r o:' thf; tiniucvsiio of Califoinia* .To. //Mr Division ... ' Range Shelf Received e/^^W/'/ 187^, ■♦•"♦•'>..-x .^V^." - ■^''^>ru;i \ INSANITY AND INSANE ASYLUMS. REPORT OF E. T. WILKINS, M. B., COMMISSIONER IN LUNACY FOE THE STATE OF CALIFOENIA, MADE TO HIS EXCELLENCY K. H. HAIGHT, GOVERNOR, December 9d, 1871. t^"" T. A. SPRIXGER STATE PRINTER. COjSTTEISrTS. CHAPTEE I. INTRODUCTORY. Powers, Duties, and Appointment of Commissioner— Importance of the Commis- sion—Asylums Visited— i^ umber of Patients in Asylums Visited- Other Insti- tutions Visited— Plans of Asylums— Statistical Tables— Meetings of Superintend- ents Attended— Importance of such Meetings— Books Obtained for the State Library — Sources of Information — Acknowledgments CHAPTEE II. IXSAXITY A DISEASE OF THE BRAIN. VTliat is Insanity? CHAPTEE III. INSANITY AS IT NOW EXISTS. The Subject Generally — Insanity in England — In Scotland — In Ireland — In France — In Italy— In Prussia— In Austria— In German States— In Bavaria— In Switzer- land—In Belgium- In Holland— In Denmark— In Sweden— In Xorway— In New South "Wales— In the United States — In California CHAPTEE IV. CAUSES or INSANITY— SOME OF THE INFLUENCES OPERATING IN ITS DEVELOFMENT. General Observations — Assigned Causes— Physical Causes— Moral Causes— Observa- tions upon Assigned Causes — Principal Assigned Causes — Insanity Found in all Countries— Enumeration of the Insane— Tables Eelating to Enumeration— Enu- merations Imperfect— Difficulties in the way of a Perfect Enumeration— Influence of Age— Influence of Age in the Different Paces- Influence of Sex— Influence of Marriage 32 CHAPTEE Y. INFLUENCE OF SOCIAL DISTINCTIONS. Diseases of the Brain Peculiar to no Class in Society 49 IV CHAPTEE YI. APPAEEXT IXCEEASE OF I^SAXITY. Increase of Insanity Demonstrated 5-4 CHAPTEE Til. IXSAXITT IX FKAXCE. General Statistics of the Insane from 1854 to 1866 — Doctor Motet's Analysis of Le- goyt's Work 66 CHAPTEE Till. rS'SAXITY AMCXG THE AXCIEXTS. In the time of the Ancients — In the Middle Ages — In the Eighteenth and Xine- teenth Centuries — In England — In France — In Eome — In the Germanic Con- federation — Ohservations upon Eoregoing Subjects — Cruel Treatment the Eesuit of Ignorance — Xew York Poor Houses — Amelioration in the Treatment of the Insane as compared with Former Periods — Proof of the Advantages of Moral Treatment 86 CHAPTEE IX. IXSAXE ASYLUMS, LOCATIOX, SIZE, SITES, ETC. Location — Influence that Distance ought to have on Location — Effect of Multi- plying Hospitals— Effects of Kailroads and other Facilities of Travel — Hospitals Better Known to Xeighhoring People — Observations on Foregoing Topics — Xew York State Lunatic Asylums — General Suggestions — Propositions relative to the Stnicture and Arrangements for American Institutions for the Insane — English Lunacy Commissioners on Sites, Construction, Size, etc. — Suggestions of the Scotch Board — Size of Hospitals — Quantity of Land Xecessary — Comments upon Kirkbride's Views lOS CHAPTEE X. IXSAXE ASYLUMS— DOCTOR MAXXIXG's EEPORT. Synopsis of Doctor Manning's Eeport— Comments upon the same..... lU CHAPTEE XL CRIMINAL IXSAXE. An important question connected with the care of the insane should not be passed by without notice 161 CHAPTEE XII. CHROXIC IXSAXE. Provisions for Curables and Incurables in Separate Institutions 164 CHAPTER XIII. TREATMENT OF INSANITY. Treatment in English As3'lum?—J/«»?'a—Epilep^^y connected with Insanity— Paraly- sis connected with Insanity— Melancholia— Observations on present Treatment of Insanity- I'^o CHAPTER XIY. INSANITY IN GENERAL. Increased attention to Insanit}^— Growth of Hospitals in United States— Increase of Hospitals in United States — Increased Accommodation — Hospitals exhibit Insan- ity— IS'on-residents-Should other States send their Insane to California— Insanity in other States— Kesults of Treatment— Curability of the Insane— Etfects of Early Treatment— Good Hospitals necessary to Favorable Ecsults— Eesults in our Asy- lum—Doubtful and Hopeless Cases— Economy of Early Treatment— Probable Duration of Life in Chronic Cases— Increase of Patients in our Asj^lum— Causes tending to this Eesult— Will the Children of Foreigners be as Liable to Insanity as their Parents— Observations upon Physical and Moral Causes producing Insan- ity— Intemperance a Leading Cause of Insanity— Duty of State relative to Asy- lums—Physicians not generally Informed on the Subjectof Insanity— Psychology recommended to be Taught in Medical Schools— Effect of the Liberal and of the Economical Plan of Care and Treatment l^S . CHAPTER XY. ECONOMY OF PROVIDING AMPLE CURATIVE ACCOMMODATIfXN'S. The Economy of Eestoration, and the Amount Saved the State by the Cures already Effected in our Asylum ". 218 CTIAPTEE XYI. PLAN BEST ADAPTED TO CARE AND TREATMENT OF THE INSANE. General Observations— Cottage System— Farm Asj^lums- Close Asylum.-— Pavilion Plan -;/i*>^ 900 APPENDICES 231 IIS^DEX. Pagp. Asjium? visited 2 Acknowledgements 7 ^Asylum at Stockton overcrowded 136 ^Asylum at Stockton should be finished I37 Asylums. New one needed I37 -Asylums. Results in California 194 ' Asylums. Increase of patients in ten years ; 197 Asylums. Duty of State 212 Asylums. Manning's Report I44 Attendants 1,S7 Asylums in process of erection 190 Asylums. Good ones necessary to favorable results 194 As3'lums. Location, size, etc , 108 Asylums. Influence of distance 109 Asylums in ]S"ew.York 117 Asylums. Propositions relative to the structure 121 Asylums. Best plan 222 Asj^lums. Growth of. 189 Asylums. Should be in healthy locality 138 Asylums, Quantity of land necessar}' 138 Asylums. Organization of 142 Asylums. Increase of in the United States 191 Asylums. Better known to the neighboring people 115 Books obtained for State Library 6 Cruel treatment the result of ignorance 100 Concluding remarks 228 Commissioners 138 Comments on Kirkbride's views 144 Construction 152 Comments on Manning's Report 158 Criminal insane 161 Chronic insane 164 Curability of insane 202 Dining halls 135 Directors and Superintendents 186 Doubtful and hopeless cases 195 Till Duration of insanity .' 196 Enumeration of the insane *iO Enumeration. Difficulties of. -iO Enumeration imperfect -iO Effect of multipl^nng hospitals 11- Effect of railroads 115 English Lunacy Commissioners 124 Economy of early treatment 195 Effects of liberal treatment -15 Economy of cure -18 Establishment of asylums in the Briti.-^h Provinces 190 General results -95 Introductory 1 Importance of the Commission 1 Insanity a disease of the brain 8 Insanity as it now exists 8 Tnsanity in England 9 Jjisanity in Scotland 19 lasanity in Ireland 1- Insanity in Erance H Insanity in France. Ztlotet's Analysis 06 Insanity in Italy 15 lugeaity in Prussia 10 Insanit3' in Austria 1' Pnsaraty in the German States 19 Insanity in Bavaria -9 Insardtj'' in Sv/itzeriaud 21 Insaaity in Belgium 22 Insanitj- in Holland 23 Insanity in Denmark and Sweden 25 Insanity in Norwaj- 26 Insanity in New South Wales 27 Insanity in the United States 28 ^"InsanitA- in California SO Insanity- Causes and influences producing it 32 Insanity, xissigned causes 32 InsanitjT. Observations 31 Insauitj^ Comparative view of assigned causes 36 Influence of age -±1 Influence of sex ••• -16 Influence of marriage "1^ Influence of social distinction 49 Insanity. Apparent increase of 54 Insanity among the Ancients 86 Insanity in the Middle Ages 93 Insanit}'. Condition of in England 94 Insanit3^ Condition of in France 97 Insanit}^ Condition of in Kome and Limerick 97 Insanity in the Germanic Confederation 98 Insanity. Observations *• ••••• 99 Insane in New York Poorhouses 100 IX Insane. Amelioration in the treatment of insanity . Re^t!•aiIlt and seclusion HHI ln.-=anc. One to four hundred and eighty-nine ];{<) [ncrea*ed mortality in Stockton i;>7 Insanity. Treatment of. 1^5 Insanity in general IHS Tn-ianity. Duration of the disease UU livCormatio!). S 754 In Lucan 43 In Central 167 Lunatics at large 6,936 7,696 6 936 Totals 9,498 17 1Q4 Proportion of insane to population, one in three hundred and two; or, ratio per one thousand, three and thirty one hundredths. Proportion of 13 insane (under treatment) to population, one in seven hundred and twenty- nine; or, ratio i^er one thousand, one and thirty-seven one hundredths. Number of insane in asylums, January 1st, 1870 ' 7,121 Admitted during the year 2,532 Cured. 1,088 Died 708 Number treated in 1870 ' 9,Go.3 Per cent of reco'veries on admissions 43 Per cent of recoveries on number treated I H Per cent of deaths on admissions 27 Per cent of deaths on number treated Number of EstablisJiments-for the Insane. District Asylums 23 Private Licensed Houses ; 20 Asylums for Criminals ; 1 Total I 44 The average weel^ly cost per head in District Asylums is eight shill- ings and eleven and a half pence, or two dollars and seventeen cents. The principal assigned causes of insanity are: hereditary, grief, fear and anxiety, intemperance and irregularity of living, disease of the brain, bodily injuries and disorders. The principal causes of death are: thoracic disease, cerebral disease, debility, and old age. In eleven asylums visited dent was Admitted Treated Cured Died 1870, the number of patients resi- 2,437 1,206 3,043 457 256 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated. 37 12 21 7 14 INSANITY IN FRANCE. Population, 1866 37,988,905 Xumber and Distribution of the Insane, 1866. Insane. Idiots. Totals. In asylums 31,992 ; 3,980 At home 18J34 | 35^973 Totals 50.726 39,953 35.972 54,707 90,679 i Males. Females. Totals. Insane I 24.190 | 26,537 | 50.726 Idiots f 22,736 I 17,217 | 39,953 Proportion of insane to population, one in seven hundred and forty- seven; or, ratio per one thousand, one and thirtv-three one hundredths. Proportion of idiots to population, one in nine hundred and fifty. Pro- portion of insane and idiots to population, one in four hundred and eighteen; or, ratio per one thousand, two and thirty-eight one hun- dredths. Proportion of insane and idiots (under treatment) to popula- tion, one in one thousand and fifty-seven; or, ratio per one thousand, ninety-four one hundredths. Population, 1860. 170.942 J^umber of insane in hospitals and asylums. January 1st, I860.. Admitted during the year Cured or improved Died ,,'''', Number treated in 1860 28.761 10,786 4,337 4,970 39,546 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 40 11 46 12 Xumbl?r of Asylums for the Insane in eighteen hundred and sixty (public and private establishments), ninety-nine. In eighteen hundred and fifty-three, the average weekly cost per head was one dollar and twenty-one cents. 15 The principal assigned causes of insanity, as per reports eighteen hun- dred and fifty-three, were: hereditary, epilepsy and convulsions, intem- perance, destitution and misery, loss of fortune. The principal causes of death: paralysis, disease of brain, pneumonia, insanity, brain fever. In thirteen asylums visited in 1870, the number of 2")aticnts resident was Admitted (in eleven of these) * Cured (in eleven of these) ^:;rrs!!?»5!2^ . . .- Died (in eleven of these) /■^..'^XJ^.i.tc'.^»?':>^. •' -i- ^'.^^ 4 Number treated (in eleven of these) ^ 7,938 3,324 873 1,292 11,262 ^ Per cent of recoveries on admissions......... Per cent of recoveries on number treated... Per cent of deaths on admissions Per cent of deaths on number treated •••e>^^4 26 7 38 11 INSANITY IN ITALY. Population, 1864 22,291,181 By the addition of Yenice, in 1866, the population was increased to 24,263,320. ]N"umber of insane in asylums, January 1st, 1867 8,191 Proportion of insane (under treatment) to population, one in two thousand nine hundred and sixty-two; or, ratio per one thousand, thirty- three one hundredths. ]N"umber in asylums, January 1st, 1867 8,191 4,909 3 210 Admitted Discharii^ed Died 1,504 13,100 JS'umber treated during the year Number remaining January 1st, 1868 8,386 Per cent of discharges on admissions Per cent of discharges on number treated Per cent of deaths on admissions , Per cent of deaths on number treated 65 24 30 11 * Leaving out the Asylum La Salpetriere (for chronic cases only), the per cent of cures on admissions would be twenty-seven. 16 Fifteen asylums were visited in eighteen hundred and seventy. In fourteen of these the number resident was In thirteen of these the admissions were In twelve of these the number treated was In thirteen of these the number cured was — In thirteen of these the number died was 4,259 1,967 5,816 764 621 Per cent of recoveries on admissions 38 Per cent of recoveries on number treated 13 Per cent of deaths on admissions 31 Per cent of deaths on number treated 10 The average w^eekly cost of maintenance of indigents in eight public asylums is one dollar and seventy-seven cents. Principal causes of death: disease of the lungs, paralysis, marasmus. Principal assigned causes of insanity: pillagra, hereditary, intemper- ance. INSANITY IX PRUSSIA. Population, 1864 19,252,363 jVumber of Insane Under Treatment. In Public Asylums . In Private Asylums Total 4,796 944 5,740 Proportion of insane (under treatment) to poj^ulation, one in three thousand three hundred and fifty-four; or, ratio per one thousand, twenty-nine one hundredths. Number of Asylums. Public Asylums i 32 Private Asylums | 27 Total I 59 . L Expenses of Public Asylums, six hundred and fourteen thousand six hundred and sixtj^-four thalers, or four hundred and forty-eight thou- sand seven hundred and four dollars and seventy -two cents, which gives a weekly cost per head of one dollar and eighty cents. 17 In two asylums visited in 1870, the number of patients resident was Admitted Cured Died Number treated 1,065 297 105 110 1,362 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated 35 7 37 8 The average weekly cost of maintenance of indigents in these two asylums is one dollar and ninety-five cents. Principal assigned causes of insanity: The Director at Halle says that eighty per cent of cases of insanity are from hereditary causes. Principal causes of death: general paralysis, epilepsy. Population, December, 1867 23,971,337 The total number of insane. The total number of idiots . Total number of unsound mind. 16,929 21,031 37,960 Proportion of insane and idiots to poj^ulation, one in six hundred and thirty-one, or ratio per one thousand Proportion of insane to poj^ulation, one in fourteen hundred and sixteen, or ratio per one thousand 1.58 .70 Population, 1864 INSANITY IN AUSTRIA. German Austria^ exclusive of Hungary, Number of Insane in Asylums. 13,000,000 In Public Asylums . In Private Asylums Total 3,065 150 3,215 18 Proportion of insane (under treatment) to population, one in four thousand and forty-three, or ratio per one thousand .24 Number of Asylums. Public Asylums.. Private Asylums. Total 14 4 18 Expenses of Public Asylums, eight hundred and seventy-three thou- sand seven hundred and fifty-six florins, or four hundred and twenty- two thousand eight hundred and ninety-seven dollars and ninety cents, which gives an average weekly cost per head of two dollars and sixty- five cents. In six asylums visited in 1870, the number of patients resident' was 2 302 Admitted Cured , Died Number treated. 1,741 377 543 4,043 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions "^Per cent of deaths on number treated. 21 9 31 13 _ The new asylum, Klosterneuberg, was also visited. It was opened in eighteen hundred and seventy, so there was no report for the year. The number resident was one hundred and twenty-three. The average weekly cost of maintenance of indigents in the Public Asylums visited was two dollars and thirty-nine cents. The Statistical Bureau gives three hundred and ninety-seven thousand and ninety dollars as the cost of supporting four thousand four hundred and ninety-nine pauper patients in eighteen hundred and sixty -nine — ■ An annual cost per head of. A weekly cost per head of.. §88 26 1 70 The principal assigned causes of insanity: inherited or congenital tendency, affliction, poverty, remorse, intemperance. The principal causes of death: disease of the lungs, paralysis of the brain, marasmus. , 19 INSANITY IN THE GERMAN STATES. Population, 1864 13,747,637 Number of Insane in Asylums and Ilosjntals. In Public Asylums... In Private Asylums. Total 9,962 633 10,595 Proportion of insane (under treatment) to population, one in twelve j hundred and ninety-seven, or ratio per one thousand .77 Number of Asylums. Public Asylums... Private Asyhmis. Total. 46 18 64 In ten asylums visited in 1870, the number of patients resident was Admitted Cured Died Number treated. 2,495 1,046 276 290 3,541 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated. 26 7 27 8 At Illenau the numbers for ten years were obtained, follows: They were as A dmiRRions 4,086 Cures 1,570 Deaths . 597 "Nninlipr tTPatpd 4,512 20 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated. 38 34 14 13 The average weekly cost of maintenance for indigents in the Public Asylums visited was one dollar and sixty cents. INSANITY IN BAVARIA. Population, 1864 4,807,440 Xumher of Insane Under Treatment. In Public Asylums.. In Private Asylums. Total 1.831 19 1,850 Proportion of insane (under treatment) to population, one in two! thousand five hundred and ninety-eight, or ratio per one thou-! sand ! Nwnher of Asylums. Public Asylums.. Private Asylums. Total. 9 2 11 In 1861 the population was ! 4,689,837 The total number of insane Proportion to 2Dopulation, one in nine hundred and fifty-seven, or ratio per one thousand 4,899 1.04 In the six District Lunatic Asylums the number of 2^atients Octo- ber 1st, 1865, was Admitted during the year Cured Died Number treated in 1865-6. 1,651 529 171 150 2,180 21 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 32 7 28 6 The average weekly cost of maintenance per head in the above Dis- trict Asylunis was, in 18G5-G, two doHars and fifty-three cents. Causes of insanity not specified; but in about twenty-nine per cent of the whole number of cases the insanity was hereditary. The principal causes of death: consumption, general paralysis, pleurisy and pneumonia, marasmus. In three asylums visited in 1870, the number of patients resident Admitted Cured Died Number treated. 658 324 112 57 982 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 34 11 'I INSANITY IN SWITZERLAND. Population, 1860 2,510,494 In two asylums visited in 1870, the number of patients resident was 462 The report for the asylum at AValdau is as follows: Number resident I -"^^ Admitted | ^^ Cured ?^ Died I 1^ Number treated i ^*^ 22 Per cent of cures on admissions ■ 38 Per cent of cures on number treated I 8 Per cent of deaths on admissions I 22 Per cent of deaths on number treated I 5 i i . Average weekly cost of maintenance of indigents is one dollar and sixteen cents. INSANITY IN BELGIUM. Population, 1865 4,984,451 Number and Distribution of the Insane, December Slsf, 1865. Private. Pauper. Totals. In hospitals and asylums , 1,579 2,000 3,852 5,431 Estimated number at large who are their families supported by Totals 3,579 3,852 7 431 Proportion of insane to population, one in six hundred and seventy! one, or ratio per one thousand i 1.49 Proportion of insane (under treatment) to population, one in nine' hundred and seventeen, or ratio per one thousand j 1.09 . i Number of insane under treatment in hospitals, January 1st, 1865.' 5,441 Admitted during the year I 1,851 Cured ! 642 Died Number treated in 1865. 595 7,292 Per cent of recoveries on admissions \ 34 Per cent of recoveries on number treated I 8 Per cent of deaths on admissions : 32 Per cent of deaths on number treated 8 23 Number of Asylums for the Insane, 1865. For male patients only . . For female patients only For both sexes Total 17 17 17 51 Twenty-seven of these asylums are for private patients and paupers; sixteen are for private patients only, and eight for paupers only. The average weekly cost of pauper patients varies from live francs and four centimes to ten francs and fifty centimes, or from ninety-five cents to two dollars. The fifty-one asylums of Belgium have a total capacity of five thou- sand three hundred and eighty-seven patients. The principal assigned causes of insanity are: poverty, losses, etc., intemperance, domestic trouble, disappointment. The principal causes of death are: cerebral marasmus, general paral- ysis, consumption, chronic bronchitis. In eight asylums visited in 1870, the number of patients resident Admitted into five of these asylums. Treated in five of these asylums Cured in five of these asylums Died in five of these asylums 3,029 769 3,567 232 311 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 30 8 40 8 INSANITY IN HOLLAND. Population, 1868 T. 3,592,415 Number of patients in Lunatic Hospitals, January 1st, 1868. Admitted Cured Died Number treated in 1868. 3,179 994 380 358 4,173 24 Per cent of cures on admissions Per cent of cures on number treated . . Per cent of deaths on admissions Per cent of deaths on number treated. 38 9 36 8 Proportion of insane (in asylums) to population, one in eleven hun- dred and thirty, or ratio j^er one thousand .88 Number of Lunatic Asylums 12 Cost of 2Iaintenance. At Peinier Yan Arkel: First clasSj seven hundred florins, and twenty-five florins as entrance fee. Second class, four hundred florins, and twelve florins as entrance fee. Third class, two hundred and twenty-five florins, and are clothed by the Institute. At Meerenberg: First class, one thousand florins. Second class, seven hundred and fifty florins. Third class, five hundred florins. Fourth class, three hundred florins. Fifth class, two hundred and seventy florins. At Eotterdam (for indigents) : Two hundred and forty florins. Twelve other patients pay one florin per day extra for better accommodations. Average weekly cost for indigents, one dollar and eighty-eight cents. The principal assigned causes of insanity (mentioned in reports) are: hereditary, intemperance. The principal causes of death are: marasmus, consumption, apoplexy, general paralysis. In three asylums visited in 1870, the number of patients resident was * Admitted Treated Cured Died 1,245 321 1,566 123 145 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 38 7 45 9 25 INSANITY IN DENMARK. Population, 1860 Total number of insane. 2,005,024 5,135 Proportion to population, one in five hundred and seven, or ratio per one thousand 1.97 Proportion of insane (under treatment) in public institutions to pop- ulation, one in sixteen hundred and thirteen.* INSANITY IN SWEDEN. Population, 1860 Total number of insane. 3,859,728 7,512 Proportion of insane to population, one in five hundred and thir teen, or ratio per one thousand ' 1.94 Patients in Asylums. Private. Pauper. 469 530 553 598 630 641 Totals. 1861 f. 1864 1. 186711. 1,026 1,151 1,271 Calculated population, 1864 4,091,594 Proportion of insane under treatment, 1867, to population, one in three thousand two hundred and nineteen, or ratio per one thousand , .31 * See Knorlein's Keport of Asylum at Linz, published in 1866, p. 78. t Helso och Sjukvarden, 1861, pp. 30, 31. X Helso och Sjukvarden, 1864, pp. 26, 27. 11 Helso och Sjukvarden, 1867, pp. 14, 15. 4 [N'uniber of insane in asylums and Houses for the Insane, January' 1st, 1864 Admitted during the year Cured and imj)roved Died Number treated Number January 1st, 1865 1,095 332 163 91 1,427 1,151 Per cent of cured and improved on admissions Per cent of cured and improved on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 49 11 27 6 Proportion of insane (under treatment) to population, one in three thousand five hundred and fifty-four, or ratio per one thousand.! .28 Annual cost per head, three hundred and twenty-eight rix dollars and seventy-nine ore (three hundred and forty-seven dollars and sixty-eight cents, nearly), averaging six dollars and sixty-eight cents per week. According to the census of 1855 the population was 3,641,011 Number of insane I 3,893 Proj^ortion to population, one in nine hundred and thirty -five,' or ratio per one thousand I 1.06 INSANITY IN NORWAY. Population, 1864 1,6 68,254 Number of patients in asylums January Ist, 1864 Admitted 557 394 Cured 124 Died 35 Number treated in 1864 951 Number in asylums January 1st, 1865 • 583 Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions '. Per cent of deaths on number treated 31 13 8 3 27 Proportion of insane (in asylums) to population, one in two thou- sand eight hundred and sixty-one, or ratio per one thousand .,..1 .34 Kumber of asylums. According to census of 1855 the population was Total number of insane Proportion to population, one in eleven hundred and twenty - one, or ratio per one thousand 1,490,047 1,329 .89 Doctor Bucknill, in eighteen hundred and fifty-seven, reckons the pro- portion of insane to the population as one in five hundred and fifty-one. Kumber of asylums in 1867 Number of patients in asylums January Ist, 1867. Admitted Cured Died Number treated Number in asylums January 1st, 1868. Per cent of recoveries on admissions Per cent of recoveries on number treated. Per cent of deaths on admissions Per cent of deaths on number treated 667 423 140 41 1,090 727 33 12 9 3 INSANITY IN NEW SOUTH WALES. Population, 1867 447,620 Number of insane, including idiots Proportion of insane to population, one in three hundred and eighty-seven, or ratio per one thousand 1,156 2.58 The number of lunatics under treatment, exclusive of invalids, in eighteen hundred and sixty-eight, was: 28 Pauper. Private, I Totals. At Tarban At Parramatta. 397 223 347 I 189 Totals. '44 I 412 620 536 1,156 In eighteen hundred and fifty-five the number of lunatics in the Gov- ernment Asylums was: At Tarban At Parramatta. Total. 197 279- 476 In eighteen hundred and sixty-eight the number was eleven hundred and fifty-six, an increase of six hundred and eighty in thirteen years, or an annual increase of fifty-two and four one hundredths. The cost of maintenance is: at Tarban, seven shillings and eight pence; at Parramatta, eight shillings and five pence. INSANITY IN THE UNITED STATES. Population, 1870 38,555,983 Number of Insane. White 35.560 Elack i;605 169 Mulatto Chinese 35 Indian 13 Total 37,382 Number of Idiots. White 21.324 Black -. 2J43 Mulatto 445 Chinese k Indian 10 Total 24,527 Number of insane and idiots 61,909 29 Proportion of insane to population, one in ten hundred and thirty- one, or ratio per one thousand Proportion of idiots to popuhition, one in fifteen hundred and sev- enty-two, or ratio per one thousand Proportion of insane and idiots to popuhition, one in six hundred and twenty -three, or ratio per one thousand .97 .63 1.06 iS"umber of insane under treatment.* Proportion of insane under treatment to population, one in two thousand one hundred and seventy-three, or ratio per one thousand 17,735 .46 Number of patients in asylums, 1870 f . Admitted during the year f Cured f •. Diedf ]N"umber treated t 15,792 10,229 3,357 1,851 26,021 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated. 33 13 18 7 Number of Asylums. Public Asylums.. Private Asylums Total 50 16 m The principal assigned causes of insanity: ill health, spermatorrhoea, intemperance, domestic trouble, j^hy^i^'^l disease, religious excitement, epilepsy. Principal causes of death: exhaustion (from various causes), e2:)ilepsy, general paralysis, and consumption. * As nearly as can be ascertained from returns. t Report for forty -nine asylums. Returns could not be obtained from the others. 30 In thirty-nine asylums visited in 1870, the number resident was. A dmitted Cured Died Number treated. 12,907 8,639 3,240 1,519 21,504 Per cent of cures on admissions Per cent of cures on number treated.. Per cent of deaths on admissions Per cent of deaths on number treated. 37 15 17 7 Years. Population. Insane. Idiots. Total. « US [Per ct. sup'd with hospital accommod's. 1850 1860 1870 23,191,876 31,443,322 38,555,983 15,610 23,999 37,382 15,787 31,397 18,865 1 42,864 24,527 61,909 28 46 6e 4,730 ^^8.500 17,735 30.30 35.42 47.44 INSANITY IN CALIFORNIA. Population, 1870 560,247 !N"ative population ! 350,416 Foreign j^opulation j 209,831 Total 560,247 Number of Insane. Males. Fem'les Totals. White 789 15 304 2 1 09.^ Black 17 Mulatto Chinese 29 2 835 4 1 311 33 Indian 3 Totals 1 146 * See Journal of Insanity, Vol. XVIII, p# 2. 31 Number of Idiots. Males. Fem'les Totals. White 48 2 1 4 1 56 29 77 Black 9 Mulatto 1 1 2 Chinese 5 Indian 1 Totals 31 87 Insane and Idiots classified as Native arid Foreign. Insane. Idiots. Totals. Native 408 738 1,146 70 17 87 478 I^oreiffn 755 Totals 1,233 Proportion of insane to population, one in four hundred and eighty- nine, or ratio per one thousand Proportion of idiots to population, one in six thousand four hun- dred and thirty-nine, or ratio per one thousand Proportion of insane and idiots to population, one in four hundred and fifty-four, or ratio per one thousand 2.04 .15 2.20 Number of insane under treatment Proportion under treatment to population, one in five hundred and thirty-five, or ratio per one thousand 1,047 1.86 Proportion of native to total insane... Proportion of foreign to total insane.. Total 35.60 64.40 100.00 32 Number of patients in Asylum January 1st, 1870 Admitted during the year Cured Died Number treated 920 562 221 156 1,483 Of the whole number of insane, ninety-one and three tenths per cent are under treatment. CHAPTEE ly. CAUSES OF INSANITY, AND SOME OF THE INFLUENCES OPEEATING IN ITS DEVELOPMENT. General Observations — Assigned Causes — Phj'sical Causes — Moral Causes — Observations upon Assigned Causes — Principal Assigned Causes— Insanity Found in all Countries — Enumeration of the Insane— Tables Kelating to Enumeration— Enumerations Imper- fect — -Difficulties in the way of a Perfect Enumeration — Influence of Age — Influence of Age in the Ditferent Races — Influence of Sex — Influence of Marriage. GENERAL OBSERVATIONS. From the formidable array made by such an army of insane men and women, as it is seen with its banners flying in every civilized country, it behooves us to pause and give it thought; to ascertain as nearly as may be what causes are most prolific in its production; what conditions of society most readily lead to its development, and how best to meet its attacks and arrest its onward march, "more terrible than an army of banners." Let us first inquire into the causes producing this malady. In ancient times insanity was attributed to supernatural causes, but as science advanced and shed its light upon the human race this suj^ersti- tion passed away, until at the present time the causes which lead to it are known to be as varied as those which affect the physical system, as w^ill be seen from the following table, taken from a paper on the supposed increase of insanity, read before the Association of Medical Superinten- dents of American Institutions for the Insane, by Dr. Jarvis, of Massa- chusetts, at their annual meeting at Philadelphia, May, eighteen hundred and fifty-one: ASSIGNED CAUSES OF INSANITY. Physical Causes. Congestion of the brain. Disease of the brain. Phroenitis. Epilepsy. Arachnoiditis. Apoplexy. Convulsions. Hydrocephalus. Nervous irritation. Moral Causes. Mental labor and excitement. Mental fatigue. Mental shock. Mental perplexity. Excessive study. Study of metaphysics. Study of phrenology. Excitement of lawsuits Politics. 33 Physical Causes. Excessive pain. Neuralgia. Typhus fever. Nervous fever. Bilious fever. Scarlet fever. Intermittent fever. Yellow fever. Gastritis. Measles. Gout. Dyspepsia. Dysentery. Erysipelas. Phthisis. Eheumatism. Bilious rheumatism. Suppression of hemorrhoids. Suppression of perspiration. Suppression of secretions. Suppression of eruption. Suppression of tumor. Suppression of fistula. Smallpox. Yarioloid. Irritation of the spine. Disease of the spine. Ill health. Ill health and solitude. Ill health and perplexity in busi- ness. Ill health and family trouble. Ill health and pecuniary difficulties. Ill health and lawsuit. Old age. Irregular decay of powers in old age. Congenital. Hereditary. Injuries. Concussion of brain. Lesion Of brain. Blow on the head. Fracture of the head. Burn on the head. Malformed head. Fall. Kick on the stomach. Surgical operation. Mesmerism. Insolation. Want of exercise. 5 Moral Causes. Political commotions. Excitement of Mexican war. Excitement of visiting. Sea voyage. License question. Anti-rent. Fourierism. Preaching sixteen days and nights. Blowing fife all night. Application to business. Eeading vile books. Seclusion. Sudden joy. Hope. Faulty education. Day dreaming. Extatic admiration of works of art. Seduction. Domestic affliction. Domestic trouble. Family affairs. Bad conduct of children. Ill treatment. Ill treatment from husband. Ill treatment from parents. Abuse from husband. Infidelity of husband. Infidelity of wife. False accusation. Imprisonment for crime. Difficulty in neighborhood. Avarice. Anticipation of wealth. Speculation in stocks. Speculation in morus multicaulis. Speculation in lottery tickets. Perplexity in business. Pecuniary difficulties. Disappointment in business. Loss of money. Loss of property. Eeverse of fortune. Fear of poverty. Death of relations. Death of husband. Death of father. Death of son. Sickness and death of a friend. Sickness and death of friends. Sickness and death of kindred. Murder of a son. Anxiety. 34 Physical Causes. Sedentary habits. Idleness. Insolation and drinking cold water. Exposure to excessive heat. ExjDosure to cold. Bathing in cold water. Sleeping in a barn filled with new hay. Tight lacing. Excess of quinine. Metallic vapor. Prussic acid vapor. Charcoal vapor. Pregnancy. Parturition. Abortion. Puerperal. Cold in childbed. Lactation. Sexual derange.ment. Disease of uterus. Irregular menstruation. Profuse menstruation. Suspended menstruation at change of life. Suppressed menstruation. Hysteria. Carbonic acid gas. Working in white lead. Acetate of lead. Excessive labor. Bodily exertion. Loss of sleep. Intemperate use of snuff. Intemperate smoking. Intemperate opium eating. Syphilis. "Vice. Immorality. And winds up by saying: "These are not all the diseases, accidents, events, etc., that can d^isturb the regular action of the brain." OBSERVATIONS UPON ASSIGNED CAUSES. From this formidable list of assigned causes of mental disturbance we see there is scarcely a disease of the body, an emotion of the mind, or a feeling of the heart that may not act as an exciting, if not an actual cause in the dethronement of man's reason. " Dr. Ludwig, of the Hep- penheim Asylum, expressed the opinion that the cause of insanity is extremely obscure and not easily defined, and thinks that most of the assigned causes are made at the writing desk of the Committing Boards ; Moral Causes. Anxiety and loss of sleep. Anxiety for absent friends. Home sickness. Fright. Disappointment. Disappointment in love. Disappointment in ambition. Unrequited love. Want of employment. Want of occupation. Destitution. Mortified pride. Ungoverned passion. Virulent temper. Misanthropy. Jealousy. Envy. Duel. Eeligious anxiety. Eeligious excitement. Eemorse. Millerism. Mormonism. Struggle between the religious prin- ciple and power of passion. Epidemic influences. 35 that predisposition must exist, and that the form is only the effect, not the cause." AVe very well know that mistakes are often made by Com- mitting Boards, even when composed of physicians, and that symptoms are too often mistaken for disease ; nevertheless we cannot agree with Pr. Ludwig and other German Superintendents who assign nearly all cases of lunacy to hereditary taint. Intemperance was admitted by a few of those with whom we conversed to be a cause of mental disturbance, but all others were set aside as unworthy of being assigned a place. Dr. Koeppe, the intelligent Director and Physician in Chief of the cele- brated Asylum at Halle, in Prussian Saxony, informed us that eighty per cent of those committed to his Asylum were from hereditary causes, and that this was in accord with the experience of the Superintendents of other institutions in Germany. To say the least, this does not agree with the opinions of the learned and practical men who have charge of Asylums in most other countries, and especially in Great Britain and the United States. The preceding list was inserted as a matter of general interest. The following table comprises the principal assigned causes of insanity: 36 : : 'S* bi ! : : c sc o si -»J )s . . "o ■f si •: : : w W.5 : i 1 6 1 : : : : : -tj , -t^ i fe oa s 5 o 3 Q,? : : : : : »-< 'o ^^ri^so-o g ^ pp 0-5 -g S o-^.ii' S : : : r : P^ M O A ;?:.•.- p o • b'i : \ 5^ Ci SJ S ' '. >4 3 : : : w a^whh w o-^ . ':::':: M 5h ■^ >^ ^ - ^ , : : : : : 1 ni > lis ; ; M : ^ -§ 5-2^ &&-^ S : : ;■ : : 5 50 H^ *^ M : : : : : . 1 &i : Ej •+J >^ , r o 1 ° c o • g Ah Wh4 •: m P $ >. r^. :' c 2 ^ : -gas : t^ o a • O O ^^ CS : 05 Km I QQ ^ ^ >i : : : ; 2 o ^ft>c?5^o d : : : : B ca.o^c:SciS5 : : : : '^ g WH h; P ^ : f : .• . ^ >i i i : » TJ b-'^-s '^^^^"o ^^ 1 » Cf J ? ^S S-S.S .-^ . : H eS iS'-^5S^oSc&gi>,g| : O g ffi^D h; « 02 "^ i o ? M .3 iyj. 8 Il-Slil^ -< o^sS^'q"^ ^ !< 'S fii "^ >> r fS _ S.2 i cS a S o c S 2:;: G-g o S c g g 1 , .2 « . 43 rCO f- Offi ' Vl -• ' ^iJ|S|sl.3;S.5l 3 ^g^fH-gCC^^cS-^Oft P MOQ M « P H P^ W 37 INSANITY FOUND IN ALL COUNTRIES. As the causes enumerated in this Chapter operate with more or less power and energ}^ in producing insanity, we learn that it is found in all countries and among all nations, but is more prevalent among civilized than among savage people. It is true that we have no statistical data upon which to predicate this assertion, as *no census of the insane has ever been taken in savage or semi-barbarous nations. From those who have resided in these countries, and from travellers who have gone among them, we learn that but little insanity is known among them. Caleb Cushing, former United States Minister, states that after a some- what protracted residence in China he had concluded there were but few lunatics to be seen or heard of. Mr. AYilliams, an American missionary, after a residence of twelve years, says that he only saw two who were '' upside down," as the Chinese call it, during the whole time. All travellers agree that it scarcely exists in Nubia, and that it is extremely rare in Egypt. In eighteen hundred and forty-four, according to a statement in the London Medical Gazette, there were only fourteen in Cairo, being one to twenty-three thousand five hundred and seventy- two of the population. A few isolated cases have been reported by Doctors Moreau and Furnari, among the tribes bordering on the African shores of the Mediterranean, but agree in the general conclusion as to its scarcity. Doctor Furnari thinks it is in consequence of their "total abstinence." Doctor De Forest, of the Syrian Mission, in a letter to Doctor Butler, of America, says: "It is impossible to obtain accurate statistics of the insane here, but I think the disease far less frequent than in our own land." He gives a fearful picture of the treatment of those who are unfortunate enough to be insane. Doctor Paulding, in the Boston Medi- cal and Surgical Journal (1852), bears testimony to the same facts. Doctor Wise, Superintendent of an asylum in Bengal, states as the result of his experience, "that insanity is less frequent and assumes a less acute form among the East Indians than among the civilized nations of Europe." Cajitain Wilkes, of the United States Exploring Expedi- tion, in a letter to Doctor Brigham, says: "During the whole of my intercourse with the natives of the South Sea I met no deranged person. I am confident that had any instance of mental derangement among the natives occurred, it would have been observed by us." We all know in this country that for a long time it was supposed that no Indian had been known to become insane; and so we might show of all other countries where savages are found in similar conditions, if deemed important. That it exists in much larger proportions in Europe and America scarce needs be stated, as it is a fact well known to all who have paid the least attention to the subject, and will be abundantly proved in this report. That it is not due to any peculiarity of race will also be shown, at least with regard to some of these peoples, when brought in contact with more civilized nations and subjected to the influences by which it is developed. It is believed to be due to causes inherent in man, or connected with his condition, habits, and exposures. Some of these causes belong to the body, as physical diseases — apoplexy, epilepsy, palsy, scrofula, injuries to the head, general ill health, consumption — and some are called moral causes, such as anxiety, exces- sive study, grief, remorse, distress, struggles for gain, ambition. Some of these causes apply to the savage as well as civilized nations, while 38 others are applicable exclusively, or nearly so, to a condition of civili- zation. They vary m their frequency, intensity, and power, and conse- quently the mental diseases also differ in frequency and durability: to what extent we will endeavor to show, in a measure at least, hereafter I:^lV,Z^^^^^ ^^'^'^* ^^^^^ ^^-^^-^ ^^-^ '^^P-^^ose ENUMERATION OF THE INSANE. w?^''^;$ f^*-''"^ in their enumerations take account of the insane: thus we find their numbers as seen in the following tables: 39 Table O 1 o Population. Numbers of Insane and Idiots. Proportion of— COUNTRY. Insane Idiots. Total. Insane to Popula- tion. Idiots to Popula- tion. Total to Popula- tion. United States England 1870 1870 1870 1870 1866 1867 1865 38,555,983 22,090,163 3,222,837 * 5,195,236 37,988,905 23,971,337 37,382 24,527 61,909 54 713 1 in 1,031 1 in 1,572 1 in 623 1 in 403 9,571 17,194 90,679 37,960 1 in 336 Ireland France Prussia 11,122 50,726 16,929 6,072 39,953 21,031 1 in 467 1 in 747 1 in 1,416 1 in 855 1 in 950 1 in 1.139 1 in 302 1 in 418 1 in (81 Belgium 4,984,451 7,431 1 in 671 Total 136,008,912 279,457 ...' 1 in 486 1 Table. t Countries. Census ta- ken once in : Populat'n. Number of Insane. Males. FemPs Totals. Proport'n to Populat'n Ireland England and Wales Newfoundland Nova Scotia Prince Edward's Island. United States France Savoy Belgium Holland Hanover Prussia Saxony Bavaria Wurtemburg Hesse Darmstadt Oldenburg Denmark Sweden Norway Piedmont 10 years 10 years 10 years 10 years 7 years 10 years 5 years 4 years 10 years 10 years 3 years 3 years 3 years 3 years 3 years 3 years 5 years 5 years 10 years 10 years 1861 1861 1857 1861 18B1 1860 1856 1861 1856 1859 1861 1858 1861 1861 18G1 1861 1855 1860 1855 1855 1858 5,798,967 20,066,224 122,638 330,857 80,857 31,445,080 36,012,669 542,535 4,529,560 3,308,969 1,888,048 17,739,913 2,225,240 4,689,837 1,720,708 856,907 287,103 2,605,024 3,641,011 1,490,047 5,041,853 3,500 11,249 50 166 143 2,019 1,038 1,591 2,576 690 446 2,543 1,898 619 3,565 13,096 38 174 167 1,998 1,101 1,493 7,065 24,345 88 340 148 23,999 35,031 810 4,017 2,139 3,084 1 in 821 lin 824 1 in 1,394 1 in 973 1 in 546 1 in 1,310 1 in 1,028 1 in 1,750 1 in 1,128 1 in 1,547 1 in 612 i 1,559 2,323 I 4,899 648 I 1,338 1 in 1,427 1 in 957 1 in 1,286 508 2,592 1,995 710 954 5,135 3,893 1,329 1,750 1 in 301 1 in 507 1 in 935 1 in 1,121 1 in 2,881 * Calculated population. t From Vital Statistics of Ireland. 40 Table. Countries. Spain Italy Belgium Holland France United States. Malta & Gozzo Westphalia... England Ireland Scotland Norway Brunswick Cities. London Paris Petersburg Naples Cairo Madrid Eome Milan Turin Plorence Dresden Brunswick.. 1844.-^ Population 4,058,000 16,789,000 3,816,000 2,.302,000 32,000,000 17,069,453 120,000 1,283,142 13,089,358 7,784,536 2,365,807 1,051,300 262,948 1,400,000 890,000 377,000 370,000 330,000 204,000 154,000 151,000 114,000 80,000 70,000 37,583 Insane. 569 3,441 3,763 2,300 32,000 17,457 130 1,535 16,222 10,059 3,652 1,909 7,000 4,000 120 479 14 60 320 618 331 236 150 104 1 in 7,180 1 in 4,876 1 in 1,014 1 in 1,001 1 in 1,000 1 in lin lin lin lin lin lin lin 932 846 807 774 648 551 539 1 in 200 1 in 222 1 in 3,142 1 in 772 1 : 23,572 1 in 3,400 1 in 480 lin lin lin lin lin 244 341 339 446 361M 1850.t 1857.$ Eatio. Eatio. Eatio. 1 in 7,181 1 in 3,785 1 m 1,000 1 in 666 lin lin 400 531 1 in 795 1 in 577 1 in 551 1860.1 Eatio. 1 in 1,667 1 in 3,690 1 in 816 1 in 1,223 1 in 1,773 1 in 700 1 in 2,125 1 in 513 1 in 550 1867.1 Eatio. 1 in 444 1 in 432 1 in 325 1 in 368 ENUMERATIONS IMPERFECT. These statements of the insane are doubtless imperfect in all countries, and certainly very imperfect in some of them. It is impossible to obtain full accounts of the insane through public offices as at present organ- ized, and any other and more perfect system would probably be deemed too expensive by most Governments. We have reason to believe that many are concealed from public view, and that families refuse to report them to ordinary officers. DIFFICULTIES IN THE WAY OF PERFECT ENUMERATION. Massachusetts seems to have understood and appreciated these diffi- culties at an early date, and in eighteen hundred and fifty-four appointed a Commission, consisting of Levi Lincoln, Doctor Edward Jarvis, and Increase Sumner, to ascertain the number and condition of * See London Medical Gazette, April, 1844. t American Journal of Insanity, Vol. YII, p. 286. J Bucknill & Tuke on Insanity, p. 47. § Journal of Insanity, Vol. XVII, p. 348. U Manning's Eeports, p. 109. 41 the insane in the State; distinguishing as accurately as may be between the insane, i^roperly so considered, and the idiotic or non compos; between the furious and harmless; curable and incurable; and between the natives and foreigners, and the number of each who are State paupers. (See Insane and Idiots, Mass. 1854). This Commission addressed circulars to every j^hysician in the State, setting forth the facts that they desired to obtain, and asking their assistance and cooperation. There were at that time fifteen hundred and fifty-six physicians in the State, of whom all but four responded, giving every case within their knowledge. Besides these, many of the clergy, Overseers of the Poor, and other persons known or supposed to be interested in or informed upon the subject were consulted and their assistance asked. After twelve months of constant, persistent, and untiring labor the most comj^lete, able, and satisfactory report ever made of the insane and idiots in any State or country was the result. It Avas not only impor- tant to Massachusetts, but to all other States and countries. The subject of inquiry was of a general character, and the facts found and infer- ences deduced as applicable to all the world as to Massachusetts. Without going into the details of the modus operandi by which the information was obtained, it is sufficient to state the result in a few par- ticulars. Of the lunatics found, fifteen hundred and twenty-two were paupers, and eleven hundred and ten were supported by their own prop- erty or by their friends, making a total of two thousand six hundred and thirty-two, or one to every four hundred and twenty-seven of the population; whereas an enumeration made by another Commission, in a different way, a few years previously (eighteen hundred and forty-eight), showed only one to five hundred and ninety-two of the population. The United States census of eighteen hundred and sixty showed one to five hundred and eighty-five, and in eighteen hundred and seventy, one to five hundred and forty-seven. These figures demonstrate the imperfec- tions of general enumerations, and the difference exhibited by a census perfectly taken. This difference, we think, may safely be added to the enumerations made in other countries. INFLUENCE OP AGE. Among the causes of insanity, age is supposed to have its influence; at all events, it is a fact established by the observations of most men who have written upon the subject that a larger proj^ortion become insane between the ages of thirty and forty than at any other period of life. The general enumerations of the insane do not show their ages, but this is stated in all those who are committed to hospitals, and thus the deficiency is in a measure supplied, and we are thereby enabled to arrive at approximate conclusions. There are, however, some notable exceptions to this general rule. The experience of Esquirol at Charenton showed the largest number of admissions between twenty and thirty. The experience of Doctor Erie at Bloomingdale, and that of Doctor Hood during ten years at Bethlem, is in accord with that of Esquirol at Charenton, though the whole expe- rience of Esquirol was in accordance with the general rule, while that of Doctor Tuke was in favor of the earlier period, between twenty and thirty. It will be seen by the following table that in France, Italy, and 42 Holland the greatest number become insane between the ages of thirty and forty, while in Ireland and at the York Eetreat the greater number was between twenty and thirty. The table also shows that the numbers decrease as we ascend or descend the scale. This result may be attrib- uted to the fact that at that period of life both males and females are more exposed to the various exciting causes than at any other. It is contended by some authors, however, that the age between thirty-five and forty exercises a special influence over the production of insanity; but of this we have no other evidence than that already cited. The fol- lowing table will show the influence of age, illustrated by statistics of different countries: Table. Influence of Age, illustrated by Statistics of Different Countries. France. 1853. Ireland. District Asy- lums, 1870. Italy. Florence Holland. 1844 to 1864. Total. ^ ^ i^ hi ^ hi t^ »TJ "A ^ AGE. 1 a B CD II B ^ i| II c 3- c o ri- O r+O ^5 o := C 3 op ^ S^!3 < SS ^ SS fo » O P .'^P ■^p ^ '^ - rt) -, ^ : S ^ g ^ • P p a:} XT o ■ o : c : cf tr " O Under 10 years "1 10 to 20 years... J 1,809 5.90 1 2 1 187 .08 8.14 3 18 .96 5.73 66 653 .56 5.57 } 2,738 6.08 20 to 30 years 5,912 19.27 713 31.05 68 21.66 2,681 2 2.87 9,374 20.83 30 to 40 years 8,470 27.61 593 25.83 77 24.52 3,045 2 5.98 12,185 27.08 40 to 50 years 7,011 22.86 374 16.29 66 21.02 2,370 2 0.22 9,821 21.82 50 to 60 years 4,610 15.03 229 10.00 41 13.06 1,672 1 4.27 6,552 14.56 60 to 70 years 2,022 6.59 145 6.31 24 7.64 867 7.40 3,058 6.79 Over 70 years 839 2.74 53 2.30 17 5.41 367 3.13 1,276 2.84 Unknown 2,203 37 2,240 "'•■ \" . ........ Totals 32 876' 2,333 314 i 11 791 L. 47.244 1 Doctor Tuke says: "During the forty four years between seventeen hundred and ninety-six and eighteen hundred and forty, of those admitted at the Eetreat "the greater number (one third of the whole) were attacked between twenty and thirty years of age. Each subsequent decennial period is marked by a gradually decreasing proportion. Thus, of every hundred cases at the origin of the disorder there were, at suc- cessive periods of life, as follows: 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 .96 12.77 32.53 20.00 15.9 10.6 6.3 .97 .24 43 " Now it is obvious that to render these statistics of any value they must be compared with the numbers living in the same community at the same periods of life. This means of comparison we afford in the following table. <' Of every hundred individuals there were living, at successive decen- nial periods of life, as follows: 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 16.7 18.9 15.4 12.4 11.9 10.8 7.8 4.9 1.2 <' From which it is evident that the large proportion of persons who become insane, of those admitted at. the Eetreat, between twenty and thirty years of age, cannot be explained by the greater proportion of the number living at that period. On the contrary, there were more living under ten years of age and between ten and twenty. These facts, therefore, exhibit an mcreased liability to insanity connected with the age between twenty and thirty; or man during that period is brought into contact with an increased number of the causes of insanity. It is probable that it is the combination of these two circumstances which induces this result."* In eighteen hundred and fifty the greatest number of inhabitants of a given age in the United States was under ten, the next greatest between ten and twenty, and so on, gradually decreasing to the end. We pre- sume that these proportions have been maintained to the present time; and as we have not by us any census of a later date setting forth this particular fact, we have made use of it in preparing the following table, taking, however, the number of insane for eighteen hundred and seventy instead of eighteen hundred and fifty, and leaving idiots out of the com- putation. From this it will be seen that though there are many more persons living under ten, between ten and twenty, and between twenty and thirty, than between thirty and forty, still the number of insane of the latter age are greatly in excess of those of any other age. * See Bucknill & Tuke on Insanity, p. 245. 44 Table. Influence of Age illustrated by Statistics of the United States. AGE. Population No. Insane, 1870. Proportion at each age to total of known ages. Popula'n No.Ins'e Under ten years 6,739,041 5,420,421 4,277,318 2,825,819 1,846,660 1,109,540 609,926 257,234 77,382 11,695 2,555 14,285 324 1,992 7,096 9.109 7,976 5,264 3,307 1,569 455 62 15 213 29.08 23.38 18.46 12.19 7.97 4.79 2.63 1.11 .33 .05 .01 .87 5.36 19.09 24.51 21.46 14 Ifi From ten to twenty years From twenty to thirty years From thirty to forty years From forty to fifty years From fil^y to sixty years Prom sixty to seyenty years From seyenty to eighty years From eighty to ninety years From ninety to one hundred years. One hundred years and upwards.. Unknown 8.90 4.22 1.22 .17 .04 Totals 23,191,876 37,382 100.00 100.00 INFLUENCE OP AGE IN THE DIFFERENT RACES. The following table has been made for the purpose of showing the susceptibility to insanity of the different races inhabiting our continent, and the ages at which they are most liable to the seizure of this terrible malady. 45 CO 5S 1^ 3 i3il3i§iSip»Ss i o : ,-(i-oit-^iotcr-T ^ H •. 3 S H f^ — d •:S2igigg§|ii5S'°s S ^ : ec-^coi4''-i og '3 : 10 CO '*< rH r-i : -^ i : : CO • • o d H : : : : © •rH (M : ^ : ^ Cj rS a ^ fa : • : :iMCOC 53 OS . . . S : ! : rJ 5 : i^^^g^sSSSS^^ i ; i 1 1 o H : : : : i : :^T}«oioo^;^^osvO(Mr1 • i : 8 a © s Pm . . ... © i iyqcooorHt-^t-iocq : ! : : g "3 S 'a :''-^^?5iiiiS^^^'^^ i : H © '3 ; N I— ( 1— (I— ( i PQ fa • © i'ssssesissas--"'"" i oJ ^ "3 isiilipiJIJ^^s S o t-H :o a'iiini 1,555 9,273 712 Holknd Bavaria (Asylum at Irsee).... Totals 16,224 14,964 31,188 The various arguments made and facts adduced to prove the one theory or the other, are conclusive evidence to our mind that there is but little difference in the gross number of the sexes. As classes they seem about equally subject to this malady, yet different causes operate in various proportions on the sexes. Men "are more intemperate, which is well known to be one of the most prolific causes of insanity, its vic- tims being in proportion of about four men to one woman. More men are engaged in hazardous enterprises and doubtful business speculations, in gambling and other dissipation, more subject to disappointment and failure in business operations, more use their brains excessively in study, in scientific investigations and ambitious projects, and more are liable to ordinary accidents and the casualties and exposures of war. On the contrary, domestic trials, ill health, loss of relatives, and disap- pointments in love act more powerfully on women, while a few other causes belonging to peculiarities of organism affect them only. We must conclude, therefore, that the liability of the excess to insanity is very nearly equal, and that any difference in numbers in different countries and localities depends more on the exposure to the various causes that produce it than to difference of liability in the sexes; and these must vary with different nations, different periods of the world, and different habits of the people. The fact that the percentage of recoveries is slightly greatest among females, and a fortiori, the i3ercentage of deaths among males, is too well established to require an argument. The reason of this is obvious; we have already seen that the causes operating on the sexes are different in some important particulars; general ill health and the puerperal condition adding largely to the list among females, give to insanity its most curable cases; while ej)ilepsy, palsy, and mas- turbation are more frequent causes among men, and are among the most incurable cases. INFLUENCE OF MARRIAGE. The experience of all writers upon the subject, as far as our observa - tion has extended, shows conclusively that a greater number of single than married persons become insane, notwithstanding there are more of the latter class of the ages most subject to insanity. 48 ^2^ ^ .^ t-? « S < '^ H ^^ Totals... Female. Male. lit- P^ CO Cj CO 5 CO So g^ Totals... Female. Male. Totals... Female. Male. Totals... Female. Male. Totals... Female. Male. Totals... Female. Male oo ^x 1^ CO 1-- o i-H Tt< X Ci T— I 1-H IC i-< CO -f >C C5 ^ C5 1- -* CO o ■* O <— I CO UO O '^ rJH CO .-( (X) QO CO O — I CO uOO CO CO CO '^ O CO 00 Ci O -f QC CM CC -* X- CO X t^i-( t^ 5it§ i cocsiri : il« ! CO o_-*co^co^ x'"x'~-; •o ,^ M o < ^ ■^ H -.^ '^ -S^ ^^ fis lO CD ■■^j f^" o '^ ■S Ratio of Idiotic to Population Ratio of In sail G to Population Idiotic Insane Population Ratio of Idiotic to Population Ratio of Insane to PopulatioJi Idiotic Insane Population cc i.c -+i I-- :c -H lo o i-i cc u:; o *>! 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Oq c; o o ci O X r; O ~ '■-/•- o ^ o o-H*^ g ^%S'. g^^^§^^t^^;^^5o£Si^H>f^^^S|fil^^! 64 ^ •2 I' Katio of Insane and Idiotic to Poi^ulation Total Insane and Idiotic Eatio of Idiotic to Population. Ratio of Insane to Population. Idiotic Insane Population oooooooooo S S S S S '^ "^ 1^ O GO 1^ « 1^ ^ t-^ LC -tl M CO 'J' O Tfi C5 O l^ CO 'O u'^C0_O_T^^u't_0C_Gl0 CO_0_C-l_(N_CC_rH_uO_C::5 i-H_X^35_ •ooooooooooooooooooo rH^r-rr-TcO i-To^r-Tr-r. iM rH i-l 1-1 OOOOOOOOOOOOOOOOOOO Cil^f--( uo i-o -t* 1-1 Ci oo uo Ci 1^ Tti lo 1— I -^ o Ci CO C5 CI -— < .— ( 1— I crs i-c i-o O^C;_rH00^'O^t^^C0^O_C:5^Ci_C0_C0^O^ ijrrco~o"Tjro"i^irri--^'*"crcrr-r-^-H~<:c~co~o~t-^'i^ uOi-lCiGO:OCOJCN(MaOiOGO l-0i-lC^'^C.OOeOCOCOC>-^^>OirOMr^O ^S^S^IoO^OoS ^^CO O lO I- sssssssssssssss «5 ^O O CO !M rf X__C5 X^X SS3SSSSSSS Tt" i>- o 00 0^ xi t-:,i^^'-< '-i"* i^ '^^i^ ^Si"^ "^ 00^.0 COOCCOOXOO ,-lt-OC3C:C:x4 tH of tH CO r-l r-Tr-l o o c o o '^_^s_QSS3SSS COX-Mlr^OCiXt-i-ti-i TJH iC CM OIW O C5 rt 1^ 'tl 1^ ! --I '-T O :-J l^ iS X cofMoq^MTh-HOxi-ooiojT-^pjra ->* X 1^ rM CO Ci CO O O LO CM 1^ (M ooc^ii-^oosiCTjicoin coin-coxooiosi^xio of cT oT Ttn" --T ^ o" .-T co" co" Ttl CO T-l CO r-l (M Oi X CM ■> ci '^, ce ^;^ ^- ^ t> p: ^ ^ "E .:=; g- c c . «5 « oj C >> a "a .^-^ c; 0. o o c:£ £ g J § g ^ S.SUj^r; 9 o ^ o «.— ^ c^ !> ipP^ 66 Table, Showing the Pojmlation, with numh'ers and proportions of Insane and Idiots^ Classified according to Race, in the United States in 1870. KACE. Population. Insane. Idiotic. li Total of Insane and Idiotic Eatio of Insane and Idiotic to Population. . . •White? 33,586,989 4,880,009 62,254 25,731 35,560 1,774 35 13 21,324 3,188 5 10 1 to 944 1 to 2,750 1 to 1,807 1 to 1,979 Ito 1,579 Ito 1,530 1 to 12,450 Ito 2,573 56,884 4,962 40 23 1 to 590 Colored 1 to 983 Chinese 1 to 1,556 1 to 1,118 Indians Nevada will of course come out with flying colors, since all of the insane of that State, with two exceptions, have been credited to us. As the table shows a larger projDortion of the insane to population in the District of Columbia than in almost any other community in the world — - being one to two hundred and forty-eight — we deem it not only just, but proper, to show why this is so. The Government Asylum, located in the District, is not only intended for those who reside within its limits, but also for the soldiers and sailors of the army and navy of the United States; and as these are brought from all parts of the Union, of course the list is swelled far beyond the ordinary pro2)ortion in other communi- ties. The causes leading to the rapid development of insanity in this State will be considered in relation to other matters pertaining to Cali- fornia. CHAPTEE YII. IIS^SANITY IN FEANCE— GENEEAL STATISTICS OF THE INSANE FEOM 1854 TO 1866— DE. MOTET'S ANALYSIS OF LEGOYT'S WOEK. Having alluded in the preceding Chapter to the imperfect manner in which the insane in France had been enumerated, even at so late a date as eighteen hundred and fifty, we take pleasure in laying before our readers the following able and interesting analysis of M. Legoyt's great work on the Statistics of the Insane, by Dr. Motet, Secretary of the Medico-Psychological Society of France, who kindly presented us with a copy. This able review of one of the most important public documents ever published in France cannot fail to interest and instruct all who read it. We believe it gives a better idea and affords a more comprehensive view of the number and condition of the insane in France than any work that has hitherto been offered in the English language; and though it treats of some topics upon which we have already touched it is given entire: 67 DR. motet's analysis OF LEGOYT'S WORK * The subject of insanity has for some time actively interested the French mind. People are now no longer satisfied with barren sympathy; they question, they are anxious. Each one imagines it his right and his duty to probe this'deep wound of society, and doubtless with a laudable, but sometimes inopportune zeal, reforms are proposed on all sides; an almost radical modification of the legislation which here regulates the condition of the insane is desired. A word which in our country is never uttered without exciting a tumult — liberty — is the watchword at which rally a great number of writers who lack only one thing, a little experience. To these publicists who are animated by the best inten- tions, we will not reply by cold disdain-. We have remarked elsewhere f and we gladly repeat it here, generous illusions are deserving respect; everything which relates to insanity acquires a dignity, a magnitude just m proportion to this measureless misfortune, and those who, excited by a deep sympathy, demand of us by what right we violently separate from society a being whose reason is aftected, deserve to be answered not merely by denying their competence, but by arguments and facts of a nature to justify our conduct. Moreover, the time has passed when knowledge was an exclusive monopolv in the hands of a few. Social problems are debated in open day. AYe cannot stay the movement of thought, which, after all, tends toward progress; and to be silent will be to expose ourselves to deserve the reproach which, from habit, is still easily enough addressed to us, of seeing nothing beyond a narrow specialty. It would be a singular incon- sistency for us to refuse to examine the elements of an investigation which every one may possess. The Moniteur of April 16, 1866, published a report of" the Minister of Commerce, the impression of which cannot vet have been eftaced. These figures, which seem to increase each year, and which statistics present from time to time to the impatient but legiti- mate curiosity of economists and philanthropists, need to be commented on and discussed; what is of especial importance is to give them a correct interpretation, and, accepting them as the stern expression of facts unfor- tunately too true, not to force results from them — not to deduce too hasty, and therefore, very probabl}', erroneous conclusions from them. Many minds, even the best, accepting them without question, and seduced by their eloquence (the expression is restricted to a particular signifi- cation), imagine it their duty to take up arms against us. Although silence sometimes serves a just cause better than too much discussion, it seems to us that we ought not to be silent to-day. We have at our com- mand the elements which are always wanting to those who can only make abstracts of accounts. Is it that we consider fruitless those patient investigations which present to us, at stated periods, the balance of our intellectual and moral condition? Such is not our idea. We well know (for we have been aided by it) what labor and research have been necessary to present at once the imposing array of figures wdiich consti- tutes the statistics of the insane in France from 1854 to 1860. M. Legoyt possesses a thorough experience in these matters, and we are merely just in tendering to him here the tribute of praise which he deserves: * Translated by Miss Martha W. Sawyer, Harrison Square, Massachusetts. t Of the possibility and propriety of allowing certain classes of insane to leave special asylums and of placing them either at agricultural improvement or with their own families. (Medical Congress at Lyons, 1864); (The Insane before the Law). Paris, 1866. 68 he has well completed a thankless task, the scattered materials for which would have remained in confusion if he had not collected them, sul'Sti- tuting in place of chaos a fruitful harmony. It is not, then, a criticism which we are about to make; it is a complement of instruction which we would present. To harsh figures we would oppose facts; what seems to us important is to explain how results, apparently deplorable, are due to the influence of causes very readily appreciable; in short, to solve a question which has been put to us, and which, in our opinion, will place us in a most humiliating situation if we leave it unanswered. The sequestration of the insane in public or private as^dums is, at the same time, a measure of i^ublic order and of personal safety. The lunatic is a sick person who has the right, by very reason of the special disease with which he is aft'ected, to special care; he is also a being dangerous to those around him; in presence of this terrible scourge, the most pre- possessed minds cannot refuse to admit it, family devotion is, for the most part, fruitless; they are exhausted by vain efforts; the most gen- erous sacrifices result only in cruel deception; they are obliged, sooner or later, to adopt the serious measure of placing in an asjdum the patient whom they can neither protect nor take care of at home. ^Ye under- stand too well how serious are the questions which sequestration in- volves, even when it is most justifiable, to seek always to hasten it. Although cure is a performance too often compromised by unwise delay, we are but feebly disposed to blame the family affection which resists our advice and waits until the last moment to take leave; but we do not hesitate to blame those who entertain unjust suspicions and represent the asylum as the sepulchre of intelligence. It is too lightly flinging the shroud over the head of the dying; it is too seriously undervalueing the wisdom and the honor of the physicians who devote themselves to a task always sad. The lunatic is not fatally condemned to leave the little reason which still remains in those establishments which the vivid imag- inations of some philanthropists transform into a kind of extinguisher. There is something better to be done than to address petitions to the Senate; it is necessary to give an account of things, not to seize, with unreflecting haste, the maticious lucubrations of unfortunate minds still affected, although they may present the fairest appearance. But to restrain impulse in France would be to reform our national character, and although these excesses may not be to our taste, they have, as a point of departure, a sentiment so elevated as to merit being reduced to their just value without passion on our part; we have, moreover, good reasons enough to produce to maintain, without fear, an attitude of defense, and never to attempt to assume an aggressive attitude towards those who try to save, by a bold couj) de 'main, their compromised cause. We shall proceed in this matter in a calmer way, consulting rather the experience of our predecessors than our own; but, nevertheless, we do not wish to be hastdy accused, or to have it thought that we have gained nothing during thirty years. We do not think, whatever may be said, that we are behind neighboring nations; our legislation, if it is not per- fect, does not deserve the reproach which it receives, of being, the greater part of the time, insutncient or arbitrary. One cannot den}', without systematically closing his eyes to evidence, that nowhere is the solicitude of the State, of the Government, more active than in our country. AVe find a proof in these statements which we now possess, and which we wish to explain to all. We have been preceded in this design by our learned colleague, Dr. Brierrc de Boismont, who published in this coUec- 69 tion an excellent analysis of the statistical works of M. Legoyt.** Wo cannot do better than to follow his steps; finding ourselves, moreover, in perfect conformity with his vicAvs, we shall be obliged to refer to points already noticed by him. The number of establishments, public and private, devoted to tho insane was one hundred and eleven in eighteen hundred and fifty -three. At the close of eighteen hundred and sixty there were only ninety-nine, as several of them may have been sujipressed on account of their trifling importance or of their incomplete or irregular organization. On tho first of January, eighteen hundred and fifty-lour, their population was twenty-four thousand five hundred and twenty-four lunatics of both sexes. This number increased in the succeeding years, but the progres- sion has been much less rapid than in the period between eighteen hun- dred and thirty-five and eighteen hundred and fifty-three. The follow- ing table will show this: January 1st, 1854 ! 24,524 January 1st, 1855 1 24,896 January 1st, 1856 Januar}' 1st, 1857 January 1st, 1858 January 1st, 1859 January 1st, 1860 January 1st, 18G1 25,485 26,305 27,028 27,878 28,761 30,239 The increase was enormous from eighteen hundred and thirty six to eighteen hundred and forty-six, each quinquennial period presenting an increase of five and a half per cent; but since eighteen hundred and forty-six the progression has been greatly diminished. It appears: From 1846 to 1851. From 1851 to 1856. From 1856 to 1861. 3.71 per cent. 3 87 per cent. 3.14 per cent. These results should not astonish. The increase in the population of asylums corresponds to the relief which they bring to the lot of the insane — a new organization, in which much more attention is given to the conditions of material life of the patients than formerly. On the other hand, the foundation of new estabUshments; the confidence in- spired by officers and physicians; and, it must be allowed also, the greater facility of communication. The changes brought about within thirty years in our customs, in our needs, all favored this movement of entry. It was the necessary result, foreseen in advance, of a new order of things. Now the equilibrium tends to become reestablished, and we doubt not that from this time for some years a sensible diminution will be proved in the still continuous increase of which statistics accuse us. Everything has contributed to increase these numbers; and it is from settled convictions that we assert that there has not actually been the *Annals of Public Hygiene and Legal Medicine, Second Series, vol.xi, p. 197. Motet. 70 enormous increase which is indicated. The investigations have been more carefully made during these last ten years than they had ever been. Those of whom information was sought understood the import- ance of such work, and the French Statistical Bureau has been able to collect materials much more complete than those heretofore placed at its disposal. This result, the extent of which will be better appreciated in the future, is due to the active and persevering energy with which M. Legoyt has inspired every department of his administration. If the population of the asylums increases, the proportion of the insane in relation to the population of France ought also to increase; but it is imj^ortant constantly to bear in mind, in presence of these figures, the increased extent each year of public assistance; more patients relieved and treated; that is all which can be deduced from them. Thus it is estimated in Tear. Population of France. Insane Under Treatment. Proportion to Population. 1851 1856 1861 35.783.170 36.139.364 36'717,254 21.353 25,485 30,239 1 to 1,676 inhabitants. 1 to 1,418 inhabitants. 1 to 1.214 inhabitants. This is not the exact proportion of the insane to the total population of the Empire; we must add the insane remaining in families, of Avhich the number was in eighteen hundred and fifty four neiirly twenty-four thousand four hundred and thirty-three individuals; in eighteen hundred and fifty-six. thirty-four thousand and four; in eighteen hundred and sixty-one, fifty-three thousand one hundred and sixty — which makes for this last year, including the insane treated in asylums, about two insane to one thousand inhabitants. To what, then, is this increase due? To the idiots and cretins being included in the statistical tables, and it is impossible on seeing their number "increase from twenty-five thousand two hundred and fifty-nine in eighteen hundred and fifty-six to forty- one thousand five hundred and twenty-five in eighteen hundred and sixty-one, not to conclude, as M. Legoyt has judiciously done, that there was a serious error, the more easily committed since the greater part of the idiots and cretins remain at home; since previous to eighteen hun- dred and sixty- one they were confounded with the general population, and since, if in accordance with the more complete instructions given to the Census Marshals, they have been classed apart, it is not surprising that results so difterent in apjDcarance have been obtained. This reason (a more rigid, more exact appreciation of mental condition) should be the true one. It is scarcely probable that the number of idiots increased everywhere at once. But one thing is certain, that in eighteen hundred and fifty-six there were only two thousand eight hundred and forty idiots in the asylums, and in eighteen hundred and sixty-one three thousand seven hundred and forty-six of them were counted. The influence of Ferrus had made itself felt; he had, in a remarkable rej)ort, described the incon- venience which might arise by withdrawing imbeciles and idiots from the action of the law, and the administrative power had adopted his views. The number would have increased much more if they had not 71 made so great a restriction in the admission of idiots. It would doubtless be desirable that all who belong to indigent families should be effectually relieved. There is, in this way, a progress to be effected, and some efforts have already been made; but it is difftcult to think of j^lacing indefinitely in an asjdum inoftensive beings who live a wholly vegeta- tive life. It is at the same time imposing too heavy a tax upon the department, and, on the other hand, increasing a burden which is already too real in a large number of our asylums. Moreover, under the general name of idiots'is included a class of beings who are not entirely useless. There are imbeciles, feeble minded, as they are called in some localities, who are good workers and who regularly accomplish a slightly compli- cated task. Until now they have been unnoticed in statistical state- ments; they apjDcar there now, and augment by so much the total humber. The situation is not then so deplorable as might have been suj^posed, and we believe that the deviation will be much less for several years from now. AYhat we have remarked concerning the influence of the reorganiza- tion of asylums upon the increasing number of insane under treatment is especially noticeable in the statements of the admissions. One is con- vinced, by consulting them, that the greatest increase corresponds to the period nearest to the promulgation of the law of eighteen hundred and thirty-eight. M. Legoyt divides the period from eighteen hundred and thirty-five to eighteen hundred and sixty into five sub-periods, and he finds that the proportional increase has beeUj^annually: < YEAKS. Per ct. From 1840 to 1844 7 94 From 1845 to 1849 3.38 From 1850 to 1854 3 83 From 1855 to 18G0 2 00 Here is also the exact number of admissions from 1854 to 1860: 1855 9,303 9,246 10,024 1858 10,314 10 086 1856 1859.. 