!MAGE EVALUATION
TEST TARGET (WT-3)

£<.

1.0

I.I

11.25

- 1^

2.0

U 11 1.6

.'^I'V'

Photographic

Sciences
Coiporation

33 WEST MAIN STREET

WEBSTER, N.Y. 14580

(716) 872-4303

:t*

^^\

^
^

<^'

CIHM/ICMH

Microfiche

Series.

CIHM/ICMH
Collection de
microfiches.

Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques

Technical and Bibliographic Notes/Notes techniques et bibliographiques

The Institute has attempted to obtain the heat
original copy available for filming. Features of this
copy which may be bibliographically unique,
which may alter any of the images in the
reproduction, or which may significantly change
the usual method of filming, ere checked below.

n
□

D
D
D
D
D

□

Coloured covers/
Couverture de couleur

Covors damaged/
Couverture endommagde

Covers restored and/or laminated/
Couverture restaur6e et/ou pellicui^e

Cover title missing/

Le titre de couverture manque

Coloured maps/

Cartes gdographiques en couleur

Coloured ink (i.e. other than blue or black)/
Encre de couleur (i.e. autre que bleue ou noire)

Coloured plates and/or illustrations/
Planches et/>/u illustrations en couleur

Bound with other material/
Reli6 avec d'autres documents

Tight binding may cause shadows or distortion
along interior margin/

La reliure serree peut causer de I'ombre ou de la
distortion le long de la marge mtdrieure

Blank It^aves added during restoration may
appear within the text. Whenever possible, these
have been omitted from filming/
II se peut que certainds pages blanches ajoutdes
lors d'une restauration apparaissent dans le texte,
mais, lorsque cela 6tait possible, ces pages n'ont
pas 6t6 filmdes.

Additional comments:/
Commentaires suppl^mentaires:

L'Institut a microfilm^ le meilleur exemplaire
qu'il lui a 6t6 possible de se procurer. Les details
de cet exemplaire qui sent peut-dtre uniques d'j
point de vue bibliographique, qui peuvent modifier
une image reproduite, ou qui peuvent exiger une
modification dans la mithode normale de filmage
8ont indiquds ci-dessous.

I I Coloured pages/

Pages de couleur

Pages damaged/
Pages endommagdes

Pages restored and/or laminated/
Ps^ss restaur6es et/ou pellicul6es

I yT Hages discoloured, stained or foxed/

Pages ddcolordes, tachetdes ou piqudes

Pages detached/
Pages d6tach6e&;

Showthrough/
Transparence

Quality of prir

Qualitd indgale de I'impression

Includes supplementary materit
Comprend du materiel suppiementaire

I I Pages detached/

I y Showthrough/

I I Quality of print varies/

I I Includes supplementary material/

D
D

Only edition available/
Seule Edition disponible

Pages wholly or partially obscured by errata
slips, tissues, etc., have been refilmed to
ensure the best possible image/
Les pages totalement ou partiellement
obscurcies par un feuillet d'errata, une pelure,
etc.. ont 6t^ filmdes d nouveau de fapon &
obtenir la meilleure image possible.

This item is filmed at the reduction ratio checked below/

Ce document est tilm6 au taux de reduction indiqu6 ci-dessous.

10X

14X

18X

22X

2rjx

30X

12X

16X

20X

24X

28X

32X

1'he copy filmed here has been reproduced thanks
to the generosity of:

National Library of Canada

L'exemplaire filmd fut reproduit grdce d la
g6n6rosit6 de:

Bibliothdque nationale du Canada

The images appearing here are the best quality
possible considering the condition and legibility
of the original copy and in keeping with the
filming contract specifications.

Les images suivantes ont dt6 reproduites avec le
plus grand soin, compte tenu de la condition et
de la nettetd de l'exemplaire fllmd, et en
conformit6 avec les conditions du contrat de
filmage.

Original copies in printed paper covers are filmed
beginning with the <ront cover and ending on
the last page with a printed or illustrated impres-
sion, or the back cover when appropriate. All
other original copies are filmed beginning on the
first page with a printed or illustrated impres-
sion, and ending on the last page with a printed
or illustrated impression.

The last recorded frame on each microfiche
shall contain the symbol -~^ (meaning "CON-
TINUED), or the symbol V (meaning "END"),
whichever applies.

Les exemplaires originaux dont la couverture en
papier est imprim6e sont filmds an commenpant
par le premier plat et en terminant soit par la
dernidre page qui comporte une empreinte
d'imprecaior. ou d'illustration, soit par le second
plat, salon le cas. Tous les autres exemplaires
originaux sont filmis en commenpant par la
premidre page qui comporte une empreinte
d'impression ou d'illustration et en terminant par
la dernidre page qui comporte une telle
empreinte.

Un des symboles suivants apparaitra sur la
dernidre image de cheque microfiche, selon le
cas: le aymbole — ► signifie "A SUIVRE ". le
symbols V signifie "FIN".

IVIaps, plates, charts, etc., may be filmed at
different reduction ratios. Those too large to be
entirely included in one exposure are filmed
beginning in the upper left hand corner, left to
right and top to bottom, as many frames as
required. The following diagrams illustrate the
method:

Les cartes, planches, tableaux, etc., peuvent §tre
filmds d des taux de reduction diff6rents.
Lorsque le document est trop grand pour §tre
reproduit en un seul cliche, il est filmd d partir
de Tangle sup6rieur gauche, de gauche d droite,
et de haut en bas. en prenant le nombre
d'imnges ndcessaire. Les diagrammes suivants
illustrent la m6thode.

32X

THE

iisrs-.^isrE

IN THB

PROVINCE OF QUEBEC

{Eeport to th? Honorable Provinoial Socrctary)

Dr A. VALLEE

MBDICAI, 81TPER1NTE.NKANT OF THK QIIKUEC LUNATIC ASYLUM, MEMBRK A88OU1S DK

LA SeClETt MtDICO-PBYClIOLOaiQUB DE PARIS BT DK LA SOClfeT*; DK

MRDECINK JIBMTALB DB BE' 8IQUK

QUEBEC :

Printed by Bet.lkau »fc Co.

1890

^j^-'.m!gfi<ftW^

REPORT

Quebec,^20th January, 1890.
The Honorable the Provincial Secretary

Sir,

I have the honour to submit the accompa-
nying report on the labours of the Congres de
mfdedne mentale, held at Paris during the course
of last summer, and upon some of the establish-
ments for the insans which I visited.

In the two last pages of my report, I have
taken the liberty of pfiving some suggestions
by way of conclusion.

I have the honour to be,
Sir,
Your obedient servant,

A. YALLfiE, M. D.

Quebec, 7th January, 1890.

Honorable C. A. E. G-agnon,

Provincial Secretary,

Quebec.

Sir,

Thanks to the kind authorization of th(!
Government, I was enabled to take part in the
Congres cle mMecine mentule, held in Paris during^
last August. Specialists in mental diseases
from nearly all parts of the civilized world
attended this Congress, which dealt with the
most varied subjects connected with the patho-
logy, treatment. legal.m<'dicine, legislation and
the relief of the insane. I was also present at
the proceedings of the Congress on anthropo-
logy, legal medicine and public relief, at which
various questions connected with mental alie-
nation were discussed. Most of these subjects
owing to their technical nature can be of in-
terest only to physicians but, on the other
hand, there are some the knowledge of which
cannot but be of iiso to those who have to deal
with the cause ol the insane, especially legis-
lators and those who are called upon to or-
ganize and direct the services of this important

branch of public relief, 1 therefore deem it my
duty to submit you a summary report ou the
labours of these various congresses and upon
some of the principal institutions for the insane
which I had an opportunity of visiting.

During past years public opinion in our
Province has been greatly aroused with respect
to the relief of the insane ai<d the organization
of our asylums. Thih qviestion which is a
comparatively new one in our country is in
every way worthy of the attention of the
Government. Humanity is liable to many woes
but there is none more aistressing, I might say
more humiliating, than that w^hich attacks man
in the noblest of his faculties. It has always
excited the deepest interest not only in legis-
lators and scientific men but also in the general
public. Unfortunately it is beyond the power
of human means to remove this evil more than
any other and all we can do is to diminish its
effects by beneficial legislation.

At one of the sittings of the Congress, Pro-
fessor Ball read a report which he had drawn
up jointlv with Dr. Rouillard, the chief clinical
lecturer on mental diseases in the Paris Faculty
of Medicine. The paper was intituled : De l^

^jr^,—^

__6 —

Legislation wmparie sur le placement des aliinis
dans let itablissements publics et privis. (Legisla-
tion on the placing of the insane in public or
private institutions.) I will take the liberty
of giving a brief summary of this report which
gave rise to a most interesting debate.

In all countries and in every age the confine-
ment of the insane has been recognized as an
inevitable necessity and this for three reasons,
the weight of which cannot be denied.

The following are the reasons :

1. The necessity of protecting the public;

2. The necessity of protecting the lunatic
against himself ;

3. The necessity of the medical treatment of
insanity which can be cured if submitted to
proper treatment.

Therefore the necessity of protecting the
lunatic against himself and society against him,
and the possibility of curing him in confine-
ment are the reasons which justify confinement.

The two-fold object which the legislator in
all civilized countries has had in view has
been to secure the confinement of the insane
for the reasons we have just given and at the

|;a.

