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Original copies in printed paper covers are filmed beginning with the 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. 28 " 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 M — 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 ■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 3 ■^ >-': — 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 i — 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- m\ ■ I m — 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 pl 43 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 % I Bi — 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 -. Stuffing Brushmaker's s. Date of Numt)cr of appren- tices. January. December •Ztith Aug '83 34 34 8th Oct " ;m 34 8th " •' 58 70 l«Jan. 1884 15 17 30 Oct. " 10 I' 30 " " 13 14 36 Nov. 1888 13 8 167 183 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 r 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 El MP — 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 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 i — 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 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 66 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. f — 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 i M. D. L. Quebec me Asylum :.: I