiently a more surt) protection to till! rights of the iiulivulnal.but jmi^'in^^ from my exjx'rience, it is n ^'I'eat re- lief to the Superintendents of ilie Hospitals Ironi whom it has removed all respDMsihility, ina/i caKcs, for the eommitint Ml of the paiiiiit. " The emer<,'ency section of tlu^ Mass. hiw hiis \wv\\ freipiently ri'sorted to ia liuHtou, but here (Norihampion) we have had only two or three cases iiiHin'4 tlio nearly live years sinco the Act took off.ct. I huvo inyst'lf heard no complaint of the law arisinj? from its requirement of the e-aminalion of tho patient by tho judfje, but such a cun\plainl would hi' much more likt 'y to oi'cur in the lan,'o cities than in a community like ours, where tho population is very luigily rurul,'' 7"' Inspection. for greater checks upon the atliiiission of patients into asyhims, is another question ; for the public, or a certain section of it, nught ieel very suspicious in regard to mental physicians whom no judge or magistrate would for a moment hesitate to guarantee. B. Ins2U'ction. — 1 now turn totlie other point of Lunacy Legislation to which I have referred, namely, the vastly important subject of inspection. (a.) At the present time the inspection of asylums is usually performed by State Boards of Charities, which have been constituted in a considerable number of tk States, and are likely to increase. They had not been established in three of the States I visited, New Uaini)- shire, Vermont, and I\Iaryland. In Illinois and Wisconsin, as we shall see, they have been very active bodies. In Massachusetts there is an active and effective Board, entitled the State Board of Health, Lunacy, and Charity, established in 1870, when two previously existing Boards. the State Board of Health and the Board of State Charities were abolished, and their lunctions merged into the present Board. The members of the Board, with the exception of the Inspector and clerks, receive no compensation what- ever for their services, the expenses incurred in travelling being, of course, re-imbursed. Whatever may be the reforms which it is desiiable to introduce from America into England, I suppose this is hardly one which will fnul favour ; at any rate, it is not likely to receive support from the Board in Whitehall Place. I was fortunate in meet- ing with the Inspector, Hon. F. B. Sanborn, a highly intelligent man, inteiested in all questions connected with lunacy, and liked by the superintendents whose asylums he inspects. He was for several years Secretary of the Board of State Charities, ajid has acted as Secretary to the present Board, which at the itrcsent time has no official Secretary, but a " Clerk and Auditor." The Board consists of nine persons, who are appointed by the Governor of the State, with the advice and consent of the State Boards of Massachusetts. 78 Council. It has tlio f,'eiieriil supervision ol" the State Lunatic IIosi)itals and the Stato Aliiishouses as well as Schools. It must visit at least once a year all places where State-paupers are supported, and must inspect every i>rivate asylum or receptacle for the insane at least once in every six months. It is ex[tressly enacted that the Board shall act as " Commissioners of Lunacy," with power to iuvesti;^'ate the (piestion of the insanity and condition of any person comniitled to any public or jii'ivate asylum, or restrained of his liberty by reason of alh';;cd insanity in any place Avithin the Commonwealth, power bein^^ n and laywomen, and were inclined to resent interference. That this feelin;,' is natural must be admitted. Some irritation and annoyance will almost inevitably arise at times, in regard to advice tendered on points upon which doctors ought to be, if they are not, better Judi,'es than their advisers, liut it a})poars to me that, officious and harassing as individual members may sometimes be, such a Board is of use, and must certainly be continued until medical Lunacy Uoards are introduced ; and even then I should rei^ard it as very desinible to secure the unpaid services of the same class of men and women as visitors, lliough no lon«,'er Commissioners. Thry would make any suggestions which might occur to them trristown, thocxccllcnt asylum near I'hila- delphia, lujder Dr. Chase and Dr. Alice liennett, which has contribute.! lar^'cly to tho practical solution of the (piestion of i)rovidin^ accommodation for tho chronic insane in Pennsylvania. (c.) In tho State of New York there exists, in addition tf tho State Board of Charities, a Lutuicy Commissioner, Dr. St<'phen Smith, to whom, as well as to Dr. (J ray, 1 am under obligations for help rendered in forwardiii;^' the objects I had in view. I have reason to believe that his visitations and reports have done i^ood service. I re^^rct that the salary of this oltice is not such as Avould allow of a physician renouncing private practice. It is no doubt considered that his whole time could not bo occupied in inspectin<^ tho State-institutions in which the insane are con lined. This is one of tho ditlieulties connected with tho ap- pointment, in each State, of Lunacy JJoanls on our model — a proposal which has been much discussed by asylnni superintendents in America. I found from Dr. Stearns, the Medical Superintendent of the Hartford Ketreat, C(»nnecticut (so lon^' associated with the name of Dr. Butler), which I visited with j^reat satisfaction, that he was disposed to rey-ard the apj)oint- ment of a Lunacy Board with favour, if it could be administered under tho same conditions as in Britain. He Provision for Chronic Insane, 76 fours it is impnictieiiblo in his own country, because there is no central appoint'.;)*,' power or iiutliority.. Each State must make its own appointment; but the number of nsvhims, unless it be in tlie State of New York, is too small to make it worth while or possible to set iipiirt one Boanl lor sui'li a purpose. Dr. Stearns is well tie(piainted with ]h'itain, and fully conceiles the benclit which has iiccrued from the appointment of our Lunacy lioards. A stran^'er may well hesitate to su^'<(est a plan whieh a man so impartial an V 6^ n. ^^ ,<^^ % 1? 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 /. . &?/ CA fA i 76 Distribution of Inmne. States of America in connection with their insane popula- tion if I state that at the hist census in 1880, the number reported to be insane amounted to 91,959, or 1 in 545 of the general population, and the number of idiots to 76,895, making a total of 168,854. The distribution of the insane was as follows : — In hospitals and asylums for the insane* In other institutions... In almshouses In jails, &c. ... At home or in private families 40,942 or 44-42 p.c. 235 or -26 p.c. 9,302 or 10-12 p.c. 397 or -48 p.c. 41,083 or 44-68 p.c. Total 91,959 Thus, no fewer than 50,782, or 55'28 per cent., were not in any special institutions. It is calculated that the annual increment in the numbers of the insane in the States is about 5 per cent. The asylums have been much crowded ; and many efforts have been made, and some carried out, to supplement existing asylums by buildings of a less exi^ensive character. Of this we witness one example in an Eastern and another in a Western State, namely, the Asylums of Willardf and Kankakee, which are examples on a large scale of what has been and is being done in the same direction by other institutions. This problem, which has occasioned so much discussion and led to such definite action in England, was discussed at a meeting of the Kew England Psychological Society in Boston last September, when I listened with much interest to the various opinions expressed by its members, elicited by a paper read by Dr. Quinby, the Superintendent of the Asylum for the Chronic Insane at Worcester, Mass. Considerable diversity of sentiment prevailed. Some pre- ferred retaining the acute and chronic in the same building, the necessary additions being made as accumu- lation rendered the original capacity insufficient; others * It is said that 90 per cent, of the insane in this catep;ory are incurable, t So called from Dr. Willard. It is at Ovid, Seueca Lake, N.Y. Dr. Ckapin and " Willard." 77 advocated distinct asylums, ■whetlier in the same or different localities. All admitted the existing pressure, and the necessity for further accommodation. The venerable President, Dr. Pliny Earle, observed that he did not see what disadvantage would result were he, for example, to reside in one building and an assistant medical officer in another, one taking charge of the acnte, the other of the chronic cases. On the whole the balance of opinion in this debate was in favour of annexes or cottages on the same estate as the original hospitals. I must here dilate a little on the Willard institution. Its establishment was the outcome of an attempt made in the State of New York to grapple with this problem of chronic insanity, and to rescue lunatics from the neglect and cruelty from which many of them suffered in alms- houses. In common with some similar attempts, it was a considerable departure from beaten ti-aeks and the tradition of the elders. Dr. Chapin led the way, and superintended the group of buildings known as the Willard Asylum, from its opening in 18G9 to 1 88 1. He informed me that the idea was suggested to him by the Fitz-James Colony, Cler- mont (France) . I met Dr. Chapin in Philadelphia, where he has succeeded the lamented Dr. Kirkbride in the manage- ment of the Pennsylvania Hospital for the Insane ; and I conversed with him very fully in regard to the disposition and arrangement of the detached buildings at the Willard Asylum, and heard from him in what respects the experi- ment has proved a success. Although I regretted being imable to visit the institution itself, I was made so thoroughly acquainted with it by the description of my informant that, like a certain royal personage who seriously maintained before Wellington that he was present at the battle of Waterloo, I have for some time entertained the idea of having actually visited the Willard Asylum. Be this as it may, it is always better to behold the genius loci than merely the place from which it has departed ; that is to say, when one cannot see both. 78 Kankakee. m ■Wl! When " Willarcl " was opened, there were as many as Ij-'jOO lunatics in almshouses in the State of New York, while there were only 500 in the State Asylum at Utica, under the charge of Dr. Gray. Four years before Willard was opened, there were as many as 200 pauper lunatics in chains in the almshouses of the State. Dr. Chapin claims as important advantages in the Willard Asylum system : first, economy of construction; second, economy of maintenance ; and, third, greater facility for taking patients out to work on the farm. Without entering into details, I may state that it provides for about 1,800 patients, and is the largest asylum in the States. The main building contains nearly 600 patients ; Dr. Chapin, however, disapproves of so large a number, preferring 300. There are also twenty detached blocks, in four groups, each group comprising five. There is another building, formerly an agricultural college, adapted to the requirements of the insane. The cost of three buildings, which are to be erected for 200 patients in all, will be under £50 per bed, exclusive of land and furniture. One of the detached buildings accommodates 250 women, a matron and an assistant physician residing there. All patients, when admitted, go in the first instance to the central building, and are subsequently classified and distributed according to their mental con- dition. Profiting by his experience at Willard, Dr. Chapin would prefer having only 50 patients in a detached building. At present there is a kitchen pro- vided in every house, but if he only had houses with a capacity for 50 patients, Dr. Chapin would plan to have, in a separate building, a kitchen and a large dining-room for common use. I now ask the reader to accompany me to the other locality, Kankakee, Illinois, some 50 miles from Chicago, where a similar, though in some respects a different, experiment has been made. Some years ago a gentleman was deputed by this State to visit the asylums of Britain, before a de- Mr. Wines. n cision was arrived at as to the best mode of construction to adopt in the erection of a new State Asylum. Those who, like myself, met Mr. Wines in England, will re- member the careful and intelligent study which he made of our institutions. On his return he recommended the erection of a main building and several others entirely detached from it, with the view of avoiding one huge many-storeyed building, and facilitating classification by providing dwellings as much as possible resembling those to which the patients had been accustomed at home. Mr. Wines, as Secretary to the Board of Public Charities, has made this institution his special care, and continues to take a lively interest in it. Segregation is here carried out to its fullest extent, and, as some think, to an objec- tionable extreme. Apart from any errors of detail which may have been committed, it is a pleasant thing to see this breaking up of buildings on so extensive a scale. It must do good. The air blows more freely and freshly through this group of houses, which will soon form a little village, than it would or could through monster structures filled from top to bottom with the insane. I saw with pleasure, one evening, a number of patients sitting at ease under the verandah of one of these cottages, some of them, if not all, having been engaged in wholesome work on the farm during the day. There was an air of freedom and homeishness which is necessarily more or less lost in an ordinary asylum, especially when of giant proportions. And I may say that, although not a few in the States look with a critical eye at what they regard as segregation run mad, the principle itself, that of providing many small buildings in place of a large one, is rapidly advancing in the United States. In fact, there has always been a strong feeling against the aggregation of a large number of patients under one roof; but until compara- tively recent times it did not become necessary (or perhaps it would be more correct to say, the necessity was not recognised) to provide in every State of the Union asylum w 80 Dr, Dewey. accommodation for a large number of acute and chronic cases. The asylum of Kankakee was built in 1878 and '81. When I visited it I found some of the detached buildings in course of erection, and more will eventually be built. There are about 480 acres. Dr. Dewey, the superinten- dent, speaks warmly of the success of the experiment. The number of patients at the present time is C15 (370 men, 2i5 women). Eventually there will be accommoda- tion for 1,500 patients. One large unfurnished building contains a dining hall for 500 patients, 85ft. by C7ft., and is very light and well proportioned. Below this room is a kitchen. The patients will eventually come here to dine from some of the detached buildings for males. At the present time, dinners are conveyed by hand -cars from the main building to the cottages, and, as the dis- tance is considerable, there has been a good deal of criti- cism on this part of the arrangement, but I was assured that the food was not more chilled in the transit from the central kitchen to the detached buildings than when con- veyed to the extreme ends of the main building. It is intended, however, to make use of a special apparatus invented by the New York Catering Company, for keeping meat warm when carried from one spot to another.* I may add that two of the bm'ldings are infirmaries, one for each sex ; the rooms are well adapted for the wards of a general hospital. I regret to say that the male infirmary, which was only just occupied at the time of my visit, has * This, I hoar from Dr. Dewey, lias been tried and has failed to give satisfac- tion. Food-cars of palvanized iron have now been introduced that are closed tightly, atul surrounded with an air chivnibcr, throuirh which a small stove under the car circulates a continuous current of hot air. These prove en- tirely successful. They run easil}' by iiand over the concrete walka which have been provided. There is no covered corridor required. With the tea and cotTeo made in each dining-room, the warniiug closets provided for each, and the tightly closed car, Dr. Dewey maintains that they are able to tret food to the dining-rooms in as goo5eo Chap. iv. Detached Buildings at Washington. 81 been recently burnt, the lives of a number of the patients being lost. There are two houses called " Convalescent Homes," one for each sex. Another is the " Relief Build- ing," which provides for 50 epileptic patients and 21 criminal lunatics. They appeared to be under very good care (one attendant was from an English asylum), and no patients were under mechanical restraint. There is also a recreation hall, used as a chapel as well, which accom- modates 350. As is usual in American asylums, ministers of various denominations from the neiprhbouring town con- duct the services in rotation. While I was at Kankakee there was an evening entertainment in this hall, at which there was music and dancing. In harmony Avith the ruling idea of making as little difference as possible between home and asylum life, the recreation hall is not connected by any covered passage with the main building ; for it is thought that while, on very cold evenings, some patients may be deprived of the pleasure of the entertainment, something is gained from the freshness and change conse- quent upon having to dress and go to a distinct building. I should mention that at Washington also. Dr. Nichols and his successor Dr. Godding have favoured the erection of small additional buildings at Saint Elizabeth, the Government Hospital for the Insane. There was, in the first instance, a cottage for the patients of colour ; and sub- sequently, detached buildings have been erected for (I) feeble-minded children ; (2) quiet, working patients, " The Home ; " (3) the " Relief House," for tranquil patients ; and lastly, " The Rest," the name fitly given to the fosi mor- tem room and mortuary. Here the body is placed in a refrigerator, which is situated between these two rooms, and can be conveyed to either when required. Dr. Shew has carried out the plan of separate buildings at the Middletown Asylum, Connecticut, where there are 900 patients. Here is one annexe for 325 men and women patients, the cooking being done in the building. An assis- tant medical officer and his wife reside here. o 82 Mid(llctow7i, Norristown, etc. An unfinished building, -whicli will be three storeys in height, is designed for chronic cases and epileptics. In addition to these annexes there are no less than five cottages for 25, 20, 33, 16, and 2(5 patients respectively. At Norristown, near Philadelphia, segregation has also been carried out to a considerable extent. Again, at the Concord Asylum, New Hampshire, a very attractive cottage has been erected, at the suggestion of Dr. Bancroft, for a select number of female patients, whoso mental condition allows of their living in an ordinary resi- dence. The provision here is on a small scale, and does not profess to provide for the chronic insane. At Brattleboro, also, in the State of Vermont, Dr. Draper has what is called the '' Summer Retreat," built like a Swiss chidet, and accommodating 20 patients. This house cost £145 per bed. At this asylum there is a se^jaratc ward for criminal lunatics. I will next describe the course pursued in another State, Wisconsin, with a view of providing accommodation for chronic lunatics at a moderate cost. There are already two State asylums (Mendota and Winnebago), and what may be called a semi- State asylum (County Milwaukee), for botb State and county contribute to its support.* They receive both acute and chronic cases, but they are much crowded, and there is constant pressure upon the authori- ties for more room. When we consider the vast sums which Jiave been spent upon the construction of the pro- verbial palatial asylums, amounting in some States to * " Whenever the totsil number of inoaiio persons in this State shall exceed the total number of siieb persons who can be conveniently and properly cared for in the State Institutions for the Insane already existing under the laws of this IState, the Hoard of Supervisors of any county in this State, upon the conditions hereinafter named, may purchase or otherwise provide a proper site, within said county, for the erection of a county asylum for the cure of the insane and inebriate persons, said site to contain not less than 40 acres ; and when said site shall have been apjtroved by the (iovernor, such Board of Supervisors may proceed, as hereinafter jirovided, to erect thereon suitable buiklini;s for the proper care of the number of insane and inebriate persons, not less than 'M nor more than 50 per centum greater thaa the entire number of insane persons then belonging to such county, as such Board of Supervisors may determine.'' (Law of 1S81). Tho Sf/stem in Wisconsin. 83 £G0O per bed, and this without any extraordinary curative results, we cannot be surprised that guardians of the poor and boards of charities sliould make a desperate effort to escape such expenditure, and should set themselves to work to provide humbler domiciles for at least the more harmless and chronic classes of patients — those who are, for the most part, re<:jarded as being incurable. Al- though the cost per bed in the Wisconsin State Asylums would be less than half this amount, the pecuniary element is a strong reason for the course pursued. Thanks to the Wisconsin State Board of Charities, I had every facility afforded me for examining these Institutions ; and from this body collectively, as well as from its Chairman, Mr. Elmore, and its Secretary, Professor Wright, individually, I received the most kind and considerate attention while engaged in inquiring into the operation of the system which they have adopted. This may be described in brief as County care under State supervision. The power to decide whether the counties care properly or not for their insane, upon which depends the all-im- portant matter of an appropriation from the State, rests with the State Board of Charities, and was conferred by the law of 1881, chap. 233, which runs thus :^ "Whenever it ehall appear to the State Board of Charities and Reform that iiisnfficient provision has been made for the care and support of tho insane in the State Hospitals and County Asyhiins previously established, &c., the said Board may tile with the Secretary of State a list of counties in which no County Asylum exists, and which counties, in tho opinion of the Board, possess accommodation for the proper care of the chronic insane ; and thereafter each of tho said counties so-nanioil, which shall care for its chronic insane under such rules as the said Board shall preRcribe, &c., shall receive 1 dollar 50 cents (Os. yd.) per week for each person so cared fcr." It is obviously important that the State should exercise this supervision over counties in regard to their asylums, but in no other State having them, is this check provided except in New York, and there the Board, although it inspects, does not possess the State-appropriation at com- mand to support its actio a. Thus, the counties which take care of their insane under 84 Dane Count )j Asylum, the authority of the Board, receive Gs. 3d. a week for each person so cared for. * I may state that, during' the last year, £9,845 was paid by the State of Wisconsin for this object. Existinii almshouses are adapted to the purpose by the Board, or small asylums are built in their neigh- bourhood. In two counties, however, the asylnms are entirely separate, as there are no almshouses, all relief being out-door relief. In the Consolidated Montlily Report of chronic insane under County care in this State, under the provisions of the above-mentioned Act, it is stated that there are 1 1 counties with asylums varying in capacity from 40 to 100 beds, and containing in all I'o'l patients. It may be added that 4GG, or 63 per cent., of these patients were employed, and that during the month four had been discharged recovered or improved out of this chronic class. No patient had been in continuous, but four in temporary, restraint. I found these small county asylums, on the whole, in a satisfactory condition. The superintendents or masters of the house are laymen of a respectable farmer class, and a medical man in the neighbourhood is engaged to visit at fixed periods, and oftener if necessary. There is a considerable amount of land attached to these houses ; and on visiting one of them (the Dane County Asy- lum at Verona), where there were 97 patients, I found 16, with an attendant, engaged in husking corn. Ordi- narily, a larger number work on the land. One patient had, previous to admission, been confined in a small pen in an almshouse, while others had been rescued from neglect or cruel treatment. The patients chop up a great deal of wood in the winter, and slight rewards are given to workers, by way of encouragement. As I * Last year it cost the counties lid. more a week per head than they received from the State, without allowinjj^ for the investment in buildings and land. It is stated that the salarifs of attendants are much the same in County and in State Asylums. The total cost of chronic insane per head per week in the latter is exactly '6S% dollars, while in the County Asyluma it is only 172. Bodge County Asylum. 86 approaclied this house I observed that tho doors and several of the windows were wide open, and that no bars of any kind were to be seen. It has had open doora from the first. In the dietary of that day the patients had coffee for breakfast, with eggs, pork, and potatoes ; while for dinner they had beef, potatoes, and parsnips. For supper they had tea or milk, with mush (corn meal), and bread and syrup; some had pie. This institution cost about £G,800, or £G8 a bed. In regard to restraint, I found, on referring to the record, that three patients had been restrained in the course of the year. Seclusion had been rarely resorted to. The master, Mr. Myers, evidently felt a warm interest in the patients, and took great pains to induce them to employ themselves. He has a salary of £200 a year. The visiting medical officer has £40. In another of these asylums (the Dodge County Asylum at JuneauJ, built at a cost of £G0 a bed, and having a capacity for 90 patients, I found a considerable number employed in the potato field, in digging, and in husking corn. Some of the latter were formerly immured in the cells of a wretched "crazy-house," long used in con- nection with the almshouse. Maize, potatoes, barley, oats, hay, tomatoes, peas, beet, beans, turnips, parsnips, cabbages, and celery, are raised on the farm. Some patients take the entire charge of the cowhouse, and two are employed to milk the cows. Twenty women were em- ployed in the institution, and four in the adjoining poor- house. The mistress of the house, who was formerly at the old poor-house, gave a graphic description of the con- dition of the patients who had been in the crazy-houses hard by, which I visited. They are interesting in their present empty state, as relics of the past. Prior to 1871, when the State Board of Charities was organised, the patients used to lie on the straw, either naked or in " slips,'* generally without any underclothing. The food used to be given to them on a tin plate thrust through a li 86 Rock County Asylum. hole in tho door. No Utiivcs or forks wero allowed, and a patient would often throw the food on the straw, and eat it like an animal. Tho straw was removed from these pens with a pitchfork. When the present treatment was introduced, the patients had to be taught cleanly habits like children, and made to dress, come to table, and go to bed. I saw an epileptic woman, a German, who had been immured in one of these pens. When they dressed her in blue calico she was mightily pleased, and exclaimed, " Schcin ! " There are ten men and ten women in this asylum who formerly were in the crazy-houses. One day tl.'f mistress took an old woman who had been immured there to revisit them. " She was that uneasy and wild, and said, 'Are you going to put mo into that crazy-house again? Why don't you burn it up?'" The cost per week, including clothing, is 8s. 9d. for each patient. I was curious to examine the record of restraint and seclu- sion in this somewhat out-of-the-way institution, and I thought it worthy of transcription : — Jane 15t]i, 1883. — A. B., shut up in room 8 hours for quarrel- ling. Result, good. July 5th. — Ditto, 9 hours for quarrelling. Result, good. July 29th. — Ditto, 16 hours for disobeying and using indecent language. Result, promised to behave in future. Nov. 8th. — J. L., shut up in room 9 hours, for raising a chair on an attendant. Result, promised good behaviour in future. Dec. 3rd. — C. D., shut up in his room for 10 hours, for assault on attendant. Result, don't seem to have much, if any, effect. Sept. 8th, 1884. — C. D., shut up in bis room half a day, for striking an inmate. Result, don't seem to mind restraint much. No women had been in restraint or seclusion. At another similar institution (the Eock County Asylum, at Johnstown), where there were 75 patients, the master and his wife appeared to be thoroughly in- terested in their work. Active and successful efforts were made to employ the patients. The first three patients Dangers of this Sysf'em, 87 whom [ saw were busy in tlio yard with a cart and potatoes just brouj^ht from the field. One patient who had been admitted from a State Asylum, in rofjfiird to whom the master was warned that he must only allow him the use of a tin plate at meals, was put to work the day after admission, and the result has been very satisfactory. One patient was out with the team six miles off. I saw sixteen patients working in a potato field without an attendant, a competent i)atient acting as overseer. They work five hours a day, and I was glad to hear the master observe that it was not wise to let them work until they are sick of it. On examining the record of restraint for the year ending October, 1884, I did not find more than one case of restraint, viz., by mittens for half a day in June, for violence and striking an attendant. Seclusion had been employed five times for four different cases. Wristlets, mittens, and the camisole had been used during the previous year, but to a very slight ex- tent. Two crib beds were in use, one for an idiot, and another for a restless elderly man, constantly getting out of bed. I should be glad to think that they are never used less considerately in any of the State Asylums on the American Continent. It is stated, and I have no reason to doubt the statement, that there is no resort to "chemical restraint" in these County Asylums. A physician, Dr. Rockwell, resides half a mile off, and visits the house nearly every day. The estimated annual value of the labour done by the 75 inmates is upwards of £200. It was estimated that the labour of IG of the patients was equal to that of the same number of sane persons ; that of 20 equal to half the number of ordinary work people, 15 below this mark, and there were 21 who could not work at all. j\Iany fear that the system thus pursued in Wisconsin for providing for chronic cases will end in grief, as it has done before, and that these institutions in the course of time will become as great a scandal as the old almshouses. p 88 Conditions of Success. However excellent the present Board of Charities may be (and, in my judgment, is), it is urped that its constitution ■will change ere long, and that inferior men will very prob- ably be appointed. In reply to these objections it is said that the management of the State Asylums themselves may fluctuate according to the composition of their Boards, and that, in regard to mechanical restraint, its use is at least as great in these institutions as in the county houses. Further, it is alleged that the County Boards of Supervisors, which are assumed to be composed of an in- ferior class of men, are by no means insusceptible to influence in the right direction from the State Board of Charities, which meets with them and explains the objects in view, and the means by which it considers it necessary to obtain them. Political motives, it is admitted, are a source of weakness and danger. It is very clear that the success of the system requires constant care in the selection of cases, so as not to place in these small county asylums, where there is no resident doctor, acute and curable cases requiring constant medical care. I believe that, among the chronic insane, there is as a matter of fact very little selection of cases, probably too little. The superintendents of the State hospitals furnish the I'sts of chronic insane which are to be returned to the counties. They will, of course, retain the best cases, and sometimes send unsuitable ones to the county asylums. Occasionally the counties return a homicidal or filthy patient. Otherwise they have so far taken all the chronic cases from their own counties, who usually are the worst treated, and therefore, probably, the worst behaved, insane inmates of almshouses. The appointment of similar able and well-intentioned men on the Board of Charities, as well as of thoroughly reliable masters, is also essential to success. Otherwise there will inevitably be a return of the evils from which the insane in the old almshouses have escaped. It is a noteworthy fact that at the present moment, in Relative Merits of American and English Asylums. 89 England, the Lunacy Commissioners are encouraging the increased use of workhouses for the chronic insane by the recent action they have taken in regard to sending a number of this class to workhouses from county asylums. Nothing has been done in America in imitation of Gheel, and there does not appear to be any tendency in that direction. rV. Relative Merits of American and English Asylums. I wish that I could now convey in a few words, by way of summary, a just idea of the respective merits and de- merits of American and English asylums, but this is not altogether an easy, and is certainly rather an invidious, task. Instead of directly giving the palm to either (though what may be regarded as insular prejudice would scarcely allow of my being discontented with our own), I would say that I believe each has something to learn from the other. I think, first, that English asylum-superintendents will, in passing through the wards of American asylums, pick up not a few hints in regard to practical details, which they would find very useful indeed. The Americans are so ingenious and inventive a people that it would have been strange had their asylums not borne some evidence of this ; and there are many little, but still important, matters in which this inventive faculty is applied to the good working of the institution. Again, I think the Americans have been wiser than ourselves in avoiding the construction of so many very large asylums. A third advantage on their side, and partly due to the above fact, is the greater proportion of medical men in most asylums in the Jr^tates than obtains in England, and consequently the possibility, to say the least, of more individual interest in the patients and their treatment. The proportion varies considerably in diflierent States, m 90 Salaries. Black List. but on taking tlio average of a number of American asylums I found it to be 1 in 150; while on making a similar calculation for those in England I found it 1 in 300. At the New York City Asylum for about 1,500 male patients, there were 15 assistauts, several of these being clinical clerks. Further, I like the more frequent practice of having married assistant medical officers. It is thought to in- troduce or retain a better class of men, and to give greater confidence to the friends of patients, especially in the absejice of the superintendent. As a rule, assistants are better paid than with us. Some receive £300 and £380 a year. Attendants are also very liberally paid ; male supervisors receiving from £70 to £100 a year, and ordinary attendants ranging from £50 to £60; female attendants receive £30 to £50 ; matrons and stewards are handsomely paid. The superintendents them- selves are, strange to say, rather under-paid, seeing that they have no pension. I should set the absence of pension against the allowance of full rations granted to the American superintendents, and the liberality of their Committees in paying for their travelling expenses, in many instances, when making even long journeys abroad. Superintendents are often allowed the free use of carriages, horses and servants, so that if they had pen- sions they would be much better paid than British s uperinten dents . I may mention here, in passing, that a good plan is adopted among the superintendents of the New England Asylums, of keeping a "black list" of attendants. Thus Dr. Pliny Earle recently warned the Superintendent of the MidJletown Asylum (Dr. Shew) in the words, " Be- ware of Brown.