-7 —

sarao time to oppose all arbitrary confiaement.
These two objects are not in the Itast contra-
dictory and, in practice, may be consistent ,
with each other.

It yet remains to be seen whether, in some
countries, legislation has not sacrified the
former condition to the latter and whether,
under the pretext of defending individual
liberty which is not threatened, there is not a
danger of the insane being left uncared for and
of society bein<^ left defenceless.

In all countries efforts have been made to
establish a species of equilibrium between
medical authority and the administrative or
judicial authority. The balance inclines now
to o- . side now to the other.

Amongst the countries where medical au-
thority preponderates we may mention: Russia,
Belgium, Austria, Sweden, Norway and France.
In these countries the administrative authority
controls medical action to a greater or less
extent, but leaves the greater part to the phy-
sician. In France for over fifty years the insane
have been under the law of 1838. This law
drafted from a most humane point of view was

8 -.-

in a great measure inspired by the illustrious
Pinel. This philanthropic physician devote his
whole life to improving the lot of the insane ;
he emancipated them as it were by raising
them to the dignity of invalids. Consequently
this law of 1838, drafted with exceptional care
by very enlightened minds iiaj been justly
admired and taken as a model in other coun-
tries. Our legislators have taken from it the
inineipal provisions respecting the admission
and discharge of the patients.

Nevertheless, notwithstandin'^ all the gua-
rantees which it offered, the law of 1838, has
been the object of attacks which have dis-
turbed public opinion and have induced the
public authorities to inquire into the matter.
For instance, in 1882 the Fren(;h Government
submitted a bill to the Senate, which, while
retaining the general plan and many of the pro-
visions of the law of 1838, supplied certain
deficiencies and made several important amend-
ments. It was first drafted by an extra-parlia-
mentary commission and afterwards submitted
to a committee of the Senate which spent two
years in careful consideration. Finally, in 1887,
the new law was passed by the Senate but it

— 9

haH still to go before the Chtmibor ot Deputies.
There are certainly Home very important
ieservationH to be made with reference to some
of the changes in the new law, especially
that which tends to snbstitute judicial ac-tiou
to medical action in connection with the admis-
sion of the insane into asylumK. This provi-
sion is a concession to public prejudices with
reference to the possibility of arbitrary confine-
ment. It is not inopportune to observe here
that of all the alleged facts of this nature
whii'h served as a pretext for the revision of
the law of 1838, not one h*is been judicially
proved.

Consequently the Congress unanimously
condemned this innovation which consists in
calling upon the magistrates, on every occa-
sion, to decide upon the sending of the insane
to asylums.

Dr. Falret said that to leave the examina-
tion of the insane to the magistracy was to
commit the same error as to transfer to the
medical faculty the prosecution and sentencing
of criminals. This provision is moreover im-
possible to execute. In the Department of the
Seine there are over 3,000 insane sent to the

lit

— 10 —

■

asylums every year. This would mean that
the tribunals of the Department would have
every year 3,000 insane or persons alleged to
be insane, to examine, interrogate and keep in
confinement cr to discharge. But amongst
these insane there are some, and they are
perhaps not the least numerous, who can
answer as well as the magistrate who ques-
tions them. How will the magistrates be able
to decide if thby do not take the advice of the
physicians and if they do take it, can we not
say that their intervention in the matter ie
fictitious.

Mr. Barbier, first President of the Cour de
Cassation, said that he fully concurred in the
remarks made by Mr. Falret. In his capacity
of ex-magistrate he wished to state emphati-
cally that he did not admit that the courts
were competent to decide in cases of mental
alienation. It would be a sorry present to give
the magistracy to drag it, by exaggerating its
powers, into a subject beyond its proper sphere.
Not Medicine alone which protests against
such an abuse, common sense itself is opposed
to it. He therefore hoped that the provision
would not be retained when the new law

came up for discussion befoie the Chamber of
Deputies.

I have laid strees on this particular point
and I have cited the evidence of two of the
most eminent members of the Congress, because
in this country we have to contend against
pretty much the same prejudices with reference
to illegal detention. There are many people
who think that there is nothing easier than to
arbitrarily confine sane persons.

Up to the present moment hardly one
authentic case can be mentioned which has
occurred in this Province, and I think I may
say that with the (guarantees which the present
law gives us, such an accident is hardly pos-
sible. In fact no one can be admitted into
an asylum without a certificate from a phy-
sician, a certificate from the parish priest, a
minister or a justice of the peace, a certificate
from the mayor of the municipality. Moreover,
during the fifteen days following the admis-
sion, the medical board must examine the new
comer and report to the Provincial Secretary
upon his mental condition. It would be diflB.-
cult to admit that all these controlling agents
would combine with an unavowable object,..

^^M

l..^ ' -

— 12 —

that of depriving a sane person of his liberty.
I do not think that individual liberty is better
protected in any other country than it is in
this, by cur legislation.

In France, the law of 1838 requires each
Department to have a public establishment
specially destined for the reception and treat-
ment of the insane, or to enter into an agree-
ment in that respect with a public or private
institution of the Department or of another
Department. Mr. Fallieres said, in speaking
of the r^'asons in support of the Bill : " We
must not ov rlook the fact that one of the
greatest drawbacks of the law of 1838, is this
faculty given to the Departments of entering
into agreements with private patients for the
care of their insane. What is the res-ult ? These
institutions are founded for speculative pur-
poses and necessitate considerable expr nditure.

" In ordei- that the patients may receive that
care whicn their condition requires, it would
be necessary that the amount paid for them
by the Department be so calculated as to cover
their expenses and at the same time leave a
reasonable profit for the managers. Now, in
practice such is not the case, the average rate

■PSW-

— 13 -

per day being, when the last statistics were-
compiled in 1874, about 1 fr. 10 or 1 fr. 15.

" It is consequently to be feared that, not
finding sufficient renumeration in th« prices
llaid by the Departments for their insane, the
proprietors of these establishments may seek to
obtain it by economizing in the treatment of
the patients and by imposing upon them tasks
beyond their strength and contrary to rational
medical treatment.

" Even laying aside the supposition of a
culpable speculation on the insane, we are
compelled to state that the Departments are not
in a position to insist upon these establishments
making the sacrifices necessary for securing
an improved service.

" Consequently, without wishing to incri-
minate all the private asylums, we think that
to give them the care of the indigent insane
would be to establish" an inferior means of
relief which would be to the detriment of this
class of patients. The treatment of thes(^. unfort-
unates is a social duty which the public
authorities have to perform by agents alike
responsible and disinterested. It should never

III

— 14 -

become nor Appear to be the object of a specu-
lation."

Under the new Bill, the Departments which
have entered into agreements with private
establishments will be obliged within a specified
delay to found an asylum which will belong
to them or deal with a public institution.

Notwithstanding the fact that each Depart-
ment is bound to have an asylum for its insane,
ofiicial' statistics show a want oi" proportion bet-
ween the resources of the special establishments
and the requirements of the population for
whom these establishments are intended.

They show how well founded are the com-
plaints to which the ever-increasing over-
crowding of the public institutions gives rise.
This is not peculiar to France, but is general
and it is only necessary to open the special
reports to see that everywhere, in Belgium, in
Germany, in the British Isles, in the United-
States, the number of insane is increasing to an
alarming extent in the asylums which have
become too small.

Thus, in the Province of Quebec, we had,
fifteen years ago, but one asylum the number

ill

— 16 —

of whose inmates did not exceed 800. In 18*75
the St. Jean de Dieu asylum was openod with
about 200 patients. At the present day the
Quebec asylum has 8t5 and that of St. Jean de
Dieu over 1100. There are also about 100
female idiots in the asylum at St. Ferdinand
de Halifax. Now each of these establishments
is more or less over-crowded and their enlarge-
ment is spoken of. This fact is, beyond a doubt,
a most serious one and it is important to ascer-
tain the cause and remedy for it.

The question has naturally arisen whether,
owing to the progress of civilization, the excite-
ment and necessities of our pri^sent way of
living, the human race is not more predisposed,
more apt, to contract insanity than formerly.
This may be the case to a certain extent, but it
is not sufficient to explain so rapid an increase
in the population of our asylums. I consider
that the over-crowding of our asylums may be
attributed to two chief causes : 1st. The in-
creased number of admissions ; and 2nd. The
constant increase in the number of those remain-
ing in the asylums, owing to the fact that the
number oi admissions is always greater than
the combined number of discharges and deaths.

^■iMMlMlai

— 16 —

As Esquirol so happily says, the asylum is.
an instrument ofcure, that is to say an institution
ol special treatment where by means of isola-
tion and a combination of hygienic conditions
and medical m<'thods, the patients may be curde
or at least obtain an alleviationof their sorrow-
ful fate.

Consequently we should send there at once :

1. All insane who are really dangerous.

2. All those who have any chance of cure
and even of an improvement in their condi-
tion.

As to the others, viz : the majority of the
imbeciles, weak-minded, the senile and hemi-
plegic demented &c., as Dr. Luuier very pro-
perly says, the asylums are not created for them
and their place is with their families, and, in
default of that, in hospitals for incurables where
they used formerly to be placed and where they
should now be admitted in virtue of the funda-
mental conditions under which such hospitals
were established and have been maintained.