1857 I860 10 785 Which gives, as the annual mean of admissions, about nine thousand three hundred and fifty-three insane, seven hundred and twenty-seven idiots, and eleven cretins ; hence, of one hundred j^atients admitted, there were ninety -two insane, seven idiots, and one cretin. The admissions are voluntary, that is to say, requested by the families, or officially ordered by the authorities. The tables which we have here do not make a distinction which is, nevertheless, of some imj^ortance. Nearly two thirds of the admissions into the departmental asylums are made officially; in the departments for pensionnaires, in the private insti- tutions, including Charenton, there is nothing like it. This occurs, doubtless, from the negligence of the families of the indigent insane, 72 from the slighter disturbance of private interests which the presence of an insane person creates, and also from prejudices which have not yet entirely disappeared among the poorer classes, and which are no longer shared by the better educated classes. The voluntary entries were: In 1856 in the proportion of. ' 30.20 percent. In 1857 in the proportion of ' ,31.19 percent. In 1858 in the proj^ortion of. : 32.02 percent. In 1859 in the proportion of | 30. Gl percent. In 1860 in the proportion of j 32.02 percent. ! The official entries were: In 1856 in the j^roportion of j 69.80 per cent. In 1857 in the proportion of \ 68.81 per cent. In 1858 in the proportion of i 67.98 per cent. In 1859 in the proportion of. ! 69.39 per cent. In 1860 in the proportion of. j 67.98 per cent. In wealthier families, w^ere the physician is called, if not at the com- mencement of the insanity, at least as soon as it becomes serious, the situation is different. Judicious advice is given and often promptly fol- lowed. They do not wait for the interference of the authorities to effect an entry; they hope, on the contrary, that by combating the disease in season they will have better opportunities of eradicating it, and the official entry, which is so common to asylums, becomes almost the excep- tion in private establishments. This may be seen by the following fig- ures, which are a statement of the admissions into the hospital (^maison de sante) directed by Dr. 3Iesuet and myself: 1856 — 54 admissions, of which 9 were official ' 16.65 per cent. 1857 — 68 admissions,* of which 8 were official 11.76 per cent. 1858 — 74 admissions, of which 9 were official : 12.15 per cent. 1859 — 74 admissions, of which 7 were official I 9.45 per cent. I860 — 54 admissions, of which 4 were official , 7.40 per cent. 1861 — 59 admissions, of which 4 were official | 7.14 per cent. . L__ ^__ No other conclusion of interest can be drawn from it; in the asylums the entries, which are, after all, a kind of public assistance, should be under the supervision of the administrative power, and the right of con- trol which it reserves is not excessive. It is known, moreover, that it never refuses to open the doors of its special establishments when a request really justifiable is made; the entry, which, for j^aupers, is always made by means of the authorities, takes the name of official entry for that reason; but, if we except insane vagabonds, incendiaries, and homi- cides, the .Mayors and Prefects never make the decision before having been sought by the Aimily. One need not, then, infer from these figures (which might at first surprise) too frequent or too great an intermeddling 73 of the iidmmistration in the sequestration of the insane. For the large towns, which, lilve Paris, have private hospitals, the official entries have taken place only in desperate cases; and when an insane person has been arrested upon the highway his family is immediately notified, if possible, and invited to designate the establishment in which they wish the patient to be entered. ^ At Paris, it is the Prefect of Police who makes the arrest. He uses the right which the law gives him to protect public order and personal safety, and one cannot complain when authority takes the place of an absent or negligent family. We insist upon this point, for this right of authority is now contested with more passion than 'propriety; If all the difficulties, all the embarrassments which are constantly created by the insane in society w^ere well understood; if the consequences of their acts were examined without prejudice, and inter- vention always useful, never arbitrary, would perhaps be less promptly censured. And allow us to say, there are insane and idiots for whom sequestration in an asylum w^ould be a blessing; they would escape ill treatment, detestable calculations dictated by base cupidity; recent facts which have been developed by tribunals have shown but too well how far cruelty and ill usage of poor, defenceless beings may be carried. We believe, therefore, that it is well to leave to the Mayors and Pre- fects the liberty of the initiative, and that to withdraw it would be to promote the development of abuses already but too common. The number of women in the asylums is always a little larger than of the men, and nevertheless the admissions are in an inverse propor- tion. The reason of this fact is that the discharges and deaths, and the mean length of residence, differ much for the two sexes. The mortality and the discharges attain a higher figure among males than femak s. Wo shall refer again to this subject. The following are the figures corres- ponding to the period eighteen hundred and fifty -four to eighteen hun- dred and sixty, for the patients present at the end of each year: YEAK. Males. Females. 1QFS4. 12,036 12,221 12,632 12,930 ' 13,392 13,876 14,582 12,860 i«55 13,264 1856 .. 13,673 i«^7 14,098 1 «5« 14,486 1859 14,885 IQf^O 15,657 This difference had been already noted from eighteen hundred and forty-two to eighteen hundred and" fifty-four. The proportion was, per hundred, forty-seven and seventy-seven one hundredths males, and fitty- two and twenty-three one hundredths females. From eighteen hundred and fifty-four to eighteen hundred and sixty it is nearly the same, for we find among one hundred patients forty-eight and ten one ^hundredths males, and fifty-one and ninety one hundredths females. This is not the case among idiots and cretins. Subtracting these from the total num- ber of insane under treatment, we find among one hundred idiots and 10 74 cretins fifty-one and twenty-two one hundredths males, and forty-eiglit and seventj'-eight one hundredths females. One of the most interesting subjects of study is that of the curability or incurabilit}^ of the insane under treatment. But who does not com- prehend at the same time how researches of this nature must lack correctness? Let us, therefore, attach but an indifferent importance to the figures furnished us by statistics. They are approximate results, which could only acquire a real value in case it were possible to estimate singly the statistics of each asylum after having deducted from its lists the epileptic, the paralytic imbeciles (les dements paralytiques), the idiots and the cretins, for whom incurability' is no longer a presumption, but a certainty. We shall not insist upon this j^oint; when the discharges by recovery are presented to us we shall find more exact means of estima- tion, and such as will better merit our consideration. At what age is insanity most common? Statistics previous to eighteen hundred and fifty-four agree with those which have just been published; it is from thirty-five to forty years that we find the most insane of both sexes. It is likewise the period of life at which males and females expend the most physical and intellectual activity. It is the age of comj^lete development; it is also that at which trials are most numerous. Thus of seven thousand two hundred and ninety-two insane persons admitted (mean year) for the first time, from eighteen hundred and fifty- six to eighteen hundred and sixty, we find: TEAKS. 1 Males, Females. Total. From 20 to 30 years 762 1,107 857 688 888 676 ■ 1,450 1,995 1.533 From 30 to 40 vears From 40 to 50 vears Beyond this period of life the proportion of females increases; at a single period there is almost an equality; it is from fifty to fifty-five years — we find four hundred and ninety-five males and four hundred and fifty-eight females. YEAES. Males. Females. Tot^l. From 60 to 70 years 243 101 324 182 567 Above 70 years 283 Among idiots and cretins it is from twenty to thirty years that the greatest number of admissions takes place. That is readily understood; it is the time at which these unfortunates become most troublesome to the family. and to society, especially those whose j)hysical development is not too incomj)lete, and who manifest all sorts of imj^ulses — blind passions which it is often difficult to control. What is the result in the families of these poor creatures for whom constant Avatchfuluess is neces- sary, and who become a deeper and deeper source of anxiety? They 75 embarrass labor and they oppress by too heavy a tax an account already limited; it becomes necessary to part with them, and to ask their admis- sion into the asylum. Above fifty years the number of admissions is reduced a little; it might descend to zero without our being- astonished, for idiots rarely live to that age; it seems probable to us that they must have inserted in the table individuals who are only imbeciles; for the latter, indeed, the duration of life is more extended than for idiots. The civil condition of the insane admitted for the first time, from eighteen hundred and fifty-six to eighteen hundred and sixty, has been stated most carefully, and offers us the following results: Males. Females. Total. 9,545 7,731 1,327 545 7,624 6,671 2,718 298 17,169 IVfjl TTI pd 14,402 AVirlnwpi'*^ nnd "widows 4,045 r^ivil r'on(]ition unknown 843 Totals i 19,148 17,311 36,459 The number of unmarried insane is of itself as considerable as that of the married and widowed insane. All statistics agree upon this point. Is it because celibacy predisposes one to insanity? This problem has long been agitated, and the solutions are various. An unmarried person retains a greater freedom to temptation, and he yields more readily to those allurements which family relations diminish, if they do not entirely efface; life is less regular, less calm; in trial it is less encouraged, less supported, and having, generally, no one near to care for him if attacked by insanity, the doors of the asylum or of the hospital will open far more readily to him than to any other. The causes of the numerical superiority of unmarried persons in the admission are therefore complex. They have not escaped the sagacity of M. Legoyt, who has judiciously described them. As to Avidowhood* it seems to exercise a more unfavor- able influence upon females than upon males; but to make a correct estimate it is necessary to find out whether women do not oftener remain in the condition of widowhood than men, and whether, also, the moral causes do not play the most important part in these new conditions. As for the preceding statistics, the examination of the professions fur- nishes a sad lesson. ^It is from among the laborers of thought that insanity receives most victims.f For the period included between eigh- teen hundred and fifty-four and eighteen hundred and sixty these state- ments give the enormous number of forty-six hundred and twenty per- sons engaged in the liberal professions. Compared with the total num- ber of admissions this result presents a proportion of ten per cent. See the following table: *I have no English word more nearly corresponding to "veuvage" than widowhood, which I use for both sexes. t Our investigations lead us to believe the reverse of this to be- true in all other countries than France. 76 TEAKS. Number en- gaged in the Liberal Professions 1854 to 1855 1,839 511 1856 1857 544 1858 497 1859 658 1860 - - 571 Total 4,620 During the same time there were sixty-eight thousand nine hundred and ninety-two admissions. If in round numbers we deduct twenty thousand idiots and cretins, there remain forty-eight thousand nine hun- dred and ninety-two admissions, of which four thousand six hundred and twenty represent individuals having received a liberal education. Clergymen and members of religious orders amount to twelve hundred and forty-eight; physicians, apothecaries, and midwives, to six hundred and thirty-three; professors, learned men, and men of letters, one thou- sand and ninety-three; artists, sculj^tors. painters, musicians, eight hun- dred and sixty. The rest of the catalogiie are notaries, advocates, bailiffs, and public officers or employes. The other professions are far from furnishing so large a quota. This is, as M. Brierre de Boismont has remarked, another argument in favor of the opinion of those who think that the progress of civilization affects the development of insanity. It is just to add, nevertheless, that it is among this class of persons that the excitements of life are most incessant, that ambition is most feverish, and that the sensibilit}^ to display constantly kept in exercise is liable to the greatest extremes. Military and seafaring men are not spared; then come, finally, stockholders and proprietors, the manual or industrial professions, domestics or hired laborers, and farmers. The inhabftants of towns constitute more than one half the annual admis- sions, and yet the proportion of the people of the rural districts to those of the towns is as three to one. There are many causes which effect this result. The insane j^erson is more easih^ guarded in the rural districts than in towns; his presence in the family does not so necessa- rily become the occasion of difficulties and embarrassments of all kinds; there is more room for him, and fewer causes of annoyance; if he is sometimes noisy, the neighbors are not disturbed by his cries, so he may remain at home a long time if he is inoffensive. The citizen, even if he were just as docile and easily governed, becomes, from the fact of his insanity, a source of consant anxiety. The asylum or private establish- ment which will ojDen its doors to him will give him a material benefit which he cannot obtain at home, where, for various reasons, he would be habitually confined to his chamber. On the other hand, in a family whose means are quite limited the incapacity of one of its members becomes a source oi' exj^ense which the entry into an asylum at the present very moderate charge immediately reduces. These are constant facts, and if we add thereto the excitements constantly renewed, the 77 need of luxury and more active enjoyment, the more frequent deception, the watchiug,\he excess, etc., we shall understand the enormous dispro- portion which is presented to us in the following figures: 185G to 1860. Inhabitants of towns Inhabitants of the country Residence unknown Totils 18,228 1(3,914 1,317 36,459 950 1,481 98 2,529 M. Brierre de Boismont ascertained the same facts in preceding statis- tics, and the reasons by which he supports them remain true in our day. There is a perfect accordance, just as in the researches made to ascer- tain which are the departments which Yurnish the most insane. They are still the Seine, Seine Inferieure, Seine and Marne, the Khone, Seine et Oise, the Eure, the Loiret, the Bouches du Ehone, the Cote d'Or, and the Yonne. To conclude that which relates to admissions, we still find, as in the past, that the Summer months are the months of the most numerous admissions — that the "Winter months are less fruitful. The study of causes presents difficulties of more than one kind. We must not rely upon the very rigid estimates of statistics essentially offi- cial. There is not a physician having lived among the insane who does not remember the extreme embarrassment in which he has often found himself when he has tried to analyze the diverse influences which have produced the development of insanity. It is very rare to find only one of the number to which we can with certainty ascribe the actual de- rangement. Be that as it may, there is a portion of truth in the tables which M. Legoyt has prepared; and as it was not possible for him to obtain more accurate statements, we will accept them. Among these causes hereditary takes the lead. Modern works, those of Baillarger in particular, have represented its full importance. Of twenty-eight thou- sand six hundred and twenty-one insane of both sexes, of whom the friends have given the necessary information, there are reckoned four thousand and" fifty-six w^hose father or mother had been attacked by insanity; and pursuing the analysis still further, of the insane admitted in eighteen hundred and fifty-nine and eighteen hundred and sixty it has been found that hereditary transmission is in some degree obedient to the law of propagation from sex to sex. The insane mother transmits the insanity to her daughters, the father to his sons. We reproduce the following table, which relates to fifteen thousand two hundred and thir- teen insane: 78 CAUSES. Males. Females. Total. Issue of an insane father ; 412 356 83 2,367 4,862 294 403 110 2,132 4,194 706 Issue of an insane mother 759 Issue of an insane father and mother* 199 Issue of a father and mother not insane. Unknown 4,499 9,056 Totals* 8,080 7,133 15 213 This gives, out of one thousand insane males, two hundred and sixty- four bearing the hereditary taint, one hundred and twenty-eight from the father's side, one hundred and ten from the mother's, twenty-six from both sides at the same time; of one thousand insane females, one hundred from the father's side, one hundred and thirty from the mother's, and thirty-six from both sides. What is the share of the causes called physical and of the moral causes in the development of insanity? For a great number, as we have already said, it is very difficult to succeed in separating them fully. Sometimes they succeed each other as consequences the one of the other; some- times they are so closely linked that any distinction becomes impossible; but what is beyond doubt is that drunkenness presents itself in a great number of cases. M. Brierre de Boismont tried vainly to diminish its influence Avhen he wrote: "The man who drinks to divert his thoughts from disappointment, and becomes insane, has at first acted under the influence of a moral cause." This reasoning, which justly exhibits the complications which may exist among physical and moral causes, is only applicable to a small minority. Xow that attention is aroused in this direction, it is beyond doubt that insanity receives the greater number of, its victims from among persons addicted to the use of alcoholic drinks. The nature of intoxication, may be curious to determine, for if it is true that, under one form or another, it is always the alcohol absorbed which acts upon the cerebral functions, it is no less true that certain prepara- tions into which it enters in a highly concentrated degree give a more rapid progress to the disease, and a peculiarly serious character. A remarkable fact, and one which our personal researches have presented in all statistical tables, is that it is not in wine countries that delirium tremens is most frequent. It is in the large towns, in cities where indus- try is most developed and most active, where there is the greatest agglomeration of population, that delirium tremens is most common. It is, moreover, more frequently found at the north than at the south; and we do not consider ourselves guilty of exaggeration in attributing to the improvements made in the distillation of beet root, potatoes, and grains a large share of the increase in the number of the insane. One is justi- fiably startled at finding that more than one fourth of the persons whose insanity is attributed to physical causes sufi'er the penalty of alcoholic excess. Of eight thousand seven hundred and ninety-seven persons, three thousand and fourfeen were drunkards. Even women pay their * This is a correct copy of the figures presented in the original, but there is evidently an error, which I conclude is in either the males Or females of the third item — eighty-three for eighty-nme, or one hundred and ten for one hundred and sixteen. 79 tribute to this degrading cause. They are, however, in much smaller number — four hundred and forty-one out of seven thousand and sixty- nine. After this comes, in order of frequency, advanced age (I'ago avance), diseases of various organs, epilepsy, various diseases of the nervous system. Onanism and venereal excesses, destitution and misery, accidents and wounds. Among females, disorders of the genital organs, appearing either at the time when the uterine functions are most active or when they cease, are one of the most frequent physical causes of insanity. The proportion is one thousand five hundred and ninety-two out of seven thousand and sixty-nine. Among moral causes, domestic disappointment plays the most impor- tant part. Of four thousand nine hundred and nmeteen men, nine hun- dred and eighty became insane from this cause; of five thousand four hundred and thirty-eight women, one thousand five hundred and sixty-nine under the same influence. This is a little more than one fourth, especially if we add thereto the disappointments resulting from loss of friends, and which may, in a great majority of cases, appear among domestic disappointments (chagrins.) Afterwards come disap- pointments resulting from loss of fortune (851), from disappointed ambi- tion (520), excitement of religious feelings (1095), excess of intellectual labor (358), love (767), jealousy (45G), pride (368), anger (123), remorse (102), isolation and solitude (115), simple imprisonment (113), imprison- ment in cell (26), nostalgia (78), from a total of ten thousand three hun- dred and fifty-seven of both sexes. Under this title ("Aggravating Circumstances ") is found one of the most instructive paragraphs of all M. Legoyt's, publication. General paralysis is there considered as the complication of insanity, and its rela- tion to the total poj^ulation of the asylums is precisely stated. A com- parison between j^receding and present statistics jDresents an increase of one half; and for ourselves, who live in special circle, in a private hospital where only the insane of the wealthier classes are received, we do not find this number so great. For ten years we have seen general paralysis becoming more frequent: it appears sooner in the life of man, and if one considers that this terrible malady attacks without mercy the most gifted, one cannot help feeling profound pity for the poor creatures Avho, in the midst of their insanitj^, retain the most delusive ambition — who, with simple credulity, delight in the most deceptive chimeras. The dementia {demence) which attacks them almost unawares, the dimi- nution of their strength together with that of their intellect, the progres- sive deterioration, which may be traced, step by step, is one of the saddest and most heart-rending pictures which can be imagined. Nothing stays its victorious march; with scarcely, from time to time, a few periods of abatement, abruptly broken by the return of cerebral congestion, with epileptic {epUeptiformes) convulsions, and death, after eighteen years or two months of a purely vegetative existence, coming to end the sad trial — this is what we have daily before our eyes. Paralytic imbeciles (les dements paralytiques) now present, in the admissions, a number relatively large. • From eighteen hundred and forty-two to eighteen hundred and fifty -three the proportion was: for males, six per cent; for females, three per cent. From eighteen hundred and fifty-six to eighteen hundred and sixty the number increases to twelve per ceilt for males, and remains three per cent for females. ^^ Cest que la paralysie generale semble recon- naitre pour cause tout ce que sur excite Vappareil encephalo-rachidieu;" in its etiology is found excess of all kinds, as well of pleasure as of labor, and the ambitious delirium which is one of its commonest characteristics is . 80 very often only the incessant preoccupation of those whom it attacks in the midst of tiieir need of relaxation, of their insatiable desires. It is only too certain that, in these later years, general paralysis has had many more victims; what we have ourselves observed is confirmed by general statistics. Among epileptics the proportion seems to have diminished: we do not well explain to ourselves from what influences; we state this result. From eighteen hundred and forty-two to eighteen hundred and fifty -three it was, for males, eight and eight tenths per cent; among females, six and four tenths. From eighteen hundred and fifty-six to eighteen hundred and sixty it is only four and thirty-one hundredths among males, and three and. seventeen one hundredths among females. Something here has escaped us, and we are inclined to think that in pre- ceding statistics the number of epileptix3S under treatment were given; in the present, that of the epileptics admitted during the period, which is very different. In both cases the males are rej)resented by a higher figure than the females. Hitherto we have considered only a single side of the question. It remains for us to see what becomes of the insane admitted and treated in the asylums — that is to say, to study the discharges before or after recovery, and the deaths. The proj^ortional number of the insane discharged before or after recovery was fourteen and forty-six one hundredths per cent from eighteen hundred and fifty-four to eighteen hundred and sixty. This number is a little less than that of the period eighteen hundred and forty-two to eighteen hundred and fifty-three, during which it was six- teen and thirty-six one hundredths per cent. But that which was proved at that epoch i§, also found to-day — more males are discharged than females. Insanity of alcoholic origin, which is generally cured quicklj', being more common among males than among females, will in part explain this difference, if we do not also find, to the disadvantage of females, all chronic diseases of the utprus, difficulties succeeding delivery, irregular menstruation, etc. Depression has not so deep or so lasting an influence among males. These are all so many favorable causes which lead to a more certain and speedy recovery. Be this as it may, the proportion of discharges after recovery seems to have diminished — that of discharges before recovery to have increased a little. We do not think, for our part, that the difference can be very great. Many patients leave our establishments, public or private, reclaimed by their friends before their recovery can be completed. The heads of the office report them as improved, but not cured. It is necessary, in order that the estimate may be correct, to know what has become of these con- valescents, who for the most part, attain perfect health. These docu- ments are wanting; all correction is impossible, and the numbers have only an entirely reLitive value. Thus the mean of discharges after recovery, from eighteen hundred and fifty-four to eighteen hundred and sixty, was only seven and seventy-seven one hundredths per cent of patients treated; of discharges before recovery, six and sixty-eight one hundredths per cent. Brierre de Boismont had good reason to say, in eighteen hundred and fifty-nine, that it should not be estimated thus. Too many elements are found in these statistics, and cannot be officially separated to make the estimate correct. Who does not see at once that the general paralytics included in the total number of insane (for exam- ple) fatally condemned to incurability, the epileptics, nearly all in the same condition, make of themselves alone the proportion of the chronic insane considerable; the proportion -per cent of cures is reduced at once 81 before them, and to attain a really scientilic, really correct data, we should take the acute forms presumed to be curable, and then see the results obtained. If we should adopt this course, which after all will not lead to very great complications in the formation of tables, we shall not be discouraged by the disheartening figure of seven or eight per cent of cures. This is the weapon of which the opponents of the law of eighteen hundred and thirty-eight most I'eadily make use. Indeed, to one who has not the power to explain it there is something very sad in these official statements. We are not reduced to a situation as discouraging as might at tirst be believed; and M. Legoyt himself comes to our aid by saying that among the insane treated who are most certainly cured are military and seafaring men. Why? Because they are men in the strength of youth, who are generally attacked by acute, curable forms of mental alienation ; because they are submitted to a care- ful examination at the commencement, and because the disease is treated almost as soon as it appears. General paralysis, which w^e justly accuse of increasing the number of our failures, does not yet appear among them. It is from thirty-live to forty-five years that it commits the greatest ravages. Let one deduct from the total number of insane treated the epile]3tics, the paralytics, the idiots, and the cretins; let him retain the acute forms, in indicating each year the probable prognostics of those remaining under treatment, and he wall see that the recoveries are not so rare aslie thinks. As to the discharges before recovery, we do not attach any more importance to them than they deserve. What are they generally? Fruitless trials which, after short duration, result in return to the asylum. They are escapes followed sooner or later by reentry; thej^ are also transfers from one establishment to another, of which care had been taken to keep an account. A more correct data, and conformable, moreover, to the observations collected by the chefs de service, is that of length of treatment among the insane cured. Of thir- teen thousand six hundred and eighty-seven i]]sane discharged after recovery, sixteen hundred and sixty-three were discharged after a resi- dence in the public or private establishments of one month or less. The greater number, eighteen hundred and eighty-seven, were discharged after five or six months of treatment; fifteen hundred and nineteen after seven or eight months; seventeen hundred and forty-eight in the second month. It is, then, in the first mouths which follow the attack of insan- ity that the cures are most numerous; let us add, also, that they are most certain; yet it might have been important to describe the forms Avhich are most quickly relieved. All insanity of alcoholic origin, especially if the habit of drinking is not inveterate (if there has not been a previous attack), is decided in a period of from one month to six weeks. An attack of mania or of true melancholy {melancolle frcmche) runs its course in five or six months ; a few, nevertheless, have lasted a shorter time. Here the influence of cause makes itself felt, and the influence of constitution; and if one could determine the date of the appearance of the derangement, in view of these speedy cures, he would see that the insane who are soonest improved are those who have been most promptly treated. Moreover, w^e join without reserve in the idea which M. Legoyt has thus expressed: "It is evident that it is the interest of families, and consequently of society, that the insane should be placed under treatment as promptly as possible." As to the season of the year at which the recoveries take place, the following has been observed of one thousand recoveries: 11 82 Months. Males. Females. December, January, February.. March, April, May June, July, August September, October, November Totals 206 195 255 248 280 283 259 274 1,000 1,000 We deem it proper, also, to show the effects of the seasons on mor- tality, and for this purpose insert the following from the Thirteenth Scotch Eeport: " Cold increases the mortality among all classes of the population, and accordingly the deaths in asylums are most numerous in the colder months. But it is worthy of notice that while the mortality of both sexes is higher in Winter than in Summer, there is a difference in the tendency to death in the two sexes in the two seasons. " Of every one hundred deaths which took place in asylums in the six years from eighteen hundred and sixty-five to eighteen hundred and seventy, fifty-three and fifty-four one hundredths took place in Winter, and forty-six and forty-five one hundredths in Summer. The number of deaths of both sexes is greatest in Winter, but the tendency to death is in Summer greater among females than males. This is shown by the following table: Table, Showing the Mortality in Summer and Winter in the Asylums of Scotland for six years, 1865-1870. Summer. May to October. Winter. Xovember to April. Male Mortality. Female Mortality. Male Mortality. Female Mortality. 620 690 789 721 As to age, it is from twenty-five to thirty-five years that the greatest success is obtained; beyond this age the number of recoveries gradually decreases, as the activity of the mental faculties also diminishes. The following are approximately the causes among about one half of the patients recovered of whom, alone, any positive information could be obtained. Drunkenness, seventeen hundred and thirty-eight; domestic disappointments, eleven hundred and seventy-one; various diseases, seven hundred and sixty-one; diseases peculiar to females, seven hun- dred and twenty-three; religious excitement, four hundred and sixty. Hereditary tendency has been noted among fifteen hundred and twenty- two cured — about fifteen per cent. The mortality appears to have increased slightly in the asylums in 83 the period included between eighteen hundred and fifty-four and eigh- teen hundred and sixty. In the preceding years it was thirteen and seventy-five one hundredths per cent; in these hist seven years it has been fourteen and three one hundredths per cent. It is unnecessary to seek for reason other than the cholera epidemic of eighteen hundred and fifty-four. It decreased in eighteen hundred and fifty-nine to thir- teen and eighteen one hundredths per cent, and in' eighteen hundred and sixty to twelve and fifty-seven one hundredths. Of an equal number, one hundred and thirty-one males die to one hundred females. More than twelve per cent of the mortality among the insane took place within the first month of residence in the asylum, and this number, rela- tively very large, has given rise to explanations which are not in accord- ance with facts. It is said that " the cause of these speedy deaths must be the arrest, the violent agitation, the deep disappointment which patients must experience on being abruptly separated from their fami- lies — confined, without knowing the reason, in this violent way." This is not the truth. The insane who die so quickly bring to the asylum the diseases under which they sink. We have means to prove that there is only a very small number who have a semi-consciousness of change of i^lace. Not to extend the limits of this resume, we shall present the figures for three years only. We have gathered them ourselves, we know all the particulars of the disease, and we can prove that moral disturbances have counted for nothing in the rapidity of the fatal termination. What we have noticed many officers have also observed, and Brierre de Bois- mont has devoted himself to refute an opinion wiiich has not failed to produce a sad impression. Figures seem to err. It is evident that more than one fourth of the total number of deaths are to be attributed to the first three months. But why? It is because frequently there are brought to the as^dum poor patients attacked sometimes with cerebral tumors; sometimes with organic diseases of the respiratory, digestive, or circulatory organs; sometimes with pneumonia and fevers; sometimes with alcoholic intoxication with complication. They have been cared for as far as could be at home. They have only been sent aw^ay when frightful hallucination, continued shrieks, and ungovernable impulses have made it dangerous or impossible. A few days more and they would have died at home. They are brought; the journey is very fatiguing to them; they arrive exhausted; they sink in the midst of a delirium which has not even allowed them time to perceive that they have been confided to the hands of strangers. The asylum, then, should not be accused; it is the first disease, of which insanity is then only an acci- dental manifestation. One may better judge from the following table, which sums up our professional observations. In eighteen hundred and sixty-four, of fifteen deaths (eleven males, four females), six died in less than a year after their admission: 84 Nature of the Disease. Length of Residence. 1. 70 jears 2. 33 years 3. 48 years 4. 80 years 5. 31 years 6. 17 years Delirium tremens, third attack; epilep- tic (^pileptiformes) convulsions Acute delirium, agitation, and constant shrieks (cris); nervous exhaustion Consumptive; cavernes aux deux som- mets; delire de persecutions ^ Sordid avarice; privations of all kinds; allowing himself to starve in a garret. Interference of the Commissioner of Police. Inanition Typhoid fever, with hallucination and delire de persecutions; pneumonie h3'postatique Toung woman married fifteen days pre- vious. Acute delirium; proved her- editary • • ■ Left May 7th, 1863 reentered .lanuary died the 13th; four Three weeks. Eight days. Two days. Twenty-nine days. Fifteen days. ; relapse; 9th, 1864; days. In eighteen hundred and sixty-five, of eleven deaths (nine males, two females), five died in less than six weeks after admission: 1. 2. 45 years 28 years 34 3^ears 36 years 54 years Nature of the Disease. Complete dementia (demence) with general paralysis; cerebral congestion; epileptic convulsions General paralysis a marche galopante; m^ningo enc6- phalite suraigue Meningo encephalite; maniacal delirium; official entry: nervous exhaustion produced by constant agitation.... Dementia, with general paralysis progressing rapidly; appearance of disease six months before; venereal excess; increasing debility (atfaiblissement) Consumptive; hallucination and delire de persecutions; agitation; death rather sudden Length of Res. One month. Six weeks. Eight days. Fourteen (fays. One month. In eighteen hundred and sixty-six the mortality reached a very high figure. From January first to September first we had twelve deaths — ten males, two females. Five males and one female died in the first month. We have rarely had a year more unfortunate in this respect. It will be seen in consequence of some sad circumstances, all accidental, moreover, that the length of residence has been so short. 85 Nature of the Disease. Length Kesidence. 1. 87 years 2. 44 years 3. 28 years 4. 48 5'ears 5. 26 years 6. 39 years Appearance ten days previous; carried to the City Hospital, where his stay was impossible from his excitement and shrieks; acute delirium; pulse fili- forme General paralysis; complete dementia; convulsed condition Young priest; sick for a month at the seminary; ex- citement and shrieks which territied his colleagues and prevented their keeping him longer; six hours travel by rail; extreme exhaustion; pulse at one hundred and twelve; typhoid condition General paralysis, dating three years back; cared for until now at home, but for some time creating all sorts of difficulties; intestinal obstructions; bal- lonnement 6norme du ventre; asphyxie par com- pression • Alcoholic excess having caused two previous attacks of delirium tremens; sick for fifteen days in a hotel, where he continued to drink; frightful hallucina- tion, shrieks, and violence; on entering, coldness of the extremities; pas de pouls ._ Woman . Dread ; sleeplessness ; d^lire lypenianiaque ; refused food; then acute delirium; maniacal ex- citement Twenty-four hours Six weeks. Three daj'^a. A half hour. Fifteen hours. Fifteen days. It may be thought that we have dwelt too long upon this point; but it seemed to us iniportant to present these facts with some details; it is not possible to imagine them when one has only figures before his eyes; but to every impartial mind it will be very apparent that the mental condition of those persons who died so quickly after their admission scarcely allowed them to appreciate the new situation provided for them by entry into the asylum. Not the arrest, then; not excited feelings — nothing but serious physical conditions, which of themselves were suf- ficient to produce death. Thus that sort of accusation which charges the asylum with a mortality whose very natural explanation need not be so far-fetched, falls of itself. There still remain a few subjects of comment. M. Legoyt completed his work by researches which, properly speaking, only the administration promotes. We do not stop there; we think we have said enough to set forth the qualities which characterize his work, at the same time con- scientious, impartial, and moderate in its estimates. If we do not always agree with him, it is because we look from a difterent point of view, placed as we are in conditions of special observation which allow us to go to the root of things. But we are pleased to acknowledge that it was impossible to have done better; and such as it is, the statistics from eighteen hundred and fifty-four to eighteen hundred and sixty constitute one of the most interesting documents of the annals of mental alienation. Does this important work which we wish to show accuse us of a situ- ation as fearful as has been represented? We do not think so. It is impossible to deny an increase in the number of admissions; but it is just also to acknowledge that if the special causes which we have enu- merated have favored this increase, there is now a tendency towards an equilibrium, which we hope soon to see definitely established. Our regretted colleague, Parchappe, has noticed, with all the authority of a long experience, a few of these questions, in a discourse delivered last 86 year before the Medical Psychological Society at Paris.* We will not attempt, after him, to rehabilitate our asylums; whoever desires to be enlightened will ascertain very quickly the general movement, which, on all sides, tends towards progress, towards perfection, and, conse- quently, towards the amelioration of the lot of the insane. The statistics themselves prove to what extent everything is regularly conducted, seriously observed. The documents of which it is constituted were not obtained by an idle or ill-directed administration. There is in the supe- rior as in the inferior ranks of administrative hierarchy a unity of aims and tendencies which should suffice to reassure those who are disturbed because they do not well understand the subjects upon which they com- ment; for ourselves, who are witness of these efforts, who heartily unite in them, we cannot, without regret, see our intentions undervalued; we regret that we are judged with a frivolity which we should not have suspected among men ^^^lose habits of serious investigation should have given them an immunity from such deviations. We think that, in view of this formidable scourge, insanity, it w^ere more generous to assist us, to sustain us in our sad task, than to create obstacles and to discourage us sometimes by unjust suspicions. Happily, duty accomplished brings its recompense with it; and if, in later times, we have been the object of attacks little deserved, this justice will at least be done us, that we have never refused to reply, not ujDon the ground of delusive theories, but upon that of facts. It has seemed expedient for our cause to review the work of a man as enlightened as capable, placed by his official situation in that quiet region penetrated neither by the spirit of party nor adven- turous ideas. We have made numerous drafts upon M. Legoyt, and when, in some matters of detail, we disagree with him, it is because we have had in our hands documents which he always lacked. The statistics which he has published, more complete than those which preceded, are, in our idea, a work of rare value. They are one of the best arguments which can be presented to those who try to believe that we allow our- selves to be soothed by that easy quiet which accepts the past for fear of disturbing the future. CHAPTER YIII. INSANITY AMONG THE ANCIENTS. COMPARATIVE VIEW OF THE CONDITION AND TREATMENT OF THE INSANE AT DIFFERENT PERIODS AND IN DIFFERENT COUNTRIES. In the time of the Ancients — In the Middle Ages— In the Eighteenth and Nineteenth Centuries — In England — In Erance— In Kome— In the Germanic Confederation — Observations upon Foregoing Subjects — Cruel Treatment the Kesult of Ignorance — New York Poor Houses — Amelioration in the Treatment of the Insane as compared with Former Periods — Proof of the Advantage of Moral Treatment. The ancients regarded insanity as the result of some supernatural power; a visitation from some God, at whose shrine the person affected had refused to worship, or as a punishment for irreverance or crime; but the psychologists of modern times have endeavored to explain its mysterious eifects on scientific principles. Some contend that the mind * Annals MMico-Psychologiques, 1865, p. 66. 87 alone is diseased; others that it is a disease of both body and mind; while the great majority regard it as " a disease of the brain affecting the mind;" and while the latter theory accords with our views, and is most readily understood, w^e propose to enter into no argument with those who have lulvanced and still maintain a different view, nor is it a part of the purpose of this report to enter into any metaphysical discus- sion on the various theories that have been advanced in this or any former period of time. That it is a disease in some shape, all will admit. That it is extremely curable when properly treated in its earliest stage, none will deny. That it is equally intractable and unmanageable after it has fixed itself upon its hapless victim, is a fact that those best acquainted with its subtle nature most deplore. It seems to be an inevitable if not a natural attendant upon the human race. It has been present among men from the beginning, or from the earliest records to the present day. The feigned madness of Ulysses,* immediately prior to the Trojan war, is perhaps the earliest reference in antiquity to the existence of mental disease — otherwise the madness of Saul claims priority. Ajax was seized with madness after the arms of Achilles had been awarded to his rival Ulysses. Orestes is also described as a madman by his sister Electra. The "heaven inspired Cassandra" was regarded by the Trojans as insane. Plato alludes to the connection of divination and insanity, the prophetess at Delphi and the priestess at Dodona both being considered as insane. The Sybil and others being classed in the same category, they were said to possess the mad art. Several other allusions are made to madness by Plato and other writ- ers of antiquity. Euripides makes many allusions to madness, and the power of Bacchus to produce it. Lycurgus, King of the Edones in Thrace, refused to worship Bacchus, in consequence of which the God visited him with madness. The three daughters of Praetus, Lysippe, Iphinoe, and Iphianassa, are fabled to have become insane in consequence of neglecting the worship of Bacchus. They ran about the fields, believ- ing themselves to be cows. Praetus is represented to have applied to Melampus to cure his daughters of insanity, but refused to employ him when he demanded a third part of his kingdom as a reward, reminding us of the enormous sums received by Willis for his attendance on George III and the Queen of Portugal. This neglect of Praetus was punished, and madness became contagious among the Argive women. The persons affected, however, as also the daughters of Praetus, were restored on Melampus being feed in a more liberal manner. Athamas, King of Thebes, and Ino, his second wife, were both said to be insane. Medea, the niece of Circe, Cambyses, Clomenes, King of Sparta, and many others might be mentioned. Hippocrates makes many allusions in his writings to mania, melancholia, and epilepsy. He says that men ought to know that from nothing else but thence (the brain) come joys, despondency, and lamentations. , By the same organ we become mad and delirious; and fears and terrors assail us, some by night and some by day. Diodes (B. C. 300) and Asclepiades also discuss this subject in their writings, and the Eoman poets frequently allude to it. Persius and Juvenal both speak of hellebore as a remedy for madness. From the foregoing extracts we learn that the causes of insanity were * See Bucknill & Tuke on Insanity. 88 supposed to be very different in the olden time and at the present day. We might therefore very naturally expect a different mode of treatment corresponding with the pathological opinions of the two periods. This, to a certain extent, is true, yet it will he interesting to the non-profes- sional reader to learn how this fearful malady was treated by the doc- tors of that day. It is a remarkable fact, as we learn from Bucknill & Tuke, that some of them at least were as earnestly opposed to the use of mechanical restraint as were Pinel, Charlesworth, Hill, or Conolly, who immortalized their names in the seventeenth century by advocating in theory and carrying out in practice the non-restraint system that has done so much to ameliorate the condition of the insane in the asylums of the 2^1'esent day in most of the enlightened countries of the world. Bleeding, so much in vogue at a later day, was also condemned by one at least of these celebrated men, as we will see by the following: OPINIONS OF ANCIENT MEDICAL WRITERS ON THE TREATMENT OF THE INSANE. * Music is the first recorded remedy employed, so far as we are aw^are, for the relief of madness. That ancient musician of whom it has been said that he struck tones that were an echo of the sphere harmonies, "took an harp and played with his hand; so Saul was refreshed and w^as well, and the evil spirit departed from him." Music ajDpears to have been strongly recommended by Asclepiades. Asclepiades was certainly one of the most definite in his directions in regard to the treatment of the insane. As we have already said, he pre- scribed music. He especially recommended that the patient should abstain from food, drink, and sleep, in the early part of the day; that in the evening he should drink water, that then gentle friction should be applied, while later still, liquid food should be given, with a repetition of the frictions. By these means sleep was supposed to be induced. He regarded as Avorse than useless the application of narcotic fomentations, referring specially to hyoscyamus, mandragora, and poppies. Such reference to these remedies is interesting, as showing their use prior to the time in which he flourished. He directed that the patient should be placed in the light. To employ bleeding, was, he thought, little short of madness. According to Csclius Aurelianus, Asclepiades ordered his patients to be chained. Feuchtetsleben in his Medical Psychology, states that Asclepiades recommends "that bodily restraint should be avoided as much as possible, and that none but the most dangerous should be confined by bonds; " referring to Celsus and Cadius Aurelianus as his authorities for the opinions of Asclepiades, whose works are lost; but neither of these writers appears to assert so much. Themison, another disciple of Asclepiades, and who is often regarded as the real founder of the School of the Methodici, styled " phlebotomotos " by Cselius, followed, to a considerable extent, in the steps of his predeces- sor as regards treatment; but prescribed the bath and more liberal regimen, and ordered astringent fomentations (constrictira fomenta). The treatment recommended by the celebrated Celsus, in his chapter entitled, JDe tribas insanice generibus, may next be considered. On the whole, the directions of this physician are harsh, and scarcely merit the praise which some authors have bestowed upon them. It is true, that he admits, in regard to those who ramble in their discourses or attempt Bucknill & Tuke on Insanity. 89 some trifling injury with their hands, that it is unnecessary to employ any rough, coercive measures. He deemed it proper, however, to subdue those who were more violent by a very compulsory treatment, " lest they should injure themselves or others." Their audacity must be coerced, and they must be brought to submission by blows, as in the case of any one else who requires restraint. Excessive mirth must be checked by scolding. If conciliatory measures fail, patients must be cured by some kind of torment; thus, should they be detected in false- hood or deceit, they must be hungered, or bound in chains, or flogged. By these means, he assures us, they will before long, through the influ- ence of fear, be thoroughly disposed to come to terms, to eat anything; and even their memory, he says, will thus be refreshed. For to startle them suddenly, and greatly to terrify them, is profitable in this disease; anything, in short, by which the mind is violently disturbed. To close up all the avenues of pity this humane physician also says that you are not to believe anyone who thus subdued, while he is desirous of being released from his bonds, pretends that he is sane, however prudently and piteously he may converse, since this very deceit is the result of madness. On which enlightened principle it is difiicult to understand how Celsus himself wouldhave escaped had he once been so unfortunate as to be suspected of insanity. Celsus by no means, however, over- looked all medical treatment. "He approved of venesection, and of cup- ping applied to the head, which, he observes, will have the effect of inducing sleep. Should any symptom render bleeding unsuitable, the next best remedy is abstinence, followed by an emetic and a purgative of white hellebore, and if possible the employment of friction twice in the day. He is here speaking of those cases in which sadness appears to be the result of black bile. jSTo longer under the influence of apprehension from the violence of the patient, Celsus directs that fear should be removed from his mind, and cheerful hopes excited; pleasure being- sought in fables and sports, and whatever else may be conducive to health. Patients are to be judiciously encouraged in their several occu- pations, and their groundless fears are to be lightly reproved. Cold water is also to be poured upon the head of the patient, and his body immersed in water and oil. In maniacal cases, warm fomentations might be applied to the shaven head; when, in consequence, the febrile symp- toms abate, we are to have recourse to friction; but we must use it more sparingly in those cases in which the patients are exhilerated than in those in which they are depressed. In the maniacal paroxysm itself, however, Celsus had not much faith in medical applications; indeed, he was afraid that by such means the fever would be increased. There- fore in such cases, says he, do nothing with the patient but confine him. Severe as was Celsus upon the insane who were guilty of deception, he had no hesitation in employing similar means towards the patient, AYe need not quarrel with the direction, that should the patient refuse to swallow the doctor's favorite hellebore mixture he is to be deceived by having it mixed in his food; but we may well dissent from the pro- priety of another direction, namely: that should it be necessary to inspire fear, and should the patient be a rich man, you are to announce to him the false intelligence of a lost estate. The good effect of a full diet in some cases of insomnia was very properly pointed out. Other somniferous remedies prescribed by Celsus were friction, exercise after food, and by night the sound of a waterfall, 12 90 but chiefly the rocking motion of a suspended bed. Kor were the sooth- ing influences of music in melancholy overlooked. The mind was also to be called forth in some cases b}^ reading aloud, and occasionally errors might be made in order to elicit the critical powers of the patient. Cselius regarded it as essentially necessary to i^lace the maniacal in a room • moderately light and warm, and to avoid everything of an excit- ing character. Pictures were not to be allowed, nor was the window to be too high, nor was the room to be in the u^Dper story, the reason being added that many when seized with madness have thrown themselves out. The bed was to be firm, and so placed that the patient could not be disturbed by the sight of persons entering the room; it was to be of straw, soft, and well beaten, but not broken. If the j^atient was in dan- ger of injuring himself, soft wool moistened was aj^plied to the head, neck, and chest; thus instead of having a padded room Cselius padded his j^atient. The duty of attendants, in regard to deception, is clearly laid down. They were to beware on the one hand of seeming to con- firm the patient's delusions, and thus increase his disorder, and on the other they were to be careful not to exasperate him by too much oppo- sition, but at one time by indulgent condescension, at another by insinu- ation, endeavor to correct his delusion. Should the patient attempt to escape and be with difficulty restrained or exasperated with seclusion, then, says Cselius, with admirable perception, 3-ou must employ more attendants. Let these, he adds, without the patient perceiving the real object in view, engage themselves in applying friction to his limbs. Further: should this treatment fail, and the violence be great, a ligature may be resorted to, being quietly applied, and the limbs protected by wool. Should the patient have been accustomed to submission and rev- erence, this, he observes, will not require frequent repetition — for such repetition would induce contempt, and when patients do not yield to such a course of treatment, then it becomes necessary to subdue them by inducing fear or awe. Should the patient's eyes be affected by the light, they must, according to our author, be shaded; but, he adds, with great discrimination, in such a way that other parts of the body may not be deprived of light. Cselius directed that abstinence from food might be carried so far as to induce slight hunger, adding that the strength may be reduced by bleeding, if the malady require it, even during such abstinence should there be nothing present to contra indi- cate it. The food was to be light and digestible, as bread softened in warm water, or a preparation of wheat lightly boiled with honey, etc. Alternate days of fasting and feeding were likewise recommended. Benefit also might be derived from clysters, and the application of an emollient cataplasm to the region of the heart. Should the disorder become stationary, Calius advises the head to be shaved, and cupping to be applied, first over the chest, then between the shoulders ('• for these parts sympathize with the head "), and next to the head. A restless and sleepless condition was to be relieved by carrying the patient about on a litter or in a chair. To this was to be added the monotonous sound of running water. Fomentations, by means of warm sponges, were to be aj^plied over the eyelids, with the idea of relaxing them, and in the hoj^e of exerting a curative influence over the meninges of the brain. As reason returned, moderate exercise was strongly recommended — riding, walking, and exertion of the voice. The patient was to read compositions containing inaccuracies, in order the better to exercise the understanding; but Caslius adds a caution that this must not be too difficult, lest the patient be overdone with laborious 91 mental exercise, which were as detrimental to the mind as immod- erate exertion to the body. Theatrical entertainments were to follow for those laboring under melanchQly, and scenes of a solemn or tragic character were to^coiinteract excessive hilarity and excitement. Subjects of disputation might be added as the patient recovered, con- ducted in a low tone of voice, the preference being given to narrative and demonstrative subjects. Further, individuals known to the patients were to be employed to converse with them, in a manner calculated to encourage and aiiiuse them. These various mental exercises were to be followed by rubbing Avith oil, and a gentle walk. Here, our author suddenly remembers" that much of the preceding treatment could not be carried 'out with the illiterate; for such, he prescribes questions having reference to their particular callings; as, on farming, for the agricul- turist; navigation, for the sailor; and for those ignorant even of these, questions of a general nature must be propounded. Shampooing, as well as inunction, was an important remedy with Calius, including frictions of the head. The diet was to be improved as the patient's health returned, wine being forbidden in the lirst instance, gradually allowed after the use of fruit, but then only of light quality. As the mind recovered its tone, the patient was allowed to go and hear the disputations of the i^hilosophers, from the persuasion that the passions of grief, fear, and anger were thus dissipated. If, on the con- trary, the patient relapsed, the former treatment was to be resumed, adding exposure of the body to the heat of the sun, the head being covered. The administration of an emetic made from the root of white hellebore, was to be added, to which, if the patient objected, vomiting was to be promoted by tickling the fauces. The ears were to be injected with water containing a little nitre, honey, nettle seed, or mustard; the rationale given being, that even through the channels of the senses, a resta»-ative virtue may be conveyed to the membranes of the brain, especially as patients are often affected with tinnitus aurium. Finally, the cure of the patient was to be established by travelling and sea voyages. After thus stating the mode of treatment which recommended itself to his judgment, C^lius proceeds to condemn the practice of some who had preceded him. Some of the Methodici, he observes, have recom- mended close confinement in a dark room, forgetting that the patient's dislike to it may aggravate his disorder, and that too much seclusion from the air causes dense bodies to perspire, and that the omission of ordinary occupations will aggravate cerebral congestion. He then denounces the extreme abstinence which was recommended, in forgetful- ness of the fact that such a course disorders the bodily powers and is one which the patient will be unable to bear. The supporters of such regimen referred to the taming of wild beasts as analogous and as a proof that madness may be thus repressed; but Ceelius, anticipating the practice of the present day, states that they should have known better from a consideration of the effect of hunger upon the sane in inducing rage. He does not hesitate to assert that the starving system will induce madness rather than cure it. He then refers to a subject of especial interest to us in our time, and his observations are calculated to humiliate us, exhibiting, as they do, a far seeing philanthrophy which those who have treated the insane have, until very lately, failed to imi- tate. Cselius observes that they also order the patients to be bound with chains, without any consideration that the bound parts must neces- sarily be chafed, and how much more properly the patients might be 92 restrained by the care of attendants than by senseless chains. He is alike indignant against those who would coerce by flagellation, especially about the face and head, which, so far from relieving the disease, only induces swellings and sores; in addition to which, the returning con- sciousness of the patient could not but be hurt by the sense of his wounds. In regard to the relative advantages of cold and warm applications, Cselius sjoeaks of those who endeavor to induce sleep by warm fomen- tations of poppy, thyme, roses, etc., and observes, in accordance with the view attributed by Calius to Asclepiades, that the result is heavi- ness of the head, but not sleep — constriction being induced, when relaxa- tion is required. He then refers to an ojDposite school who made use of cold applications, believing the disorder to be caused by heat; ignorant, he observes, that internal heat is an undoubted sign of congestion, and not, as they think, the cause of the disease. He condemns the hydro- pathic treatment as being calculated to increase congestion, and there- fore to aggravate the patient's disorder. In regard to the important question of venesection in mania, Ceelius comments upon the practice of those who employed excessive bleeding from both arms to the extent of syncope and even death, and observes that the abstraction of blood from both arms is not to be j)racticed in consequence of the fearful prostra- tion of strength which may follow. Clysters he regarded as worse than useless, often inducing dysentery in consequence of the active ingre- dients which they contained. Among the many strange and opposite modes of treatment to which the insane have been subjected, intoxica- tion was not overlooked. Some, our author observes, recommend intoxi- cation, since madness is often caused by it; but without sufficient dis- crimination, since injudiciously used it may prove injurious. The plea- sures of love, which were prescribed b}^ Titus and Themison, were strongly condemned by Caelius, who regards as impious and ab^rd the attempt to indulge propensities which required restraint. In the chapter which treats of melancholy, Cselius observes that the treatment is the same as has been already prescribed for the maniacal. He would not bleed, nor depress the patient by purging him with helle- bore and aloes, but at once soothe and invigorate him by emollient and astringent applications. The celebrated Galen, of Pergamos, flourished at a period but little subsequent to C^lius Aurelianus. He is said to have died at the age of ninety, A. D. one hundred and' ninety-three. His treatment was based upon the humoral pathology, which was in such high repute among the ancients, and which exercised an almost universal influence on their practice. He lays it down that, if moisture produces fatuity and dryness sagacity, just in proportion to the excess of moisture over dryness the sagacity will be diminished. Hence, he advises the practitioner to aim above all things at preserving a just me- dium between these opposite qualities. He recommends that " should you be of opinion that the whole of the patient's body may contain mel- ancholy blood " you are to employ venesection, especially from the median cephalic vein. He adds, that should the blood flowing from it not appear to be of a melancholy quality, the vein must immediately be closed; and that should the contrary be the case, you are to abstract as much blood as the state of the patient and his habit of body shall permit. If, how- ever, madness arise from idiopathic disease of the brain, bleeding is by all means to be avoided. In forming an opinion on this subject, regard was to be had to the patient's constitution and temperament. The fat, the fair, and the flabby were not to be supposed to possess any melan- 9S choly humor; but the lean, dark, and hairy, and those in whom the veins are large, are the most subject to its accumulation. He gives a long enumeration of the kinds of food which induce melancholy, as the flesh of oxen, goats, but especially asses and camels, and also wolves, dogs, hares, and snails. Among herbs, the cabbage only is mentioned. Thick and black wine was to be particularly avoided, " as from it the melan- choly humor is made." This melancholy humor is spoken of by Galen as a condition of blood "thickened, and more like black bile which, in- deed, exhaling to the brain, causes melancholy symptoms to affect the mind." We frequently also notice, he observes, that when yellow bile is contained in the stomach, the head is painfully aifected; but it imme- diately recovers when the stomach is relieved from bile by vomiting. In mild cases of insanity Galen prescribed the bath and nourishing food. IN TQE MIDDLE AGES. We have thus taken a hurried glance at the opinions of the ancients with regard to the pathology of this mysterious disease, and of the treatment employed by them for its cure or amelioration, and it is strange, indeed, that we hear but little more of it until about the period of the reformation. It is true that an asylum is said to have existed at Jerusalem about the fifth century, but little seems to be known of its character, history, or the modes of treatment employed. Again, at a period assigned by tradition, about eleven centuries ago, the tragic death of the Irish girl, the Princess Dymphna, who was slain by the hand of her own father, led to the establishment of a church and altar at Gheel, in Belgium, where those afflicted with " minds diseased " were carried to intercede with the spirit of the patron saint for relief; and a number of these unfortunate victims, more or less numerous, are supposed to have been kept there ever since; till now it has grown into one of the most remarkable institutions for the insane that anywhere exists. The next asylum established, so far as we are able to ascertain, was that of "Eeinier Van Arkel," at Bois le Due, in Holland. It bears the name of its philanthropic founder, who established it in fourteen hun- dred and forty-two, for the care and custody of six unfortunate persons who had been deprived of their reason. From this small beginning, it has continued to increase, till it now has capacity for six hundred patients; but on the first of December, eighteen hundred and seventy, three hundred of its inmates were removed to a new asylum, just finished, a short distance from the city. At the time of our visit — seventh of July, eighteen hundred and seventy-one — there were one hun- dred and seventy men and one hundred and fifty-six women within its walls. The old asylum is immediately on one of the business streets of the city, and has been so often added to and enlarged that it can be said to possess no particular plan. It still retains many evidences of the age in which it was built, and shows more clearly than anything we have elsewhere seen, the wonderful and beneficent improvements that have been made in the character of the buildings for the treatment of the insane. Small dark cells, with high small windows, and cribs in which to cage the excited patients, may still be seen, and we regret to say have not yet been entirely abolished in this and one or two other asylums visited on the continent. The douche, solitary confinement, and confine- ment to the chair, are also used in some cases, not as a part of the treat- ment, but for punishment — showing how difficult it is even yet, in some countries, to shake off old habits and adopt new ideas in the treatment H of the insane. The inquiring mind of the young and intelligent physi- cian, Dr. Frijbank, will doubtless soon lead him to discard all of these old appliances, and to adopt the more humane and enlightened practice of the age in which he lives. Indeed, it is but just to say that he has already done so in most respects. As another link in the history and treatment of this malad}^, the fol- lowing extracts will show the condition of the insane in asylums in the eighteenth and nineteenth centuries: IN ENGLAND. '' The reader of Caelius Aurelianus cannot but feel astonished when he 'finds that nearly eighteen hundred years after that humane physician flourished it could be said in the House of Commons, by the Earl of Shaftesbury (then Lord Ashley), that the whole history of the world, until the era of the Eeformation, does not afford an instance of a single receptacle assigned to the protection and care of these unhappy suffer- ers, whose malady was looked upon as hardly within the reach or hope of medical aid. If dangerous, they were incarcerated in the common prisons; if of a certain rank in society, they were shut up in their houses, under the care of appropriate guardians. Chains, whips, dark- ness, and solitude were the approved and only remedies. " It is, indeed, to be feared that the directions of Celsus have exercised a most prejudicial influence, even till within a very recent period; and it is not difficult to recognize them in the w^ritings of the classical Cullen, who did not omit to recommend the employment of 'stripes' in the treatment of the maniacal. " The kind of treatment pursued by the highest medical men four hun- dred years ago is pretty clearly indicated by what has been handed down to us relative to the psychological history of King Henry YI, in whom mental disease was hereditary. Thus we are informed that five physicians and surgeons were appointed to attend the royal patient, and were empowered to administer 'electuaries, potions, and syrups, confec-' tions and laxative medicines, in any form that might be thought best; baths, fomentations, embrocations, unctions, plasters, shavings of the head, and scarifications.' " It is not a little singular that Bethlem Hospital, which has become on various occasions so notorious for its ill treatment of the insane, should in the first instance have provided for their care Vv-ith benevolent intentions, and under some favorable auspices. It was in the year fifteen hundred and forty-seven that Henry YIII took possession of the monastery or hospital of St. Mary of Bethlem, and presented it to the City of London, with an order that it should be converted into a house for the .reception of lunatics. It w^as situated in Bishopsgate AYard, without the city wall, between Bishopsgate street and Moorfields. Stow describes it in his time as standing in an obscure and close place in the neighborhood of many common scAvers, and as also too small to receive and entertain the great number of distracted persons, both men and woinen, who stood in need of it." In consequence of the want of further provision for lunatics in London, a large building was erected in sixteen hundred and sevent^^-five in Moorfields, where the hospital stood until eighteen hundred and fourteen. There was, in a short time, accommodation for one hundred and fifty patients; whereas, in the old building, there were usually but fifty or sixty. In the rules made March thirtieth, sixteen hundred and seventy- 95 seven, to which it is interesting to refer, it is ordered inter alia, that such of the lunatics as are fit should be permitted to walk in the yard until dinner time, and then be locked up in their cells; and that no lunatic that lies naked, or is in a course of physic, should be seen by anybody without an order of the physician. It is further humanely ordered that no officer or servant shall beat or abuse any lunatic, or employ any force to them, but upon absolute necessity for the better governing of them. Dr. Tyson, who was physician to Bethlem from sixteen hundred and eighty-four to seventeen hundred and three, informs us that, as to the care and cure of the patients, here is undoubtedly the greatest provision made for them of any public charity in the world; each having a con- venient room and apartment to themselves, where they are locked up at night, and in it a place for a bed, or if they are so senseless as not to be fit to make use of one, they are every day provided with fresh, clean straw. Those that are fit for it, at convenient hours have liberty to walk in the long galleries, which are large and noble. For the Summer time, to air themselves, there are two large grass plats — one for the men, the other for the women; in the Winter, a stove for each apart, w^here a good fire is kept to warm them. In the hot weather, a very convenient bath place to cool and wash them; which is of great service in airing their lunacy, and is easily made a hot bath for restoring their limbs when numb, or cleaning and preserving them from scurvy, etc. Their diet is extraordinary good and proper for them, which every week is viewed by a committee of the Governors. * * * There is nothing of violence suffered to be ottered to any patient, but they are treated with all the care and tenderness imaginable. If raving or furious, they are confined from doing themselves or others mischief; and it is to the credit of the hospital that in so great a number of lunatics that are con- stantly kept there, it is very rare, in many years, any one jDatient makes away with himself. * * * The time of cure is uncertain ; some have been cured in a month, others in two or three, and some continue dis- tracted many years." This was written early in the eighteenth century.