^' Another superintendent wrote opposite the name of Smith, a discharged attendant, " very bad fellow," and another wrote, " discharged Jones for rough usage of an excited patient ; " while in a fourth case the attendant was designated " intemperate." State Provision /or all Classes. 91 I am not sure whether or not I should set down to the credit of the State asylums in America, that there are usually some paying patients mixed with the others who are supported by the State or County. It is strongly urged that this helps to raise the tone of the institution, and that the non-paying patients are the gainers by this admixture of classes. It may he so. I have my doubts, however ; and rather incline to the restriction of State asylums in America, and County asylums in England, to the pauper class. Certainly, had the American Hospitals for the Insane been intended for paupers only, there would never have been such buildings as the Danvers and the New Worcester Asylums, with their costly furniture and their correspondingly expensive internal economy. Still, there remain serious evils springing from the union of the two classes, and I think I am warranted in saying that Dr. Earle would prefer separate provision for them. The idea that the State should provide accommodation for the insane of all social classes has long prevailed in America. Dr. Kirkbride maintained very strongly that " there is no justification for a State providing accommoda- tion for one portion of its insane, and leaving the restun- cared for." English opinion, on the other hand, has travelled in just the opposite direction, and the State has not seen its way to provide asylums for private patients. Whether we are coming to this, and are about to Ameri- canize our institutions, remains to be seen. There may have been a tendency in the United States to allow a dis- proportionate number of paying patients to occupy the State asylums. Until recently many patients of the pauper class were crowded out of these institutions, and suffered from the gross neglect which befell them in alms- houses. Now that this evil is to a considerable extent rectified, the friends of the higher-class patients require more provision for their relatives, and the consequence is that private asylums are on the increase. In a number of States, c.y., in Ohio, Indiana, Illinois, and Minnesota, 92 Classification. Segregation. there are no pay patients. The institutions are free to all residents of the State who are insane, regardless of their pecuniary condition. The wealthy are supposed to have paid their taxes for the maintenance of their asylums, and to be entitled to their benefits without fur- ther charge, just as they are to the benefits of the public school system. It has been said that the classification of the insane in asylums is more perfect in America than in England, but I cannot say that I was struck with this difference myself, although the arrangements for dividing the corridors at will by folding doors are especially good in some asylums. Dr. Kirkbride had eight separate wards in his asylum, but I do not think that these divisions resulted in much, if any, more practical differentiation of cases than obtains in our asylums ; and, indeed, the rule which he laid down as the basis of classification — the bringing into the same ward patients who would consort well together, and the separation of those who would not — had too much common-sense and simplicity in it to allow of great complexity of arrangement. I think I ought to mention the development of the system of the segregation of patients, to which I have referred as at the present time a feature in American practice ; for although detached buildings for different classes have been long advocated and used in British asylums, * and were at one joeriod discountenanced by alienists in the United States, the separation of cases differing in their mental character, and therefore require- ments, has now been carried to such an extent, and as some hold to such an extreme, that it really forms a marked feature of recent and present movements among the promoters and organizers of asylum provision in the States. I think, therefore, that this strong tendency to * It was originally intended to build the new Worcester Asylum (Mass.) in detached bnildings, to the game extent as at Whittingham (Lancashire), bat the intention was abandoned. Lady-Physicians. Liberal Diet. 93 segregation, which has manifested itself, must be regarded as possessing greater momentum in America at the present moment than even in this country, and that we shall be able to learn something, or be confirmed in what we have already learned, by the plans now being carried out in some of the States. T am, on the whole, disposed to reckon among the advantageous courses pursued by the Americans, the appointment of lady-physicians in some of their asylums — a practice which is certainly growing. I regard it as an experiment, and I think we ought to be grateful to our friends across the water for making it. I would go further, and say tliat if the lady-doctors of the future should be equal in ability and high moral character to those who have hitherto held office, and, if their position is so clearly marked out as to prevent all clashing with other members of the medical staff, they will prove a decided blessing to the female patients in asylums, and a real help to the medical superintendents. Before leaving the congenial task of pointing out the merits of the institutions of our Transatlantic brethren, 1 must not omit to mention the favourable impression I received as to the diet allowed to the patients. I consider it more liberal and as having more variety than in our own asylums. It is probable that in the main the Americans not only feed, but house and warm, their patients better than we do, while individual comfortSj likes, and dislikes, receive rather more recognition and attention in their hospitals than they do in ours ; this is due, no doubt, partially to national differences, and, of course, the same standard will not apply to both countries. As to the comparative demerits of the American asylums, I would repeat that in some, especially the old American institutions, there is not so much employment of the patients as there might be, and as, for the most part, is carried out in those of our own country. (1 ',s and the lectures upon a variety of subjects calcu- lated to interest the patients. The hospital is governed by a Board of Trustees, five in number, which reports annually to the Governor of the Commonwealth of Massachusetts, and the Council. In addition to the visits of the Trustees, the hospital is inspected by the State Board of Health, Lunacy, and 110 Northampton Hospital. '•'I: Charity througli its inspector, Mr. Sanborn, nearly every month. The first cost of building was £158 per bed, land and furniture included ; there bein<^ 340 acres. The number of patients is 4G0 — 227 males, 233 females. Socially, the class of patients is mixed. Dr. Earle endeavours as much as possible to avoid drawing a line of demarcation between the private and public cases. The weekly average number of State patients is 161 ; toAvn patients, 247 ; private patients, 57. Character of patients, mentally; acute and chronic, chiefly the latter. The number of recent cases is, indeed, exceptionally small. The cost per week is 13s. Gd., or £35 per annum. This amount is calculated by dividing the cost for the year (82,000 dollars) by the average number of patients, 4GG-70. If the total expenditure for the year (89,523 dollars) be divided by the average number of patients, the result is £38 4s. 8d., or a weekly average of about 15s. 3d. The previous calculation was obtained after deducting the extraordinary expenses from the year's expenditure, and allowing for certain assets. The weekly average charge per head for all the patients is 14s. Gd. Although a State institution, it has received no gratuitous assistance since 18G7, having relied, for its income, upon the farm and the board-bills of patients. For the entire support of State patients, including clothing, breakage, &c., the hospital received from the State 14s. Gd. per week for each patient, from 1870 to 1879."^ For one year after, it received 12s. Gd., and since 1880 it has received 18s. 8d., the compensation fixed by statute law. For town patients the same weekly sum is received, but the towns clothe their patients and pay for damages. For private patients, the average payment * It may be stated that in Massachusetts, the counties, as political organi. ziitioiis, havo no paupers. Tliere is one county asylum, but its patienta are supported by the towns or cities to which they respectively belong. I \y< Northampton Hospital. ni amounts to somewhat more than £1 a week, clothing and damages being extra charges. The proportion of attendants is 1 to 12. Their salaries are — Men, £4 4s. to £9 per month ; females, £2 12s. to £5. With regard to restraint and seclusion, Dr. Earle has never committed himself to unreserved approval of the non-restraint system, but the amount of restraint is small. There is one singular case, that of a man who insists upon having his wrists secured, and declares that if they are free he will break everything within his reach. The door of his room is open, but he refuses to lenve it. He occupies himself in writing, and drawing diagrams. For several years he refused to wear any clothing; latterly he has worn a long cotton shirt. lie objects to having his hair and beard cut, and they have been alloAved to grow for 18 years. He is, notwithstanding, clean and neat. Seclusion is resorted to, but not frequently. No covered bed was in use when I visited the asylum, nor has there been for the last two years. One without the cover is used by a bad epileptic. Coming now to recoveries, I have already referred to the work done by Dr. Earle in regard to the curability of insanity, and need not repeat it here. It is to be re- gretted that the series of statistical tables prepared by the Board of Health, Lunacy and Charity in 1880 contains no table showinof the total number of recoveries for a lonnrer period than the preceding year, so that unless one has a series of reports at hand, it is impossible to ascertain the experience of an asylum for more than one year, which is worthless. Dr. Earle informs me, however, that from the opening of the asylum to September, 1881, the recoveries have been 22*05 per cent, of the admissions, this low per- centage being largely due to the fact that, the hospital being originally too large to be filled by patients from the locality, it was for nearly twenty years made the recep- tacle for the overflow of the hospitals of the eastern section of the State, most of those thus received being in- 112 iV(?w England Psychological Society. curable. Be adds that of the persons directly committed to the hospital prior to September 30, 1870, the recoveries were 29'Gl per cent. The mortality, calculated on the average number of patients for 25 years (1858 to 1881), was 7*72 percent. For the first 13 years it was 9'05, and for the last 13 years it was only 6*00, a reduction which is attributed to im- provements in the hospital and in the details of the treat- ment pursued. As to treatment, I am not aware that Dr. Earle has any specially favourite drags in the treatment of the insane. He was early opposed to the depletion of patients when formerly so much in vogue in America, as already- stated (p. 21). Chloral is not administered. Cod-liver oil, bark and iron, and other tonics are freely used. Neither prolonged, shower, nor Turkish, baths are employed. The number of cases of general paralysis is very small, viz., two, one being a woman. The paucity of cases is attributed by Dr. Earle to the remoteness of Northampton from the large centres of population. The importance attached by Dr. Earle to the occupa- tion of patients has been already shown by the number employed in the asylum. In the Annual Report, the farm is stated to be one of the important means employed in the hygienic and restorative treatment of the patients, and to afford no inconsiderable source of income — con- siderably upwards of £2,000 per annum. As I shall have to mention that a large number of strangers are allowed to visit some of the American asylums, I may add that the practice of admitting the public indiscriminately to the wards of the Northampton Hospital was abolished more than 10 years ago. After spending several days at Northampton, and attend- ing the meeting of the New England Psychological Society at Boston, referred to at p. 76, I visited the McLean Asylum at Somerville, on the outskirts of the city, accompanied by Dr. Baker. It possesses about 100 acres of land. lill poi he thj call bu[ deii of McLean Asylum. 113 It niiglit have been supposed that there would not be any very novel feature to point out in an old institution like the McLean Asylum. There are, however, not a few points of interest. When Dr. Buckiiill visited it in 1875, lie was informed that before long it would be removed to the country. Unfortunately this intention has never been carried out, and the condition of always expecting to move, but never moving, cannot fail to produce a somewhat depressing effect upon the managers and staff:'. In spite of this, however, the efficient Superintendent, Dr. Cowles, has introduced many improvements, and succeeded in making the corridors and rooms of the present structure as comfortable as possible. Many of the rooms were handsomely furnished, and the patients had the appear- ance of being well cared-for in every way. I may re- mark, in passing, that the distinguished Dr. Bell, who has given his name to one form of insanity, was formerly Superintendent of this institution. The asylum is governed by a Board of Trustees of the Massachusetts General Hospital, with which it is associated ; and it is inspected by the State Board of Health, Lunacy, and Charity at irregular periods, generally twice a-year. The number of patients is 170; 95 males and 75 females. They belong mostly to the upper classes of society. In a recent Report it is stated that, of 82 persons admitted, 53 were recent cases, and 21) chronic or incurable. The cost per week is on an average as high as £3 per patient. There is a considerable annual deficiency, which is made up from a special fund. The highest payment is £15 a week; several patients pay £10. A common pay- ment is 28s. ; a few pay 48s. a week. The proportion of attendants to patients is 1 to 3; 17 persons are on duty at night — including these, the propor- tion is nearly 1 to 2. Their salaries per month are — males, £4 12s., rising to £0 ; females, £2 IGs. to £4. Those in special wards, and the females in the men's department, get £1 extra a month, or £G0 a-year. lU McLean Asylum, m m Dr. (^wlos attiiclios pfroat imiiortanco to tho employ- iTiont of I'enuilo iiursos in the male wards. lie believes this to bo as easily mana<^'ecl as in a {^'enoral hospital. He liolds that it is unnatural for patients to be placed in asylums luider entirely different conditions, in ref^nird to female society, from what they have been accustomed to at home. They de^'enerato in speech and conduct, and the male attendants are also injuriously affected. The presence of female nurses restrains and softens the insane, and enforces self-control.* All this may be true, but it is obvious that tho practical carryinpf out of the system must add {^nratly to the anxiety of the Superintendent, and that it should be introduced only by one who is confident that he can carry it out successfully. Nor should it be introduced into all asylums. I would add as a valuable feature of this asylum that it forms a trainin*^ school for nurses. This is probably rendered easier from its close connection with the general hospital. Several patients were restrained and in seclusion. In regard to recoveries, Dr. Cowles, in reporting tho percentage in one year as 30"48, observes that this is a larger proportion by five than in any year since 1870, which is partly attributed to the Danvers Asylum being full, and therefore the McLean Asylum receiving more acute cases than before. Of G,(jO !• admissions since the opening of the institution in 1818, 944 have died ; but no table shows the mortality on the average number resident for this period. Since 1837 the percentage, so calculated, is about 10. Dr. Cowles makes some discriminating remarks, in his Report, on the use of massarfe in insanity. He observes that, in his experiments during three years with the "rest treatment/' he had found it necessary to modify it, some cases having their mental depression increased thereby, while others with great nervous irritability and * Dr. Cowles might tako for his text, Emollit mores, nee sinit esseferos. Social Science, Saratoga. 115 nploy- jUcves spital. 30(1 in ard to 110(1 to it, and . The insiino, , but it system LMld(,Mlt, who is f. Nor L add as ;rainin|,' ,er from 1. ting tlic iliis is a 1870, ,n being cv more Ititution [ortality Since in bis Observes Itk the I modify Icreased lity and Bse Zeros. anguish found that enforced rest was intolt^rabh^ — indeed, positively harniful. ll(! obs(n'ves : " Wiiilo rest is usi't'ul in s(;ine conditions ol" melancholia,, ttc, and benelit has been (leriv(3d from massage, by producing tissue waste and im- proving nutrition, and from the other means of treat- ment, 'seclusion' has been almost entirely abandoned, iis not useful, and as depriving the patient of what is beneficial." Ho quotes from a, letter addressed to him l)y Dr. Weir Mitchell, in which he says that in the treatment of " not a small number of cases of melan- cliolia, with bad nutritive break-down, in which I iittempted to relievo by rest, &c., I made some successes, but more failures — made, in fact, so many that I gave up at lust tho effort to treat in this way distinct cases of melancholy. ... I may iiso massage or electricity in melancholy, but I do not seclude or rest these cases." The visit to this excellent institution was somewhat hurried by our having to be present at the American Social Science meeting held at Saratoga on Sept. 12. Here the lunacy laws were discussed, and tho opportunity occurred for a friendly interchange of sentiment on the legislation for the care and protection (^f the insane in Great Britain and the United States. Professor Wayland presided, and in the absence of Mr. F. II. Wines, Mr. tSaiiborn read a paper by the latter on the laws of lunacy ill the diil'erent States of the Union, for which the author expressed his indebtedness to Mr. George Harrison, of Philadelphia, whose useful compilation is widely known.* It proved an interesting re\nion. We proceeded from Saratoga to Utica, where wo were met by Dr. John P. Gray, whose asylum, the New York State Hospital for the Insane, next claims our attention. * '' Legislation on Insanity," &c., by Goo. L. Uarrison, LL.l)., laio Pro. fiiilint ot" tho Board ot' Public Cliariiios of I'dinsylvania. I'hiladolphiii, 1S!:<4. Dr. tharlos i\ Fulson, of Boston, Las also issuod a very useful book, entitled " Abstract of the Statutes of tho United States, relating to the Custody of tho Insane." Pliilatlelphia, 1SS4. Ur. Folsou is tho Asaid- laut Trofcsaor of Mental Diseases, Harvard Aledical ycbuol. 116 Utica Asylum. Ill The characteristic feature of this institution is Dr. Gray himself, who for 30 years has been the Superintendent. His distinctive personality has lonf^ made itself felt in the States, and, of course, more particularly in the asylum of which he has been Medical Superintendent for so many years. The well-known Dr. Brigham was the first superin- tendent. One of the noteworthy arrangements of the institution, though not peculiar to it, is the employment of a pathologist, who resides in a separate house, and has every means placed at his command for carrying out his observations and microscopical examinations. I have already mentioned Dr. Deecke as holding this post, and need not again refer to this aspect of the hospital.* It is surprising that out of between 50 and 60 deaths in a year only about a dozen post-mortems should be obtained. The entra-ice to the asylum, which was opened in 1843, forcibly recalls the stone columns and portico of Bethlem Hospital. The central building consists of four storeys ; the wings, three in number, being of different heights and having one, two, a.nd three storeys. A building is being added for female patients of the excited class, which is well adapted for the purpose. The equable temperature of the asylum is well indicated by a chart, showing a marked difference between the outer and inner ranges of tempera- ture. The fan system of ventilation, to which the American superintendents attach much importance in their variable climate, is carried out to great perfection in the Utica Asylum. In fact, this was the first American • As is well known, ho has made sections of the brain and cord for microscopic examination and photo<^ra]iliy, covering whole areas of the actual size, lie employs a very sharp knit'i- Ki inches in length, to the ends of which upright handles are attached. W'wh this formidable instrument he makes 40O sections to an inch, and can make as many as .")U0. The brain ia hardened in alcohol and bichromate of aimnonia. The amount of alcohol ia gradually increased, and the tluid changed from week to week so long as it is turbid. S(nne brains require six or seven months' soaking. The brain is fixed in wax, or rather a composition of tallow, olive oil, and paraffin, iu which material a brain was placed at the time of oar visit. Utica Asylum. 117 asylum in which the system of forced ventilation and steam heating was introduced. A very striking feature of this, and some other asylums in the States, is the enormous number of visitors who come from motives of curiosity to visit the institution. Last year as many as 6,881 passed through the wards, in addition to 4,977 friends of patients. This must be a great inconvenience to the officers ; at the same time it may have its advantages in giving confidence to the public. And yet, strange to say, there exists in regard to the management of asylums a very uneasy and suspicious feeling, from which Utica has certainly not escaped, notwithstanding the long service and celebrity of Dr. Gray. In the last annual Report of the managers, reference is made to this unfortunate feel- ing, and it is observed : " The actual accessibility of these institutions to all who wish to be informed of their management, and their actual inspection by thousands of visitors annual'y, ought to make such persons as are perfect strangers to them hesitate to insinuate charges against them except upon evidence that is verifiable and indisputable. . . . The officers of State asylums, whether managers or medical men in immediate charge of patients, can have no possible interest in retaining those who have recovered, but every interest in their discharge as soon as their condition will warrant it. . . . The report of every year contains the record of a number of persons who are brought to the asylum as insane on legal papers approved by courts, and believed to be insane by those committing them, but whom, upon examination and observation, the superintendent and medical officers found to be sane and so discharged them. This year there are 13, and during the history of the insti ution there have been brought as insane and found by the officers to be sane, and so discharged, 251 persons.'' While this statement exonerates tlie asylum from receiving sane persons, it cannot but strike an English- man as very remarkable and unsatisfactory that so large a fHliJi 118 Utica Asylum. number of sane persons should be certified to be insane so, makinjx allowance for a certain are not who number of cases in which there may be a legitimate difference of opinion. It is the more remarkable, seeing that these certifiicates have received the sanction of Courts of Law. The conclusion seems to be inevitable that, in the State of New York at least, nieflical men sign certificates of lunacy who know very litth out it, and that Courts endorse these documents as a tter of form, and that, therefore, this endorsement is not the check which the public no doubt expects it to be. Dr. Gray holds decided vicAvs on many points, and, as is well known, is a stout defender of the use of mechanical restraint, including the crib-bed. He does not, however, approve of seclusion, and prefers a waist-belt and chair for an excited patient. The record of restraint was freely placed at my disposal. The month's entries showed that 14 patients had been restrained for periods of time varying from one day to four weeks. Restraint took the form of belt and wristlets, jacket with blind sleeves, leather muff", and the covered bed. Of these we saw examples as we passed through the wards. A point to which Dr. Gray attaches much importance is classification. He holds that asylums should generally have as many as 12 wards for each sex, and as many as 14 if the number of patients amounts to 600. He observes that the collection of great numbers in one ward *Mestroys all idea or semblance of home or domestic natural life. . . A great dormitory-system is simply a process of herding people together, and an institution becomes a mere barracks and all individuality is lost." He has, therefore, no affection for the scene presented by some of our English asylums constructed to accommodate large numbers of pauper lunatics. Dr. Gray is one of the few superintendents who have made special arrangements for the supervision by night of the acutely suicidal patients. On the women's side there were 20 of this class in one ward, and 30 slept there Utica Asylum. 119 under the supervision of a nurse sitting by the open door. The night-watch, who visits every hour, is a further check on anything happening. There are at the Utica Asylum four assistant medical officers, of whom one, Dr. Brush,"^ has visited the asylums of this country. Another, Dr. Blumer, is himself an Englishman. This is a State institution (New York) under a Board of Managers, nine in number. These appoint the superin- tendent, and his subordinate ofiicers on his nomination. The Board meets quarterly to transact business. A House Committee meets much oftener. Visitation is effected by (1) One or more members of the Board of Management; (2) The State Commissioner of Lunacy, Dr. Stephen Smith, who is appointed by the Governor and Senate, visits from three to five times a year, and reports to the Governor. Further (3) the Board of State Charities, consisting of 11 members and four ex-officio members, inspects the institution through the sub-com- mittee appointed for asylums and almshouses. This Board is appointed by the Governor and Senate, and visits the asylum twice a year. The number of patients is 600, namely, 309 males and 291 females. They are of various classes. As to the class of patients mentally, chronic cases of insanity ought, as a general rule, to be sent to the Willard Asylum, so allowing more room for acute cases at TJtica, but the admissions are not determined by the asylum authorities. The County Boards of Supervisors frequently send cases to neither Willard nor Utica, but to almshouses, because the cost is less. There were six cases of general paralysis among the women, and 32 among the men. The highest number of epileptics at one time during the last six years was 22. * Dr. Brush has recently been appointed Deputy Medical Superintendent of the male department of the Feimsylvaiiia Hospital for the Insane, Philadelphia, an appointment on which all coacerued with the institution may bo congratulated. 120 Utica Asylum. «1. iui, The cost per week is 24s. With regard to the class of patients socially, and the charges, one-fifth to one-fourth of the inmates are pay patients, the amount varying from 24s. to £2 a week. If they have a special attendant and separate bedroom, patients pay from £4 to £6 a week. Last year £8,G00 was received from private patients. The rest are paid for by the counties at the rate of 16s. Sd. a week. The county pays for clothing and incidental expenses, which average about Is. 9d. weekly. The proportion of attendants to patients is creditable, namely, 1 to 7. Their salaries are, on the male side of the house, from £4 to £8 per month. The female supervisor gets £5 a month. With regard to recoveries, calculated on the admissions, the percentage varies in different years from 19'20 to 66'07. Last year it was 31 -OG. The total number of ad- missions from the opening in 1843 to 1883, was 15,207, of whom 5,508, or 36 per cent., were discharged recovered. As to deaths during the same period, the percentage upon the average population varied from 5*70 to 18*14. Last year it was 9"64. There is at this asylum a Turkish bath for the men patients, but it is not quite up to the mark. The ordinary bath-rooms are very good. As to medical treatment generally, I do not find anything specially to comment upon. About 30 women were taking sedative draughts at bed-time. I find the average percentage of men employed to be 35'31 ; women, 37"93. In September, 1883, 67 men and 47 women were employed in general work; 16 men and 27 women in ward work ; 27 men and 43 women in dining-room work ; being a total of 1 10 men and 116 women employed in a daily average population of 606 patients. At the time of our visit, 105 men were occupied, namely, 57 in-doors and 48 out of doors ; on fine days 60 would pro- bably be engaged in outdoor work ; 106 women were em- ployed in sewing, and in the laundry, kitchen, and wards. Form of Certificate. 121 It is worth wliile giving here the regulations in regard to admission of patieni;s into asyhims in New York State, and the form of certificates. No patient can be confined as a lunatic in any institution in the State of New York without the certificate of two physicians under oath. Further, no person can be confined more than five days without such certificate being approved by a judge or justice of a Court of Eecord of the county. These may institute enquiries and take proofs as to any alleged lunacy, before approving or disapproving of such certifi- cate, and may call a jury. The j)hysicians signing the certificate must be of reputable character, graduates of some incorporated Medical College, permanent residents in the State, and in practice at least three years. The form of certificate is prescribed by the State Commissioner in Lunacy, and must bear date of not more than 10 days prior to admission. The form of medical certificate is as follows : " I, A. B., a resident of , being a graduate of , and having practised as a physician, three years, hereby certify under oath that on the day of , I personally examined C. D., of (here insert age, sex, married or single, and occupation), and that the said C. D. is insane, and a proper person for care and treatment under the provisions of chapter 446 of the Laws of 1874. " I further certify that I have formed this opinion on the following grounds, viz. (facts). And I further declare that my qualifications as a medical examiner in lunacy have been duly attested and certified by (here insert the name oi the judge granting such certificate).^' Certificate of judge : " I hereby certify that A. B., of , is personally known to me as a reputable physician, and is possessed of the qualifications required by chapter 44G of the Laws of 1874, and I approve of the above certificate." The next asylum visited was the Massaclmsetfs State Hospital for the Insane, at Dancers. It has the character of having been one of the most expensive buildings for 122 Darners Asylum, tlie insane in the United States. It was designed for 500 patients, and cost witli the land over one million and a half dollars, or about £G00 a bed, without furnishing. There are 200 acres of land. As might be expected, this large outlay has occasioned no small amount of adverse criticism, and much has been said in consequence against erecting asylums for the insane as if they were intended rather as palaces for ■'nrces than institutions for State lunatics. The ten lenc\ 4)0 extremes is extraordinary ; and no contrast could possibly be greater than that presented by the cells of almshouses, from which many of the patients come, and the lofty rooms and spacious corridors provided by the State Hospital ^ "■^■^iivors. The superintendeno, !>' >'' oldsmith, is intimately ac- quainted with British ^sylu-^n.^ He is the youngest asylum superintendent 'n the Si;.' • s-, He superintends with much vigour uiid kiimne ", ^i t. ' ' ■? condition of the asylum is throughout highly sn'tisf. . -ry, so far as management is concerned. The faults which exist have reference to the original construction and arrangement of the wards. It is remarkable that an institution so re- cently built should be provided with such obtrusive means of guarding the patients from the possibility of escape, and the windows from that of being broken. One feature of this asylum is the appointment of a lady physician, Dr. Julia K. Gary, as assistant medical officer. There are four assistant medical officers. Each has charge of two floors in the asylum. Dr. Julia Gary takes charge of the two lower floors on the women's side. The government is vested in a Board of Trustees appointed by the Governor of the State. The number was originally five ; two ladies have more recently been added. They serve five years, and are re-eligible. They meet monthly. Visitation is effected by (1) members of the Board, monthly and oftener; one lady visits weekly; (2) The State Board of Health, Lunacy, &c., annually, and by Danvers Asylum. 123 their Inspector monthly ; (3) The Governor of the State annually ; (4) There is also a Board of Visiting Physicians. The number of patients is 718; 337 men, 381 women. They are a mixed class socially. There are lOG private patients. Mentally, they are acute and chronic. The patients may be classified as the quiet, the more dis- turbed, the chronic and broken-down, the sick, and the refractory. With regard to type of disease, there were about 40 patients, including six women, labouring under general paralysis. Dr. Goldsmith observes in his Report that the table of statistics of the causes of death shows that the number in any year is closely proportionate to the number of cases of general paralysis. Danvers is noteworthy for the large number of admissions. These amounted last year to 500, a large proportion being acute cases. The cost per week is 15s. 8d. As to charge, nearly all private patients pay £1 a week, and have abed and sitting- room. (Carriage drives are charged). Six pay £2 a week, four £3 a week, and have separate attendants. For a gentleman with an attendant the charge would be £4. The State pays 13s. 6d. a week for the poor patients. The proportion of attendants to patients is 1 to 10, exclusive of the special attendants on private patients. Four men and six women are engaged as night-watches. The salaries of attendants are as follows : — Males, £3 12s. a month, rising to £5 13s., the average being about £5. Women, £2 16s., with rise to £4, the average being £3 10s. No uniform allowed except caps. With regard to restraint and seclusion, Dr. Goldsmith is strongly opposed to mechanical restraint excej^t in very rare cases indeed. On the female side, restraint had only been resorted to during the last two years in cases of ex- treme violence. Several attendants were sitting by the side of, and endeavouring to soothe, noisy and excited women. During last year, only one man had been in restraint. 