However, this distinction is very far from
being observed in practice, and every year we
see admitted to the asylums harmless imbe-

i 1

— 17

cile, demented and other patients who are
entirely incurable, who are even physically
incapable of doing any harm, and who, upon
exaggerated reports from those who live around
them, are confined, as u measure of public safety.
For a long period and in all countries the most
competent men have pointed out the evils
which would result from the crowding into
the asylums, of idiots, imbeciles, harmless incur-
ablcis who take the place of those who are really
insane, whose isolation and treatment are ack-
nowledged to be necessary. On the other hand,
it ^00 frequently happens in recent cases of
insanity, that the iamily, through a mistaken
feeling of pride, through neglect or some other
motive, endeavour to keep secret, as long as as
possible, the fact that one of their members is
afflicted with mental alienation and hesitate to
follow the advice given them to at once place
their patient in an asylum. This feeling seems
natural, but is never sufficiently reasonable, for
it unnecessarily affects the chances of cure.
Hence the many incurables who come later on
to fill up the special establishments. It is now
beyond a doubt that the first thing to be done
in the treatment of insanity is to isolate the
2

i'l

— 18 —

,.„,„. the word isolation must
patient ; "-"^^J^^^leceptatiou, bnt with
not be taken m itb nsnai i alienists.

t,e special meaning gn- to -tbya^^^^^^^^^^

It does not mean *" *»* ''^ jj^ his loUow-

,e„ovehimJromaUj^^^^^^^^^

creatntes, b«t. on th ^Uer his

radical change ^^ ^^^^^ t,™ily, his friends

'"''"^•"r':tu"o^"himwithstrangersand

MsservantMo- -n ^^ in his mind. U .s

aroi^se entirely new ^^ ^^^^ ^

*''''^t"tT?ht«-tic method and there
possible » th s th. ^^ ^^^^^^^ .^^ p^„.

^iU be all the more ..ha ^j^^

portion to the recen^-f^^;^ ,,„,, „„iy

:::Xrnrtrate deU^s and cannot but
be preiudicial in most cases.

It is beyond a donbt that it these principles

It is Deyoii tnown there would be a

^ere more generally known ^^^^^

perceptible decrease «;f ? J^" '"^^^ w„„ld
oHncnrables ^^— J:J;:T: Znrage the
"rpTact^lftiirln asylums by grant,
early placin„ "1 . ^ ^o^te oases

i„g, for instance, tree boajd "^ ^^^

in which the disease has declarea
iTe than fifteen days before admission.

— 19

This is one of the principal causes of the over-
crowding of the asylums, but there are others
which are equally important, amongst which
may be mentioned the inadequateness of the
treatment and the idleness in which the
patients are left through the absence of organ-
ized labou*.

Moreover, one evil always begets another,
and over-crowding continues and aggravates
itself, as it were, by greatly decreasing the
chances of cure. The effects of over-crowding
as regards hygiene are to well known to require
any remarks on my part, but from the special
point of view now before us, I deem it advis-
able to point them out to you. It is a source
of disorder and excitement in an asylum ; for it
necessitates large divisions in which medical
police is difficult, in which the individual
influence of the physician and his assistants
on the patients is no longer effectively or satis-^
factorily exercised ; and finally in which it is
almost impossible to have a methodical and
rational classification which is so necessary.

In view of the unfortunate results of the over-
crowding of the asylums, it is urgent that every
possible means be taken to provide a remedy.

Itl

'"!

iiif

T
li!.

— 2J —

This docs not moan, however, that wo should
restrict the n^lief ofthe insane ; on the contrary
dang(^rou8 and curabh^ patients should be con-
fined in asylums as soon as possible, for they
have greater chances of improvement and cure
as their disease is more recent.

On the other hand, there is a certain class of
harmless chronic cases, which may have a
legitimate claim upon public assistance. Such
are those who are unable to provide for their
subsistence, and who have no family, or whose
family cannot provide for them. Legislation
should therefore tend as much as possible
towards facilitating the confinement of all
patients who inay benefit by it; but it is advis-
able to ittain this (;nd by the fairest and most
equitable means, as well as by m«^ans which
will be most useful to all. These are data
which should be understood by all who have
anything to do with the insane and especially
by physicians, who are nearly always called
upon to give their opinion on the matter.

The best way to attain this end would be to
develop clinical instruction on mental diseases,
which is hardly taught at all in our univer-
sities During the many years that I have been

— 21-

the physician of B(^anport asylum, I have had
an opportunity of examining all the documents
respecting the admission of the insane into that
establishment. I have often been struck with
the unsufficiency of by far too many of the
certificates which are sent un by physicians
who are otherwise very well educated. This
is due to the absolute incompetency of those
who sign them, and there is a deplorable defi-
ciency in this. There is no doubt that the study
of mental diseases is an essential p.'irt of a
physician's duties ; his general knowledge
naturally leads him to understand and learn
this speciality better than any one else, but he
must have an opportunity of studying it. This
branch, however, is not included in the curri-
culum of our schools, and on the other hand,
it is evident that our practising physicians have
hardly an opportunity of following the evolu-
tion of these diseases on the subject itself, as
those who are suffering from them are never
trefc.ted at home. Nevertheless, it frequently
happens when a patient is quiet, that an inde-
finite delay is advised until he becomes aggres-
sive, and he is then incurable.

It is certain that in many cases, if the physi-
cians who are called upon to decide upon the

(^.

"it

■A

^ ll

— 22 —

necesHity of coufineraent would insist upon its
being carried into effect at an early stage, the
number of incurables in our asylums would
decrease, and the proportion of cures would
increase. Were the imp<)rtan(;e of prompt ther-
apeutic intervention throughly understood,
acute cases would be sent to us much earlier,
and with the knowledge that the asylum
should be above all a hospital, that is to say
an instrument of cure, there would be no idea
of filling it with imbeciles, idiots, harmless
lunatics, who, if confined or sent for treatment,
should only be sent to houses or institutions of
refuge specially destined for the purpose and
which would not be so costly.

These unfortunates should rather be con-
sidered as infirm persons than real invalids.
Then, it being admitted that the asylum should
be a place for treatment, too, much importance
carnnot be attached to its thorough organization
from a medical point of view. We would
thereby obtain the maximum of possible cures
and consequently provide a remedy for the
ever-increasing number of insane patients
supported by the Government. In a well organ-
ized asylum (Constans, Lunier, Dumesnils. —

ill

— 28 —

Roport to the Minister of tho Interior, 1874),
whoro everything is done with order and me-
thod, the rao.st ob.stinat«% disorderly and refrac-
tory p^tienl, linishes by an(;on.s<'.iouHly becom-
ing influenced f)y his new surroundings and
amenable to authority, which is a iirst step
towards his cure. But in order that an insti-
tution of that kind should be worthy of its
destination there should be but one head whom
all should obey. When there is div^ided author-
ity in an asylum, the mind of the patient wan-
ders, he does not know in whom he should
confide, and without confidence, says Esquirol,
there can be no cure. The separation of admin-
istrative and medical functions in an asylum
is fraught with many dangers in this connec-
tion.

If constant conflicts are to be avoided, which
are most prejudicial to the proper discipline of
an establishment of the kind, there should be
but one management and the physician is the
natural head of a hospital in whi(jh everything
must contribute to the treatment of the unfor-
tunates in it, from diet and clothing up to the
organization of labour and internal discipline.
A well regulated asylum has, in order to do

:-M

— 24 —

the greatest possible good, only to use the
means at its disposal. It does not require a
long experience, says Dr. Marandon de Mon-
tyel. to become convinced of the uselessness of
pharmaceutic means in che treatment of insa-
ntiy. It is not with drugs that this sad disease
Cc.a be cured, but by isolation, physical
hygiene, work, hydrotherapeutics, and above
all the physician's action.

This action of the physician on his patient
should be constant ; it makes itself directly
felt during his visits and indirectly in the
intervals between the visits through the staff of
attendants whom the physician musthave well
in hand and all of whose words and actions
must be inspired by him. Such is the opinion
expressed by the G-eneral Inspectors of the
insane in France, in 18t8, and admitted by
alienist physicians.

The supervision of the patients is above all a
means of treatment in an asylum, and too much
attention cannot be paid to the "selection and
training of a good staff of teachers. Never-
theless, notwithstanding all the care which
may be taken, I am satisfied that it would be
rather difficult to form, out of laymen or lay

— 25 —

women, a staff of nurses as reliable as one com-
posed of members of a religions congregation.
The care of the insane, perhaps more than any
other work of self sacrifice, requires a tact, a
patience and a disinterestedness which cannot
always be obtained for money, and to every
non-prejudiced mind, here as elsewhere, the
Sister of Charity may be considered the ideal
nurse. For some years past in France, there is a
tendency to replace religious communities by
lay nurses, not only in the ordinary hospitals,
but also in the insane asylums. I asked some
ofthe physicians of the asylums, w^hich I
visited, what they thought of this reform and
H'ost of them, speaking from an exclusively
medical standpoint, considered it most regrett-
able.