* In seventeen hundred and thirty-four, considerable additions were made to Bethlem, and, in consequence of its still proving inadequate to meet the demand. Saint Luke's Hospital was established in seventeen hundred and fifty-one, by voluntary subscription. It was situate on the north side of Upper Moorfields, in a locality called Windmill Hill. From this period to the latter part of the eighteenth century but little progress was made in the treatment of the insane, and in the con- dition of the houses where they were received; indeed, as respects Bethlem it is probable that its state had retrogaded rather than advanced. In the middle of the century (seventeen hundred and fifty -five) a work was published the title of which appears significant, this was " Folly Predominant; with a Dissertation on the Impossibility of Curing Luna- tics in Bedlam." From time to time during this period a work made its appearance on the subject of insanity. Thus, in seventeen hundred, Herwig published his "Art of Curing Sympathetically or Magnetically; with a Discourse on the Cure of Madness;" and, five years later Fal- lowes enlightened the world with his "Method of Curing Lunatics." "*In the General Eegulation of Bethlem Hospital for 1792 we find the following orders: " No lunatic shall be put in chains without the instructions or approval of the apothecarj'. " The feet of the lunatics who are chained shall be carefully examined, well rubbed and covered with flannels every morning and evening through the Winter; and if aiw morbid symptoms require the presence of the surgeon, he shall at once be informed."— Sections 9 and 10. 96 Blakeway wrote in seventeen hundred and seventeen ( "Essay toward the Cure" of Eeligious Melancholy,") and Frings in seventeen hundred and forty-six (Treatise on Phrensy.) Batty wrote his treatise on mad- ness in seventeen hundred and fifty-seven. But none of these works deserved or gained much reputation. Perfect, whose first work on the subject was written in seventeen Hundred and seventy-eight, made some valuable contributions to the knowledge th>n possessed regarding insan- ity. His treatment appears to have consisted chiefly in venesection, emetics, setons, digitalis, antimony, and electricity. Dr. T. Arnold pub- lished the first edition of his excellent " Observations on the nature, kinds, etc., of Insanity," in seventeen hundred and eighty-two. This work, however, contains little or nothing in regard to treatment. A few years afterwards (seventeen hundred and eighty-nine), " A Treatise on the real cause and cure of Insanity," was published by Harper, which, although it possesses no merit, has, however, the honor of hav- ing been criticised by Pinel. In seventeen hundred and ninety appeared '' Observations on the general and improper treatment of Insanity," by Faulkner; and the "Observations on Maniacal Disorders," by Pargeter, in seventeen hundred and ninety-two. But none of these writings appear to have exercised any material effect in ameliorating the condi- tion of the insane in England!^ This, unfortunately, is but too correctly described in the following graphic sketch from the pen of Dr. W. A. F. Browne ("What Asylums were, are, and ought to be:") "Let us pass a few minutes," he says, "'in an asylum as formerly regulated, and from the impression made W so brief a visit let us judge of the effects which years or a lifetime spent amid such gloomy scenes were calculated to produce. The building is gloomy, placed in some low confined situation, without windows to the front, every chink barred and grated — a perfect gaol. As you enter a creak of bolts and the clank of chains are scarcely distinguishable amid the wild chorus of shrieks and sobs which issue from every apartment. The passages are narrow, dark, damp, exhale a noxious effluvia, and are provided with a door at every two or three yards. Your conductor has the head and visage of a Carib; carries (fit accompaniment) a whip and a bunch of keys, and speaks in harsh mono- syllables. The first common room you examine — measuring twelve feet long by seven wide, with a window which does not open — is perhaps for feniales. Ten of them, with no other covering than a rag roiind the waist, are chained to the wall, loathsome and hideous; but, when addressed, evident!}^ retaining some of the intelligence and much of the feeling which in other days ennobled their nature. In shame or sorrow, one of them perhaps utters a cry; a blow, which brings the blood from the temple, the tear from the eye — an additional chain, a gag, and inde- cent or contemptuous expression — produce silence. And if 3^ou ask where these creatures sleep, you are led to a kennel eight feet square, with an unglazed airhole eight inches in diam.eter. In this, you are told, five women sleep. The floor is covered, the walls bedaubed with filth and excrement; no bedding but wet decayed straw is allowed, and the stench is so insupportable that you turn away and hasten from the scene." " From the evidence given before the memorable committee of the House of Commons, in eighteen hundred and fifteen, notwithstanding the equivocation and evasion Avhich marked many of the replies, it is not difficult to form an estimate of the condition of the English asylums generally, more especially the York Asylum and Bethlem Hospital. Nor was the condition in which they were found at that period alone revealed; their past condition was at the same time rendered manifest. 97 "A miserable and empirical routine marked the treatnurt. To the question: ' Has there not been a rule in the hospital for a certain number of years that, in certain months of the year, particular classes of the patients should be physicked, bled, bathed, and vomited at given peri- ods? ■ the re-ply from Bethlem was in the affirmative. Twice in the year the patients, with few exceptions, were bled. 'After they have been bled,' said the physician, in evidence, 'they take vomits once a week, for a certain number of weeks; after that, we purge the patients. That has been the practice, invariably, for years — long before my time.' " In regard to the means of coercion employed, it was stated that the patients ' are generally chained to the wall with manacles.' When in- quiry was made regarding the use of strait waistcoats, it was replied, ' I do not believe there are any strait w^aistcoats in Bethlem now, or very few indeed; they generally use irons.' The objection to strait waistcoats was that the patients ' could not help themselves in strait waistcoats; they are so exceedingly long in the hospital without being seen by any- body, in a dark place; in Winter, from four o'clock to six or seven in the morning. If they were in a strait waistcoat they could not assist them- selves the least in the world.' When, in the following year, the head keeper of Bethlem Hospital was asked : ' Was it not the practice in old Bethlem — not in the late gallery, but in the gallery pulled down — for eight, ten, or more patients to be fastened to the tables, almost in a state of perfect nakedness?' he replied: 'Yes; they used to think they tore their clothes all to pieces; some of them would do that.' 'In point of fact, were they not fastened to the tables, sitting in a state of perfect nudity? ' Answer — 'They used to be so at the table; they were chained all around.' " With these records of the barbarity and cruelty practiced in the asy- lums of England, and so forcibly described in the able work of Bucknill & Tuke, from which they have been quoted, we need not be surprised at their having been made the basis of a sensational novel by Charles Eead, even after they had ceased to exist, nor that the prejudices against these in- stitutions should still hold a place in the minds of the people everywhere. THEIR CONDITION IN FRANCE. Esquirol says of the insane in France: " I have seen them naked or covered with rags; with nothing but a la^^er of straw to protect them from the cold dampness of the ground upon which they lay. They were kept upon food of the coarsest kind; they were deprived of fresh air to breathe, and of water to quench their thirst, and even of the most neces- sary things of life. I have seen them given up to the brutal supervision of jailors. I have seen them in their narrow cells, filthy and unwhole- some, without air or light, chained in such dens as one might fear to confine ferocious beasts." "Similar to these were the abodes of the insane throughout Europe." IN ROME AND LIMERICK. " In Eorae iron rings, armed with chains, and fixed in the wall, serve to confine the furious and turbulent maniacs, who are fastened by their necks and feet." "In one room were two rings fixed to the wall; one ring was to embrace the neck, the other the ankle, and the poor maniac was doomed to stand or suspend himself by the neck." " The accommo- 13 98 dations in the asylum at Limerick appear to "be such as we should not appropriate for our dog kennels." ''One victim was confined in one of the oblong troughs, chained down. He had evidently not been in open air for a considerable time, for when I made them bring him out he could not endure the light. Upon asking him how often he had been allowed to get out of the trough, he said: 'Perhaps once a week, and sometimes not for a fortnight.' He was not in the least violent; he was perfectly calm."* IN THE GERMANIC CONFEDERATION. In eighteen hundred and forty-five the Journal Psychiatric and Psychological Medicine was established, with Doctor Damerow, of the institution in Halle, as its principal editor, and Doctors Flemming and Poller — the latter of the lUenaw Asylum — as associates. Although printed at Halle, as a matter of convenience to Doctor Damerow, it is published at Berlin. If an opinion may be formed from the vigor with which it has been conducted, as well as the long list of collaborators — men distinguished as physicians of the insane or for their knowledge of psychical medicine and the jurisprudence of insanity, not in Germany alone, but in Denmark, Holland, and Switzerland — it will not lack for material, and is established ui)on a permanent basis. Its editor in chief is one of the most prominent advocates of the doctrines of the Psycho- Somatic school, but both his associates are Somatics. Among its col- laborators are found all the gradations of theory from the somatic to the psychic. Since the death of Heinroth, Dr. Ideler, of Berlin, is the acknowledged leader of the psychic school. But as time has progressed the Conflict of opinion has measureably subsided. The attention of physicians has been diverted from the comparatively barren field of hypothetical con- troversy to the more useful domain of practical science, the improve- ment of hospitals, and the treatment of their inmates. From the foregoing historical sketch, chiefly of the literature of insanity, it may be justly inferred that little, if anything, was done during the last century for the improvement of the receptacles for the insane in Germany. The initiative, however, was taken even in the few writings which were i^ublished, as these were the preliminary steps which led to more important practical action. The asylum at Vienna, but of late years not very favorably known as the Narrenthurm, was completed and oj^ened in seventeen hundred and eighty-four, and was at that 2)eriod the best establishment of the kind, as it was the only one exclusively devoted to the insane, throughout the German nations. As the eighteenth century was departing, Heinroth, having finished his studies at Paris, carried the principles of his illustrious preceptor within the German borders, and thus added a new and important element to the cause of improvement. An idea of the condition of the German asylums at the commencement of the present century may be derived from the language of one of their native authors, Peil, who, in his " Phapsodies upon tlie aj^plication of the Psychical Curative Treatment in Mental Disorders," published in eighteen hundred and three, wrote as follows: " They are mad-houses, not merely by reason of their inmates, but more especially because they are the very opposite of what they were intended to be. They are neither curative institutions nor such asylums for the * Browne's Lectures, Edinburgh, 1837. 99 incurable as humanity can tolerate; they are for the most veritable dens. Has man so little respect for the jewel which makes him man, or so little love for his neighbor w4io has lost that treasure, that he cannot extend to him the hand of assistance and aid him in regaining it? Some of these receptacle are attached to hospitals, others to prisons and houses of correction; but all are deficient in ventilation, in the facilities for recreation; in short, they are w^anting in all the physical and moral means necessary to the cure of their patients."* OBSERVATIONS UPON FOREGOING SUBJECTS. The foregoing extracts from various well known authorities have been made not only to show the condition of the insane, the character of the establishments in which they were kept, and the methods of treatment adopted and pursued in such cases by the most learned and eminent men in the several countries under consideration, but also to direct attention to the fact that though sundry efforts had been made by men of learning and ability to establish journals of mental science in Ger- many during the latter part of the eighteenth and early part of the nineteenth centuries, they all signally failed, not from lack of ability on the part of those who edited and conducted them, but for want of suj^port by the public. The first of these magazines was commenced in seventeen hun- dred and eighty-three, but lived only a short time. The next periodical devoted exclusively to the subject of insanity was (-stablished by Doctor Eeil, and published at Halle, in Prussian Saxony, in the year eighteen hundred and five, the philosopher Ivayssler having contributed largely to its pages. It, too, soon shared the fate of its predecessor, and died for the want of appreciation and support, too little interest as yet being felt in a class of persons supposed to be possessed by devils. In eighteen hundred and eighteen Nasse made another effort, and com- menced his Journal of Psychological Medicine, and being conducted with great ability and unusual zeal, awakened a more lively interest in the subject and its unfortunate victims. But the time for success had not yet arrived, and after a desperate struggle for eight years it, too, w^ent down to join the list of the departed. Still another journal was started in eighteen hundred and twenty-nine; and yet another, by Doctors Jacobie and Flemming, in eighteen hundred and thirty-eight, but all \yith similar results. Many valuable essays and books have m the mean time been given to the world by various German writers; but it was not till eighteen hundred and forty-five, as already stated, that a journal was established, with Daraerow^ of Halle as its head, and Flemming and liolier — the latter still at Illenaw — as assistants, that a psychological journal has been able to stem the current and stand the test of time. Since that time many able writers have aj^peared upon the field of psychological medicine and made valuable contributions to science. Among these, none stood higher either at home or abroad than the lamented Griesinger, who has left behind him in his works a monument more grand, beatitifiil and enduring than any that could be erected of marble or bronze. It is also worthy of notice that there was but one public asylum in all *Institiitions for the Insane in Germany, by Pliny Earle, M. D. 100 Germany in seventeen hundred and eighty-four''' — the '' Xorrenthurm " at Vienna — while at the present time, as will be seen in the list of asy- lums in the German Confederation,! there are ninety-two public and forty-nine yjrivate institutions devoted to the care and maintenance of this"^ hitherto neglected class of human beings. And although most of these do not come up to our ideas of first class asylums, as viewed from an American or English standpoint; nevertheless, some of them are well built, conveniently arranged and ably conducted, and would be a credit to any country. Indeed, it may be said that very nearly all of those established within the last twenty years are of this class. CRUEL TREATMENT THE RESULT OF IGNORANCE. It would appear strange indeed, and, if we did not know to the con- trary, absolutely incredible, that such cruelties, such barbarous practices as have been noticed in the foregoing pages could have been tolerated for so long a time among the refined, intelligent, and highly civilized people of Europe without a single effort — previous to the French revolution — on the part of humanity to relieve the distresses of this class of their fellow creatures. Ignorance, in law, is no excuse, and yet ignorance is the only excuse that mankind can ofter for the neglect of these wretched creatures. They w^ere regarded during these long centuries as being possessed of devils, as enemies of society, and as doomed forever, so soon as they were known to be madmen. Even yet this idea has not been eradicated from the minds of some people, while many still believe the disease to be incurable from the beginning, and its accession a dis- grace to the unfortunate victim and his family. It is high time I'or the people to lay aside these false notions, and accej^t the fact that insanity is simply the eftect of a diseased brain, and that all persons are liable to its invasion. NEW YORK POORHOUSES. But let us look into this matter at home, and see if we cannot find that these abuses and cruel practices, unfortunately, have not been confined to English and continental institutions. The following extracts will show their condition in the poorhouses of New York at a comparatively recent period. In eighteen hundred and fifty-seven a committee, consist- ing of Mark Spencer, George Bradford, and M. Lindley Lee, reported the results of inquiries and examinations made the Summer before. The fol- lowing sentence is from that report: " The poorhouses throughout the State may be generally described as badly constructed, ill arranged, ill warmed, and ill ventilated. The rooms are crowded with inmates, and the air, particularly in the sleeping apart- ments, is very noxious, and to casual visitors, almost insufterable." In eighteen hundred and sixty-five a Committee of which Dr. Sylvester D. WilTard was Chairman made a report, from wdiich we extract the fol- lowing: *NoTE.— The Alexianer Convent at Aix-la-Chappelle has been a receptacle for the insane for five hundred years; and the " Bloekdick" (private asylum), near Bremen, was estab- lished in 1750, and rebuilt in 1839. fSee Appendix B. 101 " It is not without fi confession of pain jind humiliation that the Com- missioners announce the deplorable condition of the insane poor; the ' notorious and sickening abuses ' which they found in many of the public establishments known as County Poorhouses. With unquestionable truth they aiiirni that ' the State has shifted off from itself upon the counties a duty which it ought ever to have recognized as imperative and sacred.' Nearly every count}^ house was visited. As the record of particular instances is more convincing and more affecting than general statements and summary conclusions, a few facts are condensed from the report, the selection being made from counties in the Hudson Eiver hospital district. Let us look first at Albany. Here, under the shadow of the State Capi- tol, were seventy-six insane persons shut up in thirty-one rooms, each of which was intended and is only large enough for one. A number of these rooms had three occupants in each; the ventilation in some of them was very imperfect. Notwithstanding the deficient accommoda- tions, rendering all classification impossible, recent cases are frequently received and held for treatment, with what probability of improvement under such conditions can easily be seen. The insane poor of Duchess County are bestowed in eighteen cells constructed in prison style, with heavily grated doors and^arred windows; board partitions separate these cells, and wooden bunks serve for bedsteads; for want of proper appliances the cells cannot be made comfortable in cold weather; two of the men vvere loaded with chains. For her insane Eichmond County has provided four dark cells. One poor creature has spent fourteen years in a small outhouse — a cripple, bent nearly double — and without a rag of clothing! The poorhouse in Saratoga County is nearly fifty years old; the floors and walls of this venerable structure are much broken, and the roof leaks. Though not far from the Ballston Springs, the water is scarce there. The cells of the insane measure seven and a quarter by six and a quarter feet, and each contains a wooden bunk, and nothing else ; these cells get all their light and air through gratings in the doors ; in these dungeons individuals have been confined for ten and even for eighteen successive years, never going outside, except during the short annual visits of the Board of Supervisors. In one case there had been an illegitimate birth, under circumstances most distressing and revolting. Warren County is thus described: 'Insane filthy in their persons, and stench from the place intolerable. Four cells in the building, all unfit for use. Eats the only scavengers. No medical attendance. Building entirely unsuited to the purpose.' " Very little is said in praise of Franklin, Essex, W^ashington, Greene,^ Putnam, Sullivan, AVestchester, and Queens Counties. At the time of the inspection the number of insane persons who were shut up in cells or secured by chains was two hundred and thirteen. In view of the whole picture the Commissioners might well exclaim: " AVill the people of New York, when they comprehend the inhuman treatment which the insane poor sometimes receive, leave a system in unchecked operation which admits of such enormities?" We are rejoiced to say that the people of New York have compre- hended this subject, and have nobly responded to this question in a manner not to be mistaken, and with a generosity worthy of that great State. Her legislators, advised and encouraged by her wise executive officers, have made appropriations, provided lands, selected sites, and ordered the erection of asylums for the proper care and treatment of every insane person loit/un her borders. 102 AMELIORATION IN THE TREATMENT OF THE INSANE AS COMPARED WITH FORMER PERIODS. Let US call attention for a moment to some of the causes that led to an amelioration of the condition of the insane, both in England and on the continent, and to some of the men who were conspicuous in directing public opinion in so important a matter, and instrumental in carrying out the humane doctrines they proclaimed. A brief review of the life and writings of Dr. ConoUy appeared in the American Journal of Insanity for April, eighteen hundred and seventy; a few extracts from which will subserve the purposes we have in view : Former Coercive Treatment. Few of us in America know, except from history or from travel on the continent, the extent to which mechanical restraints were used in Great Britain previous to eighteen hundred and forty, and are now in the other European countries. Dr. Conolly found on taking charge of the Asylum at Hanwells — eighteen hundred and thirty-nine — each ward j^rovided with a closet full of restraining apparatus, and every attendant used them at will. Many patients were always in restraint. Six new restraining chairs had been recently added to the stock, making forty-nine in all (pp. 53, 54). The instruments of mechanical restraint were so abundant as to amount, when collected together, to about six hundred; half of them handcuffs and leg locks (pp. 18, 20). This may be assumed as a specimen of the provision in the asylums of Great Britain and Europe at that time, and these means nearly repre- sented the ideas of the people at large, the governors or magistrates who had the outer superintendence of these establishments, and the physicians who had them under their immediate charge. Finel. Although Pinel had wrought what was deemed almost miracles in set- ting the manacled maniacs free without evil consequences to those who were in contact with them, yet few had dared to follow him, and the lunatic remained in great measure as he was before. The world still clung to the faith of olden time — that the insane were the devil's pos- sessions, and those thus possessed should be, if not punished, at least restrained, to prevent injury to the fearful community. Treatment in Middle Ages. Nevertheless, there had been a wonderful improvement upon the cruel customs of the barbarous ages. In those dark periods the religious houses were in some sort used as hospitals, and some of them took care of the insane. At one of these establishments of the Franciscans, who believed in and practiced on themselves the severest mortifications and self-chastening, the same rule was applied to their patients, and they gave each lunatic ten lashes a day. In another each patient was bled every June. Stripes, however, were but one form of cruelty, and the slightest of the kind. In the old asylums all the most terrible engines of torture, to carry out the theory of punishment, were resorted to. The inventions to give pain were marvelous. There were chairs of 103 restraint in which the patient could not move limb or bod}', and whirling chairs, in which the unfortunate lunatic was whirled at the rate of one hundred gyrations a minute (p. 47). These and other practices equally cruel were continued in Germany as late as seventeen hundred and ninety. In some asylums the patients were kept in a state of partial famine, chained, covered with dirt and filth, but half clothed, and their insufficient clothing seldom changed; cages of iron were in use, in which some of the lunatics were kept for years. These miseries were inflicted, not from carelessness, but from what was believed to be real humanity (p. 48). In an earlier age, some iron cages were made sufficiently large to hold one or more patients. These were movable and suspended by chains over water, in tanks or pools, with the patients standing in them; they were let down into the water, until it reached their chins or mouths, leaving them only a breathing place. There they were kept as long as they could endure the position and the bath. This was an established part of the treatment or punishment. The worst of these practices had passed away before the time of Pinel and his followers. York Asylum. Among the bad, the York Asylum was the worst. A female member of the Society of Friends being placed as a patient in this institution in seventeen hundred and ninety-one, died under suspicious circumstances. They immediately determined to establish an asylum under their own control, in which there should be no secrecy. William Tuke was the great founder of this new hospital, and from the first he and his associ- ates pursued those j^rincij^les in its management that Pinel was then pro- posing, and which have now become the established rule of practice in Great Britain and the United States. They did not abolish all restraints, yet they began this work, retaining only those of the milder kind. Lincoln Asylum. Dr. Charlesworth, in the Lincolnshire Asylum, in eighteen hundred and twenty-one, began his experiments of substituting the milder for the severe restraints. He persevered in this great work year after year, regardless of opposition and undaunted by difficulties, and at length arrived at the total abolition, which he found both a practicable and a more comfortable and successful method of controlling the patient. Mr. Gardner Hill was also engaged in the same work, with the same result. Br. Conolly at iraniuell. Still chains, handcuffs, and leg blocks were in general use in the asy- lums of Great Britain and the continental nations when Doctor Conolly entered the Hanwell Asylum as Eesident Physician, on the first of June, eighteen hundred and thirty -nine. He was familiar with the writings and practices of Pinel, Charlesworth, and Hill. He had confidence in the success of these measures and in their applicability to any other hospital. At once he determined to try the experiment on the patients at Hanwell. He began his work June first. There were then over forty under mechanical restraint. Immediately he commenced removing the shackles, fetters, etc., from those who were the most promising, or who suffered 104 most, and proceeded gradually until the whole were removed in less than four months. In his work on the treatment of the insane he quotes from the asylum records: "After the first of July, when 1 required a daily return to be made to me of the number of patients restrained, there were never more than eighteen so treated in one day. After the thirty-first of July the num- ber never exceeded eight; after the twelfth of August it never exceeded one, and after the twentieth of September no restraints at all were employed." On the thirty-first of October, in his first report to the Quarter Ses- sions, he said: "Since the twenty-first of September not one patient has been under restraint. No form of straight waistcoat, no handcufis, no leg locks, nor any contrivance confining the trunk or limbs, or any of the muscles, is now in use. The coercion chairs, about forty in iiumber, have been altogether removed from the wards " (p. 20). In his eleventh and last report he says: "For ten years no hand or foot has been fastened in this large asylum, by day or night, for the control of the violent or the despairing; no instrument of mechanical restraint has been employed, or even admitted into the wards, for any reason whatever; no patient has been placed in a coercive chair by day or fastened to a bedstead by night. Every patient, however excited or apparently unmanageable, arriving at the asylum in restraints has been immediately set free, and remained so from that time. The results, more and more seen in every successive year, have been increased tranquility, diminished danger, and so salutary an influence over the recent and newly admitted and most recent cases, as to make the spectacle of the more terrible forms of mania and melancholia a rare exception to the general order and cheerfulness of the establishment" (p. 33). Effect of Bemoval of Mesiraints. The effect of this removal of restraints was at once noticed in the general tone of the whole hospital. The excited were sooner calmed, the irritable less easily disturbed, and a general quiescence prevailed more than before. The wards were managed with less difliculty. The new sj'stem tended to remove, as far as possible, all causes of excite- ment from the irritable, to soothe, encourage, and comfort the depressed, to repress the violent by methods that leave no ill effect on the temper, no painful recollections in the memory, and in all cases seize every opportunity of promoting a restoration of the health}' exercise of the understanding and the affections (p. 27.) Mania not exasperated by severity, and melancholia not deepened by want of ordinary consolations, lose the exaggerated characler in which they were formerly beheld. Hope takes the place of fear, serenity is substituted for discontent, and the mind is left in a condition favorable to every imj)ression likely to call forth salutary efforts (p. 28.) Effect of Br. ConoUi/s ITethod on other Physicians. Many physicians, managers of other institutions in Britain, visited Dr. Conoily, and a few from the continent. These became converts to his views and strong friends of his plans. One asylum after another followed him, until, be lore many years, non-restraint seemed to be the universally accepted doctrine of the whole psychological profession in England and Scotland. 105 Proof of the Advantage of Moral Treatment. As proof of the advantage of moral over mechanical means of treat- ment, Dr. Broadhurst points to " the general quietness and decorum of his establishment, the cheerful aspect of the patients, the comparative freedom from acts of destructive violence, the large proportion con- stantly engaged in useful occupation, a decreased mortality, and an increased percentage of cures." (p. 78.) Mr. Wilkes, formerly Superintendent of the Stratford Asylum, now Commissioner of Lunacy, writes: "The effect of the change upon the old inmates was in marked degree beneficial." The excitement of the patients generally diminished. They were less noisy and restless at night; destructive propensities and objection- able habits were, in many instances, overcome. With greater oppor- tunities of doing mischief, less occurred. And now, without a window in any way protected, and a much larger number of patients, there is probably less breakage of glass than there ever was. (p. 79.) Reputation of Dr. Conolly. He was very much consulted in the cases of the greatest importance, and was considered the chief authority in all matters of doubt. Ever affable and courteous, he drew many to his house from his own country and from abroad, and alienists from the continent and from America found and enjoyed the most cordial hospitality. Several of the psycho- logical physicians of the greatest power on the continent were among his visitors and became the strongest friends of his doctrine of non- restraint. Among these were Doctor Griesinger, of Berlin ; Baron Mundy and Meyer, of Germany; Morel, of France; and Guislain, of Belgium. They used their utmost exertion to introduce the practice into their several countries, but, except in the institutions within their immediate influence, they made but few converts; and Continental Europe vv^as yet to accept the new method and to unchain its lunatics. Doctor Conolly's opinions in regard to the Management of the Insane. In the management of the insane he considered the provision of large establishments, however desirable as a matter of economy, was at the cost of some of the remedial powers of the institution and of the chances of restoration of the patients, and that the proper conduct of lunatic as^dums requires the whole power of mind and heart that belong to the superintendmg physician; and that whenever the governors or directors of each institution require their medical officers to leave their high vocation and sacred responsibility of watching mental disorders and guiding mental weakness, and give their time and thought to the subordinate matter of finance and stewardship, to collect bills, and watch the market, they take from the suffering patients a part of that influence upon which their best hope of recovery is founded. Such were the life and character of Doctor Conolly, and such were his works, as described by his friend Sir James Clark, and as known, in part, to most of us. Few men have fulfilled a nobler destiny; few will be remembered with more affection and gratitude. 14 106 KIRKBRIDE ON RESTRAINT AND SECLUSION, AND THE MEANS OE AVOIDING THEIR USE. Restraint and Seclusion. The use of mechanical means of restraint and the i)rotraeted seclu- sion of patients in their rooms — although the former of them may be, and as I believe is, occasionally desirable but not absolutely necessary in the management of our hospitals for the insane — ought both always to be regarded as evils of no trifling magnitude, and to abate which, as far as j^ossible, no effort should be left untried. They both tend to produce a relaxation of vigilance, and it cannot be too often repeated that whatever tends -to make vigilance unnecessary is undesirable about a hospital for the insane. Besides leading patients into bad habits, the frequent use of the means referred to in a ward induces attendants and others to look upon them as a common recourse in cases of difficulty or danger, to regard them as their grand reliance in every emergency, and to forget the great power of other measures that are entirely unobjec- tionable — the value of tact and kindness and sympathy in controlling the violence and dangerous propensities of the insane. And yet, with- out a 23roper force of attendants and an efficient classification the use of mechanical means of restraint and the protracted seclusion of certain classes of patients is almost unavoidable. Objectionable as I deem the use of restraining apparatus in a hospital for the insane, it cannot be too earnestly insisted on that it is no advance to give up mechanical means of restraint and to substitute the frequent and long continued seclusion of the patients. Occasionally an individual may really be more comfortable and much better off in the open air, with some mild kind of restraining apparatus on his person, than he would be confined to his room without it; for this kind of long contin- ued seclusion is pretty sure, sooner or later, to lead to habits revolting in themselves and most unfortunate for the future prospects of the patient. The subject is introduced here as a reason why no false notions of economy should be j^ermitted to influence any Board of Trustees to ask the Superintendent of an institution to attempt its management with a force so inadequate as to compel him, against his better judgment, to resort to means so objectionable, and w4iich are so destructive to the comfort and proper treatment of his patients. Labor, Outdoor Exercise, and Amusements. Having referred to the unfavorable results of an habitual use of restraint and seclusion in a hospital for the insane, it is proper to indi- cate in more detail some of the means by which those unfortunate effects may be obviated. A properly constructed building, admitting of a liberal classification of the patients, and the employment of an adequate number of intelli- gent and kind assistants, is indispensable for such an object. The design in establishing every such institution being the restoration and comfort of the afflicted, the relief of their families, and the protection of the community, there can be no question but that it is sound economy to provide everj^thing that will effect these objects promptly and in the most thorough manner. Without adequate provision for outdoor exercise and occupation for 107 the patients, and a liberal supply of means of amusement, the excite- ment of the wards and the violent and mischievous propensities of their inmates will be apt to be such as to require modes of manaf^ement that might otherwise be easily dispensed with. The first cost of some of these arrangements will necessarily be considerable, but the ultimate results can hardly fail to be so gratifying as to satisfy the most rigid stickler for economy that the only wise course is to provide liberally of everything likely to be beneficial to the patients. The farm and garden otfer admirable means of useful occupation to the insane at certain periods of the disease; for, useful as they are to a large number, no greater indiscretion could be committed than attempt- ing to set all insane men at work in every stage of their malady. To those accustomed to such pursuits, as well as to many who have been dilferently occupied, regular, moderate labor in the open fields or in the garden contributes most essentially to their comfort and tends to promote their recovery. Labor, then, is one of our best remedies; it is as useful in improving the health of the insane as in maintaining that of the sane. It is one of the best anodynes for the nervous; it composes the restless and excited; promotes a good appetite and a comfortable digestion, and gives sound and refreshing sleej) to many who would with- out it ]3ass wakeful nights. The provision of adequate and comfortable w^orkshops, in a convenient position and under the care of competent superintendents, may be made a source of profit to an institution, and furnish another means of labor of an interesting kind to a large number of the insane. The usual means of amusement, which demand active muscular exer- cise, should not be neglected. A gymnasium, suitable in its fitting up for insane men, and a calistheneum for insane women, will be found use- ful. The various games of ball; the exercise of using a car on a circular railroad; the care of domestic animals, as well as regular walks on the grounds or in the neighborhood, are also among the kinds of exer- cise that will be enjoyed by many patients; while means of carriage riding seem almost indispensable for many, who from physical and other causes cannot resort to the more active forms which have already been referred to. Within doors the means of keeping a comfortable house are, in addi- tion to the medical treatment, the constant presence among the patients of intelligent attendants, active suj^ervisors, and judicious teachers or companions, always ready to check the commencement of excitement, to separate quarrelsome individuals, and to change the train of thought of those who seem disposed to be troublesome. The means to efi:ect the objects in view are very numerous, and the tact of an individual is shown in selecting those that are most applicable to a case. The introduction of regular courses of lectures, interesting exhibi- tions of various kinds, and musical entertainments in the lecture rooms of our hospitals for the insane, has done much to break up the monotony of hospital life, which is so common a source of comj^laint among the insane. liegular courses of instruction in well furnished school rooms, reading aloud by the teachers to the patients of the more excited wards, the use of well selected libraries, the inspection of collections of curiosities, the use of musical instruments and various games, are all among the many means which an ingenious Superintendent will suggest for the benefit and amusement of his jDatients, and which ought to be provided for in every institution for the insane. 108 In most of the asylums in the United States the dance is either added to this list or substituted instead of some of its items. It is a favorite amusement among the patients wherever it is allowed; and we have been informed by some of the Superintendents that patients will often con- trol themselves for a whole week with a promise that they may be allowed the privilege of going to the next dance. CHAPTER IX. INSANE ASYLUMS, LOCATION, SIZE, SITES, ETC. Location — Influence that Distance ought to have on Location— Effect of Multiplying Hospitals— Effects of Eailroads and other Facilities of Travel— Hospitals Better Known to Neighboring People— Observations on Foregoing Topic? — New Yoik State Lunatic Asylums— General Suggestions— Propositions relative to the Structure and Arrangements for American Institutions for the Insane— English Lunacy Coinmis- sioners on Sites, Construction, Size, etc. — Suggestions of the Scotch Board— Size of Hospitals— Quantity of Land Necessarj'- Comments upon Kirkbride's Yiewjj. LOCATION. The location of an asylum has, perhaps, as great an influence over its usefulness as any other matter connected with its establishment, and those to whom this important trust may be delegated, here or elsewhere, cannot be too careful with the selection they may make. There are certain general rules that should never be overlooked nor disregarded by them, as on their action may depend, in a great degree, the success of the asylum to be established at the present time, as well as those that must, in the progress of events, come after it. The admissions in our Asylum during the last ten years was an average of three hundred and fiftj^-eight each year, and the average annual increase has been sixty-seven. If w^e take a shorter period, these numbers will be augmented. We see by the report of Dr. Shurt- leff, that " for the past five years the annual admissions have averaged about four hundred and fifty, and the net increase has been about eighty." With the increasing population, we may estimate with cer- tainty that no decrease in these numbers will take place, if indeed, in the providence of God, and the better habits of the people, it be per- mitted to remain at these figures. This proportion of increase would give us eight hundred additional insane persons in the next ten years. But let us suppose that insanity will continue in its present ratio to the population, or one to four hundred and eighty-nine inhabitants, and that the population increases no more in the next decade than during the last, and it will be seen that more than eight hundred will be added to the regiment of insane men and women already in our Asylum at Stockton. It therefore behooves us, in any present provision Ave may make to meet the pressing necessities of immediate demands, to look wisely to the future, and so shape our action that it may have its proper bearing on similar provision to be made at some subsequent and not dis- tant time to come. 109 INFLUENCE THAT DISTANCE OUGHT TO HAVE ON LOCATION. That the importance of locating an asylum in convenient proximity to the greatest number Avho will be likely to require its use may bo thoroughly understood and appreciated, we have made the following extracts from a Treatise on the Influence of Distance from and Nearness to an Insane Hospital on its Use by the People, prepared for the State of New York, by Edward Jarvis, M. D.: "An insane hospital is, and must be to a certain extent, a local insti- tution. People will avail themselves of its privileges in soijie proportion to their nearness to it. No liberality of admission, no excellence of its management, no power of reputation can entirely overcome the obstacle of distance, expense, and of the difficulties of transporting lunatics, or the objection of friends to sending their insane patients far from home, and out of the reach of ready communication. " The operation of this principle, in some degree, seems probable to any one who gives a thought to the matter; but the facts, the particular history of those institutions in which the records of the homes of their patients are kept, show that the objection of distance prevails with all of them, and that those hospitals have been and are used by those who live near by much more than by those who live farther off; and conse- quently they are practically much more local in their usefulness than they are intended or are supposed to be. " The State Hospital at Utica was opened in eighteen hundred and forty-three, and offered to the people of every county, both near and remote, on the same conditions. The people of Oneida, Schoharie, Orange, Washington, and Chautauqua, were alike invited to send their insane on the same terms. Between them there was and could be no difference of advantage after their patients should be placed in the hos- pital; the only difference was in the distance between their homes and the institution, in the labor, cost, and burden of traveling to a hospital with a lunatic. To make this matter more certain and to show the dif- ference of enjoyment to the eye, the whole State has been divided into four districts, according to their distance from the hospital. " The First District is Oneida County, in which the hospital is situated.' " The Second District consists of eleven counties: Chenango, Cortland, Fulton, Herkimer, Lewis, Madison, Montgomery, Onondagua, OsAvego, Otago, Schoharie. These are mostly within sixty miles of Utica. " The Third District includes seventeen counties, which are from sixty to one hundred and twenty miles distant: Albany, Broome, Cayuga, Columbia, Delaware, Greene, Hamilton, Jefferson, Eensselaer, Saratoga, Schenectady, Seneca, Tioga, Tompkins, Warren, Washington, Wayne. " The Fourth District includes the most distant counties, which are from one hundred and twenty to three hundred and fifty miles from Utica : Allegheny, Cattaraugus, Chautauqua, Chemung, Clinton, Dutchess, Erie, Essex, Franklin, Genesee, Livingston, Monroe, Niagara, Ontario, Orange, Orleans, Putnam, Queen, Eichmond, Eockland, Schuy- ler, Steuben, St. Lawrence, Suffolk, Sullivan, Ulster, Westchester, Wyoming, Yates. " These four districts include all the counties of the State, except New York and Kings, which have each hospitals of their own, and therefore little or no occasion or inducement to send patients to Utica. " The population of each o^these districts has been ascertained and 110 calculated for each of the twenty-three years, eighteen hundred and forty -three to eighteen hundred and sixty-five inclusive, since the hos- pital was opened. The number of patients sent to the hospital from each district within that period has also been ascertained. '' Taking, then, the sum of the annual populations for twenty-three years, and dividing it by the number of patients sent in that time, shows the proportion of patients which each district has sent out of its whole number of people. These numbers and facts are presented in the fol- lowing statement: " For these twent^'-three years — eighteen hundred and forty-three to eighteen huncii'ed and sixty-tive — Oneida County sent one in two thou- sand seven hundred and seventy-two of their number to the hospital. The Second District sent one in five thousand eight hundred and twenty of their number to the hospital; the Third District sent one in seven thousand three hundred and fifty-one of their number to the hospital; the Fourth District sent one in eleven thousand five hundred and thirty- five of their number to the hsopital. POPULATION AND PATIENTS OF DISTRICTS. SUMMARY. Districts. Sum of the annual population for twenty- j three years j 2,292,643 Patients sent to the hospital in twenty-three years Average annual population Average patients sent to the hospital Population to one patient sent to the hos pital in each year 827 99,680 36 10,528,406 1,809 457,756 5,820 16,337,520 2 222 710^327 96 7,351 28,146,477 2,440 1,223,760 106 11,535 V This shows a great disproportion in the uses made of the hospital by the people of the near and of the remote counties. -' Taking a basis of one thousand for the extent of the enjoyment of the hospital by the remotest districts, the proportionate enjoyment of the districts will be: Fourth, one thousand; Third, onethousand'^five hundred and sixty-eight; Second, one thousand nine hundred and eighty-one; First, four thousand one hundred and ninety-six. '' The advantages of the hospital enjoyed by Oneida County have been more than double those enjoj'ed by the counties next beyond, but within sixty miles; they are nearly threefold those enjoyed by the counties which are from sixty to one hundred and twenty miles distant; and more than four times as great as those enjoyed by the people of the counties which are more than one hundred and twenty miles distant. '' It will not be supposed that the insane persons who needed the hos- pital care or treatment in these districts were in these proportions. It cannot be supposed that the number of lunatics in Oneida County is twice is great as that in Oswego; Fulton, Schoharie, Herkimer, and the counties beyond Oneida, but within sixty miles; or four times as great as that in counties one hundred and twenty and more miles from this district. " The State censuses of eighteen hundjFbd and fifty-five and eighteen Ill hundred and sixty-five show the numher of the insane in the several counties of New York. Arranging these in the districts herein described, according to their distance from Utica, they were in proportion to the' popuhition: • POPULATION TO ONE LUNATIC IN NEW YORK. DISTRICT. 1855. 18G5. First 1,224 1,525 1,457 1,788 1,300 1,611 1,396 1,904 Second Third .*.' ..'.'.*.' Fourth " This diversity of advantage of an insane hospital enjoyed by the people of near and remote districts is not an accident, nor a peculiarity of New York alone. It is a general and probably universal principle — a natural and necessary law of nature or humanity; for in all other States whose hospital records of patients' residence have been obtained, the same law is found to be in operation, and the people send their patients to these institutions in j^roportion to their nearness. " In twenty-six States, for various periods of years, insane hospitals have been in operation, whose doors are and have been open alike to all of their people. The reports of most of these institutions state the number which have been sent to them from each county. From the others, copies of the records of facts have been obtained, showing the number which the various parts of the States have contributed to till the wards of these institutions. In order to determine the extent and application of the law of distance in the use of hospitals, these other States and two of the British Provinces have been examined and analyzed in the same way as New York. " They have been divided into concentric districts, making the county in which the hospital is situated the first, and the contiguous counties the second district, and the others more distant. The populations of these several districts have been calculated and determined for each of the years in which the hospital has been in operation, or in which the records of the residence of the patients were kept and have been ob- tained, and the comparison made of the proportion of patients to popu- lation of the several districts. '' It should be here stated that, in making these concentric circular divisions, it has been impossible to make them perfectly regular, with an exactly equal radius from the common centre, or equal distance of the inner and outer boundary from the hospital, for the counties are very diversely and irregularly shaped, some of them, as in Maine, being nearly one hundred and fifty miles long. While, then, a district may be stated to be within certain specified distances from the hospital, circles drawn upon the radii would, on both sides, exclude some part of the territory that belongs to it, and include some that belongs to its neighbor. Never- theless, these irregularities of border or exceptions to the rule will not militate with the general plan nor vitiate any calculations made upon or deductions made from this analysis of the States and hospital receptions. " Twenty -two States and two British Provinces furnish the conditions 112 requisite for the purpose of this report, and are included in the calcula- tions and statements. POPULATION TO ONE PATIENT ANNUALLY SENT TO LUNATIC HOSPITALS. Maine New Hampshire Massachusetts Khode Island New York Kew Jersey Pennsylvania East Pennsylvania "West Pennsylvania Maryland Virginia Korth Carolina Mississippi Louisiana Tennessee Kentucky Ohio Illinois .. Michigan Missouri Canada Nova Scotia " In all these States the privileges of the hospitals are offered equally to the people of the counties. Tbe patients of Oneida and Allegany Counties in Xew York, of Mercer and Warren Counties in New Jersey, of Dauphin and Yenango Counties in Pennsylvania, can enter on the same terms, enjoy the same advantages, and for the same price. The only difference is the burden of cost, care, and labor of travel from their homes to the place of healing. And yet the actual use of the hos- pital by and the practical value of these institutions to the people of the remote districts have been only one fourth as great in New Y^ork, about one third as great in New Jersey, and less than one third as great in Pennsylvania as they have been in the districts near to them. " Similar discrepancies in favor of the central counties and against the district counties are seen to have existed in all the other States whose record has been obtained. EFFECT OF MULTIPLYING HOSPITALS. " This principle has been remarkably manifested whenever and wher- ever a second hospital has been opened in any State and placed in a district remote from the one previously in operation. The people who * There is apparently something unexplained in the record of one county in each of these districts. t Excluding 1844, 1845, 1846, and 1847. t Excluding 1861, 1862, and 1863. 113 sent a few patients to the distant institu^on now sent many to the hos- pital which was brou<;-ht to thoir neighborhood. The number of luna- tics that found a place of healing was suddenly and permanently increased. " In Massachusetts, the hospital at Worcester was the only State insti- tution for the insane in the Commonwealth from eighteen hundred and thirty -three to eighteen hundred and fifty-four, when the second hospital was oj^ened in Taunton, Bristol County, for the southeastern part of the State. The Worcester establishment continued to receive all the patients from the northern, central, and western counties until eighteen hundred and fifty-eight, when the third hospital was opened at Northampton, Hampshire County, for the western district. In both of these districts there was a sudden and large increase of the insane whose friends sought and used these new places of healing for them. During the eight years — eighteen hundred and forty-five to eighteen hundred and fifty-three — previous to the opening of the Taunton Hospital the people of Bristol County had sent one hundred and fifty-one patients to Worcester, which was an annual average of one patient in four thousand four hundred and thirty-four inhabitants. During the eight years after the hospital was opened within their borders they sent three hundred and twenty-four patients to it, which was an annual average of one patient in two thou- sand one hundred and ninety -four people. " In the former period the people of Plymouth County sent one in three thousand seven hundred and nineteen of their niimber, and in the latter period one in two thousand seven hundred and seventy-four. <' Barnstable, Dukes, and Nantucket Counties sent in the former period one in four thousand one hundred and eighteen, and in the latter one in three thousand five hundred and seventy-three to the hospitals. POPULATION FOR ONE PATIENT SENT ANNUALLY TO THE STATE HOSPITALS. 1845 to 1853. 1854 to 1862, 1 ^ cc hd hj m ^ o COUNTIES. 3 It 13 &3 2 £. 1.1 o Cti -^ 3 ^ s- p '-^ 3 r*- p f^ .•^o ' f ^5 r O ct> !►§ : o i^ • 2 : c : 3 : P : 3 . CO Bristol 151 669,581 493,215 4,434 324 810,903 2,194 102.1 Plymouth 132 3,719 204 565,981 2,774 34. Barnstable ] Nantucket > Dukes J 104 429,319 4,118 118 421,662 3,573 15.2 Totals 387 1,592,115 4,111 646 1,798,546 2,784 42.9' " During the four years — eighteen hundred and fifty-four to eighteen hundred and fifty-eight — the people of Hampshire County sent thirty- seven patients to the Worcester Hospital, which was an annual average of one in four thousand and eight inhabitants. In the four years after the opening of the third hospital in their midst, the same people sent eighty- 15 114 five jDersons, or one in one thousand seven hundred and eighty-seven of their number to its care. " Franklin County sent in the former period nineteen patients, or one in six thousand five hundred and seventy-four people, to Worcester; and in the latter j^eriod fifty-two, or one in two thousand four hundred and nineteen people, to ]S"orthampton. Berkshire County is geographically fifty miles nearer to jS"ortham2)ton than to Worcester. But a range of mountains lies between, and the roads are difficult for travelers, who can use only private conveyances, except the Western Eailroad to Spring- field, and the Connecticut Eiver Eailroad from Springfield to North- ampton. This practically reduces the difference of distance betw^een the two hospitals to thirty miles. And many w^hen once in the cars on the Western Eoad find it easier to continue fifty-four miles further to Worcester, than to change cars and go twenty miles to Northampton, with their j^atients. Therefore the increase is less in Berkshire County than in the others. Nevertheless, there w^as an increase. <' Before eighteen hundred and fifty-eight the Berkshire people sent thirty-three patients, or one in six thousand nine hundred and thirty- seven people, yearly to AYorcester, and after that they sent to Worcester and Northampton forty-seven jjatients, or an average in each year of one in four thousand seven hundred and fifteen peoj^le. " To the towns in the eastern j^art of Hampden County, Worcester is nearer and more accessible than NorthamjDton. Most of the people must necessarily use the Western Eailroad, whether going to Worcester or Northampton, and all must change cars at Sj^ringfield if they go to Northampton, but not if they go to Worcester. " The people of Hampden County sent in the former period one in two thousand one hundred and eighty-five of the living to Worcester, and in the latter, one in one thousand nine hundred and eighty-eight in each year. POPULATION TO ONE PATIENT SENT TO HOSPITAL BEFORE NORTHAMPTON HOSPITAL WAS OPENED. AND AFTER Western District. 1855 to 1858, four years. 1859 to 1862, four years. Increase. COUNTIES. en- 11 It i w o 3 fi People to 1 patient. 33 19 37 101 212,437 124,916 148,294 220,680' 6,437 6,574 4,008 2,185 47 52 85 116 221,640 125,830 151,897 230,784 4,715 2,419 1,787 1,988 38.6 Franklin 171.2 Hampshire Hampden 124.3 9.9 Total Counties 190 706,327 3,717 300 730,151 2,433 52.7 " The peoi:»le of Hampshire County nearly trebled the number and proportion of their patients in the hospital. The people of Franklin and Bristol more than doubled them, and the other counties also increased 115 them very greatly, and thus so many more of their hmatics found places of healing and protection when the hospital was brought to their neigh- borhood and within their reach. EFFECT OF RAILROADS AND OTHER FACILITIES OF TRAVEL. "Facilities of travel, navigable rivers, canals, railroads, i^ublic high- ways, jHiblic conveyances, which render communication easy and cheap, and intercourse familiar, and virtually diminish distance from the hospital, increase the ratio of patients that are sent to it. We therefore find that three counties which are situated along the course of rivers, canals, roads, etc., leading directly to the situation of the hospitals, have sent more patients to these institutions than other counties of equal popula- tion and at equal distances, but not favored with these facilities of com- munication. Ten counties in New York along the line of the railroad, canal, etc., east and west of Utica, with easy means of travel, sent two thousand one hundred and fifty-one patients to Utica, or one in seven thousand two hundred and sixty-six. While during the same period ten other counties, northeast and southwest from Utica, with no easy means of communication, sent six hundred and forty-seven patients, or one in eleven thousand nine hundred and thirty-four of their number to the State Hospital. Taking all these facts into view, we have here indis- putable proof of the effect of distance in diminishing the practical bene- fits of lunatic hospitals to the people of any district. In all these States these hospitals are as open and their advantages as freely granted to the patients from the most remote towns as to those in their very neigh- borhood. It is not hinted, or even suspected, that the lunatics whose friends reside afar' off are not as kindly, as faithfully, and as success- fully treated, and at as small a cost, as those whose friends are so near as to keep a watchful vigilance over their welfare. HOSPITALS ARE BETTER KNOWN TO THE NEIGHBORING PEOPLE. " The idea of the hospital purposes and its management is familiar to those who live in its vicinity. They know its means, its objects, and its administration; they know the character of its officers and its attendants. They are frequently witnessing its operations and results in the many who are going to and returning from it in improved or restored mental health. Whenever they think of the possibility of their becoming insane, the idea of the hospital jn-esents itself to their minds in the same connection almost as readily as the idea of their own chambers, their own physician, and the tender nursing of their own family is asso- ciated with the thought of having a fever or dysentery; and w^hen any one of their family or friends become deranged the hospital occurs to them as a means of relief, and they look upon it as a resting place from their troubles. " But this ready association of the hospital with lunacy and this generous confidence in its management diminishes as we recede from it. The people in the remoter j^laces know the general facts; but distance lends an obscurity to the notion, and thus the character of the hospital and its administration do not stand before them as the thought of home and domestic arrangements, of w^hich they can cheerfully and trustfully avail themselves in any emergency. To them the hospital -seems a strange place; perhaps a place of unkind restraint, or even of needless confinement, rather than a home of tenderness. Its officers are to them 116 strangers rather than friends; and its attendants, though good and honest persons, are not as household comforters and nurses, or even as neighbors, whose ready and affectionate sj'mpathy is sure, and on whom they are accustomed to call in time of trouble, and to whom they unhesitatingly commit the care of their disordered and distressed relatives or children. '•' Then the unwillingness to be far separated from their suffering or weakened friends operates with many. This is, indeed, a mere feeling or sentiment ; but it is converted into practical facts, and retains some at home who would otherwise be sent to and cured in a hospital if it were nearer to them. The State Lunatic Hospital, when it is used, is no better to the people of Oneida than to those of Cattaraugus and Clinton; but so long as a jDortion of the people of the remote counties do not feel so their insane friends are not sent there. " The difficulties and expense of sending lunatics over long distances, or unfrequented and indirect roads, or by private conveyances, are per- haps the most effectual obstacle in the way, and more than any other diminish the number of patients with the increase of miles that separate them from the hospital. " For these reasons the towns in the neighborhood of the public hos- pital in this State have enjoyed more than four times as much of its benefits as the remote towns; and all the other hospitals mentioned in this article have been compelled to confer their blessings in a similar and some of them in a much greater disproportion upon the people of the neighboring than upon those of the distant districts of the State to which they respectively belong. " We think we have here presented facts enough to establish it as a general principle that the advantages of any public lunatic hospital, however freely and equally they may be offered to all the people of an}^ State, are yet to a certain degree local in their operation, and are enjoyed by people and. communities to an extent in proportion to their nearness to or distance from it. '• Whenever and wherever the same causes exist the same effects must be produced, and any hospital that may be hereafter established must be subject to the same law. This law of nearness, inviting and increas- ing the patients, and of distance, preventing and diminishing the number in hospital, is our very nature, and must operate in the future as well as the past. The people will be influenced by the same motives in time to come, as they have been in the years that have gone by." OBSERVATIOXS ON FOREGOING TOPICS. Thus we are shown, by the interesting paper prepared with the great- est care by this able and accurate observer, that insane asylums dispense their blessings almost in proportion to their convenience to the people. We also learn from other sources that the proportion of cures from the nearer counties is much greater than those in the second radius of dis- tance, and so on with corresj^onding ratio to the third and fourth. This is what we might naturally expect, as those who live near the hospital would be sent to it for treatment at the earliest j^eriod after the attack, while those living at the greatest distance would defer the separation from the afflicted member of the family to the latest moment, and too often till, all hope of relief has j^assed away. It is interesting to notice in this connection that since the publication of Doctor Jarvis' paper the State of i^ew York has inaugurated an 117 entirely new' policy, and we are informed by Doctor Charles S. Hoyt, Secretary of tlie Board of State Commissioners of Public Charities, in a letter recently received from that gentleman, that it has been determined to bring every insane person within its borders under the supervision of its otticers; and that bills have already been passed autlioriziug tho establishment of first class asylums for the accommodation, care, and treatment of all the insane in the State. The following brief description of these asylums, with amount of appropriation for each, as well as their location, will best convey an idea of the noble work that has been undertaken, and may serve to guide us in the judicious location of our new asylum: THE NEW YORK STATE LUNATIC ASYLUM^ AT UTICA. This asylum, the only State institution for the insane fully completed, was organized by the Legislature in eighteen hundred and forty-two, and opened for patients in eighteen hundred and forty-three. The buildings consist of a central edifice, two front and two rear wings, a cross wing, additional wings, and outbuildings. The front and centre are constructed of stone, and the other portions mainly of brick. The central building is four stories in height above the basement, and one hundred and twenty by seventy-six feet on the ground. The front wings are three stories high, and each has an area of two hundred and fifteen by thirty-five feet. The rear wings are of the same height, two hundred and fifty feet each in length, and thirty feet in width. The cross wing is two stories high, twenty -five feet wide, and three hundred and fifty feet long; One of the additional wings is two, and the others are one story in height. The former has an area of eighty-five by twenty-five feet, and the latter one hundred and sixty-three by thirty- four feet. The entire edifice presents a front of five hundred and fifty, and the flanks a depth of two hundred and fifty feet. It is heated by steam, lighted by gas, and ventilated in the most approved manner. The outbuildings are a mortuary, bakery, coal house, work shops, boiler and engnie house, containing also the fans for ventilation, and drying and ironing rooms, wash house, farm buildings, carriage house, barns, ice house, etc. The asylum, as first erected, and until eighteen hundred and fifty-two, had room for only four hundred and fifty (450) patients. Since that date, the original buildings have been remodeled, the additional wings erected, and the cross wing adapted to the insane, by which the institu- tion has been made to accommodate six hundred (600) patients. It also furnishes apartments for the resident officers and necessary attend- ants and employes. Cost — six hundred and sixty-one thousand and sixty-five dollars and fifty-eight cents. THE WILLARD ASYLUM FOR THE INSANE, AT OVID. This institution, designed for the chronic pauper insane, heretofore provided for in the county poorhouscs, and for those who may be here- after discharged from the State Asylum at Utica as incurable, was established by an Act of the Legislature, passed April fifth, eighteen hundred and sixty-five. The site, known as the " State Agricultural Farm," contains four hundred and seventy-five (475) 'acres, near the Tillage of Ovid, on the east shore of Seneca Lake. The erection of the building was commenced in the Spring of eighteen hundred and sixty- 118 six, and it was so fur advanced as to be opened for patients in October, eighteen hundred and sixty-nine. "The main asylum building is situated^near the lake. The plan of this edifice comprises a centrarbuilding for the Superintendaut's residence and offices, and a north and a south wing, Avith extensions from the extremities of these to the rear, for patients. It is a plain, substantial, three story brick structure, well planned and arranged, and furnished with the appliances and conveniences requisite for its purposes. In addition to the main asylum, there is the '• Agricultural College Building," on the premises when acquired by the State, and now known as the "Branch." This building, situated about one mile from the main edifice, was remodeled and fitted up the past year, and occupied by' female patients in November last. It is a plain, substantial brick struc- ture, in good preservation, and appears to be well adapted for the j^ur- poses to which it is applied. The Trustees estimate -it to have cost one hundred and fifty thousand dollars. The cost of the buildings now in use for the insane, and the Trustees' estimated cost for the completion of those in process of