1 124 Danvers Asylum. Danvers is the only hospital for the insane, among those I visited, which was provided with padded rooms, of which there are three. One man was restrained. Seclusion is but little used, as the records showed. The recoveries given in the tables are for the past year only, and so in regard to deaths. They do not afford any information as to the percentage of deaths on the mean number resident, excejit for the same period. As to employment, a number of patients are employed in brush-making, which takes the place of sewing among the women. It is easy work, and has been found very useful. It is stated that 40 per cent, of the men, and 43 per cent, of the women, were employed in one way or another during last year. This includes hair-picking, work on the farm, and in the laundry, kitchen, &c. It may be stated here that there is a (locked) letter-box placed in the wards for the use of patients, as at North- ampton, &c., which the inspector from the Board of Health, Lunacy, and Charity examines every month. As a rule he finds very few letters. In consequence of the overcrowding in this and other asylums in Massachusetts, Dr. Goldsmith suggests the boarding-out of a select number of patients in private families, accompanied by systematic supervision by a pro- perly qualified medical man. The insane in large towns might, he thinks, be provided for in buildings of their own, as is already partially done. Demented and broken- down cases might be cared for in a department of the almshouses, provided they are subjected to vigilant inspection. But a large number would remain unpro- vided for, and for these it would become necessary for the Commonwealth to erect a building located near the present hospitals, though suflSciently distant to prevent the incur- ably demented habitually coming in contact with the cura- ble. Such a building would be after the pattern of those at Willard or Middletown (Conn,), costing only about £60 a bed. Had the Danvers Asylum been old, Dr. Worcester Chronic Asylum, 125 Goldsmitli would have suggested its occupation by chronic cases, provision for curable patients being made in a smaller building in the vicinity. Dr. The next institution visited was the Worcester Chronic i4s!/?wwi, established bylaw in 1877 in the buildings of the old Worcester Hospital for the Insane, which was opened in 1833. The present superintendent, Dr. Quinby, was appointed in 1879 ; he is the Secretary to the New Eng- land Psychological Society. The well-known Dr. Wood- ward was the first superintendent of the original hospital in 1833. What is really remarkable in this asylum is, that an old building in the town, very near the Hail way Station, is rendered exceedingly comfortable and homeish by the ability and attention of the superintendent, who devotes himself to making the wards and the patients clean, neat, and comfortable to an extent which is highly creditable. In fact, with such minute and considerate attention to details, I can well understand how patients find themselves more at home in such a building, what- ever its structural defects may be, than in asylums with wide corridors and lofty day-rooms, built on the most expensive scale. There is one assistant medical officer. The government is vested in a Board of Trustees, five in number. Two women trustees have been recently added. Visitation is made by the State Board of Health, etc., at least once a year; also by the governor and council annually. The inspector (Mr. Sanborn) visits almost monthly for the above Board. The number of patients is 387; 209 men, 178 women. There are none of the private class. The weekly cost is 12s 8d. The State pays los. ()d., which includes clothing. The town pays extra for clothing and breakage. The salaries of attendants are as follows : — Supervisor, £4 per month ; men attendants begin with £4, rising to 126 Worcester Chronic Asylum. £4 12s. per month; nurses begin with £2 12s., rising to £3. Dr. Quinby said that the chief difl&culty lay in getting good me)i. He speaks of the pay as little better than that of a day labourer. With regard to restraint and seclusion, I found that since January 1st, 1884, no mechanical restraint had been resorted to on the male side of the house, except in the case of one man who had worn a belt and wristlets, on ac- count of his attempts to commit dangerous acts. He nearly succeeded in killing one attendant and two patients. Another patient was restrained in the same way at the time of my visit, but was very loosely fastened. Seclusion had been employed since January on only three occasions, and for a short time. On the female side there had been, during six months, viz., January to June, three women on an average in some form of restraint, and there was a continuous record of seclusion in regard to one woman. During the three months prior to my visit, there had not been more than two women in restraint at any one time. Crowding has been the chief cause of restraint, it not being thought safe to allow certain patients who sleep in the corridors to be free. There is no crib bed. Dr. Quinby characterized it as a " nasty arrangement." No recoveries are reported. There were during last year eight discharges, four having been removed to poor- houses, three taken by friends, and one male having "eloped," which, more Americano, means nothing worse than "escaped." The statistical tables in the Report do not afford any information as to the recoveries or the mor- tality of patients during the history of the hospital. As is observed in the annual Report : " From the nature of the cases of disease, no very satisfactory results can be expected." If, however, curative treatment is out of the question, the patients are made as comfortable as is possible. Lastly, as to employment, it is observed in the Annual Report (1884) : " Although we compel no one to work, wel evj fac A be I wol sin dul thjj the moi wo State Asylum^ Worcester. 127 we usG every effort to persuade patients to do so, how- ever little their labour may be worth. As a matter of fact, it is worth but little save to the patient himself. A record of the number of day's work performed would be misleading as, save in very exceptional cases, it would not mean a days' work in the ordinary sense, but simply that the patient had been more or less employed during the time specified ; nor would it necessarily mean that anything had been added thereby to the income of the asylum, for in a majority of cases it actually costs more for necessary supervision than the work itself is worth." Dr. The State Lunatic Asylum at Worcester is some distance from the town, and bears a general resemblance to that at Danvers. It is superintended by Dr. Park. It was opened in 1877, and was designed for 500 patients. There arc 300 acres of land. The cost per bed was about £250. The view from the front is very extensive and beautiful, comprising Lake Quinsigamond, seven miles in length, which is frozen over in winter. The centre of the building contains the oflices of administration ; the wings on either side admit of complete separation of different classes, and retreat en echelon. When shown into the reception-room, we found several persons waiting to be shown round the establishment, according to American custom. Visitors arrive every day except Sunday. This asylum is charac- terized by the excellence of its management, as well as by the size of the building, the spaciousness of its rooms, and the haudsome way in which many of them are furnished. There are four assistant medical officers. A lady physician will be appointed this year. The Board of Trustees consists of five men and two women, who meet once a month. Visitation is made by the State Board of Health, Lunacy, and Charity. There are 749 patients, of whom 378 are males. 128 State Asylum, Worcester. The patients belong socially to the private and public classes: State patients, 1G9; town patients, 4G1 ; private, 119. Although the old Hospital is reserved for incurable cases, the new institution admitted last year 05 chronic maniacs, 28 cases of chronic melancholia, 9 cases of chronic dementia, and 17 ,of senile dementia. There are 30 criminal lunatics in the house — a great misfortune. The average cost per week is Hs 5d., and the charge per week 13s. 6d. Some patients pay from £3 to £7. The proportion of attendants is 1 to 10. As regards restraint and seclusion, several criminal patients were in restraint. Some are of a very dangerous class, and ought to be in a special asylum for criminal lunatics. The total number of patients restrained was IG. Three of the criminal patients are in constant seclusion. Of the total number of cases admitted since the opening of the asylum, viz., 13,487, 4,857 recovered, or 36 percent. The annual percentage of deaths on the average numbers has varied from 3*73 to 15*90. During the last six years it has varied from 7'29 to 9"32. Since the opening of the institution to the present time, the percentage of deaths on the mean number resident was per cent. In his treatment. Dr. Park uses hyoscyamine ; A of a grain is the largest amount he has given hypodermically. He usually gives -j\y or j\ of a grain. He does not often give it by the mouth. In several cases he has had to administer an antidote. He only gives it when the patient is in bed or in a chair. In reference to employment, it is stated in the Annual Eeport that " a large number of patients in charge of attendants have been employed in outdoor labour with much benefit to themselves." On the women's side, " a large number who would otherwise have spent tbeir time in absolute idleness or worse, came to be quite expert in the use of knitting-needles in consequence of the purchase of yarn in order to encourage this work." Hand-looms for weaving rugs and mats were being made for the use of both sexes. Butkr Hospital for Insane, 129 rge of with de, " a r time ert in rchase ms for use of The Tinilcr Uoxpital for the Insane, at Providonco, Rhode Tslaiul, was next visited. Special interest attaches to this institution from its having been, tor more than 20 years, superintended by the late distinguished alienist Dr. Riiy, through whom it has become tamili;ir to English physicians. Fortunately, the present superintendent, Dr. Sawyer, has carried on the administration of the institu- tion ii same spirit as his predecessor. A v^.j pleasing feature of this hospital is a drive in the grounds of the institution, 2^ miles in length, through I'eautit'ul trees and by several streams of water. [ do not know any asyhnn for the insane possessing within its own boundary as tine a drive and more delightful views, al- though the hospital for the insane at Brattleboro possesses in some respects equal advantages. There are 150 acres, oO or 00 of which are under cultivation. The nett profit of the farm last year was £o50. On the farm are 25 cows, a largo number of i)igs, and 15 horses, 1 1 of which are for carriage use in taking out patients. Two of the female attendi> drive. There are thirteen carriages. An c .nt additional building called "■The Duncan," from the gentleman at whose expense it was built, niu t be mentioned among the features of this institution. It acconnnodates oO patients, nearly all the bedrooms being single. The general condition of this hospital is highly satisfactory, and most of the wards are exceedingly well furnished, bright and cheerful. The bedrooms are built on one side of the corridor, and an endeavour has been made to break up the wards as much as possible, so as to avoid having too large a number of patients together. "The Ray Hall " is so designated in honour of the late Br. Ray, by whom it was planned. It contains a bowling alley, for the use of the female jMitients, 50ft. by 10ft. Another is provided for men. Above are the reading- rooms and museum. There is also a billiard-room. The government of this institution is vested in a Board of twelve trustees. fj 130 Butler Hospital for Insane. As to visitation, in addition to the Visitinj^ Committee, two of whom are appointed for weekly inspection, there is the State Board of Charities, consistinf^ of nine persons, appointed by the Governor of Rhode Island, who him- self visits occasionally. The nuinbor of patients is 198 ; 92 males, 106 females. Socially they are of a mixed class. The cost per week is Sis. Gd.,'^ and the charge per week averages about the same, varying from 21s. to £10 a week. Forty-two patients are paid for by the town, at the rate of 21s. per week. There are 15G private patients, of whom twelve pay about £3 ; three pay £3 12s. ; five pay £4; one pays £5; three pay £7; and one pays £10 per week. The proportion of attendants to patients is one to be- tween five and six. There are also five night-watches, four inside the building and one out. Salaries of attendants : Male supervisor,! £180 a year ; other male attendants, £5 5s. to £7 7s per month ; Female supervisor, £100 a year; attendants, £2 18s. to £4 4s. a month. With regard to restraint and seclusion, the record con- tained very few entries under either head. The use of mechanical restraint is quite exceptional. There were two women in seclusion in the refractory wai'd. In the door was a small slit, glazed, to allow of inspection. On the male side no patient was in seclusion or restraint. In reference to recoveries and deaths, the only statis- tical table in the annual report, is one of admissions and discharges since the opening of the institution in 1848. 3,039 have been admitted, and of these 1,015 have re- covered, being at the rate of 33-3 per cent. There have been 510 deaths. The mean annual mortality per cent, resident since 1848 is, as nearly as can be given, 10. There is nothing special to remark in regard to the • At f'hcndlo (^^a)^cllo^itol• l^nviil Hospital for the Insane), the cost nor week is 4l.'s. ( at tlio Yoik Retreat, 37s. 4(1.; and at St. Andrew's Hospital for the Insane, Northampton (Enpiand), 40s. per week. t Has been 'J5 rears at the Asvluni. Butler Hospital for Insane. 131 medicines used in this hospital. Tlie common mixture of chloral (10 grs.) and bromide (15 grs.) is given at bed- time for insomnia, and repeated in the night if necessary. Tlie record of employment shows that there are 20 men employed out of doors and three indoors ; Avhile on the female side 26 patients are employed in the laundry, and in the Superintendent's house. " There is hardly a patient or employe who does not take some interest and find pleasure in some part of the farm operations." The recreation -I'oom accommodates 180 patients and 20 atten- dants. An exhibition of the magic lantern is given on Tuesday evenings, and a concert or dramatic entertain- ment on Friday evenings, during nine months of the year. Dancing is not practised. Certificates. — The medical certificate, signed by two physicians, does not waste words; it simply says : — "1^6 herehj certify/ that A. B., of C. D., is insane," and the order signed by a guardian or nearest relative or friend is equally simple: "/ rcqued that the above named insane 'person may he admitted as a patient into the Butler Hospital for the insane."" The Secretary of State and the Agent of the Board of State Charities constitute a Board of Commissioners with whom any patient may communicate by letter (un- opened), and whose duty it is to investigate complaints and correct abuses. It may be added to the above summary that the Board of Trustees, in their report of 1881, state that insanity is evidently becoming more prevalent every year in the United States, and especially in New England. As the hospital is overcrowded, increased accommodation is to be provided; it is also intended to erect detached cottages. Dr. Sawyer uses, for checking the night-watches, an electric clock, called " the American Watchman's Detec- tor" (New York). The original price was £25. The extra expense of connecting it with the wards was about £10. A carpenter and a man from the office were engaged for 132 State Asylum, Rhode Island. a fortniglit in the work. Altogether the clock cost the asylum some £50. Its advantages were laconically sum- marised by Dr. Sawyer as " simple, noiseless, and suc- cessful." It is a 2r)-station clock. This asylum was planned by Dr. Bell, formerly well- known as the siii)erintendent of the McLean Asylum. In the public cemetery (Swan Point), not far from the institution, lie the renniins of Dr. Ilav, and on his tomb, wliich is of granite, is the following inscription : — "Isaac Ray, M.D., LL.D., born at Beverly, Mass., January 1(!, 1807. Died at Philadelphia, Pa., Marcb IJl, 1881. Super- intendent and Physician of the Butler Hospital for the Insane, from January 1, 18tG, to January 1, 1807." There is also an inscrip.tion recording the death of his only son, B. Lincoln Pay, M.D., who died in ]87l>, aged 43, to the great grief of his father, whose end is said to have been hastened thereby. After leaving the Butler Asylum, we proceeded, accom- panied by the assistant medical officer, Dr. Hall, to the State Asylum for the Incurable Insane, Ehode Island. This institution, in operation abont 12 years, is situated at Cranston, a few miles from Providence. Dr. Stimson is the deputy superintendent, under the direction of the Superintendent of State Institutions, Mr. Hunt. Taking all the institutions on what is called the " State Farm," namely the asylum, the prison, the almshouse, and the reformatory school, there was during last year an average of 1,138 inmates. The government and inspection centre in the Board of State Charities and Corrections of Ehode Island. There are nine members, and they frequently meet at Cranston, and at Providence, where we had an interview with them. The chairman, Mr. Pendleton, kindly joined ns at the farm, which consists of about 500 acres, eleven of which are available for the insane. Of four buildings occupied by the male patients, one U State Asylum, Rhode Island. 133 one is a cruciform building of wood on a stone foundation, uncellared, and of only one storey, with slate roof, for 72 mild cases, with two attendants. It cost about £1,200. Another building of stone accommodates 12 patients, and is used as a hospital. It cost £1400. A third building, 112ft. in length, providing accommo- dation for 40 patients, some of whom are epileptics, cost about £],000. A fourth is designed for 50 patients, who arc more excited. At one end of the corridor is an atten- dants' room, Avhich commands a full view of the ward. A building called the AVomen's Pavilion accommodates 55 iiatients. Only 38 patients sleep in this house, the remainder sleeping in the " Stone Hall." This is the next building, and is 140ft. in length. It is for the quiet class, and provides 41) beds in single rooms. There is only one long day-room. The next building is a hospital for 9 female patients. A fourth house for lemale patients, similar to the one in the men's department in the form of a cross, provides beds for GO patients. The total number of patients is 31C, the sexes being about equal. Tliere are, it need hardly be said, no i)rivate patients. As to their mental state, although, as 1 have said, the asylum is for incurables, a recent law allows of acute cases also being admitted."^ The cost per week is low, namely, 9s. 4d., including salaries and clothing as well as food. A certain appro- priation is made annually by the Legislature, and it olten happens that a portion of it is returned to the (jovern- mcnt. It may be added that the nett cost of all the in- unites of the State Farm, sane and insane, during the year, was under £22 per head, while at the Butler Hospital the weekly cost was 338. 9d. The proportion of attendants is very low, namely, 1 to 15 ; in the ward for the quiet women, only 1 to 24. They stay a very short time, although well paid. * This l;i\v Las, 1 iim yliui to suy, bc».'ii ii'iifiiktl. 134 State Asylum, Rhode Island. As to restraint and seclusion, I regret to say restraint is freely used. Wyman's apparatus for confining the patient securely to the bed was shown us. It consisted of shoulder- straps and belt, with a strap at the bottom of the bed to which the ankles were attached, and with this was con- nected a strap passing to the back of the patient, who was thus firmly secured to the bedstead. The " monkey jacket " is a canvas dress blind at the legs and arms. To this are fixed straps made of canvas, which go to the side of the bed. It was stated that there were 20 of these in a closet in the ward. Two women, in the Women's Pavilion, wore strait waistcoats, and were fastened to the bench on which they sat. Three women were attached to the bench, but without strait waistcoats. One was secured by the jacket, but was otherwise free. In another building a woman was secured to her seat, and in the hospital two females were restrained, one simply by a strap to her chair, the other not only by a strap but by the strait jacket. In the cross-shaped building for GO patients, were re- strained. No recoveries are recorded in the last report, which is not surprising, considering the class of patients. Beyond the fact that 4G patients died last year, no statistics of mortality are given. As to treatment, it cannot be expected that medical treatment will be carried out to any considerable extent in an institution of this description. With regard to employment, Mr. Hunt attaches great importance to labour, and endeavours to carry it out sys- tematically, but the number able to work is very limited. This establishment well exempli lies the advantages and disadvantages of this mode of providing for the insane poor. It is cheaply done ; it is in good charge, and a very intelligent Board directs it. There is every facility for out-of-door work, and every desire to carry it out. At the same time the relative positions of the lay and medical elements are not calculated to work satisfactorily. Further, MidcUetown Hospital. 135 the large number of patients congregated in one room, and the insufficient staff of attendants, have led to undue per- sonal restraint in order to protect quiet patients from the mischievous and excited. iSuch a system is only calculated for quiet, harmless lunatics. Trom the State Farm, Rhode Island, we passed on to the Middletown Hospital for the Insane, Connecticut. Fore- most among the characteristics of this Hospital must be placed the annexes which have been added to the main building, and the utilization of cottages in the immediate neighbourhood. Of two annexes one, when finished, will be three storeys high, and will provide accommodation for chronic cases and a number of epileptics. This building is of red brick with stone foundation, and accommodates 325 patients, 1G8 of whom are women, and 157 men. Dr. Kenniston and his wife reside in the house. It is provided with a good kitchen, the cooking being done by steam. The baking is done at the main building. The corridor is 10ft. Cin. in width, lG4ft. in length, and 10ft. in height. Ventilation is from open fire-flues and a ventilator. Heating is carried out by fire and by flue, with which are connected two grates in the corridor. The windows are guarded outside, but not inside. There are nine single rooms on the male and as many on the female side of the house. A roomy recess extends 58ft, from the wall, and is 52ft. wide. There is an attendants' room, and dormitories; woven wire bedsteads are in use here, as in so many x\merican asylums. In this annexe a housekeeper, and a farmer and his wife, reside, in addition to the assistant medical officer. An infirmary building of two storeys has been erected at one end of the female ward, for 21 acute cases, in as many single rooms, arranged on one side of the corridor. By means of sliding doors two wards can be converted into six, so that separation can be efiected very readily. 136 Middktonn Hospital. 'I I There are four assistant medical officers and a patho- logist. Three, I am glad to say, were married. The Board of Trustees consists of twelve members appointed by the Senate of the State. The trustees visit the asylum monthly by a committee ; not a week passes without one member of the Board paying a visit. The State Board of Charities, which was organised about five years ago, frequently inspect the asylum. Their visits average one every fortnight in the winter. The land attaclied to the asyhini covers 300 acres. The cost of building, including land, was £200 per bed. A stone building for insane convicts cost £125 a bed. The number of patients in this hospital is 892; 40G males, 48G females. In regard to the class of patients admitted it is satisfactory to find that out of 1,113 under treatment during the last twelve months not more than 11 belonged to the paying class, while 774 were paupers, and 328 were " indigent," that is, were paid for by the State and by their relatives. It is stated in last year's re- port that the amount received per week for these various classes was, with one exception, the same. They are all treated alike, unless urgent symptoms require special attendance. The cost per week is 15s. Gd., which is the weekly charge for board, including washing, mending, and attendance, for those supported at the public charge. Curable and incur- able patients are admitted. Thei-e are about 50 idiots, for whom Dr. Shew desires to have special wards provided. Out of 271 admissions last year 13 were gen(}ral paralytics, two being females ; only one woman had been previously admitted. From the opening of the institution in 18(38 57 patients with general paralvsis have been admitted. Dr. Shew has no doubt that there is a steadily increasing ratio of this furm of insanity. There is a large number of epileptic patients (about 70) . For these Dr. Shew strongly urges another building. Criminal lunatics are admitted, and occupy a separate house. lit 1 I patho- d. Tlie ppointed imittee ; d paying rganised L. Their ?r. The per bed. 3ed. W2; 40G patients l;i under ore than paupers, ir by the rear's re- various hoy are special y charge mce, for d incur- iots, for ovided. •alytics, viously n 1808 initted. Iroasing Inber of trongly luitted, Middletown Hospital. 137 There are 93 attendants, or about 1 to 9. They are paid, per month :— Males, £4 to £0, and £9 for supervisor; females, £2 15s. to £3 12s. With respect to restraint and seclusion, during last year •5 per cent, of those treated were restrained. There is on each side of the house one " covered " bed. Dr. Shew mentioned the ca^jc of a maniacal woman who persisted in standing and was much exhausted, who, in his opinion, was greatly benefited by being obliged to lie down in one of these beds. At the time of our visit to the asylum no patient was restrained. Dr. Shew feels at liberty to resort to mechanical restraint as a dernier ressort. One patient was in seclusion. The statistics of recovery show that from the opening of the hospital Oil out of 2,952 admissions have recovered, or 20'Gper cent. The annual percentage of deaths, calcu- lated on the daily average number resident, ranges, since 1808, from 3-28 to 17-57. In 18S2-83 it was 9-30. In connection with treatment it may be stated that on the male side 13, and on the female side 17 patients were taking sedatives. Dr. Shew attaches much more importance to the prevention of insanity than to its medical treatment when it occurs. More than 50 per cent, of the patients are employed. On examining the record of employment I found that 20 men were engaged on the farm, 18 in the stables, and 37 on the grounds. On the female side there were 2 !• work- ing in the laundry, 10 in the kitchen, 28 in the sewing- room, and 23 sewing in the wards. The latter figure has the merit of being understated, as I saw a good many engaged in sewing in their rooms whose work was unre- corded. Dr. Shew in his last report thus expresses the wish that he had some useful outdoor employment for the female patients : — " Their work seems to be restricted to domestic labour indoors. Why not set apart a large garden plot for their especial use, and allow them to have the entire charge of it '? The experiment is 138 Hartford Retreat. certainly worthy of trial. If successful, tlie advantages of such a project can scarcely be over-estimated." To the foregoing it may be added that Dr. Shew has set aside a ward for male epileptics in the south hospital. Twenty patients are under the supervision of two attendants during the day, and under tbe care of a special attendant at night. There are two large dormitories separated by a corridor, in which the night attendant sits, the doors of the dormitories being always open to allow of constant observation. Although I have pointed out the provision made by means of separate buildings as the most striking part of the management of the Middletown Asylum, I should observe that the arrangements made in the way of classification and treatment in the main building are admirable, and reflect great credit upon the zealous superintendent. Passing on to the Hartford Retreat^ I may say that to myself and to Dr. Baker the institution possessed more than ordinary interest, from having been designed to follow in the path of the York Eetreat ; and Dr. Butler, who was for about thirty years the superintendent, has faithfully carried out those principles of humanity and individualization which characterised the latter when so many other asylums were in an unsatisfactory condition. I cannot do better than quote from a letter received from Dr. Butler since visiting him at his own house, in his honourable retirement from active practice. " From tiie York Retreat and its founder, the Connecti- cut Retreat took, in 1821, both its name and guiding principle of treatment. It is a most grateful duty to one Avho for nearly thirty years was the superintendent of the latter, thus to recognise and assist the long-time quiet and unassuming source of this blessed power to heal the sick and alleviate the sufferings of the most grievously afflicted of mankind. That quiet, unpretentious hospital Hartford Retreat. 139 near York, and the iiifliionco for blessiiij^ which has gone out from it, recall what Emerson says : ' Every man is not so much a workman in the world as he is a suggestion that he should be.' And again : ' Men walk as prophecies of the next age.' "As our poet says : — Tlic Imiul that rotuuled Peter's Dome, And groined the aisk's of Christian liotno, Wrought in a siid tjincerity. * m * * * IIo buikled better than ho knew ; The conscious stone to beauty grow. " How cheering to us all to realise that this ' beauty ' is ;» being more and more recognised all round the world. Dr. Butler retired from his office twelve years ago, and now resides at Hartford, at an advanced age, but takes un- diminished interest in the great work of his useful life — the welfare of the insane. His annual reports form a valuable series of papers which, whether long or short, reflect the valuable experience of his long superinten- dency. Dr. Stearns is the worthy successor of Dr. Butler. The Retreat has been fortunate in its superintendents, those of former times having been Dr. Todd, Dr. Fuller, and Dr. Brigham. The Hartford Retreat was at a very early period de- voted exclusively to the insane, an asylum in Virginia hav- ing been the first, and the Friends' Asylum, at Frankford, having been the second to pursue this course. The Con necticut Medical Society originated the Retreat, and contributed 500 dollars to establish it. The asylum stands in grounds resembling an English park. Eighty acres are devoted to the farm. The view from the balcony of the original building commands a beautiful prospect of the surrounding hills. The Connecti- cut river lies between them and the asylum, but is con- cealed from sight. Dr. Stearns is justly proud of a very handsome villa on the grounds for a single patient, occupied by a lady. 140 Hartford Retreat. There are two sittinc;-rooms, a bath-room, and four bed- rooms. It is built of wood, with slate roof, the cost being about £800. It was presented to the institution. There are two assistant medical officers, one of whom, Dr. Page, recently visited our asylums in England. This institution is under the care of directors chosen every year and a Board of Managers. A visiting committee consisting of directors appointed for the purpose, and a committee of ladies, periodically visit the asvlum. There are also six medical visitors. There are loO patients, the sexes being about equal. They are of the middle and higher classes. Both curable and incurable cases are admitted. Since 18G9, when the institution was re-organized, 1,471 cases have been admitted ; of these 395 laboured under acute mania and 2G3 under acute melancholia, 37 were cases of general paralysis, and 33 cases of senile insanity. The cost per week is £2 2s., including everything, and the weekly charge ranges from 24s. to £20. Three or four pay nothing. The patient in the villa pays £800 a year. 'J"he salaries of attendants are, as a rule, £5 a month for males, and £3 for females ; supervisor, £0 6s. a month. Restraint is seldom resorted to. A crib-bed is used for a patient who would stand for hours during the night if allowed to do so. Lastly, with respect to recoveries and deaths, of G,488 cases admitted since the Retreat was opened 60 years ago, 2,890 have recovered, or 44 per cent. Of the above admissions, 793 jiatients died, but as the average number resident is not given, we are unable to state the perctnt- acre in a correct form. After Hartford, New York was visited, where, as already intimated, every facility was given, through the instru- mentality of Dr. Gray and Dr. S. Smith, for seeing the institutions for the insane, the first of which was the New York City Asylum for males (Ward's Island). ■)\\v bed- :ho cost :itutioii. ' whom, md. i cliosen )pointed odically visitors, it equal. curable rlien the re been uiia and general cost per weekly our pay ir. month month, used for light it' f 0,488 years e above number yerccnt- ilready instru- ing the as the New York City Asijlum. 141 The unique feature of this institution is its salt-water swimming bath in the grounds of the asylum, to which 1 have already referred on a previous page. Another feature is the large proportion of medical assistants to the nunber of patients, there being 1 to 100, some of whom, however, are unpaid, and are rather clinical clerks than assistant medical ofticers. A third feature is the ap])ointment of an assistant medical officer, whose duty it is to attend to the wards by night. He is on duty from 7 p.m. to 8 a.m., and patrols the wards twice during the night. This asylum is not, however, alone in this excellent arrangement. Jt is stated in the l^eport of the State Commissioner in Lunacy, that the assistant medical officers take turns in such order that each will be on duty once in twelve nights, and so that an interval of at least one day elapses before the same physician returns to day duty. The following, from the same source, illustrates the kind of report made each night by the medical officer in charge : — 10.30 p.m. Ward II. Mr. S., being noisy, received medicine ; quiet after. 11 p.m. Ward 14. Messrs. K. and B., being noisy, received medicine ; quiet after. 11 p.m. Ward 21. Mr. B — r, being noisy, received medicine ; quiet after. 11.30 p.m. Ward 1. Messrs. B. and K., being noisy, received medicine. 11.30 p.m. Ward 3. Mr. B — h, noisy, received medicine ; quiet after. 