In Belgium, on the contrary, there are reli-
gious orders in nearly all the principal asylums
For instance, the Female Asylun^ at Mons, and
the Male Asylum at Tournai, belong to the
State and yet there are Sisters of Charity in the
former and Brothers of Charity in the latter.
At Ghent there are also Brothers of Charity and
as, in this eftablishment, labour is thoroughly
organized as a means on treatment, the fore-

t: !

!•,

— 2t) —

men of the workshops are Brothers. One of the
great advantages of this system is the absence
of the great evil of frequent changes of keepers
and as the latter are employed for many years
in nursing the patients, they acquire very valu-
able experience. The head physician of the
institution, Dr Morel, pointed out to me in the
vyard for violent patients, an old Brother who
had been in that division for thirty years and
who, notwithstanding his feeble appearance,
was able in to manage the most violent of them.

But I do not wish to enlarge at greater length
on this question of the organization of the staff
of keepers and nurses in asylums. I have
already dealt more fully with this subject in a
special report addressed to the Honorable Pro-
vincial Secretary, on the 31st October, 1885, and
also in my annual report for the year 1886.
But I deem it advisable to cite the opinion of
one of the alienists who has contributed in the
greatest measure to the improvement of asylum
organization in France.

" Keepers in asylums, says Dr Parchappe,
have duties of the same nature to perform as
nurses in hospitals ; their duties should be of
greater dignity as they are of higher condition
than those of paid servants.

— 27 —

" From this point of view in Cathr lie coun-
tries, sisterhoods supply the rery best possible
nurses for the female wards of our asylums.
Everything that one can expect from woman's
heart in the way of affectionate devoledness and
compassionate, delicate, enlightened care, we
get from the Sisters under conditions of self-
abnegation and with guarantees as to morality,
that we cannot obtain to the same degree from
lay nurses. The entire suppression of the lay
element in the staff of female nurses in asylums
is, in my opinion, an inestimable advantage
which should be more generally and more
unrestrictedly sought for.

" Experience has shown that the drawbacks
caused by a tendency to ueurpatiou of power,
which is generally imputed to religious congre- >
gations. do not exist in our public asylums,
and while admitting that this result might
have been obtained by the stipulations of the
contracts and by the regulations, it is but fair
to admit that several communities of nuns
which have included the care of the insane
amongst the objects of their foundation, have
shown themselves worthy of their object by
their aptitude, their devotedness and esprit de '
conduue, or administrative ability.

" The reasons which justify the preference
to be given to religious communities as com-
pared with lay-women for the female wards,
do not apply to religious communities of men
for male wards. The formation of a good staff
of keepers in these wards, as well as in the
female wards, when religious communities are
wanting, is a problem which has constantly
been worked at and the solution of which has
been considered possible by some alienists, only
on the condition of the establishment of special
institutions for training male nurses.

" The realization of these theoretical views
which would give rise to probably insurmoun-
table difficulties is fortunately not indispen-
sable. Experience has proved that it is poB^^iblo
to arrive at a sufficient degree of efficiency in
the organization of a staff of keepers by the
strict observation of certain rules of which onhr
the principal ones need be mentioned : The
appointment of a head keeper who should be
a qualified, capable and reliable official ; the
classification of the nurses into categories with
certain definite regulations as to promotion ; a
qualifying examination to be passed at the end
of the year ; the adopting of a uniform, just
and strict regulations for discipline."

— 29 —

We have already seeu that the first steps to
be taken towards the cure an insane patient is
to remove him from his ordinary surroundings,
but in order that this isolation may be effective,
he must not be left in a hospital abandoned to
himself and to all the vices of his first education
and the evil propensities bred by disease. Such
an isolation is more harmful thau useful. He
should be removed from his preoccupations,
from his imaginary world, by subjecting him
to the common law of labour. This is one of
Ihe principal conditions of the treatment. All
the insane who are physically capable of it
should be made to work whether their labour
be productive or not, for it must not be looked
upon exclusively as a means of increasing the
resources of the institution. It should be em-
ployed in asylums chiefly, if not entirely, as a
means of treatment and distraction.

Manual labour, especially in the open air,
which involves the simultaneous or successive
action of the locomotor muscles, together with
a certain amount of application, should be
given the preference over all other as a means
of cure but on the condition that it be never
allowed to fatigue the patient. It is generally

— 30 —

1 ,-i

admitted that working in the fields is more
beneficial to the health of the patients ; however
as this kind of occupation jis not liked by all
and as it is impossible in this country to indulge
in it tor a long period of the year the patients
might be employed in work about the house
or in easy trades under the supervision of com-
petent keepers.

Amongst the asylums which I had an oppor-
tunity of visiting, that of Gruislain, at Grhent,
is certainly ono of the best organized as regards
the labour of the patients. In the month of Sep-
tember last, out of 489 patients, 325 worked
regularly. Clothing of every kind was made
in the asylum by the patients themselves and
ordinary repairs to the buildings were likewise
made by them. There are workshops for tailors,
weavers, shoemakers, joiners, blacksmiths. At
the head of each workshop is a foreman who
is a skilled mechanic and all the other work-
men are patients. Moreover some are occupied
about the houses and yards and assist the
keepers.

One can scarcely believe how greatly such a
generalization of labour alters the appearance
of an insane asylum. There is a feeling of

81 —

satisfaction and the eye is not saddened, as in
owT asylums, by the distressing spectacle of
spacious wards full of idlers, who are left from
mornina: till night to the impulses of their
delirium and to the mercy of their evil instincts.
I have visittnl many institutions for the insane.
I have seen some more luxurious, more modern,
but, thanks to its excellent internal organiza-
tion, none impressed me so favorably as that
of Gruislain, which has been in existence since
1852.

It is moreover quite evident that in selecting
the occupation to be given to the patients the
physician must take into account their aptitu-
des, their tastes, their temperaments ; their
state of calmness or agitation. But it must
never be forgotten that he is the only judge in
these matter!^.

But is not alone sufficient that the head of
the institution should be willing to organize
labour in his establishment, the expense of
providing what is required must be incurred
once for all. In the first place it is necessary
to have intelligent, patient and skilful foremen.
It should be easy to procure such men if reaso-
nable wages were paid. Then the plant required

■i]

— 32 —

for the various trades must be procured. But
in the end this comparatively trifling expendi-
ture would be soon compensated for by the
proceeds of the patients' work.

The greatest difficulty in the organization of
labour in insane asylums is to get the jiatients
to work regularly and steadily. They are essen-
tially restless and changeable and soon con-
tract idle habits. They have to be stimulated
and encouraged by the hope of a reward or
remuneration, however small it may be. In
the asylums which I visited andin which
the patients' labour had assumed some propor-
tions, all thepatients are paid for their work
Thus, in France, a ministerial decisionof the
6th April, 1884, and, later on, a regulation of
the 20th March, 185*7, established the principle
that a slight remuneration was to be paid to
insane persons who worked.

By the very fact, says the report of the gene-
ral inspectors, that labour was considered as a
therapeutic means, it became necessary to en-
courage the patients to devote themselves to it
with a certain amount of assiduity. All work
deserves wages ; most of the insane are aware
of this and consider that their labour should be

33 —

paid for. The working day is ten hours and
it is paid nearly everywhere at the rate of two
sous It is not however nec^essary for the
patients to work ten hours a day to obtain this
remuneration ; ail they have to do is a fair day's
work. Thus the tailors, shoemakers, masons,
joiners, benefit by this tariff. In most of the
best asylums in France, patients who do vert/
productive work get extra pay. The first fruit of
these economies serves to form a reserve fund
called pecule de sortie (discharge money) the
object of which is to give the patient who is
cured the means of reaching his home and of
supporting him until he finds employment.
With the surplus he can purchase whatever
he likes or may take a fancy to.

In Belgium we find very nearly the same
organization. At the Guislain asylum the work
of each patient is paid according to its value.
A great many, for instance, are employed in
winding spools of cotton for a manufactory of
Ghent, which pays them two sous ixwkilo.

We have just seen what an important role

labour should play in a well organized asylum.

It is beyond a doubt that it is one of the chief

elements of cure, but it may be supplemented

■^

>-':

— 34 —

by other methods ofamiiHoment and distraction
which alHO form part of the moral treatment of
the insane, such aH outdoor walks, assemblies,
muHic, games, etc.

Open air walks are an excellent hygienic
exercise for quiet patients and they should
be indulged in at all seasons when the wea-
ther is favorable. Games, dances and (-on certs
may exert a beneficial influence provided they
do not be-'ome the chief occupation of the pa-
tients and that they are used only as a means
of diverting the mind from the habits of more
serious daily labour.

However, nothing can be neglected as re-
gards moral treatment and we should not hesi-
tate to resort to suc^h kinds of distraction when
patients have to be kept from idleness and \Then
it is impossible to do so by labour.

Music has a beneficial influence on most insa-
ne people and it is pretty generally resorted to.
Thus in a great many asylums in France and
Belgium, bands and schools for vocal mucic
have been organized amongst the patients In
some establishments, elementary schools have
been instituted for the purpose of amusing the

II;

35 —

patients and providing them with a useful
occupation.