erection and proposed,- is shown by the following statement: Cost of the main asylum and branch in use, including fur-, niture, out buildings, etc. (as stated above) j 8446,998 44 For the completion of the south wing, including the amount' already expended (estimated) 81,728 67 For the extension to the north wing, erecting a single group j of detached buildings, furniture, fences, further Avater-sup-| . ply, etc. (estimated) 200,000 00 Total. $728,727 11 The completion of the buildings as proposed will give accommodations for the insane as follows: in the main asylum, five hundred (500); the ''branch," two hundred (200); single group of cottages, two hundred (200); total, nine hundred (900) patients. The Trustees of this asylum express the opinion that its capacity may be very properly extended by the erection of additional groups of detached buildings similar to the one proposed at difterent points on the farm, so as to include nearly if not all the chronic pauper insane of the State not suitably provided for otherwise. In the judgment of these officers this would prove economical, by lessening the cost of the build- ings per capita, and utilizing the labor of the insane, and at the same time secure to them under a single responsible direction and control, better treatment and care. This subject is one of such great public importance, not only as atfecting the insane, but as to the cost of pro- viding for their maintenance, that the Board deems it proper to present it to the attention of the Legislature. THE HUDSON RIVER STATE HOSPITAL FOR THE IXSAXE Was established by the Legislature ]\Iarch sixteenth, eighteen hundred and sixty-seven. The site, previously selected b}^ Commissioners ap- pointed by the Governor, contains three hundred (300) acres. Its loca- 119 tion is on the* east bank of the Hudson Eiver, two miles north of the City of Poughkeepsie. The plan of this hospital comprises a central edifice for administrative purposes, and a north and a south wing, composed of four sections each, for patients. It also includes a chapel, general kitchen, boiler and engine house, workshops, gas house, etc., to be situated at the rear of the cen- tral structure. The erection of the building was commenced in September, eighteen hundred and sixty-seven. The three extreme sections of the south wing are nearly finished and partly furnished, and it is stated, if funds were provided, could be soon ready for patients. The boiler and engine house are built and two boilers set; the foundations for the four remaining boilers required for the entire building are laid; the great chimney, con- taining flues for the boilers, kitchen range, bake shop, gas retorts, and central ventilating shaft, is also built; the underground air duct is made, and the main sewer laid from the chimney to the river. The reser- voir for the fall capacity of the hospital is two thirds completed, and the arrangements for water are said to be adequate for its present purposes. The hospital is being constructed of North Eiver brick, with a better quality for face work. The window heads are of Ohio stone, with blue stone introduced to increase the artistic effect. The centre building and a part of two sections of each wing will be three, and the residue two stories in height. The portions of the building erected will accommodate one hundred and twenty (120) patients, and when the hospital is comj^leted according to the plans adoj)ted it will furnish room for four hundred (400). The Medical Superintendent reports that the estimated cost of the building when the plans were adopted was six hundred and sixty-six thousand dollars; but in the event of the continuance of the inflated prices for materials and labor heretofore paid it will cost, when com- pleted according to these plans, twelve hundred thousand dollars. It is stated, however, by this officer, that this estimate may be modified by the gradual decrease in prices now taking place, and the advantages to be derived from the increase of power from the boilers, in the use of the machinery, etc., but that no great reduction can be anticipated. The institution is designed for the treatment of cases of acute insanity, and the building is being constructed with the adaj)tations and appointments necessary to carry out its objects. THE BUFFALO STATE ASYLUM FOR THE INSANE "Was organized under chapter three hundred and seventy-eight, laws of eighteen hundred and seventy. The site, previously selected by desig- nated Commissioners, consists of two hundred (200) acres, situated near Buffalo, and was presented by that city to the State. The Managers report that the ground plan of the building has been adopted, and that the plan of the elevation will probably be soon ap- proved, and the work of erection commenced. The Board had expected information as to the estimated cost of the building from the Managers, but it has not been received. We learn that it is to be constructed of brick, with arrangements for the treatment of cases of acute insanity, and with capacity for the accommodation of five hundred (500) patients. The general estimate of superintendents of in- sane asylums for the erection of plain, substantial buildings of such 120 character, and appropriately furnishing the same, at the present prices for material and labor, is one thousand six hundred dollars per inmate. On this estimate it will cost, when completed, eight hundred thousand dollars. The following statement shows the capacity and cost of the State Asylums for the insane in use, and the estimated capacity and cost of those in process of erection, or for which appropriations have been made, when completed according to the several plans adopted, as hereinbefore referred to: 1 NAMES OF ASYLUMS. Capacity. Cost of the buildings. The New York State Lunatic Asjdum at Utica. The Willard Asylum for the Insane at Ovid.... The Hudson Eiver State Hospital for the Insane at Poughkeepsie 600 900 400 500 200 $661,065 58 728,727 11 1,200,000 00 800,000 00 360 000 00 The Buffalo State Asylum for the Insane at Buffalo The New York State Homoeopathic Asylum for the Insane at Middleton Total 2,600 $3,749,792 69 In conclusion, the Board deems it proper to submit a general view of the present number of the insane in custody, of their condition in res- pect to recovery, of the present provision made for them, and the requirements for the future. It will be observed that there were at the close of the first year, four thousand four hundred and eighty-four (4,484) insane persons in public institutions. Of these, nine hundred and twenty-five (925) were in the State Asylums, and one hundred and forty-eight (148) in incorporated institutions receiving State aid. The Counties of New York and Kings contained one thousand nine hundred and sixtj'-seven (1,967); and there were in the County Poorhouses and City and County Asylums one thousand four hundred and forty-four (1,444). Thus we see that the State of New York has not only determined to provide asylums for the reception of all of her insane population, but has wisel}' chosen locations in different jDortions of the State, that they may be easily accessible to all of her citizens who may be so unfortunate as to require their healing influences; though while we commend the generous liberality and muni- ficent appropriations that distinguish this noble act of humanity, we cannot advise our legislators to follow her example in all respects. In the enlightened policy of providing suitable hospitals for all who require their use, we most heartily and unequivocally concur; but we cannot see the necessity of such lavish expenditure in building palacial resi- dences for a class of persons who can neither appreciate the magnifi- cence of the edifice, nor pay for the luxury. The Poughkeepsie Asylum, it appears, will cost three thousand dollars for each patient to be accom- modated; which, according to our view, is at least twice as much as any State institution should cost under any circumstances; and for buildings alone, we are satisfied that one thousand dollars ($1,000) per patient is 121 enough. It is true that all asylums of this class should present an attractive and cheerful appearance, its architectural proportions should be in good taste, plain, neat, and substantial; but all expenditures simply for ornamentation should be scrupulously avoided, otherwise charity may be crippled at the expense of pride and vanity. But this is a digression from the subject under discussion. We have desired to show, and trust we have succeeded, that asylums are intended for the use of the people, and to be most useful they must be accessible. This being admitted, it will be easy to conclude that our next hospital for the insane should be located somewhere on or near the Bay of San Francisco, and withm easy reach of that city. At what particular lo- cality, must necessarily depend on many important circumstances and indisj^ensable conditions; an(,l that the commission to which this respon- sible duty should be confided may not, from inadvertance, overlook or neglect any of them, we append the following suggestions from the As- sociation of Medical Superintendents of American Institutions for the Insane, and of the English and Scotch Boards of Commissioners in Lu- nacy, who, from their great ability and long experience, would not be likely to make unnecessary recommendations on the one hand nor over- look important matters on the other. PROPOSITIONS RELATIVE TO THE STRUCTURE AND ARRANGEMENT OF AMERI- CAN INSTITUTIONS FOR THE INSANE, 1853. I. Every hospital for the insane should be in the country, not within less than two miles of a large town, and easily accessible at all seasons. II. No hospital for the insane, however limited its capacity, should have less than fifty acres of land devoted to gardens and pleasure grounds for its patients. At least one hundred acres should be possessed by every Slate hospital or other institution for two hundred patients — to which number these propositions apply, unless otherwise mentioned. III. Means should be provided to raise ten thousand gallons of water, daily, to reservoirs that will supply the highest parts of the building. lY. Ko hospital for the insane should be built without the plan having been first submitted to some physician or physicians who have had the charge of a similar establishment, or are practically acquainted with all the details of their arrangements, and received his or their full appro- bation. Y. The highest number that can with propriety be treated in one building is two hundred and fifty, while two hundred is a preferable maximum. YI. All such buildings should be constructed of stone or brick, have slate or metallic roofs, and, as far as possible, be made secure from acci- dents by fire. YII. Every hospital having provision for two hundred or more patients should have in it at least eight distinct wards for each sex — ■ making sixteen classes in the entire establishment. YIII. Each ward should have in it a parlor, a corridor, single lodging rooms for patients, an associated dormitory, communicating with a chamber for two attendants, a clothes room, a bath room, a water closet, a dining room, a dumb waiter, and a speaking tube leading to the kitchen or other central part of the building. IX. No apartments should be provided for the confinement of patients, or as their lodging rooms, that are not entirely above ground. 16 122 X. No class of rooms should ever be constructed without some kind of window in each, communicating directly with the external atmosphere. XI. No chamber for the use of a single patient should ever be less than eight by ten feet, nor should the ceiling of any story occupied loy patients be less than twelve feet in height. XII. The floors of patients' apartments should always be of wood. XIII. The stairways should always be of iron, stone, or other inde- structible material, ample in size and number, and easy of ascent, to afford convenient egress in case of accident from fire. XIV. A large hospital should consist of a main central building with wings. XV. The main central building should contain the offices, receiving rooms for company, and apartments entirely private for the Superin- tending Ph^'sician and his family, in case that officer resides in the hospital building; XVI. The wings should be so arranged that if rooms are placed at both sides of a corridor the corridors should be furnished at both ends with movable glazed sashes for the free admission of both light and air. XVII. The lighting should be by gas, on account of its convenience, cleanliness, safety, and economy. XVIII. The apartments for washing clothing, etc., should be detached from the hos2:)ital building. XIX. The drainage should be underground, and all the inlets to the sewers should be properly secured to prevent offensive emanations. XX. All hospitals should be warmed by passing an abundance of pure fresh air from the external atmosphere over pipes or plates, containing steam under low pressure, or hot water, the temperature of which at the boiler does not exceed two hundred and twelve degrees Fahrenheit, and placed in the basement or cellar of the building to be heated. XXI. A complete system of forced ventilation in connection with the heating is indispensable to give purity to the air of a hospital for the insane, and no exj^ense that is required to effect this object thoroughly can be deemed either misplaced or injudicious. XXII. The boilers for generating steam for warming the building should be in a detached structure, connected with which may be the engine for pumping water, driving the washing apparatus, and other machinery. XXIII. All water closets should, as far as possible, be made of inde- structible materials, be simple in their ari*angement, and have a strong downward ventilation connected with them. XXIV. The floors of bath rooms, water closets, and basement stories should, as far as possible, be made of materials that will not absorb moisture. XXV. The wards for the most excited class should be constructed with rooms on but one side of a corridor, not less than ten feet wide, the external windows of which should be large, and have pleasant views from them. XXVI. Whenever practicable, the pleasure grounds of a hosj^ital for the insane should be surrounded by a substantial wall, so placed as not to be unpleasantly visible from the building. Additional Declarations, 1866. The following comprehensive resolutions were proposed by Dr. Nichols, of the Government Hospital for the Insane at Washington, and 123 adopted by the Convention of Medical ^perintendents of American Institutions for the Insane, in eighteen hundred and sixty-six, and em- phatically reaffirmed in eighteen hundred and sixty-seven. They com- prise a full and clear declaration of sound principles, tested by expe- rience : 1. The large States should be divided into geographical districts of such size that a hospital, situated at or near the centre of each district, will be practically accessible to all the people living within its boun- daries, and available for their benefit in case of mental disorder. 2. All State, county, and city hospitals for the insane should receive all persons belonging to the vicinage designed to be accommodated by each hospital, who are affected with insanity proper, whatever may be the form or nature of the bodily disease accompanying the mental disorder. 3. All hospitals for the insane should be constructed, organized, and -managed substantially in accordance .with the propositions adopted by the association in eighteen hundred and fifty-one and eighteen hundred and fifty-two, and still in force. 4. The facilities of classification or ward separation possessed by each institution should equal the requirements of the different conditions of the several classes received by such institution, whether these different conditions are mental or physical in their character. 5. The enlargement of a city, county, or State institution for the insane, which, in the extent and character of the district in which it is situated, is conveniently accessible to all the people of such district, may properly be carried, as required, to the extent of accommodating six hundred patients, embracing the usual proportions of curable and incur- able insane in a particular community. Besolutions offered in the same Assoc^ition in 1870. Besolved, That this Association reaffirm in the most emphatic manner its former declarations in regard to the construction and organization of hospitals for the insane; and it would take the present occasion to add that at no time since these declarations were originally made has any- thing been said or done to change in any respect its frequently expressed and unequivocal convictions on the following points, derived as they have been, from the patient, varied, and long continued observations of most of its members: Fii-st — That a very large majority of those suffering from mental dis- ease can nowhere else be as well or as successfully cared for for the cure of their maladies, or be made so comfortable, if not curable, with equal protection to the patients and the community, as in well arranged hospitals specially provided for the treatment of the insane. Second — That neither humanity, economy, or expediency can make it desirable that the care of the recent and chronic insane should bo in separate institutions. Third — That these institutions, especially if provided at the public cost, should always be of a plain but substantial character; and, while characterized by good taste and furnished with everything essential to comfort, health, and successful treatment of the patients, should avoid all extravagant embellishments and every unnecessary expenditure. Fourth — That no expense that is required to provide just as many of these hospitals as may be necessary to give the most enlightened 124 care to their insane can properly be regarded as either unwise, inexpe- dient, or beyond the means of any one of the United States. These resolutions came before the Association in eighteen hundred and seventy-one, and were unanimously adoj^ted, the following Superin- tendents voting upon the question: Yeas — Doctors Kny, Butler, Kirkbride, McDill, Shew, AYalker, Hughes, Parsons, Landor, Reidle, Compton, Gundry, Clopton, Grissom, Lewis, Bancroft, Curwen, Evarts, Dickson, Eoy, Gray, and Eead. Nays — None. In the discussion upon their adoption, Doctor Eay used this language: "Mr. President: I feel very much as Mr. Webster did on one occasion when called upon, as he said, to reaffirm an ordinance of nature. The opinions of the Association on certain points have been so well fixed for many years that I supposed they would never be altered; that they were correct from the very nature of things. I am not clear now about the necessity of bringing up again the subject matter of these resolu- tions. It does seem to me like reaffirming the laws of nature. The questions implied in these resolutions you are aware have come up at various times before the Association, ancl have been very thoroughly dis- cussed. It seems to me we have discussed them until they are thread- bare. For this reason I do not feel like s^jcaking uj^on them at present." In reply to a question asked by Doctor Cook, Doctor Kirkbride made these remarks: " Speaking for myself, ^ should say, without any hesitation whatever, that I do mean, as the fourth resolution declares, tliat every State should provide enough institutions to accommodate all the insane within its borders. It is my firm conviction that the poorest State in this country is perfectly able to provide just as many hospitals as are necessary. I do not believe any Government has the right to say to one family, ' We will take care of your afflicted one,' and say to another, ^ We will not take care of yours,' simply because one is a more recent case than the other. If we undertake to provide for a part of the insane, we are bound to provide for all. One family has just as good a right to claim the bounty of the State as another." Doctor Cook — "You would not exclude chronic cases?" Doctor Kirkbride — " I certainly would not." ENGLISH LUNACY COMMISSIONERS ON SITES, CONSTRUCTION, ETC. [Snggeptions and Instructions in Keference to (1) Sites, (2) Construction and Arrangement of Buildings, (:}) Plans of Lunatic Asylums, by the Commissioners in Lunacy for England and AVales.] No. 1 — Sites. — General. 1. The site of an asylum should be of a perfectly healthy character, and offer facilities for obtaining a complete system of drainage. A chalky, gravelly, or rocky subsoil is most desirable; but if a clayey sub- soil only can be obtained, an elevated position is indispensable. It should not be near to any nuisances, such as steam engines, shafts 125 of mines, noisy trades, or offensive manufactures; neither should it be surrounded, or overlooked, or intersected, by public roads or footpaths. Froportion of Land. 2. The land belonging to the asylum should, when practica])le, be in proportion of not less than one acre to four patients, so as to afford ample means for agricultural employment, exercise, and recreation; and should be so situated as to offer facilities for any extension which may become necessary at a future period. Form of Ground. 3. The site of the building should be elevated, as respects the sur- rounding country, and (if to be obtained) undulating in its surface, and cheerful in its j^osition, and having a fall to the south. Position and Aspect of Budding. 4. The building should be placed near the northern boundary of the land; and it is important that the site should afford a j^lateau oi" sufficient extent for the structure, and for ready access from the north; the whole of the southern portion of the land being available for the undisturbed use of the jDatients. Zocality. % 5. The asylum should be as central as possible to the mass of popu- lation in the country or district for which it is to be erected, and should be convenient \^th respect to its easy access by public conveyance iu order to facilitate the visits of friends and the supply of stores. Supply and Quality of Water. 6. It is of the utmost importance that there should be a constant and ample supply of good water, of which a careful analysis should be made with a view of determining the proper materials for pi2)es and reservoirs, and also to ascertain its titness for the purposes of drinking and wash- ing. The quantity, exclusive of rain water, should at the dryest season be not less than twenty-five gallons i)er patient per diem, and the amount should be accurately gauged. No. 2. — Construction and Arrangement of Buildings, — General Form. 1. The general form of an asylum should be such as to afford an unin- terrupted view of the surrounding country, and the free access of sun and air, and be so arranged as to give the principal day rooms on the lowest and middle stories a southern or southeastern aspect. Entrance and Offices to the North. 2. There should be no road of approach or public entrance on the south side of the asylum. The general entrance, the porter's room, the reception and visitors' rooms, the clerk and steward's office, and store- rooms, and the other offices, should be placed on the north side cf the building. 126 Character of Building. 3. As the building is intended for the accommodation of pauper patients, all superfluous external decoration should be avoided; at the same time it should be rendered as cheerful and attractive as due consid- eration of economy will permit. Separation of Sexes, and Classification. 4. The accommodation for the male and female patients should be kept distinct on either side of the centre, and the building should be so con- structed as to admit of the separation of the male and female patients, respectively, into three classes. As a general rule the numbers in each class should be such as to require the services of not less than two attendants. Stories. 5. The building may consist of three stories, provided the uppermost story be devoted to sleeping accommodation. Buildings for Working Patients. 6. Buildings of a cheap and simple character, consisting merely of associated day -rooms and dormitories, without long corridors or other expensive arrangements, should be provided for the use of working patients. These buftdings should be placed in connection with the washhouse and laundry on the female side, and be conveniently situate in reference to the workshops and farm buildings on the male side. For Idiotic and Epileptic Patients. Provision of an equally simple and inexpensive description should also be made for a portion of the idiotic and ej^ileiDtic j)atients, and also for chronic cases. Size of Chapel and Offices. 7. The chapel and all offices and parts of the building common to the establishment — such as the kitchen and scullery, the washhouse and laundry, the workshops and storerooms, should be sufficiently sj^acious to meet the prospective wants of the asylum in case of an increase in the number of patients. Position of Chapel. 8. The chapel should not be placed over the kitchen. It should be capable of comfortably accommodating at least three fourths of the patients. It should have the usual character and arrangement of a church, and contain no special or peculiar provision for the separation of the sexes. General Dining Hall. 9. A general dining hall, conveniently situate with reference to the. kitchen, and capable of being made available for the purposes of recrea- tion, should be provided for the patients of both sexes. 127 Officers' Residences. 10. A good residence should be provided for the Medical Superin- tendent, with kitchen and other necessary domestic offices. Suitable apartments of moderate extent should also be provided for the Assistant Medical Officer, the Steward, and the Matron, but for these officers a separate kitchen is not required. Domestic Servants. There should also be sleeping accommodation for the domestic servants of the institution, with whom might conveniently be associated those patients who habitually work in the kitchen. Fropo?iion of Single Booms. 11. The proportion of single rooms throughout the Asylum need not exceed one third. The single rooms should be chiefly in the wards appropriated to the excited and the sick. A few should be available for special cases in the other wards. Arrangement of Upj^er Stories — Passages and Corridors. 12. In the upper stories passages of communication of moderate width should be adopted in lieu of wide corridors, and the dormitories should be placed to the south. Generally, long, wide, and expensive corridors should not be constructed, but only so much passage or corridor pro- vided as may be absolutely necessary to connect the several parts of the building. Stairs. 13. The stairs should be built of stone, without windows or long, straight flights. The well should be built up, and hand rails should be provided. Staircases. 14. The staircases should be so arranged that the medical officer, attendants, and others may pass through from one part to another with- out necessarily retracing their steps. Material for Floors — Provision Against Fire. 15. All the corridors and day and sleeping rooms should have boSrded floors, and it is desirable that the boards should be tongued. It is indis- pensable that they should be of the best wood, and thoroughly well seasoned. The floors of the sculleries, lavatories, and water closets need not be of wood. There should be a disconnection of the floor and joists at all the internal doorways, by means of a stone sill; and in all cases where a fireproof construction is not adopted similar separations, at not greater distances apart than fifty feet, should be made in the floors and joists of the galleries or corridors. Provision should also be made for a complete fireproof separation of the timbers of the roof at the same distance, and the parapet should be carried through the roof one foot above the slating. Oak floors, capable of being cleaned by dry rubbing, are preferable for the corridors and day rooms. 128 Plastering. The walls of the galleries and rooms generally should be plastered. Number of Beds in Dormitories. 16. No associated bedrooms should be designed to contain less than three beds. Height of Each Story, and Dimensions of Booms. 17. The general height of each story should not be less than eleven feet. The associated dormitories should not contain less than fifty feet superficial to each bed or patient. Dormitories. The separate sleeping rooms generally should be of not less than the following dimensions, viz: nine feet by seven superficial, and eleven feet high. Those appropriated to sick or bedridden patients should be of somewhat larger dimensions, and some of these should be provided with a fireplace. Size of Day Booms. 18. The day rooms, of which there should be at least one in each ward, should contain not less than twenty feet superficial for each patient, and should be calculated for the whole of the patients in each ward, exclusive of corridors or galleries. Position of Day Booms, 19. The day rooms should be so arranged as to afford ready commu- nication with the grounds, and those appropriated to the aged and infirm should be on the lowermost stories. Attendants' Booms. 20. Eooms should be provided for two or more attendants to each ward, and single attendants' rooms should not be of less dimensions than one hundred and twenty feet, and whenever practicable, these should be placed between two dormitories, with glazed doors of com- mun^ation. Windows. 21. The windows of the day rooms and corridors should be large and of a cheerful character, and every one be made to open easily, and so as to allow a free circulation of air, but not so far as to expose patients to danger. The wall below should not be sloped or splayed, but recessed, to admit, if requisite, of a seat. In the dormitories and single rooms the windows should, as a general rule, not be placed more than four feet from the floor. Shutters. Sliding shutters should be provided for a majority of the single sleep- ing rooms. ' 129 Doors. 22. The doors of the single rooms should open outward, and be eo hung that when oj^en they will fold back close to the wall. Lavatories, Baths, and Water Closets. 23. In each ward there should be conveniences for washing the person, a slop room containing a sink, a store room or closet, water closets, and a bath. (In many instances the bath room may be so arranged as to be available for two or more wards.) It is very desirable that all water closets, lavatories, etc., should be placed in projections. Infirmaries. 24. Suitable infirmaries, in the proportion of at least one tenth of the whole, should be provided in which the cubical contents of the sleeping rooms should be greater than in other parts of the building; and every room, including the single rooms, should have an open fireplace. A small day room in each infirmary is also desirable. Wannhig. 25. All the day rooms and galleries should be warmed by means of open fireplaces, or open fire stoves, and in large rooms two fires should be provided. Fireplaces should also be built in all associated dormi- tories. In large rooms, such as the chapel or general dining hall, and in the corridor, further provision for warming may be necessary by means of some simple system of hot w^ater pipes in connection with the open fire stoves or fires. » Ventilation. 26. The ventilation generally should be provided for by means of flues taken from the various rooms and corridors into horizontal channels connecting with a perpendicular shaft, in which a fire box should be placed for the purpose of extracting the foul air. Smoke Flues. 27. In all cases where descending or horizontal smoke flues are used, they should be entirely constructed of brickwork, rendered or pargetted inside and out; and flues from any of the heating or other furnaces, which are carried up through any of the main walls, should be con- structed with a hollow space round them to prevent the inconvenient transmission of heat into the building during the warm periods of the year^ and to allow of a moderation of the temperature of the building at other periods, when, owing to a change in the atmosphere, it may become inconveniently hot. Ventilating Flues. 28. Whenever ventilating flues are constructed of inflamable material, such a quartering, lathed and plastered a distance of at least twenty 17 130 feet from their point of coDnection with any shaft, furnace, rarifiying chamber, or smoke fine, must be constructed entirely of brick, stone, or other fireproof material. The rarifyiug chamber for ventilation, together with the adjoining roof, must be entirely fireproof; and a com- munication should be made with it by means of a slate or iron door frame. Drainage. 29. The best and most approved system of pipe or tubular drainage should be adopted, with a sufiicient fall, so as efiectually to carry off to a sufiicient distance from the asylum the soil and all other impurities; and the sewerage should be collected in closed tanks, and so placed and constructed as to render the contents available for agricultural purposes. Means of flushing should be provided. Airing Courts. 30. The inclosed airing courts need not be more than two in number on each side, and should be of ample extent, so as to afford proper means for healthful exercise. They should all be planted and cultivated, and any trees already existing within them should be preserved for shade. The walls should be sunk in a haha. Rainwater. 31. The whole of the rainwater from the building should be collected in tanks suitably placed, for the purposes of the washhouse, and if pos- sible, at such levels as will dispense with the labor of pumping. Lead is an objectionable material for pipes and reservoirs, as adulterating the vrater. Lightning Conductors. 32. Lightning conductors should be placed on the most elevated parts of the buildino;, and they may be connected with the stacks of iron rain water pipes, which in that case should be fixed so as to answer the double purpose of rain water i:>ipes and lightning conductors. . Farm Buildings. 33. Farm buildings, with suitable stables, etc., for visitors' horses, should be provided. Ko. 3 — Plans Bequired. * 1. One or more sheets of the ordnance map containing the county, borough, or district, in respect to which the asylum is to be erected, or some other large map, in which the situation of the proposed asylum and all the public roads and footpaths in the vicinity thereof are fully de- fined. Scale of 100 feet to an Inch. 2. A general plan of the land (with the block of the buildings and offices) and of the exercise grounds, garden, and road of approach, with the levels of the surface of the ground at the quoins of the building, offices, and fence walls figured thereon. 131 Scale of 20 feet to an Inch. 3. Plans of the basoment, ground, and each other floor of the building and offices, also of the roofs and gutters and of the principal elevation. Scale of 10 feet to an Inch. 4. Elevation of portions of the principal front, and also of any other parts in which any variation therefrom takes place. Scale of 5 feet to an Inch. 5. Transverse and longitudinal sections or sufficient portions thereof to show the construction of every portion of the building. Scale of 1 foot to one half an Inch. 6. Plan and section of one separate sleeping room, dormitory, and eat- ing or day room respectively, or of part of the same, showing the method of warming and ventilating each; also, of the baths and' washing rooms and water closets, and the construction of the apparatus for each. 7. An abstract of the draft, contract, and specifications, giving a con- cise statement of the whole of the intended work, and also a detailed estimate of the building, and the prices at which the different materials and w^orkmanship have been calculated in making the estimate. 8. The thicknesses of the Avails, and the 'scantlings of the timbers of the floors and roofs to be figured. 9. The general system of heating and ventilation proposed to be adopted throughout the asylum, to be fully described in the drawings and specifications. 10. Each i^lan to show" the several classes and number of patients to be accommodated in the wards, day rooms, dormitories, cells, galleries, and airing courts, respectively, to which each plan relates. SUGGESTIONS Ot' THE SCOTCH BOARD. The following suggestions and instructions by the Scotch Board of Commissioners are the only ones differing from those by the English Commissioners: Suggestions and Instructions in Reference to (1) Sites; (2) Construction and Arrangement of Buildings; (3) Plans of Lunatic Asylums; by the CommiS' sioners in Lunacy for Scotland. Locality. (First part of description same as for England and Wales.) The asylum should be within such distance of a town as to command the introduction of gas, water, etc., and of one of sufficient size to afford the means of amusement and recreation for the medical staff', the attend- ants, and such of the patients as might derive benefit from a change in the asylum routine. Supply and Quality of Water. (First part, same as for England and Wales.) The quantity, exclusive 132 of rain water, which should be collected in cisterns on the roof, should, at the dryest season, be not less than forty gallons per patient per diem, and the amount should be accurately gauged. jVb, 2 — Construction and Arrangements of Buildings — Entrance and Offices to the North. 2. There should be no road of approach or public entrance traversing the grounds. The general entrance, the porter's room, the reception rooms, the committee room, the store rooms, and the other offices should be so placed as not to interfere with the amenity of the buildings occupied by the patients. Buildings for Working Patients — For Idiotic and Epilejjtic Patients — Cottages. 6. (First part, same as for England and Wales.) Provision of an equally simple and inexpensive description might also be made for a portion of the idiotic, imbecile, and fatuous patients, and also for chronic cases; or cottages might be erected for the accommodation of a large proportion of the working and inoffensive patients, who might be placed either under the care of the families of the attendants, or of cottage tenants of the asylum. Position of Chapel. 8. The chapel should be of easy access, and it should be capable of comfortably accommodating at least three fourths of the patients. (Eemainder of description same as for England and Wales.) General Pining Hall, Library, and Beading Boom. 9. A general dining hall, conveniently situated with reference to the kitchen, should be jn-ovided for the patients of both sexes; and also a library and reading room, capable of serving for the general purposes of instruction and recreation. Arrangement of Pay Booms and Pormitories. 12. Passages of communication of moderate width should be adopted in lieu of wide corridors, and the day rooms and dormitories should be placed on one side, and to the south. Under certain circumstances the day rooms and dormitories ma}^ occupy the whole breadth of the building. Cottages. 32. The cottages, if adopted, should be of different sizes, each calcu- lated to accommodate from three to five patients, in addition to the family of the occupier. The male patients should be placed either in single rooms or in dormitories for three or four, and each cottage should contain a water closet. Farm Buildings. 33. Farm buildings, with suitable stables, etc.j should be provided, aind 133 also workshops, suitable for the employment of the patients according to the prevalent occuj)ations of the district. English Commissioners on Size of Hospitals. The English Commissioners of Lunacy are of opinion that an asylum to contain four hundred to five hundred patients is the best size, but that on an emer2;ency they may be enlarged to contain six hundred to seven hundred patients without sacrificing the special characters which all modern asj^lums should possess. When there are more than seven hundred patients, the expenses increase, and all individual treatment vanishes. The Superintendent can only know the patients en masse, and not individually, and the establishment grows out of eifective super- vision, although the number of attendants may be increased. This opinion may be found in the reports of the Commissioners again and again stated during the last ten years. Thus, in eighteen hundred and fifty-seven they state: " It has alwaj^s been the opinion of this Board that asylums beyond a certain size are objectionable. They forfeit the advantage — which nothing can replace, whether in general management or the treatment of disease — of individual and responsible supervision. To the cure and alleviation of insanity few aids are so important as those which may be derived from vigilant observation of individual peculiarities; but where the patients are so numerous that no medical officer can bring them within the range of his personal examination and judgment, such oppor- tunities are altogether lost, and amid the workings of a great machine the physician, as well as the patient, loses his individuality. When to this also is added, what experience has of late years shown, that the absence of a single and undivided responsibility is equally injurious to the general management, and the rate of maintenance for the patients in the large buildings has a tendency to run higher than in buildings of a smaller size, it would seem as if the only tenable plea for erecting them ought to be abandoned. To the patients, undoubtedly, they bring no corresponding benefit. The more extended they are, the more abridged become their means of care; and this, which should be the first object of an asylum, and by which alone any check can be given to the present gradual and steady increase in the number of pauper lunatics requiring accommodation, is unhappily no longer the leading character- istic of Colney Hatch or Hanwell." The Scottish Commissioners are equally opposed to large asylums. They consider that no asylum should contain more than three hundred and fifty patients; that the individual treatment of a larger number is impossible; and that cost increases with anything above that number. These opinions they repeatedly expressed in their various reports. M. Parchappe, lately Inspector of Asylums in France, says: "After taking every consideration into account, I think the minimum of patients ought to be fixed at two hundred, and the maximum at four hundred. Below two hundred the economical advantages rapidly decline without compensatory benefit; above four hundred, although the economical advantages augment, it is at the detriment of the utility of the institution in its medical character." 134 M. Guislain, the eminent Belgian authority, in his large work on insanity, which is quoted by Doctor Arlidge, says: " It would be absurd to bring together, in the same place, a very large population. It would tend to foster an injurious degree of excitement, w^ould render the management difficult or impossible, would destroy the unity of plan, and neutralize all scientific effort. The maximum number ought not to exceed three hundred or three hundred and fifty insane persons." Doctor Arlidge, in his work on " The State of Lunacy," mentions the opinions of Eoller and Damerow — two of the most eminent of German alienist physicians — on this subject, both of whom consider that asylums for acute cases should be limited to two hundred and fifty, but that those for both acute and chronic cases may admit from four hundred and fifty to five hundred inmates, but no more; and at page one hundred and eighteen states his own opinion that six hundred " represent the maxi- mum which can economically and with just regard to efiicient govern- ment and supervision, and to the interests of the patients, be brought together in one establishment." OBSERVATIONS ON FOREGOING PROPOSITIONS. We have preferred the suggestions of associations and the recom- mendations of bodies of men high in authority to anything we might have said on these subjects, for the reason that they will be justly regarded as the results of wisdom and experience, w^orthy of attention and thoughtful consideration; whereas the same suggestions from us might be considered as the expression of individual opinion, carrying with it no weight of authority. The good of the cause is what we desire to promote, and for this reason have not hesitated in any instance to make free use of the ideas or words that the wisdom of others have given to the world. With no experience of our own, we have endeavored to carry out the instructions of our mission — to collect, compile, and report the result of other men's experience. We have, of course, exercised our own judgment in drawing conclusions, after listening to the arguments and observing the particular operations of theories; and all of our deductions have been made upon this basis. When we say, therefore, that the next asylum should be established for the accommo- dation of the City of San Francisco and the counties around the Bay, and on this account should be located in that vicinity, we are only carry- ing out the ideas of others, and obeying a law of common sense and universal experience; and when we suggest that another asylum will be necessary in the northern and still another in the southern portion of the State, ere many years shall have clasped, it is in obedience to the dictates of the same ideas and natural laws. It will be seen from the foregoing suggestions that the English Board of Commissioners in Lunacy regard hospitals that will accommodate from four to six hun- dred as the best size for the pauper class of patients; while in Scotland, owing possibly to the fact that both private and pauper patients are more generally received in the same asylums than in England, the Board expressed the opinion that three hundred and fifty should constitute the largest number that could be properly accommodated in one institution. The best authorities at this time in France, Germany, Switzerland, Italy, and Belgium have placed the limits at four hundred, and in the United 135 States, until very recently, the Superintendents, in their collective capacity, declared that two hundred and fifty should never be exceeded. But in eighteen hundred and sixty-six they so far modified this expression as to say that under certain peculiar circumstances the number might be carried to the extent of accommodating six hundred l^atients. This concession was made, as we have been informed by most of those giving their consent to its utterance, more to what seemed to be a necessity, than from convictions of propriet}', most of them still adher- ing to the correctness of the original declaration — such too, as will be seen from the Massachusetts Eeport on Insanity and Idiocy, page one hundred and thirty -four, a copy of which will be found in our State Library, was the opinion of most of the Medical Superintendents in Europe and America at the time that report was w^ritten. PRESENT CUSTOM IN ALL COUNTRIES. Notwithstanding the modifications that have been made in this respect, and notwithstanding the further fact that most of the asylums being erected at the present time are intended for the accommodation of from four hundred to six hundred, both in the Old World and the New, our observations of the practical workings of asylums of all sizes, compels the conviction that all things taken into consideration the smaller num- ber — two hundred and fifty — is the best; and that under no circum- stances should this number be exceeded under one roof. If this should be deemed too small, it might with propriety be supplemented by addi- tional separate buildings for the accommodation of one hundred and fifty more; one with a capacity for fifty patients of the convalescent class, for both sexes, and two others of equal size — one for the inolfensive and quiet males, who may or may not labor on the farm, in the garden, or shops, and the other for females of the same class, who may work in the laundry or sewing room. Such buildings may be seen at many of the asylums in England and Scotland, as well as on the Continent, and are not only pleasant features, but are considered of so much value in the treatment of the patients, and the general management of the asylums, that we were assured by the Superintendents that they would not dis- pense with them on any account. They are by no means uniform in the i^roportions which they accommodate, nor as to the classes we have specified above. They are usually more cheaply constructed than the main buildings, and free from the grated or barred windows and other necessary arrangements made use of in the main building as precautions against escape or injury. They are warmed by open fireplaces, and are surrounded by their own little gardens, redolent with flowers and beau- tified with shrubs cultivated by the patients. Of course they are never left to themselves, as it is a universal law that no ward of a hospital should, under any circumstances, be left without an attendant, even for a short time; otherwise serious accidents might be the result. DINING HALLS IN EUROPEAN ASYLUMS. In Great Britain and Ireland, as w^ell as on the the continent, the pa- tients take their meals in a common dining hall, the males occupying seats on one side the hall and the females on the other. When the num- bers are too great for this arrangement to be practicable, two dining halls are provided, one for either sex, and are situated on either side of 136 the kitchen. At Newcastle-upon-Tyne they not only dine in the same hall, but sit where they please; and it was interesting to observe that while the first tables on the female side of the room were occupied exclusively by them, and so with the males on their side, that the next set of tables had a sprinkling of the opposite sex, and so on till the cen- tre tables were reached, which were occupied by about an equal number of either sex. Doctor AYickham informed us that this Avas always the case, and that he had never experienced the least excitement or trouble on this account. For these reasons the patients occupying the detached buildings of which we have spoken resorted to the common dining halls for their meals, with the exception of the convalescent patients, who were in some instances provided with meals in their own establishment. ASYLUM SHOULD NOT BE ENLARGED. When an asylum of this size has received its intended complement, instead of building still further additions, another should be established in another district of the State, where the population most strongly indi- cates its need, whether at some other point upon the Bay — should San Francisco still continue to pour its hordes into the new asylum as it has done into the old — or in some more distant part of the State, in the great north or the mild and genial south, must be determined by the condition of things as they may exist at the time. Of one thing we are positively certain, that so long as the habits of our people remain as they have been; so long as the proportion of the foreign population remains the same; so long as the causes of insanity remain unchanged, just so long will insanity continue to be produced and hold its present ratio to the inhabitants of the State. ONE INSANE TO FOUR HUNDRED AND FIFTY OR FIVE HUNDRED PERSONS. We may as well make up our minds now as at any future time that every community of four hundred and fifty or five hundred persons will have to support or provide for the treatment and care of one insane per- son. When this becomes to be a recognized fact among the people, the whole subject will have been stripped of more than half its difiiculties and embarrassments, the system for which we have labored will have been established, and the just and regular provision for the insane will be made for their support, as it is now for the common schools or the ordinary and inevitable expenses of the State Government. Until this has been accomplished the constantly recurring and ever renewing ques- tion of provisions for the insane will be brought before our Legislature, to occupy its time and perplex its members. ASYLUM AT STOCKTON OVERCROWDED. But there is another question that must not be overlooked, in our so- licitude for the establishment of a new asylum, and which is a matter of equal concern. It is the present crowded condition of the asylum at Stockton. With accommodations for not more than six or seven hundred patients, there are packed in its Avards about eleven hundred — or four hundred more than it can properly accommodate. Doctor Shurtletf tells us in his report, " that beside two j^atients in the rooms intended for but one, in eight out of the eleven Avards, tAvo hundred and twenty-seven patients are sleeping on beds nightly prepared for them in the halls." 137 Two of these wards, the second and tenth, intended for thirty patients each, now have about eighty each. These wards are poorly ventilated, low, and uncomfortable in the extreme, and should be erased from the face of the earth and the memory of man. They never were fit recep- tacles for any human being, and have been tolerated altogether too long. INCREASED MORTALITY. To the crowded condition of these wards and the hospital generally must be attributed the increased mortality of the last four years; and should it be our misfortune, which God forbid, to be visited with cholera or other epidemic, there is no place to which these patients could possibly be removed, and they would consequently be swept away like sheep with the rot. Let any member of the Legislature visit these w^ards at bed- time, and if he does not conclude that it is a sin and a shame not to do some- thing for their immediate relief, we will be willing to acknowledge that w^e ourselves have lost our reason and our heart, and a fit subject for the very wards that we have described, or that he himself is in such condi- tion; for no two sane men could ever agree to the policy of "doing nothing," after having visited them. How Dr. Shurtleff and his assistants have managed to get along so well, under the disadvantages with which they have been constantly beset, is a matter of wonder and surj)rise, and the untiring energy and constant w^atchfulness that has been displayed by them are wor- thy of the highest commendation, as well as the gratitude of the com- munity at large. • NEW BUILDINGS SHOULD BE FINISHED. The new building at Stockton is of the most creditable character, and when completed would be considered a first class asylum anywhere in the world; indeed, with a few modifications, w^e know of none that would be better suited to the climate in which it is located. The press- ing demands for further and immediate room, make it of the greatest importance, nay, an absolute necessity, that it should be completed by the immediate construction of the north wing, and thus finish the work that has been too long delayed. It is not necessary to stop to discuss the question as to w^hether Stockton is or is not the j^roper place for the location of an insane asylum. One has been located there, and has been in successful operation for the last twenty years. It could not be removed, even if such an event w^ere desirable. We therefore heartily indorse all that Dr. Shurtleff has said with regard to the necessities of the institution over w^hich he has so long presided, with such marked ability and success. OTHER PROVISIONS NEEDED. The strongest reasons and the plainest motives of sound policy would indicate the propriety of providing for the improvements at Stockton, and for a new asylum in the same bill. The past experience of Doctor Shurtleff, aided by his Board of Trustees, would insure the completion of the work there in the shortest time and best manner; when it would only remain for the Governor or the Legislature to make a judicious 18 138 selection of the men who are to choose the site, decide upon the plan, superintend the erection of the new building, and control its subse- quent management. COMMISSIONERS. As great power is commonly placed in the hands of these individuals, it will readily be understood how important it is that they should be men of high character, strict integrity, active benevolence and business habits. They should be willing to inform themselves of the character and responsibility of the high trust confided to them, and should heartily avoid taking any step that might mar to a greater or less extent the usefulness of the institution as long as it may exist. SITE. Great caution should be observed in the selection of a site, as the best style of building and most liberal organization can never compensate for the loss sustained by a location that deprives the patients of valuable privileges, or subjects them to annoyances; nearness to manufacturing establishments, houses of correction, penitentiaries, or other public insti- tutions calculated to disturb the quiet or unpleasantly affect the mind of the patients should be especially avoided. Great stress is laid upon all of these matters both by the Commissioners of England and the Superintendents of our own country. As has been observed by Doctor Kirkbride, than whom no better authority can be found: "It is now well established that this class of hospitals should always be located in the country not within less than two miles of a town of considerable size, and they should be easily accessible at all seasons. They should, if possible, be near turnpikes or other good roads, or on the line of a railroad. While two or three miles from a town might be named as a good distance on the former, the facilities afforded by a railroad might make ten or twelve miles unobjectionable; for it is the time spent in passing and ease of access that is most important. Proximity to a town of considerable size has many advantages, as in procuring supplies, obtaining domestic help, or mechanical workmen, and on account of the various matters of interest not elsewhere accessible to the patients. In selecting a site, facility of access from the districts of country from which the patients will be principally derived should never be over- looked." SHOULD BE IN A HEALTHY LOCALITY. The building should be in a healthful, pleasant, and fertile district of country; the land chosen should be of good quality and easily tilled; the surrounding scenery should be of a varied and attractive kind, and the neighborhood should possess numerous objects of an agreeable and inter- esting character. While the hospital itself should be retired, and its Xjrivacy fully secured, it is desirable that the view from it should exhibit life in its active forms, and on this account stirring objects at a little distance are desirable. Eeference should also be made to the amount of wood and tillable land that may be obtained, to the supply of water, and to the facilities for drainage, and for inclosing the pleasure grounds. QUANTITY OF LAND NECESSARY. While it is the duty of the State to provide for and take care of every 139 citizen who may be afflicted witti insanity, on the other hand it is no more than right that they should make the burden as light as possible; and although we do not believe in making patients work for the profits of their labor, yet when they have been accustomed to labor on the farm, in the garden, or in shops at home, and when they are well enough to perform this labor at the asylum, not only without detriment but with advantage to their health and improvement in their mental condition, it should be exacted from them; the Superintendent in all cases being the judge as to the results. In most of the asylums in our country too little employment is given to the body, and too little occupation to the mind, to prevent a state of ennui that naturally follows the occuj^ation " of doing nothing." Many cannot labor for medical reasons; others, on account of previ- ous occupations and professions, have not been taught to labor, and require other forms and methods of employment; yet all in whom there exists no special reason contraindicating it should be emj^loyed in some way during a portion of every day. Hence ever^^ State Asylum should have at least half an acre of land for each patient intended to be accommodated, not only for farming and gardening purposes, but for pleasure and exercise grounds as well, as the latter are the most beautiful and attractive features of every asylum where they exist, and in wdiich the English Asylums especially, so far excel those of all other countries as a rule, and those in our country more particularly, where this feature has been too much neglected. Supply of Water. An abundant supply of good water is one of the necessaries of every hospital, and should be secured whatever may be the cost or trouble required to eifect it. A very extensive use of baths is among the most important means of treatment, and the large number of water closets that are indispensable in the wards, the great amount of washing that is to be done, as well as various other arrangements requiring a free use of water, and above all, abundant means for extinguishing fire, in case such an accident should occur, make it of the utmost im23ortance that the supply should be permanent and of the most liberal kind. The daily consumption for all purj^oses in an institution for two hun- dred and fifty patients will not be much, if any, less than ten thousand gallons, and tanks to contain more than this amount should be i^laced in the dome, or highest part of the building. Drainage. All the drainage should be under ground; and in selecting a site, facil- ities for making this very important arrangement should never be over- looked. All tlie waste water from the kitchen, sculleries, baths, water closets, etc., should be carried off beneath the surface, and to such a distance as will prevent the possibility of its proving an annoyance to the hospital. All the entrances to the culverts should be trapped, and the culverts should be made so large and with such a descent as will obviate all risks of obstructions. If the rain water from the roof and the surface drainage are taken in another direction, that from the hospital may be made to add greatly to the fertility of the farm; but it is much better to carry all off through the same culvert and lose this advantage, than incur the 140 slightest risk of having the air in the vicinity of the hospital contami- nated by these fertilizing arrangements. Inclosiires. It is desirable that the pleasure grounds and gardens should be securely inclosed, to protect the patients from the gaze and impertinent curiosity of visitors, and from the excitement occasioned by their presence in the grounds. This inclosure should be of a permanent character, about ten feet high, and so located that ii will not be conspicuous, even if it is at all visible from the building. The site, as well as the position of the building on it, should have some" reference to this arrangement. If sufficient ine- qualities of surface exist, the wall or fence, as it may be, should be placed in the low ground, so as not to obstruct the view; but if the country is too level to admit of this, the same end may be attained by placing the wall in the center of a line of excavation of sufficient depth to prevent its having an unpleasant appearance, and yet be entirely etfective. Although^the first cost of a wall will be about double that of a fence of the proper kind, still, its durability and greater efficiency in every re- spect will make it cheaper in the end. The amount of land thus inclosed should never be less than thirty acres, while forty or even fifty acres will be a more desirable amount, so that the pleasure grounds of the male and female patients, which, as before observed, should be entirely distinct, may be sufficiently extensive. Important as I regard the per- manent inclosure of extensive pleasure grounds and gardens, in the manner suggested, as protecting the patients from improper observation, keeping out intruders, enlarging the liberty of the insane generally, securing various improvements from injury, and permitting labor to be used as a remedy for more patients than could otherwise be done, still it is proper to add, that high walls around small inclosures, and in full view from the buildings, are even less desirable than a simple neat railing, which would neither keep determined visitors out nor active patients in. The first of these objects — keeping the public out — :t must not be for- gotten, is the prominent one thought of in recommending a wall to be placed around the pleasure grounds of a hospital. The presence and watchfulness of intelligent attendants must still be the grand reliance to prevent the escape of patients, and I regard any arrangement that does away with the necessity of constant vigilance undesirable about a hospital for the insane. Patients' Airing Courts. Although it does not seem to me desirable to have a large number of private yards in immediate connection with a hospital for the insane, it will still be found convenient to have two for each sex, of a large size, well provided with brick walks, shade trees, and such other modes of protection from the sun and weather as may be deemed useful. These yards enable many patients, who at certain periods wish to avoid the greater publicity of the grounds, to have the benefit of the open air, and to take exercise at hours when the attendants cannot conveniently leave the wards; but most of the patients should have a more active and longer continued kind of exercise than these yards aff'ord. They should look to the walks in the open fields and about the grounds, which can readily be made a mile long for each sex for their principal exercise. 141 Four fifths of all the patients will, under proper regulations, be able to take walks of this kind for at least a couple of hours, morning and afternoon, at all seasons; and in warm weather, when proper summer houses and seats are provided, they may thus profitably spend one half the entire day in the open air. It is always much better for patients to be comfortably sealed in 'a pleasant parlor or hall at any season of the year than to be lying on the ground, or otherwise soiling their clothes, and exposing themselves to the risk of taking cold, as is very apt to be the case when certain classes are allowed to consult their own pleasure as to the mode of passing their time while in the small yards adjoining the building. Size of the Building. A suitable site having been selected, it will next become necessary to decide upon the size of the institution. Whatever difference of opinion may have formerly existed on this point, I believe there are none at present. AH the best authorities agree that the number of insane con- fined in one hospital should not exceed two hundred and fifty, and it is very important that at no time should a larger number be admitted than the building is calculated to accommodate comfortably, as a crowded institution cannot fail to exercise an unfavorable influence on the welfare of its patients. The precise number that may be properly taken care of in a single institution will vary somewhat, according to the ratio of acute cases received, and of coarse to the amount of personal attention required from the chief medical ofiicer. In State institutions, when full, at least one half of all the cases will commonly be of a chronic char- acter, and require little medical treatment. Even when thus propor- tioned, two hundred and fifty will be found to be as many as the Medical Superintendent can visit properly every day, in addition to the perform- ance of his other duties. Whenever an existing State institution built for two hundred and fifty patients contains that number and does not meet the wants of the community, instead of crowding it, and thereby rendering all its inmates uncomfortable, or materially enlarging its capacity by putting up additional buildings, it will be found much better at once to erect an entirely new institution in another section of the State, for under any circumstances the transfer of acute cases from a great distance is an evil of serious magnitude, and constantly deplored by those who have the care of the insane. Position, Form, and General Arrangements. The size of the building having been determined, its form and general arrangements will next require attention; and no plan, however beauti- ful its exterior may appear, nor how apparently ingenious its interior may seem, should be adopted without having been first submitted to the inspection and received the approval of some one or more pTiysicians who have had a large practical acquaintance with thejnsane, and who are thoroughly familiar with the details of their treatment, as well as with the advan- tages and defects of existing hospitals for their accommodation. So different from ordinary buildings or other public structures are hospitals for the insane, that it is hardly possible for an architect, however skill- ful, or a Board of Commissioners, however intelligent and well disposed, unaided to furnish such an institution with all the conveniences and arrangements indispensable for the proper care and treatment of its pa- tients. No desire tb make a beautiful and pidture^que exteridr should 142 ever be allowed to interfere with the internal arrangements. The inte- rior should be first planned, and the exterior so managed as not to spoil it in any of its details. A hospital for the insane should have a cheerful and comfortable appear- ance; everything repulsive and prison-like should be carefully avoided, and even the means of effecting the proper degree of security should be masked, as far as possible, by arrangements of a pleasant and attractive character. For the same reason the grounds about the building should be highly improved and tastefully ornamented; a variety of objects of interest should be collected around it, and trees and shrubs, flowering plants, summer houses, and other pleasing arrangements should add to its attractiveness. No one can tell how important all these may prove in the treatment of patients, nor what good effects may result from first impressions thus made upon an invalid on reaching a hospital — one who, perhaps, had left home for the first time, and w^as looking forward to a gloomy, cheerless mansion, surrounded by barren, uncultivated grounds, for his future residence, but on his arrival finds everything neat, tasteful, and comfortable. Nor is the influence of these things on the friends of patients unim- portant. They cannot fail to see that neither labor nor expense is spared to promote the happiness of the patients, and they are^thus led to have a generous confidence in those to whose care their friends have been intrusted, and a readiness to give a steady support to a liberal course of treatment. Great care should be observed in locating the building, that every pos- sible advantage may be derived from the views and scenery adjacent, and especially from the parlors and other rooms occupied during the day. The prevailing winds of Summer may be also made to minister to the comfort of the inmates, and the grounds immediately adjacent to the hospital should have a gradual descent in all directions, to secure a good surface drainage. PROPOSITIONS RELATIVE TO THE ORGANIZATION OF HOSPITALS FOR THE INSANE. I. The general controlling powers should be invested in a Board of Trustees or Managers; if of a State institution, selected in such manner as will be likely most effectually to protect it from all influences con- nected with political measures or political changes; if of a private cor- poration, by those properly authorized to vote. II. The Board of Trustees should not exceed twelve in number, and be composed of individuals possessing the public confidence, distin- guished for liberality, intelligence, and active benevolence, above all political influence, and able and willing faithfully to attend to the duties of their station. Their tenure of office should be so arranged that when changes are deemed desirable the terms of not more than one third of the whole number should expire in any one year. III. The Board of Trustees s*hould appoint the Physician, and, on his nomination, and not otherwise, the Assistant Physician, Steward, and Matron. They should, as a Board, or by committee, visit or examine every part of the institution at frequent stated intervals, not less than semi-monthly, and at such other times as they may deem expedient, and exercise so careful a supervision of the expenditures and general opera- tions of the Hospital as to give to the community a proper degree of confidence in the correctness of its management. 