1 1 .30 p.m. Ward D. Mr. B — y, noisy, had medicine ; quiet after. 3.5 a.m. Ward 19. Mr. P., noisy, had medicine ; quiet after. 3.5 a.m. Ward 0. Messrs. McK., and McX., restless, had hypodermics ; quiet after. 142 Emigrant Hospital for fnsanc. 8.80 a.m. Ward 15. Mr. B — n, noisy, hiul modieino as ordered ; quiet afterwards. M. A. received stimulants as ordered durinj^ the niglit. All attendants in tlieir rooms at 10 p.m. Frequent inspection is secured by the visits of the State Commissioner in Lunacy (Dr. Stephen Smith), of the State Board of Charities, and also of three Lay Commis- sioners of Charities and Corrections. Tliere are Ij-IOi patients, all males, and of the poorer class. The proportion of attendants to patients is 1 to 12. As regards restraint and seclusion, the last entry of resti-aint was on SeptemLcr ]()th, 188:3, and the last entry of seclusion on the 18th September."^ When a patient is much excited, the attendants have strict orders to send for the superintendent or one of the assistant physicians, in order that he may bo promptly placed under medical supervision. Since the year 1874, 4,G11 patients have been ad- mitted, of whom G92, or 15 per cent., have recovered; 810 have been discharged relieved, and 1,528 have died. There is also on Ward's Island the Emhjrnnt Ilosintal for the Insane. There are, in this asylum, 70 men and GO women. In one room in the female department seven patients were engaged in sewing. The more excited, 15 in number, were placed at the end of the building, and were in charge at the time of only one attendant. It was stated that this was temporary. It cannot be said with truth that these patients were in a satisfactory condition ; in short, they were evidently neglected. Twenty-five men were employed out of doors. There was little satisfaction derived from visiting this institution, but there seems no good reason why, with the present building and the amount of land attached, the * That is, more tliaii a vcav before the date of oar visit. Bloomingdale A»ylum. 143 patients should not bo marlo more comfortable, iinilcr vigorous and otHcient maiuij^'cnient. Tihnmimjdnlo Asii/inn, Now York, was first visitod, in (ho absoiico of (he ^ledicid Suporintondont, Dr. Nichols, under tho n^nidiince of the senior assistiint, Dr. Saiijj^or Brown. On a subsoquont occasion, I had tho advantaj?c of being Dr. Nichols's guost for several da^s. This as}]um (a department of tho Now York Hospital) has boon so frequently referred to in tho forogoini,' pa<,'os, tliat a short notice will suffice. It is the oldest institution for the iusane in the State of New York,* and the oldest but throe in the United States. The New York Hospital w;is opened in 1701, and it so happonod that the th'st cases admitted wore insane patients. In 1808 a separate " Luinitic Asylum" was built b}' the Governors, which was not occupied till 1821, when the liloominn'dale Asylum was opened, situated in tho avenue of that name. The great feature of this institution is the large amount of good it elfocts for the indigent classes who are socially above the poor. Thus, at the time of my visit about two- thirds of the patients were paying nothing, or else a sum below the cost of nuiintenance, the doticiency arising from those cases amounting, during the year, to more than £0,000. This deficiency was met in part by a charitable endowment — the "Green Fund" — and by the higher rates paid by the remaining third. Kvou thou the ex- penditure exceeded tho income by at least £1,000. I wus glad to find that, in summer, excursions are fre- quentlv nin.lt' ' the sea-side, or to a farm at " White Plaii V niiles oft'. It appears from the report tlm* .11 nd eight women were boarded in private .mill. n T .' country', three of them being with the liirmor at " White Plains " for several weeks, and in some iusta: OS for three months. This practice has been only * Elevcntli Annual Report ' lo State Commidsloucr in Lunacy, p. 32C. II ; li ■.. 144 Bloomingclate Asylum. lately introducetl, with, as may well bo supposed, great advantage. An important feature in tlie management of this Insti- tution, and one deserving much more general adoption, is the large proportion of attendants to patients. For forty refractory patients tliere were no less than twenty attend- ants ; so that, in addition to the advantage of ample super- vision, ])atients labouring under paroxysms of excitement, whether by night or by day, can be thoroughly attended to, and the necessity for mechanical restraint reduced to a minimum or altogether avoided. The visitor to this institution must be struck with the fine grounds, in which are seen pines, oleanders, and two very fine yew trees. There is a beautiful drive, two miles in length, round the estate, which comprises forty acres. A recently erected addition for about eighty female patients, called the " Green Memorial Building," is in every way adapted to the purpose for which it is designed, and here, as at St. Elizabeth's, Washington, Dr. Nichols has displayed his architectural skill. The windows have large panes with ornamental frames outside, and command a fine view of the Hudson. This building contnins a number of very good and well-furnished private rooms. Eugs are preferred to a carpet covering the whole floor, as being hea. thier and cleaner. The case-books and journals of this institution are admirably kept. There are two assistant n^cdical ofiicers. The number of patients is 247; 115 males, and 1'32 females. The cost per week is about £o 3s. for each patient. The weekly charges vary from £o to £10. A special fund exists by means of wliich some patients can be treated, if curable, for twpl vf» months, for £1 a week, or even gratis. A patient paying highly has the exclusive use of an attendant, daily carriage exercise, and wine. With regard to the salaries of attendants, the highest pay is £G for male, and £4 for female attendants. New Jersey State Asylum. 145 No patient was in restraint or seclusion at the time of my visit. (See p. 55). Recoveries. — Of 7,641 admissions from tlie opening of the asylum in 1821, 3,157, or 41*31 percent., recovered. Deaths. — Of the above admissions 1,036 died, but the average number resident during the period embraced is not stated, so that no percentage can be given. However, from 1872 (inclusive) the annual mortality has been about 9 per cent, of the average number resident. The treatment pursued by Dr. Nichols has already been given (p. 59). Before quitting the asylums of New York, I add the re- turns of the number of the insane and idiotic in this State, as given in the census of 1880. Idiots. 93 602 537 1 70 4781 Insane. In Asylums 8079 Institutions for Idiots Almshouses 1577 Jails 6 Charitable Institutions . 32 At Home 4361 Total ... 14,055 6084 The population of the State of New York in 1880 was 5,052,871. I proceed to notice the New Jersey State Lunatic Asylum,n,t Trenton. One of my objects in visiting it was to see Miss Dix (see p. 37), who has for many years of her life been accustomed to make it her home at leisure times. At an advanced age, and in very feeble health, she retains her interest in the chief object to which her energies have been devoted for more than fifty years. She referred with especial pleasure to her visit to Scotland in 1855, and the reform she was instrumental in ejffecting in the condition of the insane in that country. This asylum, opened in 1848, is superintended by Dr. i" ■•46 New Jersey State Asylum. Ward. Dr. Buttolpli was the Superintendent for many years, and left for the asylum at Morris Plains'**" in the same State. The institution, possessing or renting 350 acres, is pleasantly situated in the country several miles from Trenton, and presents a handsome exterior, including portico and dome. The centre building, four storeys high, has the steward's apartments, store-room, and kitchen on the first floor ; parlour and public office on the second floor; and the Superintendent's private rooms and the chapel on the third floor. The fourth is occupied with bedrooms. The wings are three storeys high, and contain, as is usual in American asylums, a large number (300) of single rooms. With some exceptions, the rooms are placed on both sides of the corridors. Ventilation is secured by the customary fan. There are two assistant medical officers. The asylum is governed by a Board of Managers, con- sisting of 10 members, who report annually to the Governor of the State. They make monthly and weekly inspections by means of small committees. The State Board of Charities also inspects the asylum from time to time. The number of patients is G74; 329 men, 345 women. The capacity of the asylum is for 500. It is therefore much crowded. The patients are chiefly of the middle-class ; there are very few paupers. Since the Morris Plainsf Asylum was opened, this institution is regarded as more especially for the curable class, but of the 177 admissions last year, as many as 30 were cases of chronic mania, and 33 of chronic dementia. Thirteen of last year's admissions had been insane from 5 to 10 years, five from 10 to 15 years, and as many as ten over 30 years. The cost per week is IGs. 8d., and the average charge for * Since the abovo was writton Dr. Puttolph has retirccl, t 2i)7 patients have been trausferrcd to the Asylum for chronic cases at Morris Plains. Nero Jersey State Asylum, 147 mis are paying patients, (from whom £125 per week is received), is 25s. The proportion of attendants is 1 to 12 ; for the refrac- tory class, 1 to 8. Their salaries vary, for males, from £4 10s. to £5 a month ; females, from £3 5s. to £3 10s. The male supervisor receives £7 a month ; the female supervisor £6. In regard to restraint and seclusion, Dr. Ward prefers mechanical restraint to prolonged seclusion. Four women patients wore camisoles at the time of my visit, and in an airing court one wore a muff, and one was attached to the seat. On the male side, there was in one airing court, containing 90 patients with two attendants, one man re- strained by a muff, and another by belt and wristlets. Several patients were in seclusion. Of the whole number of cases admitted from the open- ing of the asylum, namely, 0,181, 2,179, or 35 per cent., recovered. The number of deaths was 1,100, but as un- fortunately the average number resident is omitted, we are unable to give the j)ercentage. It is greatly to be re- gretted that so few of the American asylum-reports afford this important information for the period of years for which the mortality is recorded. With regard to employment, 50 men and 75 women are occupied in or out of doors. In mid-winter only 15 men could be employed out of doors. On the female side a satisfactorv amount of work is executed in the sewing- room. Last year this comprised 370 dresses, 20t che- mises, 272 vests, 219 drawers, 119 pairs of socks, and 132 curtains. There is a large room designed for calisthenics, but it is chiefly used as a sewing-room. A bowling-alloy for women — an unusual feature of iin asylum — is pro- vided at this institution. There are frequent exhibitions of the stereopticon ; and entertainments consisting of (lancing, theatricals, &c. The patients are well supplied with books, of which there are about 2,000 in the asylum Hbrary. The pleasant circumstance occurred hero of a 148 Hudson County Asylum. former female attendant presenting a library, which is called after her name. Certificates. — A request for admission is made by a friend of the patient, accompanied by a certificate of insanity from a respectable physician ; and a bond with satisfactory sureties is required. A judge of the Court of Common Pleas gives an order for admission, after calling to his aid a physician and other witnesses. If he deem it necessary he can call a jury. The form of medical certificate is as follows: — "I, A. B., physician, of the township , in the county of , do hereby certify that I have examined into, and I am acquainted with, the state of health and mental condition of C. D., &c., and that he is in my opinion insane and a fit subject to be sent to the State Lunatic Asylum/ i» In New Jersey I also visited the Hudson County Lunatic Asylum (Jersey City). It contains 246 patients, 89 being males, and 157 females. It has a capacity for only 150, and is therefore excessively crowded. It was built 11 years ago. A separate building for excited patients was built two years ago. In the new building are strong rooms, with a narrow space between them for the purpose of ventilation. There are six rooms on each side of this space. The doors have bolts above and below, an<] a wicket with a wooden bar. The rooms are lighted from above the doors. The floors are stone. There is a wood bench attached to the wall, on which a patient who destroys his bedding can lie, and escape the cold floor. There were three women in seclusion in the rooms on one side ; and on the other there was a youth in the first room, a woman in the second, and a man in the third. A building has just been erected for +he excited men, one of whom was in the corridor restraiuv J by a muff, and suffering from lupus. There were several men in a small airing court adjoining. None were in seclusion. There are eight male and nine female attendants, or about 1 in 14. Penn. Hospital for Insane. 149 As the asylum at Morris Plains, superintended by Dr. Buttolph, is for the chronic insane in New Jersey, and as it is not full, it seems surprising that some of the patients now in the Jersey City Asylum are not transferred thither ; hut the explanation, no doubt, lies in the fact that while the weekly charge at the former is £1 a week, it is only 12s. at the latter, and of this 4s. is paid by the State. It is to be regretted that the attempt has been made to provide such accommodation as that now described, which consists of bare cells. It cannot have been done under the direction of any medical man acquainted with modern asylum construction. The New Jersey City authorities cannot be complimented on their action in this matter, which seems to have been mainly directed by one motive — economy. A young physician is in charge, and very courteously showed Dr. Nichols and myself over the establishment. The census of 1880 showed that there were in this State, the following number of insane and idiots : — Insane. Idiots. In Asylums ... 1632 56 Almshouses 116 127 Jails 3 Charitable Institutions ... 2 1 At Home ... 652 872 Total 2405 1056 The population of New Jersey was 1,131,116 in 1880. An object of special attraction for psychological travellers in the States is the Pennsylvania Hospital for the Insane. This institution, popularly known as *^ Kirkhride's," situated in the vicinity of Philadelphia, will be always associated with the name of the distin- guished physician, who for forty years superintended it with so much zeal, ability, and kindness. His memory ^ill ever be treasured by those who knew him, whether patients or others, and when a generation has sprung up ! 150 Penn. Hospital for Insane. that know him not, he will still live in the beneficent results of his long life's labour and earnest work. It was not to bo expected that at the age he had attained, his benign reign should last much longer. He is dead, but non omnis moriar is emphatically true of him, when his life and its effects are considered. Dr. Kirkbridc passed away in December, 1883, and Dr. Chapin reigns in his stead. Dr. Kirkbride in his sketch of this Hospital, written in 1 810, after observing that " from the York Retreat soon after its foundation emanated a code of moral treatment which even at this day can hardly be surpassed," states that " the mild and rational system pursued at the Re- treat was soon adopted in the Pennsylvania Hospital for the Insane ; long, indeed, before a reform was more than thought of, in many of the establishments of a similar kind in Great Britain." This institution is a department of the General Hospital in Philadelphia. There are two distinct buildings, one for the male, and the other for the female patients. Dr. Kirkbride held strongly that this complete separation of the sexes is desirable. As I have already spoken of Dr. Kirkbride's opinions in regard to classification, it is unnecessary to refer to them again. It is difficult to single out any one feature in the management of the Kirkbride Asylum, but perhaps the point which he would have more especially dwelt upon ■with satisfaction, was the social meeting of the patients on very frequent occasions for recreation, readings, and amusements of various kinds, in which he himself took part for so many years with unflagging interest. Especially did he take an interest in, and attach importance to, the officers' weekly tea-party — established in 1800, and con- tinued from that time. On these occasions about 40 per- sons, three-fourths of whom were patients, were invited from every ward in succession, to meet at the officers* Pen7i, Hospital for Insane. 151 ineficont ork. It ittained, 1 is dead, n, when [irkbridc reigus in •written L'eat soon reatment ," states the Re- jpital for lore than a similar Hospital lings, one nts. Dr. mration inions in to them in the laps the elt upon patients flgSj and elf took specially e to, the nd con- 40 per- invited I ofl&cers' tahle, Dr. Kirkbride himself presiding at this meal. In- cluding this tea-party, every evening of the week during nine months of the year had its appropriate engagement. The institution is managed by a Board of Trustees, con- sisting of 12 members. It is visited every fortnight by members of the Board. The Lunacy Committee of the State Board of Charities inspects periodically. The co.st of building was 1280 per bed, the number of patients being 308 ; males 175, females 193. The number of acres is 113. The charge jjer week averages £5. The weekly cost is about 28s., exclusive of clothing. The proportion of attendants is at least one to three. Their salaries are: — Males, £3 15s. to £1 4s.; female supervisor, £5 ; lady companions, £0 ; and female at- tendants, £2 18s. a month. There are three lady com- panions on the female side. With regard to restraint and seclusion, the muff is occa- sionally employed for very violent cases. As is well known, the late Dr. Kirkbride was distinctly of opinion that mechanical restraint was advantageous in certain cases. It is stated that there was an average of two patients restrained last year. On September 30, 1884, one male patient was restrained by wristlets, for destructive habits and denuding the person. Two violent male patients were in seclusion at the same time. Two women were re- strained, and two secluded. Dr. Chapin, the successor to Dr. Kirkbride (see p. 77), has recorded his views on treatment in the second Koport of the Committee on Lunacy, of which I avail myself. He uses warm baths, with cold applications to the head, in certain cases of acute mania, &c. The cold bath, douche, and shower bath are not used. Counter-irritation is rarely employed. Opium is occasionally prescribed, as in some forms of melancholia, with wakefulness, dilated pupils, and, a soft compressible pulse. He attributes rapid dementia to its prolonged administration. Digitalis is chiefly given in > f 152 Penn. Hospital for Insane. the noisy stage of general paralysis. Of liyoscyamus Dr. Cliapin observes that the contradictory results obtained from the use of this drug are due to its different habitats. It appears that while the leaves and preparations of the English plant are reliable, those of the American plant are comparatively inert. Chloral is occasionally used in acute delirious mania, and in the status e2nlepticn8. Bromide of potassium (or, in preference, bromide of sodium) is used with most excellent results in mania and in insomnia, as well as in epilepsy. Dr. Chapin is fond of the combina- tion of bromide, tincture of liyoscyamus, and the fluid extract of cannabis indica. Hyoscyamine (Merck's white crystals) is administered, by mouth or skin, in states of mania with excessive motor restlessness. I have already referred to the employment of some of the female patients in pottery work of a useful and ornamental kind (see page 03). There is a gymnastic hall, which is used for two evenings in each week in winter, for calisthenics, skittles, dumb-bells, and music. No patients are allowed to do any menial work in the wards. Without entering upon any details of construction, it may be well to note that the department for males, situ- ated in fifty acres of pleasure grounds, consists of a centre building with wings running north and south, the frontage extending 512 feet ; also other wings running east, 180 feet; all being three storeys high ; the last communi- cate at their extreme ends with one-storied buildings for the excited and noisy — an arrangement to which Dr. Kirkbride attached great importance. The airing courts connected with these have an open palisade in front. The walls, of stone, are stuccoed, the interior being brick. The centre is 115 by 173 feet, and has a Doric portico of granite ; it is surmounted by a handsome dome. For the 250 patients for which this building provides, there are fourteen wards. Ventilation is secured by the customary fan ; heat, by fresh air passing over steam- Penn. Hospital for Insane. 153 lus Dr. t)tained ibitats. 3 of the ant are n acute tnide of is used inia, as )mbina- le fluid 's white itates of some of ful and for two .skittles, 1 to do tion, it situ- , centre I'ontage east, knmuni- ngs for ch Dr. courts front. ', brick, tlco of For there y the steam- pipes in basement, the temperature being 70° in the winter ; lighting, by gas. There are 220 rooms 9 feet by 11 feet, and 20 rooms 15 feet by ] 2 feet ; there are no associated dorn)itories. Infirmaries are not provided, but there is a special ward to which patients when ill can be removed. Epileptics are not separated. The building for the female patients presents also a centre and wings, with a frontage of 43G feet. The former, like the building for the male patients, has a Doric portico, and is surmounted by a dome. There are about 50 acres of land, 20 of which are gardens, and 25 nre appropriated to the recreation of the inmates, one hour in the morning and one in the afternoon. The par- ticulars given in regard to the department for the males apply also to this building.* It is greatly to the credit of the management of this excellent institution that, with the exception of an ai)pro- priation by the Provincial Assembly of £10,000 towards the original hospital buildings in the city, the work has been carried on by means of subscriptions, no aid having been sought from the State, county, ^c city. It may be stated that Dr. Kirkbride,t whose life was de- voted to the insane, was first connected with the Hospital in 1833, as a Resident Physician in " The Pennsylvania Hospital " in Pine Street, Philadelphia, which was estab- lished in 1751, and opened in 1752. J In 1841 the Insane Department was removed to its present locality in West Philadelphia, at wliicli time Dr. Kirkbride was elected the Medical Superintendent. There was then only one hospital for both sexes, but in 1851), a new one was opened * See 2nd Report of the Comtnitteo on I (1 erect it' Public Report that an architect from Philadelphia has stated that the woodwork, in close contact with the steam pipes in the collar, is a source of i^reat danger from fire. He was also struck, it seems, with the "shallow, dark, ill-sinellin<^, nialaria-breediuf^ vaults and passaj^es," and " with the total absence in the wards of the proper appliances for successful ventilation, and the bad arrangements of the plan of the dormitories Avith reference to sunshine and pure air." Both he and another architect wisely rocom- iiiond an entirely new building in place of the old. A Committee of the Senate of the House have concurred in this opinion. The cost is estimated at -1100,000, or about 12:52 per bed. Dr. Gerhard, however, mentioned a nmch lower estimate. From the dome there is a splendid view of the Alleg- hanies and the 8us(juehanna. The asylum is situated several miles from Harrisburg, on a plateau of ground seventy feet above the surrounding district. There are four assistant medical officers ; two in the male and two (women) in the female department. The number of patients is 120: males, 210 ; females, 21(5. The building Avas originally designed for :iOO ; accommodation for 200 more has been ailded. The class of patients socially is mixed. Th(» State re- (luires that, in order of as. 8d. per week, which is stated to be sutticient. With clothing, the c ">■ is 18s.; without, 17s. Id. £. s. d. 4 private V itie nts p«y per weclv .. 10 5 84 „ »» ... 12 « 59 „ »» ... 14 7 2:5 „ » .. l(j 8 12 „ >» ... 1 10 1 ,^ >> ... 1 5 ^r^T 162 Harrhburg Asylum. m The proportion of attendants is one to ten. Tlie salary of the male supervisor is £7 7s. per month, and of the female supervisor £4. I found that, in regard to restraint and seclusion, Dr. Gerhard is a decided advocate of non -restraint save in very exceptional instances. On tlie male side three years have elapsed without his resorting to restraint, but it so happened that an exception to the general rule occurred in this department on the day of my visit. This was in a case of violent epileptic mania, in which Dr. Gerhard believed it best to restrain the patient's limbs. He was secured by straps to his bed. He was excessively abusive and excited. The complaints which he made did not refer to his restraint, but manifested an active antipathy to all around him. Hyoscyamine in doses of one-twentieth of a grain had been administered. I have since learnt that this attack passed away in a few hours, rendering restraint no longer necessary. In this asylum are no padded rooms, in one of which the patient would have probably been placed, in an P]nglish asyhim. On the female .side of the house some form of restraint —camisole or wristlet — isnotunfreqnently in use. Three or four patients pass a very considerable part of their time in seclusion ; one of these is an epileptic. The recoveries have been 20*'* ner cent."'*" since the opening of the institutiim. Dr. Gerh.^rd is as sceptical as Dr. Earle in regard to the prevalent notions about the curability of insanity. The (loaths amount to 5 per cent., calculated on the averader were doiiblful cases. Only oao-Kixth woro iTgarded us hopeful. Government Hospital for Insane, 163 up during the night. In the Annual Report facilities are asked for giving different kinds of baths and for massage. Employment. — There is a cobbler's shop, but only two patients were employed in it. About (VI men are employed in ward work ; 45 join in games ; 70 are engaged in reading and writing ; one helps in the kitchen, and five in the laundry ; 22 patients are employed on the farm and garden. Many of the women are engaged in needle- work. Dr. (jraiver, one of the lady-assistants, desires to have a person qualified to teach calisthenics and dancing, and to play upon the piano. She observes in the last report that there is only one piano in the wards from which it is possible to extract a tune ; " the other two are jangling and discordant abominations." There is a service in the chapel every evening. The staff and about 80 patients were present when I was at the asylum, the medical superintendent officiating. r.S. — Recent intelligonce is to the effect that the old building is to be retained. If so, it is to be hoped some course may be decided upon to render the contingency of fire more improbable than it is under the present condition of the asylum, in referring to which the last Report of the " Committee on Lunacy " afresh lays stress on " its liability to become a crematory for the afflicted patients within its walls." The asylum at Washington was visited on two occasions, and the pleasure derived from the sight of the beautiful buildings of the City was not marred by that of the (iovcniment llosinhtl for flie Tnti(t)ic. It presents two pro- minent featunM. One is the architectural appearance and arrangements designed by the first supcrintcinltMit, Dr. Nichols (now of lUoomingdale), who is Ihoroiiglily at home in <»stablislinicnts of this description, from the L'oneral outline down to the minutest detail. The main building is castellated in form, five storeys in height, in souie portions four. On the windows are ornamental iron IGt OoTcrnmcnt ITospitnl for Insane. fjnard.s. A striking-, and to an Englishman a pleasinc,', foatnro of tho exterior, is the extent to which the walls are covered witli ivy, an unusual circumstance in the United States. Dr. Goddin<]f, formerly an assistant medical officer here, is the worthy successor of Dr. l^ichols. He throws an ample stock of ener<»'y into the service of the institution, and is supported by able medical assistants, one of whom. Dr. Whitmer, visited our asylums in 1881. Ample oppor- tunities wore afforded me for obtainin;^ information, while the <;uest of the superintendent for several days. Another marked feature of the institution is the ac- commodiitioii jtrovidod for different classes of patients in separate l)uildinfjs, which merit a brief enumeration. 1. Detached lbiildiii<^ for Idiots and women of colour (East Lod<,'e). — Nine feeble children, black, and white. The women of colour in this cottage are 15 in number; in the main building there are 80. Dr. Godding states that negroes are less excitable than whites. The above is a brick house with stone facintr. Tho basement is used for coals, &c. The house is heated from the steam boiler in the main boiler-house. A passage, under ground, commuuiciites with tlie next building. 2. Atkins' Hall.— This was built in 1878 for the quiet working class of patio* ^. It accommodates (51 patieuti^, and was built at a cost of £l,r)(H). This includes furniture, but is exclusive of laud i having been built ou the estate. It is about (! dimensions of the dormitory nrt- 118ft. in length, 25 in breadth, and 11 in height. Government Hospital fur Insane. 165 ^. "The Homo," built for 150, or if nocossiiry, 100 pcatieiits, at a cost of 113,000, incliulin*^ furniture, but not land. One lialf of tlio rooms are sinylo. The rooms and corridors are very liylit. The water closets, kc, are detacLeJ. The buildiuL,^ is fire-proof. It will be occupied in the course of a month or two. It is proposed to have a separate building for criminal lunatics, and another buildinij for convalescents. Dr. (ioddin^ would like to have a separate dining-room in a distinct building-, to which as many patients as pos- sible would <,'o from the other detached houses. This only depend upon a sutlicient appropriation being made. 4. A separate building, called the West Lodge, the first erected separate from the main building, was built in 1850 for men of colour. It accommodates about 00. 5. The "Relief llous<'.'- — This is built for the accommo- dation of 200 patients, at a cost of £10,000, ov 150 a bed, inchuling furniture, but not land. It was built in IST'.I. The excavations were made by patients. There are four storeys, three of which are occupied. There is a large dormitory with 27 beds, and another with 13. Each storey has back stairs. One patient in six has a single room. Partitions between rooms are of brick. There are 11 attendants, and a man and his wife are in immediate charge of the building. In the fourth storey are work-rooms. Many brushes are made; also mats of husk or ''shuck." There is also a billiard-room. Summary of Numbers in Detached Buildings. The East Lodge, for Idiots, &c. ... ... 2t Atkins' Hall 01 The Home 100 The West Lodge 00 The Relief House 200 505 Thus, when the buildings are ciwnplete, the total accom- modation will amount to about 500. ^m^ * ': 166 Government Hospital for Insane. A dotacliod building?, Ciillecl "The Kest," serves tlio purposes of a patliological room and mortuary. (Sec p. 81). Dr. Godding", when speaking, in a recent report, of the detached buihliiigs, observes" that some such provision for the quiet chisses will bo found a satisfactory solution of the great social problem of the care of the chronic insane. . . . What is wanted for them is care, and com- fortable but inexpensive homos connected with our present curative establishments for the insane." "The Relief liuildiiig, with outer and interior walls of brick, was constructed and furnished at a time when both labour and material were exceptionally low, and the whole expenditure did not exceed 250 dollars (t50) per patient. Allowing that this would be an unsafe figure on which to base an estimate at present prices, as it certainly would, still it is demonstrable that accommodations, which are all that are needed for the comfortable care of the mild cases of insanity, can be provided at an expense, for furnished buildings, of less than 500 dollars (£100) per patient. When it shall become the settled policy of the States to care for all their insane, taking them out of the town and county almshouses, placing them in homes connected with the existing hospitals, and giving them workshops and tillage lands, it will be a greater advance in their treat- ment than any that has been made since the earnest philanthropy of Miss Dix first called attention to the condition of this unfortunate class, and created so many of our present hospitals, which was a noble charity and meant for all. But practically it has been found thr.t the liberal and expensive provision for the cure of insanity, admirable and necessary as it is for a part, has proved so great a tax that no State has thus far been willing to pro- vide such elaborate asylums for the whole." (jovernment. -—There is a Board of Manajxers consistinij of nine members, including two ladies, appointed by the President of the United States. They meet twice a year. OS tho (See of the ion for tion of L'lironic 1(1 coin- present fvalls of an both 3 whole patient, rhich to would, 1 lire all Id cases rnished patient, ites to wii and ed with IS and treat- urnest to the many ty and ir.t the sanity, ved so to pro- Govcrnmcnt Itospital for Insane. 1C7 3 sisting by the .1 year. Three of the Board in.spect the asylum every month. There is no Lunacy Board. There are 420 acres bolon^'inff to the hospital, of which tho detached buildini^'s and their land will eventually cover 12. Number of Patients. — Males, 890 j females, 2G0; total, 1,150. Class of patients socially. — The asylum was originally designed for the army and navy insane. Now, 5:J5 of the patients do not belong to this class. The District of Columbia contributes to the su2)})ort of about 25 per cent, of the patients, the renuiining 75 being paid for by the Government. Class of Patients mentally. — Acute and chronic ; about 25 per cent, are excitable. Cost per week. — lOs. lOd. for expenses per week, including ordinary repairs, but not patients' clothing. Charge per week. — 20s. to 50s. per week for paying patients. Proportion of Attendants. — One to six or seven on the female side ; one to nine throughout the asylum, exclusive of two supervisors and the night watches. In addition to the latter, Dr. Codding has devised the admirable plan of appointing a medical assiistant to go through the male wards during the night. Being always dressed, he can at any time be called to see a patient on the other side of the houiie. In any difficult case an attendant is detailed to bo in the bedroom during the night. Kestraint and Seclusion. — About vjper cent, (restraint). Six patients o '. an average are secluded for a part lc tho whole of each day. Recoveries. — During 80 years 11 '2^ per cent, of tho admissions. Deaths. — 0'5 per cent, of average number of patients. IkEany patients work on the grounds, others on the farm, and some are engaged in excavations. As regards brush- making, there is at present a glut in the market, so that i / 1C8 Government llospital for Insane. the pritionts luivo less to do. There is a tailor's shop; hair is prepared for mattresses; some patients paint. Tho work ill the stables oe^iplt'S some ; (»thers help in the laundry and kilchen. Tlu; women are employed in sewin;*, knittinj,', and fancy work. Thirty nifn on an aveni^'o are cmphtyed in the different shops. Takin<,' the male and female sides, it nniy he said lliat li-") [x'r cent, are steadily om[»loyed. It is found that soldiers do not take kindly to work. Amusements for the patients are steadily carried out; the room in which they are assendjled is lar<,'e and hand- some. Thrice werkly durin«j^ six months in the year there are dances, dramatic performaners, and exhibitions of the ma;,'ic hmtern. On Sundays oOO patients attend the service held in the same room. Five ministers come in succession from Washi lyton, and other denominations would be represented, were there any considerable number of patients beh)n^'in;3' ^o them. Before passinj,' to the next State, 1 add the census returns of insane and idiotic in 1880 in the District of Columbia: — Insane. In (iovernmont ]Iospital for the Insane, Washington Almshouses Jails Charitable Institutions At Home ... Idiotic. 