We have considered some of the conditions
which an asylum should comply with as an
instrument of cure, and we have brieily pointed
out the means which the asylum physician
should have at his disposal in order to pro-
perly execute the mission confided to him. In
this respect the Quebec asylum is far from
having- accomplished the same progress as has
been accomplished elsewhere. There is hardly
any medical organization, and it may be said
that it is more of an asylum than a hospital
for treatment. For thirty years the medical
service has been performed by a house physician
appointed by the proprietors. The number of
inmates at that time was 400, it now exceeds
860, and, in some yeyrs, has even been much
greater, and yet the medical stafi* has never
been increased. That physician has not only
to treat the diseases incidental to a popula-
tion of 850 but he has also to correspond with
the relatives, keep the medical registers, com-
pile the annual statistii^s and make up the me-
dical prescriptions. He is not the real head of
the establishment and the inferior position he
occupies takes a"*' iy the presti^-e which he
should have with the patients.

ill

■d

— 86 —

In order to render the racdioal tr<'atmont mort>
effifiont, tho raodical authority Khould bo jjiveu
the greatest weight by placing under his imme-
diate control all the keepers and nurseH. There
should also be at least one house physician lor
each establishment (male and fomal'). He
should devote all his time exclusively to the
patient, without having to attend to the phar-
macy and book-keeping, correspondence, &c.
At the St. Jean de Dieu asylum there are three
attending physi(dans, and 1 am told that there
will soon b(j a fourth one. They have nothing
to do but to study and treat theirpatients ; the
nuns carry on the correspondence, keep the
books and dispense medicine.

The recruiting of a good staff of keepers is, as
we have seen, one of the essential points in
the organization of an establishment for the
insane. Now, I do not think that proper dis-
cretion has always been used.

Ah to the organization of labour as a means
of treatment there is none at all or hardly any.
It is true that som^ of the patients are employed
Vti various occupations, but there are very few
who work ste.^dily. Amongst the men and th(!
women, there are some who assist the keepers
in domestic duties ; but the very nature of such
an occupation means but an interrupted labour

87 —

of short duration and n'hl(5h is chielly done in
the morning In the lawt rt»port published by
the proprietors of the asylum we find ihat
out 991 patients under treatment, 153 were
employed in household work, 147 in the gar-
dens and fields. Now, as I hav^e just stated, the
former cannot have worked for more than one
hour a day in sweeping, making up the beds,
&e,, while the others work only a few days
in the year especially during the haying season.
Out of a total of 397 workers there were, there-
fore, only 97 who were more or less steadily
employed in sewing, knitting, in the work-
shops, the laundry, the linen room and in the
kitchen. This is a rery small proportion com-
pared to the number of inmates during the y ar.
Moreover, as I said in my last annual report,
the general house hold duties, even in a large
establishment, are not sufficient to give occu-
pation to all the patients who are able to work,
and to attain this end some easy trades should
be introduced. By this means it hns been
found practicable, in the United States and
Europe, to give steady work to from 60 to 90
per cent of the patients. For some years past
the asylums of Ontario have made considerable
progress in this direction. From 1882 to 1887,
the number of patients at work has increased

— a« —

in proportion to the number of inmates, as
follows : in the Toronto asylum, from 32.15
to 61.49 ; in the Kingston asylum, from 45.11
to 68.26, and in the London asylum, from
54.61 to 77.84. According to the report of the
London asylum for the year ending the 30th
December, 1887, out of 983 patients, the
average number employed at work erery day
was 826 and the total number of those who
worked was 947. The total number of days'
work was 259.883.

We have already stated that the placing of
idiots and imbeciles in asylums contributed in
a great measure to the over-crowding of our
asylums. In our Province the relief of these
unfortunates has hithe^-to been mixed up with
that of the insane. This amounts to the same
as admitting deaf-mutes or blind into ordinary
hospitals. An essential distinction must be
made between the iusane and idiots. The
former are invalids who are susceptible of treat-
ment, the latter are infirm persons whose con-
dition may be improved, it is true, but who
require a very different kind of care. Ovir law
admits idiots and imbeciles only when they
are dangerous, scandalous, epileptic or deformed.

This distinction is but fair, for in ordinary
cases, these unfortunates require only the sviper-

39 —

vision and attendance of their families, and it
is only when they have no family to look after
thnm that the public authorities should do so.
As I stated in one of my annual reports,
asylums for the insane should not be refuges,
and their character of hospitals for treatment
should be maintained. On the other hand it
is quite certain that a great many idiots and
imbeciles should be confined, because they are
dangerous or a source of scandal, or because
they are unable to support Ihemselves. But
since the Grovernment is obliged to take charge
of them, would it not be better to place them
in special establishments. This would b ' l-^ss
expensive and allow of our improving their
condition by educating them. For it must not
be forgotten that a certain number of these
idiote are susceptible of education to a certain
degree. These are what professor Ball calls
spontaneous ot: partial idiots. Some of them are
more or less endowed with intellects which
may be developed by exercise.

As Dr. Roussel says, the education of idiots
cannot resemble ordinary education more than
that of the youthful blind and deaf-mutes ; it
must be made to suit the condition of these
incomplete organizations, out of which we can-
not expect to form men with complete facul-

■ I

— 40 —

ties but which we may, economically and
morally speaking, turn to advantage according
to the rudiments of faculties and professional
aptitudes which we discover in them.

The establishment of an institution for idiots
should be based on such data as are now sup-
plied us by science and observation, the essen-
tial elements whereof are hygiene, gymutotics
in their widest sense, and varied kinds of lab-
our.

At one of the sittings of the international
Congress on Public Relief held at Paris ii Tu
last, Dr. Bourne vi lie read a paper on the oda-
cation and protection of idiot and ei)ileptic
children in France and abroad. The conclusion
of his paper is as follows : " The fourth section
of the international Congress on Public Relief
expres^-es the wish that provincial, depart-
mental or innter-departmental asylums be
established wherever there are none which
shall be devoted to idiot, imbecile and epileptic
children, that is to say to the most important
class of abnormal children." Dr. Bourneville
attaches great importance to the vote which he
proposed for, he says, foreign countries, in
which no departmental or communal asylums
exist, can rely upon such a vote. The project
was unanimously adopted by all the members

— 41 —

"present. Ou the other hand the Commission
appointed to consider the Bill voted by the
Fench Senate in 1881, suggests in its report that
the State should erect one or more special
establishments for the education of young idiots
and the treatxnent of epileptics.

There are such establishments in several
counties : England, fi'cotland, the United States,
France etc In England, the Earlswood asylum?
founded in 1347? gives instruction to nearly 600
idiots of both sexes ; that of Darenth, which is
much more recent, has schools for about 300
idio^ boys and 300 idiot girls, and, finally, the
Royal Albert asylum lor idiots can receive
nearly as many. In Scotland thero are several
asylums of the same kind amongst others that
of Baldovan and that of Larbert. In all these
institutions the results obtained haA'^e been
most satisfciclory. Dr. Roussol says that not
only do they succeed in deriving a benefit from
the work of those who are the least susceptible
of being taught trades, such as the making of
mats, but many are taught to work fairly well
as basket makers, joiners, locksmiths, shoe-
makers, tailors, seamstresses, and printers, be-
sides those engaged in agricultural labour for
whom Earlswood has a farm of 9u acres with a
sheep fold, byres and schools in which the more

— 42 —

intelligent receive a fuller education, so that
some of them succeed, as musicians, draughts-
men, calculators etc., iu securing a position in
society and earning their livelihood in an
honorable manner. To a French physician. Dr..
Felix Voisin, is due the idea of reforming edu-
cation so as to adopt it to idiot children. This
work was afterwards taken up by Belhomm.e,
Seguin and Delasiauve, and yet, afler having
started the movement, France has been left
behind by England and the United States
which merely appropriated its ideas. Never-
theless, the steps taken tu educate young idiots
who had been iu the Salpetriere for many ye?.rs,
and the colony established near the asylum of
Vaucluse have already produced sufficient re-
sults to induce the General Council of the
Department of the Seine and the Municipal
Council of Paris to devote three millions of
francs to the foundation of a sp^^cial establish-
ment under the direction of Dr. Bourn* ville
for the youthful idiots of Bicetre.

I had an opportunity of visiting these various
establishments and I was greatly struck with
their excellent organization and the wonderfui
results they obtain. In tne Department of Dr.
Jules Voisin, at the Salpetriere, there is a section
set apart for young girl idiots, to the number

of 150. These children are taught to read, to
write, to sew and do , various kinds of work.
Many of them thereby learn to earn their living
and some of them have been sufficiently trained
to become underkeepers in the institution. The
school, which consistsof four or live classes, is
still under the direction of Mademoiselle Nicole
who founded it forty years ago. The sy^.ten ol
education followed in it is very similar to
those for deaf-mutes. Object lessons are chiefly
given and objects are shewn to the children of
which they are taught the names ; such as
vegetables, fruits, grains, tools, furniture and
fuel. Of course it is difficult to secure the
attention of such a class of pupils for any length
of time, consequently the occupations are very
various and interspersed with many recrea-
tions. HoweA''er emulation is stimulated by
examinations, competitions, etc., etc., and the
success obtained is mos.t encouraging, For
instance, I saw amongst these unfortunates
hydrocephalous and microcephalous idiots who
could barely pronounce a few words when
they were admitted, and who had been taugh
not only to speak, but to read, to write, to work
and to make artificial flowers. Dr. Voisin
pointed out to me a girl idiot about ten years
old, who wht^n admitted, two months before,
was absolutely like a wild cat. No one could

— 44 —

go near her without being scratched, struck or
being spat in the face^ When I saw her she
was quite gentle and tamed, and was beginning
to speak.