143 IV. The Physician should be the Superintendent and chief executive officer of the establishment. Besides being a well educated phj^sician, he should possess the mental, physical, and social qualities to tit him for the post. He should serve during good behavior, reside on or very near the premises, and his compensation should be so liberal as to enable him to devote his whole time and energies to the welfare of the Hospital. He should nominate to the Board suitable persons to act as Assistant Physician, Steward, and Matron. He should have entire control of the medical, moral, and dietetic treatment of the patients, the unrestricted power of appointment and discharge of all persons engaged in their care, and should exercise a general supervision and direction of every department of the institution. V. The Assistant Physician, or Assistant Physicians where more than one are required, should be graduates of medicine, of such character and qualifications as to be able to represent and to perform the ordinary duties of the Physician during his absence. VI. The Steward, under the direction of the Superintending Physi- cian, and by his order, should make all purchases for the institution, keep the accounts, make engagements with, pay, and discharge those employed about the establishment, have a supervision of the farm, garden, and grounds, and perform such other duties as may be assigned him. VII. The Matron, under the direction of tjtie Superintendent, should have a general supervision of the domestic arrangements of the house, and, under the same direction, do what she can to i^romote the comfort and restoration of the patients. VIII. In institutions containing more than two hundred patients, a Second Assistant Physician and an Apothecary should be employed; to the latter of whom other duties, in the male wards, may be conveniently assigned. IX. If a chaplain is deemed desirable as a permanent officer, he should be selected by the Superintendent; and, like all others engaged in the care of the patients, should be entirely under his control. X. In every asylum for the insane there should be one supervisor for each set, exercising a general oversight of all the attendants and patients, and forming a medium of communication between them and the officers. XL In no institution should the number of persons in immediate attendance on the patients be in a lower ratio. than one attendant for every ten patients; and a much larger proportion of attendants will commonly be desirable. XII. The fullest authority should be given to the Superintendent to take every precaution that can guard against fire or accident within an institution, and to secure this an efficient night watch should always be' provided. XIII. The situation and circumstances of different institutions may require a considerable number of persons to be employed in various other positions; but in every hospital, at least all those that have been referred to, are deemed not only desirable, but absolutely necessary to give all the advantages that may be hoped for from a liberal and enlight- ened treatment of the insane. XIV. All persons employed in the care of the insane should be active, vigilant, cheerful, and in good health. They should be of a kind and benevolent disppsiti on; be educated, and in all respects trustworthy; 144 and their compensation should be sufficiently liberal to secure the ser- vices of individuals of this description. COMMENTS ON KIRKBRIDE's VIEWS * The foregoing views of Doctor Kirkbride on some of the most impor- tant of the many subjects connected with hospitals for the insane, their location, site, and organization, should be carefully considered. No man in America is better or more favorably known, and but few have had so successful a career or so large an experience. His opinions have been accepted by all as the best authority, and if not always concurred in, certainly always command attention. If we have imbibed some of his ideas it may not be regarded as strange or unexpected, since they are supported by reason and confirmed by experience. Others more experienced and able than we are have done likewise. If we differ with him on some points of importance, it is because other men of ability have impressed us with their views, and our observations have led us to different conclusions. We think, for instance, that no Board of Trustees for the management of an asylum should consist of more than seven members — five being still better than seven. Small Boards seem to be more efficient than large ones. They do not leave matters so much to each other, and thus neglect their duties. We believe that detached buildings for the purposes ^that w^e have suggested are desirable features in an asylum; he does not. But in most of his views we heartily concur, and only regret they are not as well known by the people as by the profession. Let us hope, at least, that they may be carefully w^eighed and duly considered by our legislative committees and Boards of Com- missioners. The subjects of ventilation, warming, lights, water closets, comparisons between the asylums of different countries, and many other matters of more or less interest, have been so completely and minutely noticed and discussed by Doctor Manning, and his conclusions ordina- rily so just as to challenge our approval on most subjects, that we are induced to incorporate the following sketch of his able and interesting report into our own. CHAPTEE X. INSANE ASYLUMS— DOCTOR MANNING'S REPORT. Synopsis of Doctor Manning's Report— Comments upon the same. SYNOPSIS OF DOCTOR MANNING'S REPORT. Doctor Manning commences his report, made in eighteen hundred and sixty-seven, to the Government of New South Wales, by considering briefly the various existing methods of providing for the insane, which he divides into five classes: 1st. Indigent — supported mainly or wholly by local or General Gov- ernment. * N5te.— Sefe Kirktridfe on Ho'sp'itals for thfe Insane. 145 2d. Non-pauper — supported bj friends or from their own estates. 3d. Criminal. 4th. Idiots. 5th. Inebriates. He spealvs first of the provision made for them in private dwellings^ especially in England, Scotland, France, and Belgium; thinks that even in Scotland, where there are peculiar advantages (from the character and sparseness of population) for this method of treatment, the fact that the number of insane thus accommodated has steadily diminished since the visitations of the Board commenced, is worthy of note; and alludes to the evils of this method (see p. 9). Li a neiv country such a plan is altogether irnpracticahle. Describes Gheel (pp. 9 to 14). Next treats upon farm asylums, and describes Clermont (p. 15), and in conclusion says: "A full examination of the system of farm asylums shows that it is economical, and calculated to promote the comfort and happiness, and be beneficial to the mental health of the inmates." Next, close asylums; speaks of the poorhouse wards, and quotes from Doctor Willard, of their miserable condition in the United States; then contrasts them with the State asylums; considers it "remarkable that proprietary asylums for pauper patients are unknown in America." Page 22 — Describes general construction and organization of asylums for paupers. • ^ 1. Elevation of position; 2. Aspect; 3. Distajice from town. Table of amount of land owned and cultivated by several asylums, p. 25. Before treating of asylum construction, considers the two questions: 1. Separation of the acute and chronic cases; 2. The size of asylums. Arguments for and against separation are presented on pages twenty- eight to twenty -nine. Dr. Manning says : " Upon the whole, it must be considered that the balance of argument is strongly in favor of one asy- lum, to contain both classes in such proportion as they occur in each district." In regard to size, he says: " For the new institutions on the continent, wherever placed, the maximum number is fixed at six hundred; and in many cases a much smaller size is preferred;" then presents two tables (p. 30) of asylums in England and of a few in Scotland, France, Ger- many, and United States, showing number of patients and rate of main- tenance. Treats of Construction under four heads: Form of building; Number of stories; Material; Architecture. Form — 1. Corridor, or ward form; 2. House form; 3. Block, or pavilion form; 4. Cottage form. His objections to the corridor form are "that the asj^lum is spread over an immense area, is costly in construction from the immense length of corridor and roofing required, and from the absence of all those social and domestic arrangements which characterize an English home." 19 146 The advantages of the house form are "that the condition of the patient is assimilated to that of ordinary life by the separation of the sleeping accommodation from that required for the duties and employ- ments of the day, the supervision of the j^atients by the attendants is more complete, ventilation is more easy, since the windows and doors of the sleeping rooms from which the j^atients are removed can be kept fully open all day, and those of the day rooms, all night; whilst the cleaning, always a matter of difficulty in the ward plan, is rendered easy from the fact that the floors are in use at different times." The block or pavilion plan is " a still further development of the house plan." " As supplementing an ordinary asylum, the cottage system has worked admirabl}^, but when fully employed the system has not, on the whole, been found to answer. The inconveniences which have been felt in this arrangement have been chiefly from difficulties of supervision owing to the large space over which the asylum, extends. The best form of cottages, whether for a complete asylum or as adjunct to an existing institution, are the ' conjoined cottages ' designed by Mr. Stack and Doctor Campbell, at the Essex Asylum," (see p. 33 for description, and App. G, Nos. 10 and 11 for plans.) Page 34 — Water supply. This inquiry includes: 1. The»source and mode of supphj; 2. Quantity; 3. Storage; 4. Precaution against fire. As supplementary to this question are considered arrangements for the cleanliness of patients: 1. Baths; 2. Lavatories; 3. Sinks; Their situation, material and fittings, and their number. The propor- tion of baths in English and American Institutes, about one to twenty patients; on the Continent, less. Page 38 — Drainage. Page 45 — Warming, by: 1. Open fires; 2. Hot air; 3. Hot water; 4. Steam. Page 47 — Lighting: 1. Windows; 2. Lamps. Examining windows is noted: 1. Position and proportion to wall space: 2. Material and jnethod of opening; 3. Size of panes; 4. Guards and accessories, as shutters, etc. Page 52 — Ventilation, either artificial — by propulsion or extraction; or natural — by doors, windows, and fireplaces only, or by oj^enings in addi- tion to these. Doctor Manning says; "it is noteworthy also that those with windows, doors, and fireplaces only, and those with the more simple accessories in addition to these, seem as well ventilated as those in which there is an elaborate arrangement of ventilating shafts." 147 Page 54 — Cubic space. — In the new asylum at Madras fifteen hundred cubic" feet is the space fixed for European patients. Day and night accommodation: 1. Bay or sitting rooms. 2. Dining rooms. 3. Dormitories. 4. Airing grounds. Considers the question of single rooms or common dormitories quite an important one. It is universally agreed that violent, noisy, dirty patients should be accommodated in single rooms, but it by no means is decided what proportion of patients it is necessary to isolate thus. Page 59 — Floorings, Jittings, and furniture of rooms. ' Page 64 — Staircases and stairs, bells. Page 65 — Treats of the different i^rovisions made in asylums for con- valescents and quiet patients, for the sick and infirm, and for the violent and excited. " The j^roportion of violent patients for which provision is gen- erally made would appear to be about one tenth." Kitchens, laundry, chapel, dead-house and cemetery, amusement room, library, are each considered separately in turn, followed by a brief notice of the provision made for employes of all classes. Page 75 — Organization and government, which Dr. Manning considers "even of greater importance than asylum construction;" reviews briefly the method in use in different countries, and concludes: "On examining closely the general condition of asylums, those are almost always found to be best managed in which the physician is the Superintendent, one and supreme; in which the committee of visitors act only through him and with his advice, and in which the appointment and dismissal of all attendants are delegated to him; and those are found to be least satisfactory in which the responsibility is divided; in which the committee of visitors or controlling Board meddle in the internal management of the institution, and direct, themselves or through other officers, any ^^vt of it, appoint or dismiss attendants, or clip in any way the authority of the Medical Superintendent." Page 80 — Gives a table of the salaries of Superintendents in some English asylums and the number of assistants. Then follows a consideration of each of the classes of subordinate employes. Page 84 — Table of proportionate number of attendants to patients in the principal asylums of England, France, Germany, Holland, and the United States. Ages of attendants (in English asylums), from eighteen to thirty-five; generally deemed advisable that they should not be under twenty-one. Discusses the desirability of placing attendants in uniform, but expresses no decided oj^inion. Diet of attendants and the privileges allowed them follows. Page 88 — Artisans and servants. Page 91 — Hospital dietary, followed by considerations as to clothing of patients; next, labor — several tables relative thereto being given; then follows amusement and school; classification of patients; animals kept at asylums; system of supply (commissariat); provision for relief of patients on discharge; asylum reports. Page 108— Statistics. Page 116 — Eestraint and seclusion. — Doctor Manning quotes from Doctors Bucknill, Wilkes, Ewerts, Meyer, Kirkbride, and Gray, and 148 shows the practice in many asylums. lie says: '-'During the last few years there has been a certain reaction in the feelings of Superintendents of asylums on this subject. In quite half of the asylums visited, although restraint was not practiced, its advantage in certain cases was distinctly admitted, and it does not now meet with the all but wholesale condemnation»which was accorded to it some few years ago." After sj^eaking of the use of the shower bath, lie concludes as follows: " It is not a little curious that owing more or less to popular clamor, and to a fear of the abuses to which they are liable, mechanical restraint has been virtually abandoned in Great Britain, and the shower bath has ceased to be used in America, and so a mode of treatment useful in a certain number of cases is lost to the physician in each country." Page 122 — Accommodation for patients paying for their maintenance. Page 125 — Criminal lunatics; which are divided into two classes: 1. Those who whilst insane commit criminal acts. 2. Those who become insane v\'hile undergoing punishment. He treats of the distinction made between these classes and the man- ner in which they are provided for; thinks that Scotland is broader in principle and has been more successful in her treatment of this class; then describes at considerable length the Broadmoor Criminal Asylum and the Criminal Lunatic Asylum at Perth, Scotland. Page 139 — Asylum for idiots. Page 148 — Asylum for inebriates. Page 154 — Suggestions, from which are quoted the following para- graphs: " The moral and material advantages which follow the system of ]}yo- vision for the insane in private dwellings are undoubted." " It is necessary that population should so increase as not only to form aggregate bodies, towns, and villages, but to form a united, related, fixed, and settled people; and that the masses shall have received a cer- tain education on lunatic matters, by j^ublic papers and by the existence of well conducted asylums, before the separate system is adopted. An attemj)t to place any large number of the insane in private dwellings must necessarily fail in a new country, colony, or State. Neither the Belgian system nor the Scotch is possible in Nevv^ South AYales at present, but the advantages of these should be ever kept in view, and the whole asylum organization should tend towards the development of such sys- tems in the maturer age of the colony." " The close asylum, however, has been in long years past, and must be in the years yet to come, the chief method in which the insane of all countries, in the acute stages of their maladies, are provided for." Page 157 — Doctor Manning quotes from Doctor Wilson, the Catholic Bishop of Ilobart Town, in reference to locating a hospital near a large city, as follows: " The advantages of having a hospital near a large city are incalcula- ble. Here are a few: " 1. The securing judicious visitation of a properly selected Board of Commissioners for the general management of so important an institu- tion, a measure absolutely necessary for its permanent well working. 149 "2. The means of procuring the best medical and surgical assistance when required. '^3. The opportunity afforded almost daily to convalescent, quiet, and orderly patients of visiting the city for amusement, going through the markets, sometimes strolling through the public pleasure grounds, and obtaining that change so beneiicial to them, both mentally and phy- sically. "4. Affording facility to humane and well qualified persons of grati- fying in the asylum, not unfrequently of an evening, patients whoso minds are in a state to profit by such kind ofi^ccs, with music, instru- mental and vocal, recitations of short and cheerful pieces, or appropriate readings, and such like friendly acts. "5. Of affording patients likely to profit by such visits the means of attending such public exhibitions in the city as ofter from time to time suitable for them. Many other advantages might be mentioned." On page one hundred and sixty-six Doctor Manning says: " The site to be chosen for an asylum is a matter of primary impor- tance. On it must depend in no small degree the comfort, happiness, and health, both mental and bodil.y, of the inmates, as well as the cost of the institution and the whole work.ng of its internal economy. "An elevated position is desirable, because more healthy — command- ing, as a rule, more extended views, both from the rooms and airing grounds, and aftbrding greater facilities for drainage and ventilation. "In the suggestions and instructions to architects, issued by the Com- missioners for England and Scotland, it is suggested that 'it should not be near to any nuisances, such as steam engines, shafts of mines, noisy trades, and offensive manufactories; neither should it be surrounded, or overlooked, or intersected by public roads or footpaths;' 'that the site of the building should be elevated as respects the surrounding country, and, if to be obtained, undulating in its surface and having a fall to the south.' " Doctor Manning con^nues: "The subsoil should, if possible, be calcareous, gravelly, or rocky; but if the position is elevated and the drainage good, a clayey subsoil, such as is occupied by more than one of the best English asylums, is not objectionable." The advantages to be derived from proximity to a large town are: 1. Facility of access for patients and their friends, Commissioners, Inspec- tors, and other Government ojficials, medical officers, etc. 2. Diminished cost of conveyance of coed, stores, and provisions. 3. Facility for amusement of patients. 4. Supply of gas and water. 5. Increased facilities for procuring good attendants and for inducing them to remain for a longer time. The special need of the attendants (who are always with the insane) for change and amusement away from the institution is sj^oken of at considerable length. In reference to land, Doctor Manning recommends " the j^roportion of 150 one acre to every two patients," "instead of the minimum of one acre to every four patients, suggested by the British Commissioners." " The full amount which will be required for the institution, according to its estimated eventual extent, should, if possible, be acquired at once. It might either be cultivated by the patients in the institution, if sufficiently numerous for the purpose, partly cultivated by hired labor, or let on short lease till the number of patients was sufficient to work it; but as much as possible of it should be brought under cultivation — fruits, root or cereal crops, grown according to the nature of the soil, the wants of the institution, and the capabilities of the inmates. The more an asylum is self supporting in this respect the greater will be the economy of expenditure. ''It has been calculated that^the labor of the insane is only equal to one fifth of that of the sane, so that one hundred patients are equivalent only to twenty healthy field laborers. In most asylums there will be found one inmate in every five suitable for field labor, so that in an asy- lum of five hundred patients, there will be about one hundred inmates capable of such employment. But if it is supposed that only half this number c. n be so employed, it will be equivalent to the constant labor of ten healthy men; and what these are caj^able of eftecting in agriculture and horticulture can be estimated by all those conversant "with the matter." In regard to the question of the separation of acute and chronic cases, Doctor Manning says: "The solution of this, like many other practical questions regarding asylums, depends very much upon the population of the district, upon the nature of the existing buildings, and upon the special aims which it is intended to combine with their erection (e. g., clinical instruction). Wherever a large population is crowded within a small space, and two asylums can be made fairly accessible to the whole population of the district, the greatest argument against the separation of acute and chronic cases ceases to exist." In regard to the size of asylums. Doctor Manning quotes the opinions expressed by many eminent authorities, and concludes as follows: " Weighing well all the opinions of eminent men on this subject, and the arguments with which they are backed, and judging from personal inspection of existing asylums, the opinion may be expressed that from four to five hundred is the preferable size for an asylum, and that six hundred should never be exceeded. The asylums which are vv^orking smoothly and well, with every care for the treatment of patients, and effective supervision, are, as a rule, below this number; and" "for eco- nomical reiisons, from four to five or six hundred is the preferable number. The maintenance rate generally increases where the population is below or above it." 151 Table, Giving a List of certain American and European Asylums, with the Amount of Land about them and the Amount used for Pleasure Grounds {Airing Courts included). [Manning's Report.] ASYLUM. Acres of Land. Pleasure Ground. 100 200 96 252 150 150 80 100 96 80 100 77 40 Worcester County Sussex County Essex County Three Counties New Surrey Middlesex County (Colney Hatch) Gloucester County Derby County Lancashire County Leicester County Stafford County (New) Stafford County (Old) Lincoln County ' Bristol Boroui^h ; 32 Cotton Hill Lunatic Hospital | 80 Northampton Hospital | '^5 Eetreat, York | 30 Elgin District Hospital ' 92 Perth Hospital ^ | 60 Haddington Hospital 12 Fife Hospital ^57 Montrose Royal Government Asylum, Washington Pennsylvania State Northampton (Mass.) State New Jersey State New York Evreux, Departement Eure Quatre Mares, Departement Seine In ferieure Sainte Anne, Departement Seine..., Yille Evrard, Departement Seine... Yancluse, Departement Seine Colony of Fitz James, at Clermont 110 230 130 200 120 200 150 100 *'l4 750 700 1000 Meerenberg, HoUan d | 70 Guislain's Asylum, Ghent Hamburg Illenau Frankfort Gottingen 35 65 42 40 20 152 Table, Shoirlng Number of Fatients and Assistants in certain Asylwns, with the Sala- ries of the Superintendents in certain of the English and Scotch Asylums. [From Manning's Eeport.] II : '5 Bristol Derby Leicester Stafford liincoln Sussex Three Counties Worcester Essex Gloucester ]S"ew Surrey Lancashire, Lancaster Lancashire, Prestwich York, West Eiding Colney Hatch Perth District Cupar Montrose 206 342 391 469 502 510 534 540 554 590 650 836 962 1,124 2,026 220 213 380 1 ;£500 1 1 I 650 1 I 550 1 550 1 600 1 I 800 2 I 500 1 i 600 2 ; 600 2 1 750 9 2 i 600 1 I 350 1 300 1 400 Quatre Mares St. Yon St. Anne Ville Evrard Evreux Guislain's Asy., Ghent Meerenberg Hamburg Frankfort Gottingen Illenau ; I Washington Xew Jersey State Pennsylvania State.... Northampton New York State 715 950 600 600 500 450 600 350 200 300 450 380 500 380 420 608 CONSTRUCTION, • To make the lunatic as much " at home " as possible, to make the household arrangements of an asylum resemble those of a large private dwelling house so far as is consistent with salubrity of structure, economy of expenditure, and facility of supervision and management, should be the leading j^rinciple in the construction and internal arrangements of asylums. Asylum construction must depend somewhat on the classification of the patients which is considered necessary. The classification recommended is: 1. Becent cases. 2. Sick and infirm. 3. Violent and noisy. 4. Ordinary patients. In an asylum for five hundred patients, at least six divisions for each sex are necessary; and in this case the "ordinary" patients may be placed in two divisions; but with a smaller number, three or four will 153 suffice; the "recent" and "ordinary" cases being amalgamated or not. Thirty to forty patients are a sufficient average number for each division. For a small aeylum the maximum population of which is never to exceed two hundred, the modified cottage plan is the one to be most recommended. For an as^dum built originally for one hundred and fifty or two hun- dred patients, but intended for enlargement, so as eventually to contain four hundred, the " house " plan or the pavilion 2)lan are most fitted for the original structure. For an asylum built originally to contain five hundred patients in six divisions, the pavilion or block plan ma}^ be mainly adopted and supple- mented by cottages; or plans may be so modified as to embrace the house, pavilion, and cottage plan, blended into one harmonious whole, as in the New Surrey Asylum.* If the three plans are combined to form one asylum the two classes who require most constant care and attention (the sick and the acute cases recently admitted) should be placed in the part built on the "house" plan, which will be under one roof with the administrative department, and so within easy access of the Resident Physician. The ordinary patients and the violent class may be placed in detached blocks, two or three in number for each sex; and the small asylum town thus built be supplemented by cottages for idiotic and convalescent patients. The cottage plan is particularly fitted for patients of good education. It adds vastly to their comfort to separate them from the other inmates. For convalescent patients also, the association with sane people is very beneficial, and they by this means are allowed greater liberty, and are able to resume gradually their accustomed life, instead of j^assing at once from the asylum ward and its artificial existence to the realities of actual life abroad. The special block for violent and noisy patients, which should be the smallest division of the house, should have connected with it and open- ing from it, a one-storied building, capable of containing four or five patients. It should consist of corridor and single rooms, and should have one or more small airing courts, opening either from the corridor or the rooms. The question as regards the number of stories in an asylum must depend chiefly on the uses to which the rooms on the ground floor are applied. If the ground floor is to be divided into day room and dining rooms, and so the patients occupy only half of it at once, the number for which it will serve will not be greater than can be contained in one dormitory floor; but if the dining room accommodation is 2')rovided else- where, the space for sitting or day room accommodation will be doubled, and made sufficient for the number of patients who can be accommodated in two stories built over it. The sj^ace required for sitting and day room in asylums is reckoned to be about half that required for the night. The material to be selected for asylam construction may fairly be that which is most readily procurable, so long as it is durable and not porous. So long as the windows are of large size, the particular style may fairly be left to the architect entrusted with the planning of the building. A full supply of pure water is an important requisite in an asylum, * See Appendix F, plates 5, 6, 7. 20 154 and no site should be chosen where this cannot be obtained. If the as^'lum be near the town, the town supj^ly will be found cheaper and altogether more convenient than any other arrangement; but when at a distance, the supply from a well or spring, especially if this is close to the buildings, is the best method, since the steam engine which will always be necessary to pump and fill tanks, may be made to serve other purposes also, as turning machinery, either at the laundry or farm build- ings, whilst the boilers which supply it may be used also for heating hot water for baths and lavatories, the kitchen and laundry. No supply from a running stream should be used without careful filtration, and if water is procurable in any other way, surface drainage should not be resorted to, since, with this method in use, high farming is almost impossible, without running risk of dire illness to the inmates from animal poison contained in the water. The quantity required for the use of an asylum, even when earth closets are used, is not less than fifteen to twenty-five gallons per head j)er diem. For safety in case of fire. Dr. Manning says: "Eelianr-e should be placed mainly on hydrants, for which proper hose should be kept always at hand, placed both outside in the grounds and inside on the staircases. These should be connected both with the ordinary water supply and with the tank; and where a steam engine exists, the pipes should be so arranged that the water may be played by steam power. Fire drill, at w^hich attendants and patients should assist, should be practised at fixed intervals, and the hose and other aj^pliances kept always in order. In asylums in which force of water sutficient to play the hose cannot be obtained, ordinary hand fire engines should be kej)t at the asylum, and the patent contrivance called 'L'Extincteur ' may be also kept at hand." Every asylum should be lighted throughout with gas, which is at once the safest, cheapest, and most eftective mode of lighting. If gas cannot be conveniently obtained from a company's works, it may be made on the premises without difiiculty, at a cost which will render it cheaper than any other kind of illumination such as it is necessary to have in an asylum. Dr. Manning gives it as his opinion that open fireplaces, especially when built with air-chambers, as in use in English asylums, form the best, simplest, and cheapest mode of warming asylums in a moderately cold climate; but in America the elaborate system of heating by steam, which has been almost universally adopted, is perhaps the best which could be used. Natural ventilation, with such accessories as may be deemed expe- dient — and the simpler these are the better — can alone be recommended for an asylum in a temperate climate. The height of twelve feet, proposed by the American Association of Medical Superintendents, seems ample for all the purposes of an asylum room. Every room should have its cubical contents painted on its door. In all asylums separate day and diningroom accommodation should be provided. It will be well that one diningroom should be provided for each sex, and that they should be placed on each side of the kitchen. Day room accommodation should be provided for each section of the asylum, at the minimum rate of five hundred cubic feet for each person. A general dining hall, or two dining halls — one for each sex — should be built conveniently situate with reference to the kitchen, capable of con- taining three fourths of the entire number of inmates. Experience has 155 shown in English asylums that this number may with safety and advan- tage be allowed to dine in common. Two airing courts for each sex are all that are absolutely necessary for an asylum. If a third is added for the use of the sick, infirm, and for special cases, such as epilepsy, it will be found frequently useful. It may save the more feeble among the patients from the accidents which might happen to them in the large general court. In everj" airing court there should be a sunshed and a verandah or covered walk, to afford shade and allow patients so inclined to take exer- cise in wet weather. The floorings of all the day and diningrooms and dormitories should be of wood. The boards should be tongued; and the English and Scotch Commissioners suggest that there should be a disconnection of the floor and joists at all internal doorways, by means of a stone sill. In all cases where a fireproof construction is not adopted, similar separations, at not greater distances apart than fifty feet, should be made in the floor and ceilings. There is but little necessity for oiling or j)olishing the floor except in rooms devoted to dirt}^ j^atients. The w^alls should be plastered or cemented, and subsequently painted or colored so as to make the rooms as cheerful and bright as possible. All rooms devoted to dirty patients should be whitewashed. The keys for the male and female side of the house should be different, and each attendant provided with one key which will unlock all the doors on his or her side of the house. A sim2:)le railway key will serve for each attendant to turn on or off' water, gas, or to chock the window sashes, close or open shuttersi| etc., so that each attendant will have two keys only. Asylum stairs should be of stone or iron; the flights short and straight. Wooden or iron handrails should be provided for all stairs, and let into a groove in the wall. One kitchen, in a central position, is all that is required for an asylum, and in it, if properly arranged, all the food for patients, ofiicers, and attendants can be cooked. The laundry should be detached from the main buildings, and may be placed at some little distance, if water supply is thus made more easy. The arguments for a special chapel in connection with every asylum need not be repeated here. The best argument is the existence of such a cha2:>el in the well ordered institutions of all countries. For minor amusements, the day rooms of the institution are suflicient, but a room where the majority of the inmates can be collected for dances, concerts, theatrical performances, gymnastics, lectures, etc., is absolutely necessary in an asylum. It is scarcely necessary to j^i'ovide a special room for a library. The building for the recej^tion of the dead should consist of two rooms at least. One of these should be the reception room, fitted with shelves for the dead, in which they may be seen by their friends. The other, a room for post mortem examinations, in which every convenience for the purpose should be supplied — a central table, hot and cold water, etc. It is desirable that the dead should be buried in the ordinary cemetery of the town or district. The balance of the report is devoted to " Organization," " Dietaries," forms for asylum reports, and architectural plans. 156 ORGANIZATION. A Board of Control should be aj^pointed by the Government for each asylum, or for each district, and should consist of not less than five members, one or two of whom should be medical men, and the remainder men of high social standing, residing in the district in which the asylum is situated. The necessary expenses of the Board should be l^aid, and such remuneration made to tlie professional members as may be deemed fair, but the other members should not receive salaries, the 2:>osition being entirel}^ an honorary one. The members of the Board may either retain their seats permanently, or one or two members may retire annually, and be eligible for rea]3- p ointment. The duties of the Board should be: 1st. The control of the finances of the institution, and the preparation of the necessary estimates for the consideration of the Government. 2d. The appointment and dismissal of all officers, viz: Superintendent, Assistant Medical Officers, Secretary, Chaplain, and Housekee2:)er, sub- ject to the aj^proval of the Government. 3d. The visitation of the asylum and inquiry into its management and the general conduct of officers and attendants. 4th. The inspection of the forms of admission sent with all j^atients, and the ordering of the discharge of all such as are recovered, or for whom their friends promise to make provision, one medical member of the Board being always present to examii^ the patient and afiix his signature to the certificate of discharge. The Board should also be charged with the presentation of an annual report to the Government, in which the general and financial condition of the institution under its care is set forth. On the appointment of a Board of Control, asylum government will be thus divided: Superintendence and Management. The whole internal economy of the asylum will be under the contio^ of the Superintendent, and with him should rest the patronage, so far as the appointment of attendants and servants is concerned. Legislation. The making of all general laws for the conduct of the asylum, and for the guidance of all officers and attendants, will be the duty of the Gov- ernment. A general code of laws will serve for the government of all the asylums of the country; and all marked alteration in such laws should be made, or at least aj^proved, by the General Government; whilst minor alterations, which are not contrary to their general spirit, may be made by the Suj^erintendent or Board of Control. Fina?icial Adm inistration Will be under the Board of Control, exact accounts of the financial con- dition of the asylum being submitted to the Government, with the esti- mates for each year. The estimates should include a sum for incidental expenses, to be spent at the discretion of the Board, and not exceeded. (The sum placed under the control of the Board is fixed, in the case of 157 the English county asylums and the State asylum, Broadmoor, at four hundred pounds for each year.) Patronage. The appointment of the Board of Control (and the Board of Inspec- tion, to be hereafter considered) will rest with the Government. The Board of Control will appoint all the officers, who are immediately re- sponsible to it, the Government approval being necessary to ratify the appointments. The Superintendent will appoint the attendants and ser- vants who come immediately under his directions. There remains to be considered the duties of Inspection and Supervision. Doctor Manning then speaks of the way in which this is managed in the United States, Great Britain and Ireland, France, Belgium, and Hol- land, and then gives his opinion of wdiat it should be in New South Wales: The duties of such a Board of Inspection should be: 1st. The inspection of all asylums, public and private, at fixed periods not less than twice a year. At such inspection inquiry should be made as to their management; as to the regularity of admissions and dis- charges; thenumber of attendants; the dietary, and the general conduct of the institution. 2d. The frequent inspection of the criminal asylum, which it is recom- mended in a subsequent part of this report should remain under the immediate control of the Government, without the intervention of a Board of Control. 3d. (Is of local application, referring to the'' Eeception House at Dar- linghurst.") 4th. The examination of all criminal lunatics, either acquitted on the gTound of insanity or found to be insane, in prison; and the direction as to their maintenaiice in the prison for observation, or their transfer to an ordinary or criminal asylum. 5th. The transference of patients from one asylum to another for any reasons that may be considered good. 6th. The registration, visitation, and official guardianship of all luna- tics under certificate residing with friends or with persons paid for their maintenance, with power of inquiry in all cases of detention and ill treatment by relatives of any insane person, whether under lunacy cer- tificate or not. 7th. The examination of all certificates in lunacy, to see that they are in proper form and that all necessary particulars concerning the history, circumstances, social and mental condition of the patient are given. 8th. Inquiry into all cases of complaints in asylums, and all cases in which the Lunacy Acts have been infringed. Super i7itendent. The Physician of every asylum should be Superintendent and chief executive officer of the establishment. He should have entire control of the medical, moral, and dietetic treatment of the patients; the power of appointment and discharge of all attendants and servants, and exer- cise a general supervision and direction of every department of the insti- 158 tution. He alone should be responsible to the governing body for the state and condition of every part of the institution, and he should be the recipient of all their orders. As$ista?it 3Iedical Officers. The Assistant Mediciil Officers of asylums should be qualified medical practitioners, whose duty consists in assisting the Superintendent in the medical and general duties of his office, and representing him in his absence. Doctor Manning is of opinion that " the medical staff of an as^dum containing acute and chronic cases in the usual proportion, should never consist of less than one to every two hundred and fifty patients; that whenever the asylum poj^ulation exceeds two hundred and fifty, an Assistant Physician should be appointed; and that when the number of five hundred is reached, an additional assistant is necessary." COMMENTS UPON DOCTOR MANNING'S REPORT. We are of the opinion that no asylum should be without an Assistant Phvsician, and that an asylum of five hundred patients should be j^ro- vided with an additional assistant, as suggested by Doctor Manning. The Guislain Asylum, as well as many others in the Old World, are greatly at fault in this respect, and the bad eftects of such jjolicy are ever appa- rent. AYe have thus given a brief sketch of this exhaustive and admirable report, and can only again express a regret at our inability to obtain a copy for the State Library, and still hope an order sent to New South Wales, through Messrs. TrLibner cc Co., Ko. 60 Paternoster Eow, London, Tn&y succeed in procuring one."^ In most of the conclusions arrived at by Dr. Manning, as well as suggestions made to his Government, we heartily concur. But, as we cannot do so in all, we deem it due to our- self and what apj^ears to be the interest of the insane in our midst to point out a few of the most important points of difference: 1st. For reasons already stated elsewhere, we think that tWo hun- dred and fifty patients as large a number as can be treated in the best jwssible vianner in one asylum, and that this number should never be extended beyond four hundred. We admit, however, that the practice •of the present day is to build asylums for four hundred, five hundred, and six hundred patients, as he has suggested. 2d. We are satisfied that the number of single rooms for one third of the patients is too small to insure the best results. His conclusions coincide with the custom in Great Britain and the continental countries, where one third is the greatest number j^rovided with single rooms, even in the best asylums; whereas we agree with the custom in our own country, where the best asylums are never provided with single rooms for less than two thirds of their patients, and many of them a larger proportion. Under no circumstances should this be reduced to a less number than one half. We are fully aware of the advantages to be derived from the association of patients, but think this can be done to best advantage during the day, in large and j^leasant airing courts, sitting rooms, and pleasure grounds. * Note. — Since the above was written the report of Doctor Manning has been received, and we recommend its perusal to the committees, Commissioners, and others especially interested in the subject. 159 3d. The recommendation for six divisions for each sex, in an asylum for five hundred patients, seems to be too small, and is two less than proposed bj the Superintendents in the United States; eigl^t divisions for either sex is a better number. 4th. Dining halls .for three fourths of the patients of either sex, one on each side of the kitchen, does not commend itself to our mind as the best method. The system in the United States of having each division take their meals in their own wards is preferred, as classification is best preserved in this way. Here we must also admit that in all the asylums in Great Britain and on the continent w4iere we witnessed the patients of hospitals taking their meals in common dining halls, and often where males and females ate in the same room, no inconveniei.ce or excitement was observed; but it must not be overlooked, that in all or nearly all of the instances referred to the patients were paupers, and the asylums almost exclusively occupied by them. This custom does not prevail in the asylums intended for the independent classes. In our country, all are accommodated in the same asylum, wath very rare exceptions. GDhe rich, the poor, the educated, and the ignorant, the refined and the vulgar, are all in one and the same institution, hence greater attention to classifi- cation and separation is an absolute necessity. Separate Asylum for Faiienis who Pay. Some eminent men in all the countries we have visited have given as their decided opinion, that ^Datients who pay and those wiio do not should never be kept in the same asylums nor placed under the same administration, as the privileges that will be allowed the one begets jealousies on the part of the other, w^iile the necessities of a crowded asylum often enforces associations that w^ould not be recognized at home, and with all the sensibilities sharpened by insanity, as sometimes happens, disgusts and dissatisfactions are engendered, and detrimental results the consequence. What is best to be done and what can be done are two very difi'erent propositions, and in a majority of cases we have to accept the latter. If it were possible, ho.wever, there is no question it would be best for each State to furnish one asylum for the accommodation of all of its citi- zens who desired to pay for accommodations superior to those that can be given to the indigent. These should be charged a sufiScient sum to defray all the expenses of such an establishment, including officers' fees, repairs, and other expenses, the State only furnishing the buildings. All other asylums should hQ free to every person belonging to the State who might elect to enter them, without the payment oi fee of any, kind. If this system could be adopted, many economical changes might be made in the construction of our asylums, without detriment to any class of patients. An asylum for one hundred pay patients would probably bo suflEicitnt for all of this class now in our asylum, or likely to be com- mitted during the next ten years. It should be as much under the con- trol and watchful supervision of State officers as the others, and all charges should be regulated by State authority, in order that no person should profit by its operations save and except the j^atients who paid for the privilege of having more quiet, more comfort, and more attention than the State could afford to give. This idea, we fear, is in advance of American notions of propriety; yet believing it to be supported by sound policy, and with no injustice to 160 any, we hope to see it carried out in our State at some no distant period in the future.* 5th. The common bath house on the ground floor, one for each sex, is another European custom adopted in nearly all asylums, many of which, admirable in all other respects, have not a single bath tub on the second or third floor. This is certainly a great defect, and must suggest many inconveniences to all who are acquainted with asylum management. We found in one asylum in Austria only one bath room for all the patients, the men using it one day and the women the next. One bath in four- teen days was all that could be obtained by each patient. This asylum was new, neat, comfortable, and well managed in all other respects, but the Medical Director could not prevail on his Board of Managers to supply even one other. We could but conclude that economy in this instance was a poor financier. 6th. We cannot see any special advantage to accrue from a law requir- ing one of the Board of Control to sign certificates of discharge, as sug- gested by Doctor Manning. Surely the Superintendent must first say that the patient may be discharged without detriment ere the Trustee aflixed his name; hence it would only seem an additional complication without corresponding benefit. Let us give the patient every protection and throw around him every necessary guard, but at the same time incumber our rules with no useless requirements. With these few differences with Doctor Manning, and some of them may be influenced by prejudice engendered by long habits of thought that observation has failed to remove, we most heartily indorse what he suggests, and commend his remarks to all readers. ^ It has been our desire to present the ideas and opinions of others with quite as much freedom as our own, that our people may have the benefit derived from the experience of many observers. * ^i^oTE.— Statement of the Niiynber and Nativity of Pay Patients in the Insane Asylum of the State of California, January 1st, 1872. NATIVITY. Males. Females. Total. 5 4 1 1 2 3 1 1 1 1 1 6 4 1 1 1 Chili 1 1 1 1 1 TTnifpfl Rtatps 11 8 11 3 22 11 Tntnl'; 19 14 33 The foregoing table shows how small a proportion of the patients in our asylum pay for their support and treatment. There are a tew others, no doubt, who would gladly avail themselves of asylum care and the benefits to be derived from the skill and experience of its medical officers, if proper accommodations could be offered them, but who shrink from the disadvantges and discomforts of the overcrowded wards of our asylum, and are thus kept at home till all hope of recovery is passed or the means of support have been exhausted, when they are sent to the asylum, to become life burdens upon the Fubhc Treasury. Until the system suggested can be carried out, we think it would be iar better to abolish all charges, so far as they relats to citizens of the State. 161 It is scarcely necessary again to call attention to ventilation, warm- ing, lights, water closets, window guards, flooring, stairs, infirmaries, kitchens, laundries, chapels, dead houses, amusement halls, theatres, dances, employes, attendants, airing courts, keys, etc., as we have done so to a suflicient extent in the sketch from Doctor Manning's report, and especially as we must necessarily touch upon 'some of them in speaking of the character of asylums which we think best adapted to the nature of our climate and the characteristics of our people. CHAPTEE XI. CRIMINAL INSANE. Another question connected with the care of the insane should not be passed by without notice. In England, Scotland, Ireland, and some of the contin^tal countries, and in I^ew York, in this country, asylums have been erected for keeping the* criminal insane separate from the others, and strong arguments have been advanced in favor of the uni- versal adoption ot'this system. These have been divided into two classes: 1st. Those who have "been convicted of crime, and become insane while serving out their sentence of punishment. 2d. Those Avho have committed criminal acts during their insanity. We can see no good reason why those of the latter class should be deprived of treatment in an ordinary asylum. In the eyes of the law they have really been acquitted of any criminal intent, and cannot be punished; nor should they be disgraced by being confined in an asylum with those whose crimes have led them to insanity. With the first, or convict class, the case is entirely difterent. Though they have become insane, and are thereby entitled to every consideration of sympathy, and every effort at restoration, they have not been cured of their immoral ideas, low cunning, gross vulgarity, and vicious habits. On the contrary, these arc often whetted by insanity, and exhibited in an intensified degree. They have no power to conceal the real hideous- ness of theiy character, nor restrain the debased vulgarity of their nature. They are not only unfit associates for the unfortunate people who occupy the wards of an asylum, but have a detrimental influence upon their recover}^ But this whole subject has been so ably and forcibly argued in the report of the Worcester Hospital, we cannot better bring the matter to the favorable notice of the Legislature than by quoting from its pages : FROM THE WORCESTER REPORT, 1862. Criminal Insane. The experience of nearly thirty years operation of this hosjntal, and the careful observation of the successive Boards of Trustees, of the Superintendents, and others engaged in the management of this institu- tion, all go to establish and to strengthen their conviction that it is impolitic and wrong to place insane criminals in the same rooms, wards, 21 162 or even establishments with the honest and untainted patients, and require them to live together. No one will assert that the prison is a proper place for a lunatic; and it is equally clear that the hospital, created for and occupied by patients from general society, is not a proper place for a criminal. Admitting that the insane convict should be removed from the one, it by no means follows that he should be carried to the other. Whether viewed in the lii^ht of humanity or of economy, it is better that he be detained in his prison than be admitted into the hospital, for, at the worst, if he be not removed, he may remain insane for life for want of the means of heal- ing, while if he be placed in a ward filled with* other and respectable patients, he may be an obstacle to their restoration, and prevent some, perhaps many, from ever regaining their health. The question is not simply whether the insane convict shall or shall not have an opportu- nity of being healed, but whether an attempt shall be made to save a criminal and worthless citizen, by the peril and perhaps the sacrifice of the restoration of some, possibly many, honest and valuable men who must live and associate with him in the hospital. Insanity disturbs the mental health of its victims in va^ous ways.^ Among the most common of these morbid conditions, is the exaltation of sensibility, which makes the patients timid, anxious, suspicious, irrita- ble, and even sometimes quarrelsome. Some are depressed in spirits, and almost crushed with a sense of imaginary sinfulness, or an int^ense consciousness of un worthiness. To meet these morbid conditions of the patient, the hospital Managers endeavor to bring the most favorable influences to act upon him; they surround him with everything sooth- ing, gentle, and acceptable. They provide everything to cheer, encour- age, and elevate him, and inspire him with confidence that his new position in the hospital is all for his good. They arrange all the circum- stances, select his associates, and control the conversation; they deter- mine the scenes that may be visited and the ideas that may be presented, according to their influence on the over sensitive and disordered mind. It is among the best established principles of the treatment of insanity, that a patient should be opposed or interfered with as little as possible, consistently with his good; that his notions and arguments should not be disputed, his wishes and inclinations indulged, so far as they can be safely, his opinions and tastes treated with respect, whdh they are proper, but always with tenderness, and that everything should be done to encourage his self respect. Among the patients in the hospital i re always the members of our own families— our parents, our brothers and sisters, our sons and daughters. From their childhood they have been taught to love virtue and abhor vice, to avoid even the appearance of wickedness, to associate with good and shun evil company. They have been accustomed to run from the base, the degraded, and the corrupt. Their sensibilities, their tastes, and their consciences have been cultivated and shaped in accord- ance with their education and their habits. They lose none of these in their disease. Insanity tends to exalt and intensify them. They become morbidly sensitive, and even irritable, in respect to them. To put a convict among such patients as these, to compel them to associate with him in the same halls, to eat at the same table, to hear his coarse and offensive conversation, his vulgar slang, his profanity, his curses at religion and honesty and religious and honest men, his contemptuous jeers at what they have been taught to regard with rev- erence, his tales of cunning and crime, of successful and unsuccessful 163 vilhiiny — all this is in contravention of the best principles of managing mental disorders, and diminishes if it does not counteract the influence of the curative measures that may be used. It is at least a singular view of governmental res])onsibility that, look- ing for the highest good of the community and the moral and spiritual welfare of allots members, educates children and youth to walk in the ways of holiness, and encourages all of every age to associate only with the pure and the upright, when they are well and able to choose for themselves, but gives them felons for familiar companions when they are broken down Avith mental disease and too weak to choose their company. The hospital is provided for all the families of the commonweath. In the chances of life any one of us may be exposed to the accidents or influences that cause insanity, as well as to those that cause fever. Any of our children may be afllicted with disease of the brain, as well as with disease of the lungs. A daughter, the idol of her parents, becomes insane. Her anxious and almost agonized friends ta\e her to the hospital and leave her there, in confidence that her intensely sharpened sensibilities will be soothed by the gentlest associates, the tenderest language and most refined man- ners of those that surround her; but she is shocked to find in the same hall with her, perhaps sitting next to her at table, a convict from the House of Correction, a woman that had previously been the keeper of a brothel, and still retains her vulgar obscenity and her lascivious ways. Or a son, trained in the same w^ay, may become deranged on the subject of religion. Self chastening and downcast, he enters the ward and finds among the inmates a burglar from the State Prison, who has been edu- cated and practiced in all manner of wickedness, and takes a pleasure in the display of his own corruption and in offending the sensibilities of such as he considers to be over nice and fastidious. Among the insane there are always some whose recovery is doubtful, whose chances of mental life or death hang like a balance so evenly adjusted that the slightest weight will turn the scale, the least disturb- ing cause will decide the issue against them. These are watched by the officers and attendants in the hospitals with the tenderest solicitude, and guarded with anxious vigilance to protect them from every unfavorable Influence. To such as these, standing on the verge of mental death, the presence and companionship of a felon from the prison may be sufficient to overthrow^ them and determine the fatal course of their disease. These are cogent reasons, strongly put, and must carry conviction to the mind of every man as to their propriety and justice. The convict insane in Calilbrnia are not sufficiently numerous, however, to justify the establishment of a separate asylum for their accommodation, but it would be an easy matter to erect a suitable building in conjunction with the hospital at San Quentin, to be devoted to this class of patients. The hospital physician could give them the needful medical attention, and they would cost no more to take care of them there than at Stockton, where there is no suitable place to keep or retain them, to say nothing of the cost of transportation. 164 CHAPTER XII. CHRONIC INSANE. Provisions for Curables and Incurables in Separate Institutions. SEPARATION. This is a question that has excited some attention in all countries. And though it has been practicably decided as unwise and improper by the Association of Medical Superintendents of American Institutions for the Insane, and most of the bodies of a similar character in other coun- tries, still it finds individual advocates in some of them. In Italy it is by no means uncommon, while in Austria and some of the German States it is rather the rule than the exception. It was one of the subjects to which we directed especial attention in our inquiries, and the opinions of every Superintendent with whom we met during our investigations was solicited. About one fourth of those in Italy, one half in Austria, Moravia, Bohemia, Saxony, and a few other of the German States, per- haps a tenth in other continental countries, and one in twenty of those in Great Britain and the United States, were in favor of separation, while all the rest were opposed to the principle and the practice. Economy seemed to be the leading argument of those who favored its adoption, though a few placed it upon higher grounds, and contended that while the chronic and incurable cases were quite as well cared for, and could be better employed, and allowed more liberties than in a cura- tive establishment, that their removal increased the chances of recovery in the more recent cases; while another class seemed to favor the erec- tion of different buildings for the two classes in proximity to each other, and under the same administration, in order that transfers might be made from the one to the other, as might in the judgment of the Super- intendent be deemed expedient. On the other hand, it is contended that all such institutions are more liable to degenerate into negligence, inattention, and decay; that they are cruel to'the patients who are thus told of their hopeless condition and must therefore spend the rest of their days within asylum walls; that instead of being a disadvantage to the more recent and curable cases, the reverse of this is actually the case; that by their habits of obedience and order, others submitted more readily and cheerfully to the rules and requirements of the institution ; and that by their example and willing- ness to labor and to take part in other occupations and amusements, the acute cases more readily joined in these necessary and healthful pur- suits; with many other arguments familiar to all w^ho have paid any attention to the subject, and which might be introduced here if deemed of the least importance. Candor compels us to say that our observations of the results of the two systems forces us to the conclusion that sepa- : ration is wrong in principle and detrimental to the best interest of the insane. While this is decidedly our opinion, however, we most cheer- fully admit that some of the asylums for the chronic insane^ were admirably managed in every respect, and their Superintendents intelli- gent, zealous, and attentive men, devoting their whole time and all of their energies to the unfortunate patients under their charge; and that this is true of some of these institutions in all the countries we visited. That at ^ Ovid, on Lake Seneca, in the State of New York, with .its 165 ^ splendid location and beautiful and picturesque surroundings, especially impressed us most favorably, and was such a paradise in comparison to the miserable wards of the poorhouses from which they had been taken that we cannot but regard its establishment as a boon to the insane poor of the State. We failed to discover, however, even the shadow of a reason why a person becoming insane in the neighborhood of this beau- tiful asylum should be sent to TJtica because he w^as considered caral3le, and that one in Utica should be sent to Ovid because the reverse of this Avas true. It would seem infinitely better that each asylum should admit all of either class occurring in their respective vicinities. They should be as successfully treated at the one asylum as the other; while it is too plain a proposition to require argument that economy of trans- portation and convenience to family and friends would be best subserved by keeping them at the asylum nearest their homes. With regard to the results of treatment, the facts dieted are altogether in favor of non-separation; the percentage of cures being less and that of deaths greatest in those coulitries where the system of separation is most generally pursued. CHAPTER XIII. TKEATMENT OF INSANITY. Treatment in English Asylums — Mania — Epilepsy connected with Insanity — Paralysis connected with Insanity — Melancholia — Observations on present Treatment of Insanity. TREATMENT IN ENGLISH ASYLUMS. • In the further report (18-1:7) of the Commissioners in Lunacy for Eng- land and Wales will be found a circular letter, addressed to the proprie- tors or Superintendents of Asylums, containing several questions in reference to their methods of treating cases of insanity, and the disor- ders complicated with it. These questions referred es2:)ecially to the treatment adopted: First — In mania. Secondly — In epilepsy connected with insanity. Thirdly — Paralysis connected w4th insanity. Fourthly — In melancholia. Replies were received from fifty-three physicians in charge of these establishments, from which w^e extract the following as a fair sj^ecimen of the w^hole, as elucidating the most approved methods of treatment adopted at that time by the most learned men of the day. MANIA. • First — in regard to Mania: The Practice pursued at the Devon County Asylum, as described by Doctor Bucknill. With hot scalp, full pulse, etc., from six to twelve leeches to the tem- ples or behind the ears; the head shaved, and evaporating lotions applied; a warm bath for half an hour at bedtime; the bowels open, by one dose • 166 of calomel and jalap, followed, if necessary, by salts and senna; then one fourth or one third of a grain of tartar emetic in solution, every three or four hours. The patient is not kept upon low diet; he is clothed warmly, and in the open air as much as possible, and the opportunity of muscular exertion and fatigue is allowed. If he does not sleej:), two drachms of tincture of henbane, with camphor mixed, are given at bed- time: if this does not succeed, one drachm of laudanum, with one drachm of sulphuric aether, are given when the acute symptoms have yielded. When the head is cool, the face pale, the pulse compressible, I give warm baths, with aether and ammonia, and sometimes aether and lauda- num, or Hoffman's anodyne, with aloetic aperients. "When these symp- toms are accompanied by great unsomnolence or restlessness, with illu- sions, and when I can ascertain that the patient has been a drunkard, I give wine, aether, and large quantities of opium, the indications of treat- ment being the same as in delirium. When the patient, with the ordinary' s^-pii^toms of mania, presents those of typhus fever, with sordes on the teeth, picking the bedclothes, etc., 1 give warm negus, frequently ammonia, camphor, aether, with occa- sional doses of calomel. I have fortunately never lost a patient suffering under acute mania. BemarJis. General bloodletting I never use, and cannot, therefore, give an opinion upon. Local Bloodletting I use frequently, by leeches, to the groin, temples, or neck; or by cupping the n^pe of the neck. In inflammatory diseases within the chest, I find that free cuj^ping between the shoulders, followed by the use of anti- mony or mercurials, is sufficient, and that bleeding is not required. Emetics I have given, with benefit, where exacerbation of melancholy is accom- panied by foetid breath, or discharge of gluey mucous from the stomach; also in incii3ient dementia with lethargy and indigestion, and for chronic cough. Purgatives. Patients are often admitted with obstinate constipation, and for them the stronger purgatives are necessary; but afterwards, this condition is not allowed to prevail, and an occasional, or, if need be, a small daily dose of compound rhubard pill, or castor oil, or decoction of aloes, or house medicine, is all that is requisite. Five or six grains of calomel are given when the state of the liver requires it, but I have now discontinued the use of drastic pui'gatives. I have used them with decided benefit in maniacal cases, but have made up my mind that antimonials are more manageable and safe. The house medicine above mentioned is made of the sulphate of magnesia and soda, with senna, and extract of liquorice, decocted, and peppermint water added, when cool; the patients like it, and a dose, to produce two or three dejections, will often cut short be- ginning excitement. 167 Antimonials. 1 use tartar emetic frequently in acute and recurrent mania, dissolving three or four grains in mint water, with simple syrup, and giving one twelfth part every three, or four, or six hours. After a few doses the medicine does not usually produce sickness, the appetite is not dimin- ished, and the patient often gains flesh during its use. Two or three gamboge colored evacuations are generally passed in the day. I believe that this medicine acts less by its depressing agency than by some influ- ence upon the congested capillaries of the brain, enabling them to con- tract. I find that repeated doses of ipecacuana, though more nauseat- ing, are not equally useful. Opiates and Anodynes I use sparingly. In the cases before referred to as resembling delirium tremens, opium is given in large quantities. It is not given if there is heat of the scalp and a strong pulse. In other cases of sleeplessness, where it is not thus contra-indicated, it is usually combined with sul- phuric ether, or with camphor. Hyoscyamus, in combination with ammo- nia and camphor, is often given as a sleeping potion, but sleep is more frequently induced by w^arm baths, cooling lotions to the head, or some food in the middle of the night, than by means of narcotics. A plaster of extract of belladonna is sometimes used to the epigastrium or peri- cardium as an anodyne. Other narcotics have been tried without encour- aging results. Antlspas)nodlcs. The compound galbanum pill and mixture, containing the foetid spirits of ammonia or the tincture of assafoetida, are sometimes given to females with uterine derangement; but the only antispasmodic in frequent use is the spirits of turpentine, given to epileptics with a view of reducing the number and the severity of the fits. Tonics. Vegetable bitters, with ammonia and aromatic stimulants, or with mineral acids, or with liquor potassa3, or with small doses of iodide of potassium, are frequently used; also, chalybeates, in the form of steel wane or compound steel pills, or iodide of iron dissolved in simple syrup, which prevents its decomposition, are given in numerous cases with ben- efit. The only tonic not in general use wdiich has been given is the sul- phate of strychnia, in doses "from the thirtieth of a grain upwards. It is never given to produce nervous twitchings. It requires occasional doses of aloetic medicines, and is useful in some cases of melancholia in old people. Stimularits Are frequently used medicinally. Those preferred are aether and ammo- nia, strong beer, porter, and wine. They are mostly given to patients who are admitted in a reduced condition, or to those w^hose strength is failing from general decay, paralysis, or other cause. 168 Bathing. Tepid, warm, shower, and vapor baths are used. A tepid bath is given to all the patients once a week in Siimn>er and once a fortnight in Winter, for the sake of cleanliness. Warm baths are constantly used to allay excitement and to induce sleep. Shower baths are used as a tonic to dyspeptic and hysterical young patients, but not to old ones. They are also sometimes given to the refractory as a penal remedy. YajDor baths have been tried upon some old persons suffering from melancholy, with dry and harsh skin, it is thought with benefit, but further experi- ence is required. Practice pursued at Middlesex {or Hamvell) County Asylum, as described by Doctor Conolly. A kind and soothing reception, immediate removal of restraints, a warm bath, clean clothing, comfortable food, encouraging words, a medical treatment first directed to any manifest bodily disease which may occasion the cerebral disturbance, as of the uterus, stomach, etc., or the general loss of strength; and if such disease or debility is not manifest, attempts to allay the irritation of the brain more directly by leeches occasionally applied to the head, gentle aperients, moderate doses of tartarized antimony, sometimes combined with sedatives, cold applica- tions to the head, blisters behind, the neck, shaving the head, and friction of the scalp with the tartarized antimony, the warm bath, or in violent cases the cold shower bath efficiently applied; tranquility, occasional exercise in the open air, exercise and occupation in chronic cases, clean- liness, order, good diet, attention to relieve heat and thirst, particularly in the night, a careful avoidance of everything that can irritate the brain, including the avoidance of the strait waistcoat, etc. Antimony and all sedatives are of uncertain effect, and sometimes of none, time seeming alone to effect a cure, j)rovided -proper and constant care be taken of the patient. General Remarks. It will be observed that I consider the direct treatment of any form of insanity by mere medicinal application to be very limited; but the indi- rect treatment of mental maladies by innumerable means acting upon the body and mind of immeasurable importance. These means can, I believe, seldom be efficiently applied, except in well constructed and well conducted asylums, superintended by well educated men, aided by benevolent and active attendants. By such means I believe many insane persons to be capable of cure, and all, however incurable and hojDeless, capable of improvement and relief I will merely add, that I am convinced that general bloodletting is rarely admissible, and generally dangerous in insanity, and that local bleeding by leeches is safe and serviceable in most cases. I have no faith in emetics. 