800 13 '4 4 8 17 OG 7;i Total 0;J8 The population in 1880 was 1 77,02 !•. lo: |i A continuous journey of about twenty-four hours, through ma;^nnliL'ent scenery, brouj^ht me from Wash- in<^ton to Chicai^o, where, throu;;h the kind forethou<^ht of Mr. Wines, .'aciliti'^j were afforded me for meeting Mr. McCagg, the rresident of the Board of Trustees of the Eastern lIofti)ital for the Insane at Kankakee, Illinois, and Kankakee. 1C9 Dr. Dowoy, tho medical suporintt'iidont. With llioso ^-•iMithMiicii I procoodotl to Kiuikakce, u town of 7,000 in- habit ants (.situati'tl on ii river of tliu .same name), distant more than oO mih's fi'(»ni C'hiea^'o. Tlio central buildin;,', with its win^^s for both sexes, constructed in the linear form, is three-storeyed, and accommodates 275 patients. There are six wards in each win.r, and, at the extreme end, three short wards. Each win^ consists of two sections, but one of these sections, (111 the male side, has m-ver been completed, and the capacity of the whole budding' is, in consetpicnce, less by 7") l)t'ds than was intended. A covered corridor leads from the centre to the kitchen, bakery, tScc, in tho rear, l-'rom the kitchen there is a corridor to the en.) Cost per bed of all land and building of every kind (1,500 patients) illU (o.) Cost per bed for buildings alone, including all appropriations made to date for erection of buildings of every kind (1 ,500 patients) . ill2 ('?.) Cost per bed of 18 detached buildings, accom- modating 1,225 patients (including general dining-room and cjh^*/o //(>•' (piarters) . . £7G (e.) Cost per bed of all buildings of every kind to date, deducting nor'ili and south -.vings of main building (1,225 patients) . . . £103 <^ ^\a^ ^ '.,*:> ^-<& IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I '■"IIIIIM IIIIM " IIIIM 11111^ 12.0 116 1.8 1.25 1.4 1.6 ^ 6" — ► ^1 '" s>l O /,. /n /A 7 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 I 4is fe' i^ % %p< V.x !i Urn i^ 170 Kankakee. {/.) Cost per bed of 31 institutions for the insane as given in report of Illinois Board of Public Charities for 1870 £23G Dr. Dewey adds with regard to land that about £5,800 have been expended, the number of acres being 476. It appears that Dr. Eay considered £200 to be the minimum cost per bed, in the States, for construction of buildings alone. It is maintained that no figures have hitherto shown a cost per bed more favourable than that at Kankakee, considering the substantial character of the dwellings. In reference to (£^),it is remarked that the cost per bed (£76) of the 18 detached buildings for 1,225 patients is favourable, " when it is recollected that they are all substantial two-storey stone buildings (accommo- dating an average of 37 patients in 33 wards), with many brick partitions and all slate roofs, hard wood floors and basement concreted throughout, that they are connected with an ample system of sewage, have hot and cold water and gas in every part, and are provided with fire hydrants ; also are arranged for thorough heating, either by steam or hot air furnaces." I have already (pp. 80-1) mentioned the principal de- tached buildings at Kankakee. In all they number 18, and are built of stone, with slate roofs. Of these the following are devoted to the female patients : — An Infirmary, providing 50 beds. No. (1) Quiet and industrious, and some excitable ; accommodation in four wards for 40 patients in each, a total of 100. (2) Industrious and inoffensive ; for 104 patients in two wards. (3) Ditto, ditto. (4) Quiet and convalescent ; 44 patients ; eleven single rooms (nearly all the bedrooms in the detached buildings are large dormitories with 10 to 50 beds). (5) General dining-room for 500 patients, and kitchen ; also rooms for 150 male and female employes. Kankakee. 171 £236 £5,800 6. be tlie ition of 18 have m that r of the ;he cost r 1,225 at they 3ommo- h many ors and nnected d water drants ; f steam Dal de- 8, and owing ;itable ; each, a in two single ildings tchen ; Detached buildings for male patients are : — An Infirmary, providing 50 beds. A Kelief building for 50 epileptic and 35 criminal patients ; total, 85. These are in distinct divisions ; and of the epileptics, the demented are separated from the more intelligent. The violent epileptics are in the main build- ing. The ward for dangerous or criminal patients is built with special regard to security, and the windows are guarded. The epileptics sleep in one associated dormitory, and are placed under the care of a night watch. Adjoin- ing this bedroom is the dormitory for the dangerous class. There are three attendants within call, should the night watch require assistance. No. (1) provides 34 beds. (2) j> 31 (3) j^ 46 (4) J5 42 (5) )y 34 (6) » 31 (7) i> 44 (8) j> 160 (9) i> 104 (10) 3> 104 5» J> >J JJ JJ 5> 5> ;> also a dining-room for 114. ditto for 104. more troublesome patients, mostly employed in out -door work, convalescent patients; eleven single rooms, four wards, having 40 patients in each, industrious and inoffensive (two wards), ditto ditto. To what has already been said as to the distribution of meals, may be added that in the detached buildings for males, the patients in the infirmary have their dining-room there ; those in the relief building dine in that house, while the patients in Nos. 1, 3, and 5 use the dining-room for 114 in No. 3. The patients in Nos. 2, 4, and 6 use the dining-room for 104 in No. 4. Lastly, the patients in Nos. 7,8,9 and 10 dine in the " general dining-room" (p. 170). In the detached buildings for females there is a dining- room in the infirmary for its 50 patients ; there are two 172 Kankakee. in No. 1, one of which is used hy the inmates of this building, and the other for the patients in No. 2. Those in Nos. 3 and 4 dine in their own buildings, but their supplies come from the general dining-room kitchen, which also does duty for the other buildings in the same (the west) line, namely, 7, 8, 0, and 10 (males). The meat, however, is not cooked in this kitchen, but in the main central kitchen (more than 150 yards distant), which is used also for the dinintj-rooms of the several detached wards. The mode of conveying the meat in close metallic cars provided with a small coke stove, has been already described sufficiently at p. 80. Then as to transit ; in each dining-room hot tea and coffee are provided for on the spot, by an apparatus heated by steam or by gas. Provision will be made also for a warming closet in each dining-room. The buildings are houted by steam, and hot water is carried to the detached buildings from steam generators. The buildings are mostly about 85 feet apart. The patients who dine in the general dining-room would have to walk about 1 'o^ yards from the farthest, and 33 yards from the nearest, domicile they occupy. The number of beds provided in the 18 detached build- ings amounts to 705 for the male patients, and 4G2 for the females, a total of 1,227, the discrepancy in the pro- vision for the two sexes arising from the non-completion of a section in the male wing of the main buildinjr. As the main building accommodates 275 patients, the total capacity of the whole institution is reckoned at 1,500 ; the number of inmates being 600. It is maintained that the breaking-up of an establish- ment into moderate-sized detached buildings affords its insane population " a variety, a freedom, and a satisfaction not attainable in any hospital constructed upon the type now prevalent in the United States." In the Report of the Board of State Commissioners of Public Charities of Illinois, issued in 1882, regret is ex- Kankakee. 173 pressed tliat tlie main building has been made so promi- nent. Were the work to be done over again, no centre building would be erected, and the wards designed for recent and curable, or refractory and troublesome, patients would be detached, and only two storeys in height. It i.j also regretted that the structures erected have not been even cheaper than is the case. At the same time the Kankakee buildings are sufficiently plain ; and had lesa money been spent upon them, they would have been less durable and might have been exposed to the criticism made by Dr. Nichols in regard to some modern erections, of being "card-board shanties." They are described correctly in one of the annual reports as being built in the style of an ordinary dwell- ing-house, two storeys high, with front and rear entrance and hall, verandahs, sitting-rooms on first floor, and sleeping-rooms upstairs. There are no guards on the windows, except in three rooms of the IJelief building. The windows have an ordinary double-slung wooden sash, with panes of common glass, IG x 20 inches. The charge of the patients in the detached and main buildings is apportioned as equally as possible among the three assistant medical officers, one of whom, Dr. Bannis- ter, supervises the detached cottages for men. Their salaries vary from £200 to £240 per annum, with rations. The Superintendent has £000 and rations. No retiring pension is given. The matron's salary is £120. The supervisor on the male side, who also acts as bailiff, receives £200. Male attendants have from £4 to £G, and female from £3 to £4 a month. The proportion of attendants to patients is 1 to 10. All patients, of whatever class, are free, the law of Illinois, as of some other States, providing care and treat- ment for the insane gratuitously. The cost per patient amounts to £40 per annum, including clothing and every other expense. mi i M ^ 174 Kankakee. I found, on examining the record of restraint .-nd seclu- sion, that during September, 1884, three male patients had worn mittens or muffs, or wristlets and belt, in each case chiefly for surgical reasons. This is about the average for the year. There had been no instances of restraint in July ; in June three wore wristlets, and the same in May, the average time of restraint being eight hours. During April one man had been in restraint. No female patient had been restrained in August and September. In July there had been one instance of restraint for half-an-hour. The average amount of restraint during the whole pre- vious year had been under 1 per cent. In regard to se- clusion, there was during September an average of two patients a day for several hours on the female side, which was above the average for the year ; while on the male side there was an average of under one a day. It is stated in Dr. Dewey's report that restraint has been much abridged by constant efforts to employ destructive patients usefully, and by the introduction of strong dresses, locked clothing, &c., as in England. In the detached buildings, the wards are in many instances open, and the number of patients on parole is very large, fully 40 per cent. The ratio of patients employed in the detached build- ings is stated to vary from 68 to 72 per cent., rising as high as 79 per cent. The Trustees of the asylum, who are appointed by the Governor, meet monthly. The President, Mr. McCagg, although residing at Chicago, devotes a large amount of his time to the service of the institution. It is inspected by the State Board of Public Charities (Secretary, Mr. Wines) at least twice a year, and by a Committee of the State Legislature when in session. This bald description of a very interesting experiment, conscientiously carried on by an excellent superintendent, is merely supplementary to the general remarks made m Kankakee. 175 upon the Cottage system, at jd. 80, to wliicli the reader is referred."^ The census returns of the insane and idiotic in Illinois (1880) are appended. At that time there were only 88 patients in the Kankakee Asylum. Insane. Idiots. In Hospitals for the Insane and Asylums 2195 81 Institutions for Idiots . . . 306 ALxishouses 749 411 Jails 12 21 Charitable Institutions ... 30 9 At Heme 2148 3392 Total 5134 4170 The population of Illinois at the same date was 3,077,871. From Illinois I proceeded to Wisconsin, the State of small county asylums — examples, as I have already said, of institutions under county care with State control. Having described them in a former chapter (p. 82), I do not propose to notice them further here, as their essential features have been sufficiently delineated. Whatever may be the ultimate verdict passed upon them, I regard it as a healthy sign when we see a number of laymen of the middle classes taking an active personal interest in the insane, alive as I am to the dangers which arise when unsuitable cases are treated outside asylums posses- sing a medical head. One good feature of county asylums is that, generally speaking, the area of land on which the patients can work is considerable. * To the reader interested in the Cottage system of providing for the insane, I wcnld especially recommend Dr. Dewey's clearly and temperately written pamphlet, " Congregate and Segregate Buildings for the Insane," read at the Conference of Charities, held at Lonisville, Ky., 1883. See also "The Alienist and Neurologist," 1884. A paper by Air. Wines should likewise be read, " Provisiou for the lusane iu the United States : A His- torical Sketch," 1885. !i 176 Milwaukee Asylum. There are two large institutions in Wisconsin, one a semi-State asylum, and the other a State asylum. To the former — the Milwaukee hisane Asylum, Wauwato&a — the following notes have reference : — I visited this asylum, which is situated six miles from Milwaukee, in company with two members of the State Board of Charities, Prof. A. 0. Wright, its energetic Secretary, and Mrs. Fairbank, of Milwaukee. The latter related to me, from her own personal experience, many striking instances of patients confined within a recent period in almshouses, frightfully neglected and treated like felons, who had been removed to asylums in con- sequence of the action of the Board, and rendered com- paratively comfortable. In approaching the asylum itself, I saw the almshouse and a small home for 32 idiots close by. In the neighbourhood a private asylum is being built, of which Dr. McBride, the late superinten- dent of the asylum, will be the head. This institution is a county asylum, but in con- sequence of having received assistance from the State, it may be called a semi-State asylum. The assistant medical officer, Dr. Scriviner, was in tem- porary charge of the institution, and readily aiforded all the informuition required. He has since been appointed superintendent. The institution is governed by a Board of five Trustees, appointed by the Governor. The County Board of Super- vision, consisting of 24 members, attends to the finances. Visitation is performed by the Trustees and by the State Board of Charities, consisting of five members, including one lady. There is no fixed time for their inspection. The cost of building this asylum was £160 per bed, the capacity being 250, and the number of patients 300. The building, of yellow brick, consists of three storeys, with stone basement, the ground attached amounting to 150 acres. It ^^^as opened in 1879. There are rooms in the centre of the building handsomely furnished for a few Wisco7mn State Hospital. 177 private patients. The provision made for the poorer patients appeared to be on the whole ^'ood. The cost per week is ]5s., and the charge for pay patients in the centre building is £2 to £5 a week; in the other wards it is £1 to £2 a week. The proportion of attendants to patients is 1 to 10. Tliere are too few in the refractory wards. The character of the attendants in this asylum appeared to me to be below the average. Their salaries range from £3 12s. to £5 a month for men, and £2 8s. to £3 for women. There are two night watches. Several patients were in restraint, who, it seemed probable, might have had the free use of their limbs, had there been a sufficient number of good attendants. One man was seated in a strong room, fastened to his chair, his hands also being secured by a leathern muff. He was very tall, and was said to have proved himself a dangerous patient; he had torn up a portion of a floor, although, strange to say, one of his hands was totally disabled by an injury received before his admission. Another man, who was dancing about the gallery, had his hands secured by a leathern muff. A number of statistical tables are given in the annual report, but as, unfortunately, they only refer to one year, it is useless to attempt to draw any inference from them in regard to either recoveries or deaths. It is extraordinary that the insertion of a table, comprising the movements of the inmates from the opening of the institution, or, at least, for a few years back, should be the exception, instead of the rule, in American reports. The Wisconsin Staie Hospital for the Inscmc is situated •it Mendota, on the lake of that nume. It is a limestone building, surmounted by a small dome. There are six wards on each side. T'leir general appearance was home- like, and much has been done in the way of pictures and furniture. In some of the corridors there was a strong N |>l 178 Wisconsin State Hospital. iron frame a few feet from the -window at the end. Tliere were pictures inside, and a table and chair, so that what is an undesirable construction, is thought in some instances to prove useful in separating one patient from others in the ward. Dr. Buckmaster is the medical superintendent. As this asylum is unfortunately crowded, some day- rooms have been converted into dormitories containing eight beds. In one corridor there were 51 patients with three attendants, and in another 50 patients with four. In the ward for excited cases there were 51 patients witli four attendants. In a ward in which were excited patients, there was the iron guard already described at one end of the corridor, but not at the other, thus leaving the glass window exposed, but the glass was not broken. On my remark- ing upon this, Dr. Buckmaster said the guard was retained only for the convenience of separation, and for placing plants and pictures within the enclosure. In the con- valescent ward there were many plants, and ivy liad been carefully trained over the window inside the corridor. There were ornamental guards outside the sashes, the panes of which were of large size. There is one assistant medical officer. The government is vested in a State Board of Super- vision, which was appointed three years ago in place of a Local Board of Trustees then abolished. It has charge of the State institutions in Wisconsin. The members receive £400 a year, and all their expenses are paid. A member frequently resides in the asylum ; in fact, one is almost constantly there. Visitation is made by the Governor of the State, who visits the asylum annually. The Legisla- ture appoints a Committee before closing the session, whose duty it is to visit the hospital for the insane. They can appoint a physician to accompany and assist them. Further, there is the inspection by the State Board of Charities, the members of which are unpaid, with the Wisconsin State Hospital, 179 exception of the secretary. The State Board of Super- vision are Commissioners of Lunacy, and inspect monthly. The farm consists of 400 acres. It may be mentioned that last year there were 250 tons of hay housed ; up- wards of 2,400 bushels of oats, 5,000 of mangold wurzels, and 1,200 bushels of potatoes. There are 75 acres devoted to Indian corn, which yielded 3,000 bushels. There are 80 cows— shorthorn, Jersey, and Alderney — 300 pigs and nine horses. The garden covers 15 acres. Fruit is largely used. The building cost about £200 per bed, exclusive of land. It was designed to accommodate 500 patients. Now there are 533 ; males, 289 ; females, 244. There is a great accumulation of chronic cases. It is stated that not more than 30 or 40 of the patients are curable. There are 12 general paralytics on the male side; none on the female. There are 40 epileptics. The proportion of attendants to patients is 1 to 12. Their salaries range from £4 8s. a month to £0 for men, and about £3 to £4 4s. for women. The male supervisor, who has been at the asylum 14 years, receives £125 a year, while the female supervisor receives £02. One of the male attendants had been eight years at the Somerset County Asylum, England. I was informed that owing to the high wages obtained in other vocations it has been found difiBcult to procure sufficient help on the men's side. Dr. Buckmaster considers that 10 or 12 would be a fair average of patients restrained.* There are generally three on the men's side. It should be stated that criminal lunatics are admitted into the asylum, and that as several are restrained by order of the Governor of the State, the superintendent has no choice. The forms of i-estvaint are the camisole, the muff, and the wristlets. There are no less than 50 covered or crib-beds in use. The reasons assigned for restraint, as given in the carefully kept I'ecords * More than 2 p.c, exclusive of crib-becl, the use of which has since been reduced to half the number. 180 Wisconsin State Tlos^ntal. I I W' of the institution, are to prevent destructiveness, the re- moval of dressings from wounds, self-injury, and escape. It is only just to the kindly superintendent to state that he has been a short time at the head of the asylum, and that he is proceeding to reduce the amount of restraint within much narrower limits, and this he will do, I am quite certain, with a right good will. In regard to seclusion, very little use indeed is made of it. Whatever may be the shortcomings of this asylum, or, rather, the sins of com- mission in the matter of restraint, there are no dark cells in which patients are immured and left to themselves, day after day, manacled and secluded at the same time. The recoveries amount to 27*3 per cent, calculated on the admissions. There are many relapses. The deaths are at the rate of 0'12 per cent., reckoned on the average number rosident. There is nothing to note specially in regard to treatment, but it may be stated that hyoscy- amine, in doses of ^^ to -„',^ of a grain, is occasionally administered. In one case alarming symptoms arose from the administration of -^g gr. With regard to employment, about 35 per cent, of men and women are employed during the greater part of the day, and about as many more partially, making 70 per cent, more or less occupied. The remainder go to the " Groves," and even those who are excited, and cannot or will not walk, are carried there. Quoits, swings, and croquet are among the outdoor amusements. Sometimes there ij not a single patient in the house, except a few feeble invalids in bed. Excursions are made on Lake Mendota once or twice a week in summer ; bathing and swimming in the lake are much enjoyed by the patients. I understood Dr. Buckmaster to say that the religious services are usually conducted by the medical officers of the hospital. It would seem desirable that this should be alwayi* the case, for after a sermon on fasting (not by a medical officer) the tube had to be employed in nine cases for the purpose of forced alimentation ! Mary land State Hospital. 181 of men of the per to the nnot or js, and letimes a few Lake g and tients. igious ers of uld be »t by a cases Prior to the admission of a patient tlie proceedings nro as follows: — Application is made on behalf of any person supposed to be insane, to the county court judge, &c., for a judicial iufiniry as to his mental condition, or for an order of commitment to the hospital. It must be specified whether or not trial by jury is desired. The judge is to aj)point two phj'sicians to examine the alleged lunatic and report. If a jury is not demanded the judge may make an order of commitment. In the event of trial by jury, it must be in presence of the alleged lunatic and his counsel, the iunnediate friends, and medical witnesses, all other persons being excluded. The census of 1880 shows that the number of insane and idiotic in this State amounted to ; — Insane. Idiotic. In Hospitals and Asylums for the Insane 1230 30 Almshouses ... .. ... ,.. 315 120 uiiiin ... •>■ «.• ••• ••• '•'^ '^ At home 959 1027 ^ii ).. i'^i Total... 2520 1785 The population of Wisconsin was 1,315,497 in 1880. The Spring Grove Asylum, Baltimore, is the State Hospital for the Insane for Maryland. It was re-organized in 1870. Dr. Gundry, formerly of the Dayton Hospital for the Insane, Ohio, has been superintendent for six years, and has done much to improve the appearance of the walls, and employed the patients in decorating them, as well as in other ways. There are a considerable number of patients of colour in this asylum, the prejudice agai"^t whom is very strong — so strong that Dr. Gundry has been unable to break throusrh it on the Avomen's side of the house. These number 19, and have one attendant ; their bedrooms are crowded. The number of men of colour is 11. '-;■ 182 Maryland Htate Hospital. This institution, to which Dr. and Mrs. Gundry zealously devote their time and interest, would present a much more satisfactory aspect were it not so lamentably crowded, it is highly desirable that more money should be spent in furnishing it, and adding to the general ap- pearance of comfort. Without a sufficient appropriation, the dcjctor's efforts are, to a large extent, paralysed. The cost of the building and land (13G acres) was £450 per bed. The Board of Managers, in their report for 1883, state that the small balance then on hand lias necessitated "■ the leaving undone many matters of improvement and repairs which good order and proper preservation of the property called for, but which we could not accomplish owing to the limited appropriation by the last Legislature to the support of this great State charity.'' The crowded condition of the building is then referred to, and the absolute necessity of providing another hospital. It is stated that the limited grounds, absence of abundant water supply, and difficulty of sewage and drainage, forbid maliing increased accom- modation at Spring Grove. It is added — and this is but too apparent — that " Maryland is largely behind many of the States in caring for the disabled poor within her borders." The Board urge that the State of Maryland should adopt the policy of caring directly for all its pauper insane. It appears that some of the counties are in arrear in their payment, and one of them was sued by the hospital several years ago. Dr. Gundry in his report makes the same compUiints, and says that every year's delay only increases the evil. Ventilation is not by any means so complete as in many American asylums ; the fan is not in use. Earth closets only are resorted to, because the authorities do not allow the employment of drainage; and they work badly. Dr. Gundry proposes in his report that there should be a steal— pump, with conducting pipes to various parts of the land, BO that stations for distribution can be made at various Maryland State Hospital. 183 distant points. With a view to extend the application of the sewage to the land, thorough underdraining will be necessary. There are nine trustees or managers, one of whom, Mr. Francis White, kindly drove me to the institution, which is some miles from the city. The trustees, who are appointed by the Governor of the State, meet every month, and one of their number visits the asylum weekly. The grand jury pay a formal visit periodically. Mr. White regrets that there is no State Board of Charities. There are 400 patients in the hospital — 22G males and 17-i females. Classification is according to mental condi- tion. There is a mixed class of patients socially. The cost per head per week is IGs. The city and county pay £30 a year for each patient. There are 50 patients who pay from 24s. to £2 a week. The rest are main- tained at the public expense. The proportion of male attendants to patients is 1 to 14. There are two outdoor attendants. In the female depart- ment the proportion is 1 to 13; there is also a sewing girl. The above includes the supervisor. Their salaries are : — Male supervisor, £5 8s. ; ordinary male attendants, £4 8s. per month. There is no female supervisor. Female attendants have £2 r2s. a month. Dr. Gundry is strongly in favour of non-restraint. I was informed that there was little use made of seclusion, especially on the men's side. One patient is always secluded by express desire of the Board, he having once escaped and committed murder in the neighbourhood. The recoveries are, unfortunately, not stated in the annual report for a longer period than the past year. The same may be said of the mortality. About 80 patients are employed out of doors. Five men and eight women are employed in the laundry. Not quite 50 per cent, of the total number of patients are more or less ! i; ployed. Dramatic scenes are represented in the 184 Mount Hope Asylum. recreation-room, which is used also for the chapel. The mapjic lantern is a favourite amusement. The mode of proceeding in Maryland in regard to the admission of paupers into asylums is as follows: — "It is enacted that when any person is alleged to he a lunatic or insane pauper, the Circuit Court for the county in which said person may reside, or the Criminal Court of Baltimore, if he be resident in the city, shall cause a jury to enquire whether he is insane, and if found so shall cause him to be sent to the almshouse or hospital, &c., until he hava recovered. Nothing in this provision shall prevent the friends of such lunatic from confining him or providing for his comfort."* It is said that the almshouses in Maryland are in a very bad condition. There is one at Baltimore. A gentleman informed me that when he visited it a year ago the insane inmates were in an unsatisfactory condition, and that some were chained. A separate receptacle for the insane paupers is in course of erection near the almshouse. Another institution for the insane at Baltimore is the Mount Hope Asylum, an institution under the charge of lloman Catholic Sisters of Charity. The building, situated a few miles from Baltimore, is a very extensive edifice of red briclc, five storeys high. It stands in 400 acres of land, and it provides accommodation for 546 patients, the females preponderating. One feature of the asylum noticeable on passing through the first storey, a ward for 31 patients of the worst class, is that they are attended to by not only a male attendant, but by two Sisters. This plan of having female attendants in the male department is general through- out the house, and is regarded as an important anu successful arrangement. On the female side of the house there are two Sisters and one help in each ward. Pictures were on the walls, and the floors were carpeted. * See Earrison's Collection of Lunacy Laws, ISS^t. Mount Hope Asylum. 185 The the [rough chiss, id ant, [em ale louj^h- It aiui the I ward. )eted. The rooms as well as the corridors were very tastefully furnished. The windows of the strong rooms were high ; none of these rooms were without a bed. The rooms in the storey above, for a rather better and more curable class, were cheerful. The dress of the patients was very neat ; one man was playing the violin surrounded by a group of patients. The windows are protected by ornamental iron frames throughout. In the rooms in the roof were 31 patients who were ca.red for by three Sisters and one male attendant. The day-room here also was carpeted. In some single rooms distinct from the ward there were two patients in seclusion, but not otherwise restrained. In another gallery containing about the same number of patients one was playing the violin to the rest. The beds were clean and comfortable. There was a large dormitory in the attic, which was somewhat bare. The view from the roof, on which there is a cupola, commands an extensive prospect of the surrounding country. The number of wards is sixteen. Patients are classed according to mental condition. There is one assistant medical officer. Dr. Stokes, of Baltimore, is the visiting physician, and has been so about forty years. He attends three times a week, and the assistant medical officer, who resides near the asylum, visits on the other days of the week. The weekly charge for paying patients, of whom there are 290, varies from 20s. to £3 a week. The city cases (156) pay 12s. Cd. a week which includes clothing, while 100 of the patients pay next to nothing. No patient was in restraint. Several were in seclusion. Recoveries. — Here, as so generally is the case, the annual report affords no information as to the number of patients recovered during a term of years. During the past year 65 patients were discharged recovered ; 53 of these being recent, and 12 chronic cases. The admissions during the year were 184. It is stated by Dr. Stokes that he has often proved in his reports that 70 or 80 per cent, of acute ii m 186 Mount Hope Retreat. cases admitted within three months after the inception of the disease have recovered, and that, when the case was not complicated with organic disease of the brain, even 90 per cent, have been cured. We are not informed whether this high percentage is calculated on single admissions ; in other words, whether it has reference to cases or persons. The statement is, indeed, made that it seldom happens that patients are re-admitted on a recurrence of the dis- order. This experience is so contrary to that of every other asylum 1 know to which patients, if they do relapse, would return, that I should have greatly valued statistical tables covering the history of the asylum from its com- mencement to the present time. As regards the mortality, also, we have only the deaths for the past year, namely, 45 ; but as the average number resident is not given, we are quite precluded from obtain- ing a correct percentage for even one year. We can only tell that it was 7*19 per cent, of the whole number under treatment. Dr. Stokes is fully alive to the importance of labour on the land as an aid to recovery. He observes that the farm, the garden, the laundry, the kitchen, and the sewing-room furnish the means of occupation, by which the recovery of convalescence is advanced, and the incurable are relieved from the misery attendant on a state of idleness. No figures, however, are given to show the actual number of patients employed. There is a Eecreation Room distinct from the chapel. It constitutes a large central parlour. Once a week evening-entertainments are given. Billiards on the male side, and pianos in the female department, are provided, and appreciated by the patients. The so-called "Picnic Grounds," situated in a re- tired situation not far from the asylum, are stated to be very popular. Tennis and croquet are provided, also boats for rowing on the lake, which, although " manned,'^ are each under the care of the Sisters, and are much used in Summary. 