The colony ..i' Vaucluse was founded on the
1st July, 1876 It was intended to receive 116
young boys from 8 to 15 years of age, who were
either idiotic or imbecile but in good bodily
health ; g'dteux, uncleanly and epileptic patients
being excluded. When I visited the institution
there were 120 inmates and most of these chil-
dren were occupied in one way or another
either at- school, in the workshops, at house-
hold work or on the farm. About 40 per cent
are regularly employed in field labour under
the direction of experienced farm foremen.
Others learn trades and work in the shops
while others attend school where they are
taught reading, writing, arithmetic and the
knowledge of ordinary things. The most intel-
ligent even pass examinations or these various
subjects.

But of all the establishments of this kind
which I visited in France, the most important
is, beyond contradiction, that of Bicetre. Owing
to the method followed there and the efforts of
the staff trained by Dr. Bourneville, who may
be considered as the founder of this new and

— 45 —

remarkable department, the idiot ward, at Bi*
eetre, may bo considered as, a model from which
useful information can be derived. This insti-
tution for th(3 education of idiot children is the
outcome of the putting into practice of the
doctrine laid down by Dr. Segttin about fi-^y
years age. This modest physician has been for
the idiot child what Abbe L'Epee was for the
<leafmute ; he devoted his whole life to his
emancipation by seeking to elevate him by
education to the dignity of a rational being.
Foreign countries were the first to appropriate
the ideas of Seguin, and it is only of late years
that efforts have been made in France to place
it on a par with England, the United States and
other countries, is regards ir^ proving the the
condition of idiots.

At Bicetre the basis of education lies in object
lessons and lessons of action. Edi.cation and
professional teaching are imi)arted in the
schools and w^ork-shops. All the spaces between
the buildings have been converted into gardens
for the purpose of object lessons : 1st. A garden
for geometrical figures (trees cut in the shape of
cones, cubes, etc) ; 2nd. A garden for surface
figures (small plots surrounded with a box-tree
border in the shape of triangles, squares, etc) ;
3rd. A flower-garden ; 4*^h. A kitchen garden ;

— 46

5th. An orchard with apple, pear, plum,
cherry-trees, etc. ; there is also a field with
cereals and fodder-plants. 6th Finally a small
grove of various kinds of trees extending to the
end of the section.

All the children spend a certain r umber of
hours, each day, in school alternating with
work in the chops, gymnastic exercises, outdoor
walks, etc. "The organization of the teaching
of trades is especially admirable and the follow-
ing table which I have taken from the last
published report, shows the results obtained.

WOKKSHOrS.

Joiner's shop.
Shoemaker's do
Sewing rooiiii.'.
Lockemitli's sli.
Basket makiu<>-.

Stuffing

Brushmaker's s.

Date of

Numt)cr of appren-
tices.

January.

December

•Ztith Aug '83

8th Oct "

8th " •'

l«Jan. 1884

30 Oct. "

30 " "

36 Nov. 1888

167

183

Value of
labous.

6.467 francs 80

3.413 "

5.417 "

4.568 "

3.113 "

336 "

38 "

65
70
70
80
75
40

il.3.54 frs. 10

— 4Y —

I have perhaps laid too much stress on this
subject of the relief of idiots. I might, how-
ever, have said mueh more by giving, at
length, the numerous details of the organiz-
ation of the classes, the physical exercise, the
hydotherapy, the amusement ot the children,
but I thijik I have said enough to show what
can be done in this connection. Up to the pre-
sent we have remained entirely outside of this
path of progress and if some day the Govern-
tnent should determine to make the relief of
idiot or imbecile children a speciality, by esta-
blishing institutions for them, such as those I
have just described, they will do away with
the abuses which may result from the existing
cOiifusion in our insane asylums whe^'^ these
unfortunate children are mixed up with
adults.

The immediate result of the organization of
such a system for the idiots and imbeciles
would be a perceptible decrease in the amount
voted for the support of the insane, or, rather,
this separation of the infirm from the sick
would allow of an equitable distribution of the
sums voted for that important brancih of public
relief. In fact the care of idiots and imbeciles

amnw .» J jjiMiHWiM

48 —

costs lesB than that of the insane, so that we
could devote the amounts economized on the
former to secure the better workiuo- of our
asylums for the really insane.

Such a reform would be a great improvement
on the present system, in so far as it would
enable our asylums to retain their true character
of institutions for the treatment of the insane.
We mii^ht thus, by raising the wages in these
establishments, increase and improve the staff
of keepers and place the medical service on a
proper footing. On the other hand, idiots and
imbeciles would no longer be abandoned to the
unfortunate consequences of their natural infir-
mity. Society would benefit by having these
unfortunates become, if not beings quite adapt-
ed for social life, at leist beings capable of
doing useful work sufficient to defray a por-
tion of the expense of their education. For
we must not overlook the fact that most of
these unfortunates have at least a spark of
intelligence which may be kindled by educa-
tion, and it is the duty zi tht Government to
assume the initiative in this charitable work
which would tend, as Esquirol energetically
expresses it, to remove the mark of the beast
from the forehead of the idiot.

40 —

Wo have just seen what it is possible to do
towards improving the condition of idiot chil-
dren, bnt there is another i^ass of harmless
and inonrable insane who contribute to a crreat
extent to the over-crowding of our asylum.s and
who may, nevertheless, beassirail.ted to idiots
as regards tho relief to be afforded them. For
instance, we have in our asylums a goodly
number of the quiet, demented, maniac or
melancholic patients without hallucinations,
who have long since passi 1 into the chronic
state and become immobilived, if I may use
the expression, in a form of inoffensive delirium,
patients atHicted with a partial madness and
even intermittent mania whose hmghty lucid
intervals might without danger be ; assed in
the bosom of their families

What measures should we apply to these
unfortunates ? And, in the first place, w juld
there be any benefit in ridding the a8;"^lums of
them ?

If we consider only the best interests of these
establishments, the answer must evidently be
an affirmative one. The asylum, whatever may
have been said,. must, above all, be an instru-
ment of treatment. In order that the physician
4

— 50 —

may he able to treat his paticats successfully
he must not be encumbi'red with the care of
incurables. It is these harmless incurables,
whose daily inspection is truly the most weary-
ing, the most monotonous and often the most
useless of spectacles, that we should endeavour
to relieve in another way.

Admitting on the one hand the possibity of
removing certain patients from the asylums,
and on the other hand, the undeniable advant-
ages of such a step as regards the proper keep-
ing of these establishments we may reduce to
four the i)rincipal systems which have been
proposed lor eflfecting this >fold object :

1. It has been proposed lu i-stablish houses ot
refuge exelnsively reserved for incurables ;

2. These unfortunates may be collected in
agricultural establishments ;

3. They may be confided to the care of other
families than their own ;

4. They may be sent back to their own
families

1. Physicians are not unanimous on the
question as to whether it is advisable to have
distinct asylums for the curable and incurable

— 51

insane. So Hay the Innpoctors General of inHane
asylumH, in France in their, report for the year
1878. " The most radical opinion in this respect
has been maintained by professor Griesinger of
Berlin, who would have liked to see as many
asylums as there are su(!cessive periods of insa-
nity : city asylums for acute cases; country
asylums for chronic cases ; colonies or settle-
ments for those in good bodily health. This
opinion has been contradicted by all, even in
Germany, the only country, however, with
German Switzerland, where they admitted iu
prin<uple for a certain time the separation of
the curable from the incurable. In France, as
well as in America, in England, in Belgium,
in Spain, in Italy, in Russia, the separation of
the curable from the incurable has never been
admitted, and at the present time, it is given
up nearly everywhere in Germany and Swit-
zerland." Parchappe very properly observes
that to adopt such separation as a fundamental
principle in the classification of the insane iu
an asylum would be to uselessly complicate
the problem to be solved and compromise its
solution by the necessary exclusion of principles
of classification, which are much more impor-
tant and useful.

52 —

However, while admitting that this system
ofrigourous separation of the curable from the
incurable presents serious disadvantages in
practiceit cannot be denied that there is in our
asylums b}' far to large a class of unfortunates
who would be better in refuges. The quiet
demented, the gdteux, the harmless patients
over 60 or 65 years of age and others of the
same kind are of this class. Some suffer from
primitive dementia while others have fallen
into that intellectual and physical state since
they have been in the asylum, after having
been afflicted with some form of mental disease.
The resources of the asylum are of no use to
these patients, they are a source of encumbrance
and increase the cost of expensive services
which have not been organized for them and
for which they become a positive inconvenience.
On the other hand it is hardly possible to
place these patients in ordinary hospitals
Houses of refuge should be established for them
which might be attached to the insane asylums.

2. But in addition to this comparatively
limited class of harmless, demented and gCiteux
patients, the ordinary inmates of an asylum,
consist in a great measure of those chronic,
more or less incurable patients who are spe-

— 53 —

cially deserving of attention as regards public
relief.

In truth there is hardly any more hope of
curing them and of curinir the first mentioned ;
but by getting them to work we can at least
reduee the cost of their support while improv-
ing their condition. It is for these patients
especially, that recourse has been suggested to
the boarding system or again to establish
farming institutions which have been called
agricultural colonies but which are in reality
only farms attached to close asylums.