1 think purgatives are often needlessly employed. Antimony is often of temporary service; sedatives, though occasionally most efficacious, are also most uncertain in their effects. The acetate of morphia, the hyoscyamus, and the cannabis indica, have apj^eared to me to be the most frequently useful. Tonics and stimulants are frequently of service, and every form of bathing in different instances. I have ceased to employ the douche bath, as it occasions more distress to the 169 patient than the shower bath or than cold affusion, without correspond- ing benefit. A liberal diet, moderate use of malt liquor, exercise out of doors, employment, recreation, mental occupation, friendly intercourse, and judicious religious attentions, are all important anxiliaries to amend- ment. Practice in the Surrey County Asylum, as described by Sir Alexander Morison. If the patient is brought under mechanical restraint, this is removed and the warm bath is generally employed. The hair, if considerable, is thinned, and in some cases removed; and recourse is had to laxative medicines, as jalap, rhubarb, senna, calomel, sulphate of magnesia, cro- ton oil, castor oil. ]N"auseating medicines are sometimes given to allay excitement — in particular, small doses of tartrate of antimony; also . sedatives, as hyoscyamus, morphia, camphor, nitre. Cooling lotions are applied to the head. Topical bloodletting by cupping or by leeches (general bloodletting has not been employed). Blisters to the nape of the neck. Animal food daily. Porter or wine have in some cases been given. Few recent cases of mania have been received, owing to the vicinity of the public hospitals of Bethlem and St Luke's. Practice pursued at Stafford County Lunatic Asylum, as described by Mr. James Wilkes. In the medical treatment of the cases of mania sent to this Asylum the first indication is sought in the careful examination of the patients' general condition, in ascertaining how far the cerebral excitement depends upon increased vascular action, and in detecting the nature of any bodily disorder that may be present. Although the latter is often obscure, still some derangement of the thoracic or abdominal organs, either functional or organic, is a constant complication of mania, and remedies directed to their relief are often sufiicient to cure the men- tal disorder. In many instances the patient when brought to the asylum is in so prostrate a condition, either from exhaustion, produced by the disorder itself, from having refused food, or from the extent to which bleeding, purgatives, and low diet have been carried, that the course of treatment IS at once clear, and good nourishing diet, stimulants, and tonics often restore the patient, unless, as is too frequently the case, the symptoms of sinking have already set in. The injurious efi'ect of active medical treatment in cases of mania, and the tendency there is to exhaustion and sinking is so fully established that the general practice in this asylum is chiefly directed to supporting the vital powers, subduing the cerebral irritation, and correcting the existing physical derangement, not by any peculiar or specific mode of treatment, but uj^on ordinary principles. In pure cases of mania, however great the excitement may be, general bleeding is never employed. The cerebral irritation is often materially relieved and every advantage gained by local bleeding, without mate- rially depressing the patient's strength. For this purpose, leeches to the temples or behind the ears, and cupping on the same parts or on the nape of the neck, are the means usually employed, due regard being had 22 170 in using these to the amount of vascular action and condition of the patient. Any obvious derangement in the patient's general health, or in the function of any particular organ, is attended to, and appropriate reme- dies prescribed; but the usually defective state of the digestive and assimilative organs renders attention to them of much importance. The bowels, when torpid, are freely acted upon, and if there is nothing to contra-indicate such a course, the morbid and accumulated secretions are removed by a dose or two of calomel, either alone or combined with colo- cynth; and if the patient refuses medicine, croton oil and enemata are employed. If there is much exhaustion, an enema alone is prescribed. The various narcotics and sedatives are constantly used in this asylum in the treatment of cases of mania, both acute and chronic, and though they are uncertain, and no very precise rule can be laid down for their employment, they are, on the whole, found to be highly serviceable. They appear to be of the most benefit in cases attended with great ner- vous excitement, and are of little use and often positively injurious when there is much febrile disturbance, especially in typhoid symptoms or vas- cular determination to the head. The description of narcotics to be used, and also the dose, can only be determined by experience in individual cases. The free action of the bowels should be previously obtained, and then either solid opium, the tincture, Battley's sedative solution, or mor- phia, are prescribed, combined in some cases with antimony or ipecacu- ana, hyoscyamus, camphor, or a?ther. In cases of great excitement any of these, in small doses, rather increase it, and it is important to prescribe it in full doses and frequently to keep up the narcotic action by repeating it every four or six hours. The Indian hemp has latterly been used here, and, when genuine, is a valuable and powerful remedy. In several cases in which I have employed it the excitement has been subdued and sleep obtained, when large and repeated doses of opium and morphia only added to the restlessness of the patient. Its after effects also seem to be less injurious than those of opium; constipation is not produced, and the constitutional disturbance is often relieved. When there is much febrile disturbance, with heat of skin and thirst, the saline mixture (composed of liq. ammonise, acet. vin. antimon., pot. tart., tinct. hyoscyami, potassse nitras, and mixtura camphoras) is fre- quently prescribed with good effect, the action of the skin being pro- moted by it and the restlessness relieved. In certain cases of acute mania, and also iu the chronic form, the employment of tonics is found to be of much use, especially in enfeebled constitutions with weak pulse and depressed vital powers. Quinine, iron, and the vegetable bitters, combined with stimulants and aromatics, are prescribed in these cases. The exitement in mania is rather increased than relieved by low diet, and the usual difficulty is to get the patients to take sufficient food. The diet used here is ample and nutritious, and the principle of supporting the patient's strength and making up for the waste and exhaustion which are going on in the system, by an abundant supply of nutriment, is here fully acted upon. Thus, jDatients who are laboring under much excitement are not restricted to the ordinary dietary, but are supplied with meat daily, soup, milk, eggs, sago, arrow root, etc., and often with wine, brandy, ale, and other stimulants; and daily experience proves that in many chronic cases life may be prolonged by a liberal diet, and that in recent 171 cases it alone often cures the patient and crcn supersedes medical treat- ment. The use of the warm and shower bath is found here to be of much importance in the treatment of mania. The warm bath seems to exert a sedative influence in many cases of excitement, and may generally be employed in safety. The tepid or cold shower bath, when cautiously employed, is also a powerful means of subduing the paroxysm, and many patients acknowledge that it alone has cured them. It seems to be of the greatest benefit in cases of mania attended with heat of scalp and increased vascular action, and when unattended with much general dis- turbance of the system or symptoms of thoracic or abdominal disorder. In the latter complications the use of the shower bath is at once contra indicated, and the warm bath may be substituted for it. Cold lotions, ice, and cold affusion to the head are constantly employed whenever heat of scalp, suffused eyes, and increased arterial action indi- cate fullness of the cerebral vessels. In acute cases of mania, blisters are not often used here, as they serve to add to the excitement by the irritation they produce. In cases of chronic mania they are employed, and especially when there is evidence of slow mischief going on in the brain. Remarks. Emetics. — These, as directed to the treatment of insanity, are never employed in this asylum, nor are the depressing doses of tartarized anti- mony which some practioners recommend. In cases of gastric or biliary derangement, in which emetics would be indicated under other circum- stances, they are occasionally employed. To the observations on general bleeding I may add that not only is there a want of proof of relief having been obtained by this popular remedy in any of the cases brought to this asylum in which it has been practiced, but its injurious effects have been so repeatedly and decidedly witnessed, either in producing fatal exhaustion or reducing the patients to a hopeless state of imbecility, that in cases of simple mania, uncom- bined with inflammation, its adoption cannot be too strongly deprecated. In reference to the diet of the insane, daily observation increases my conviction that a liberal supply of good, nutritious food both adds to the recoveries and diminishes the mortality in institutions for the insane, being an important means of cure in recent cases and of prolonging life in the chronic and incurable. Practice pursued at Brislington House, as described by Doctors F. and C. Fox. In cases of mania, which, we must observe, seldom come under our notice in the incipient stage, we have rarely seen benefit derived from general bleeding. Small quantities of blood are often abstracted by the cupping glasses from the nape of the neck; the bowels are evacuated freely by aloetics combined with nauseating doses of tartar emetic taken each night, and succeeded b}^ castor oil in the morning. The cold plunge or shower bath is usually taken each morning, and it is repeated with much advantage in the evening in cases of sleeplessness. In the more protracted cases of mania, the principal medical treatment has consisted of counterirritants to the scalp or to the pit of the stomach, with atten- tioti to the state of the skin and bowels, the maintenance of a warm at- 172 mosphere in the sleeping ajDartments, a plain and nutritious diet, and the use of much exercise, unattended with violent bodily exercise. Remarks. We have found it impossible to comj^rise under either of the foregoing heads a large proportion of the cases which have been in this asylum, or to describe any uniform mode of treatment as applicable to the cases in either of the divisions. In those cases of moral perversion which occur without the existence of any delusion, we have seen much benefit de- rived from the system adoj^ted in an asylum. In this form of insanity we have generally discovered a propensity to excess in diet and to intoxication, or to the indulgence of lascivious habits; and we have found a spare diet, cold bathing, saline 23urgatives, early rising, and active exercise, with a 2)rolonged sejDaration from the scenes and habits of former excitement, most useful to such patients. "We believe that such a system can be enforced only in an as^'lum, and that moral treat- ment and the services of a chaplain are of much importance in these cases. General bloodletting is only resorted to by us in those cases of mania in which the physical condition of the patient induces the apj)rehension of apoplexy, and never for the j^urpose of quieting a paroxysm of excitement. Previously to admission, most of our patients have been under medical treatment, and we have often had reason to suspect that the general bloodletting to which they have been subjected has been detrimental, and that it has in some cases induced jDcrmanent fatuity. We have found general bleeding useful in some cases of melancholia. In most forms of insanity, Ave find benefit derived by the local abstrac- tion of blood from the head or nape of the neck; in some cases, by the apj^lication of leeches to the pit of the stomach, and in females, to the groin. We value antimonials in the treatment of insanity much less for their emetic action than the change which they effect in the circulation, and we find that this object is gained by nauseating doses, which tend to allay maniacal excitement and to procure sleep. AYe consider that the use of purgatives is indicated in almost all forms of insanity in the incipient stages, and we find them esj^ecially useful in melancholia, until they can be dispensed with by attention to diet and exercise. Opiates and anodynes have frequently been resorted to by us, with a hope of success which has but rarely attended their use. In paralysis and epilepsy we have derived benefit from the use of antispasmodics, tonics, and stimulants, and in some cases of melancholia dependent upon uterine disturbance, but we have not found these reme- dies in the treatment of mania. We attach much value to the use of hot and cold bathing. In mania, we chiefly use the cold plunging and cold shower bath, and we find the warm bath and the cold shower bath, with the feet of the patient immersed in hot water, more applicable in cases of melancholia. We are of opinion that maniacal and melancholic patients almost invariably require a generous and nutritious diet; this we find to be equally necessary in cases of chronic insanity. In epilepsy and paral- ysis, connected with insanity, we often find it necessary to place the patients upon a very restricted system of diet. 173 EPILEPSY IN CONNECTION WITH INSANITY. Secondly — in regard to epilepsy, Ave quote: Remedies used in Cases of Epilepsy at Devon County Asylum., as described by Di\ Bucknill. The patients are placed on a wholesome and nutritious diet and regimen. Indigestion is treated by tonics and other appropriate reme- dies; costiveness is removed by small daily doses of co. rhubarb pills, decoct, of aloes, castor oil, or house medicine; when the fits are severe, one drachm of sj^t. of turpentine, with mx. of liq. of potass, every four hours; sinapism to the legs and feet, and three or four ounces of blood from the neck by cupping. Turpentine undoubtedly diminishes the strength and frequency of the fits, and I have only seen it once produce bloody urine. In young patients, the frequent application of croton oil to the scalp, and the long continued use of mercurial alteratives (hyd. chloria. is preferred) have apparently effected cures. Bemedies used in Cases of Epilepsy at the^ Middlesex {or Hanwell) Asylum, by Doctor Conolly. Cases of epilepsy being generally associated with occasional mania, are treated on the principles before mentioned. In the fit, care is taken that the patient sustains no injury. Epileptics should sleep on low beds or cribs, or beds on the floor. In the excited or maniacal state nothing is done to irritate the patient. When restraints were resorted to the epileptics were often furious, and generally dangerous; since their dis- use, the epileptic ward has become the quietest in the asylum. I have never seen a case of epilepsy in an adult permanently cured by any medicine whatever. Attention to the general health, the occasional application of leeches to the head, blisters behind the neck, and, in some cases, an incision in the scalp, have served to lessen the cerebral conges- tion. Setons appear to me to be useless, as well as issues, and all other modes of severe counter-irritation. Bemedies used in Cases of Epilepsy at the Surrey County Lunatic Asylum, by Sir A. Morison, M. D. Many cases of this description have been admitted. In them attention is given to the general health by remedies tending to improve the state of the digestive organs. Leeches, in some cases, have been of service; also, rubefacients, coun- ter-irritants, and blisters, and tartrate of antimony, externally applied. Preparations of silver and turpentine have been given internally, but with little good effect. Organic mischief, to a greater or less extent, has been found in the brain in all the cases of epilepsy, connected with insanity, which have been examined in this asylum. Bemedies used in Cases of Epilepsy at the Stafford County Asylum, by Mr. Wilkes. The cases of epilepsy usually sent to this asylum are usually connected with congenital defect, or are of such long standing and so intense in 174 degree that any hope of cure or material relief is out of the question; and the only indication seems to be, to attend to the patient's general health, and guard against and relieve cerebral congestion. In cases of obvious debility the employment of tonics is of use, especially those of the mineral class, as the preparations of iron, zinc and the nitrate of silver. The excessive state of congestion ^^hich frequently occurs is here treated by the free exhibition of purgatives, as large doses of calo- mel and croton oil; the application of leeches or cupping to the temples; ice, cold lotions, and cold affusions to the head, blisters to the nape of the neck, stimulating pediluvia and enemata, especially those containing turpentine and assafoetida. While the diet should be nourishing, it should not be stimulating; and the disposition to over-nutrition should be carefully guarded against. As a general rule, the free action of the bowels is kept up by the frequent exhibition of purgatives. Remedies used in Cases of Epilepsy, at Brisliagton House, by Doctors F. and a Fox. If such cases are of recent date, we have sometimes seen good results from the use of nitrate of silver, with small doses of turpentine; an incision on the scalp, leeches on the perinseum, the tepid shower bath, much friction of the skin, as much pedestrian exercise as the patient can accomplish, and a restricted vegetable diet, have often been useful. By paying close attention to the periodical tendency which this disease so frequently displays, and by meeting the gradual increase of nervous irritability by a small local bleeding and a moderate anodyne, we have sometimes succeeded in prolonging the intervals between the attacks, and on some occasions in effecting a cure. PARALYSIS CONNECTED WITH INSANITY. Thirdly — In regard to paralysis, we quote: Remedies used in Cases of Paralysis at Devon County Asylum, by Doctor Bucknill. When the patients are not admitted in a bedridden and ulcerated con- dition, good diet and regimen generally improve the strength, and the progress of the disease ai^pears to be very slow. A few leeches are sometimes applied to the temples, when the face is apt to flush and the scalp to become heated. Having observed that some patients who had sore legs appeared to be more comfortable when the suppuration was free, I have tried setons, but cannot as yet give an opinion about their utility. In sinking cases, wine and porter are freely given, and slough- ing sores are dressed with equal parts of tinct. of kino and liq. of subace- tate of lead, and a yeast cataplasm is ax)plied for three or four hours ever}^ second day. Remedies used in C-ases of Paralysis at the Middlesex (or Hanwell) County Asylum, by Doctor Conolly. The paralytic complication {parcdysie generate of the French) makes great care necessary to prevent injury to the patient. Good food, porter, occasional tonics, and in all cases warmth and comfort, evidently prolong life for many years. The patients neither bear reduC'tiori nor excite- 175 ment; even baths are scarcely to be recommended. Leeches and aperi- ents are somethnes required to lessen congestion in the head. Small doses of calomel and squills have occasionally seemed useful, but I am satisfied that all specific modes of treating this form of paralysis are inefl'ectual as regards a cure. Many of the miseries of the malady, as uncleanliness, ulceration, and fits of violent anger, are prevented or long retarded b}' kind treatment and the absence of all bodily restraint. Remedies used in Cases of Paralysis at the Surrey County Asylum, by Sir Alexander Morison, M. JD. The same may be said as to the existence of organic mischief in cases of this description, of which a large number have been examined. The remedies employed have been laxatives, leeches, blisters, generous diet, and tonics, especially quinine. In most cases recourse has been had to water beds on account of the extensive ulceration which frequently attends the termination of these unfortunate cases. Remedies used in Cases of Paralysis at the Stafford County Asylum, by 31 r Wilkes. Cases of paralysis connected with insanity, like those of epilepsy, are rarely sent to this asylum before the disease is in an advanced stage, and as far as my experience goes, the patient in a hopeless and incurable state. Life, in many cases, is prolonged by care and attention, and it is especially needful to guard against congestion of the brain, and so to regulate the diet as not to encourage undue nutrition and plethora, which is often at- tended with serious aggravation of the symptoms. The occasional exhi- bition of purgatives, and even those of an active character, are necessary to relieve congestion, and the tendency, which usually exists, to consti- pation. Local bleeding, by means of leeches and cupping, to the temples, behind the ears, or nape of the neck, is also employed, together with blisters and other counter-irritation, especially when there are symptoms of coma. The iodide of iron and a mild mercurial course, combined in some cases with tonics, have been tried in this asylum, but without per- manent benefit; the organic changes in the brain, upon which the disease depends, appearing to be be^^ond the influence of medical treatment. Remedies used in Cases of Paralysis at Brislington House, by Doctors F. and C Fox. We have arrested this disease by the use of iodide of mercury, by the prolonged application of open blisters to the parietal junction of the scalp, and by the use of the electro-galvanic apparatus to the affected portions of the body. As such cases have generally occurred in aged or wasted constitu- tions we have often had recourse to chalybeate medicines, but have experienced their injurious efi'ects upon the mental disease. These cases are rarely presented to our notice in a curable state. 17/3 MELANCHOLIA. Fourthly — in regard to melancholia, we quote: Remedies used in Cases of Melancholia in the Devon County Asylum^ by Doctor Bucknill. I endeavor to appreciate and to treat the bodily condition wherever it is disordered. In young women with suppression of the menses, I order leeches to the vulva, hip baths, aloetic aperients, and often chalybeates. In elder women, at the critical period, an occasional blue pill, a small daily dose of decoction of aloes, vegetable tonics, sometimes galbanum, or assafoetida, or chalybeates. In various cases with dyspepsia, I have given bitter infusions with mineral acids or alkali, or gr. iij. doses of iodide of potassium with liq. potassas or lime water. In some cases emetics have been very beneficial, and shower baths are good tonics and safe in the Summer months. When pain, sense of burn- ing, etc. is felt in the head, I have given blue pill to twitch the gums, and used counter-irritation to the scalp. When the skin is dry, warm bath with friction, or vapor baths are used. I have found the electro- galvanic apparatus beneficial in some cases, when used moderately so as not to produce fear or pain. Hemedies used in Cases of Melancholia at Middlesex (^or HamcelV) Asylum^ by Dr. Conolly. The attention is first directed to any manifest bodily disorder, or to existing debility or plethora, often with the eftect of curing the patient. Leeches behind the ears or to the forehead, blisters behind the neck, small and sometimes large doses of sedatives, give relief in some cases. The warm bath is soothing; and, in some instances, the shower bath has great efi'ect. Occupation of mind and body, cheerful and encouraging conversation, and the absence of all restraints or apparatus calculated to alarm the patient, are of great importance; direct attempts to stimulate the faculties, by various impressions, by frequent change of scene, or by wine or spirituous liquors, are seldom successful, and sometimes very hurtful. Tonics are, in some cases, serviceable, as calumba, cascarilla, or preparations of iron. AVhen plethora is manifestly present, daily saline aperients are generally useful. Remedies used in Cases of Melancholia in the ^^iurrey County Asylum, by Sir Alexander Morison, M. D. Few recent cases of this description have been sent to this asylum, owing to the cause stated in regard to recent cases of mania. Laxatives, sedatives, tonics, warm baths, shower baths, and blisters, have been chiefly employed. The most numerous cases are those of dementia, in a more or less advanced stage. The object in them has been to imj^rove the general health. Warm baths, shower baths, and blisters, have been occasionally employed. In all cases where practicable, recourse is had to occupation, useful or agreeable. As little restraint is employed as is deemed to be consistent 177 with the safety of the patient and of others, and this is continued for as short a time as possible. Eemedles used in Cases of Melancholia at Stafford County Asylum, by Mr. James WiUies. This state is generally found to be connected with a low condition of health and a depressed state of the vital powers, independent of direct symptoms of cerebral disorder, and the medical treatment followed in this asjdum is chiefly directed to restore the functions of any organ which may seem to be impaired, and to invigorate the patient's general health. The frequent association of melancholia with various forms of dyspepsia and disorders of the assimilative organs is not overlooked; neither are the defective quality and quantity of the urine, and the changes which so often take place in its chemical composition. The employment of purgatives is rarely to be dispensed with, and these are often required in large and repeated doses to obviate the ten- dency to constij^ation which usually exists. The various combinations of tonics and stimulants with purgatives are here advantageously used, as the bitter infusions with sulphate of magnesia, and compound spirits of ammonia, aloes, quinine, and iron, in the form of pills, with sulphate of iron; alterative doses of calomel, or blue pill, are also given when the functions of the liver are disordered. When there is headache and symptoms of fullness in the head, the application of leeches is of service; and much benefit is often derived in cases of melancholia from the regu- lar use of the shower bath whenever there is no obvious reason for not applying it. Sedatives and narcotics in various forms are used in this asylum with gi-eat benefit, the restlessness of patients being subdued by them and the nervous system tranquilized. The preparation of opium (especially Battley's sedative solution), morphia, Indian hemp, hyoscyamus, conium, camphor, lactucarium, in different combinations, are given with the best effect. The diet in cases of melancholia requires regulating in reference to the state of the digestive organs, but should always be nutritious, and in many cases may be advantageously combined with stimulants. Remedies used in cases of Melancholia at Brislington House, by Doctors F. and C. Fox. In melancholia which has succeeded to an attack of mania we have .80 often found that the disorder has again reverted to the maniacal form,, that we generally confine the medical treatment to moderate evacuations, of the patient's bowels, with regulation of the diet, and we encourage, that increased indication to quiet and to sleep which such cases usually exhibit. Melancholia, as an idiopathic disease, is the only form of insan- ity in which general bleeding has appeared to us to be useful. In such cases we often open the vena saphsena, prescribe warm and aloetic pur-> gatives, counter-irritation to the region of the stomach, warm bathing,, carriage and horse exercise, and animal diet. TREATMENT AT THE PRESENT DAY. The foregoing extracts show the most approved treatment of insanity 23 178 as practiced in the English asylums twenty-five years ago. In many respects it is essentially the same at the present time. A few of the remedies then employed have been laid aside, or are regarded with less favor now, while a few others have been discovered or brought more prominently to notice, and have been substituted for them or given in conjunction with them. General Bleeding. General bloodletting was not approved by any of the authorities we have quoted, though we see that the practice was spoken of as one too much in vogue, and as detrimental in the extreme. Such is the uni- versal opinion of the physicians at this time, and in no instance nor in any form of insanity was it recommended by those with whom we met as a proper remedy to be employed. Local Bleeding. Local bleeding, by cups or leeches, is still practiced by some physi- cians, and regarded with as much favor as ever, while it is rarely resorted to b}" others, and therefore not so generally employed. Counter-irritants. Shaving the scalp, blisters, and counter-irritants, including setons, are also less employed than formerly, while tartar emetic and digitalis have become extremely unpopular with many, and are now cautiously and sparingly used by all. Baths. Baths in all forms seem to be less used in England than formerly, and in the asylums of the United States have a less prominent place than they deserve, while in Italy, the German States, and in some portions of France and Holland they are relied on as of paramount importance. Indeed, they seem to be the chief agents employed in some of these countries, and are administered in one way or other in nearly all forms and phases of the disorder. The shower bath, the douche, the plunge, and continued bath, are all supposed to have their peculiar virtues as stimulants, tonics, or sedatives, and are used ad libitum et ad infinitum. We have often seen half a dozen patients in one bathroom, each with the head only visible, the body being immersed in warm water, and the "bathtub covered with a lid having a hole in one end to fit around the neck. Here they usually remain from one to three hours; in some cases six to eight hours, and in occasional instances for days at a time. Doctor Gudden of the Asylum at Zurich, in Switzerland, informed us that he had on one occasion kept a man thus confined in a bath five days. In this instance there was a high state of excitement connected with bed- sores; and the treatment was for the double purpose of allaying the one and relieving the other. The patient is represented as having slept well during a portion of the time spent in the bathtub, while the bed-sores were entirely healed. The most remarkable feature in this case was the entire freedom from exhaustion or any other evil consequence. We would have supposed that such relaxation of the physical powers would have ensued as to have rendered resuscitation impossible. We were also informed that in a case at Vienna, where a man had been scalded by 179 steam, Doctor Hebra had him placed in a tepid bath and kept there for a period of three wet?ks, until a new cuticle had formed over the entire body. The patient recovered without inconvenience. This case was not one of ii] sanity, and has been introduced to show how much endu- rance is i^ossessed by some persons under peculiar circumstances, and to direct attention to this treatment. . The water, of course, was kept of uniform temperature, and at such degree as was most agreeable to the patient. The agonizing pain usually attendant upon scalds is said to have been effectually overcome. In most of the asylums in these coun- tries there is a general bathroom for either sex, and in many of them, especially Santa Maria della Pieta at Eome, and St. Ann at Paris, are fitted ujD in the most elaborate manner. In addition to the ordinary appliances for the warm and vapor bath, the douche, plunge, and shower bath, there are the Turkish and medicated baths, and a peculiar contri- vance made with metallic pipes an inch in diameter, forming circles like the hoops of a barrei. These tubes are perforated with innumerable holes on the inner side, so as to send small streams of water under heavy pressure upon every inch of the body at the same time. This the poor fellow has to submit to till the doctor or master of the bath concludes that the object sought to be accomplished has been attained. It seemed to us a frightful ordeal through which to pass, and from the contortions and grimaces of the j^atients we infer it was regarded in the same unfa- vorable light by them. At the Asylum San Yon, at Eouen, presided over by Doctor Morel, a writer well knovv^n to the scientific world, a man of ability, and a wor- thy successor of Esquirol and other celebrated men who had charge of this famous old asylum in bygone days, we also found them both much emi^loyed, and esj^ecially in the treatment of epilepsy. The shower bath is used twice a day in these cases, after which the patient is wraj^ped in a sheet. He reports one case of great violence entirely cured by this method, in which bro. pot. and other remedies usually resorted to had signally failed. He had also seen great benefit in other cases, and entertained thQ opinion that no remedy equalled it with which he was acquainted. There can be no question about the efficacy of baths in the treatment of insanity, when judiciously prescribed and proj^erly administered, but like all other j^owerful agents they are liable to abuses, by which they are brought into disfavor. Doctor Blanche, of Paris, and Doctor Skae, of Edinbargh, informed us that after many years of persistent and suc- cessful use of the warm bath in the treatment of acute mania, they had been induced to abandon it entirely, for notwithstanding the happy effects derived from it in most cases, they had become convinced that several patients for whom they liad prescribed the warm bath had died in consequence of its depressing influence. We conclude, therefore, that baths, like most other valuable agents, are too much used in some countries and too little in others. No remedy is so general in its effects as to be aj)plicable to all cases, and its failure to accomplish all that may be expected of it is no reason why it should be totally abandoned. Chloroform and opium are sometimes fatal when administered in ordinary doses, yet they are too valuable to be aban- doned on this account. Let us use all the remedies of value that science has given to our profession, but let us watch their effects and administer them with prudence. 180 Purgatives. With regard to purgatives, no change seems to have taken place for many years. They are regarded as absolutely necessary in certain con- ditions in all phases of insanity, the particular kind to be employed being a mere matter of taste with the physician prescribing them. Those employed twenty-five years ago are as much in vogue to-day as they Avere then. Emetics. Emetics are even less popular now than formerly, and are not often administered. Indeed, what we have said of tartarized antimony in its sedative and other capacities may also be said of it as an emetic, ^one of the emetics are popular remedies at this time. Anodynes^ Narcotics, etc. Anodynes and narcotics, which have occupied such a high place in the confidence of most medical men who have been engaged in the treat- ment of insanity during the last quarter of a century, are now being subjected to earnest criticism by some, and almost angry, if not unrea- sonable, opposition by others. They are remedies used in some form, though in various degree, by nearly all the Superintendents of asylums with whom we have met, regardless of country or differences of opinion on other subjects. Hence, we might naturally expect to find that they have been misused in Bome, and greatly abused in other instances. Dr. Maudsley, the President of the Psj^chological Association of Great Britain, in an able and interesting address, read before that association August third, eighteen hundred and seventy-one, made narcotics the subject of special notice, and deprecated their use, in most cases, in decided terms, denominating them the '* chemical restraint,", that had been substituted for the mechanical restraint of former times. It was, perhaps, natural that this class of remedies should have been used to excess in a country where public opinion had .been so much excited by and had waged such vigorous war against the employment of mechan- ical restraint — even in its mildest forms — in any asylum in the realm. In almost every asylum of ordinary size, there are a few patients who at times become so much excited, and have such irresistible propensities to injure themselves or others— to tear their clothing, indecently to expose their persons, or commit other equally unreasonable acts — that it becomes absolutely necessary to restrain them by some means — mechan- icall}^, if you choose, by seclusion in padded rooms; by the muscular power of attendants, or by narcotics, anodynes, etc., the " chemical re- straint" of which Dr. Maudsley now complains. Mechanical restraint beino- tabooed by public opinion, was not to be thought of ten or twenty years ago. It would have cost any Superintendent in England his ofiicial head to have undertaken it, and let the fact be known. Seclusion, when long continued, is attended with many evil results — loss of appetite, depression of spirits, the engendering of filthy habits, or other effects detrimental to physical htalth and mental integrity. Attendants, unfor- tunately, are not always blessed with that amount of sweetness of temper, of untiring j^atience, and unlimited self-control, that will enable them, either through a sense of duty or from Christian principles, when " struck upon one cheek to turn the other," even though the offender be a lunatic. Hence the necessity, in England, more than in other countries, of resort- 181 ing to sedatives and other chemical restraints to produce the quietness and relief that could not otherwise be attained. The debate that Ibl- lowed the reading- of Doctor ^laudslej^'s address revealed the fact that all did not agree in the views he had expressed; but, on the contrary, man}'- stoutly maintained that anodynes were among the most valuable agents employed in the treatment of insanity; while all admitted that cases did occur in which it was necessary to employ them in some form. In such a discussion, it was natural to inquire which of the many neu- rotic medicines was best calculated to accomplish the desired end with least injury to the patient. Opium, morphine, Battley's sedative, hyos- ciamus, cannabis indicus, bromide of 2>otash, chloral hydrate, and, in some Instances, a mixture of two or more of these drugs, ^vas given j^refer- ence. But the most remarkable and varied views were entertained with regard to the effects and efficacy of the hydro-chloral. It is thou^■bt, by Doctor Ehys Williams and a few others, to be of little consequence either one ^vay or the other. Doctor Browne, of Wakefield, has reported three cases of death from it ni the asylum under his care — two of these having occurred the same daj^, and within half an hour after taking thirty grains of chloral. AVhile Doctor Clouston, of the Cumberland and Westmoreland Asylum, near Carlisle, and manj^ others, have admin- istered it in large doses with no dangerous symptoms, but the best results. It is used with more or less freedom in very nearly all the asylums of Italy, Austria, the German States, Switzerland, and Holland; but very rarely in France and Belgium. Doctor Lehman, of Pirna, in Saxony, gives it in doses of from thirty to one hundred and twenty grains; Doctor Koeppe, of Halle, in doses of forty-five to one hundred and thirty- five grains; Doctor Guentz, of Thonberg, near Leipzig, gives from forty- five to seventy-five grains; and Doctor Ludwig, of Heppenheim, admin- isters from thirty to ninety grains, repeating the dose three times a day; while Doctor Leiderdorf, of Doblins, near Vienna, expresses the opinion that chloral hydrate will supersede all other remedies as a quieting agent. Dr. Professor Ner^ of Perugia, Dr. Serafino Bifiii, of Milan, Dr. Eoller, of Illenau, and others, have also used it, and express the highest opin- ion of it as a quieting, sleep-producing agent. Dr. Eoller thinks, when long continued, it has a tendency to produce congestion of the skin; wdiile Dr. Lehman thinks it has a tendency, under similar conditions, to produce stranguary; but as he also gives very large doses of cannabis in- dicus, it may possibly have been confounded with the effects of that drug. In the asylums of the United States it has been more or less employed for the last two years, and the testimony in its favor has been vt3ry gen- eral. But few, if any, of the Superintendents claim for it curative prop- erties, while nearly all regard it as one of the best hypnotics known to the profession. We must conclude, therefore, from all the testimony w^e have been able to collect from various sources, that chloral hydrate is not only one of the most innocent but one of the best remedies that can be used in most cases where sleep alone is the object desired. We know that it, like most other remedies of its class, will fail to produce like effects uj^on all persons; and it may be so much adulterated as to be either worthless or dangerous; and in no other way can we account for the varied results observed by the English Superintendents. We have spoken more esj^ecially of this remedy because less is known of it by the general reader than almost any other of equal importance. We prefer to administer it in twenty grain doses, given at bedtime, and repeated every hour till sleep is produced; and never to give it, or any other remedy of its class, except w^hen the end to be accomj^lished is esteemed 182 an absolute necessity. Of this necessity the physician must be the judge in each case as it presents itself. If chemical restraint seemed to be the proper remedy, we would use it. If mechanical restraint should seem of more importance in any giyen case* we should not' hesitate to employ that instead of the other; nor can we see any good reason why the physician should be left with unlimited power to use the more dangerous remedy, while the other is entirely prohibited. The camisole or mufi* is the only kind of mechanical restraint that should eyer be- employed under any circumstances, except for surgical reasons, and these oul}^ by the order and in the presence of the physician. In these yiews we are confident that two thirds of the Superintendents in Great Britain will heartily concur, and at least nine tenths of those in other countries, in- cluding our own. In truth, we are disposed to belieye that mechanical restraint is too freely used in most of the asylums in our country as well as on the continent; and in this respect we go quite as far wrong in one direction as they do in England in the other. Dr. Morel, of St. Yon, is one of the warmest adyocates of the non- restraint system with whom we met in all France. He had paid a yisit to Dr. Conolly, at Hanwell, where he had seen its practical operations under the eye of the master, of whom he was an ardent admirer. Haying imbibed Dr. Conolly's yiews, he made to his Goyernment one of the ablest reports on the subject that we haye read, and so thoroughly was he conyinced of the propriety and practicability of the system that he at once put it in practice m the asylum oyer which he presided, nor did he abandon it, eyen in surgical cases, until a deformity in a case of fracture of the leg demonstrated the absurdity of treatino- lunatics and those possessed of their reason alike in all cases. Had this patient been strapped to the bed during the process of union, this calamity would haye been ayoided, and so it may be said of others of like char- acter. Hence, Dr. Morel now thinks the use of the camisole as necessary in rare instances as any other remedy intrusted to the judgment and discretion of the physician, nor does he hesitate to prescribe its use when he thinks the patient will be benefited, byt under no circum- stances does he permit an attendant to eniploy it without his direction. The chemical restraint, opium, morphine, chloral, etc., are prescribed by the physician only, and so should it eyer be with mechanical restraint, the camisole. EpUepsy. We haye seen that the remedies employed in this fearful disease were principally the metallic salts — nitrate of silyer, oxide of zinc, citrate of iron, bichloride of mercury, etc., assisted by setons, blisters, cups, pur- gatiyes, and anti-spasmodics — and that all were equally unayailing. The disease is still considered incurable by almost all who haye been called upon to treat it, though it is now claimed by a few that in rare cases among the young, and especially in those cases where insanity superyenes on a preyiously existing epilepsy, it is not necessarily incu- rable, and that, in a large majority of cases, the frequency and seyerity of the attacks may be lessened, thus modifying the disease and amelio- rating the unhappy condition of the patient. AVe haye already- stated the treatment by shower bath pursued by Doctor 3Iorel, at San Ton, and. giyen the results. Similar claims have been made by different persons in fayor of each of the remedies above enumerated. Thus, Doctor Leiderdorf, of Dobling, near Vienna, reports one case, cured with ox. zinc; another, when there was a syphilitic taint, with iod. pot. Doctor 183 Fiscliel, of the Eoyal Bohemian Asj'lum at Prague, attributes the cure in one ease to Fowler's solution; and so on through the entire list. But the remedy most used in the present day, and that in which there is most confidence, is unquestionably the bromide of potassium. It is given by nine tenths of the proibssion who have charge of asylums; and while but few ascribe to it curative powers, most of them claim that it greatly ameliorates the attacks, and often wards them off entirely during its administration, thus giving its victims long intervals of relief and repose, while in a few instances complete restoration is effected. It is given in doses varying from five to one hundred and tw^enty grains, according to the urgency of the case and the peculiar views of the physician. ISTor is its employment confined alone to the treatment of epilepsy. Some use it in the treatment of nymphomania and kindred afltections, while it is the only neurotic medicine emj^loyed by Doctor Blanche in his asy- lum at Passy. He gives fifteen or twenty grains three times a day as a quieting agent. It is often administered in combination with other seda- tives, anodynes, or narcotics — and is thought to increase their efficiency, and is one of the few remedies that have attained almost universal popu- larity. Paralysis. In the treatment of this disease as connected with insanity but little change has taken place within a quarter of a century, unless, we should say, it is not so much treated as formerly. Blisters, the galtanic bat- tery, counter-irritation of all kinds, and the shower bath, seem to be less used than formerly; while the only new remedy employed, so far as we know, is the ergot of rye, as prescribed by Doctor Chrichton Browne, . of the Wakefield Asylum in England. He thinks good eftects have been accomplished by its use, but sufficient time has not yet elapsed to test its eflScacy. MORAL TREATMENT. The moral treatment of insanity is considered of more importance by many persons having charge of the insane than the medical, and the tendency to this opinion seems to be gradually increasing. It compre- hends all of those means Avhich operate on the feelings and habits of the patient, and exerts a salutary influence by tending to restore them to a natural and healthy condition. The means to be employed under this heal are as varied as the diseases leading to or the symptoms develoj^ed by insanity. It is in the judicious employment of the remedies of this class that the physician and the attendants are called upon to use the greatest skill and tact of which they are capable, whether as connected with individual cases or collective numbers. One important particular belonging to moral treatment has been already alluded to in our remarks on the non-restraint system. The English Commissioners in Lunacy say: " There is nothing moi'c important in the moral treatment of the insane than the proper use of means which contribute to their employ- ment, both mental and bodily, and tend to withdraw their attention from thoughts and feelings connected with their disordered state." The provision made for the attainment of these objects in our asjdums cannot be too strongly- recommended, nor insisted upon with too much pertinacity by those whose duty it is to watch over them. Employment in agricultural labor, in the vegetable garden, among the 184 vines and fruit trees, or in cultivating flovrers for their amusement and entertainment, will be of the greatest advantage to all of the insane who can be induced, either by persuasion or slight compensation, to partici- pate in them. The general health will be improved by this exercise in the open air, the appetite increased, the nervous sj^stem is less easily disturbed, the mind more composed, sleep is sweeter, sounder, and more refreshing, and the patient, with less opportunity to brood over his disease or imagined troubles and wrongs, gravitates naturally and by degrees into old habits of thought, health, and cheerfulness; the equi- librium is restored, and the patient is well. Single Booms. Another matter eom.ing under the head of moral treatment or manage- ment may be j)roperly mentioned here. It is the general opinion, expressed in words and carried out in practice, that all excited patients should be kept by themselves in single rooms, or cells, as they are unfor- tunately called throughout Europe; and especially, that they should be 80 kept at night. Doctor Morel is decidedly of the opposite opinion, and while he admits their necessity in a few isolated cases, has demon- strated to his own satisfaction that the theory is wrong and the practice injudicious in most instances. He has, therefore, taken out the partition walls between most of these cells and converted them into dormitories, and assured us that where four noisy, restless, sleepless patients were formely kept in single rooms, sixteen were now passing quiet nights, sleeping well, and giving every evidence of being better satisfied. He argues that most of the excited, noisy ]3atients are afraid to be left alone at night, and that this very fear disturbs their quiet and prevents them from sleeping. Schools. He has also recently organized a class of excited patients, which he examines each day when passing through the wards. Thirty were in attendance on the da}^ of our visit, and we found them more quiet and orderly than at any other time. All would clamor for the privilege of showing how well they could read, or repeat some little piece of prose or verses of poetry that they had committed for the occasion, but as soon as the doctor would decide who was entitled to the floor, all became quiet and listened attentively till the piece was spoken, when they would rise to their feet and again put in their claims, and so on to the end of the recitation. They really seemed to take great interest in these exer- cises, and doubtless many moments of comparative happiness were passed in learning their lessons that would otherwise have been spent in miserable contemplation of their unhappy condition. These schools have long existed in some of the continental asylums, and a few in Great Britain aud Ireland, though this was the first and only one we have seen especially devoted to the excited patients. Music, drawing, and singing are taught in most of the Italian asylums and in some of those in other countries. At Aversa, near IS^aples, there is a regular band, who play for their own amusement and that of the other patients. A theater has been fitted up, in which they play, give concerts, and other entertain- ments; and here, as at York, in England, and Morningside, in Scotland, a printing press has been provided, and the patients encouraged to write articles that are set up and printed by themselves. Here, too, as at Lyons, in France, Ghent, in Belgium, and Wakefield, England, we saw 185 many looms, on which the patients wove the cloth used by the asylums. At [San Servalo, in Venice, the band plays every day from eleven to twelve, and the patients are as much delighted as if at a regular concert, while those who belong to the band gave signs of evident satisfaction. In some of the asylums in Milan, schools have also been established, but we will only make an extract from our notes of a visit to one of them, the last we visited in Italy: April od-^To-day we visited the private asylum of Doctor Serafino Biffi, one of nature's noblemen, who seems as generous as a prince and as kind as a woman, one of those real loveable men with whom we sometimes meet in our journey through life. The asylum is a quiet, homelike place, such as we might expect to grow up under the care and management of so good a man. No pains l:0ve been spared to make it in reality a home for the homeless, and a retreat for the heavy hearted and afflicted. Two teachers are employed, who, in addition to other branches, teach vocal and instrumental music. They play and sing with as much accuracy and expression as if no illusion or hallucination dis- turbed their minds. They played and sang several pieces and tunes for our benefit, and showed us some of their paintings and drawings that would have been a credit to artists of no ordinary pretentions. Twenty of the seventy-four patients in this asylum were engaged in these occu- pations at the time of our visit, and as good order prevailed as at any school to be found. Others were reading, playing billiards or draughts, while others still were promenading about the beautiful grounds. This, as we have stated, is a private asylum, where patients are charged from sixty cents to two dollars per day, and is not given as a specimen of the public institutions, which are greatly inferior to it. The most thoroughly organized school that we have anywhere seen, however, was in the Eichmond Asylum, at Dublin. The sj^stem has been completely established, and the organization as perfect as any schools in the country. The able Suj^erintendent, Doctor Lalor, has taken great interest in and paid particular attention to the subject, demon strat'ing not only the possibility of promoting good order and discipline by means of schools, but also of increasing the knowledge and improving the morals of persons while in a state of insanity. There were about nine hundred patients in the asylum at the date of our visit — August twenty-ninth, eighteen hundred and seventy-one — more than a fourth of Avhom attended school. In the school for males we saw one hund. el and twenty engaged in their recitations and exercises, which were conducted with perfect order and propriety. Eeading, writing, arithmetic, object lessons, music, drawing, and painting are taught, and Doctor Lalor informed us that considerable advancement had been made by some, while all had been benefited in a moral point of view; self- control, power of concentration, and regularity of habits had been attained in many instances where they had been totally absent before; and that he regarded the school as one of the chief agencies in promot- ing good order and in establishing a comparative degree of contentment and cheerfulness in his asylum. The school for females is conducted on similar principles, though needlework is added to the list of studies in this department. Six teachers, three of either sex, are regularly employed, at salaries about double the amount paid attendants, and in addition to their duties as teachers are required to assist in '' keeping the house in order." Some of them always accompany the patients, in their 24 186 walks outside the asylum walls, in the public park, and other i)laces to which they are permitted to go. These teachers, being better educated, more intelligent, and of a higher order than those whose services can be obtained for the ordinary wages paid attendants, exercise a salutary influence over the patients at all times. Their morals, habits, and man- ners, being thus cultivated and controlled, are necessarily improved, and we confess our surprise at having seen this kind of occupation intro- duced into so few of the asylums of our own country. DIRECTORS AND SUPERINTENDENTS. Unfortunately the custom still prevails in some of the asylums oil the continent of placing a Director at the head of the institution. Its gen- eral mauagement, the powm* to employ and discharge all the attaches and attendants, and to say how the patients shall be fed, clothed, and occupied, are invested in him, though generally a non-medical man. The Medical Superintendent occupies a subordinate position. He of course prescribes the medical treatment for all, and the diet for the sick, but no other j^owers are assigned to him. As may readily be supposed, this divided responsibility begets evil results. The physician is lessened in public estimation; the employe and attendant look to the Director for his position or his place, and naturally take sides with him in any con- flict of opinion that may arise. They place themselves in antagonism to the wishes of the physician, and but half carry out his orders, and thus destroy the harmonious workings of the institution. In Great Britain no man is chosen as Superintendent of an asylum who has not served as an assistant. He must be armed with recommenda- tions as to his qualifications, standing, and moral character, and is sub- jected to a searching examination. Having passed this ordeal and obtained the position, he retains it for life, unless removed for cause. He has supreme control of the asylum over which he presides, nominates his assistants and other ofiicers, and selects his attendants. He is j^aid a liberal salary, and given one month's leave of absence each year for recreation; and after serving fifteen years is allowed an annuity equal to three months of his salary, provided he desires to retire from service. Harmony is the result of this system, and the consequence is good order and thorough discipline in every asylum in Great Britain. Under these circumstances, men of the highest order of intellectual capacity and thorough education j^i'epare themselves for the position of Superintendent, and being under a local Board of 3Ianagers, and sub- jected to periodical visitations by the Commissioners in Lunacy, strive to merit their good opinion. These Commissioners are always men of first class ability, high character, independence, and influence, who make searching examinations, and comment upon matters as they find them, without fear or favor, and are a power in the land that cannot be ignored nor disregarded. The vigilance exercised by the Boards of Commissioners in Great Britain, and the admirable organization above referred to, make their system superior to any that elsewhere exists, and should be adopted in all countries with centralized Governments and circumscribed bound- aries. The form of our Government, composed of thirty-seven States, each managing its OAvn local aifairs and having its own method of pro- viding for the insane (even if the vast extent of territorial limits did not forbid), would render it impossible for such a system to be adopted in the United States, while the small number of asylums in most of the . 187 States would not justify the establishment of Boards of State Commis- sioners. In Ireland and in some asylums on the continent, in addition to the resident officers, a Visiting Physician is appointed, who makes regular visits and consults with the Superintendent. The advantages claimed for this custom by the Directors are, that he forms a link between the asylum and the outer world; that the people have more frequent oppor- tunities to converse with one who is in constant communication with the patients within; that they can make more frequent inquiries about their afflicted friends; and that a physician engaged in general practice is better prepared to treat diseases of a purely physical charactei%]ian one who has devoted his time to the study and his energies to the treatment of insanity alone. An asylum should be open to the friends of patients at all times, except when such visits might be thought by the Superintendent to be injurious to the patient; and even in this case the desired information as to his condition might as properly be communicated by the Superin- tendent as by the Consulting Physician. We are well aware of the injurious etfects upon the j^atients of too much indiscriminate visiting by families or friends, but the proi:)riety of these visits must be left to the discretion of the Superintendent or other resident medical officer, and these should ever be accessible to all who desire to make legitimate inquiry as to the condition, prospects, and treatment of their friends. They should be the " connecting link " mentioned hj our friends in Ire- land. The last reason referred to is of still less weight. We cannot comj^rehend how any i^hysician who does not thoroughly understand the pathology and treatment of j^hysical diseases can successfully treat l^ersons who are insane, since we hold that all cases of mental derange- ment are in some way connected with or dependent upon physical disease. ATTENDANTS. To accomplish the best results, however, in addition to a skillful med- ical staff and proper hospitals it is all-important that intelligent, patient, and self-sacrificing attendants should be procured; those who will not- only be attentive to their duties, but are kind and cheerful in disposition, and who are j)ossessed of tact and discriminating judgment. For these reasons, liberal wages should be paid, and a system of rewards established for those who are faithful to their trust and con- tinue in the service. Eeasonable leave of absence should be given at regular intervals to admit of visits to family or friends, and comfortable quarters provided, that proper rest may be procured and contentment prevail. Seeing that their comforts, happiness, and interests are not overlooked, they will become interested in the duties assigned them and in the general welfare of the institution with which they are identified. In some asylums in this country and in Europe the wages of attend- ants are regularly increased for a given number of years, and in some of those in England and on the continent an annuity is allowed after a con- tinuous service of fifteen years. These are all good features that may Avell be considered in the organization of a hospital for the insane, as nothing is more detrimental to the harmonious management of an asy- lum than inefficient and constantly changing attendants. The best authorities agree that there should be at least one attendant for every ten patients; and we are thoroughly convinced that the number has not been placed too high, for though some classes of patients require less 188 than this proportion, others need more, and cannot be i)roperly treated or managed without them. We also observed in a few of the English asylums a man and wife acting as attendants in the wards for intirm men, and learned from the Superintendents w^ho had adopted the system that it gave great satisfac- tion to the patients, and always added to the neatness and cheerfulness of the wards. That the restraining influence of woman and the sooth- ing effects of her tender care were as ajDparent among the insane as among sane men; and if this be true, all will admit the propriety of the system. ^ For ourself, we would at anytime rather be nursed by one woman than ten men, and in this respect we probably agree with all classes of our fellow men. We have thus given a brief synopsis of the treatment of insanity and the management of insane persons, as practiced in some of the best asy- lums in most of the enlightened countries of the world; and it may fairly be presumed that the medical men who have charge of them are among the most able and learned of the profession to which they belong. From this we hoj^e the non-professional reader may be able to form some idea of the methods of general treatment ordinarily adopted in the usual, forms of insanity. No specific treatment can be laid down that would be applicable to the same class, as this must vary with the peculiarities of each case. But we desire to impress this important fact upon the public mind, that "insanity is a disease of the brain affect- ing the mind," and that an asjium is nothing more than a hospital adapted to the treatment of this peculiar malady; that patients commit- ted to its care will be skillfully treated and kindly nursed, and that if sent in the early stage of the disorder a large majority will be restored to health and to reason. CHAPTEE XIY. IXSAXITY IX GEXERAL. Increased attention to Insanity-— Growth of Hospitals in United States — Increase of Hos- pitals in United States — Increased Accommodation — Hospitals exhibit Insanitj^ — Non- residents — Should other States send their Insane to California— Insanity in other States — Results of Treatment— Curability of the Insane — Effects of Earl}' Tieatment — Good Hospitals necessary to Favorable Results — Results in our Asylum — Doubtful and Hope- less Cases — Econoni J' of Early Treatment — Probable Duration of Life in Chronic Cases —Increase of Patients in our Asylum— Causes tending to this Result — AVill the Chil- dren of Foreigners be as liable to Insanity as their Parents — Observations upon Phys- ical and Moi-al Causes producing Insanity — Intemperance a Leading Cause of Insanity —Duty of State relative to Asylums— Physicians not generally Informed on the Sub- ject of Insanity — Ps3'chology recommended to be Taught in Medical Schools — Effect of the Liberal and of the Economical Plan of Care and Treatment. INCREASED ATTENTION TO INSANITY. From the foregoing considerations, derived from various sources and authorities, setting forth the' history of insanity, the receptacles in wdiich the lunatics were kept, and the methods of treatment pursued towards them, we learn that it is only within a century that it dawned upon the world that lunacy Avas curable in any considerable degree. The doctrine, however, made very slow^ j^rogress and but few converts. Even in the beginning of this century, hospitals were built to give to the insane a more humane confinement than the prisons in which they 189 had been kept could afford; and it was not till within the recollection of many now living that the faith in the curability of the disease became general, even among professional men. Ileneo, hospitals began to be built for the twofold purpose of custody and curability, for beside the difficulty of managing and taking care of lumitics at home, it was found that comparatively few recovered. From this period hospitals began to be regarded as not only the best, but to most persons the only place for the insane. Hence an increasing denumd for their accommodation, and though their numbers have multiplied with astonishing rapidiiy, and have greatly increased in size, they are still inadequate for the recep- tion and accommodation of all who knock at their doors, and with j^iteous appeals seek admission for the treatment they afford and the benefits tliey are known to confer. At the beginning of this century there were only four recej^tacles for the insane in the United States, and only one of these, that at VYilliamsburg, Virginia, devoted exclusively to the treatment of insanity. Previous to its establishment, however, in seventeen hundred and seventy-three, a ward had ..been set apart for their accommodation in the Pennsylvania Hospital, and contained eigh- teen patients as early as seventeen hundred and fifty-two. Similar insti- tutions followed in seventeen hundred and ninety-seven — the Maryland Hospital, at Ealtimore, and the Bloomingdale Asylum, at New York. But little attention, however, had yet been paid to this subject, and, as will be seen from the following table, no other asylum was established till eighteen hundred and seventeen, when the Friends opened one at Frankford, near Philadelphia, followed the year after by the McLean Asylum, at Somerville, Massachusetts. GROWTH OF HOSPITALS IN UNITED STATES. Showing date of establishment of the following Asylums, loith a list of those in process of erection. ^ The following hospitals first received insane patients before the year eighteen hundred: Philadelphia, Penn., Hospital.. 1752 Williamsburg, Ya., established at that time 1773 Baltimore, Md 1797 Bloomingdale. K Y 1797 Asylums Established between 1800 and 1820. Frankford 1817 | McLean 1818 From 1820 to 1830, Bloomingdale 1821 Columbia, S. C 1822 Lexington, Ky 1824 Hartford, Conn 1824 Staunton, Ya 1828 From 1830 to 1840. Worcester, Mass 1833 Baltimore, Md 1834 Brattleboro, Yt 1837 Columbus, Ohio, destroyed by fire 1839 Boston, Mass 1839 190 From 1840 to 1850. Xashville, Tenn 1840 Augusta/Me 1840 Philadelphia, Penn., Hospital for Insane 1841 Concord, N. H 1842 Milledo-eville, Ga 1842 mica,^]S\ Y 1843 Insane Department of Phila- delphia Almshouse 1845 Flushing 1846 Providence, E. 1 1847 Indianapolis, Ind 1848 Jack son, La 1848 Trenton, X J 1849 From 1850 to 1860. Jacksonville, 111 1851 Fulton, :yj:o 1851 Harrisburg, Pa 1851 Stockton, Cal 1852 Lono'view, O ". 1853 Madison, Wis 1854 Taunton, Mass 1 854 Hopkinsville, Ivy 1854 Jackson, Miss 1855 Flatbush, L. 1 1855 Canandaigua, N. Y 1855 Dayton. 1855 AYashington, D. C 1855 Dixmont, Pa 1856 Paleigh, N. C 1856 Auburn, N. Y. .1858 St. Vincent, Mo 1858 ]S"orthampton, Mass 1858 Kalamazoo, Mich 1859 Troy, N. Y 1859 1859 New burgh From 1860 to 1870. Kellyville, Pa 1860 Tuscaloosa, Ala 1861 Mt. Pleasant, Iowa 1861 Blaekwell's Island, K Y 1861 Philadelphia City Asylum Immigrant, N. Y 1861 Austin, Texas 1861 St. Peter, Minn 1866 Portland, Or 1869 Weston, W.Ya 1866 Ossawatamie, Kansas 1866 Mt. Hope Petreat, Md 1867 Alameda Park, Cal 1867 Middletown, Conn 1868 St. Louis, Mo 1869 Ovid, N. Y 1869 From 1870. Howard Grove, Eichmond, Ya 1870. ASYLUMS IN PROCESS OF ERECTION. Anna, 111. Elgin, 111. Independence, Iowa. Catonsville, Md. Towsontown, Md. Ward's Island, N. Y. Poughkeepsie, N. Y. Columbus, O. Athens, O. Danville, Pa. Buffalo, N. Y. Middletown, N. Y. ESTABLISHMENT OF ASYLUMS IN THE BRITISH PROVINCES. Toronto 1841 Quebec 1848 St. John, K B 1848 Halifax, K S 1859 During the next ten years, eighteen hundred and tw^enty to eighteen hundred and thirty, the Bloomingdale Asylum was rebuilt, and four 191 others added to the list. During the next ten years a like number were built, but it was not till after eighteen hundred and forty, about the time the mind of the English public was directed to the abuses existing in the asylums of that country, and the heroic efforts of Doctor Ilill, Charlesworth, and Doctor Conolly to abolish the vile and cruel custom of confining nearly all patients sent to asylums with chains, handcuffs, and the straight jacket, had been crowned with success, that a general interest in the subject, and a corresponding impetus was given to the erection of asylums in this country. And as the result we see that during the next ten years eleven asylums were built. In the ten years that followed twenty-one were established; till to-day, as we see h'om. the table, no less than sixty-six asylums in perfect operation, accommo- dating seventeen thousand seven hundred and thirty-five patients, exist in the United States, to say nothing of twelve others in process of erec- tion. Some of these, in architectural elegance, completeness of design, convenience of arrangement, adaptation to the purposes for which they are intended, and beauty of location, are unsurpassed, if indeed they are equalled by any institutions in the world. SHOWING INCREASE OF HOSPITALS IN THE UNITED STATES. ? !z! !z! ^ > ^ s c < 2^ o "^ a =;-q B 2 3 2 o r 1 § o 1-^ o K 1 a i%^ YEAK. M S ? 2_ ^ Km a 3 O t. < O 3 Q f 1 1844 17,069,453 23,191,876 31,44^-S'^^^ *17,457 23 2,.561 ] 4 730 ] Lll 14.67 1850 15 610 28 L68 30 30 1860 23,999 37,382 50 1-8,500 ] 17,735 1 L70 35.42 1870 38,5 55,983 m >G8 47.44 It is not in our country alone, however, that this increased attention has been paid to the requirements of these unfortunate people. We have already pointed out this fact with regard to Germany, and we might do so for every country we have visited* — France, Italy, Belgium, Holland, Ireland, Scotland, and Canada — but will be satisfied with a table setting forth this progress in the United States and England, as specimens of the whole: * Including idiots, as these two classes were not separated until the census of eighteen hundred and fifty. t See Journal of Insanity, Yol. XYIII, p. 2. 192 Table, Showing the per cent of the Insane provided loith Hospital Accommodation in the United States and England at different periods. UNITED STATES. ENGLAND. H _g1 1 H 1 '^ 1 ^ 1 : =■? Propoi sano hosp mod o 2 ^"^-{L '^ 1 J3 S 2 <- "p^ '^- <-+ a ^ r« >i H-s* c s- ■D 3 3^ §-:§§ i s g2= o ^ /■ t^ ; F^as. o r M ; gay. o '-*5 L 2 : S In- with com- C -b ': 1 : 5 1850 15.610 4,730 30.30 1 1 1847 26,516 13,832 52.00 1860 23,999 8,500 35.42. 1857 33,791 21,344 63.00 1870 37,382 17,735 47.44 1867 1 49,082 31,914 67.00 INCREASED ACCOMMODATIONS. From the above table it will be seen that of the whole number of luna- tics in England in eighteen hundred and forty-seven, fifty-two of every hundred were provided with asylum accommodation; and in eighteen hundred and sixty-seven, sixty-seven per cent were j^i'ovided for. In eighteen hundred and fifty, the asylums in the United States accommo- dated only thirty per cent, and in eighteen hundred and seventy, forty- seven per cent. As rapidly as insanity has appeared to increase in these countries within the twenty years specified, this shows that the pro- visions made for the care, comfort, treatment, and restoration of its vic- tims have outstripped it by fifteen per cent in England, and in the United States by seventeen per cent. *As given in the reports of the Commissioners in Lunacy, including idiots. 193 H E! Under throe months.. Three to nx months- Six to tv,'clvo months. One to two j-ears Over two years Unknown Period under Treat- ment of Patients who PiGcovored. to 1 liSI§ ••a|i;mo^.[ o '-^ 1 : l^iox mmm ai«K j 00^ 1 5 ^mmi ••oierao^q; bi to tv:. Ci en --; j ^==gsrl 0I^IV[ 1^1 IP §r-p" H 2 S i Soo^^c. •■eiKwo,,[ i ^^33Sc. IB?ox 1^ o . Cl I-- p4- OC -I ^imi H 1 : ti;±^^S •aiBmoj s ie?ox 1 ^l^K 1 1: §iisll ■OlXilUQ^Cf CO •-'t-'r>iio iiiSIS IG^OX i s : CI o >-« o c; ^mz s.