187 ption of ise was even 90 kvhether ions ; in persons, happens ;lie dis- )f every relapse, atistical ts coiu- 5 deaths number L obtain- 3an only er under bour on e farm, ig-room ecovery Irelieved is. No liber of I ebapel. week le male lovided, a re- Id to be lo boats >) are summer. There is also a pavilion for dancing, and a cottage-kitclien in which meals are prepared. The form of medical certificate is extremely simple, namely, " I hereby certify that I have seen and examined A.B., of CD., and believe him to be insane and that he ought to be placed for treatment in a hospital for the in- liii; )} sed in sane. The order for admission, to be signed by a citizen of Baltimore, is as follows : " I request that the said A.B. shall be admitted into the ' Mount Hope Retreat,' and in con- sideration of his being so admitted, I hereby guarantee the performance of the above obligation " (a bond to pay for board, &c.). It only remains to add the statistics of insanity and idiocy in Maryland as given in the census of 1880 : — In Hospitals for Insane and Asylums , Almshouses Jails Charitable Institutions At Home ... The population of this State at the above date was 934,943. As this is the last State the figures of which I give in relation to the provision for the insane, I would add that, throwing together the figures of all the States visited, the result shows that there were at the last census 44,824 insane. Of these there were in hospitals for the insane and asylums 22,798, and in almshouses 5,531. There were 57 in jails, 90 in charitable institutions, while 10,348 were at home. In the same .States were 25,005 idiots, of whom 421 were in hospitals for the insane and asylums, 2,400 in almshouses, 24 in jails, 124 in charitable institu- tions, 1,514 in institutions for idiots, and 21,110 at home. Insane. Idiots. 912 37 200 86 9 5 9 731 1187 1857 1319 188 ^t Nummary, f The figures, altliongli they accord in their general cha- racter with those obtained from the aggregate cens'is for the whole of the States, show some difference in a favourable direction, seeing that more than one-half were under care in hospitals or asylums for the insane. I am surprised, however, that in the States which I visited, the proportion of the insane in almshouses is as high — namely, 10 per cent. — as in the total number of States. The number at home or in private families was 32 instead of 44 per cent. ; favourable by comparison, but still a large proportion. The total population of the States I visited was, in 1880, 19,364,200, and as the number of insane and idiotic in these States amounted to 70,429, there was 1 person of unsound mind to 274 of the general community — a some- what higher proportion than that in the total States. (Appendix C.) In England and Wales the proportion of insane in hos- pitals and asylums (including idiots) in 1884 was 70 per cent. The number in ordinary workhouses was 15 per cent., or 5 per cent, higher than in the States. I think it may be said that our workhouses are, as a rule, fit re- ceptacles for the class of patients sent there. For more detailed information in regard to the insane and idiotic in the United States, the reader is referred to the Appendix. h I leral clia- ite cens^^s ence in a I one-lialf ae insane, wliicii I )uses is as lumber of milies was irison, but ,s, in 1880, idiotic in person of — a some- al States. ,ne in hos- as 70 per as 15 per I think le, fit re- insane ?f'erred to CHAPTER V. The Insane in Canada. Province of Quebec. On the 30th August last (1884) I visited the lunatic asylum at Longue Pointe, seven miles from Montreal, called the Hospice des Alienes de St. Jean de Dieu. It was built by the Scours de Provif^ence, and opened in 187G. The Province of Quebec contracts with them to maintain the lunatic poor"^ in one of the two districts into which the Province is divided; the asylum at Beauport, near Quebec, providing similarly for the other district. Private patients are admitted. The building — which, surmounted by three cupolas, is a prominent object from the St. Lawrence in approaching Montreal from Quebec — is built of red brick, and consists of a centre and wings. Some of the latter were added three or four years ago ; others are now in course of erection, and will not be finished till the end of the year. Dr. Henry Howard, the visiting physician, kindly facilitated my desire to see the asylum, and escorted a small party, consisting of Dr. Koss of Montreal, Dr. S. Mackenzie of London, and myself, to the institution. I must express to Dr. Howard my last- inof obligations for his attention and assistance. We were received by the Lady Superior, Soeur Therese de Jesus, who had been apprised of our visit. She conducted us * At the rate of 100 dollars or ^20 por annum per head at ilontreal and li50 dollars at Quebec — a very itisufficieiit sum, it would tjoem, tor board, lodf^'inj^ aud clothing. I understand that the money on'j,'iiially borrowed of the Provincial Government by the Montreal Asylum has been refunded, and that money li is been borrowed from private quarters to assist iu the erectiou of the additional buildiugs. 190 Longue Pointe Asylum. througli the buildinf^, and was most courteous in her manner^ and in replying to the numerous questions with which I troubled her. I am glad to have this further opportunity of thanking her and the other Sisters for their kindness throughout the visit. The neatness and cleanliness of the hall, reception- room, and office strike the visitor very favourably on enter- ing the establishment. The Ai^othecaire is a model in these respects. The Sisters have themselves published a phar- maceutical and medical work, a large volume entitled "Traite El^mentaire de Matiere Medicale et Guide Pratique," a copy of which the worthy Lady Superior was good enough to present to me. I was somewhat dis- appointed to find, on examining its pages, that only one was devoted to mental alienation, of which nine lines suffice for the treatment of the disorder. Among the moral remedies, 1 regret to see that ^^punitions" are enumerated ; their nature is not specified. Two skeletons in the Apothecaire were shown to us by Sceur Therese, as being much valued subjects of anatomical study for the nuns, who would, it is not unlikely, consider their know- ledge of the medical art sufficient for the needs of the patients. The law, however, obliges a medical man to reside in or near the asylum. Dr. Perrault, whom we did not see, occupies this post. This officer is api3ointed and paid by the Sisters ; the visiting physician, on the con- trary, is appointed and paid by the Provincial Govern- ment. We looked down upon a very large kitchen, where cooking by steam was going on actively, and a favourable impression as to the supplies was left upon the mind by the busy scene which presented itself. The amount of vegetables (potatoes, turnips, cabbages, &c.) produced on the land, is very large — more potatoes, I believe, than they consume. Maize, wheat, oats and buckwheat are raised. The estate consists of 600 acres. There is a large number of cows, and the asylum buys beasts to fatten and kill, thereby saving a considerable i Longue Pointe Asylum, 191 IS in her ions with s furtlier isters for •eception- on enter- j1 in these d a phar- ^. entitled et Guide Superior swhat dis- t only one line lines tnong the ions" are skeletons |herese, as y for the eir know- ds of the 1 man to m we did nted and the con- Go vern- kitchen, and a eft upon If. The es, &c.) atoes, I iits and acres. ra buys iderable sum. I was informed that about fifty patients were usually employed out of doors, and more in harvest time. That such an establishment should be conducted by nuns must seem remarkable to those who are unacquainted with the large part taken by Sisters of Charity in the manage- ment of hospitals in countries where the influence of the I Eoman Catholic Church extends. Theoretically, it would seem to be an admirable system, and to afford, in this way, a wide field for the employment of women in occupa- tions congenial to their nature, and calculated to confer great advantages upon the sick, whether in mind or body. That women have an important role in this field will not be denied ; but experience proves only too surely that to entrust those of a religious order with administra- tive power is a practical mistake, and leads to abuses which ultimately necessitate the intervention of the civil power. The asylum consists of a succession of corridors and rooms similarly arranged, there being dining-rooms, recesses, and single and associated dormitories. There are four storeys uniform in construction, exclusive of the basement and the rooms in the roof, and these four are supplied with open outer galleries or verandahs, pro- tected by palisades. The lower storeys are clean and well furnished, and the patients appeared to be comfortable. The apartments of the private patients were, of course, the best furnished. It was curious to see in the day rooms on the male side a nun with a female assistant. They are in the wards all day, and sleep together in another part of the building. In the refractory ward for men there were two male attendants, and in the other wards one male attendant, in addition to the two females. In eacli ward on the women's side there were two assis- tants with the nun in charge, and in the refractory gallery there were three assistants. The nuns and female assistants are not paid. The corridors, the width of whicli was fair, were carpeted down the centre, and there were 192 Longue Pointe Asyluyn. pictures on the walls in considerable number. In the day-rooms, on the floors of -which was oilcloth, the furni- ture, though simple, was by no means insuflieient. Tn the recesses of Uie corridors, as well as in the corridors themselves, were seats for the patients. Although there were rooms on both sides of the corridor, the latter was fairly lighted by the recesses, &c. The dormitories were very clean, and presented a neat appearance ; the beds were of hair, and a bright-coloured counterpane had a pleasing cfFect. Single rooms, used as bed and sitting- room, wore very neatly furnished, and had every appear- ance of comfort. For paying patients, and for a consider- able number of the poorer class, I have no doubt the accommodation is good, and as I must shortly speak in terms of strong reprobation, I have pleasure in testifying to the order, cleanliness, and neatness of those parts of the building to which I now refer, and over which wo went in the first instance. It is as we ascend the building that the character of the accommodation changes for the worse. The higher the ward, the more unmanageable is the patient supposed to be, and the galleries and rooms become more and more crowded, and look bare and comfortless. The patients were for the most part sitting listlessly on forms by the wall of the corri- dor, while others were pacing the outside gallery, which must afford an acceptable escape from the dull monotony of the corridor. The outlook is upon similar galleries in the quadrangle at the back of the building; and, to a visitor, the sight of four tiers of palisaded verandahs, with a number of patients walking up and down the enclosed spaces, has a strange effect. These outside galleries are, indeed, the airing courts of the asylum. There are no others. If the patients are allowed to descend, and to go out on the estate, they usually do so in regular order for a stated time, in charge of attendants, like a procession of charity school children. Those who work on the farm must be the happiest in the establishment. ' 'J? r ' Lortgue Pointe Asylum. 193 In the fourth tier were placed the idiots and imbeciles —a niolancholy si^lit ncci'ssarily, even when cared tor and trained in the best i)ossiblo manner, but especially so when there is no attempt made, so tar as I could learn, to raise them to a hi^'lier level or educate them. It, how- ever, they are kindly treated and kept clean, my regret on account of educational ne^'lect would be much less than the pain caused by the state of the patients and their accom- modation in the parts of the establishment next described. Far be it from me to attribute to these Sisters of Charity any intentional unkindness or conscious neglect. I am willing to assume that they are actuated by good motives in undertaking the charge of the insane, that they are acute and intelligent, and that their administrative powers are highly respectable. Their farming capacities are, I have no doubt, very creditable to them. It is not this form of farming to which I have any objection or criticism to offer. In the vegetable kingdom I would allow thein undisputed sway. It is the farming-out of Imman beings by the Province to these or any other pro- prietors, against which I venture to protest. It is impossible to convey an adequate idea of the con- dition of the patients confined in the gallery in the roof, and in the basement of this asylum. They constitute the refractory class — acute and chronic maniacs. Tliey and the accommodation which has hitherto been provided for them, must be seen to be fully realized. To anyone accus- tomed to a Avell-ordered institution for the insane, the spectacle is one of the most painful character. In the course of seven-and-thirty years I have visited a large number of asylums in Europe, but I have rarely, if ever, seen anything more depressing than the condition of the patients in those portions of the asylum at Longue Pointe to which I now refer. I saw in the highest storey, that in the roof, a gloomy corridor, in Avhich at least forty refractory men were crowded together ; some were walk- ing about, but most were sitting on benches against the ii \H Lunyue Pointe Asylum, wall or in restraint-clniirs fixed to the floor, the occu- pants beiiij^ socuivd to tlioni by straps. Of these sciittMl on the benches or pacing the <,'allery, a considerable number were restrained by hand<.'iifi's attached to a belt, some of the cutis beiii^ tbe ordinary iron ones used for prisoners, the others beiiiL;* h'atlicr. Ifestraint, I should say in passinjjf, was not condiied to the so-called refractory wards; for instance, in a lower and quieter ward, a num was tifjfhtly secured by a strait-waistcoat. Dr. Howard had him released, and he did not evince any indication of violence. It was said lie would tear his clothes — a serious matter in an asylum conducted on the contract system ! The walls and floor of the corridor in the roof were absolutely bare. But if the condition of the corridor and the patients presented a melancholy si^'ht, what can be said of the adjoiniii;^- cells in which they sleep and are secluded by day i* These are situated between the corridor and a narrow passa<,^o lighted by windows in the roof. Over each door is an opening- the same width as the top of the door, and three to four inches in height, which can be closed or not as the attendant wishes. This aperture is, when open, the only means of lighting the cell. The door is secured by a bolt above and below, and by a pad- lock in the middle. In the door itself is a (jtiichet or wicket, secured, when closed, by a button. When opened, a patient is just able to protrude the head. There is, as I have intimated, no window in the room, so that when the aperture over the door is closed it is absolutely dark. For ventilation, there i.-^ an opening" in the w^all opi)()site the door, which comnumicates above with the cupola; but whatever the communication may be with the outer air, the ventilation must be very imperfect. Indeed, I understood that the ventilation only comes into operation when the heating- apparatus is in action. What the con- dition of these cells must be in hot weather, and after being occupied all night, and, in some instances, day and night, may be easily conceived. When the bolts of the \ Itr Longue Poinfo Asijlum. 105 door of tlio first coll which I saw oponetl wore dravvn back iiiul the piidlock roiiiovod, a man was seen crouchin*^ on a straw mattress rolled up in the corner of the room, a Ujoso cloth at his feet, and he stark naked, ii|,'un)usly restrained by handcuffs and belt. On beinj,' spoken to he rose up, da/zled with the lij^^it; he looked pale and thin. The reason assigned for his seclusion and his manacles was the usual one, namely, " he would tear his clothes if free." The door bein<^ closed upon this unfortunate man, we heard sounds proceediii;^' from nei<^'hbourinfj cells, and saw some of their occupants. One, who was deaf and dumb, as well as insane, and who is desii^Muited lliomine incon^m, was similarly manacled. In his cell there was nothing Avhatever for him to lie or sit upon but the bare Hoor. He was clothed. Some of the cells in this gallery were supplied with bedsteads, there being just room to stand between the wall and the bed. When there is no bedstead a loose palliasse is laid on the floor, which may be quite proper. In reply to my inquiry, the Lady Superior informed mo that it was frequently necessary to strap the patients diwn in their beds at night. Passing from this gallery, which I can only regard as ii "chamber of horrors," we proceeded to the corresponding portion of the building on the female side. This was to me even more painful, for Avhen, after seeing the women who were crowded together in the gallery, on benches and in fixed chairs, many also being restrained by various mechanical appliances, we went into the luirrow passage between the pens and the outer wall, the frantic yells of the patients and the banging against the doors con- stituted a veritable pandemonium. The ett'ect was heightened when the guidiets in the doors were un- buttoned, and the heads of the inmates were protruded in a row, like so many beasts, as far as they could reach. Into this human menagerie, Avluit ray of hope can ever enter P In one of the wards of the asylum I observed on the walls u card, on which were inscribed words to the 196 Longue Pointe Asylum. efiPect that in Divine Providence alone were men to place their hopes. The words seemed to me like a cruel irony. I should, indeed, ref,mrd the Angel of Death as the most merciful visitant these wretched beings could possibly welcome. The bolts and padlocks were removed in a few instances, and some of the women were seen to be confined by leathern muffs, solitary confinement not being sufficient. One of the best arguments in favour of re- straint by camisole or muff is that the patient can walk about and need not be shut up in a room, but we see here, as is too often seen, that unnecessary mechanical restraint does not prevent recourse being had to seclusion. A cell, darkness (partial or total), a stifling atmosphere, utter absence of any humanizing influence, absolute want of treatment, are frequently the attendants upon cami- soles, instead of being dispensed witli by their employ- ment. When such a condition of things as that now described is witnessed, one cannot help appreciating, more than one has ever done before, the blessed reform in the treatment of the insane which was commenced in England and France in 1702, and the subsequent labours of Kill, Charlesworth, and Conolly. But it is amazing to reflect that although the superiority of the humane mode of treating the insane, inaugurated nearl}' a century ago, has been again and again demonstrated, and has been widely adopted throughout the civilized world, a colony of England, so remarkable for its progress and intelli- gence as Canada, can present such a spectacle as that I have so inadequately described as existing, in the year of grace 1884, in the Montreal Asylum. Before leaving the asylum, I visited the basement, and found some seventy men and as many women in dark, low rooms. Their condition was very similar to that already described as existing in the topmost ward. A good many were restrained in one way or another, for what reason it was difficult to understand. Many were weak-minded, as well as supposed to be excitable. The ' ■I \ inoae ago, been colony intelli- that I ear of it, and dark, that 1. A er, for were The , I Longue Pointe Asylum. 197 patients sat on benches by the wall, the rooms being bare and dismal. A large number of beds were crowded together in a part of the basement contiguous to the room in which the patients wore congregated, while there were single cells or pens in which patients were secluded, to whom I spoke through the door. The herding together of these patients is pitiful to behold, and the condition of this nether region must in the night be bad in the extreme. I need not describe the separate rooms, as they are similar to those in the roof. The amount of restraint and seclusion resorted to is, of course, large. Yet I was informed that it Avas very much less than formerly. To the statement in regard to the crowding of the patients in this asylum, it will be objected that I have given a dcbcription of a state of things which will shortly disappear, as additional wards are being provided for their accommodation. While I am glad to hear that other rooms will be available before long, I am not by any means convinced that the lowest and topmost wards of this asylum will be disused for patients. There are now, the Lady Superior said, about 1,OUO lunatics in the buildings ; and when first informed that new wings were being prepared, I concluded that it was for the purpose of jjroviding increased accommodation for the existing number of inmates only. That hope, however, was greatly lessened, if not wholly dispelled, when I learnt from this lady that when these new wards are ready there will be room in the institution for 1,400 patients. It is said the new rooms will contain GOO beds, but how many cubic feet are allowed in this calculation I do not know. I have no hesitation in saying that when the patients are removed who now occuj)y the two portions of the build- ing I have described, and when the occupants of the other galleries are reduced to the number the latter ought properly to accommodate, there would be at least 400 patients who should be removed from the old to the new , i ii il !1 i 1 i :i i i 198 Longue Point e Asylum. building. If I am correct in this opinion, the present lamentable evils will continue after the opening of the additional apartments, or if they are mitigated for a time they will but too surely be renewed as fresh admis- sions take place. Assuming, however, that overcrowding is lessened, and that these dark cells should cease to be used, what guarantee— what probability — is there that the manacles will fall from the wrists of the patients of this asylum? I am not now speaking from tlie stand- point of absolute non-restraint in evei-y conceivable in- stance of destructive mania. It is sufficient to hold that the necessity for mechanical restraint is exceptional, and that in proportion as an asylum is really well managed the number whose movements are confined by muffs, strait-waistcoats, and handcuffs will become smaller and smaller. The old system of treating the insane like felons has been so completely discarded by enlightened physicians devoted to the treatment of the insane, that it can no longer be regarded as permissible in a civilized country. The astonishment which I experienced in wit- nessing this relic of barbarism in the Province of Quebec, is greatly increased when I see such excellent institu- tions as the lunatic asylums of the adjoining Province of Ontario. I am perfectly certain that, if it were pos- sible to transfer the worst patients now in the asylum at Montreal to these institutions, they would be freed from their galling fetters and restraint-chairs. They would quit their cells also, and, in many instances, be usefully occupied where they are now restrained, with the result that in not a few cases perfect recovery to health would follow. " Look on this picture and on this," were words constantly in my mind after visiting the institutions of the two Provinces. It can hardly be urged that a system which is attended by great success in the one Province, would be less successful in the other. The recoveries at the Montreal Asylum during the last ten years have been decidedly few ; while the L ongiie Pointe Asylum. 199 the ^ 1 mortality has been above the average of asylums, namely, 11 per cent, of the average number resident. The question arises, why this difference in the condition of the insane in the asylums of the two Provinces? What- ever other reasons there may be for this extraordinary contrast, I have no doubt that the main cause is to be found in the different systems upon which the financial management of these institutions is based. It is a radical defect — a fundamental mistake — for the Province to contract with private parties or Sisters of (Charity for the maintenance of lunatics. This, it cannot be too often repeated, is the essential root of the evil ; and unless it be removed, the evil, although it may be mitigated, will re- main and will bear bitter fruit. If any stops are to be taken to remove the present deplorable condition of the insane in the tisylum of Montreal, it must be by the Province taking the actual responsibility of these institutions into its own hands. Whatever may be the provision made by private enterprise for patients whose friends can afford to pay handsomely for them, those who are poor ought to have the buildings as well as the maihtonance provided for them by the Legislature. They are its wards, and the buildings in which they are placed should belong, not to private persons, but to the public authorities, with whom should rest the appointment of a resident medical officer. The official inspection of this institution must now be referred to. There are, I am informed, three inspectors of the asylums and prisons of the Province, namely, Drs. L. L. L. Desaulniers, A. de Martigny, and Mr. Walton Smith. They report to the Provincial Secretary, who resides at Quebec, and is the Government officer to whose department these institutions pertain.* I was informed * I little knew at the time of my visit tliat a correspondence had re- cently taken place between the La- asylums for the insane of this Province will become institutions of wliicli Canadians may be justly proud, instead of institutions of wliicli they are now, with good reason, heartily ashamed. Beauport Asylum, Quebec. I visited the Beauport Asylum, at Quebec, August 18th, 1884. It was established in 1845 ; additions were made to the original buihling, in 18(35 for the male patients, and in 1875 for the female patients. The medical superintendents reside in the city, several miles away, and I had not the pleasure of seeing them. There are two visiting physicians. The asylum is inspected by Dr. Desaulniers, Dr. A. de Martigny, and Mr. Walton Smith. Resident on the premises is the warden, and in the vicinity is an nssistiint physician. I have to express to both these gentlemen my obligations for the kind way in which they received me, the time they devoted to my visit, and their readiness to show me the various parts of the building. My thanks are especially due to Mr. A. Thomson of Quebec, for the assistance he rendered and for accompanying me. The asylum is a striking object to visitors to the Mont- morency Falls, as they pass along the road where it is situated. The approach is pleasant and the entrance attractive, being marked by the taste and cleanliness which characterise the dwellings of the Canadians gener- ally. The warden received us politely, and took us round the building devoted to female patients. His wife occupies the post of matron, and has two assistants under her. The corridors into which we first went are sufficiently spacious, and serve the purpose of day-rooms to a large extent, the patients being seated or walking about. The patients here were well dressed, and appeared to be as coniortable as their condition would allow. The asso- >l 202 Beauport Asylum. I/iy ciated dormitories are large, cheerful rooms, well venti- lated, and the beds neat and clean. I supposed that the linen had been clean that morning, but was informed that it was the last day in use, and that it was changed weekly. Strips of carpet and mats in the dormitories, as well as in the corridors, relieved the bareness of the floor. The position and construction of a series of single bedrooms attached to the wards, are most unfortunate. They are placed back to back, so that there is no window in them, the narrow passage which skirts them receiving light from a window at either end. There is an aperture over the door, and a small one in the door itself. The ventilation is most imperfect, and it was not denied that in the morning their condition is the reverse of sweet. Some of these cells — for cells they must be called — were very close when I visited them. How such rooms came to be built for lunatic patients, for whom good air and suificient light are so important, it is difficult to com- prehend. I was informed they were planned to expedite the escape of the inmates in case of fire, there having been a conflagration some years ago in which twenty-six patients perished, but I failed to see the fitness of such an arrangement. It appeared to me to be due to the desire to economise room, and I am not surprised to find, from one of the annual reports given me, that credit is claimed on the ground that the cost for care and mainten- ance is less than at ten asylums with which the Beauport Asylum is compared. I have spoken favourably of the associated dormitories opening into the corridors. Those, however, in the attic were very gloomy and crowded with beds. J have* also referred favourably to the dress of certain patients. I must add that in some parts of the house they were barely clad, and presented a very neglected appearance altogether. The number of women in restraint was very con- siderable. iSome wore the manchon or muft', others the ■Mil Beauport Asylum. 203 [ venti- hat the formed hanged »ries, as le floor, single [•tunate. window jceiving iperture [f. The ied that f sweet, d — were ms came air and to com- expedite > having renty-six of such to the to find, credit is nainten- Jeauport mitories the attic ave* also ents. I ey were earance iry lers con- the close glove (mitaine) ; others were restrained by leather wristbands [poicjiiet) fastened to a belt, while some were secured by the cjilet de force, so that movements of the arms wei'o effectually prevented. Several were secured to the bench on whicli they were seated. In one small airing court upon which I looked down, not a few were restrained ; the whole company appeared to be unattended, or if there were attendants, the latter did not consider it a part of their duty to keep their dress in decent order. In referring to mechanical restraint, I beg it to be dis- tinctly understood that neither here nor in any other asylum do I judge of the condition of the patients from the total non-restraint point of view. The amount resorted to in this asylum would not be seriously jus- tified by any physician of the insane, with whom I am acquainted, whatever his views on non-restraint may be. After leaving the building in which the women are located, we walked into the grounds over a stream to a steep, grassy, airing court, which was fortunately shaded from the blazing sun of that day. Here a number of female patients were congregated, with one or two attendants. A wooden fence separates this ground from a correspond- ing grass plot for the men. From a window in the build- ing for the latter sex I looked down subsequently, and the sight of the female patients lying or sitting on the grass in unseemly attitudes, and with scant and neglected attire, did not commend itself as one altogether desirable. The number of attendants is quite insufficient, and I cannot say I was favourably impressed with their appear- ance. Where so much importance is attached to economy, this cannot excite surprise. Their pay is very insufficient, as well as their number. Passing to the building for the male patients, over whicli the resident physician escorted us and manifested the greatest willingness to show every corridor and room, I would observe that there are certain wards which, like those for the corresponding class of women, are both !i m raff 204 Beauport Asylum. clean and respectably furnished ; but when I have done justice to the accommodation afforded in these galleries, I have said all that 1 can say in the way of commendation. The higher one ascended in the building, the lower the condition of the patient — the corridors were much crowded, and the amount of mechanical restraint was excessive. In the worst ward, the sight was in the last degree painful to witness. Here were some thirty patients. Some had leathern muffs, others the belt and poignet, while several were in cells as dark as those on the women's side, and were also restrained. One had his legs fettered at the ankles. There were also several men in restraint-chairs, to which they were fastened, and not only so, but they wore muffs. Thev were in their shirts, and over their exposed persons flies were crawling in abundance — a spectacle which it must suffice to mention without characterizing further. Among patients of the class now referred to, I counted fourteen restrained, but I do not pretend to have noted them all. For a man who was given to scratching his face, it was considered neces- sary not only to secure his hands by the muff, but to place him in a crib-bed. But it is needless to describe in more detail an institu- tion which, however willingly I may praise where praise is due, is so radically defective in structure and so funda- mentally different from any well-conducted institution of the present day, in the matter of moral, to say nothing of medical treatment, that no tinkering of the present system will ever meet the requirements of humanity and science. I regret to write thus. It is a thankless task for a visitor, courteously treated as I was, thus to criticise any institution which the officers permit him to inspect. But I write in the hope of helping, in however humble a way, to bring about a reform in the injurious practice of the State contracting with private individuals for the main- tenance of its insane poor. The proprietors receive 11 dollars (45s. lOd.) per head per month for maintenance 1 f Resolutions Adopted by Medical Men at Montreal. 205 and clothing. This system involves the probability of patients being sacrificed to the interests of the proprietors. It has the disastrous tendency to keep the dietary as low as possible, to lead to a deficiency in the supply of cloth- ing, and to a niininiutn of attendants, thus inducing a want of proper attention to the patients and an excessive resort to mechanical restraint, instead of that individual personal cure which is so needful for their happiness and the promotion of their recovery. I consider that the number of attendants in such an asylum should not be less than 1 to 8, instead of I to 15; and that a higher class should be obtained by giving higher wages. At present they are as follows: £1 l(3s. to £2 a month in winter for male attendants ; £2 8s. to £2 IGs. in summer. Women attendants have 5 to G dollars a month, or £12 to £15 a year. With a liiglier class, it might no longer be an irony to speak, as the chaplain does in one of the Eeports, of " the good and virtuous keepers who are selected with great discernment." I venture also to express the earnest hope that the Province of Quebec will itself undertake the responsi- bility of providing the necessary accommodation for its insane poor and their skilful treatment, that a resident medical superintendent, with full authority, will be ap- pointed, and that there will be a Board of Management, as well as really efficient inspectors. 