At one of the sittings of the last Congress
on Mental Medicine, held at Paris, Dr Baume
read a treatise on the relief of the insane, in
which he asked that the departments be obliged
to establish, under the name of agricultural
colonies, farms which would be distinct from,
but dependent upon, and as near as possible to
the public asylums, to which the quiet insane
or idiots in good bodily health should be sent
after their period of treatment or observation
in the asylum was completed.

This suggestion gave rise to a very interest-
ing debate at the close of which the Congress
expressed the hope that to each insane asylum

— 54 —

there would be attached an agricnltural colony
in proportion to the number of inmates.

Some days previous, the Congress on public
relief had voted a similar resolution at the
request of Dr Magnan, the physician of the
Ste-Anne asylum. " The asylum physician
should establish, develop and extend the agri-
cultural colonies and the familial system
around his institution."

" In most of the insane asylums now in
existence, " wrote Dr Parchappe, in 1853,
" there is a more or less extensive area of land
cultivated by the insane. But it is chiefly in
Grreat Britain that the material organization of
farm labour by insane patients in asylum has
attained its fullest development. " The farms of
several English establishments, those of Han-
well and Surrey for instance, are on an exten-
sive and costly footing ; the stables, byres,
swine-styes, etc., are of the best; the dairies are
splendid. The manner in which the farm of
Quatre-Mares has been fitted up and provided
for on the advice of eminent agriculturists
seems to me to make it a model to be followed,
although it is not so extensive or so costly as
the English farms. "

— 55 —

Since Parchappe wrote the above, the de-
velopment of agricultural labour in insane
asylums has made constant progress both as
regards importance and extent, in England,
in G-ermany, in France and in the United
States During the month of July last (1889),
I visited the colonies of Fitz-James and Villers
attached to the Clermont asylum in the Depart-
ment of rOise, France. This institution pro-
bably shows the most ample and successful
application of the colony system which has
hitherto been attempted. It comprises three
different sections : the close asylum which is
in the town of Clermont, and the two colonies,
which are situated at a distance of two or three
kilometres in the communes or municipalities of
Fitz-James and Villers.

In the asylum proper there are boiler, cooper,
joiner, locksmith, blacksmith shops, etc, in
which some of the patients work under the
direction of foremen. All around are extensive
gardens where patients under treatment or
observation and those who are not quiet enough
to be sent to the colonies are employed in
growing flowers and vegetables. The farm
comprises 500 hectares under cultivation, but

1?
i

56 —

a portion only belongs to the asylum, the
greater part beir^g rented. The general aspect
is that of a grand and magnificent rural pro-
perty ; nothing recalls the idea of restraint ;
there are courts, gardens, wheat-fields ; the-
eye roams over a vast extent. The farm of Fitz-
James is about 240 hectares, and that of Villers
260. The grounds of each touch the other, but
the dwellings and farm buildings are at a dis-
tance of a fifteen or twenty minutes drive.
Farming and stock-raising on a large scale are
carried on. There is a director of agriculture
for both farms.

At one end of the colony of Villers, in a
charming situation, completely separated from
the remainder of the farm, dwell about a
hundred female patients who do the washing
and mending for the whole establishment, that
is about 1,500 patients. There are a huge
lavatory through which a river runf», and an
immense laundry with a steam engine to drive
the apparatus which is all of the most recent
pattern. The great amount of labour which is
performed in this building make this section
the most interesting portion of the colony.

At the time of my visit over 300 patients,
male and female, w^ere regularly employed at

— 57 —

various kiuds of work in this double colony.
There is a resident physician on each farm and
both are under the control of the head phy-
sician of the asylum so that there is but one
medical direction. Moreover, there is constant
communication between the colony and the
asylum. If any change occurs in the mental
condition or general health of the patient neces-
sitating his removal to the asylum, he is at
once transfeired there and another able-bodied
patient comes to take his place ; the asylum
and the colony are a complement one of
the other ; one could not exitt without the
other. Such an organization may be looked
upon as the ideal of the kind, since it contri-
butes to relieve the asylum while increasing
the comfort of many patients by giving them
a healthy and agreeable occupation.

3. Is it possible to confide the insane to the
care of strange families and can it be done to
a sufficient extent to make it an institution ?

The colony oi insane at Grheel in Belgium, is
the application no a largescale of this principle
of the boarding out system. I already knew
this remarkable institution by reputation, but
I wished to study and see the working of the

— 58 —

system for myself. It was in the month of
September last, (1889), that I visited this sin-
gular establishment where the insane are enti-
rely free from restraint and share in the domes-
tic life of the families to whom they are con-
fided.

The village of Gheel is isolated in the centre
of " La Oampine " and is nine leagues in cir-
cumference, separated from all neighbours by a
wide strip of moor and heath. Its geographi-
cal situation made it therefore particularly
suitable for the establishment and development
of a colony of insane which is .said to have been
founded in the sixth century by Ste. Dymphe.
Tradition tells us that this young Irish prin-
cess wishing to escape from her father's perse-
cution, sought refuge in a wild part of La
Campine to the north of Antwerp. Her father
found out her retreat and killed her. She was
canonized and several persoiis afflicted with
mental alienation having been cured at her

< >

tomb, Ste, Dymphe was considered as the patron
saint of the insane. The sick flocked to her
tomb in everincreasing numbers and gradually
a small village grew up around it and imper-
ceptibly the relatives and friends of the pilgrims

— 59 —

who were not cured acquired the habit of lea-
ving them with inhabitants of the place, who
received them into their families, and adopted
a humane and kind method of treatment which
was in strong contrast to the cruel and savage
method followed in the hospitals fortho insane
of that day. It is not surprising therefore that
more cures were obtained there than in those
sorry hospitals which were more like prisons,
where the vacillating reason of those who were
confined in them fii(;kered away before being
extinguished for ever.

Up to about the middle of this century the
colony had developed itself spontaneously
without the aid, as well as without the salu-
tary control of public authority. Private enter-
prise left to its own resources had engendered
abuses which had to be suppressed. It is beyond
a doubt that it is to the devotion to Sainte
Dymphe that G-heel owes its existence as a,
colony for the insane but it must not be ima-
gined that it is through a purely religious
spirit that the inhabitants of the place recei-
ved and sheltered the unfortunates who were
brought to them. *The former organization
left much to be desired ; there was no curative

('k

— 60-—

treatment, the food was insufficient and coarse
and the means of restraint were left to the will
of the nurses.

The colony, was completely reorganized by a
regulation dated the Ist May, 1850, The super-
vision was taken away from the municipality
and transferred to the State. At the present
day the 18 hamlets composing the municipality
of Grheel, are divided into four sections at the
head of which is a physician with four keepers,
whose duty it is to move about all day long
through their sections, inspi'ct the rooms, ascer-
tain both by day and by night that the patients
are cared for and treated according to the regu-
lations. The medical service is under the direc-
tion of an inspecting physician Dr. Peelers.

An infirmary has also been built in the centre
of the town which is in reality an ordinary
close asylum. In it are placed : 1. Patients
on arriving, who are kept under observation
for five days before being placed in the families ;
2. Those who are attacked by serious incidental
diseases which cannot be treated in the private
houses ; 3. Those who are confined for having
been guilty of insubordination, intoiication,
•etc.

-- 61 --

The patients treated at GHxe(4 may be divided
into two classen : the boarders or paying
patients and the indigent patients. In each
house only two or three patients are received
and they must always be of the same sex.
They live entirely with the family which has
received them take their meals with them and
share their labours, sorrows and joys.

The indigent patients ar(^ divided into
three categories : th(3 cleanly, the demi-g-dteux
or partially unclt^anly and the gateux or
uncleanly. The first class cost 84 centimes
a head per diem ; of which only 60 cen-
times go to the family ; the balance goes
to pay the general expenses of administration
and the medical service. The partially uncleanly
{demi-gdteux) cost 94 centimes, 70 of which are
for the family ; the uncleanly {gdteux) cost 99
centimes, 75 being for the family. Open air,
full liberty, home life, such are the fundamental
principles of the system as followed in the
Flemish colony. It is forbidden to admit
suicidal, homicidal or incendiary insane. In a
colony of this kind, as Dr. Moreau, of Tours very
properly says, the lunaticshave not entirely lost
their dignity of reasonable beings for they have

— 62 —

not eutin'ly broken off with society to which
they remain bound by all the intellects which
the disease has spared.