« i si i 1" i 8 : (-< o o 00 w •'OIUUIOjX ! I § l^w. 1 to -I go o £- lis gg 1 1 j ::• H 25 194 Although this table does not show that ninety, nor even eighty per cent have been restored in those cases treated within twelve months after the accession of the disease, it does show that of all the recoveries more than seventy-eight per cent were cured within that period, and that less than twenty-two per cent were cured where the treat- ment was commenced after the disease had existed more than one year. It is the experience of the Southern Lunatic Asylum, of Ohio, that only seventeen per cent get well where the treatment has been deferred for two years and over, and in some other asylums that only eight per cent recover under such circumstances. Let us add to the large percentage of recoveries of those treated in the early stages of this malady, the usual number of deaths occurring in asylums, and it is quite certain that a small proportion only would remain as chronic cases to be sup- ported by the State during the remainder of their days, which, as will presently appear, is about seventeen years. GOOD HOSPITALS NECESSARY TO FAVORABLE RESULTS. These results, of course, can only be expected, under the most favor- able circumstances, when all of the conveniences, comforts, and ap- pliances of the most approved hospitals and the best medical treatment are brought to bear upon the disease. It is hopelessly impossible for any amount of care and attention, any degree of medical skill that the power of man can supply, to overcome the disadvantages and drawbacks of a poorly constructed'^hospital, vrith its ill ventilated and overcrowded wards, where proper classification and necessary sanitary regulations cannot be fully carried out, such, unfortunately, as are some of the wards in our own asylum. But notwithstanding all of these drawbacks and disadvantages, the percentage of cures to admissions is surpassed by a few only in any country. RESULTS IN OUR ASYLUM. In eighteen hundred and seventy there were but few asylums in the United States that showed so large a percentage of recoveries, while the average in all is far below ours. This may be accounted for in a measure from the fact that a large majority of the patients are sent to our asylum at an early period after the accession of the disease, while it is yet within reach of the physician's skill; and none can doubt that the same amount of care, watchfulness, and skillful treatment in a better arranged and less crowded hospital would largely augment the per- centage of cures and lessen the percentage of deaths. They are sent to the asylum at an earl}^ period because it is not only kn"own that they will be received, but kindly and skillfully treated, and that the chances of recovery are greatly in their favor. The ver}^ character of the popu- lation, too, leads in some degree to this result. Many are without homes and families; but few are blessed with kind and steadfast friends to look after, watch, and nurse them when the evil day comes, and as there is no other place for them the}^ are sent to the asylum, fortunately for them, in time to be treated while there is yet hope of recovery. Lnder these circumstances a large number get well and are restored to society' and the State. But, as already stated, under more favorable conditions, with a hospital less crowded and better ventilated than man}^ of the wards in our asylum are, with facilities for proper classification, and where there are not so many for the medical officers to watch and pre- 195 « Hcribc for, a much larger .number would recover. Abundant evidence lias been adduced in another j^lace to show that large asylums are not considered the best in any point of view — neither for curative purposes nor on economical grounds; the latter being the only argument that has ever been brought forward to justify large establishmerits for the treat- ment of the insane. DOUBTFUL AND HOPELESS CASES. ^Ye are fully aware that many cases of insanity are incurable from the beginning. The very causes producing it places recovery bej^ond the bounds of probability, if not of possibility. Thus, when apoplexy, palsy, or consumption, epilepsy, or even masturbation is the cause pro- ducing mental alienation, there is but little hope, and all who have been deprived of treatment for more than two years liave forfeited their best chances of recovery and gone within the limits of chronic insanity, from which but few return with inental integrity. Fortunately, there is not a large proportion of these committed to our asylum, and had the oft repeated recommendations of our Superintendent been heeded by our legislators the accumulated numliers would not have reached such appalling proportions. SOME SELF-LIMITED, BUT MOST REQUIRE TREATMENT. While the cases we have been considering are of such a hopeless character, others appear to be self-limited, and if left to themselves or removed from exciting causes and disturbing influences will recover. But far the greater number require treatment, medical and moral. In most instances this can only be accomplished in hosj)itals. Men of dis- ordered mind, when they need a change of air or scene, cannot go to a hotel or 2:)rivate boarding house, or even to the house of a friend, w^hen they are so fortunate as to have the one or possess the means to com- mand the other. They require more caution, forbearance, and oversight than those who are mere invalids suffering from ordinary diseases. Many of them are suspicious, and annoying to those about them, and dangerous to themselves and others. They must therefore go to hos- pitals, places, or people devoted to their care, and jirepared to give them the needful attention and watchfulness. But hospitals are too expensive to be provided even by the rich, while a large majority are jDOor or entirely destitute. It is therefore the duty of the State to provide these hospitals, that all may receive the early treatment so essentially neces- sary to their restoration, not only that they may cease to be a burden upon the State, but that they may return to it and to society the benefits of their labor and usefulness. ECONOMY OF EARLY TREATMENT. To show more clearly the economy of early treatment, the •following table has been prepared and introduced. It shows that of all the cures efl'ected in the Worcester Hospital during a period of fifteen years, those treated during the first year of the attack required an average of five months and ten days; while all who recovered whose treatment com- menced after the expiration of one year, required to be treated ten months and ten days — showing conclusively that it cost the State only half as much to cure the earlier cases. And when it is considered that 196 more than three times as many of those treated in the early stages got well than of those treated at a later period, it will be seen that the advantages of the former are immense. Let US add to this the large proportion of those who never recover when treatment is postponed" and who consequently are added to the chronic list to be maintained through life, and some idea of the advan- tages of early treatment may be comprehended by the dullest mind. The table also shows that the average duration of treatment in those who died during this period was four years, three months, and twenty- two days. Table, Showing the duration of Insanity of those icho recovered in the Worcester Hos- pital from 1833 fo 1848. ^ i Duration of In- 1 ' sanity previ- ous to Admis- 2. sion. ^ { Total Duration Average Dura- of Insanity. tion. One year or less. 1,179 More than one year j 201 Unknown i 41 855 1,181 Total Time in Average Time Hospital. I in Hospital. 25 10 523 173 33 g u H g O Si o 3 «<3 S ^ ^ • 10 29 5 10 ] 7 2 10 9 10 Q 'H Duration of Insanity of those ivho Died. No. Cases. Years. Months. 1 j Days. Years. | Months. 1 i 1 Daj^s. 272 1,171 : 5 I i 29 4 3 22 Probable Duration of Life in the Incurable Insane. Males. Females. Average Duration of Life. Age. Insane. Sane. 20 21.31 28.66 24.99 36.32 30 • 20.64 26.33 23.46 34.54 40 17.65 21.53 19.59 23.46 50 13.53 17.67 15.60 19.59 60 11.91 12.51 12.21 15.60 Averae'e 16.74 • 29 years. 197 PROBABLE DURATION OF LIFE IN THE CHRONIC CASES. This tabic shows the probable duration of life in the incurable insane to be about seventeen years, while that of the sane of similar ages is twenty-nine years. This is doubtless as applicable to California as to Massachusetts and other countries, and will enable us to estimate with tolerable certainty the length of time we will have to support a large majority of those in our asylum at the present time, as w^ell as to appre- ciate the great difference between the cost of cure and the burden of maintenance. INCREASE OF PATIENTS IN OUR ASYLUM IN TEN YEARS. During the last ten years the average annual admissions in our asylum has been three hundred and fifty-eight, and the average annual increase sixty-seven. In eighteen hundred and sixty every fifteen hundred and thirty-two inhabitants of the State furnished one insane person from their numbers, and in eighteen hundred and seventy every nine hundred and sixty-four furnished a lunatic; or an average of one in twelve hundred and forty-eight for each year from eighteen hundred and sixty to eighteen hundred and seventy. This is an annual increase of twelve and six tenths per cent. Since the asylum was opened in eighteen hundred and fifty-one, there have been admitted five thou- sand six hundred and eighty-one patients, of whom forty- seven and sixty-eight one hundredths per cent were cured, nine and sixty-eight one hundredths per cent Avere discharged or removed uncured, twenty- three and forty-six one hundredths per cent died, and nineteen and eighteen one hundredths per cent remain, most of whom must be left as a charge upon the Treasury during the rest of their days. This is indeed a serious state of things, and behooves us seriously to look the facts in the face, endeavor to find the causes, and if possible devise means to arrest the progress of this fearful malady ere it gets beyond our power to control it. In eighteen hundred and forty-six, according to tables prepared by Doctor Campbell, of New South Wales, there was in that colony one insane person to eleven hundred and "fifteen inhabitants, at the next census one to four hundred, and in eighteen hundred and sixty- seven the proportion had risen to one in three hundred and eighty-seven. This more nearly approximates the increase in California than that in any other country; and as there are many points of resemblance be- tween the two, it will be well to note what observers there have said in regard to the subject. Doctor Norton Manning, who was apj^ointed by that Government to make an investigation similar to the one in w^hich w^e have been engaged in behalf of California, made to his Government one of the most able, comj^lete, and interesting reports that we have seen. A synopsis of this valuable document will be found in this report. On the increase of insanity he uses the following language: " This increase is to a great extent accounted for by the growth of a large mass of chronic insanity, which perhaps even yet has scarcely reached its limits. In the earlier emigrant days of the colony, notwith- standing, as has been said by an authority on this subject, that every emigrant ship brought one or two either insane or soon to become so, the vast mass of the population came in the prime of mental and bodily health. Their sick had been left behind in their fatherland. It would necessarily take some years for those becoming insane and remaining 198 incurable to grow old within the rcSjlum walls, and reach by accumula- tion to that number of old, chronic, and incurable cases with Avhich all other countries are burdened. It may be fairly estimated that, if the full extent of increase from this cause has not already been reached, it must soon be so, and that the number of removals by death will reach the proportionate number of yearly entries on this greater chronic list, and so a balance will be effected. Tpon the whole, then, though the con- temi^lation of this mass of suffering humanity must occasion deep sorrow, the Colony of New South "Wales has cause for a feeling of satisfaction on estimating the number of its lunatic population. With some causes in addition to those existing elsewhere, the ratio of its insane to popu- lation is not now markedly above that in most of those countries where the numbers have been ascertained with even tolerable exactness. These special causes will, it is to be expected, gradually disappear; the convict element will become fainter; the excitements of life will diminish; it may fairly be hoped that the use of poisonous alcoholic compounds, also,^ will decrease with the increase in quantity and diminution in price of wholesome colonial wine and beer, as well as under the better moral feelings of the future. AYith the diminution of these, the special causes of insanity in older countries may make their appearance; but it can scarcely be supposed that the ratio of insanity will rise higher than at present. A ratio equal to this, though the burden is great, is borne cheerfully by States not more wealthy than New South Wales, both in the Old World and the New." In speaking of the causes, he says: "First, the earlier population came under exceptional circumstances — the relations of crime and in- sanity are very intimate; second, the ups and downs of early colonial life, the influence of the gold diggings; third, the lonely life of the shepherd, alternating with long periods of debauchery; fourth, the abuse of ardent sj^irits in a warm climate. On the other hand, the ab- sence of grinding poverty and the salubrity of the climate tend to dimin- ish mental disease." With the exception of the convict element in the population of New South Wales, what is here said is as applicable to this State as to that colony. CAUSES TENDING TO THIS RESULT. These causes have acted as powerfully here as there, and Dr. Manning might have added, with equal propriety, other causes that act quite as potently in producing this malady as any of the foregoing: First — The total change in the habits of life. Second — The absence of those salutary restraints imposed by the pres- ence of well organized society. Third— T\\Q separation from family and friends; and, above all, the strange and mysterious influence of being away from home in a foreign land. In many cases with no mother nor sister near to watch over and care for them in sickness; no wife by to soothe their sorrows with cheer- fulness and smiles, and by tender sympathy drive away the gloom of despondency, and with heroic fortitude encourage them after failure in some cherished project again to buckle on the armor of determination and fight for success. All of these causes, and doubtless many others, must be opemting, with various degrees of activity and power, on the foreign born citizens of our country and State — in what degree in the different States and Ter- ritories will be seen in the table next hereafter; Avhile the succeeding 199 table has been prepared to show the relation of California in this respect to the whole country; the next to show the rate of increase of the popu- lation, the insane, and the idiotic, from the birth of the State to ei.i»:hteen hundred and seventy; the next to show the percentages of tliese ele- ments; the next table shows that more than sixty -two per cent of the population of California in eighteen hundred and seventy Avere born in the United States, while less than thirty-six per cent of the insane were supplied from their number — being a proportion of one to eight hundred and fifty-eight. The proportion of citizens of foreign birth is thirty- seven' and forty-five one hundredths per cent, and the proportion of the insane from their numbers sixty-four and thirty-nine one hundredths per cent, or one' to two hundred and eighty-four; thus showing that per- sons of foreign birth are three times as susceptible to the invasions of insanity as those Avho were born in the United States. By reference to the table next hereafter, it will be seen that the proportion of the foreign element is much greater in California than in any other State, and there- fore we need not be surprised at the greater increase of insanity in our midst. And as the same causes, oj^erating under similar circumstances, will always produce the same results, we may reasonably expect the growth of lunacy to continue till these conditions are changed. 200 .^ S "S" Z/1 ^! ^' S ^ r>^ "•<> ^ '^^ ■:; o «J ■l-) •^-j ^ ^ >^ Proportion of Foreign Insane to Illative Insane Proportion of Foreign Insane to Foreign Population Proportion of ^Xative Insane to Xative Population Proportion of total In- sane to total Popu- lation Foreign Inss Native Ins Total Insane. Foreign Population. Native Population... I Total Population. O H I— I < m *cc o " rH rH ^' c4 C-l* CS (N* (£ -^ I o o o opoooooooooooooc '*! ui t-- 1- .-I ec W O CO O -*i 'ti O Lt 'M <:C O O Ci 1^ LC 00 1-1 CO Tt( o u- ooocoooooo o o o o o o Ti<:0r^\O(x>^(Zil■^■L'rtl-^cJ0d•<-iO^o^y-f -o O C:C -+I rH 1- O O C-l C/2 1- LC IC 1-1 ?C l-t ^ 1- C^C r-1 1-1 i-H CO Ci CM lO O CO t^ in; ClCOin!.-(CO(NLOOTt0 rt^ rH CO C5 CO I— I ! 1^ 1 t^CO COCO r-(0 O C^ CN CO CO tH 00 lO i-l 0< CO QOt-^l-^iOCOQOOOr-IOCiCOI^COOO COCD0 1^000CiCO'MOC0 CO CO Cq 00 CO CO Ci T^ Ol O Ol CO iC O <-l lO Tt< CO CO rH O 'tl CO Ol C5 rH lO 1^ rH (M Crs tH CO OH^ 0-1 Ol 1^ 'tM CO^CO CO (M (M^ -* C3 CO^l^ TJH^i-H OO CO CO Ci CM 1- r-i_CO GO C-T r-T co~ co^ co" r-T < C-1 O iC CO O !M C^ csor^^i^cO'Hi-Hcocoocoor-ico'+icoTHiJO-^.-icri »— li-HCSOiCOrflOrH'+liOtMCiOCOOl-'— lrHiOlf:iCiCr:i C0OC0i-IC^l-00C0C5C0O'*IC0 01C0OC0'*. -+I Ci l-^ -— ( of C>fGO~C£rof r-TlO cTrH l-«^kO 00"Q6~C^lO~C^^■^ lOCOCO(MCM(M'*r-IOa)l^COC5CM.-IOlOrHCO(M-^iO ■* I— I ""^ OO !■- I— I CO C5 CO O CO lO Ol 1-- OJ CC CO CM rfl O oa)-*-5 f^ r- ■"^ ^ : Q ryj O ^ O ry;. ;i ~ O 26 O IJ ® 1.'-' L"" 1>» Li»- o -^UH ^ hij h3 5i < P2 ?:j W ^ ^ Deatlis on Nunxber Treated Deaths Recoveries. Numbers Resident. Admissions Numbers Resident.. i-IOf-ICOO^K^GO—l'-t lo ci Ci o t- o o >o Tt< c:> CO 1^ -;t< 1^ O lO lO CO 1^ lo c-i 00 1^ I O O CO CO CO CO C5 X O CO 01 O O CO O CO r-l ,-1 i.o cq CO CO o oi CO o 1^ 0-1 LO (M O Ci iH -tI CO l CO o C^H !^ ' ' CO be =s S H M-e 206 Average weekly cost for ; g i 2^ 9^ o g g g i^ i^ =c g oc ; Pauper Patients ^ • ^^ ^^ ^^^ ^ !Ii Z^ c^ r-i rn ,h t^ ' Death? on dum- ber Treated... i^ ^ w ci^ ^ X X or O i-t X Ci Deaths on Ad- missions Cares on dum- ber Treated... X c^i -1 1^ 1^ i^ c; r: X *-c i^ " Cures on Admis- I sions -f irt ur; ir: c-: 'M T-^ cq CO CO Qo 1^ o „ , c:r:xc^7'^">c-ti:o^i-n^ia5o Xo. Treated ^1^^ ^-:,^.'^.H'-v^.R,« £^'-^S. Xo. Died. Xo. Cured Xo. Admitted. Xo. Resident., Ci^5-i 1^ X ci o t^ X 1-':^ L-: c-T ci c! Xo. Asylums visited from which Reports were ob- ' ?: "" ^^ "~^ ^^ ^ tained o n " L- -7 X Cft O tl O I^ --i' O to -* '>C 1^ r-l 1^ CO C5 ^ CO 1^ CO CO' O CM -H Ci -J- -^ X -^ -1 O C5 O Ol CO O CM 1^ Ol s=l- CO ^11 o o p^ ;i : : : : : rt I :^ : • • : :^ ! S'^ ci ci s o 5 "^ V. 207 ^ ^ o* ;i -.> -t"^ o <^ &s ^^ ^^s o C^iS^ *;:r^ '^ 'TS ^ si '~~^ '^S "^^ ^-^ s:> ?i • - ^ ^§ 02 H ^ ^(S <1 « ^ ^ H hJ .^ » rr> M "^ V < S ^ ft H -^ N o ^ H f— 1 ^•s ^ S '^ P S^"" P^^ 5^ 5S 5i> ^ g l< ^ •^ ^ S'Ei^ ^ c:- s 1 GQ ■ Proportion of the Foi-- eign Insane to the Native Insane 1 to 1,261 1 to 496 1 to 233 i Proportion of the For- eign Insane to the Foreign Population- Proportion of the Na- tive Insane to the Native Population... Proportion of the Total Insane to the Total Population T— 1 CO o l^'n7'Oir''n Tii^?inp T— T r-t Native Insane t CO T— < co'^ CM Total Insane (M CO co^ CO i Foreign Population CO lO CO la Native Population 00 GO ^. (M OO i Total Population 38,555,983 o .& 'o rH O o .2 o 0^ 208 Table, Showing the Population and N^imbers of Insane and Idiots in 1850. 1860, and 1870, icith the proportion per one thousand of Insane and Idiots to Pop\dati ^r4- = .-f-r^ r+r4. a M h-( ion ioti 2§" "^ §' i°§ hj3 TEAKS. f" O : 5" Bio 0-. igs. |2> : : » i ^ 9*^ i gfei IS^ 1— • : o : o P : o : o : crq" • 2.' tive Pop ft : H : '^ : ^ : c M • HH i ? i ^ : o i ?r : 't^ 1850 87 6 1 85.71 14.28 16.66 1 to 11,723 I860. 1870 70 17 80.45 19.54 24.28 Ito 5,005 1 to 12,343 CALIFORNIA NO EXCEPTION. This shows that Califorjiia is not an exception to the general rule; for while the insane have increased within her borders more raj^idly than in any other country during the same period of time, it must not be overlooked that her citizens have not only been exposed to a greater number of causes by which this malady is developed, but that she is perhaps the only State in the Union, if not the only Government in the world, that has never refused admission to a single person who has sought to enter her asylum, notwithstanding it is a well known fact that among those received there have been and still are many citizens of other countries, who have not claimed California as a home, but who have come here hoping to better their fortunes and enrich themselves at her expense, and then return to their own homes and country; but failing to realize their dreams of wealth, give way to despondency, break do^u in health, or enter upon a course of reckless dissipation that leads them to insanity and to our as^dum, either to be cured by our treatment or maintained through life at the expense of the State. How far this evil may be remedied or ameliorated by judicious legis- lation, is a problem that we are not ])repared to solve; but surely it would seem that some preference should be given, some difference made, between this class and our own citizens; but if we must keep them, it does seem that the comity of nations should prompt them to reimburse us for the expenditure made. The doctrine has been proclaimed, and repeatedly confirmed by the superintendents of American institutions for the insane, and by those who have paid any attention to the subject the world over, "that it is the duty of every State to provide for its own insane." In this sentiment we heartily concur, and earnestly urge its adoption by our noble State, without equivocatioAi or reservation. But the other is a very different question; nor do we now remember any instance of a declaration to the effect that it is the duty of one Govern- 27 210 ment to defray the charity expense of another. In other countries, and even in different divisions of the same country, persons of this class are often transferred to the communities to which they belong. The ques^ tion is at least worthy of consideration. SHOULD OTHER STATES SEND THEIR INSANE TO CALIFORNIA ? In this connection another question, though intrinsically different, is nevertheless analagous to some extent, and deserves notice, not so much on account of its present importance as its future results. It is to inquire how far a sister State may be justified in establishing her institutions within the borders of another? Is it just or proper for one State to send all of her insane in the limits of another, even though she may pay the expense of care and maintenance? It is fair to presume that when they are considered sufficiently recovered to require no further medical treat- ment that they will not be returned to the State from which they come, but turned loose upon the community where the asylum is located. Should a speedy relapse follow their discharge, they would of course be sent back to the asylum in which they had been treated; but when a few months have elapsed they would be committed under our laws, and sent to our asylum, and thus become an additional charge upon the State. We all know that a large majority of the insane are from that class who are not able to pay, and that persons who have been afflicted with this malady are more liable to be attacked than an equal number who have not been thus affected. The burden of all these will inevitably fall upon us. For these reasons it would seem j^roper for the State to express an opinion on this subject. WILL THE CHILDREN OF FOREIGNERS BE AS LIABLE TO INSANITY AS THEIR PARENTS? We do not know and have no means of ascertaining how far this liability extends to the children Avho are born of parents of foreign birth, but venture the opinion that it will be only in a small degree. If this hypothesis be correct, it must necessarily follow that the proportion of insane will diminish very nearly in proportion to the increase of the native over the foreign element in the mass of the people. This will of course become more and more rapid with each successive generation; for while the one is supplied with emigration from the other States and all the children born in the State, regardless of the nativity of their parents, the other must be increased by immigration alone. PHYSICAL AND MORAL CAUSES PRODUCING INSANITY. Having considered some, perhaps most, of the prominent causes of insanity, r,o far as it is affected in a social or political point of view, it may be expected that we will enter upon the consideration of the more prominent of the physical and moral causes leading to this malady; but we scarcely consider it necessary to do more than allude to some of them. We have already given a table showing a few of the more prom- inent assigned causes in all the countries visited during the prosecution of our mission, but without special comment. By referring to that table it will be seen that they very generally agree with those operating in our State, but differing in degree and intensity in some countries. Thus, hereditary predisposition and intemperance are assigned as prominent. 211 causes in all countries, and in Prussia and the German States they arc the only causes of prominence. In Italy we find pellagra (disease of the skin jieculiar to that country) added to the other two, while in most other countries we find added to the list ill health, pecuniary and domes- tic troubles, and spermatorrhoea, including- self-abuse, etc. In our State, we see by the report of Dr. Shurtleff, just published, that masturbation still holds its place at the head of the list of assigned causes, though wo agree with him that it is high time for '' Committing Boards " to be more careful in their conclusions with regard to this particular cause. Many patients who have been received at the asylum with this charge of self- pollution resting upon them, have, after weeks or months of watchful- ness, been proved to be entirely free from such evil practices. That it is a cause in some cases we have every reason to believe; and further than this, when it is the cause its victims rarely recover; they seem to be doomed from the very beginning. There are Other cases in which it is merely a symptom of a diseased brain, or some of its appendages — an efi'ect, not a cause. These cases are more hopeful when treated in time. Indeed, many men of prominence with whom we have met on the conti- nent, in Great Britain, and in the United States, believe that it is almost universally the effect of insanity, and not its cause, INTEMPERANCE A LEADING CAUSE OF INSANITY. AYith regard to intemperance the case is altogether different. It seems to be the bane of all countries, and claims its victims in every civilized nation and under every form of government. It is the common enemy of mankind, the destroyer of domestic happiness, the copartner of every crime, from petit larceny to murder. It is the father of pov- erty, the creator of debauchery, and the principal working tool of the Devil. No man is bold enough to defend it, and yet it is tolerated by all classes of society. It finds its way alike to the house of the rich and the home of the poor. It is a boon companion at the festive board of the aristocrat, and the poorly provided table of the cottager. It has caused more heartaches, produced more tears, engendered more sorrows, starved more babies, and led to more insanity than any other agent in existence — if not more than all others combined. We are strongly inclined to the opinion that directly or remotely it is more potent in pro- ducing these results than all other causes. It is the sin of civilization that it has found out manifold ways of extracting alcohol from natural substances, so that it is offered in tempting forms and accessible abundance to the weak and incautious, who would not instinctively seek it, as well as those whose appetites demand it. If, then, civilization is responsible for the introduction of this destructive element among mankind, it is certainly its duty and it should be compelled to provide for its victims. How to arrest its progress, if, indeed, it be possible, we must leave to the Aviser heads of the legislator and the statesman; and he who can solve the problem will be the wisest of men, and a greater benefactor to his fellow men than has ever yet appeared among them. We have thus briefly considered this last, as it is the most prolific, among the causes that have given us so large a number of persons de- prived of their reason; who crowd the wards of our asylum till there is scarce sleeping room or breathing space for the numbers they contain, to say nothing o^ the accumulations that must take place ere additional accommodations can be provided for their reception. The question must 212 be determined as to what is best to be done in performing our duty and relieving their distress. DUTY OF THE STATE RELATIVE TO ASYLUMS. The State must elect whether it will build other hospitals, and thereby pay the cost of cure, or support all those for life who become incurable from our failure to provide sufficient and suitable accommodation for their early treatment — whether to make the effort to regain a productive citizen, or support a non-jDroducer for seventeen years. We must either provide hosj^itals for the reception of every citizen who may become insane within our borders and under our jurisdiction, or surrender this noble charity to degeneracy and decay. As already stated, this has been done. Xo other State, so far as our knowledge extends, has done so much; a fact that is doubtless a source of gratification and pride to every man who claims California as a home. We regret, however, that candor compels us to say that some of the wards of the male department of our asylum are wretched in the extreme, and would be disgraceful if not taken in connection with the fact, that the number of applicants have been so far beyond expectation as to render it next to impossible to provide accommodations for them all. Eeceived they have been, but during the last two years at the discomfort of many who were thus compelled to give up a portion of the space, already too small, that had been allotted to them. Doctor Shurtlefi* in his rejDort just published, has truly said "the rooms are not only full, but crowded.'' In addition to this, two hundred and twenty-seven patients are sleeping on beds nightly prepared for them in the halls. The number in excess of the accommo- dations has grown to j^i'oportions too vast to admit of being properly provided for by the erection of cheap detached wards. The institution, in point of numbers, is already double the size of the average of similar ^institutions in the other States. With the completion of the new build- ing, therefore, all further expansion should be discontinued. This done, aside from the cost of support, every other effort and exjDenditure in behalf of the asylum at Stockton should be directed to repairs, the con- struction of inclosures, and the improvement of the grounds, etc. " If this view be concurred in, the only alternative left is for the State to make further provision elsewhere. The character, extent, and loca- tion of such provisions are questions upon which every possible light should be shed. In character, nothing less than a first class hospital, with all the modern improvements and appliances for the curative treat- ment of such as may be benefited thereby, and for the proper care of all classes of the insane, will meet the general approval of the most experi- enced;" and, we may add, the expectations of the people of the State. Doctor Shurtlefi' continues: "If additional provision for the care of the insane be made at some other place than Stockton, the question of locality is one of no less importance than those of character and extent. Topo- graphical and climatic fitness are matters of such primary importance that they will not be likely to be overlooked. Convenience to the great- est number who will be likely to need its benefits is a very important consideration, in many resjoects, in the location of a hospital for the insane. Officers' fees and travelling expenses, which dej^end on the distance, and are a public charge generally, the difficulty and even danger in conveying the insane, and the visits of friends, are all matters which should be considered and have their influence in arriving at conclusions. In this connection it should be borne in mind that of the five hundred 213 and twenty-three patients admitted during the last year, about three hundred came from the counties bordering on the Bay of San Francisco, and that two hundred and twenty-two — more than two fifths of the whole — came from the City of San Francisco alone. This proportion is no exception to those of several years past." These suggestions, emanating from Doctor ShurtleflP, a close and accu- rate observer, with a correct judgment, and a larger experience than any man on this coast, should not be lightly passed over nor disregarded. They are the results of serious reflection on an important subject with which he has been intimately identified for years, and his conclusions can be maintained with manifold reasons of the strongest character. With a single exception, that of size of hospital, they entirely accord with the views expressed to your Excellency soon after the completion of our visit to nearly one hundred and fifty asylums, wherein we had noted with especial interest, among other things, and observed with more than ordinary scrutiny and careful consideration, the effects of overcrowded wards and courtyards, the location and sites of asylums, their nearness to and distance from some city or important town, the character of scenery, quantity and quality of land, the sources of water supply, the. facilities of communication, the convenience and cheap- ness with which fuel, supplies of all kinds, and building material could be obtained, as well as all other matters in any way connected with the construction, ventilation, warming, organization, etc., of hospitals for the insane, and which are treated more or less at length under, their proper heads; and above all, to the importance of locating these institu- tions in the midst of those most likely to require the benefits they confer. In many of the States inadequate j)rovisions are made for treating the insane, followed by the most disastrous results. Large numbers who desired to gain admittance have been turned away and told, " not in w^ords, but in acts that are more powerful than words," to wait till some- body gets well or dies, and then after the disease has fastened itself upon your brain so firmly that it cannot be removed, when all hope of recovery has passed, you may come in, and in your turn keep some other equally unfortunate person out till he, too, becomes hopelessly incurable, lost to himself, lost to his family, and lost to the State — yet a burden to the public treasury so long as he shall live. No one who is at all familiar with the nature of this malady wiU deny these facts; every person who has written or sjDoken upon the subject during this generation has asserted them till they have ceased to be denied. Last year, as we learned from personal information obtained from some of the superintendents of asylums, and from the published reports of others, the following facts existed: At Staunton, Yirginia, of two hundred and eight applicants, only fifty-nine were admitted; rejected In the ^Michigan Asylum, rejected In the Asylum in North Carolina, rejected 149 155 150 Dr. Everts, of the Indiana Asylum, informed us that not more than one third could be accommodated in that State, and as three hundred and fourteen were admitted, it follows that six hundred and twenty- 214 eight must have been rejected. Yes, strange as it may appear, this young and vigorous State, the sixth in point of population in the Ameri- can Union, and, as we are informed, the only one free from the burden of debt; with low taxation and abundant resources; with one mil- lion six hundred and eighty thousand six hundred and thirty-seven inhabitants, has turned away from her asylum two thirds of her own unfortunate children who have sought relief at her hands. Who could have believed it possible in this enlightened age that any community of American citizens could be guilty of such cruel practices and such par- simonious conduct as this? And yet the fact is as stated. Doctor Hills, of West Yirginia, rej^orts from sixty to seventy-five in the jails of that young State; and the State Board of Charities report thirteen hundred and twenty-six in the poorhouses of Xew York. The States of Maine. Iowa, Illinois, and others are no better oif. Unlike Indiana, however, most of these States are making noble efforts to remedy this evil, because they recognize the obligation and the duty, and feel no disposition to shirk the responsibility nor to avoid the expense. Indeed, we would like to know what right a State has to make such unjust distinctions between its citizens; to say to one, ''Come and be healed," and to another, "Go hence; you shall not partake of the benefits you have helped to create."' To one, "You shall come in, be fed, clothed, housed, and nursed; our physician shall minister to your diseased frame and release your troubled mind from its agonizing thraldom.*' To the other, " We have no house to shelter your head from the. pitiless storms; no food to appease your hunger; no raiment to cover your nakedness or add to your comforts; no nurses to watch over you in sickness and minister to your necessities. For you there is no sympathy; you must take care of yourself, pay your own expenses, and provide for your necessities as best you can. For you 'there is no balm in Gilead, there is no physician there.' " What is the result of this policy? Nine tenths of these people have no means of consequence. AVhile in the possession of health, and en- dowed with that greatest of earthly blessings, their reason, they were able to support themselves, and, it may be, lay up a little something for their families; and if this had not already been exhausted by ill health or other cause that has led them gradually to insanity, this calamity has deprived them of the chief part if not all of their capital — the ability to work. The family who have hitherto depended upon these resources must now look to other means and other persons for supj^ort. They cannot afford to send this afliicted member of the family to a private asylum — it may be in another and distant State — nor can they aftbrd to keep him at home and have him properly treated. They are out of rela- tion with social and domestic life, and should go away. It is often the case the very presence of family and home is a source of annoyance and vexation that they cannot endure. THE INSANE CANNOT BE KEPT AND CURED AT HOME. They are a great burden to the family, and disturb its quiet and its peace; and if retained, as is not unfrequently the case, drag all down to poverty and misery with themselves. Besides, they require to be man- aged with fitting wisdom, that few can give, however willingly and cheerfully disposed, and with that amount of patience and forbearance not often found outside of asylum wails. Indeed, many cannot be man- aged at home on account of a disposition to wander, to be violent, or 215 destructive. Some cannot be persuaded to submit to the needful reme- dies for their proper treatment, even when this could be obtained. PHYSICIANS NOT GENERALLY INFORMED ON THIS SUBJECT. Unfortunately, but few of the medical men in general practice in our country or any other have made themselves familiar with this myste- rious disease and its proper treatment. The reason of this is obvious — it is a branch not taught in any of our medical schools as a part of the course. It is not a part of the curriculum in the colleges of any coun- try; hence, proficiency in this branch is not a " sine qua non " for a medi- cal diploma. They are sometimes called upon to pronounce as to the sanity of some unfortunate person and to decide whether or not he is a proper subject to be sent to an insane asylum. In the majority of cases they have never seen the patient before and never see him afterwards. Again : when some criminal puts in the plea of insanity to save his neck or his reputation, the physician is called upon to testify in the case, and, as often happens, is mortified to find that the lawyer knows more about the subject than himself. The one has "read himself up" for the occa- sion, and can ask more questions than an author of medical jurispru- dence could answer satisfactorily to the Judge or jury; while the doctor, perhaps, has given the subject but little thought or attention. We trust this condition of things will soon be changed, as more attention is being paid to the subject both in this country and Europe. PSYCHOLOGY RECOMMENDED TO BE TAUGHT IN THE MEDICAL SCHOOLS. The Superintendents of many of the asylums in Italy, Austria, Ger- many, France, and England are giving courses of lectures on the science of psychology, and the Association of Medical Superintendents of Ameri- can Institutions for the Insane has strongly recommended its adoption as a branch in the medical schools of this country. When this sugges- tion has been carried out a wonderful advance will have been made m the right direction and many persons saved from the calamity of chronic insanity by having their diseases early detected and properly treated. But let us return to our patient who has not been able to procure proper treatment in an asylum in time to obtain even a chance of recovery while relief was possible, and we find him at last admitted to a place made vacant by the death of some patient who has paid his last debt to the "grim tyrant," or the recovery of some other who, more fortunate than himself, was received in proper time. But, alas! it is too late for him. His case has become chronic, perhaps incurable, and he is doomed to eke out a wretched existence— a burden to himself and to the State during the remainder of his days. EFFECTS OF LIBERAL AND ECONOMICAL PLAN OF CARE OR TREATMENT. The following extracts from the report of the Worcester, Massachu- setts, Hospital for eighteen hundred and sixty-two, will show the effect of the two policies on the use of hospitals, and cure of patients: " The natural effect of the liberal and the economical policies of offer- ing the hospitals to the use of the people, is manifest in the different ratios of the patients sent in the early and in the later stages of their malady to the hospitals in Massachusetts and Ohio. 216 " In Ohio seventy-three and one seventh per cent, and in Massachu- setts sixly-four and one eighth per cent of the patients in their State hospitals were sent in the first year after they were attacked. "As a necessary consequence, those States which sent the largest pro- jDortion in the early and curable stage received back the largest propor- tion in health and power of usefulness, and had the smallest proportion left in confirmed immovable lunacy to be supported for life by their estates or the public treasuries. '-In the three jDublic hosj^itals of Ohio, fifty-four and fifty-nine one hundredths per cent of all that were sent to them were restored, and forty -three and forty one hundredths per cent remained insane for life. In Massachusetts, forty-four and five one hundredths per cent were restored, and fifty-five and ninty-five one hundredths per cent remained a life burden on the people. '• It must be remembered in this connection that the reports of admis- sion into the hospitals of Massachusetts include both the foreign or State j)aupers who are admitted free, and the American paying j^atients who are charged more than the cost for their support. If distinction were made in the reports, and it were shown -how many of each of those two classes were sent in the several stages of their disorder, it would, without doubt, be found that a much larger proportion than thirty-five and two one hundredths per cent of the native patients were kept out of the hospital until their disease become more difficult and even impossible to be removed. ''It is not necessary to go abroad to find the connection between the terms of admission and support, and tlie readiness with which people avail themselves of hospital privilege for the ctire or custody of their insane friends. We have proof of this in our own daily experience. Our Irish patients go free and stay without cost, and they are sent early and have the best opportunities of restoration. The Americans go at their own cost, and pay all and more than all of the expense of their support, and consequently a large proportion are kept away, some for months and years, as long as their friends can endure or take care of them, and many for life, because their friends lack courage or money to take due advantage of the means of restoration so largely provided in the State. In eighteen hundred and fifty-nine, ninty-seven and five tenths per cent of all the foreign and only fifty-eight per cent of the native lunatics then living in the State had been sent to some hospital. " The proportion of patients restored out of all admitted to the hos- pitals, is twenty-three per cent greater in Ohio than in Massachussetts. ^ow, no one will suppose that the hospitals of Ohio are managed with more skill than those of this State. But the difterence in the result of their labors is due to the diff'erence in the proportion of patients sent i]i the curable stages of their disorder. "Looking U2:)on this matter merely as a question of political economy, in its bearing upon the remote as well as present means and prosperity of the State, it is jjlain that there are important advantages on the side of the free and open system of managing these public charitable institu- tions. They send back to society a larger proportion of workers, pro- ducers, self-su2:>porters, and contributors to the public treasury, and leave a smaller proportion of the useless and burdensome class. Inasmuch as they have a better or more available material to work upon, they pro- duce a more successful result, and convert a larger ^^roportion of costly men and women into profitable members of the body politic. The Wor- 217 cester and Taunton Hospitals have received eight thousand four hundred and ninety, and restored three thousand seven hundred and forty to health. If these could have beeii sent at as early a stage of their dis- ease, and as large a j^roportion restored as in Ohio, then twenty-three per cent, or eight hundred and sixty would have been added to the use- ful and self-sustaining citizens sent back to the Avorld, and as many taken from the class that has been or must be supported and cared for through life. " It must be further considered that it costs no more to administer these institutions on the free principles of Ohio than on the economical principles of Massachusetts. Both there and here provisions, groceries, clothing, labor, and salaries would be the same under either system. The only difference is in the way in which the cost is assessed upon the peoi^le. Here it is imposed upon those who receive the immediate per- sonal advantage, many of whom are the least able to bear it, and always at a period when they are the weakest, and any burden is distressing. In the other case, this cost of rescuing the peoi)le from permanent insanity, like the cost of schools, roads. Government, justice, and police, is assessed upon the whole community, in the proportion that each one is able to pay; and in both cases it comes out of the aggregate propert}^ and income of the Commonwealth." Any attempt to save money by failing to i^rovide for the insane is indeed poor economy, and worse philanthropy. Let us, therefore, adhere firmly to the policy we have so wisely inaugurated, and which has placed us in the front ranks among the States of the Union and the nations of the world, and build asylums for all of our people wdio may be so unfor- tunate as to require their use and need their healing influence. In this connection, we deem it of some imj^ortance to introduce the following- extract from a Message from Mr. Seward (when Governor of New York) to the Legislature: " I cheerfully exj^ress my approbation of the undertaking. Nations are seldom impoverished by their charities. The number of the insane in this State is not exaggerated, and I am not prepared to say that any erection less extensive would afford the space, light, tranquility, and cheerfulness indispensable to this interesting department of the healing- art. Among all His blessings, none call so loudly for gratitude to God as the preservation of our reason. Of all the inequalities in the social condition, there is none so affecting as its privation. He sees fit to cast upon our benevolent care those whom He visits with that fearful afflic- tion; it would be alike unfeeling and ungrateful to withhold it. Let then this noble charity be carried forward, with what measure of munificence it remains with you to determine." Like sentiments have been 2^1'oclainied by the intelligent executive officers of most of the States of the Union, our own included, but unfor- tunately in too many instances legislators are frightened, or driven from their duty by the " criticisms of that class of public benefactors who make capital from their sympathy with our overtaxed j^eople," and no appropriation is made. Fortunately, at this time, however, no such objection can be urged. The Democratic party has seen the necessity of additional accommodations for the insane, and it only remains for the 28 218 Eepublican party, ever the friend of progress, to carry forward the sug- gestion and complete the work. It is a noble charity, and no excuses should be needed to justify any appropriation that may be required; under judicious expenditure, to meet the necessities of the case; nor should the subject of politics weigh a feather in the balance of any man's mind in his considerations or his actions upon the subject. It did not do so two years ago, when the investigation was ordered to be made of which this report is the result, and there is no reason why it should do so now. Our labors have been performed with the hope that suffer- ing humanity would be the gainer by the results, and if this shall prove to be the case we will have reaped the most earnest desire of our heart, and a reward beyond price. Hence we have ventured the suggestion that the one party and the other will be equally responsible for any appropriations that may be made and equally entitled to the honors of so beneficent a deed. "We can lose nothing by our charities in this direction.'' Let us not only provide ample accommodations for all of our insane, but let us so locate our asylums that they will be easily accessible to the greatest number of those who will probably require their use, and then with an enlightened public opinion all will be encouraged to seek the benefits of early treatment and speedy restoration. Comparatively a few only will be left as permanent charges to the State. A much greater number will be restored to usefulness and labor. The State will be the gainer by the operation, and humanity will smile at the triumph of wise legislation and judicious treatment over the most appalling disease with which the human race has ever been afflicted. CHAPTEE XY. INSANE ASYLUMS — ECONOMY OP PROVIDING AMPLE CURATIVE ACCOMMODA- TIONS. Before entering upon the discussion of the plan of building best adapted to the care and treatment of the insane, we desire to call the attention of the business man, the financier, and the taxpayer, as well as the legislator, to the economy of restoration and the amount saved the State by the cures already eflected in our asylum. A similar showing was made by Doctor Jarvis a few years since to the State of Massachusetts, and to him we are indebted for the idea and most of the facts set forth in this article. We have applied them to California, and in making the argument must necessarily touch upon some matters already considered. It is a proposition universally admit- ted that it is the first interest of every State to preserve itself, to develop its own strength, and to sustain it to the fullest degree. The strength and wealth of the State are the aggregate of the wealth and power of the individuals who compose it. If a member of the community is strong, his strength increases the power of the State. If he be a pro- ducer and create riches, this adds so much to the common wealth. If, on the contrary, he become sick or weak and lose his power of pro* duction, his loss of personal power takes so much from the general power. His failure to add to his own estate is so much loss to the gen- / 219 era! prosperity. If, more than this, he loses power to provide for his own wants, his support becomes a charge upon property that he or others have created, or are at the time creating. If his own means o*v those of his fiimily are insufftcient for this purpose, then the public treasury must and does assume the burden. Whether this support of a dependent citizen comes from his own or others' estate, or the general treasury, it inevitably comes from the property of the commonwealth, either that which has already been paid in form of taxes to the Government, or that which, in the hands of indi- viduals, is the basis of taxation. In either case the body politic is the loser to the extent of the cost of supporting the disabled person. In all cases this cost is first chargeable to the estate of the one sup- ported. If that be wanting, then his natural friends should pay it; and if they fail, the expense falls on the town or State. This last resort is sure, for the town or State is the responsible indorser of every sick, disabled, or insane person within its borders, to restore him to health or support him through life. There is in every community, especially in such as have had a genera- tion of existence, a large body of the insane who are a constant burden on its resources. In Massachusetts, in eighteen hundred and fifty-five, there was one insane person in every four hundred and twenty-seven living. In other States and counties there are estimated to be from one in four or five hundred to one in a thousand. A part of these are the recent cases, that have a hope of restoration; a larger part consists of old and iucurable cases that have been submitted to the healing pro- cesses without avail, or have been neglected until the day of relief was past. The burden of sui^porting these is constant, unavoidable, and very great. It is the first claim of humanity, as well as the duty and interest of the body politic, to keep the numbers of these as small as possible, by healing all that can be healed in the curable stage of their disorder, and allowing none but those whose disease is primarily incurable to fall into chronic and permanent lunacy. Insanity, although it suspends the power of production, self care, and self support, is not in itself very dangerous to life. A man becoming insane at twenty, if not restored, has a prospect of living, on an aver- age, twenty-one years in lunacy; but if restored his prospect is for thirty -nine years in health. The average of life for a permanent lunatic is twenty years, and for a sane man thirty-two years, from their thirty- first year; and these prospects are respectively seventeen and twenty- six years from their forty-first year. Persons taken with lunacy at these ages have, then, the doubtful prospect of living twenty-one, twenty, or seventeen years, more or less, according to the age when attacked, in dependence, a burden on their own or the public estate, if not restored; or of being cured and of living thirty-nine, thirty-two, or twenty-six years, more or less, in health, ability to take care of themselves, and acid to the strength and wealth of the community. Insanity is one of the most removable of grave diseases, if the proper measures are used in its early stages, as they are in cases of fever, dys- entery, etc. The experience of hospitals shows that from seventy to ninety per cent may be thus restored to health. The average time required for restoration in hospitals varies from five and a half to seven, and even eight months. But the average of the whole, especially those taken early, does not exceed six months. The average cost of supporting patients in the California asylum for 220 the four last years was thirteen dollars and eighty-five cents ($13 85) a month. This is eighty-three dollars send ten cents (383 10) for six months, and one hundred and sixty-six dollars and twenty cents (8166 20) for a year. The actual cost of restoration necessarily includes the whole expense of the experiment. It is impossible to determine in advance who may be restored — who must remain uninfluenced by reme- dial measures. These must then be used for the whole; some may be restored in a few weeks, others in all periods from this to two years and more — averaging six months to all; but none must be given ujd as incur- able until they have had at least two years trial of the means of cure. The cure of the seventy-five per cent thus necessarily involves the necessity of two years board and care of the other twenty-five per cent. This must also be included in the list of cases and assessed upon the seventy-five who are restored. The cost of seventy-five cured, for six months is The cost of twenty-five not cured, for two years each is. Total §623 25 831 00 $1,454 25 Assessing this equally upon them makes the average cost of curing the insane in California to be one hundred and ninety-three dollars and eighty-six cents. It must be remembered that this cost of supporting seventy-five for six months and twenty-five for two years in a hosj^ital — fourteen hun- dred and fifty -four dollars — for the restoration of the seventy-five is not so much additional expense thrown upon the people. These hundred persons were already insane, helpless, powerless, unable to support them- selves. They were already thrown upon the community and its indi- vidual members, who were responsible for their maintenance whether they were sent to the hospital or not; whether any attempt was or was not made to restore them. The Commonwealth collectively, or its estates separately, must pay the cost of their board, care, and guar- dianship. It is questionable whether out of a hospital, a private house, or other abodes, at home or with strangers, these patients could obtain food for less than it cost the asylum for them — three dollars and twenty cents (83 20) a week. If not, then the curative measures in the asylum caused no additional expense to the State or its people, except the cost of the establishment itself The interest on the capital; the wear and depreciation of the buildings; the cost of repairs; the insurance, and the taxes which would other■s^'ise have been paid to the public treasury on this amount of property, are j)roperly chargeable to the cost of curing the insane, and nothing more. Here, on the contrary, must be weighed the gain to the community from the restoration of the insane to health. The annual earnings of a man over and above the expense of his living may be considered as an annuity, or so much annually contributed to the commonwealth. Accord- ing to the best Euroj^ean calculations of these values — the earnings and expenditures — the present worth of the excess of the former over the latter, for an unskilled laborer at twenty-five, is twelve hundred and eight dollars (81,208). That is, such a laborer at that age is worth so 221 much to the body politic. This is the English, and very nearly the German valuation. In this country wages are higher and earnings more, and of course the annuity and its valuation are greater. This, too, is the estimated value of an unskilled laborer, who earns the lowest wages. The value of the skilled mechanic, the merchant, the profes- sional man, whose earnings are larger, must be very much greater. It is at least safe, then, to assume the European calculation of twelve hun- dred and eight dollars as the average worth of men of all conditions and occuj^ations in California who may become insane at the age of twenty-five. This is lost by his lifelong insanity. Add to this the cost of his sup- 2)ort, at least as great as that charged in the asylum — thirteen dollars and eighty-five cents a month, one hundred and sixty-six dollars and eighty-five cents a year, for an average of twenty-one years: Making for each uncured patient a total expenditure for sup- port Add the loss of the value as a producer Showing a total loss of. 83,490 83 1,208 00 ^4,698 So much is gained by restoring an insane laborer twenty-five years old. It would have been less if he had been older, with a prospect of fewer years before him; it would have been more if he were a mechanic or man of business, with power to earn more if in health. The cost, only one hundred and ninety -three dollars, is neutralized b}^ the consid- eration that it would have been as great for his support if no attempt had been made to restore him. During the twenty years of the operation of the California Asylum, five thousand six hundred and eighty-one lunatics were admitted. Of these two thousand seven hundred and nine, or forty-seven and sixty- eight one hundredths per cent, were restored. This relieved the State and people of the burden of supporting these through life in their dis- ease. Taking the numbers in their several ages, their average life, if not cured, would have been twelve years each; or the whole sum of their insane lives would have been thirty-two thousand five hundred and eight years, and their life support, at one hundred and sixty-six dollars a year, would have been four million four hundred and ninety-seven thousand and four dollars, which was saved for the State. Their average valua- tion, considered merely as laborers earning the lowest wages, when restored to health and productive power, was eleven hundred and two dollars eaph; making a total of two million seven hundred and sixty- three thousand and eighteen dollars which was regained. Both of these make a total of seven million two hundred and sixty thousand and twenty-two dollars which has been gained to the State and people by the restoration of these twenty-seven hundred and nine insane joersons in the asylum at Stockton. This calculation presuj^poses that all these were original cases, and ' then no readmission; but although the record does not state it, there must have been here, as elsewhere, periodical cases, some being more than once and some several times attacked, sent to the hospital, and there cured. These of course had shorter periods of health than this average, and their years should be deducted. This would reduce the sum, but would still leave a very great amount lost by uncured insanity. CHAPTEE XYI. INSANE ASYLUMS— PLAN BEST ADAPTED TO CAPvE AND TREATMENT OP THE INSANE. General Observations— Cottage System — Parm Asj'lums — Close Asylums — Pavilion Plan. GENERAL OBSERVATIONS. From the foregoing considerations, then, there will be no question that the State has a very great interest in the cure of the insane. Yet there may be a question as to the best manner of effecting it. ^Ye have already shown why they cannot be properl}' cared for, treated, and cured in private houses, at least in California; and also why we prefer moderately small to very large asylums. As it is not probable, however, that an appropriation could be obtained for two asylums with a capacity for two hundred or two hundred and fifty patients each, in accordance with our views, we trust that none for more than four hundred patients will ever be built. In saying this, we have not forgotten the suggestion made, that the north Aving of the Female Asylum at Stockton should be finished. It must be remembered that the removal of two or three most uncomforable, unsightly, and objectionable wards was at the same time deemed a most desirable end to be accomplished, so soon as a new asylum could be erected; and furthermore, that having already con- structed a centre building (always the most expensive part of any asylum), together with kitchen, chapel, engine house, boilers for heating, and otlier necessary comcomitants for an asylum to accommodate a given number, this improvement can be made at less cost than at any other place, to say nothing of the pressing demands for the room it would more speedily supply than in any other way. We have an asylum at Stockton which in some respects is not what it should be; and we desire to see these evils remedied. The improvements suggested would accom- plish this object; nor do we consider this improvement at all incon- sistent with the views expressed Vvdth regard to the size of asylums; this would only be the completion of a hospital already begun, and is simply a matter of necessity; whereas a different system may and should prevail in the construction of all asylums to be hereafter built. THE COTTAGE SYSTEM. We have already had occasion to speak of the different kinds of as}'- lums in vogue in several countries, in our sketch of the report of Doctor Manning. AVhat he had to say of the cottage system, as practiced at the Colony of Gheel, and the modification of that system, as adopted to some extent in Scotland, entirely agrees with the conclusions at which we ourselves had arrived: that however well adapted the system may be for old and thickly settled communities, it is '• altogether inapplicable to a new or sparsely settled country."' Much has been written upon this system by some of the foremost men of the Continent, of Great 223 Britain, and the United States; some advocating its adoption in their respective countries, while others condemn it in no mild terms as being- unworthy even of respectful consideration. Esquirol, Guislain, Morcau, Parigot, Bulckens, DeMundy, Duval, Roller, Droste, Halliday, Ste- vens^ Brown, Sibbald, Earle, Gait, Tyler, Bemis, and a host of others, have visited the famous old Colony at Gheel, and given the results of their exj^eriences and observations to the world. Manning came next, and we followed in the wake of all, and had set forth our views at some length, not only with regard to Gheel, but also the Scotch system, of keeping a certain class of lunatics in private dwellings. But as we have no Gheel in America, and no such population as that among whom lunatics are kept in Scotland, it is unnecessary to print them. Nine tenths of the patients kept at Gheel in Belgium, and at Kennoway in Scotland, we believe, are better satisfied than they would be in hospitals; but it would be impossible to induce our people to take charge of such patients for the cost of keeping them in our asylums. Hence, it would be useless to discuss the cottage system with a view to its adoption in our country. We refer the curious, and those who may desire to learn more of the history of Gheel and the cottage system, to the interesting essays of Dr. John Sibbald, of Scotland, who has written the most satisfactory account of them with which we have met, and which may be found in the Jour- nal of Mental Science for April, 1861; to that of Dr. Henry Stevens, pub- lished in the same journal for April, 1858; and to that of Dr. Merrick Bemis, to be found in the Worcester Hospital Report for 1869 — all of which, with numerous other articles upon this and kindred subjects, are among the books which now adorn the shelves of the medical depart- ment of our State Library. Indeed, with Winslow's Psychological Jour- 7ial, the Journal of Mental Science, and the American Journal of Insanity in our library, to say nothing of the large number of other works that keep these company, it would be difficult, if not impossible, to touch upon any subject relating to insanity that cannot be found ably and thoroughly discussed in some of them. Had a tithe of the information which they contain been known by our people, or could they have been accessible to all, then, indeed, would this report have been a useless undertaking; but should it only serve to direct public attention to them, and to the subjects of which they treat, will much good have been accomplished. For a thorough understanding of the Scotch system, we refer the reader to the interesting work of A. Mitchell, M. D., " On the Insane in Private Dwellings." The plans that we have selected for publication in this report are chosen from a large list, and are believed to be specimens of the best in the world. There are many others equally good, and in giving prefer- ence to these we by no means intend or desire to disparage others. All cannot be published, and to insert an account of so many asylums, such as w^e find in our notes, would constitute a volume, and must therefore be omitted, however agreeable it would be to us to give our experience of each institution visited. We must therefore be content with descri])- tions of a few only, as samples of the best, and again refer the reader to the journals and other works on the subject already alluded to, for any additional information that may be desired. FARM ASYLUMS. The farm asylum — of which Clermont, Avith its colony of Fitzjames, 224 iibout fifty miles from Paris, is perhaps the best specimen — possesses some advantages, in an economical point of view, but would scarcely be applicable in this country. It consists of an asylum proper, situated in the Town of Clermont,. and is intended for all patients who cannot safely be trusted with the liberty given the patients at the colonies. One of these, called '• Fitzjames," is near the town, and is approached by a wide avenue, finely shaded by trees. Here there are several buildings appro- priated to the use of the different classes of patients, who pay from thirty francs a month to three hundred. Those paying the higher prices have rooms to themselves, a larger number of attendants, better diet, greater facilities for amusements and entertainments, and are not required to work. Of this class there are very few. Those who arc charged thirty francs a month are paid for by the Department from which they came, and are expected to do such labor as may be required of them. The colonies contain one thousand acres of land, and the men Avork upon the farm, in the garden, and in the shops, while the women sew, do housework, wash, iron, etc. The buildings occupied by the men Avho work on the farm are two stories high, and consist of day rooms on the first and dormitories on the second floor. They eat in a common dining room, and no classification is attempted. The flouring mill, barns, stables,' piggeries, sheep sheds, fowl yards, butcher shop, etc., are near these buildings, and are all kept in the most complete order. They are under the management of M. Jules Labitte, one of the three brothers to whom the establishment belongs, while Doctor Gustave Labitte is the Physician in Chief of the entire establishment, having an assistant in each department. The buildings for the laundry women are located a few hundred yards distant from the last mentioned, and are of similar character. The laundry itself is so constructed that a little river or stream, the Beronelle, traverses its entire length, and presents much the appearance of an ordinary mining flume, on either side of which the women stand and wash, after the custom of washerwomen throughout France. The other colony, '• Yilliers," is about four miles from Cler- mont, and is conducted on the same principle as that at Fitzjames. Of the fourteen hundred and seven patients at this establishment three hundred and fifty are at Fitzjames, one hundred at Yilliers, and the rest at the establishment in Clermont. It is said to be a most profitable enterprise to its proprietors, and we were impressed with the idea that the patients were required to do more Avork than seemed compatible with their physical and mental condition; and the fact that nineteen and seven tenths per cent of recoveries and forty-five and two tenths per .cent of deaths to numbers admitted were reported for eighteen hundred and seventy is an additional reason to confirm this conclusion. Ordi- narily the labor of five lunatics is supposed to be equal to that of one person in perfect health, while many cannot labor for medical reasons; but here a much larger proportion are required to work, and more work required of them. Hence we conclude that this system could not be successfully carried out in our country and among our people. CLOSE ASYLUMS. This brings us to the consideration of the close asylums, including the corridor, house, and pavilion plans. All of these have their j^eculiar advantages and their strenuous advocates. Plans of each will be found in Appendix F of this report. All have notes of reference explanatory of the design, and some have been described. 