36 any But way, )f the lain- ive 11 lance Since this article was written, the following has ap- peared in the "Canada Medical and Surgical Journal " : — " At a largely attended meeting of the Medico-Chirur- gical Society of Montreal, held on November 7tli, 1884, the following resolutions were unanimously passed : — " 1. That this Society has every reason to believe that the statements contained in the Keport of Dr. D. Hack Tuke, of London, England, upon our Provincial Lunatic Asylums, are, in every material respect, true and well- founded, m^ 206 Resolutions adopted by Medical Men at Montreal. " 2. That these statements show a most lamentable state of things as regards the genoi'al, and especially the medical, management of those Institutions. " 3. That it ai)poars to this Society to bo the imperative duty of the Provincial Government to institute a thorough investigatit)n by competent persons into the entire system of management of the insane poor in this Province. "4. That the 'farming' or 'contract' system, either by private individuals or by private corporations, has been everywhere practically abandoned, as being prejudicial to the best interests of the insane, and producing the mini- mum of cures. " 5. That in the opinion of this Society all establish- ments for the treatment of the insane should be owned, directed, controlled and supervised by the Government itself, without the intervention of any intermediate party. " 6. That the degree of restraint known to be employed in our provincial asylums is, according to the vioAvs of the best modern authorities, excessive. That the ablest European, American, and also Canadian alienists liave almost entirely given up any method of mechanical restraint. That these facts call urgently, in the name of humanity, for reform in this direction in our provincial asylums. " That this Society concurs fully in the opinion already expressed by Dr. Tuke in his Report, to the effect that 'the authority of the Visiting Physician (Dr. Henry Howard), appointed and paid by the Government, has been hitherto almost, if not entirely, nil. His hands have been so tied that he could not be lield responsible for the way in which the asylum has been managed.' "* • * A Bill has been since introduced into the Lej^islaturc which, when it comes into fui'ce, will be of some service. Nolliinjr, however, bnt a radical change in the system of autiioriiy and the mode of maintenance will snfiBce. I am glad to hear that a new asylum, established ou sound prin- ciples, is to be erected near Montreal, Location of Insane in Ontario. 207 The Insane in Ontario. There were, on the ;30th September, 1883, 2,825 patients in the Provincial Asyhiins of Ontario. This is an increase of 83, or 3*02 per cent, over tlie previous year. There were two less in the Insane Warils of the Kinf,'ston Penitentiary; and tlie insane in jails, awaiting removal, were fewer, viz., 31 instead of 47. There were 23 patients at home on trial. In all there were 3,070 insane and idiotic persons officially recognised, being 137 more than in the previous year. They were thus distributed : — M. ... oho ,. Toronto Asylum ... London Asylum ... Kingston Asylum... Hamilton Asylum... 440 230 24G P. 345 455 219 301 Total insane in Asylums 1,274 1,320 Asylum for Idiots at Orillia* 122 ... 109 Total 1,39G 1,429 Insane Convicts in Kings- ton Penitentiary ... 29 ... 2 Insane Idiots in Common Jails 21 ... 13 Total. 703 895 419 547 2,594 231 2,825 31 34 I when it radical lice will tid priu- Total 1,44G 1,444 2,890 If to these numbers are added the patients whose names are on the files for admission into the above asylums, viz., 157, and the number of patients out on probation, viz., 23, we obtain the total number known to the authorities at the above date, viz., 3,070. Dr. O'Keilly, of Toronto, the Inspector of Asylums, who provided me with this information, states that there were 2,837 beds in the asylums of the Province; so that * On Lake Sinicoe. Dr. Beaton is the superintendent. 208 "Recoveries, Deaths, and Cost. as 2,825 patients were resident at the time of this return, and a certain number were out on trial, it is clear that at that period the capacity of the institutions was p'-etty fully reached. More recently, additional buildiu'jfs have been erected, but as the number of insane has increased, the relative i)roportion of supply and demand is probably about the same. It may be stated that the admissions durinj^ the year endiii<,' yei»tember, 188:5, were, as rt'<,'ards the asylums mentioned, tA'\; the nund)er dischar;;od re- covered was 174; improved, 52; and the number of deaths, 183. The ratio of recoveries to admissions, viz., 33'52 per cent., is stated by Dr. O'Reilly to be higher than in any year since 1877. The idiots are, of course, excluded. The mortality, calculated upon the avorngo number resident, was G'31 per cent., which is lower than for some years previous. The total annual cost per patient in 1883, in the four asylums for the insane, varied from 127 dollars 10 cents (Hamilton) to 145 dollars 12 cents (London); the weekly cost being, respectively, 2 dollars 44 cents and 2 dollars 79 cents. Dr. O'lieilly contrasts the losv rate of ex[)endi- ture in the Canadian asylums with that of the United States, where the lowest average is -27 dollars 75 cents per annum per patient ; while in Ontario the average is 134 dollars 08 cents. And he quotes the saying of one of the superintendents of the asylums in Ontario that this scale is " nearly poor-house rates." The same contrast has struck me as very remarkable, and the explanation is not altogether creditable to the Canadian Government. The salaries of attendants and servants are lower in Canada, but the explanation of the difference is to be found, according to the Inspector, in the relative character of the lodging, clothing, and, he proceeds to say, more especially the food. The quality is said to be good, but it is "plain and unattractive," so as to become extremely distasteful to many patients. It is difficult for a stranger to form an opinion on this subject, because he is un- "Employment. 209 I rntiira, ' that at 1 pretty i^s havo croasod, )r()bably missions rt'tjfards r^'L'd ro- niber of us, viz., 3 higher :' course, averi) ge ver than the four IG cents weekly »lhirs 71) px[)entU- United 175 cents erage is If one of lat this contrast lation is ■nment. Ivver in to be aracter ', more )d, but treuiely tranger is un- : acquainted with their diet at home ; but the asylum dietary is as good as in our county asyhims. The revenue from paying patients, of whom there were 538 in the asyhims, amounts to a very considerable sum, viz., r)0,l>2:2 dollars (tl2,4s5) during the last year. This certainly points to tiie probable success of a private asylum whieh has recently be(Ui established at Guelph, of whieh Dr. Lett is the superintendent. I find, from a return nuide of the number of patients employed in the asylums of Ontario, that r)2-57 per cent, of the patients were engaged in some occupation ; being 1,470 out of an average population of 2,813. The largest percentage was at the London Asylum, viz., 60*89. The authorities in Ontario are not blind to the difficul- ties connected with the accumulation of incurable patients, for whom the question of separate accommodation arises. I am glad to observe that the latter difficulty is being met by the erection of small buildings ; these being some- times devoted tj the curable class of cases, while the larger buildings are retained for the incurable. In some instances, however, small buildings or cottages are, and may properly be, devoted to the chronic insane ; while the recent cases are treated in the old and more expensive building. Dr. O'Reilly believes that the general feeling is entirely in favour of detached warils or annexes, and I certainly found this to be the case at the asylums which I visited. It will be advantageous to state here a few of the lead- ing provisi(ms of the existing statute relative to lunatics, enacted in 1871 by the Legislative Assembly of the Province of Ontario, entitled " An Act Respecting Lunatic Asylums and the Custody of Insane Persons'' (cap. 220). The Public Asylums are established and acquired under a grant from the Legislature of the Province, and are vested in the Crown. The Lieutenant-Governor has the appointment of the Mec'ical Superintendent. 210 Lunacy Law of Canada, Among the duties of the Medical Superintendent are those of reporting the condition of the asylum to the Inspector of Prisons and Puhlic Charities at each visit, and also of reporting annually to the Inspector upon the affairs of the institution. The financial affairs of asylums are conducted by the Bursar, who is appointed by the Lieutenant-Governor. The salaries of these officers ai'e fixed by the Lieutenant- Governor, and do not exceed £400 for the Superintendent, and £240 for the Bursar. In regard to admissions, no patient can be admitted (except upon an order by the Lieutenant-Governor) with- out the certificates of two medical practitioners, each attested by two witnesses, and bearing date within three months of admission. Each certificate must state that the examination was made separately* from any other practitioner, and after due inquiry into all necessary facts ; the medical practitioner specifying the facts upon which he has formed his opinion, and distinguishing those observed bv himself from those communicated to him bv others. Dangerous lunatics may be committed to jail by a Justice's warrant on liis receiving the necessary infor- mation, and alter evidence given with reference to the prisoner's state of iiiind. lie remains in jail until re- moved to an asylum by the Lieutenant-Governor, where he remains until discharged by the same authority. The Inspector of Public Charities is ex-ojficio the Committee of every lunatic having no other, who is detained in any public asylum of the Province. The Court of Chancery may at any time appoint a Committee of any such lunatic, if it considers it expedient, in place of the Inspector. The Chancellor, who may call experts to his assistance, decides the question of mental unsound- ness and incapacity to manage his aflairs, without a jury. I understood that the number under the lesal cuardian- * Curiously enough the previous Act rcqniroi.l the examination to be made by the phygicians together. " Three months " is a long period. License for Primite Asylums. 211 infor- to tbe itil re- •Nvliere the who is The niittee place xperts sound - ship of the Chancellor is somewhat under 400. They are placed in confinement under his warrant. For this class, the legal checks are much more stringent. They are subjected to more official recognition, and they cannot be discharged without the sanction of the Inspector. The ordinary patient, whatever may be his social position, is admitted into an asylum on two medical certificates, and he may be discharged by the Superintendent without reference to the Inspector. In regard to Private Lunatic Asylums, Justices of the Peace assembled in general sessions may grant a license to any person to keep a house for the reception of lunatics within the county. The regulations for private asylums are moulded upon those of the English Lunacy Laws, and need not, therefore, be given. Tectums are made monthly by the asylums to the Inspector in regnrd to admissions, discharges^ and deaths. It is obvious that if these returns are made with a view to prevent improper admissions, or to allow of an inquiry in alleged deaths from violence, far too long a period elapses before the Inspector has cognizance of an admis- sion or death at an asylum. It is argued that in the case of the private institution at Guelph, a Committee has general oversight over it, and that this constitutes a sufficient guarantee against abuses. But however good it may be, and doubtless is, it does not supersede the necessity of an inde[)eiKlent Government official receiving immediate information in regard to the admissions and deaths of patients in every asylum, for the inspection of which he is responsible to the public. And, before dismissing the subject of inspection, I would say it is a great defect in the law which enacted it, that it is not made imperative to have one of the Commissioners a medical man. Passing to the asylums themselves, I will first refer to the asylum at Toronto, which I visited on the 20th of August last. The contrast, as I have elsewhere inti- mated, between the asylums of the Province of Ontario M II Vi 212 Ontario and Quebec Contrasted. and those of Quebec is really astonishin<]f. The system is essentially different. The Lej^islature of Ontario recog- nises the duty not merely of discovering institutions to which it can send its insane poor at so much a head, but of providing the institutions themselves, and making the State responsible for their proper management. I do not maintain that all has been done ^^ "t can be done, or in all instances on a sufficiently li' .1 scale, nor yet that the asylums are perfect in their Ox Realization and manage- ment, still less that the system of inspection is the best that can be devised ; and I object to any alleged dangerous lunatic who has not committed a crime being in the first instance sent to jail, and thereby branded as a criminal : but I have no hesitation in saying that there is a sincere endeavour to make adequate provision for the insane of the Province ; that the inmates of the asylums are care- fully treated, and that there exists among the superin- tendents a real interest in their work, and a desire to do their duty to their patients. At the Toronto Asylum, superintended by an active administrator (Dr. Daniel Chvrk), there are 710 patients, the sexes being almost equal. The spacious corridors (lo feet in width) and rooms are carpeted, and altogether well furnished, and in those used by the destructive patients there is not the dismal bareness too often wit- nessed. There is strong evidence of the great care and attention paid in this asyhnn to cleanliness, and to the dress and general comfort of the inmates. There was hardly anything deserving the name of mechanical restraint. On the female side there has been practically none for two years, and as regards the men patients there has been none whatever. Dr. Clark informed me, for seven years. No patient was in seclusion at the time of my visit. Indeed, Dr. Clark strongly objects to its use. There is one feature in the construction of the asylum which attracts the notice of the visitor at first sight, not very pleasantly, it nnist be admitted, and that is the ! Toronto Asylum. 213 stem is recog- ioiis to 1, but of nof the I do not le, or in yet that nanage- tlie best mgerous the first riniinal : I sincere nsane of are care- superin- ire to do in active )atients, orritlors :()o-ether btruetive ten wit- care and lie dress |s liardly estraint. lone for lere lias r seven e of my lits use. asylum lit, not is the succession of semi-circular spaces or verandahs at the end of the corridors, protected and enclosed as they are by strong iron palisades. A glazed wooden frame partitions off these spaces from the corridor. In the areas of these projecting spaces the patients stand or sit on chairs, gazing on the outer world through the vertical bars. On those who look up to them from below, the impression of a cage in a zoological garden may be, and indeed has been, produced. At the same time, it is surely much better for the patients to be able to step outside the corridor into such an enclosure and breathe the fresh air, than not. The view over the Lake (Ontario), etc., is extensive, and affords variety, while the objection which may be made in regard to the effect produced upon other minds is rather sentimental than practical. In a new building no doubt this particular construction would be avoided, or an oriuimental guard would be constructed in place of simple bars. The pay of the attendants, with whose appearance I was pleased, both as regards personal expression and dress, is liberal — £3 15s. to £5 Gs. a month for males, and £2 to £2 8s. for females. In the wings there is one attendant to 12 patients ; not so many in the central large wards. There are also six night watches, three on each side of the house. There are six galleries for private patients. They pay from three to six dollars a week. There are also six free wards. Four hundred patients pay nothing. The weekly cost per patient is a little more than 2^ dollars a week, or 134 dollars (£27 Cs.) a year, exclusive of the capital account or repairs. The patients are employed to a considerable extent, namely, about 60 per cent, of the free class, from whom alone w^ork can be obtained. All the vegetables required for the asylum are raised on the grounds. There are 140 acres. Dr. Clark, however, states, in the report he favoured me with, that the last potato crop had proved a failure, but that the other crops were about the average. 214 Toronto Asylum. mii Ifj.'i: As there are about 29 acres under crop, the potato faihire was a serious one for the asylum. As there are no crops of hay and oats, the cultivation of roots is mainly attended to, and Dr. Clark calls attention to the need of more arable land. The value of the produce of the present small farm was 13,763 dollars in 1883. Buildings, including a prison, have grown up in the vicinity ; a regrettable circumstance, especially if, as I und<»rstand, land belonging to the insti- tution has been sold for building purposes. There are, distinct from the main buildings, three cottages, in which 120 female and 50 male patients are accommodated. One is cheaply built, and is well adapted for the purpose. There are good day-rooms and dormitories. The floors are partly carpeted, and there are a few pictures on the walls. The separation of cases, which these annexes allow, affords advantages which here, as elsewhere, are fully appreciated. This, as well as the other Ontario Asylums, is inspected by one of two Inspectors of Public Charities and Prisons in the Province. He visits four or five times in the course of the year, and oftener if he sees fit. The Grand Jury have the power of visiting the asylum if they wish, and when they do so they make a presentment to the Court. Their visits, however, are, I believe, of a somewhat formal character. This asylum was opened in 1843, and was at that time the only institutiovi for the insane in the Province. Indeed, this was the case when the well-known and universally esteemed Dr. Workman became superin- tendent in 1853, At that time there were only 300 patients. What the condition of the asylum was, two years after it was opened (and I have reason to believe up to the time Dr. Workman became superintendent) I have the means of stating, on the authority of my brother, Mr. J. H. Tuke, who, on visiting it in 1845, made the following entry in his diary : — Forty Years Ago. 215 failure ) crops tended arable ,11 farm prison, stance, e insti- re are, 1 which L. One lurpose. e floors on the 3 allow, '6 fully ispected Prisons e course id Jury sh, and Court. formal lat time covince. Ivn and mperin- [ily 300 |as, two believe lent) I |)rother, ide the " Toronto, Sept. IJO, 1845. — Visited the lunatic asylum. It is one of the most painful and distressing places I ever visited. The house has a terribly dark aspect within and without, and was intendea for a prison. There were, perhaps, 70 patients, upon whose faces misery, starvation, and suffering were indelibly impressed. The doctor pur- sues the exploded system of constantly cupping, bleeding, blistering, and purging his patients; giving them also the smallest quantity of food, and that of the poorest quality. No meat is allowed. " The temples and necks of the patients were nearly all scarred with the marks of former cuppings, or were bandaged from the effects of more recent ones. Many patients were suffering from sore legs, or from blisters on their backs and legs. Everyone looked emaciated and wretched. Strongly-built men were shrunk to skeletons, and poor idiots were lying on their beds motionless, and as if half-dead. Every patient has his or her head shaved. One miserable court-yard was the only airing-court for the 60 or 70 patients — men or women. The doctor, in re- sponse to my questions, and evident disgust, persisted that his was the only method of treating Innatics, and boasted that he employs no restraint, and that his cures are larger than those in any English or Continental asylum ! I left the place sickened with disgust, and could hardly sleep at night, as the images of the suffering patients kept floating before my mind's eye in all the horrors of the revolting scenes I had witnessed/' Dr. Workman reformed the asylum ; and, could an un- varnished tale be told of the condition in which he found, and of that in which he left it, no better tribute could be paid to his character and work during the period of his superintendence. Dr. Workman now resides at Toronto, and has attained to nearly 80 years of age. His mind is still extraordin- arily active ; and his pen is frequently in his hand, en- gaged in both original writing and in making translations Iw, 216 London A&ylum. from foreign medical journals. As lonf^evity is in the family, it is no mere form to express the hope that this Nestor of Canadian specialists may pursue his literary work for many years to come. In making Dr. Workman an Honorary Member of the Medico-Psychological Asso- ciation, the latter honoured itself as well as him. In conversing with me on the provision required for the in- sane in Ontario, he gave it as his decided opinion that there had been an increase in their number, beyond what either the increase of population or the accumulation of chronic cases could explain. Although the proportion of ascertained lunatics is about 1 to 700, Dr. Workman estimates that there is in reality 1 to 500. Formerly t'T've was no general paralysis, now it is common enough; n^t -o common, however, as in England, for at the ? oro;:ito Asylum there were not, at the time of my visit, more tha. . .lozen cases ; and there are only three or four G ath ' f''o u as disease in the course of a year. Dr. Clark cons^uorL . . iiiore frequent among the higher classes than among the lower. I visited with much interest the London Asylum, which Dr. Bucke superintends with great energy and enthusiasm. Not only is the town itself called after London, but the river upon which it stands is the Thames ; and it boasts of its Westminster Bridge and its Piccadilly. The re- semblance does not end here : for if it be allowed that there is a good asylum in or near our Metropolis, it will not be denied by anyone who inspects Dr. Bucke's institu- tion, that its analogue resembles it in this particular also. It was opened in 1870, and the pr':;seiit superintendent entered on his duties in 1877. The whole establishment, the main building, the separate one for the refractory patients, the cottages and the farm, convey the impres- sion of active life, and of the sustained interest of an able head. Dr. Bucke has resolutely set himself to employ the patients in some way or other, especially on the farm London Asylum. 217 — with great advantage, it need scarcely be said, to their mental and bodily health, and with the result of emptying the wards of those helpless, hopeless, cases whose drear existence in the dead-alive asylums of any country suggests cui bono to the pessimist, and makes even the optimist sad at heart. If Dr. Bucke is asked how he employs a man in a state of acute mania, he replies, " Oh, I make him break stones." Without taking the reply too literally, it may serve to show the exceeding but just importance attached to labour or being out of doors, which has been so long and fre- quently maintained in the Mother Country. I gathered from my enquiries that very few cases of mania with ex- haustion are admitted to this asylum, a very important fact in this connection, and one which might have been expected as a point of contrast between the admissions into the asylums in old and new London respectively. Mania in some form is about four times as frequent as melancholia. Only one patient was instrumentally fed last year. The number of patients in this asylum is 888 ; 438 males, and 450 females. It has a capacity for 906. The estate consists of 300 acres, 200 being occupied by the farm, and 40 by the gardens, while the buildings cover a large portion of the remainder. The main building cost a little more than £100 per bed. (Land is here about £30 an acre.) It accommodates about 500 patients of both sexes, of the quieter class ; and an assistant medical officer. Dr. Burgess, resides here. It consisi • of the usual arrangements — corridor (I2ft. in width), recess, day, and bedrooms, some of which latter are dormitories containing 16 beds. The number of single rooms in the whole establishment is 250. As I went through the men's side, as many as 250 patients were at dinner in an associated dining-room. All had meat, and I found this was usual. There is a distinct three-storied building for patients of •■f-'i 218 London Asylum. 0^- a more or less excited character, male and female. The first assistant physician, Dr. Beemer, resides here. There is nothing special in the arrangement of the wards. There are 184 single bedrooms, affording 720 cubic feet of breathing space per patient. The windows were unneces- sarily guarded by iron bars and net-work. No doubt these are survivals of the past, and if rooms for the re- fractory were now built at this asylum, no trebly guarded window would be introduced, for it is out of character with the air of freedom which everywhere prevails in the institution. More light would be also admitted into the building. There is a good airing court, shaded by trees, and provided with a shed and seats. In this asylum, as in most others on the other side of the Atlantic, the number of epileptics is small— only about 25. There was no patient in restraint, and none in seclusion. Dr. Bucke observed that it was rare to have black eyes among the patients since he determined not to resort to mechanical restraint unless absolutely necessary. No patients were crouching on the floors in strong dresses. I must add that " chemical restraint " is not resorted to in the asylum. Sedatives are rarely given, even in small doses. In addi- tion to the morning round, I went through the wards after the patients were in bed, and there was very little noise indeed. Before quitting this building for the ex- cited patients, I should state that, of 92 men residing in it, from 75 to 80 are on an average employed. Dr. Bucke observes in his last report : " The disuse of all forms of restraint, and the employment of so large a proportion of the patients in the asylum, have been accom- panied by (or have caused) an unmistakable elevation of the tone of life throughout the whole institution ; and as one evidence of the fact, I may mention that the Sunday attendance at chapel has nearly doubled during the year just closed ; a year ago the average attendance at Divine service on Sunday morning being about 2G0, and now over 400. . . . Along with the disuse of restraint and seclusion, female. The here. There f the wards, cubic feet of rere unneces- No doubt s for the re- ebly guarded of character ' prevails in Emitted into t, shaded by this asylum, Atlantic, the There was Dr. Buclce among the mechanical tients were I must add the asylum. 5- In addi- the wards very little for the ex- residing in e disuse of so large a 3en accom- evation of •n ; and as he Sunday ? the year at Divine 1 now over seclusion, London Asylum. >ve have almost entirelv c....rl • -^i^l^ "P to within tl^ ITt "'^"" «^^«"8^ dresses, of ^-^it of using a hu.,J; X;7 •"-;;^«' -e were in the ;;orosfcraiat or seclusion and W,^'''"^^' "^ "-- -«e 7 Iiave loss tearing of clotJ^^^ ^ .'"^' '^^""^ ^^^^^es, of furniture, etc., a^d far le fstHl ''"^^ ""^^ ^^^^^-^ ^' of the patients tLn wtn"^'r' '^^^^"^^^ ^ *^e dresses wore freely used It , n'^'"^"* ^"^ ^^^ong ^^•^tweuseabsoluLy "o'sed tiv r^^'^' '^ "^"^-"^^ ;eIdom indeed that an, palt ' ', .'"^ ^''''^' ^^^ it is - ^/ew minutes at a' ^ f V^^^^^^^^ or -strained, even ^i^e lust fact was a very sur.'.-iV "^' '* attendants, ^^^vvay. believed that wl en meor^'- '?' *' "^^' ^'^^ ^ ^^^^ continued in any asvlu. ^ T""^ '''^'"'^''' ^^as dis- -bstitute^l f... if, Z^Z h^r^' "^^^^^"* ^-<^ *o be J" former tin.es used, and h a ^'jlf '^'^"* ^^-^^ I ^^ave t"^uance of n.echanical restth.t 1 ^ ^T"'' '^' '^''''-^- ^ was much p.,f,,able to ts L^T n"^" '^^" ^^^^ '- tendant, always wron<.ly tak h -.^ '^' ^^"^^ «*" ^^ -liere the former was not used ' / " ^■^'^"'^^ ".at I" addition to the m'in b 1 r ""'''' "^"^^ b^'" t^-actory branch, there C, ^ ^"^^' "^^ *^^ «orth or re- ^tructed brick coTtl ;T '"^/-.^^^^-^t but cheaply con. ;-'-^- cost amounted S"o 0^00 r;;"^^ '' 1- tients 'each. ,^-^- The patients in th^e^^ f^ "' ^'^"^ ^^^ P- descent or able to appreciate T' "'' '''^''' ^onva- dence of a separate hoLew ^'^"^P^^^'^^tive indepen- of an asylum for thetX 'Thr^"^- '^"^" ^~-e ti^nnshed and very dean ""'"' ^^^'^ tastefully as somewliat scant. I was ok H. ^i" '^"'°'' '^""^^ »« ^•'-- that go to the LoL „ 1, :' ""^ P'-^'-'^ of the '•""'" "^ not accustomed 220 London Asylum. ■5i to more, at home, in the way of carpets, &c., than they find when they cotne to the asylum. It is true, also, that they are so much out of doors that they may not care much for somewhat bare corridors and rooms. The cost per head for maintenance amounts to 105 dollars 12 cents, or about £'22 a year ; this includes, in addition to food, salaries and furniture, but not any considerable re- pairs or the additional buildings — certainly a low figure — and it should be mentioned that about 80 per cent, of the patients are clothed by the institution. I have already said that the total cost per annum of patients at the London Asylum amounts to 145 dollars 12 cents, or 2 dollars 79 cents per week. The above charge for main- tenance is no doubt kept down by the large yield from the farm and garden, although the total cost is greater than in any asylum in Ontario. I wished to ascertain the exact extent of this, but the accounts at the Superin- tendent's command did not show it, nor was the Inspector, Dr. O'lieilly, able to put me in the way of obtaining this information, valuable and interesting as he felt it to be. A clear estimate of the net profit would greatly redound, I doubt not, to the credit of the institution and of the strenuous endeavour made to have a profitable farm con- nected with an asylum for the insane. Dr. Bucke drove me over the farm. Its jiroduce and that of the gardens were roughly estimated by him at about £3,000 a year. There were 200 pigs on the day I was there. Over 100 are killed every year. Some 6,000 bushels of potatoes are raised annually, and as many quarts of berries from the gardens. Last year the crop of hay amounted to 140 tons. The asylum has 40 cows. As none of the patients pay a cent (for it is a genuine pauper asylum), it is doubtless easier to induce them to work than in mixed institutions, and also to find men accustomed to farm, and to be handy at various trades. To compare the amount of work done at such an institu- tion with one for private or mixed patients would be very London Asylum. 221 ban they lIso, that not care The cost ollars 12 dition to srable re- ? figure — tit. of the re already ts at the ents, or 2 for main- yield from is greater ascertain e Superin- Inspector, lining this it to be. redound, tnd of tlie farm con- icke drove ^0 gardens )0 a year. Over 100 If potatoes Irries from Ited to 140 I a genuine le them to find men lus trades, in institu- tld be very unfair. It will not, however, be denied that there are some pauper institutions in the world in which the patients do little or no work from year's end to year's end, and spend a ninch larger pr()[iortion of the day in the wards of the asylum than out of them. Nor is it alto- gether impossible that there are institutions of a mixed class in which the patients might do a little more work both indoors and out, especially the latter, than they do already. In this I include the constant attempt to induce the patients to take exercise in the open air with as de- finite an object as possible. This can only bo effectually done by a superintendent who has his heart in the work, and who will insist upon having a sufficient staff of atten- dants, even on the score of economy, should those who hold the purse-strings be deaf to an appeal to higher motives. But what if there is no breathing space outside the walls of the asylum'? Then, woe betide the superin- tendent and the unhappy patients under his care. Their fate is sealed. On examining the record of work, and taking a single day, I found that out of the 438 men no less than 392 were employed; while out of 451 women, 404 were occu- pied in some sort of work. Of 40 that do not work, 25 are physically incapable, and 15 cannot be induced to work without more pressure than it is thought right to use. I am well aware that figures like the above may mean much or little, but I am satisfied from personal observation that in this instance they mean much. It is especially interesting to observe how a better system of treatment has become possible by the increased employment of the patients. With 880 patients the average number at work was, at the date of Dr. Buckets last report, G25. He observes : " I have always found that, no odds how violent a patient is, if you can once get him or her to work, the case will give you very little further trouble in that way. . . . The male patients have been engaged in all the 222 London Asylum. various kinds of farm and fi^ardon work ; thoy work with tlio carpenter, luuson, painter, tiiilor, onyineor, baker and butclier ; they work in the horse nnd cow stabk\s, and do most of the niilkin*^ ; they assist in dinin<^-room, kitclion and laundry ; they sew, knit, make and mend shoes, boots, and slippers ; seat chairs with eane and reed ; make mats ; they do tinsmitliinj;, ;sinithiii|:j, locksniithinjjf, upholstering, clerkin;;' ; all luiids of work in the halls, as bed-nnikinuf, sweeping, senibbin^- ; sawiuL? and splitting wood, shovelling coal, grading land, making roads, feeding and tending two Imndred pigs, working in the store, picking hair for mattresses, and doing all sorts of odd jobs. The female patients are largely engaged in sewing and knitting ; and, besides, they work in the kitchen, laundry, and dining-rooms ; do all sorts of work in the halls, as bed-making, sweeping and scrubbing ; milk, pick hair for mattresses, and gather fruit and vege- tables in the gardens." The proportion of attendants to patio? 's certainly not high in the London Asylum ; in fac, o Province ought not to complain if the Superintendent should increase the number. For the violent patients, the proportion was one in nine ; for the others considerably less. It ought, however, to be remembered that the number of ward-attendants does not adequately represent the ser- vices rendered to the patients, inasmuch as those work- men who labour on the grounds or at any handicraft, exercise surveillance over some of the patients at the same time. Several years ago, Dr. Eames (Cork A'^ylum), the President of the Medico-Psychological Association, urged upon his Committee the need of more attendants, and stated that while the proportion of attendants, with the above-mentioned helps, was one to eleven in his asylum, it averaged about one to eight in the asylums of Ireland generally. The maximum pay of male attendants at the London Asylum is about £50 a-year ; that of the females is about £30. On the male side are several female attend- London Anylum. 223 r^rlc with r, baker 7 stables, n jr. room, ml incuil en no ami smitbins, 3 of work rf ; sawilV^ d, makiii'^ vorking iu i(r all sorts engaged in )rk in the rts of work scrubbing ; t and voge- ants — not the wives of nttendunts, as at Brookwood and some other iisylnnis in Mnghind, but respectiiblo widows. Dr. Ikicke attaches great iniporlancc to this feature of Ills inanagcnHMit, jis ensuring clcanlint'ss, tidiness, and consid('ratit)n. lie states that lie has no dillli-ulty in find- ing suitable iiersons. He is forlunatc, lor he retiuircs pleasant manners, industrious habits, g(»od feeling, and, above all, good sense, in addition to widowhood. They must be widows indeed. 