Grheel has been considered by some as the
Paradise of the insane. In any case, in a
general way it produces a favorable impression.
In certain respects such an organization of the
farming out system might be cons) iered an ideal
method of relief for a good many incurable and
harmless insane ; but in i)ractice it is hardly
possible to found at once villages for the insane
similar to the village of Gheel ; this would
require a combination ofgeographical, social
and pecuniary conditions which it is impos-
sible to secure. ■ '

Eut there is a middle course. For instance,
in England, what is called the " cottage sys-
tem," the " Uock system " of Bucknill, are appli-
cations of the same idea reduced to reasonable
proportions. Attempts have also been made in
this country to place some insane patients with
neighbours around the large asylums under the
direct supervision of the physician of the esta-
blishment. In Scotland there is another form
of the same system. The insane are scattered
in villages, whi'^h are distant from each other,

•^f^r

— 63 —

with farmers whose only duties are those of
common in8pe<!tor8. This system might vvith
advantao;e be adopted in thiH Province and
the hiw should allow the m<'dical board when-
ever an opportunity occurs, to place certain
harmless pati«nits with families who would be
willino- to care for them and capable of assu-
ming such a responsibility and of properly
performing their duties. As regards the change
oH regime it (;an only be an exceptional measure •
but within these limits it is perhnps a good
thing as for some* patients it would be more
agreable to live in a small private circle than
in a crowded w^ard. Moreover it would always
be understood that in case of agitation the
patient should always be sent back to the
asylum.

4. "We have seen how important is the early
treatment of mental diseases as regards their
cure. On the other hand, a well organized asylum
is considered by all alienists as the chief means
of cure. While taking every precaution against
the possible occurrence of illegal confinements
the law should facilitate the placing in asylums
of all the insane who have the slightest chance
of cure. As regards the others they should be

•r--.—:^.^,^

— 64 ^

admitted into the aKylums only wh»Mi they are
daug-oroas or withoiit means of support or have
no families. Patients who are admitted at au
early stai^c^ of tht> disease and are treated in time,
represent nearly all the cases of cure published
in the statistics of special establishments, but
there are also a great many who, in spite of
treatment and by the very nature of their
disease, become incurable and pass into the
chronic stage. It has been asked whether it
would not be advisable to send them back to
their families after a certain time instead of
keeping them for an indefinite period in the
asylums. Families in poor circumstances who
would resume the care of their harmless insane
would be paid an amount equal to what it costs
to board them in the asylum. This was strongly
recommended by some alienist physicians, but
it is ev'dent that it can only apply to a limited
numbtn of patients.

In effect it would be necessary to eliminate
all those whose insanity, in becoming chronic,
has continued to be dangerous, either conti-
nuously or at close intervals and unfortunately
these constitute the majority of chronic cases.
It would be possible therefore to remove from.

— 65 —

the»NylumH only thoHe- i)iitieiifs who, although
dan^-eroUH whon udiriillfil, have (Miawed to be
80 and hav<^ b«coini» quiet and harnileHS ; but
even in these caHes their boini?Hent outside will
be subject to the condition that they have rela-
tives who are disposed to retseive and care for
them. In any case this system of sending the
insane to their relatives cannot be assimilated
to the system followed at Crheel and in the vici-
nity of some asylums in Europe. In the latter
case the close asylum is the centre of the orga-
nization, and it is the focus whence the medical
supervision radiates over the whole colony. The
patients enjoy the illusion of complete liberty
and the advantages of home life, but as soon
as unfavorable symptoms appear in their
mental condition, they are at once replaced in
confinement. Moreover it must not be for-
gotten that as a rule the insane are less easily
controlled in their own families than in strange
ones and experience has shewn that a great
many patients who are absolutely undisciplined
in the midst of their own families become quiet
and submissive in other families. - : ;

We have considered all the various kinds
of relief which have been suggested and applied

in favour of the insane. But there is another
class of unfortunates, such as alcoholic patients,
victims of morphine and similar habits, who
are deserving of the attention of the public
authorities. Subjects of this kind without being
precisely insane should be subject to restraint
for their own personal interest as well as in that
of society. Thus in a special report submitted
to the Congress on mental insanity by Drs
Motet and Vetault, similar wishes were expres-
sed as follows :

" The Congress, in view of the dangers with
which alcoholism threatens society, families
and individuals, and admitting that there
should be a distinction between simple drunke-
nness, pathologic drunkeness and chronic alco-
holism, expresses the hope that as a means of
social protection, permanent administrative
measures will be taken as regards alcoholic
patients according to the category to which
they belong ; that the legislative authorities
will give their sanction to the labours of Claude
(des Vosges) of Messrs M. Roussel and Leon
Say."

" That one or more special establishments
be founded for habitual drunkards, alcoholic

6*7 —

patients who have committed crimes or offen-
ses and who have been acquitted in consequence
of their mental condition. That the duration of
their confinement be determined by the courts
after a medico-legal inquiry."

" That their discharge even at the expiration
of the determined period be postponed if there
is danger of a relapse That, as these establish-
ments are of the nature of a house of treatment
and not of repression, they be organized with a
strict discipline and that labour be compulsory.
That judicial and administrative statistics be
published so as to show the results of these
measures."

But in order to obtain from these establish-
ments all the results which they are expected
to yield, they must be exclusively reserved
for inebriates. We have at Quebec the Belmont
Retreat, which has been founded for inebriates.
Unfortunately of late years, this institution
seems to have abandoned its original destina-
tion and insane of all kinds are admitted to it.
Such a mixing up of mere inebriates with the
insane is much to be regretted in every respect.
However, in this country, as elsewhere, we
have to contend against this social evil of alco-

— 68 —

holism which is becoming aggravated, and it
woulc bo advisable to have special establish-
ments for inebriates as ^recommended by the
Congi'ess on mental ailments held at Paris. This
would have the eifect of cuiing many of these
infortunates and preventing them from falling
into confirmed insanity, as happens in but too
many cases.

Before concluding this report I would like to
, say a word about the plan generally followed
in the insane asyhims which I. visited. These
have seldom more than one story above the
ground floor but cover more ground. The dor-
' mitories are on the first floor and below them
. are the dining rooms and day- wards, so that in
the morning on rising the patients go down-
stairs and at night they go to bed up-stairs.
Most of the more recently built asylums con-
sist of separate wings which enables a bettei
classification to be made of the patients. Thus,
in France, a strict classification is imposed by
law and comprises the following groups : the
quiet, thte partially quiet, the excited, the par-
tially excited, the uncleanly and in nearly all
asylums the epileptics are separated from the
others. This separation is always maintained,

— 69 —

for each group has its court yard. A coyered
gallery, 12 to 15 feet in width by 100 to 150
feet in length, runs along the ground floor and
serves as a coyered promenade in rainy weather.
The doors are always open in line weather and
lead into an extensive court planted with trees
and flowers and bounded on three sides by
ditches about five feet wide, in the middle of
which is a wall about two or three feet higher.
This gives the patients the illusion that they
are in full liberty for they can see all over the
surrounding country, for the wall that separates
them from it is hidden in a wide ditch. The
asylum^ of Ville-Evrard and Vaucluse, at the
gates of Paris, one near the banks of the Marne,
the other on the summit of a hill bathed by
the pretty river Orge, are models of this kind
which all strangers admire. The hateful iron
gratings which were formerly placed in the
windows of asylums and gave them the gloomy
aspect of prisons have disappeared in most of
the new ^establishments. They are replaced by
a very simple kind of windows which look
like all other windows. They are however
different in this that they are locked and the
frames which hold the glass are of iron and not
of wood. This prevents escapes.

— to —

It is quite certain tiiat as regards the com-
fort of the insane, this system of one story
wings offers great advantages, for it renders
classification easier and allows the patients to
go out every day in the courts opposite each
wing. On the contrary, in asylums with several
stories the patients may pass months without
seeing the sky otherwise than through the
gratings in their windows. Besides, in these
asylums there is frequently but one court-yard
in which quiet and excited patients mingle
when they go out for exercise.

Although this report may be too lengthy,
I would have still to speak of certain questions
respecting the legislation for and the relief of
the insane ; but I have already dealt with them
in my annual reports and 1 do not consider it
necessary to revert to them.

But by way of conclusion, I would like to
make the following suggestions : 1. Insane
asylums should retain their character of hos-
pitals for treatment and be reserved as much
as possible for dangerous or curable patients ;
2. As it is generally admitted that mental
diseases are all the more curable a<;cording as
they are recent, the legislation should make the

— n

conditions of admission as easy as possible for
patients who ave to be treated ; 3. Labour should
be organized as a means of treatment in our
asylums and v/orkshops should be set up in
them and agricultural work made more general
so as to provide occupation for the able-bodied
insane ; 4. Imbecile and idiot children should
be placed in institution where efforts would be
made to educate them and teach them trades
which would enable them to earn their living ;
5. Asylums for inebriates should not receive
ordinary insane patients for such a comming-
ling gives rise to serious drawbacks ; 6. The

uncleanly and demented patients should be
placed in refuges w here they would receive the

treatment they require at a lower cost than in

the asylums ; *7. The medical board should be

a uthorized to hand over to families who are

able to take care of them, certain harmless, quiet
and incurable patients who are able to work

under supervision ; these patients to be sent
back to the asylum when necessary; S.^The
system of discharges on trial should be made
more general for harmless patients with provi-
sion for their being at once sent back if neces-
sary. The present law allows the medical board
to grant these discharges on trial but the pro-

— 72 —

pnetors of the asylum have, during the past
two years, refused to acknowledg:e our autho-
rity in this connection. I have already called
your attention to this in my annual reports for
the years 1886 and 1887.

I have the honour to be,
Sir,
Your obedient servant,

(Signed), A. VALLliE,

M. D. L.
Medical Super intendant of Quebec

Insane Asylum

I'
t

ig ihe past
Dur autho-
:^ady called
. reports for

M. D. L.
Quebec
me Asylum

:.: I