'J'o do him full justice, however, I must cite a lew passages from his last annual report: — "The first was engaged in January, 18y;J, and became the supervisor of the upper storey, and does all the work that a man in that jiosition would do, and besides that, she has a general supervision over the tidiness and cleanliness of the whole wing ; the other two women act as her assistants on the other two flats. They look after the men's clothing, see to the tidiness of the beds, cleanness of the floors, &c., &c. ; and especially, they oversee the indoor work of a large number of male patients, who pick hair, sew, knit, make mats, &c. But the active duties of th ^e wonun, though important, are scarcely so valuable as is their mere presence in the halls, which has a strong tendency to check improper and unseemly talk and conduct, so that th"«e halls are ditt'erent places now from what they used to be before these women took service in them. . . . Down to the pre- sent time, none of them have been by speech or action either injured or insulted by any patient. Almost univer- sally the patients like to have them amongst them, and I find that often the women can get the patients to work when the male attendants can get them to do nothing." In an institution where the gospel of fresh air and employment is fnlly believed in and carried out, one feels especially interested in the dietary. The meals are taken at 0.80 a.m., 12, and 6 p.m., the patients going to bed after supper up to 9 o'clock p.m. I append the dietary in detail, but must premise that work, whether out or in-door, 224 London Asylum. is not encouraged by the stimulus of beer, for Dr. Bucke is an out-and-out teetotaler. He has not ordered alcohol in any form, even as a medicine, for three years. When he became Superintendent, a considerable sum was expended on beer ; more food is now given, but not more milk, which is, I think, to be regretted. The attendants never had any beer, so no money equivalent has been necessary. The dietary in the main asylum on a particular week which I chose, viz., that beginning June 8th, 1884, was as follows : — BEEiKPAST. Sunday. — Bread and butter, tea and coffee. Monday and Wednesday. — Porridge and milk. Tuesday. — Boiled rice and syrup. Thursday. — Oatmeal porridge and syrup.* Friday and Saturday. — Porridge and milk. DINNER. iuesaay. — it oast Deei, potatoe Wednesday. — Boiled beef, potuw.^^, ^ Thursday. — Haricot, potatoes, and bread pudding. Friday. — Fish, boiled beef, pickles, and potatoes. Saturday. — Roast beef, potatoes, bread pudding. TEA. Sunday. — Bread and butter. Monday and Saturday. — Bread and butter. Tuesday. — Stewed rhubarb. Wednesday. — Bread and butter. Thursday. — Currant rolls. Friday. — Apple sauce. With the foregoing may be compared the dietary of an English pauper asylum, that at Hanwell : — * MolasaeB, London Asylum. 225 BucTje is Jcohol in Wlien he expended Llk, which er had any !ular week ;84, was as Ung. as. idding. atoes. ling. dietary of an BREAKFAST. For males. — Cocoa, bread and butter. For females. — Tea, bread and butter. DINNER. Sunday. — Eoast pork, beef, or mutton. Monday. — Soup, thickened with oatmeal, rice and peas, and containing 2 oz. of meat for each patient ; also 6 oz. currant pudding or 10 oz. baked rice pudding. Tuesday. — Meat pies. Wednesday. — St. Louis corn beef. Thursday. — Boiled bacon or pickled pork. Friday. — Fish, fried or boiled, with melted butter. Saturday. — Irish stew. SUPPEE. Tea, bread and butter. For patients who are employed, luncheon, consisting of bread and cheese and beer (half-pint), is provided in addition ; and for Monday's dinner, boiled bacon or pickled pork is given instead of soup. The ioUowing are the principal salaries and wages (mostly with board) allowed at the London Asylum : — Males. — Medical superintendent, 1420 ; iirst assistant physician, £210 ; second ditto, £210; third ditto, £154; bursar, £290 ; steward and storekeeper, £106; engineer, £154 ; two carpenters, £220; tailor, £1)4; gardener, £83 ; assistant ditto, £50; butcher, £50; baker, £83; farmer, £'125; two ijloughmen, £115; cowman, £15; three night- watchmen, £157 ; three chief attendants, £195 ; twenty- nine ordinary male attendants, £1,389. FEMALES. — Matron, £105; assistant ditto (refractory ward), £52 10s. ; chief attendant, £52 10s. ; thirty ordinary female attendants, £990; three night attendants £82; live cooks and assistant cook, £137; live laund- resses, £115; nine housemaids, £195; one dairymaid, £25 ; two seamstresses, £50. Q m^fw 226 London Asylum. With the foregoing may be compared the following salaries, &c., at the Hanwell Asylum (750 men, 1,143 women) : — Officers. — (a) Resident medical superintendent (female department), £700 per annum ; (a) resident medical super- intendent (male department), i.700 ; (d) chaplain, £1550 ; (/) clerk to the Committee of Visitors, £275 : (c) assistant medical officer, £200 ; (c) ditto, £200 ; (c) ditto, £105; {c) ditto, £150; (e) apothecary, £120; {h) engineer, £450; (a) storekeeper, £500; (e) clerk of the asylum, £325 ; (e) first assistant-clerk, £130 ; (c) second assistant-clerk, £110 ; (e) storekeeper's clerk, £110; ditto, £60; outdoor inspector, £74 ; (e) matron, £345 ; assistant matron and organist, £G6; junior assistant matron, £40; superintendent of laundry, £55 ; superintendent of w^orkroom, £50 ; principal female attendant, £30 ; ditto, £34 ; ditto, £30 ; workroom assistant, £33. (a) Furnished honse, rates and taxes free, coals, gas, milk, and vege- tables; (h) part ditto, ditto, ditto, wasLiiif,', milk, and vegetables ; (c) furnished ajuirtmenta, attendance, coals, gas, washing, milk, and vego- e mati'on boards two ('0 ('■; daily servants ; (f) neither boiirded nor lodged. The others have board, lodging, and washing. (a) Male Attendants. — (fc) Three supervisors, at £80 ; (c) eigliteen charge attendants, £25 to £40; forty-four ordinary ditto, £25 to £35 ; hall attendant, £10 ; () 112 Farm 12 524 Garden 20 745 Grounds 6 211 Stable 1 91 Halls 60 6460 Store-room ... 2 156 General Work 25 1C52 Quarry 60 1400 Total 262 15177 i^ if Ik 230 Hamilton Asylum. w In the refractory galleries on the men's side, the number of the attendants was certainly too small. How- ever, not only was no patient in restraint, but none were in seclusion or in a stronntatoesand Tea. butter. bread. Porridge iuid milk. Pen soup. CoiTre, bread and Pork, beef, pota- butler. Coffee, bread and butter. toes and bread Beans. Ilonat beef and bread. Tea, l)read and batter. (Cheese. Tea, bread and butter. Rhubarb. Tea, bread and butter. Tea, bread and butter. Buna. Tea, bread and butter. Tea, bread and butler. Rhubarb. Tea, bread and butter. With this dietary may be compared that of the Ports- mouth Borough Asylum (England), -which is probably above the average dietary of County and Borough Asylums : — BREAKFAST (daily). Males. — 8ozs. bread, ^oz. butter, 1 pint tea, coffee or cocoa. Females. — 6ozs. bread, ^oz. butter, 1 pint tea. ()ffee or cocoa. SUPPER (dT'lv Males. — 8ozs. bread, 2ozs. cL oi ^ bui i ; 1 pint tea. Females. — 6ozs. bread, 2ozs. cheese 'r ^oz. butter j 1 pint tea.. ylum for Tea. )rcatl and er. )rra(l and or. rb. oread and or. jrcad and er. bread and ;cr. bread and ter. rb. )ri'ad and er. le Ports- )rt)bably Borough coffee or I flee or 1 pint (utter; 1 Kingnton Penitentiary. 237 DINNER. Sunday. — 10 to 18oza. .suet puiUliufj, witli treacle sauce, and the addition of fruit in the suniuier uiid dried fruit in the ^viuter — nudes and females. iiozs. of meat where ordered. Monday. — r)oz8. moat inale.s, and lozs. females; vege- tables not le.ss than lib. Tuesday. — Mo/s. tiuned meat, males and females ; vege- tables as on Monday. Wednesday. — 2 pints sonp, 2ozs. meat, 5 ozs. bread — males. 1^ pint soup, 4ozs. bread — fenniles. Thursday. — Meat pie, ]2ozs. — males; lOozs. — fenniles. ^Ib. potatoes «u* ^Ib of other vegetables. Friday. — Same as Monday. Saturday. — lib. fish, males and females ; vegetables same as Monday. Half-pint of ale daily for dinner, except on Wednesday, for both males and females. Women worlfing in the laundry have bread and cheese and half-pint of ale for lunch, with meat and ale for dinner on Wednesday; also extra tea at '3 p.m. W^omen scrubbin;;' in wards have bread and cheese daily for lunch, with half-pint of ale. Men the same. Men working in the shops or on the farm have half-pint of ale and bread and cheese at 10 a.m., and ale at four o'clock. Meat pie contains 3ozs. of meat without bone for each patient. Soup is made from liquor of boiled meat, thickened with i)earl barley, A:c., to which are added vegetables, herbs, &c. From the asylum I proceeded to visit the Penitentiary^ which is in the vicinity, accompanied by Dr. Clarke. Mr. Creighton, the warder, who showed me over, is a very kindly gentleman. The prison appears to be in excellent order. There is a separate modern building for 43 criminal lunatics. The number on the day of my visit was 37. The 238 Kingston Penitentiary. •V i II • c character of the cells is, I am sorry to say, similar to that of a prison, and, so far as I could judge, the patients are treated with almost as much rigour as convicts, though not dressed in prison garb. This is wrong. Either they are or are not lunatics. If they are, they ought to be very differently cared for, while every precaution to pre- vent escape is taken. In the basement are *' dungeons," to which patients when they are refractory are consigned as a punishment, although the cells above are in all con- science sufficiently prison-like. The floors of the cells are of stone, and would be felt to be a punishment by any patient in the asylums of Ontario. In a day-room above the ground floor a number of patients were congregated, moody and apathetic. Some were in mechanical restraint. Two men in the cells had once been patients in the asylum. One, with whom we conversed at the iron gate of his dungeon, laboured under a distinct delusion of there being a conspiracy against him. It was certainly not very likely to be dispelled by the dismal stone-fluor dungeon in which he was immured, without a seat, unless he chose to use the bucket intended for other purposes, which was the only piece of furniture in the room. Surely something will be done to terminate a condition of such unnecessary hardship. For criminals of the worst class, this building is no doubt admirably suited, but it is astonishing that it should have been constructed for lunatics in recent times. In these remarks no reflection is for a moment cast on the excellent warder of the Penitentiary. As to what the Visiting Medical Officer does by way of medical treatment of these patients, or to secure their comfort, I shall not attempt to give an opinion. I hasten to remark that the Penitentiary is not under the control of the Province, but the Dominion ; otherwise, judging from the asylums of Ontario, it would, I have no doubt, be in a totally ditt'erent condition. Asylum of New Brunswick. 239 nilar to patients though ler they it to be I to pre- ons," to ifjiied as all con- :he cells t by any mber of I. Some ;s in the ron gate us ion of certainly ono-ticior t, unless urposes, . Surely of such st class, it it is ted tor ilection of the Oliicer s, or to >ive an [t under [erwiso, lave no It will thus be seen that the Province of Ontario possesses in its asylums excellent institutions, in which modern views and the results of experience in other countries are vigorously and intelligently applied ; in which employ- ment is being carried out more and more to the extent consistent with the comfort of the paLie:it8 ; in which mechanical restraint is not resorted to unless all other means have failed, and in which a good example of segre- gation is exhibited, the usually constructed asylum being supplemented by an annexe or cottages adapted for particular classes. That such a system as this works well, no one who has seen it in operation in British or other asylums will be surprised to hear. To the preceding notices of the asylums in the provinces of Quebec and Ontario a few additional notes are appended. j^ew Brunswick. New BrunFwick, which had in 1881 a population of 321,129, has one asylum in the Province, for the insane, the property of the Local Government. This institution is controlled and inspected by eight Commissioners. Br. J. T. Sceeves is the medical superin- tendent, and there is one assistant medical officer. The asvlum is located at Saint John, on a heiort states that the number of patients is f380, of whom 198 were males and 182 were females, but I understiind that the capacity of the building should allow of only ;J2o patients. If so, the Saint John Asylum is no exception to the usual over-crowding, and fails to meet the requirements of the Province. I am glad to hear that Dr. Steeves is agitating for the erection of cottages, and proposes to place them on a largo farm at a distance from the present institution. Dr. Clarke, the assistant medical oliicer at the Kingston Asylum, to whom I am largely indebted for the informa- tion contained in these supplementary notes, informs me ■^ 240 Asylum of Nova Scotia. 14- that lie visited this asyhira in July (1884) and found it well ordered and managed. The wards were quite as cheerful and at least as homelike as in the institutions of Ontario. Great attention was given to decorations; pictures and flowers being placed in most parts of the building. The patients were cheerful, clean, and evi- dently well-cared for. Mechanical restraint was reduced to a minimum, and employment provided for many of the patients, although not to the extent carried out in Ontario. The farm is a very small one, comprising but a few acres, so that it is difficult for the sui)erintendent to em- ploy the men as he would wish. The cost of main- tenance last year was £20 per head. I observe that, in the last annual report, the nativity of the patients admitted since 1875 is given, showing that out of 1,249, 884 were from New Brunswick, and 57 from other provinces of Canada, while of the remaining non- Canadian population (308), no less than 220 were of Irish extraction. Of the 380 patients in the asylum, only 47 were re- garded as curable. Nova Scotia. There is one provincial asylum or hospital for the insane of Nova Scotia with its population of 4 10,585. It was opened in 1859. It is sitnated at Halifax, is the pro- perty of the Local Government, and is under the inspec- tion and control of a Board of Commissioners of Puldic Charities, six in number. Dr. Alexander I*. Reid is the medical superintendent, and there is one assistant physician. The number of patients in the asylum, Jan. 1, 1884, was 400 ; 193 men and 207 women. The weekly rate for maintenance was 10s. lOd. The asylum is said to be well managed and not behind the times. How far it fails to accommodate the number of insane in the Province I am unable to state. Prince Edfvard*s Island. 241 ound it uite as itutions rations ; 1 of the ,11*1 evi- luced to y of the Ontario. b a few t to em- )f main- itivity of ring; that I 57 from I ins; non- 3 of Irish were re- fer the 585. It the pro- inspec- )f Public id is the assistant li, Jan. 1, le weekly is said to )W far it IProvince / The statistical tables give the information so rarely vouchsafed to the inquirer into the recoveries and the deaths of patients since the opening of the hospital, along with the admissions and the average number resident. From this it appears that the recoveries amounted to 44' 6 per cent, of the admissions, while the deaths, calculated upon the average number resident, amounted to per cent. It may be observed that the Medico- Psychological Association's tables are adopted at this asylum, although the recent amendments have not been introduced. Prince Edivard^s Island. The provincial asylum is situated at Charlottetown. The population of the Province in 1881 was 108,928. Dr. E. S. Blanchard is the medical superintendent. The asylum is under the management and inspection of a Board of Trustees. The institution has accommodation for 112 patients. It is 'stated that the number of insane known to exist in the Province, but not in the asylum, is 65. The cost per patient in 1884 was about £85, including not only ordinary maintenance, but repairs, salaries, and wages. Many important changes have been made of late in the Avay of improvement. Manitoba. As might be expected, this Province has had until recently no proper accommodation for its insane, the number of whom must be considerable in a Province, the population of which has so vastly increased since the time of tlie last census (1881), when it was 50,000. In the absence of an asylum, lunacies have been kept in the penitentiary or sent to Ontario. An asylum is now being built at West Selkirk, which, when completed, will be large enough to meet the requirements of the Province for some time to come. The Local Government have taken temporary quarters in place of the penitentiary at Lower s, 242 Manitoba. Newfoundland. Fort Garry. Dr. Young is appointed medical superin- tendent at the new asylum. It is understood that the Manitoba Lunacy Law resembles that of Ontario. I am unable to state what provision has been made for the insane of the Province of British Columbia. Newfoundland. The asylum is at St. John's. It accommodates about 150 patients, and is superintended by Dr. Stabb. I cal superin- )od that the irio. sen made for a. dates about bb. APPENDICES APPENDICES A. and B. Table I. — General Statement of Insane in Hospitals and Lunatic Asylums in the United States and British Provinces on September 30, 1883. Extracted from the First Report of the Committee on Lunacy of Board of Public Charities of the State of Pennsylvania, September 30, 1883. I am unable to explain how it is that the capacity of hospitals and asylums for the insane is represented as greater than the number of patients, seeing that even in 1880 the overcrowding amounted to several thousand patients. The number of insane given in this Table as being in asylums in British North America is less by one thousand than the number reported in Table IL in consi^quence of the Committee on Lunacy having omitted the Montreal Asylum, which I have added to the latter Table. With this figure the aggregate number would be 57,085, instead of 5G,685. Table II. — In the above-mentioned Report it is stated that " several institutions of the United States in this Table, being departments of Almshouses, might with pro- priety have been excluded, but as they had been included in a list of institutions for the insane puo- lished in the compendium of the Census of 1880, we thought best to retain them, in order that a com- parison could be made with their condition at that date, and one very nearly corresponding thereto three years later " (p. 7). They number 147. 'r';i. ! •1»40X t 1^ ••00 01 1^ 'H ^ s« P5 0J "•S n i-i oiot ■9l«iiiaj 1 S m •H Ol '«^ M •-< O i-i 35 « w ^ s- (C o IN ,-< rH 1 i •c IS •)■ Ol tC ^H 00 ■ . f CO •9|WW U3 a. >n 5S i-i ^: tj; i- 0-.-5- s§ 3 s & vj- 1- o ^^s N r o p? pec in Ol r- r"!^ »"•' Si. o» p^ l-( ■e[«ui9j 0^ pj IN F4 »-i !>. 00 W IC ic ro f •* m •*« 00 g H (7. jf> 1^ -^ r-i-i a; a> c^ 8I«W IN 74 IN ^i cf r^ eo IC S? tC Oi OO 01 S^S -C •« 1-. -H 1- JO 'T 1< S ? Woi »• 00 00 Ol 00 a. OJ.C 1'^'*. 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V> H C ;3:M S — I 5=- 5 = 23 - a. s. f i ■\ .= I I C.i « c «< »> s » 2 ^•- ^ »* <^P ^ CD '3 • * 9} .«i SI "" w t H J! £« * = = = H :1 :.2 J 3 ■ = c c 5-5.: IE'' (3 _".""0!2 r* C — "^ * otsUH»^Os£ V <,Z-cfi I: o fi E- 5-5 = iSg-! r -< " C.* — — — — > J S'»S — il APPENDIX C. Table III. — Showing Total Number of Insane in each of the United States, and the Proportion to the Popula- tion in 1880. Prepared by Prof. A. 0. Wright, Madison. It must always be borne in mind that under " Insane " the American Census does not include idiots. If these be added, the proportion to the population would be raised from 1 in 545 to 1 in 297. The insane, according to the last Census, exceed the idiots by about 19 per cent., but the Census Office believes this to be too high, and maintains that the number of idiots " must be nearly or quite equal to that of the insane " — an opinion which we can- not endorse if the experience of Groat Britain may be applied to the United Stutos. The test of idiocy adopted by the Census Office is the age of puberty, all returns of mental alTection under 12 years of age in girls, and 14 in boys, being olaased under idiocy. It cannot be said that this or any other arbitrary test which might be adopted is satisfactory. The disiincti(/n, therefore, between these two classes must not be taken as at all accurate. In fact, it is difficult to credit tl t* result that the number of idiotic males in the United States exceeds the insane males, as apj^ears froui the following figures in ': .» census 1880 :— Class. Males. Insane 44,1391 Idiots 45,309 Females. 47,568 a 1,580 Total. 91,959 70,895 89,700 79,154 108,854 •j 1 each of ! Popula- Wriglit, Insane " If these would be 3, exceed e Census maintains or quite jh we can- n may be y adopted returns of and It in said that dopted is een these In fact, iiunber of le insane ,' census [OTAL. ,1)50 |;,895 Table III. Btates. Proportion of Total Insane. Insane, Malii(> 1 in 421 1,542 New Hampshire ."tL'S 1 ,(>^'6 Vi'inidiit ... ... ...; :i27 1,015 MHssacliusctts ... ...I S4.i 5,127 ('(Hiiiect icut yiii 1.721 Hlindc Maud 401 isn Ni'w York :itw 14,111 Nt'W Jj-rspy ... 4;c 2,405 Pciinsylviinia .')!« 8,:!04 Ohio 4;!H 6,286 Iiiiliaiia 560 3,5:w Illinois hm 6.i:u Miciiinan ... 586 2.796 Wisconsin ... 520 L',526 Iowa ... ... ..• 6;iH 2,544 Minnesota ... H82 1.U45 Delaware 721 198 Marylnnd ... 504 i,»rj Virginia ... 627 2.411 West Virginia 6M 982 Nortli Carolina ... i.. evo 2,028 Bout >i Carolina 895 1.112 Georgia 907 1,697 Kentucky ... .Ma 2,789 Tennessee ... 517 2,404 Missouri Kati 3,.tl0 Florida l,0.i4 253 Alabama H,"l) 1,.521 Mississippi ... m.> 1,147 Louisiana ... 94:« 1,002 Arkautias 1.017 7>9 IVxaa 1.0.1 1,.554 Nebraska l.OOli 450 Kansas 9!'6 1 ,000 Dakota 2.o:i7 72 Colorauo l.Stit) 99 Montana IW,\ 59 VVyoiiiiiig ... 5,167 4 Utah (•.•>:t 154 New A'exlco 7hl 15y California ... ■M6 2,5ii:t Orijjon V\2 ;i78 VVasliington Territory... .',56 l.W) Nevada 2,00H :tl Idaho 2,o;w 16 District of Columbia ... Total average United States ... IMI 1 in 545 p;t« Total insane 91 ,997 A'ute.— These tlgures (how a lower rate of insanity in tiie more recently settled States. k,854 ;t> APPENDIX D. Table IV. — Showing amount of Eestraint and Seclusion in twenty Hospitals for the Insane in 1882. This Table is extracted from a paiiiiihlet entitled " On Restraint and Seclusion in American Institutions for the Insane," by 11. M. Bannister and IL N. Moyer, 1882 ; reprinted from the " Journal of Nervous and Mental Disease," Vol. ix., No. 3. Dr. Bannister is the senior assistant medical officer at the Kankaki^e Asylum, and has been an able contributor to the above Journal. The observation I have made on the returns of re- straint given in 1880 may be repeated here — that the amount was much greater then than now. In a letter received from Dr. (.'luijin, July, 1885^ ho says: "A great change for the better has taken jtlaee in hospitals on this side the AfkiMtic e ''-ing the past five years. At the last annual meeting of t .w 'ouferenco of C*harities and C^)rrec- tions, it was announced that in 12 asylums of this country mechanical restraint was practically abolished." In studying this Table, the following remarks by the physicians who i)repared it, should be read : — " In No. ;J, mittens are not report(\l as restraint-, but are used to a slight extent. If reported, as in st)nie of the other institutions, they wonld slightly increase the figures of restraint. No. 5 sutlers to a xcry marked extent from the evils of overcrowding and insiithcicnt and ineonipleto accommotla- tions, and has no pr(»[)erly constructed 'back wards ' on the female side. The same is the case with No. 10. In the one instance of restraint reported at No. 9, it was ordered by the assistant physician and, in the opinion of licstraint and Seclusmi. 257 seclusion tknl " Oil IS for tlie er, 1882 ; il Mental he senior 'luni, and ml. *ns of re- -tliat the 11 a letter " A ijfreat s on this \t tlu' liist ulCorri'C- is country ks by the if, but are iii(» of the he fh^-nres he evils of •oininoda- Ivard?: ' on 0, it was •iniou of the superintendent, by an ' error of judgment/ it not bein<^ really needed. In No. 10, the only form of restraint used during the month was the crib-bed at night. In No. 11, the restraint and seclusion were, with only a few exceptions, used in the female department. The report from No. 12 was made up for the month of January instead of February. The superintendent of No. 1 !• writes that the total of hours of restraint and seclusion is somewhat in excess, as a number of short intermissions of from half an hour to an hour arc not noted in the daily ward reports. In No. l""), the sleeping doses at night are evidently in- cluded in the 'chemical restraint ' returns, instead of being reported separately. Nos. 17 and 18 were not reported on the blanks furnished by us, but our columns were filled from other reliable ligures supplied us by the authorities of these hos[)itals. In No. 2U, the crib-bed is not rei)orted as restraint, though we believe it is used. The restraint reported was, in a great majority of cases, applied only at night. Several of tlie jiiiysicians that have I'cported the use of * chemical lestraint ' in the hospitals under their charge, also send explanatory notes statingthat the term is hardly applicable, as it is impossihle for them to sej^arate entirely the use f)f sedatives to control excitement from the legiti- mate therapeutics of insanity. As one of them states it, 'the i)rimary object of the exhiiiition of this class of remedies is physiological and einative; the secondary, or that of restraint, being only incidental.' There is con- siderable force in this view, and we (h> not attach the same value to the returns in these columns as to the others in the table. Moreover, it must be remembered that medi- cine and other therapeutic measures have a legitimate use as palliatives when there? is absolutely no hoi)e t>l' any curative eifect. Thus we give bromides to certain insane epileptics merely to niudii'y the manifestations of the s r" 258 Restraint and Seclusion. 1 disease, which is itself past curiiifj, and this in the strict sense of the term niif,'ht bo called chemical restraint. If all such instances were included under this head, there is little doubt but that 'chemical restraint' mi<3dit have been reported from every hospital on our list. After allowance is made for all the possible incomplete- ness and lack of uniformity of the table, it is still suffi- ciently suy^eslive, and all'ords ample opportunity for discussion. The first point it siiyfj^csts to the examiner is that there is a wide ran<,'o of practice in hospitals on this side of the Atlantic as ro<^ards the use of restraint, seclusion, and sedative medicaiiou. If we even ^^o to the extent of throwiuLi" out all the fi<4ures of ' chi inical re- straint,' as not suHiciently separated from the ordinary therapeutic treatment and ni^lit sedatives to bo alto;^"ether reliable, we iind ilie percenta;4'e of patients nii;"htly talviuf^ sleepinjji' draughts rani^cs in the ditUjrent institutions from nothing' up to over eleven per cent, of the poi>nlation ; that the avera^'o daily peroentai;'e of patients restrained rises in the same manner to over six per cent.; and that of seclusion to nearly three per cent, of the whole number of patients. The avera^'o percentage of restraint, accord- ing to these iiuures, would be alxmt one and a half, and this cannot, in our opinion, be taken as too biyh an esti- mate of the actual averaiifo percentage in the asylums of this country. Our list includes several institutions that are practically * non-restraint ' and exceptional in that respect, and atiy ligures dnivcd from this table, including these institutions, must be affected by this fact. We have reason to believi> that the institittions that did not report to us would show fully as high a ratio of restraint as the nuijority of those I'roni which we heard, and that while the percentages of Nos. 12, 10, and 1 7 are almost certainly above the average, those of Nos. -'?, 1, 7, 0, and 10 are more than as much below it. \i is very possible, indeed, highly probable, that there are some asylums in this coimtry that would show higher figures of restraint than any from which we have had returns. Restraint and Seclusion. 259 3 strict nt. If there is it have mplete- iU suffi- iiity 'for miner is J on this estraint, JO to the iiical re- ordinary lto;;"t'thor Iv takings ions from pulation ; •ostrainod and that lo nnniLor , acc'ord- liiiir, iuid an osti- syhims of lions that in that nclndhig We have ot report nt as the |iat while certainly d 19 are I', indeed, in this Lint than The English Connnissioners' report for 1880 shows that there is vastly less seclusion in England than in this country, the special minutes of inspection of sixty-two public asylums, with a population of about 10,000, show- ing only ;5,2 10 instances of seclusion in them for a period averaging, in the whole number, over a year; whereas nineteen American institutions, containing less than eleven thousand patients, had in a single month l,i>77 instances, or more than half what all the English asylums had in a whole year, hi other words, seclusion, according to this ratio, would appear to be some twenty-eight or twenty- nine times as frerpient on this side of the Atlantic as it is in England. Space does not permit us to carry out fully the com- parison of the statistics of restraint in the two sexes, as was our intention when we sent out our circulars and blanks, but some general data can be given. There were reported to us 1,655 occasions of the employment of re- straint with males, lasting altogether ll,84y| hours. The number of individuals reported as restrained was 79, of whom 12 were kept constantly in restraint, each day counting as one occasion ; 79 males Avere also secluded, G of them constantly, on 817 occasions of altogether 0,022 hours. Ninety-three females were reported as restrained for a total of 2,023 occasions and lo,l)81^ hours, three of them being kept constantly restrained. Ninety females wore secluded on 885 occasions, for 0,2 10^^ hours, two of them in constant seclusion. These figures, though of course incomplete, even for the institutions in our table, indicate that what is the common impression is correct — that insane women are more irritable and mischievous but less dangerous or violent than male patients, and that while, as a class, they seem to undergo restraint or seclusion more frequently, there are not so many of them that are so troublesome or dangerous as to be allowed no liberty at all." ••> II III i '/I 1-1 CO (•.(Hw.tAII A||1l(|) 'S|II>t||1l(I J(l J.H) -iiinii n|(>t|.M ii| iiii)N -ii|.i>)8 j,{ CI rs ?i ic ir I" ?i t. ■-. lO o 'II- 1^ oi CI "P x » J 11 O 3 rt Tl — M T M »J O ; I- 1 - .-! 1 i. / « d-^dd-^ddddd?i'J©^dd 'o'd-^ ■||(l|Htl|.).l8 |ini|8ll(>.) Ill C|«n|l|A|pil) JO J.H|llll))|f -« 1 1 1 1 1 1 1 1^1 1 1 1 1 1 |c^ «e 1- 10 « f •* ic — -CI- - 1 « i« » M 1 1- x 1(5 ^ C*l ^ ?l 1 .— 1 i-t M F.4 CI !• If? — • X ^ iC '.C -* O r? •^ '•* "O ^ tO SSIS-^^Sl^l'^Aji^SiJ, 1 1 ll'l o> 1 01 ?i x) tc »- ^^ ?. "f ai "j« I - 1 1 t Ti'o tZ ' ^ 1- 1* tt r 6 a; r^ o* -' fj' -r r^' 1 1 1 a; '-^' •2 'I I-- J. 'p "^ *■ '* 't ?l — M X >fi I'- •»• r» •£) '|ii>l>ii|.Ma s|nnp|.\|pii| jii .i.H|iiiM,i^ 'llll|tJII|,I.IM JO e.iiioi| JO .i,ii|iiinii |ii|i>x •11 -III J" •111 -111 l))ill|.>illj JO .>.)>lll|8 1|.)IM ll{ NJIIO'I litipiiiiil hUh.i.iav |lill|.MIi JO l>,).)llll|8 |o j.iipiiiiii iipxi.W •|).>pn|.i.is jaqtlinii ^IJiip .t»iu.>AV ec w o d t- FH .I ^ ^' c c^' V o « »(: 6 ' c tc ll|lM|«.1}[ •ot<>s!Uifl3 ~ •JJIllll aotii.iisij^ •^iiauiitp.iii:.) iv.)i(panv '6J>41||0 o» 3.)ii,M()!A •J 1.18 cji s.moioi.v •lioi)«qjnj8B[^ 1? i I5!« 15 I2S l?i 12 1 1 12- 1 s§ 1 1 m s 1 1 1 1 1 II s 1 II ?3 •IwilHaiia ?.?. I""?:? IS!-^ 1 1 1 1 1 1 1 1 1 1" •9uiid!'«!a •uo!i3naiii.ia n 1 1 1 1 1 1 1 1 1 1 1 .^^ 1 1 1 1 1 •-I ri d d ?i -" © ?! d d -" •£ d d ■-< in c: d o -J •i)J)Ha.iAV.\ip!(l •sni.»n'«> p) .1.11)1111111 tM')ii A 11(1 IMjll.l)'!.!.! JO ilillipD.MiM •(upuis.u iiniisiiiM 111 siiiiui|Aipii! JO jn; •(i.iiiiwais.u spmiiiAIP"! .1" .i'"p">i!il "" 1 I-" 1 1" 1 1 1 1 1"" 1 1 1 1- e^i nsi^.FH, ,aooiia»a>, , ,«ira 00 1 « »i CO -J 1 i-i 1 o> • -<■ ^ » 1(5 1 1 1 d oJ •piUuie.u JO .i.)i.iii8 ■ u\ i|.)iM m saiioii JO J.H|IUIII1 oHl.'J.lAV •piiBii ev.w Hilti-nsfl.! ipijiiAV "I BJIIOIl JO JVMpllllll 1«1"X_ o a T 0-. "5 (Jjin fc 5-. •'I -ii-M re 'M :;i I?;?;h^ 15 sl'ily.-^ 1 II =3 M •» 5V| -JS ri ^ .15 M Ci X •£ f :i •£:" C « ?i -s ""■£ >l t « X r- — .r. •4U1U.UN.U JOS.DIIBIS -u) JO adiiiuiui .)P"1\V •p.iiijna)S.ia jsqumil .?ltvp .laiuoAV ift It -4 d — 1- 1 « V CI ic 00 d "^ w wj ic ci ■-< 00 CI f-i fH^ CI F-F^C9 Sill •jllJfpi lllS.ISop B auin'ii miu X|!«p eSwitAV cr. C3 •!• 115 X ~ •£ iC J. S «e CI , , , CC CI c: ^' 1 " ,;■ -j m" u5' ci -; «' '.c «- ifl 1 1 1 «c « -4 -UI,) . , , IC X 1- CI , . . . , CI I I'^-d:-^^;^! U:-5S3" "cii^ 1 11 1 i;;!^! 1 I.,2i5i 1 1 ! 1 a. -r xiv r c5 u5 o 1- M -t 1(5 o c; ai 1- ire o •* i- ic-*ii.-?0^"f'*ii-QDow«55iwii5aui'»c5iCCi ■wo»»*ii5-£aoveC(!t-*T'<>iSiocioiOt-us •in JO iinui a jsquii It 8ii anp srt^jBtuiij II oa«a.)A« Aijtia mnmit )o a.Kpiiiii< •MOl .-.ciP5"iiio®i-a>«o — cirt'*ii5«c>-0Ma>O ?! -1-. "U di-i 1 1 1 1" M IU?,2 1 Mil 1 1 '^•- ■". 1 1 1 j.-j 1 «t I-- 'Ci 1 71 JC l« 1 « « 3 iC '/J 1 ■^"^' o 1 C •£ <0 1 1 1 1 1 1 ^; 1 ^ 1 I I ?f I I 2 :.i, I'S iSl 1"^ i:§ 1 1 1?; Mill" M 1 1 1 1 i^ 1 1 1^- 1 •- 1« iC tC <31 1 . M C^ *!• O 110 1 ■• tiT CC o=^ 'MM- 1 ;* 1 er ic p-i 1 ". '". • 1 1 1 oo> II . ^ . C^ CO II I! I I 04 O W tii/3 lip t^ lij 13* O APPENDIX E. Tablk V. — Showinj,' the Number of Idiots in oat-li Stato iiccordin{jf to the Census 18b0, and tlioir Location at the same date. These fi<^ures, as well as many others in tills book, are extracted from the Compendium of thi; " Tenth ("en- 8US of the United States/' 2 parts, ISHO, for a copy of which 1 am indebted to the Census Office, Washin^'ton. I take this oi>pf)rtunity of specially thaidii7 Culiirailo ••• *•• 77 Coniut'ticut ... ••• • •• ... 817 DjiUt.tii ••• «i) J>rlH\vnre ••• • !• iW DisliirLof Columbia ... • ■• 107 Fhiridii .. . • «• 'M\> G«-i:i Louisiana !•• • •« ... 1.0.V1 Maine • •• ... l,.ii'-> Maryiaiiil ••• ... l.Mltf Ma.isaclnisett8 «•• • *■ ... a.oai Michigan • •• »•• ... 2,INI M innc.vota • •• til 7l'\» Mi9:iiiiH)ppi f>« • 1* ... l.-'.7!t Midsntiri • •• *■> ... 3,:t7a Montana • •• •«l ... i*'* Nt*!)rH.ska • tl ••• .^■"l Nevada • •• 1« New Hainpslr.rc • •• • •• 7o:» New .Jersey ,,, tl* • •* ... l.f'ti .^ew Mexi<'t> ,,, • •• • ■■ !.:;» New Ynrk • •• ••> ... 6,0»4 North Carolina • •• ••• ... .'i.ua Ohi.. • •• • *• ... 15,4110 Orej^on • •• *•• IM IVnna.v tvaiiia • •# **• ... «,497 Khode Island... • •■ • •• •sn bouth Carolina • •• ... l,o«8 Taiile v. {Continued). 1V)ia« Utaii Vi-rmoiit .., VirKlnlit WitnliiiiUtDri .,, MVhI Viinllilii Wisi'iitislii „, Wy>>iiiliit{ ••• ... 3.M:i • •• ... a.'i'u • • ii-* ••• Hii;i ... a.71'1 ••• 47 ■ •• ... \,'-wi ••1 ... l,7'*.'> ••• •i AlHlei, 4.'i,.1UU; Fi-niiiles, 31,M4 "rt.»«.i Total iiiiinber of Miotic Clilnose wai f>, anil of Indlaiii 84, In IHMO. Natlvfl Idiott VureiKii 7» 7i>.Hlt3 . l.ltl . I'.IJ'.I* ,. o.KlT li4i 47 . ('.7,-JOO Tfl.sit.') APPENDIX F. Tadli; VT. — Hliowinj,' the Niniibor of Idiots in Tniiuing Scliuols fur the Foeblo-iiiiiiclud in 18S0.">^ Training ScuooLa. Connectinit. Coniu'clicut Schools for Imbeciles /llinuis, •Illinois Asylum for Fceblc-mlndeii Clilldreii /itiliana. *Iii(liiiiia Atj'luiii lor I'Veblc-iniiidcd Cliildri'ii /(lira, *Iowii State Asylum for I'>(lile-mliidcd Cliililrcn ]Ii)K)iitiil for Idiots, Imbci^lli'S, lie. Institution for the Education nnd Tiaiidng of Feeble- minded Children ... ... Mastachiisetls-, MnsiinrliusettN Hchool for Idiotic nnd Feeble-minded Youth I'rivnte Institution for I'Mucalidn of Fetljlc-mlndcd Youth HilUlde H(lio(d for lliukward and i''i'i'bU'-mind<'d Children Mtviia^ota. tMlnnesofa Institution for Feeble-minded Children Anr i'lir/i. New York Asylum for Idiots Newark ,. i. (Custo. \6M. t Hutu Training Uchouls. 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