225 The asj^lnms in the United States have nearly all been constructed on the corridor j^lan, with centre building and wings. The plans of the proposed asj'luni at the City of Boston, the Pennsylvania Hospital for the Insane, and the Michigan State Asylum, though dittering in some respects, are all of this character, and are considered among the best in this country, and we think are not surpassed by any in the world. None of them could be built for less than one thousand six hundred dollars per patient, .and the Pennsylvania Hospital for the Insane — known as the Xew Kirkbride Asylum — with all of its appurtenances would probably cost two thousand dollars per patient. It is a corj^orate institution, intended for and patronized by the wealthy or independent classes, who pay from fifteen to thirty-five dollars per week, which enables it to fur- iiish many advantages, comforts, and luxuries, and sources of amuse- ment and diversion, that would be be^'ond the reach of institutions intended mostly for the accommodation of indigent or non-paying patients. Its ca2)acity is for two hundred and fifty patients. The Michigan Asylum is a State institution and was designed for three hundred, and cost four hundred thousand dollars; while the plan of the Boston Asylum was also intended for three hundred patients, and was estimated to cost four hundred and ninety-eight thousand five hundred and three dollars. ^ Descrii:)tions of these asylums will be found elsewhere in this report, and it is only necessary to say here that all of them might be built in such manner as materially to lessen the cost and yet retain the general design of the structures and convenience of internal arrangement. We will mention a few of the most prominent. The expensive apparatus- necessary to forced ventilation might in our climate be dispensed with. It is rarely cold enough in California at any season to render it neces- sary to close all the windows of a hospital, while in Summer the pre- vailing winds afford an abundance of fresh pure air. The Boston plan is fifty-six feet Avide, but we believe that thirty-six feet would be suffi- cient for all necessary purposes. This would give twelve feet for the corridors and ten feet in the clear for rooms — eight by ten being large enough for single rooms. Large dormitories we do not and never did fancy; one in each w^ard for five patients would be sufficient for most classes of patients, and anything larger than this might easily be pro- vided by having one wing on either side so constructed as to have the rooms only on one side the corridor, after the almost universal system of Great Britain and the continent, as may be seen in the plans of Apper- dix F, figures six, ten, twelve, and thirteen — the connection of the wings to the centre building and to each other giving an abundance of light and air. The bay windows and open sitting rooms dt the end of each corridor are beautiful and most desirable features of this plan., and worthy of imitation in any new structure for the treatment of the insane. In the Michigan Asylum the ceilings are fourteen and sixteen feet, which we think unnecessarily high. Eleven or twelve feet would seem sufficiently high for the wards and fourteen feet for the centre buildings thus saving another item of expense. In addition to these items that may be saved without sacrifice to comfort or design, it must be remem- bered that in our temperate climate not more than half the quantity of piping and other apparatus for heating the building will be required as- are absolutely necessary in the colder regions in which they are located. A most desirable feature in the Michigan Asylum, too, is the infirmary 29 226 for those who are suffering from physical diseases, whether connected or not with their mental condition. There is one for either sex, and it is often a great comfort — sometimes the last — for these sufferers to have a dear relation or friend with them in such times of trouble, sickness, and need. With the features that we have pointed out in these two asylums, and with the wards for excited patients as they exist at the Pennsylvania Hospital for the Insane, combined to make one asylum for two hundred and fifty patients, supplemented with detached buildings, as elsewhere suggested, for one hundred and fifty more — such for instance as are being adopted in most of the first class asylums of Great Britain and the continent,"^ we are confident that no better plan could be found in the world — whether for the purposes of cure or comfort; nor can we see any reason why such an establishment may not be as cheaply con- structed as any other. In making these suggestions and giving preference to the asylums of our own country for the main building, we do not wish our kind and enlightened friends " on the other side of the water " to conclude that we have failed to appreciate the admirable features of their institutions. It is true that we have expressed our disapprobation of their congre- gated System — the common dining halls and large associated dormi- tories — because we believe them to be incompatible with proper classifi- cation. It seems to work remarkably well in that country, where classes in society are distinctly divided, and where most of the poor are kept in asylums prepared especiall}^ for their reception and accommodation, while the independent patients are sent to hospitals suitable to their social condition, either in separate institutions or separate buildings under the same superintendence. There, too, the people are more accus- tomed to regard those vested with authority its superior beings, entitled to command, and an inherent right to be obeyed. These ideas are rather strengthened than otherwise by insanity, and are carried into the asylum with them, causing them to submit, without complaint, to the rules of the asjdum and to the orders of those placed over them. The English and continental asylums, therefore, may be well adapted to the treatment of patients thus constituted, but in our country the case is very different. Every man considers himself as good as any other, and generally claims that he has as much right to command as those whom he may have assisted to place in authority. Our people have, in their condition of health, an exalted idea of liberty, which is only perverted, perhaps, by insanity. To be thwarted in their designs or restrained in their actions is conceived to be a trespass upon their inalienable rights, a curtailment of their freedom, which tends to excite and exasperate them. We cannot bring them together with impunity in such numbers as they are in other countries; besides, in this country, wnth lew excep- tions, the asylums receive alike the rich and poor, the cultivated and the ignorant, the refined and the vulgar, who can only be separated by our corridor system, where each ward constitutes its own little family, with their own sitting and dining room, parlor, bath room, etc., which would be impossible with the English system. We are well aware of the advantages of the day roonis of the European asylums, which enables the dormitories to be vacated during the day and thorougly aired and ventilated. Hospital odors are less liable to accumulate, to become offensive and unhealthy, and it may be that the patients learn the better to control their feelings and their actions by being brought in daily con- tact with a larger number of their fellows. Indeed, we are disposed to 227 think that a modification of our system in this respect might he made with advantage — that there might be one hirge dining hall, not for all, or for three fourths, but for one fourth of the j^atients in our asylums, where the men and women who were well enough and who desired to do so might meet and take their meals together. There is at present but one asylum in the United States (at Staunton, Virginia) where this is done, and we were assured by Doctor Stribbling that it was considered a great privilege by the patients, who used extraordinary efforts at self- control that they might not be deprived of it. Seventy-five out of three hundred and fiftj^ patients were deemed proper subjects to be thus brought together, regardless of sex. PAVILION PLAN. The Virginia Asylum of which we have spoken, more nearly than any other in this country resembles the pavilion system now so generally adopted in all the new asylums that we saw in France, either as recently comj^leted, or in process of construction, and of which the asylum at Auxerre (see plan Apj). F, fig. 14), may be considered a specimen. The plan recommended by the German Superintendents, and adopted by the authorities for the new asylum at Berlin, is also on the pavilion system. Many of the more recently constructed asylums in Great Britain have also adoj^ted this plan to some extent, by suj^plementing the main hos- pital with detached blocks, such as we have suggested for a new asylum in California. The asylums at Brookwood, Brentwood, Glamorgan, Warwick, Glou- cester, Colney Hatch, Wakefield, The Friends' Eetreat, Newcastle on Tyne, Cumberland and Westmoreland, Morningside, Cupar and Fife, Glasgow, the Eichmond Asylum near Dublin, Cork, Quartre Mare, and the new Asylum San Yon at Eouen, Saint Ann at Paris, and many others, are either entirely on the pavilion plan, or are supplemented with detached blocks or cottages. The McLean Asylum at Somervillle near Boston, is another sample in our country; though we think the detached blocks in this asj'lum too small to be used profitably or with advantage in a State institution, as none should be built so small as to require less than two or three attendants, that at least one may be ever present in each ward where patients are kept.* In addition to this feature as taken from the European s^^stem, we cannot too strongly urge the adoption of another, which to our mind is the most charming of them all — we allude to the extensive'and beautiful pleasure grounds by which the asylums of the Old World, and especially those of Great Britain, are surrounded. The bright and beautiful lawns, * For further information on the pavilion system, see Journal of Mental Scieyice, for January, eighteen liundred and sixty-seven, an interesting paper by Doctor Lockhart Kohertson, read at the annual meeting of the- Medico-Psychological Association, held in Edinburgh, July thirty-iirst, eighteen hundred and sixty-six. Doctor Eobertson is the able and well known editor of the Journal of Mental Science, ex-President of the Medico- Psychological Association, and for many years Superintendent of the Asylum at Hay- Avard's Heath. The opinions of the distinguished psychologists of Germany will be of peculiar interest to all who can read German. Indeed, the shelves of our library now contain the opinions and suggestions of the ablest and most experienced men who have written on this subject, not only with regard to asylums, and hospital construction, but upon all subjects in any way related to or connected with insanity. The admirable Keports of the Commissioners in Lunacy for England and Wales, Scot- land and Ireland, are full of information and interest. We again invite especial attention to these works. 228 handsomely laid out and planted with' shade trees, shrubs, and flowers, impress the beholder with satistaction and delight, and must produce on the mind of the patient and his friends a feeling of pleasurable relief, that the bare walls of a hospital, however beatifui in design and elegant in structure, can never aftbrd. It may be well in this connection to state that no asylum in Great Britain or upon the continent is built more than three stories, and in our opinion none should ever be in this or any other country. The centre building may be three, the first wings should be two, and the last but one. If covered with a French roof, the attic may be utilized either for dormitories for quiet chronic cases or for such other purposes as may be desired. No ward should be built without a wide stairway of iron or stone at either end, that free escaj^e in case of fire may always be made. For the want of this necessary precaution many patients have lost their lives in the numerous fires that have occurred in the last lew years in our own country. We ourselves have had two fires at Stockton within the last fifteen months, but fortunately not in the asylum wards. In the first instance the laundry was burned, and in the last an outhouse used as a hayshed, and had the wind been from a different direction the wooden cottages in which patients are kept might have been consumed with the rest. We learn, too, that the private asylum of Doctor Chipley, near Lex- ington, Kentucky, has just been destroyed by fire. This admonishes us that we cannot guard with too much care against the danger and rava- ges of this fearful and devouring element. Our views with regard to the kitchen, chapel, laundry, airing courts, etc., are in -entire accord with those expressed by Doctor Manning, as previously noticed in this report. It is therefore unnecessary to sjDeak of them here. With an asylum of this kind, carefully watched during its construc- tion that the endless details from a closet to a doorlock may neither be overlooked nor neglected, and so located as to possess all the advantages we have pointed out, the most favorable results may reasonably be expected. And if in addition to this we could only have a small asylum for the treatment of such of our citizens as may desire better accommo- dations than the State can afford to give, our system would be as near perfect as i\\\j in the world. There would then be no jealousies on the part of the poor, and no complaints on the part of those who pay. The rich would have such accommodations as they desired and were disposed to pay for at rion-speculative rates, and the poor would be as comfort- ably provided for as in any other country. As already stated, we can scarcely hope that provision will be made for the execution of this last suggestion at the present time. The others are absolute necessities, requiring immediate action or disastrous consequences, while this is only a desirable end devoutly to be wished for but not of absolute and press- ing necessity. CONCLUDING EEMAEKS. In our introductorj' chapter we expressed our obligations to all who had contributed to our stock of information or facilitated our investiga- tions. We feel that something more than this is due from us, not only for courtesies extended in consequence of our position as an officer of the State of California, but for individual acts of kindness. 229 The Commissioners in Lunacy for England, and Wales, and especially Mr. "VVilkes, in addition to valiuible contributions for the State Library, gave us information that greatly aided us in our investigations. Doctor Mandsley, the President of the Medico-Psychological Association of Great Britain, kindly invited us to attend the annual meeting of that body, and thereby brought us in contact with a large number of the most able and learned men in the country, and enabled us to exchange views with and obtain the experience of such men as Doctor Bucknill, the accomplished author and Chancery Commissioner in Lunacy; Doctor Lockhart Eobertson, also a Chancery Commissioner, and editor of the Journal of Mental Science; Doctor Tuke, the Secretar}^ of the Associa- tion," and Doctors Arlidge, Blandford, Sankey, Hood, Monroe, Clouston, and others whose writings are familiar to the profession in this country, and a large number of Superintendents of asylums from all parts of the kingdom. Many of these we had seen, or afterwards visited at the asy- lums under their management. Doctor Brushfield, at Brookwood; Doctor Begley, at Han well; Doctor Marshall, at Colne}^ Hatch; Doctor Phys Williams, at Bethlem; Doctor S. W. D. Williams, at Hay ward's Heath; and that noble trio of genial gentlemen, Doctors Yellovvlees, Clouston, and Eogers, who reminded us so forcibly of three young Superintendents in our own country — Doctors Eodman of Hopkinsville, Kentucky, Cal- lender of Tennessee, and Walker of Boston. Doctor Forbes Winslow did not attend the meeting of the Association, but we had the pleasure of seeing him at his owm home. He is a man of such versatility of genius and such a fund of knowledge that to be in his presence is to imbibe information. We are under many obligations to him. A host of othei;s were equally kind and hospitable, and to whom we gratefully tender our thanks. In Scotland, our obligations are due to Sir James Coxe, one of the Commissioners in Lunacy, and President of the Medico-Psychological Association, for courteous attention and valuable reports. To Doctor Sibbald, Deputy Commissioner in Lunacy, for devoting an entire day in visiting with us the Colony of Kennoway, where insane persons are kept in private dwellings, after the fashion of Gheel in Belgium; and also for a copy of his essay on the cottage system. Doctor Mitchell's treatise on the insane in private dwellings, and other documents. To Doctor David Skae, the celebrated Superintendent of the Morningside Asylum, for giving us the results of his treatment in some cases of insanity, together with the effects of certain remedies elsewhere consid- ered; and to the SuiDerintendents of all the asjdums visited, for similar favors. Doctor Stew^art, of the Belfast Asylum in Heland; Doctor Lalor, of the Pichmond Asylum at Dublin; Doctor Murphy, at Killarney; Doctor Nugent, one of the Inspectors of Asylums, and other gentlemen engaged in the specialty, also placed us under obligations. In France, to Doctor Blanche of Passy; Doctor Lasegue, President of the Medico-Psychological Society of France; Doctor Motet, the Secre- tary of the Society; and to Doctors Falret, Dumesniel, Morel, Foville, Dagonet, Labitte, Arthaud, Carrier, Bruno, Hildebrand, and Ceilleux, we are indebted for many courtesies and all the information we were able to obtain of the condition and treatment of the insane in that country. In Italy, Doctor Fidele, of Pome, not only accompanied us to the asy- lum but to the numerous hospitals and other charitable institutions of the Imperial City, and gave us letters to several of the prominent phy- sicians throughout the kingdom. Professor Neri of Perugia, whose 230 asylum overlooks the broad Valley of the Tiber, gave us the only general statistics that we were able to obtain in Italy, and was not only well versed in psychological medicine, but was imparting his information to a class of twenty medical students who w-ere studying the diseases of the brain that affect the mind. Doctor Cardini, of Florence; Doctor Fouscarti, of Bologna; Doctor Biffi, of Milan; Doctor Salerio, of Venice; Doctor Bramanti, of Padua, and, indeed, all the physicians and Superin- tendents whose asylums we visited cheerfully opened to us the doors of their institutions and aided us in every possible manner in the prosecu- tion of our inquiries. Nor can we say less than this of the Superintendents of the asylums in Bavaria, in Austria, in Prussia, and in other German States, in Swit- zerland, in Holland, and in Belgium. Nor can we forget the services rendered us in our visits to the German and Swiss asylums by our young and accomplished countryman, Doctor B. B. Kent of Boston, w^ho accompanied us to a dozen institutions, and from his knowledge of medicine and of the German language added greatly to the interest and pleasure of our investigations and our travels. To the United States Ministers, Mr. Marsh, in Italy; Mr. Jay, in Aus- tria; Mr. Bancroft, in Prussia; Mr. Washburne, in France; Mr. Jones, in Belgium; and the acting representative of our Government in England, Mr. Moran ; and to the Consuls of the United States, wherever and when- ever called upon, we are indebted for favors of various kinds. They were ever ready to assist us in our investigations in every j^ossible way. It is scarcely necessary for us to say more of the Superintendents in the United States than that they are all intelligent men, devoted to the cause of humanity, and equal in every respect to those of any» other country. Among them are men of worldwide reputation, such as Doc- tors Pay, Jarvis, Earle, Gray, Butler, Kirkbride, Stribbling, Nichols, Bancroft, Pead, Buttolph, Gundry, Curvv^en, and Workman and others are well known in our own country. To all of these gentlemen we owe and herewith tender our thanks; and to our friend, Doctor Edward Jarvis, who not only gave us free access to his splendid library, but who ren- dered us invaluable assistance in various ways. He is a faithful worker in the harness of humanity, and deserves the gratitude of the human race. There are many others to whom we are indebted for counsel, assistance, and good cheer, and to these, with the rest, we offer our thanks. If there is any one man in this State who more than any other is entitled to the gratitude of the unfortunate class of our citizens in whose behalf we have pleaded, that man is our friend Colonel E. J. Lewis of Tehama, who, sympathizing with their misfortunes and com- prehending their sad condition, introduced the bill authorizing this inquiry in order that public attention might be directed to their necessi- ties and relief. APPENDICES [Appendix A.] UNITED STATES. Table 1. Shoioing admissions^ with principal causes of Insanity, and per cent of each to admissions, in twenty-six Asylums, in eighteen hundred and sixty-nine. In five thousand three hundred and fourteen admissions, the principal causes of insanity were: 111 health and physical disease Spermatorrhoea Domestic trou bles Intemperance , Eeligious excitement Epilepsy Per cent of each on number of admissions: 111 health Spermatorrhoea Domestic troubles Intemperance Eeligious excitement Epilepsy 1486 708 544 544. 527 357 27.96 13.32 10.23 10.23 9.91 6.71 Showing, also, the Deaths, loith pri?icipcd causes, and per cent of each to total Deaths, in twenty-seven Asylums, in eighteen hundred and sixty-nine. In one thousand and seven deaths, the principal causes of death were: Disease of the lungs Paralysis Exhaustion, from different causes Mania Marasmus Old age Per cent of each on number of deaths: Disease of lungs Paralysis Exhaustion > Mania Marasmus Old aire 162 111 107 51 40 38 16.08 11.02 10.62 5.06 3.97 3.77 30 234 S3 ^^ 'ex •BS 8 C,_j >i>5>i 3 s ^.:^ *^ o o o en p^.p^ Cost of Maintenance. ]Sr umber of Patients. Ci e I^ O Cq O C O X ^ L't 1^ ~. Lt rt .-I c-1 -^ o r: rt< s! is -# cc so ?q -*i c-5 o ?i cr. ?c '^ T^ Tt =-1 (M Cost of Building Material Mpc.c; Osa CPWOPM cqpscq Capacity o o c: — -M O -M lit CC -n . cc 1^ --1 r^ -COO .^ c: o -H r-l CC "When Opened. XXXXXXXXXXOO -xxx c: X C5 -^ lO CC 1— I iC w lO X X X X X Acres of Land. OOl^OOOt^OIC o CM X r: o Lt X --ri^ CC r-l Ol rH -M — ^ ,-( oooocq :ooi^o ■r*^ lc X o T-! : ct c-1 CC o C^l CC iC CC . — I T-l r^ C^l !M OO O CC O T-^ .-1 cq c^i Character ' o o o c c c -ij ^j -tj .+J -^ r" eScicJcictcec; I -t^ -fj -M >5 !^ I— I P ^ ?f' "" fci^.E c -^ c c X c - i^ -*3 ■— '•'- r^ O > S ixJ^^-^^^-:!^^. Ch^l^i~^?a^O^! .^^2:x^x^ >i!>>c3 CC a; oc r/3 CC V2 c o © o o o CC CC CC -- ci c: c: c: c: ce.- ;:::.m z;';ii;iiZ.i'^~cc 235 ;^ o o ^ HAh^Pr W ^ ^^^-o > ^^ C3q=| ^.^ cS OS >-.^ 'o^'^ c« O 'o , n- ^-S TJ o '""'^ O 3 rC i) ^4 =2 -S O >^"^ ■^ g ^ei ^ oqi: o ^ s*-« >^ 3 43 15 ^ Ph &^SO f^H H GO '^ O CO X 00 cc ^ tr: m ■ri^ iii (M ?a iM (N o o c; CO lo o o (M CO o :c -* CD O -# O 1^ O (M r-( CO O i-l o o GO O as o O CJ d O G S T •£:•;: -coo PPco OOOOOOOrt^O lO O lO 1-C o o o o o CO I-l (M CM lO O T}H O O CO O C:5 "-I ^M O (M o :ooooG030C0'*iot:-orH cooi::61oco^o : j^^S^ ^^ Sg S I^S^ :S o o o o o o (NO MM "* o o o o O O O l^ o (N O CO Tt< lO ?^ is ^ • CM . G (U : >.2 ■ -^ o I o o S -y-lOii-Hi— ICOiOiOOil— IC0O3C51OC0 LOX>COiOiO X0000CO00Q0COCOCO00(»COCOaO o : : lOo o : : CM 00 CO -2^ o : o o : o O . lO lo : (M Wpq o oo ooo PQCQ O O O O O lO O O O (M O l^ -0 1^ lO CM CO T-l CM 1-1 CO ■^ rH lO O 00 00 CO 00 QOOOQOOOOOl^QOGOOOOOOO CD O) -M -t-J C3 C3 O O ^ (XI (D oj ^ V fL,^p. ^ > f^yi ^ ^ ^ ^ ^ a r^ t-^-M ^3 ^ >i - -i^ -i^ d c;; Q G^ Gw ^o u^ C3 Q ^ O GQ '^ '^ ^ ^ O CS C3 13^ :_cn I '^ : Ph . CD : CD -5:5^ i 3 fcx; c3 'rS ^ 1^-^?:: ^-^ 6r=: ci ti ;:;i o -^ o . .. ^ . . ^ ^ .. '^ ?^l - ^ •CT -7^ ,Mr^MMM. ooooooooo C 2 2 C C S o • ',J4MMMM'':i '• '• : • ■aacicicici^t^a „c3goooooooooooQ ; : : : :v'-r''r 'T'T VMq o, .2.-.22 :; ci b CD o o o CD CD o CD 0) o o'^'^lSin t, S 3 S S S S.^ o 3 Oj i< Ci Cjr^. : : e3 • :^ • "5 eg ci g ^T* ;f; _^ • O'S'S'S^ S '^ cs g bxi .^ fc* '/- ^ *:: 236 c. C := ^CZ^S ^C COO o o o ceo Number of Chaplains. Number of Attend- ants Number of xVssistants. Salaiy. ooo o o o :rr^1 c s 2; o C C C G OOCO 00 o o o o C o b o o 1^ ci^ o o CO r? r-l T-H ^ ^ o ft OOH 3 5= 03 s o ^ rf;^ ^d QO c/: C O t; Z; _Q K. c: ti' ^ :; c? C i« )-.-( ^ ^ ^ J^ -J-' s-i ^ f=i ^ -J = O •5^i||?|3pp:j33 ci.S.2.H.2 >i>ii:3 ^ 'Jl tTi 'fl ^. C! a c o a; K Ct C/J !/- Xfl C3 cS c5 O O O O S r^ o o o.s w i jv 3 o o o Sr.-:r f- : ct •^ "^ r^ P r^ ^ C "^^ ^ f— r^ ^ — ,~ ;_ ;_" ;„" -y ■/ -y -/ y -j '"7" — -'- -*- '^J 237 d a c: ^ a a a a coco oooo ^ w ■4^ s©= OS rri C3 o 1— ^ r— 1 1— ^ ^^ ,— , o (S « « C5 C3 ^ COO O O OQO O CJ o ^ CD p ^2 ;- t>o^ C^ r-^ -il; _0 ^ .. -f-T ^ '—-' .^ hnr— H C3 ^ - r^ t> Ci K "^ r-t T^ H— ' "jr ^ o^S ^1^ •rricOOOOOOOOOOOQ ^ ;z; '-: >-i ;^ ;^ >-( pH ;^ pH ;>i ^ Ph P-. ^ c S S 5 5 S^ ^ o >. >. >i >4 >i>i ^. '/■ (^ c/. -y. c/. (/J cA. -X _^ ^ O a; 238 Insane at Large cc :s CO < T*i O • Ut Lt t- u:? ■ — -^ • c: X '^ ^ r: c-i ■* ^ C g ;iOO £ >: A & . 'tl O o •*ip cc ;^ K ^ o ooo c r: ££ OQ ^_o,2 ^.2 >5 >5 >-. >i >i >i > ooo c; cj cs CO PhG^Ph ; o ^GCp:.r^.. ;^ 4 .-5 ^ C ^ ;^ "^ < ^ g 6 ^ ^ ^ H P^.x.^x^^ cc M rr. zTi Oj CO CO . . . C O O W w v^ cc cc cc a: a. cc Si 5 § i 5-=^ ^ § g § g-s ^ 5 s ^ s ^: s ^ i.i.Ei^iii g 239 o X i^ c5 1- Treated i " -C C'l X - 1 T fO rj- l:: X O 1^ Proportion per cent of Deaths to Admissions... Proportion per cent of Kecoveries to Number Treated IC i-H X X ccx' is 8 X ?i i ix '^ X !>] CO cc (M Tf^ ■M M CM^ irt .- 1- -. X I- cc x' "* irt ;£ ri (M Tr< -r ri VJ1 CM ^ 1^ --C 'N J3 •-£ CM* C-i -M* x' c-^ u-: TT -* (M Proportion per cent of Eecoveries to Admis- Total.. < -^ X'tt* »*ICi r-lO (Mut^CCMrtlCC OC^-M Females ..."'"' ^-h ^ <-i ->c Males Total i^ Sg S^2 .-1 Ci 01>rti ^ C5 rc "^ -ti ^^l^i^ Females ... iSS c^ S^ ss^-^S^ ?1S| 1^ Males 1^ s^ = ?i' ;^^g=^^,?? gSS i^ Total 1,885 499 CO oi CO Tr Cv| lO c§ ^ i2^ ^ -t X c: 1- -T Ci -r •^!M Ol L.O --i t- UO X Females ... ss ^g S 220 IK) 148 404 IIS ii Males C: ^ CO gg 1^ mm 288 288 440 Numbers admitted. Or-i-^t^TfiO OOl^COCX' Tfli-I (M 1-1 Cv| CM Numbers resident. cooo OQO T+loo cot^i^-rf-ci ooooqo LO O X so UO 1^ (M X i-O .-( O -O Tfi CO X L-O (M X CO M CO .-H CO -4 Ol Ol 01 CO CO CO -.c UO 2 o. ^ o X tlr^ c^ cc ^-'-y'-'^-'c i^^flH p^.^ ^^ p^^- ^ -'- < Jill il'l^a-l^ 241 CO -* o o (MQOOOOOCOOO COOOeOCCiOI^CiOOO t^co »-H :0 X_ L.O CN IQ IC O 0-] CO CO -:JH :q O C^J t-^ 1-H CO wi CO 00 <0 CO CD 1-^ '^ CO CO* 00 f-H 1-^ lO l-"^ CO CO 1^ '^ CO COOiCCOQOOi (MCOOi«iCi-ICO-*ICi IC 00 "«0 -•: O 1-; 1-- (>| CO as O CO T-H C5 Tfi ci ic i-^ CO o -^ -•-•-•-•-•-• -• -• 00 CO --I CO CO o O CO lO CO ^ CN (M* CO* ci i-O oo' lO CO CO CO Tj< Ol -# T-HrHCiOlCOCOlOOO Oq r-i Oi^ Oq CO wJ 1-; OO ^ Tt^' CO QO' 1-' C» ci Co' ci O Tt^ CO :rj ^ i-H '■^j ■* CI CO cooi-icoco cO'-ir:icot^co C5^C5r-c0i— iCiGTi— lOl rHT-(r-l 1-1- r-( rHCq^ _r o G rt ^, :3p - ;^ c ?^ -St! c , . "^ :? ^ oj 5 o 03 bcSl3 5 ^ ^ C! cs r;5 ^ : -^ ■3i o O i-2r2 - S§5 i^S o ^00 00 : 00 o th G-q : ^§ j § CO'Tt^ CO o r-l I^ 00 o i^25 N?^ o i^ rH CO : CO ^ CO : CO ; C-i 00 Proportion per cent of Deaths on number admitted : o : o : 00 : ^1 : o o : r-i c m c ci :3 CE o 2 > p o bi ">< o ■J 243 '^ M r-l :D t- tH O b- ^Gf6iLOOo6cOTt^o6o6rHi-5iO 3 00 : CO : -^ : CO OCOCCCOOsOOOTHOOt-COO OCOr-HCO-^O^Ort^OOOO o o o CO i>^ o* id "Tt^" t>- oi '-tH »d (MT-lrHi-lTHTtli-lrHT-l CvlrH o g5 • CO : t- . : s^i ; 1—1 O OO b- t- O t- t- f>l O -t 00 01 (M T-l r^ -H W t- (M CO . CO C<1 00 c^ rH T-3 ci T^' »0 rf (N (M ' T-l t- CO CO CO CO CO : t>^ t^ Oi lO O lO CO ' lO rH ci o CO o »d . ^ . Proportion per cent of Deaths on number admitted ^ Ci on '+^ cc ir: T-; "o t^ id i-i L-^ T— 1 rH CM 1— I CO T— 1 CO CO CO '^ CO rj^ 1-1 O rH CO CO 1-H Ci ro t- i>^ CO '>i T-H CO c! O oi id c^i o T-1 rH 1-1 G- c r- c <; o DO o p or f— 1 s • > o c pq D^ c c > c > c 245 00 Ci CD Oi 'i* CO : (M O 00 C^l t- L- . cj CO CO 00 ci 'o ] O i CO 00 id CO CO rH 1—1 I:- O t- CO ^ CO * rt^ -^ G^l ro Ol O I CO CO -+^ 00 r.-j CO : T— ( 1— 1 CV| (M T-l I 1-1 ^ ' co-f : r-i CO : CO CO CO CO CO -H CO CO lO O CO OO O CO ■CO ci oi CO CO ci • o CO as b- ^ Tt^ CO oi CO r-j CO : »>; CO (Ni CO id o : rH 1—1 T—l T—l i—H ; CO I- : ^ o : riH CO : 1—1 ; rfH »0 CO CO lO CO G<1 lO o b- CO lO OS b- id 00 O CO CO crj ci o rH 00 1—1 CO CO t-O (M ' t- o CO CO CO CO : -t -,0 id jH t-^ CD CO CO CO Tt< 1-1 (?q : t- CO • ci CO : rH CO : CO CO CO lO Ci -^ b- 1— 1 T-l O 'J+l O »0 'TJH oi o Ti^ id CO T-H (M (M CO '^ CO CO CO tH 00 (^^ CO r-i CO : ^1^1-1 'O) CO o lO lO 00 Ci lO o t- o rH O CO lO O CO lO (M 00 1-1 Cq to 12,506 t- lO 1-1 CO O OD rH CO O CO CO rH CO O t- CO irO -tH (M -+ Ttl rH 1-1 rH CO -^ lO 00^ 1— r (M -fl t- lO O O CO C5 -rfH 1-1 CO CO 1—1 • CO (M lO (M :o CO CO CO cr CO CM CM 1-1 lO cj: 3 b- . ) lO CO co'^ CO.tH Ci 1-h 00 C^l CO t- CO CI t- CO 1— 1 lO T-H^ O lO r-T • to (M : CO (M : CM CO • 1-1 CO CO O rjH cq a . CO b- CO 00 ^ CO T : CO (>q CO T-l CM lO cs: ) tH H CO (M o lO CO : CO : 1—1 ; 1—1 • CO CO rH lo CO m b : o -j^ t- c; CM CO ir : CO tH 1-1 rH (M T- 5 Ci • T-l : ^ CO : CM CO ; 1—1 • CO O CM lO CO t- r- : (M CO 1-1 00 rH CO c : CO rH - a 5 CO a H CO '>:: ■1 r- ) 00 • 1-1 c : 00 c * O CO Ci O (M CO -r : (M t- lO rH rH CO C • 1— 1 r-i 1— 1 r- 1 H c> H c^ c T— 5 rHC0C0OO'+lO'r^l(^^rtl00rHO'i^OCM'-t^ri^ OrHG\lirOrHCOC'^rHOCMb-OCOlO cot- ^CO rH(M O J ^ t-^ ^ 1 -1 G 3 3 ^ L 5 M II f- sl. ^^ :;: 2j • o^ 5 o ti 2 ^2 £^ - 2 ^ o ^'S- CfS- 5 ^ ASYLT7MS. 3 ^ O ~u •-4 ^2 S 2 :^ o o 1^ i^"" p G 2 5 : Pj' p &j trt- 3 r i r'o ; ' 5^- • 5j- : t::'! : S:' ZD *: i O : o : » j : CO 1869. 1 Halifax ' 216 ' -9 1 33 i ] L3 295 ! 41 11 16 4 Toronto 518 ' 17 !. 35 M 26 595 i 45 5 33 4 Provincial Asylum, rrederickton 238 i: iO i 62 1 J 50 368 ! 47 16 23 8 Prince Edward'^ I-^land.... 31 1 25 ; ] L7 2 66 68 30 8 3 -X. 1 i±±\jsj _i_iT_i. r> cix \^ »_ j.._it*jj.\.t« 1870. 1 Halifax '.... 245 ' 509 V. 289 1. ro i 24 1 ^ 1 24 i t6 [ t4 [ 25 J7 56 315 630 363 34 38 35 7 7 12 35 30 29 7 Toronto ... 5 Provincial Asj'lmn, Frederickton 9 247 P pa < PQ 248 oo o 1:- 00 ^ ^ ^ . . ^ ., ^ c: o 1—1 OOrt^fMCiOCOCi CO CO »o Per cent ot Deaths O tH T-i O Ci GO t-^ O <::2' O !>; CC CO Tj-' C5 on No. Treated.... T— ( Per cent of Deaths on Admissions (MCOT-iCOT-fOrH^CCC5COCiO(M(M -** 1-? TJ^ cI cc 00 rf" ci i>^ tHt^ i-HCOTt^TjHTtCOCMSvlCvlCCrH^ Per cent of Cures on Number Treated.. i-it:-5; lO c^t c: c; t- o o T-< i>^ cj ci 00 ci CO CO ^' <:d 1-H o o G^i AdE ■ mssions Tt^rt^CCT^^-l<^JC^ICOCOC.0COC<^rt^C^'DT^ lOOiOOt-Mt-rOt-i^CDCOOkOrH T^ COCOOOCOOOOiOCqcOCO 1^5 Numbers Died T-H T— ( -^liiir^os^iciOcoT-icooio^x^jD T-iT^'^i-i(MT-Hroo:::;OTtc^iCi tjh Numbers Cured t-o:irHCc;oo^»o^ococoi-i»at-cOTiH t-^ t^ -D OC lO (M r-i o — 1 c; CC 1- 00 O CO Numbers Treated ... t- >3 Tji iC T— iO CC CO t- CO -f t- '-H o !>f^f »r5ooocoir:co(Mc;ot-o^-f->cco Numbers Admitted. COOCqcOi-iCvlOCOOCi^-^C^C^lO 1— li— iC^lrH'^'^T— li— It— It— IT-Ii— 1 t-I Cq' tH rH CO CO CO CO C: O C: T-^ 1-1 CO t- O ^ 1:- ^ ITS -t CI L-^ ^1 irt) cr. C^l CO CI t- 'M H Total cor-i(>qrtcoo-ooicoqcoo -* 12; r-r<>f ft M « OC CO o — CO t- OT CO r- Ct ^ o ^ Females i^ X 'f ■ CO ^ CO CO ^ GO CO r-i O rH O^OT^CO CO CO i-! rH CO s s T-< — g 1^ CO CO CO t- b- C^^ 00 r-i O CO (M CO 'A Males 1— 1 lO 1— 1 ^^Or^:o^CiOO 00 CO rH '•,OC0C0C0(MrHrH(M rH > "i m d ^ S ^ >< > ■^ o >^ I-* "S ^ Tr 3 x .1:2 OQ /■ — \ o 2 *rH < § r— 1 ^ ^s 00 r^ tH G JC!^:^ "3 "^ "^ „ao -:f o £ 1-H 2 — O G^ :5 ^J > -5 "^ P ;^ -= P ^' 5 .2 ^ c =^ ^ 1-^ ^ p5 w h-H '>^ ^ w s f— 1 r—i 5 ^ 75 A 249 t^ ci ':o z6 T'i o t-^ i>^ t^ oqoq^OrHcooosi:- O l>I O G^ j O 1-^ lO rH O CO 00 CO 00 tH C- XQ TjH CO rH (M CO O O .COOCOiOfMOOOi 1:0 c^ixiT— iTtir-io':oocoio CO ^ T— I T— t 1— < CTj b-^Q0(Mai»OCiC0^ oococooiroco»oi>-Ci lOCOtOt-CiCOt^-tli— I T-i'iiOOOOOOOI>>t-t- CO (M i-i O 1-10:} (M tH CO CO O (M (M C75 CO b- G^i CO c: »o o 00 Ci 01 (M (M I— i lO rH T— I (M +^ CO ' 3 CO p CO O r-f o '^-^ o a 111 o fl cu rt o a 32 250 P CO QQ Hi Total CO T-H CI iS 00 11,402 47,375 3,955 2,759 3,790 10,504 30,871 13.5 1 ! Pemales .. | 1 CO CO co'^ 1— t CO rH CO CO CO : 2,172 1,298 1,083 5,153 T— 1 Males CO (M 1— 1 1^5 o 1,783 1,461 2,107 5,351 PRIVATE. PAUPER. Total (M : (M : i 1 1 .J : Females.. ^. [ T— 1 : i 1 i o : CO : Males t^. 1 CO T-H i Total Females .. CO CO Males CO cr. co"^ : 1 ci CD CC o p o C«-| O o 1 c J a J ■j < 9 3 ■i I r- '. c C E I : 2 : ~^ : S : o : p :> o c : ^ I c . a 1 E- o : a S cr ) r 3 ;: I I ^ ? : fl : o I a i Ml :i o c I Pi > 1 : 1 1 > 2 2 5 3 . I 251 ENGLAND. Table 3 — Continued. • Males. Females. Total. • Proportion per cent of recoveries to admis- sions 30. 38. 34. Proportion per cent of recoveries to numbers treated .. 8.3 Proportion per cent of deaths to admissions. Proportion per cent of deaths to numbers treated 36.5 29.5 33. 8. 1871. Proportion of pauper lunatics to total pau- pgpg ■* 4.63 Proportion of pauper lunatics in asylums and workhouses 85.43 Proportion of lunatics maintained by rela- tives and others 14.57 Fifty-four English asylums made postmortem examinations in thirteen hundred and fifty-two cases, out of thirty-one hundred and thirty -five deaths, in the year eighteen hundred and seventy. 252 Table 4. Shoiving the ratio of total number of Lunatics, Idiots, etc., to poj)ulation in each year from eighteen hundred and sixty-two to eighteen hundred and seventy-one, both inclusive; also, number of patients in private houses, and number in asylums, ivorkhouses, etc. , ? ^ ^ Number in private Number in asylums, otal oi'luna iots, et uary 1 houses. poorhouses, etc. YEAR. o num tics, st... » ^ p ? hj : ^ ^•cr' O o P ^ P ^ i i 1' 'i"'^ ? 9 ^ 1862 20,336,467 41,129 2.02 146 6,157' 5,274 29,552 1863 20,554,137 43,118 2.09 153 6,405 5,354 31,206 1864 20,772,308 44,795 2.15 159 6,541 5,446 32,649 1865 20,990,946 45,950 2.18 212 6,557 5,662 33.519 1866 21,210,020 47,648 2.24 227 6,580 5.873 34,968 1867 21,429,508 49,086 2.29 223 6,638 5,920 36,305 1868 21,649,377 51,000 2.35 274 6,829 5,850 38,047 1869 21,869,607 53,177 2.43 324 6,987 5,900 39,966 1870 22,090,163 54,713 2.47 356 7,086 5,924 41,347 1871 22,704,108 56,755 2.49 392 7,331 6,062 42,970 253 ENGLAND. Table 5. Showing total number of Paupers and of Pauper Lunatics, Idiots, etc., ivith the proj^ortion per cent of Pauper Lunatics to Paupers, the pro2:)ortion per . thousand of Pauper Lunatics to population, and proportion per one hundred thousand of non-Pauper Lunatics to population. Total paup class uary Total paup tics, 1 Janu Pore p a u tics, paup Propo 1,000 lunat to po YEAR. ^2 ^ ^ ^ o '-^^ 5 p ^^ -' 2 9'%"^. %:'%% rtion 00 of s not p to en lation. p -. *^ a ?:r*^'^ : V:.'^ ^-^ : 13 :i.o : a '^ 6 • <-^ p r P cr CD : ^ s := ;d : 1 1— .-,5 : . « 1-15 \ , ^ 1862 946,166 35,709 3.77 1.75 26.G 1863 1,142,624 37,611 3.29 1.8*2 26.7 1864 1,011,753 39,190 3.87 1.88 26.9 1865 974,772 40,076 4.11 1.90 27.9 1866 924,813 41.548 4.49 1.95 28.7 1867 963,200 42,943 4.45 2.00 28.6 1868 1,040,103 44,876 4.31 2.07 28.3 1869 1,046,103 46,953 4.48 2.14 28.4 1870 1,083,532 48,433 4.46 2.19 28.4 1871 1,085,661 50,301 4.63 2.21 28.4 From the above we find there is one pauper lunatic to every twenty-two paupers; one pauper lunatic to every four hundred and fifty-one of the population, and one non-pauper lunatic to every three thousand five hundred and eighteen of the population. 254 a3 T-i CO CO ic CO ri^ a: l^ 1 ^bC CO t-. GO -o irt! (M oc 05 v o ci -o T-5 (d ,-; oc CO < CO 00 0^1 CO rH 1-H OO O O CO O CO O (M •-H o CO O 00 <>1 O fM Cv rH CO cd O rH ci 1>^ (M" OC '^* I— 1 CO -^ (M (M r-i CO 00 «M rH ^ OD ; C^l 00 OD t- O o ^ »ri CO TtH ci ,-; 00 o CO o I— 1 CO CO G<1 (M CO 1-1 1- CO t- oo . . o c^i lO CM 00 rH c: 1 CO r-i 1— ^ T-i 1^ O CO 'M (M O o O .2 ■03 CO CO -f" 00 id rt' oc CO -Ko *cc ""^ CO CO oq 5; 1^ t-; Cj ^1 CI ur: (M ^ ^ cc id 00 CO CO o CO 0-1 tH O O o CO -^ C<] CO rH r- CO 00 -+1 rf Ct) rfH T-H ■-^ 1 CO 5i -M i-i 00 0^1 O tH O rf CO lO CO •2 CO .2 ^ CO t-^ CO ^' CO t> c: r-^ I— 1 CO CO (M Cv| rH CO T-H O CO C<1 CO t- t- 1 t- •2 s* rH rH C5 lO O O 1> CO i p^ O) t-^ CD o ci ci CO CO -^ r-^i '"' CO CO CO C^l tH CO ♦o ^ o ^^ <^ s , CO iO rH t- 'Tfl rH (M -H w '^ CO Ci Ci O O C5 O in CO oi 'Ni CO i>^ rH c: 00 id ^ -2 M CO o rH CO CO CO CO rH ■ CO 1 OO rH iTi 'M C<1 rH T— 1 ^ 1 ^ ->! t^ GO CO ^_^ ci i>^ ci s. rH o: T— I GO id 'CO 00 rH 00 ic: --H CO -* M CO T-< CO CO lO Ci Ci CO CO o CO '■+-» § CO G5 L- lO rH o o o 00 o id o 00 CO ^ T-H SS o ^ CO CO OO CO G<1 CO -H i« -f CO 'M CO C-l o o CO CO O CO 'M CO rH ^ 00 ^ CO oi ci id iC. id ^ CO r^ CO CO flj O • J ;3 » • OKSS^e ;i^ £ 1 255 a3 lO O lO CO t- »o -+l S2 1 oo o CO -i-^ cr- o -^^ CO o t-^ o 00 o c^ ci o o c- t- G<1 C^T CO 'M Ci CO t- Ci 'O l- O (>1 C^l IC3 r^ ^ o t>^ CO ci 00 TjH !:d d 'S I— 1 T— I rH T— 1 1 o nr^ o T-i lO CO Ci in (M ^ lO o c; CO c; c^i oi 'O '^ "*A § O t-^ rH t-I T—J CO OO d o I— 1 T— 1 tH 1— 1 rH n:! COOiT-Ht-t-iOinl CO ■* t- CO 05 T-H (M CO Ci C/J g ^ -^ o t-^ d .CO i^ d r^ 1—1 •t— 1 rH rH tH O (M CO 'T+^ T-i CO : lo ! r:j _o =2 ^ Ci lO -Tin CD .CO C/J -M 00 d t>^ 00 1^ T-i ; CO d 1 iH 1—1 1— f • P (:^ .pH CO rH CD • i-H ! t- C^l rH CD O rH O \ i>; *^ «(-i o 00 d 1.^ T-i t-^ d ; d d c tH tH tH . • CO CO O GO CO : ^ d d T-< ; d d tH tH rH . irH CD lO -H '^ T-l • CD ! 00 ?^ rH -fH O lO t-; . ^-O . c^i d rH CO -d^ ; d •r-< 1 "^ T-H 1-H rH . T-H • lO CO 1— 1 o -H • CO I o i^ ^ CO ; »o d ? : ^ : ^ : : s : cK rjQ r^ : : IS 2;: ci qS xn ro t-H -^ l:^ >^— I >^ -O ^ < a^l^^cSfi: S 256 ENGLAND. Table 8. Showing Length of Residence in Sixteen English Asylums of Patients icho Died therein or icere Discharged therefrom Recovered in 1870. DIED. Discharged Eecovered. LENGTH OF RESIDENCE. • P 3 t. S p «2 o 3 p^ g • \ Under 1 month 52 67 56 69 76 212 32 43 31 29 52 235 84 110 87 98 128 447 15 92 105 97 52 38 10 81 182 139 53 54 25 Over 1 and under 3 months ... Over 3 and under 6 months . . . Over 6 and under 12 months... Over 1 and under 2 years Two years and over 173 287 236 105 92 Totals 532 422 954 399 519 918 Tabl E 9. Showing Proportion per cent of Kiimhers Died and Discharged Recovered in the folloiBing periods to the whole Number Died and Discharged Recovered. Under 1 month 8.80 11.53 9.11 10.27 13.42 46.86 2.72 18.84 31.26 25.70 11.43 10.02 0"v^r 1 and under 3 months ^ Over 3 and^nder 6 months >^ !^ 78.55 Over 6 and under 12 months Over 1 and under 2 years 11} 21.5 Two years and over Total 100.00 257 ENGLAND. Table 10. Showing Numbers Resident, Admitted, Treated, Discharged, Died, and Re- maining; also Proportion per cent of Recoveries and of Deaths to Admis- sions for Ten Years, 1861-1870. 1 ^ ^ ^ £ O •-! c - 3-«=o ►^.o ^Q^ o^ PATIENTS. Numbers. if . go- per reat C o C o CO 3 1 c^ • n- Numbers resident January 1st, 1861 Admitted 24,989 ... 101,927 ... Treated 126 916 ... Discharged cured 34,716 34.05 27.3 Discharged not cured 22,826 ... Died 32 087 1 Total discharged and died 89,629 ... Remaining 37,287 ... 1 i SCOTLAND. Table 11. Showing nmnher of Patients resident, number treated, admisMons, recoveries, and deaths, icith proportion of the recoveries and of the deaths to the admis- sions and to the number treated in the Lunatic Asylums visited in the year eighteen hundred and seventy-one. ASYLUMS. tz; ^ Proport'n pr j Proport'n pr centum of i centum of recover'sto • deaths to I r^- rf^ Eoyal Edinburgh. Fife and Kinross.. Dundee Eoyal Inverness District. Stirling District Glasgow Koyal Total. 754 227 190 279 545 1,995 265 I 70 I 59 ! 58 i 252 i 32G I 1,019 297 249 337 252 871 118 35 25 26 14 147 44.52 50.00 42.37 44.82 5.55 45.09 1,030 3025 365 206 35.05 25.28 18.57 22.03 7.71 6.34 21.77 12.06 11.57 11.78 10.04 44.82 5.55 16.87 20.03 6.57 4.37 5.22 7.71 6.34 8.15 6.80 33 258 P < O o H g ^ ^ r-i CO -^ (M T— 1 T— f O 1 Ci lO -t^ -* t>- -* C5 . . . . Total C0rHOC0f0iO(MCiOi0:0 < lO Oq^CO^ O ^ ^ =^^ t- 00 o t- : 'M O O t- CO o • CO ■ H Females 1-1 T-i (M Tt^ : M ^ irTT-TTtT : ^ " o Males -f< in ci ia> OD t^ la L- t^ Cl l-- c^ Ci CO t- 1^5 CO c: (M t- O -J^ -f Total 1- O -^ 'O « -tTi-TcrT (M CO iO lO t- w •tH CO -rfi CO co Females O O tH CO a r- c < ^0055 -+-S -4J ■+-» ^ zi S||32 A:5 2 o o o ^ 00 !E Issfl ^ tr.^ o ^ Ct_, C4_ C4_, q_, P ^ 1 g^ 1 o 1 -I'i 1 -5 '-r d s "^ '" ^-^-^ &§D ^'0000 1 ^ o 1-^ ;-( ;-! •- '^ '^ '^ "42 1 ^.t^-2 ^2^-^ o O O O ^ ;< rHp p ^P C: ?p- ^P. ^P^ ^P- ^ 1 CO !>; CO CO "^^ t- 11 r- c5 rt j^ j2 ro ^ ;=! s Ct! j_, ^ r-i (--) Ph ^ 5^ c3 ci C4-I C.-I C*-( 9 o" ;_, '^ P-i PPP 259 ::s ■ ;55:> p •"-O ^ ^ O-D T— ( -< ^C? p (J P rH M ^ P^ 1 ) O H ^ J2 CO CO fO >n rH O O) !» SSSigS ^5 s g Total CO CO 00 r-l iM rH t^ 1^ -A^'^^ -• c| CO Females .. 2 COrH o lO lO lO rjH o O O i^ Males ^J^^cZ^^'S -• o o 1 cq 1 (MOOfHCiO O O -"ti tni Total OCOrHrHO ,^- ^^ <^ "§ o ^'^ -o o 'O c-1 w o o :3 ^§ Females .. ^i- -^^1 o o)- t^' gPH ^^ -^ COQOlOt^CO O CO CO j;- « ^ w o i 1 1 Males liP^ 1 3 3 i s Total ^ !>i ■ S3 O O ->0 1^ CO -^ O GO Females .. CO;^l^^CO „. ^^ ^. rH 1 '^ o (MCOOiOO) '^l lO -*< 1 ^ Males 5^S^^- ^- ^- 00 c' -j Ph O t-^ 00 I^ 1^ O 01 i-H j:; Males C^OOICO-H ,^. ^. ^ CJ " CO C-l rH H O rH Ci rH '"-O CO O 1-^ ^. Total ^^^^^ CO ol 00- j:^ ^jTrn" '-' r2 s^ i^ ^ c:i -^ i>- o uo o rH CO S<1 Females .. J^^^^S o g- «=• > o cf ' O).^ OQ^ 1^ 1-- Csl lO rH 1-i O Ci f5 Males . . . . '^ . -^ .^ . 1 . o : o : n Pi : ft : cy 1 1 *"* ^ '-6 i'S i^ : ?^, s o jij o o : >:! Q .2:2*^ : r c« O t> CC t/3 C o •z; fH O (:::,=: o 1 5 «■ cr o "1? S '^ fS « ;::r^ o r- o .^ o j: gliliiili|g 1 « Ph pfi Ph P^ Ph 1 260 SCOTLAND. Table 14. The ratio per one thousand of the total number of Lunatics, Idiots, and persons of \insound mind, to the ])opidation in each year from eighteen hundred and sixty-tico to eighteen hundred and seventy-one, both inclusive. Population Total number of lunatics, idiots, etc., January 1st. Kation per one tliousand to pop- nlntimi Number in private dwellings Number in Asylums and Poorhouses. TEAR. ^ p ^ ^ 1862 3,083,989 3,101,345 3,118,701 3,136,957 3,153,413 3,170,769 3,188,125 3,205,481 3,222,837 3,358,613 6,341 6,327 6,359 6,468 6,616 6,762 6,931 7,157 7,409 7,808 2.05 2.04 2.03 2.06 2.09 2.13 2.17 2.23 2.29 2.32 1,741 1,679 1,637 1,609 1,568 1,548 1,521 1,500 1,469 1,430(?) 1,031 1,023 1,018 1,055 1,104 1,143 1,158 1,128 1,163 1,178 3,548 3,604 8,683 3,783 3 922 1863 1864 1865 1866 1867 4,046 4,224 4,494 4,728 4,817 1868 1869 1870 1871 I to 438 1 to 2,548 1 to 2,936 1 to 697 1 261 ^ 00 <^ » Si ^^ o^ ■^^ ■*o ."^ SS 5^ I5J ^^ ^f^ ^ « ^5. §^ ■-;s^ p f^ lo t*s i:>Q <1 -^ I's. ^ W ^ CO H n ^< ?^ O O r- CT) =0 rf) ^•"^ ^ 2 »v ~* ^^^q 53 s^ i- rN CU "^ Is $i « •+W <:u Sfi Se, S^ ^^ ^ g 1^ ^^ i^ •5S^ CO Si 'i ^ ^ 2 -^ s ^-^^ § ^ •^ ^ o o Total, Female.. Male., Total. Female., Male. 5qff5S CO Total . Female., Male. Total , Female.. Male. Total . Female- Male. Total. sf ccc5 S?^§^ Female.. Male.. Total. Female., Male., Total , Female., Male. pi ^ OS 2,145 347 509 38 CO ill : 3 : : : : : : : : 1 c^'c-Jcq .-T t oT 6,705 1,667 1,267 771 o 6.289 1,231 1,038 507 OJ" ■ Ti a o m a a S S ej 3'^ 26i cq H o CO "&> f^.3? co" Oh or. '^ '-* <= ^ r- s s ■<»^ '^i «: '^ ^ ^ ■s> o 1 Proportion per cent o CC b- 00 O O C<1 o ! of deaths to num- o Ci rH CO o ci CO 1> j ber treatpfl i J 1 i i Proportion per cent j -j^ rH o o CO !M_ re Ol of deaths toadmis- j ro c: ci o c1 (>1 7^ 0^1 CO 00 recoveries to ad- o6 ^' !>: CO t-^ T-5 00 l>^ missions | <^ 1 i Tt< (M r-i tH O lO CO i 1 1 -r^. -, i^ -i^ ^ O Ci ^ CO o 1 Died : ^i 'M 'M -t CO l^ T— ( (M ^ rH 0^1 00 T— 1 'b'% i T— 1 rO ^ 1 B 1 ^ lO CO CO rH -Ttf t- O lO Males i ^ C: rH 1— 1 O !■- rH la 1 CO T-( CO rH r-^ ^^ 1 i 1 _ i : g I I I " • li : 2 ! ^ : ^ :'>^ -^s UH . m -M r— 1 J- -^ ^ : <1 C3 >^ ■—I j^ 1^ ■t< fll<=2 ^ 02 T^ <^ c5 -i^ L>^-^-= i O |S ,»^ ^ -i-3 CD ■ . S % < ^ 'cj 1 1 )^ ^ o 1 '^ ^ P ? 1^ 5 o i ^ i 1 sa" p t- ^ •2 .si 263 Total Female. Male Total Pemale.. Male i Total I Female Male Total ^ Female Male .. Total Female. Male O -^ CO 05 CO i-H 00 CO CiO eo O (M lO OvJ lO .-( O •^ Oi Oi ?0 1— I (M (N 'to O -ti rfl CO «^ 'O rt< CO O^ O «0 CO 00 O Oi lO >-• C5 tH (M 05 (N O CO O CO O CJ O lO lO iM CO UO O ,-( TtH .-I (M C^ CO »0 l^ CM lO O CO iCO Tt^Oi COO^ (M ,-1 O-l CO O lO 00 CO 1^ l^ I— I (M o COCO O CO r-t kC »-* Oi 00 CO Oi 00 Oi CO (M ><*H Ci O00-*5 ^ S ;3 ft 264 lEELAND. Table 18. Calculated Population of Ireland from 1841 to 1871. Year. Population. 1 Year. Population. Y^ear. Population. =^1841 ' 8,175.124 ^1851 6,552,385 *1861 5,798,967 1842 7.996,219 ' 1852 6,472,830 1862 5,728,565 1843 7,821.253 1853 6.394,244 1863 5,659,012 1844 7.649,920 i 1854 6,316,628 1864 5,590.312 1845 7,482,687 ' 1855 6,239,928 1865 5,522,437 1846 7,318,985 1856 6,164,171 1866 5,455,387 1847 7.158,800 1857 6,089.343 1867 5,389,161 1848 7,002,164 1858 6,015,400 1868 5.323,736 1849 , 6,848.931 1859 5,941,947 1869 5,259,100 1850 6,699,063 1860 5.870,226 1870 5,195,236 1 * From census returns — remaining years calculated. Table 19. Shotving proportion of the Insane to the total of population of Ireland for the years 1848, 1851, 1855, 1856, and 1861. »^ ^ ^ "^ 5 o o| 5cg y c ^^ ►S ^^ r 1 || l-sf YEAR. o 1—1 3 D 11 o3 of II thousa tion.... P » ri i P.^ a IS 1 1 -S 1848 11.678* 7,002,164 1 to 600 17 1851 15,098 6,552.385 1 to 414 23 1855 13,493 6.239,928 1 to 462 22 1856 14,141 6,164.171 1 to 435 23 1861 16,749 5,798.967 1 to 346 29 1870 17,194 5,195.336 1 to 302 \ 33 ' •^Approximately. 265 I E E L A N D . Table 20. Civil condition of Patients in Asylums of Ireland on the first of December, eighteen hundred and seventy. CIVIL CONDITION. Males. Females. Total. Sinffle 3,006 701 113 170 2,251 ^ 747 310 162 5.257 IVTarripd 1448 Widowed 423 XJnkiiown 332 Total 3,990 3,470 7,460 Table 21. Shoioing Duration of Disease on Admission of Patients Discharged Becovered from the District Asylums for the Year ending December 31st, 1870. Males. Females. Total. Under three months From three to six months.... From six to twelve months. From one to two years From two to three years From three to four years.... From four to five years From five to six years From six to eight years Eight years and upwards.... Not specified Totals 339 313 625 35 46 81 32 32 64 21 25 46 10 14 24 7 4 11 4 1 5 1 1 2 1 1 2 11 5 16 57 48 105 518 490 1,008 34 266 I E E L A N D . Table 22. Showing the number of iKitients in the Lunatic Asylums of Ireland, loith the admissions, discharges, deaths and escapes, and proportion of readmissions to admissions for the frst time. FOR THE YEAR EXDIXG DECEMBEE 31, 1870. Males g ^ : 1 r t ■ Number of patients in Asylums Dec. 31, 1869 Number admitted for the frst time i i,'i4i 1 "971" 224 196 2,"il2" 420 3,788 3,333 7,121 Number of readmissions Total admissions 1,365 5,153 1,167 4,500 2,532 9,653 Total number under treatment N umber discharged recovered 549 1 539 166 1 110 61 1 50 378 330 9 1 1,088 276 111 708 10 Number discharged relieved Number discharged not improved Died Escaped ! Total discharged, died and escaped 1,163 3 990 19.6 1,030 3,470 20.1 2 193 Number remaining December 31, 1870 7 460 Proportion per cent of readmissions to admis- sions for the first time 19 8 Males. Females. Total. Proportion per cent of recoveries to admissions 40. 10.6 27.7 7.3 46. 11.9 28.2 7.3 43 Proportion per cent of recoveries to number treated Proportion per cent of deaths to admissions Proportion per cent of deaths to number treated 11.2 27.9 7 3 Proportion per cent of pauper lunatics in asylums and workhouses 55 2 Proportion of Imiatics maintained by relatives andbthers 44.8 267 IRELAND Table 23. The total number of insane (including idiots), December 31st, 1870, was These were distributed as follows: In district asylums In private asylums In Workhouses In Jails In Lucan, supported by Government In Central Asylum for Criminal Lunatics. At large 17,194 6,655 638 2,754 1 43 167 6,936 17,194 Of this number about nine thousand four hundred and ninety-eight are paupers, supported in asylums or Workhouses; and the remaining seven thousand six hundred and ninety-six are supported by relatives or others in asylums or elsewhere. The asylums are: Di strict asylums ^'^ Private licensed asylums 20 Asylum for criminal lunatics 1 Total 44 Table 24. Numbers of Insane {exclusive of Idiots), December 31st, 1870. In police districts, exclusive of those in asy lums. Jails or Workhouses In Union Workhouses In district asylums In Jails In private licensed asylums In Central Asylum for Criminal Lunatics... Totals Males. Females. 1,526 448 3,440 281 117 1,228 697 3,007 1 327 50 5,812 5,310 Total. 2,754 1,145 6,447 1 608 167 11,122 268 ^ p y—i M W O 1-5 ^ < H H m o '^ „" ^^S^ ?S^ « T' JO ?2 p^ m ^•2 ^1 So Proportion per cent of deaths to num- ber treatpfl CO !>; O) O ; T-i b^ o t>^ : T-l T— 1 : : ^ : : 00 CO 1 Proportion per cent j of deaths to admis- j sions CO T— 1 T-i T— 1 : i6 o -in' o : CO CO o -+ : • '• -^ : : -^ o Proportion per cent of recoveries to number treated o T^ TjH »if5 : i6 T-l (m' t>; : T— < T— 1 ; : : o : : ^ CO Proportion per cent of recoveries to ad- missions t- ci CO T-i : 1-: -Tf^' c ^ 1 [ 3 < o o ^ P o HIT li Ho r : o t 'i % 1 o i P ■ o 1? : p II • 1 i' • C/3 • "^ 1863 2,587 2,583 5,170 1,694 6,864 1 605 373 320 35.50 30.51 8.81 7.57 1864 2,673 2,693 5,366 1,669 7,035 mi 427 590 34.57 35.35 8.20 8.38 1865 2,663 2,778 5,441 1,851 7,292 642 624 395 34.68 32.14 8.80 8.15 Total.. 7,923 8,054 15,977 5,214 21,191 1,824 1 ,424 1, 705 34.98 32.70 8.60 S.04 271 BELGIUM. Table 5 . Increase of Insane Persons in Belgian Asylums for Ten Years (1856 to 1865), and Annual Increase. YEARS. Number of Insane. Increase. In 1856 4 278 In 1857 4,431 4,508 4,677 4,882 5,033 5,170 5,366 5,441 5,431 1 :^-\ In 1858 In 1859 : 169 205 151 1^7 In 1860 In 1861 In 1862 In 1863 196 In 1864 T'^S In 1865 10 less Total for ten years 49,217 Annual increase 11.5 ' ]S[umber of asylums in Belgium For the reception of men For the reception of women For the reception of men and women. For pay and non-paying For pay patients only For jDaupers only Number of j)atients in all 51 17 17 17 27 16 8 5,431 The superior medical officers of the asylums in Belgium are paid in proportion to the number of i:)atients under their care, as follows: NUMBER OF PATIEXTS. Francs. In an asylum of 50 patients In an asylum of 100 patients In an asylum of 150 patients { f.^iS'"''''''''' In an asylum of 200 to 250 patients I Head Physician I -A. ssistan B In an asylum of 250 to 300 patients | ^1^^^^^^'"'''''' 1,460 2,500 2,500 700 2,800 850 3,500 1,200 272 CO o' ?^ JJ CO Ci 0^1 O ^1 1 -2 a 33s N u m b e r treated CO d o d f^rS as §5 .rt OJ "S6 O 00 tH T— 1 a1 Admissions.... lO O CO i6 S'^ ■ cc o -t^ -r- Ph 1 -" r. X 11 m b e r treated CO CO t- CO o p d ci 1-: 1—1 i>^ c ^ '^J^ .X o "S a CO !M CO CO P-'^ Admissions.... d 00 CO CO P o -^ CO CO CO f^ 1 Deaths t- CC 'M ^ I- ^1 T— I ! Recoveries -+ (M Ir- lO O rH 1 CO T-i CO CO o o Xiimber treated C^l 'M 'M O X 'M T— i ' Aciniissions -+: '^ ^ CO CO lO T— 1 T-i Ol 1 CO 1 Ci t- O lO 1 -| Total OO 00 'O CO to -rH 3 o •^ ^ 1 1 T-^ CO o -f ! Females c: t;^ O o 1 |2 ' fl CO -H o T-( ^ 3Iales ^ CO i p k4 1 >^ 1 02 ^ (^ o ^ o <1 ^ o c= a O c o Is H c; ^ o o -^ 'i% o o -1 o • en p s uO -M tc o . i;-^ ;; l^o C ^;^ 5 >5 ^ o g !- o p. - 1 s: ?>. 1 § o 1 1 O o 273 HOLLAND Table 7. Showing nmnher of Patients in Lunatic Hospitals, with Admissions, Discharges, Becoveries, and Deaths for the Year. ^ Hi Co :? ^ s ^3 3" P O i Xumber of patients January 1st, 1868. Admitted during the year.... Treated during the year Discharged during the year recovered . Relieved Not improved Died Total discharged and died Number remaining January 1st, 1869. 177 36 35 193 33 36 165 380 69 71 358 1,521 1,658 500 494 2,021 2,152 441 1,580 437 1,715 3,179 994 4,173 878 3,295 p f CD p P o : • Proportion per cent of recoveries to admissions Proportion per cent of recoveries to number treated Proportion per cent of deaths to admissions Proportion per cent of deaths to number treated 55.4 41.0 8.7 9.4 8.6 33.8 9.5 7.6 38.2 9.1 36.0 8.5 Number of insane in asylums January 1st, 1868. Population of Holland in 1868 Proportion of insane to population 3,179 3,592,415 1 in 1,130 Principal causes of death: marasmus, consumption, apoplexy, and general paralysis. 35 274 HOLLAJS^D. Table 8 . ADMITTED. AGE. Erom 1844 to 1854. Erom 1854 to 1804. Totals. Less than ten years ... Ten to twenty years .. Twenty to thirty year: Thirty to forty years . Eorty to fiftj^ years.... Eifty to sixty years.... Sixty to seventy yeai; Over seven tj'- 3-ears.... 13 142 551 672 564 303 135 47 m\ 480 I 569 I 462 i 382 I 198 ' 101 20 236 1,041 1,241 1,026 685 333 148 27 255 788 888 692 490 242 19 162 852 916 652 497 292 140 46 417 1,640 1,804 1,344 987 534 219 40 397 1,339 1,560 1,2.56 793 377 126 26 256 1,-342 1,485 1,114 879 490 241 66 653 2,681 3,045 2,370 1,672 867 367 Totals 2,4: 2,303 •■ 4,730 ! 3,461 \ 3,530 0,991 : 5,J 5,833 11,721 Married Unmarried 1,040 1,387 927 1,.376 1,967 1,334 2,763 I 2,127 Total:. ^427 2,303 I 4,730 | 3,461 1,274 I 2,608 2,374' 2,201 j 4,.575 2,256 I 4,383 3,514 | 3,632 j 7,146 3,5S0 6,991 j 5,888 5,833 11,721 Insane for the first time... Eelapsed cases .. 1,985 .. 442 1,790 3,775 513 955 2,762 699 2,736 794 5,498 1,493 4,747 1,141 4,526 1,307 9,273 2.448 Totals .. 2,427 1 2,303 4,730 3,461 3,530 6,991 5,888 5,833 11.721 TT PTp rl it firv 366 ■ 457 823 '■ 879 j 1,039 1,918 1,345 2,061 1,846 3,907 2,582 2,491 5,073 , 4,643 1,496 4,337 2,741 "N^ot hereditary 8,180 Totals 2,427 1 2,303 , 4,730 ' 3,461 [ 3,530 , 6,991 5,888 5,833 11,721 Erom intemperance Not liom intemperance 307 2,120 53 360 586 2,250 ' 4,370 2,875 109 3,421 695 6,296 893 4,995 162 1.055 5,671 1,066 Totals 2,427 2,303 4,730 ; 3,461 ■ i 3,530 6,991 ■5,888 5,833 ; 11,721 "\T nnin 871 436 322 507 98 193 981 331 434 391 70 96 1,852 707 756 898 168 289 1,554 "12 635 622 162 276 1,574 221 883 554 99 199 3,128 2,425 2,555 552 1,317 945 169 295 4,980 T^rnnnni'iiiifi .. 433 1,518 1,176 648 957 1,129 1,200 Melancholia 2,274 2,074 Trlint.i«!mp 261 260 475 ! 469 429 Epilepsia 764 Totals 2,427 2,303 4,730 3,461 3,530 6,991 5,888 5,833 11,721 275 HOLLAND. Table 8 — (Continued.) CUKED. AGE. From 1844 to 1854. From 1854 to 1864. Totals. . CD a' f 1 o Less than ten jeAvs Ten to twenty years... Twenty to thirty years Thirtv to fm'tv vphts 1 44 188 222 1 39 227 244 2 83 415 466 358 249 94 28 1 87 313 312 246 184 80 14 1 59 419 437 267 164 76 18 2 146 732 749 513 348 156 32 2 131 501 534 428 294 125 20 2 98 646 681 443 303 125 40 4 229 1,147 1,215 Forty to tifty years 182 ! 176 110 ! 139 45 49 Q*' 22 871 597 Sixty to seventy years 250 60 Totals 798 897 1,605 1,237 1,441 2,678 2,035 2,338 4,373 393 405 407 490 800 895 533 704 614 827 > 1,147 926 1,531 j 1,109 1,021 1,317 1,947 2,426 TTti m nvri pr1 Totals 798 897 1,695 1,237 1,441 2,678 2,035 2,338 4,373 Insane for the first time Eelapsed cases Totals 611 187 r98 640 257 897 1,251 444 1,695 905 332 1,237 997 444 1,441 1,902 776 2,678 1,516 519 2,035 1,637 701 2,338 3,153 1,220 4,373 Hereditary Not Hereditary 124 674 Totals 798 164 733 897 288 1,407 1,695 338 899 1,237 437 1,004 1,441 775 1,903 2,678 462 1,573 2,035 601 1,737 2,338 1,063 3,310 4,373 From Intemperance Not from intemperance. Totals 135 663 21 876 156 1,539 231 1,006 50 1,391 281 2,397 366 1,669 71 2,267 798 897 1,695 1,237 1,441 2,678 2,035 2,338 Mania Monomania.. Melancholia Dementia ... Idioti^me ...... Epilep.sia Totals ... 425 515 940 782 818 1,600 1,207 1,333 154 135 289 84 79 163 238 214 132 198 330 260 442 702 392 ()40 61 41 102 83 90 173 144 131 4 2 6 7 2 9 11 4 22 6 28 21 10 31 43 16 798 897 1,695 1,237 1,441 2,678 2,035 2,338 437 3,936 4,373 2,540 452 1,0J52 275 15 59 4,373 276 HOLLAND. Table 8 — (Continued.) DIED AGE. From 1844 to 1854. From 1854 to 1864. Totals. : : B a' ^ 3 p g 9 5 p" TO : Less than ten years Ten to twenty year'^ 2 28 107 216 2 7 4 34 107 211 204 204 213 • 173 ! 1 11 1 9 j 4 69 ! 63 ' 41 290 { 290 ■ 111 519 n24 ; 331 13 1 70 120 35 177 336 391 320 199 35 104 Twenty to thirt}. years 183 308 317 261 146 81 467 855 Forty to fit't3"Vear* 258 133 521 465 359 254 575 431 234 129 337 854 324 275 912 Fifty to sixty years Sixty to seventy years 170 88 48 150 111 102 785 558 404 Total"? 917 " 693 1 1,610 1 1,338 1,150 2,488 2,255 1,843 4,098 t 437 480 1 265 j 702 428 1 908 1 557 781 378 772 935 1,553 994 1,261 2,255 643 1,200 1,637 2,461 Unmarried Totals 917 693 1,610 1,338 1,150 2,488 1,843 4,098 Insane for the first time Kelapsed cases 815 102 618 75 1,433 177 1,186 152 1,006 144 2,192 296 2,001 254 1,624 219 3,625 473 Totals 917 693 1,610 1,338 1,150 2,488 2,255 1,843 4,098 Hereditary 100 817 87 606 187 1,423 230 1,108 252 998 482 2,006 330 1,925 339 1,504 669 Not hereditary 3,429 Totals 917 693 1,610 1,338 1,150 2,488 2,255 1,843 4,098 From intemperance 91 286 15 678 106 1,504 190 1,148 31 1,119 221 2,267 281 1,974 46 1,797 327 Not from intemperance 3,771 Totals 917 693 1,610 1,338 1,150 2,488 2,255 1,843 4,098 Mania Monomania Melancholia Dementia ... Idiotisme Epilepsia Totals 1 247 186 433 400 124 88 212 77 70 89 159 182 1 358 245 603 414 i 40 29 69 63 78 56 134 202 917 693 1,610 1,338 348 748 647 536 77 154 201 165 200 382 252 289 368 782 772 613 42 105 103 71 115 317 280 171 1,150 2,488 2,255 1,843 277 o a o O T 00 Eh Totals Females Males. Totals.. Females Males. Totals. Females Males. Totals..., Females Males. Totals- Females Males. Totals. Females Males. H c^ w -o cc '^ ti cc cs ira lo ■ 1 i-l .-ISM ^ CM CO CO (M ^Tt^Tt^COCOOOO^-IOrH ^^■;;tJ'Oooocioutio Oq CO b- rH rH Ci t^ (>; i^ ,-1 o ^^a\Z]'^'^ i^ !■- Tj^ lo in CO T-((M (M i-H tH O CDiOCOOiuDQOl^OCOr-l ^t^QOOOiO^COTt^CqcO Ci COOOrHCqCOrHOlMTHO CO.-ITtiCOt^lOTflCO(Ml^ CO CO lO GO lO Ol O ( IC CO Ci 1^ O) O CO ( Oi rH 1— ( CD r-l I— I Tf^COrHGOOOOWrHCOO W O CO LO CI 1-^ CO . CO 00 1--COCO(MOOCO(M ■^ lO O CO lO 1^ i^ TjH ,H OOOOOCOCiTt^OlCNCOCO CO 00 O CO lO TJH CN| rH OrHLO--t0 r-l r-{ CM CO CO rH 'S 'J' t^ (M — I O Oi UO CO lO O Ci CM lO CO CO CO (M rH rH CO T^l -* CM lOiOCOiOOiCOiOCiC01> OrHlO(MCO(MrH (M0 Ci t>; CO <>! \0 '^^ C^l ^ O ci t-^ GO' ci -+■ 00 (M o 00 t> iq o CO id ci CO T-H i6 o CO -^ CO CO r^i lO CM t- t-. ,-H 00 <© o o c?i TjH 06 00 CO CO CO Tt; t- CO lO lO lO rH ai -f -H c-j id CO CO ^ C>0 rti (M CO - -XOX 1^ : o : : : os : oi x F- »0 • Cq rH CO rH T-H CO X O X CO COlOCOiCiJOCOOCOOi— (COLCX Tfi cq CO X ^ Ci CO IC !>^ CO ^ CC CO 1— I (>« CO (M 1—1 1— I CO Ci O I CiO — IX LO CO : CM CO CO r-( O ;5h t- lC 07 O : 1^ O Ci O rH CO 1-- ^ CO CO ^ 0-1 t- —I : CO CO X O W CO 1-- t^ O CO CO I— i lO • "^ 00 CO CO i-O (M t^ CO Tt< :si .-I i-H C CO O O O rt^ CO rH UO 0-1 COCq rH CO : i^ lo Tt< c'fac? JP^ c^ : si b G o . 281 ITALY. Table 12. General Movement of Population of Lunatic Asijlums — 1867. Number of patients in asylums January 1st, 1867 ... Number of j^atients admitted during the year Number of patients discharged during the year Number of patients died during the year Number of patients remaining December 31st, 1867 Proportion per cent of discharges on admissions*.... Proportion per cent of deaths on admissions Proportion per cent of deaths on number treated.... 8,191 4,909 3,210 1,504 8,386 65 30 11 * The discharges are all given together, hence it is impossible to say what proportion recovered. Table 13, Showing the Hereditary Tendency to Insanity among Patients Admitted and Cured during the Year 1868, and among those remaining January 1st, 1869, m the Lunatic Asylum at Florence. Admitted. Cured. Kemaining. CASES. CD* 5^ si E (—1 pa 1 CD* 1 Hereditary tendency admitted 67 44 62 41 i 10S 28 18 26 17 24 16 45 42 42 80 104 142 2 102 110 167 182 214 309 2 Hereditary tendency not admitted.... Hereditary tendency uncertain; 55 45 99 107 Not proved insane ........ Tota\ 173 141 314 72 57 129 328 379 707 36 282 ^^ "K^ to "^■s ^1 s ."^^ ^t2 ^ < o a w -^^ J>2 ^ -^5 ^ pq n S ^ <1 H "^ ^ H r>r-^ m •S '^ ^S S r^^' ^ ^^ ^ S - 0-1 lO 01 GO O Ol 1- Ol CO Ol Ol O O X o -t^ o 1- iC CO 1- 05 — I CO 01 CO CO o C CO 01 .-! >o||| t^ "^ CC CO ci Tj^ CO ■'^ Ct Ol -to X -+I .-' C; Ol Ol ■^ r-i c» CO i-o 00 o t- CO cq (M Ci tr; ci CO c: o O LO ICl^ Lt O O O d r-t i-H C: CO 1^ ^ X C5 CO ci oq CM CO CO (M Ol 1-1 lilffl k is X c HO 283 Oi IC rf CO r- 1 lo :. Ci >C '^_ -^ ic : CO 00 i t^ O O (N* C-( CO : 00 ■* IC CO rH o: :t~^ 't : 1 oi ci co' CO t-'' 1-- X •3:, 00 : . ^ (M »0 tH i.O CO 'X CO 1 tH lO i o -^' ic c O O O O i-" ~^ ico CO ; 1 1- r-l iC TJ. X 1- X :x 00 : tH lO C-: u. :0 : co" iri- : 00 CO O X CO 1^ X ^ ic cr ~^ CO CO LO t^ Ci cc CO oi 0:1 1-1 Ti- CO (M rH T^l coc- X cq r-i \C •^ O ^+1 CO cc oc: CO ^ .-1 C2 -)H c; 01 coc; TtH 1-1 CO ^^ T-^ 1— t TtlOOl 01 CO ■rt< CO a. ro; -*" ^ ct ?-1 '"' N fl "^ r/ c =: I— 1 C Ph-^ ^l-l Cir^ cS o r-i ^ S "o Cj ^ 'o5 P p. 2 St M " "^ ^ C (D H c3 ijali c ■s 5 -5 2-^ = ! in ■3 *o " --^'^ _^ - ri^ ? Ti cQ oi ^.S"" £i£- "gT 2 m : ^ 5 3 5 ^ H U : 5 E M i If 1 ll f- tf >.'- C^ a ; c: i- t ;?§P 2 t i?- H S ^ ; ^ ■■& \ 284 Recovered Admitted during the Year Number of Patients, Jan. 1st, 1864 5:^ Si ^ ^ >^ ^ K5 ^ o ■*-' cr.o n:3t^i, GO O) I — t r-\ o a"" £3 "=^ <;o cc a; ^ o^ o (v> T^ W §-5' 81 rH ;_• r- C3 O «3 00 o n3 O .1-1 ^ fi -|j ?. oo S ^ -4J a; CD n r". rt f^sss o "5 ^^ 3 o'c: ■^ ;=^ 2 p^^^ V 2 o " -^^ — 1. . . w ^ ^ ""^ S rt g § g g £ 2 5 g pq pq ;5 ^ ;q p^ o a so o C ^1 © r^ '^ -, "w ; 1^ o O ;C-' js « -^ : f^ c f^ ^ X = JH 3j c St So C >::■ ^ CO 285 OC5 ' ■* i.o o CM : cq CO Ci o ■* -* (M.-( :.-ICOrHrH':ClO coco l^ : w' ^ Tti (N CC CO 00 cc o . CO coo ( : >^-5 ^ \-%< 3 >s-+- : ^: ■ t« I ; • 03 • . o C • fi : : : o : ; : ^ : • n cc O TtH . o n« s a o s^ : p X -^ - P .2 >< C : o o ^<1HP^ c5 o (M O o "* o o o ^ C CO o <-< I- 2 CO ;0 W : tico o ^ t, :"^ >:S SO . ::: c c; O'^ . -LJ (-5 O r-. O a: C o : c a 5^ ill, - 1 il o 3 ii o o o g§ c3 : , ^ i ;^ =^- w ^ PfipqS3;^p^fv:fv,r^;z;^^0 COeO^rsOffiK! IKKMtt f= 2 9 ''^..2 5, o.qo 0^:S po c.-tin; 2^ G O (-1 ci '^ ,— C 5 cc "^ a; O) © S ^ « c3 i-l CD £ g 'JD. ^ >^ -'^^ Si c:C0.2 G S ^' -2 ^^.^6 I , o"^ c - S c; 2 Q;ti >I-H1-| -o6 ji.-s S^ 2 0^ ^P, S rV-;3»7.^-= = _J irS ^ i . ^ _ . . 03 ^^ i:-^ o C/J CA. ^ G G G.CM ■HI— ('+-' (D o onq o s'-e G o4 C 03 .s ^.s P o o C2_,'C 03 G' 03 O ^ ^ "^ tS =2 tS .,^^G=:; a-^s.2.2.2 . G -•-- G _S 3 ^r'SS : ■G cj : 2.2Ph S «5 ci ^ 2 § :^ G cAj ^ 03 G m ,— • G . '^^^ si, ° - *^ _ =3 eg 03 03 G (-! C K g M2 Sl3^ O G h^ Oc£rG^nd '7. a S gIssSs-Is^IS :§ 5 ^=5.^ 2 ^=2,5^ |^|||G|f3i-o ::::>jJo3o3.-tio3.-G«c;~^?; •|,|||>:-||^-i-||^ o o ; -iS >i o G iJ a) £^ 3 ^ pij ^q fij (ij ei Ph P^ f^ M 286 Recovered Ci 1^0 I Admitted during the cc lo : cc (NOi-i CO LO coc ico in^t^o Lt 't »H Year CO : IM r-(,-l CM cq '^^ J^^OCOCi " 'I tH Number of Patients, Tf ci : c;oc : N : ■+-(» C ■:t C Tj -^ ^ HI gS ■~c > : S J ^r§ 3 : j : ^ iT .ill . : := ^ 1? 11 ■ 3 ill -9^ ti 2 X 2 J £ p2 S ^ .1 ; 1 y i ^i is i i^ , ==^1 M^:) : : i g r^ :- ■-- - 6 ; O : 5 : III S2E t 6 I 4 a 2^ 1^ 1-^ 11 1 nil a-, p V- br. ^ -n 1— 1 H^ H- ^ •— 1 1— 1 l-n ^ J • • cc ry* : : , .__^ • • 1^ ^ '. • • ^+^ rj r' I : :.2 •2 : : ^A d K 1 i : SP"! f5 : 5 : '^.2 2 5 2 Cl- 1— 1 : r^ ''' o ! 2 — — i > : 5 2^ a; C Hi 2 c : o"^ 2i§ C a.' cs C H- 1 s S S £ ' fl : e3 : > : - : a • 1 !2h S S c -^ C s: s: ? 1^ i-l i'sj^iii M c; c: 1— CI— ir— ll— CD f^ MC-cM— ;;^^j: ^, j-; — ^ ^ ^ * 2 2 X ^11 a ? S.^.^ ci fe g c "♦^^^ "-^ I-* 1; 1^ '^ "-^^ -^ *-^ > •-^ a 2 c -^ -^ "^ '-^ "^ •1 i c i 1— 1 o & - c; £ c: 3 o r till -->:t^ ;^ E C P •J b ? § § 1 ^.£^.2.2.2 =i 111 ilil m.SPh-^ 2 <= c F :>^ .c .£ : : i\ 1 \ :== 5 -S = llllll llllll.ll.fl mP ^^ H^ C 1— P- H^ H' c 1— P^ ^ ^ ^ H- r5p= ;ii S (5 M ^ c ^ 1— 1 287 ft® ^ a-: s o ^ g •+3.0 ;:: 00 O ft; o : ft iSJof^ o <1^ ^ SI I C cS O "t^ "r^ •■;:^ ^ 7^ -^ ■ Ci O is Oj— 1 O O M O O O 'i: ^ xv-^ i.r SQoo ; OS cs gHi-^^MO dO. OQ ^- ;- . CO- ^ '^ II -^ t2 ^2 ^5 r2 -^ 5 "5 -^ HH '-^ ' «3 5 o 5 :^ ii fH i; :72 S C3 fl . jZj 3^1^ a; =^ g r^ ^ r^ >- i-M O CD 0,_|-^ ' ?> ^ P j : o : o : 00 ^ p; CO ot a; © o o G C s= C coco COCO o : ^ : IrO oo ."n- : • 3 •S : B : : <^ '^ : c; : c : c : : S-^ ^ i Si t^p~&ccf;c:c- fes^S^^^^^^^I^^^I i^ : : : 2 S c c c c : : : =; c c cs c - : : i^t-i ?:'^ «: ^ - - "'S o c'k^ 2 G O ■ • •' '5 -5 •-I ^ i-H >— I C .:S c--£^ « C o c o:S c'' 2 p G S G =r: fi'-j 2 +-r3 o G p o -•<1*~_ odl-fill :OJ.5|.o.g.|i^ 2-5 •«2"5 S^ ~ S f=^S^d: Jljfllffjjlljll Fig. I. Beference: D C— Douch Cockg. B S— Barrel Shower. H S— Head Shower. L S— Lumbar Shower. S S— Spinal Shower. 0— Foot Pans fixed. Fig. 2. Reference: B— Ventilating Pipe L— Floor. 0— Rubber Gaskets. 289 [Appendix G.] ^ HS HS HS Homn Bath 6 O Baths o Pulverising Both Dressing Room Dressing Boom Fool Biilhs 00 00 00 Rni/pn Pnnm Se_.L Sent *"'"■'" '"'"'" 1 00 00 00 FonI Dafhs J*lan of Baths at Evreux. Plan of Water Closet. L^Z^ Section throxigh I K. 37 PWn of W»t€r Cles«t, Washington. 290 [Appendix G.] Fig. 3. Kitchen Boiler on pivot, at Ville Evrarcl Asylum, Fig. 4. Gas Lamp at Evreux. Fig. 5. fFal/ Ha-ha Fence and Seat at the Darbp Asylum. 2»1 LIST OF ASYLUMS IN FEANCR. WHERE SITUATED. Department. Commune. Naico of Establishment. Aisne Ain Ain AUier Ardeche Ariege Aude Avejron Eous. du Ehone. Bous. du Ehone. Bous. du Ehone. Calvados Cantal Charente Char en te Inf..... Cher Correze CoteD'Or Cotes du Nord... Cotes du Nord... Doubs Eure Eure et Loir Finistere Finistere Haute-Garonne . Haute-Garonne . Gers Gironde Gironde Gironde Herault Herault Ille et Vilaine.... Indre et Loire... Isere Jura Jura Loir-et-Cher Hte. Loire Loire Inferieure Loire Inferieure Laon (Premontin). Bourg Bourg Yzeure Privas St. Lizier Limoux Eodez Marseille Aix St. Eemy Caen Aurillac Angouleme La Eochelle Bourges Mouestier-Merline. Dijon St. Brieuc Lehon Besan^on Evreux a Chartres Quimper Morlaix Toulouse Toulouse Auch Bordeaux Cadillac Bouscat Montpellier Montpellier Eennes Tours Ste. Egreve. Dole Dole Blois Le Puy. jSTantes . Nantes . St. Lazare. Ste. Madeleine. Ste. Catherine. Ste. Marie Assompt'n. St. Lizier. St. Joseph de Cluny. Eodez. St. Pierre. La Trinite. St. Paul. Bon Sauveur. . Aurillac. Angouleme. Lafond. Bourges. La Cellette. La Chartreuse. St. Brieuc. Sacres Coeurs. Mon. M. Guibard. Evreux. Bonneval. St. Athanase. Morlaix. La Grave. Mon. Delage. Auch. Bordeaux. St. Leonard. Cast el d'Andorte. St. Charles. Pont St. Come. St. Meen. Tours. St. Eobert. Les Carmes. Les Capucins. Blois. Montredon. St. Jacques. I'Grande Providence. 292 LIST OF ASYLUMS IN FEA]S"CE— Continued. "WHEKE SITUATED. Department. Commune. Name of Establishment. Loire Inferieure.. Loiret Lot Lozere Maine et Loire... Manche Manche Manche Manche Marne Hte. Marne Mayenne Meurthe Meurthe Meurthe , Meuse Morbihan Moselle , Nievre Nord Nord Nord Oise Orne Pas de Calais Puy de Dome Puy de Dome Bas-Pyrenees Bas-Ehin Phone Phone Phone Phone Phone Phone Phone Sarthe Savoie Seine Seine Seine Seine Seine Infre Seine Infre Deux-Sevr©8 I^antes Orleans Leyme St. Alban Ste. Gemmes et Loire Pontorson St. Lo Priauville Le Mesnil Garnier Chalon3 St. Dizier Mayenne Laxon St. Nicolas Jarville Fains Yannes Gorze La Charite s. Loire... Lille Armentieres Marquelle. Clernjont Alencon St. Tenant Clermont-Ferrand .... Piom Pau Brumath Lyon Lyon I^yon Lyon Lyon Calvere Yaugneray Le Mans Chambery St. Maurice Gentilly Paris Paris et environs Pouen Sotteville les Eouen.. Niort Mon. Gouin. Orleans. Leyme. St. Alban. Ste. Gemmes. Pontorson. Bon Sauveur. Bon Sauveur. Ancien Convent. Chalons. St. Dizier. La Poche Gandon. Mareville. St. Francois. La Malgrange. Fains. L'Humanite. Depot Mendicite. La Charite s. Loire. Lille. Armentieres. Lommelet. Mon. Labitte. Alen9on. St. Yenant. Ste. Marie Assompt'n. Piom. Pau. Stephansfeld. L'Antiquaille. St. Jean de Dieu. St. Yincent Paul. Croix Pousse. Champ- Yert. St. Julien. Yaugneray. Le Mans. Bassens. Charenton (Imperial) Bicetre. La Salpetriere. Les 13 Asiles prives. St. Yon. Quatre Mares. La Providence. 293 LIST OF ASYLUMS IN FEANCE— Continued. WHERE SITUATED. Name of Establishment. Department. Commune. Tarn Alby Bon vSauveur. Tarn et Garonne.. . MoHtauban St. Jacques. Mont de Yerirues. Vaucluse Avignon Yendee Napoleon Yendee Poitiers Napoleon Yendee. Poitiers. Vienne Hte. Yienne Limoges Limoges. Yonne Auxerre Auxerre. [Appendix H.] THE TWELFTH A:N"NUAL COM]!iIEMOEATION OF THE OPEXIXG OF THE SUSSEX LUNATIC ASYLUX WILL BE HEL*D On Tuesday, 2Dth July, 1871. Hours — 12 noon — Morning Prayer, with Commemoration Sermon. Preacher, Ptev. A. P. Perfect, M. A., Eector of St. John's. Lewes. 1-2 p. M. — Dinner in the Wards (Eoast Beef and Plum Pudding). 1:30 p. M. — Luncheon for the Visitors in the Eecreation Hall. 2-3:30 p. M. — Games on the Grounds. Athletic Sports. The Ock- enden Band will play. 3:30 p. M. — Air. Basil Young will give a Musical and Comic Entertain- ment. 6 p. M.— Tea. 7 p. M. — Patient's Ball. To conclude at 9 P. m. THE BALL FOE THE HOUSEHOLD WILL TAKE PLACE On Thursday, July 27th, 9 p. M.-3 a. m. Mr. Squire's Brighton Quadrille Band will play. Haywood's Heath, July, 1871. THE ASYLUM, BOOTHAM, YOEK. PROGRAMME OF ENTERTAINMENTS. WINTER SESSION, 1870-1. Thursday, October 13th, 1870— Ball. Saturday, October 15th — Meeting of Singing Class. Thursday, October 20th — Eeading. Saturday, October 22d — Discussion Club Conversazione and Meeting of Singing Class. 295 Thursday, October 27th — Yocal and Instrumental Concert. Saturday, October 29th — Meeting of Singing Class. Thursday, November 3d — Ball. Saturday, November 5th — Meetings of Discussion Club and Singing Class. Thursday, November 10th— Lecture, " Hull Worthies," by T. T. Lam- bert, Esq. Saturdaj^, November 12th — Meeting of Singing Class. Thursday, November 17th — Eeading and Musical Entertainment. Saturday, November 19th — Meetings of Discussion Club and Singing Class. Thursday, November 24th — Vocal and Instrumental Concert. Saturday, November 26th — Meeting of Singing Class. Thursday, December 1st — Ball. Saturday, December 3d — Meetings of Discussion Club and Singing Class. Thursday, December 8th — Magic Lantern Exhibition. Saturday, December 10th — Meeting of Singing Class. Thursday, December 15th — Lecture, ''A Yisit to a Coal Mine," by Dr. Procter, F.C.S. Saturday, December 17th — Meetings of Discussion Club and Singing Class. Thursday, December 22d — Eeading and Musical Entertainment. Friday, December 23d — Meeting of Singing Class. Thursday, December 29th — Lecture, "The History of Music, with Illustrations," by the Rev. H. Y. Palmer. Friday, December 30th — Meetiug of Singing Class. Thursday, January 5th, 1871 — New Year's Ball. Friday, January 6th — Second ditto. Saturday, January 7th — Meeting of Singing Class. Thursday, January 12th — Lecture, "Thomas Gent, an Old York Printer," by the E^verend Canon Eaine, M.A., Secretary to the Surtees Society. Saturday, January 14th — Discussion Club Conversazione and Meeting of Singing Class. Thursday, January 19th — Magic Lantern Exhibition. Saturday, January 21st — Meeting of Singing Class. Thursday, January 26th — Yocal and Instrumental Concert. Saturday, January 28th — Meetings of Discussion Club and Singing Class. Thursday, February 2d— Ball. Saturday, February 4th — Meeting of Singing Class. Thursday, February 9th — Lecture, " Some African Tribes," by Doctor Needham. Saturday,. February 11th — Meeting of Discussion Club and Singing Class. Thursday, February 16th — Lecture, "Caverns and their Contents," by S. W. North, Esq., F.G.S. Saturday, February 18th — Meeting of Singing Class. Thursday, February 23d — Yocal and Instrumental Concert. Saturday, February 25th — Meetings of Discussion Club and Singing Class. Thursday, March 2d— Ball. Saturday, March 4th — Meeting of Singing Class. Thursday, March 9th — Magic Lantern Exhibition. 296 Saturday, Marcli 11th — Meetings of Discussion Club and Singing Class. Thursday, March 16th — Eeading and Musical Entertainment. Saturday, March 18th — Meeting of Singing Class. Thursday, March 23d— Lecture, " The Northwest Highlands and West- ern Islands of Scotland," b}^ the Eev. Canon Hey, M.A. Saturday, March 25th — Meetings of Discussion Club and Singing Class. Thursday, March 20th — Yocal and Instrumental Concert. Saturday, April 1st — Meeting of Singing Class. Thursday, April 6th— Ball. Saturday, April 8th — Meetings of Discussion Club and Singing Class. Thursday, April 13th — Eeading. Saturday, April 15th — Meeting of Singing Class. Thursdaj^, April 20th — Lecture, "An Analysis of the Franco-Prussian AYar," by ^Y. Wallen, Esq. Saturday, April 22d — Discussion Club Conversazione and Meeting of Singing Class. Thursday, April 27th — Eeading and Musical Entertainment. Saturday, April 29th — Meeting of Singing Class. The lectures and readings commence at six o'clock p. m.; the discussion meetings at half-past six; the balls at seven; the concerts at half-past seven; and the singing meetings at a quarter past eight. NIGHT ATTENDANTS. 1. The duties of night attendants shall commence at eight P. m. on v^eekdays and nine on Sundays, and cease at six a. m., during which period they shall be responsible for the condition of the patients. 2. They are to obtain every night from the attendants on duty in each ward the names of such patients as require particular attention, either on account of their habits, fits, illness, or disposition to self-injury-, and to see that sufficient changes are provided for those whose habits are dirty. Should they find any patients wet or dirty when they go on duty, they must require the day attendants in charge of such patients to attend to them and hand them over to the night attendants in a clean. dry, and proper state; and the night attendants must themselves deliver over to the day attendants all patients in a like proper condition. 3. They shall visit each ward at least seven times in the course of the night, and oftener if necessary, commencing their rounds at eight, nine, ten, and twelve p. m., and at two, four, and half-past five a. m. 4. They shall administer any medicines, extra diet, wine, etc., (which may have been ordered by the Superintendent), at the times appointed; but shall not disturb any patient whom they may find sleeping, for the purpose of administering either food or medicine. A dry cloth or bib shall always be used when any patient has to be fed. 5. They shall visit every epileptic patient on each round of the wards, and see that they are so lying as not to endanger life from suffocation during an accession of fits. Should any patient at any time be found out of bed or lying on his face, or with his head oft' the pillow, he must be put to bed, placed upon his back or side, with his head on the pillow, and shirt neck unbuttoned. 297 6. They shall devote particular attention to all supposed suicidal cases, and remove any articles by which they might possibly injure themselves. 7. They shall use every exertion to improve the dirty patients in their habits, by getting them up at the stated times, and by taking such measures as will tend to keep them clean. Whenever any bedding is found wet or dirty it shall be removed immediately, and fresh clean bedding substituted; or if necessary the patient shall be removed to another room, and the one previously occupied washed out. No patient shall be allowed to remain in a damp or dirty room. 8. The general quiet of the galleries must be strictly attended to, and any noisy patient visited and quieted, or if necessary removed to a room where he will not disturb the other patients. In going round the gal- leries, the night attendants must avoid disturbing the patients as much as possible; and for this purjDose shall wear list shoes, and unbolt and shut the doors quietly. They must also lock and secure the various doors and windows of water closets, etc., on windy nights, to prevent rattling. 9. They shall see that the various galleries are properly ventilated, and shall personally attend to any fires which may require to be kept burning during the night. 10. In the event of any sudden illness, accident, escape, or death during the night, they shall report the same to the Superintendent with the least possible delay. 11. They shall call the day attendants at half past five a. m., stating to them any peculiarity which may have occurred to their respective patients during the night; and before going off duty shall fill up the report for the night, to b^ left in the Superintendent's room. 12. On Thursdays and Saturdays they shall be at liberty from two to eight p. M., and on Sundays from two to nine p. m.; but on other days they will be exj^ected to perform certain light duties in the afternoon. 13. In all their intercourse with the patients, they must bear in mind that they are insane, and consequently not responsible for their actions. Should any of them make use of abusive language, or offer them violence, they must on no account take it as an insult, but, on the contrary, use every endeavor to gain an influence over them by firm yet kind and attentive treatment. g8 298 Ph ^ a c o u !2; o^ P 3 c b > : ^ : ?. -2 J= -r! be O O -^2 -- -5 C O C 2 ci ^ o. w ^ " ^ -73 TJ ^ ^ .r- H-. ^ ft 2 V. ^. bfi .J: 5 ^ o C r^ ^ B B -± m r/J » M -)j -ij i^ -u fl >^ c fl ri C! c C '^ fl ^ a ,0) p. .2 •■43 2 ■+3 .2 "S c3 11 S-i. Q ft ft ft ft ft ft ^H W ^ ^ ;h ^ f- ;-< ;^ ^1 ~ -^ aj o O -e -t-> aftp^ftftftftftft CJOOOOOOOO saaasssss :s^^ eS ni > s. O <1 ^ ^ CJ r> 3 5 o ft OT !>> r> ni T) f) TS e3 a i:::^ a < o 1 rO o O ^ 299 MISSING LIST. Ward, No.. 187 Articlea. Patients. Attendants. Attendant. laundress. "When signed to be given to the Head Attendant. BEOOKWOOD ASYLUM. NEAR WORKING STATION, SURREY. Application for Situation of. * (To be filled up in the candidate's own writing). Name and age Married, single, or widowed * Eeligious persuasion Post address Can you read and write? Brought up to any particular trade, or class of work? Any knowledge of music, vocal or instrumental? Present occupation Name and address of various employers, in regular order, particularly of all recent ones; length of time with each, and cause of leaving. 300 BEOOKWOOD ASYLUM. BATHS — REGULATIONS FOR THE GUIDANCE OF THE ATTENDANTS. 1. Every patient to be bathed immediately after admission, and once a week afterwards, unless exempted by medical order. Should there be the slightest doubt as to the advisability of bathing any patient, owing to sickness, feebleness, or excitement, immediate reference to be made to one of the medical officers. 2. The name of every patient not having the customary bath to be inserted in the daily report sheet. 3. In preparing a bath the cold water is always to be turned on first. 4. Before the patient enters the bath the temperature is to be ascer- tained by the thermometer, and is not to be less than eighty-eight degrees, nor above ninety-eight degrees. In case of the thermometer becoming inefficient from injury, etc., all bathing operations to be sus- pended until another be obtained. 5. Not more than patients to be bathed in the same water. Any infringement of this rule to be entered in the daily report sheet. 6. Under no circumstances whatever are two patients to occupy the bath at the same time. 7. During the employment of the bath, the room is never to be left without an attendant. At all other times the door is to remain locked, and the floor to be kept dry. 8. Under no pretence whatever is iyhe patient's head to be put under water. 9. In the bath the body of each patient is to be well cleansed with soap. After coming out of the bath especial care must be taken to dry those patients who are feeble and helpless, and to clothe them as rapidly as possible. 10. The keys are never to remain on the bath taps, nor are they to be employed by patients. When not in use they are to be locked in the attendants' room. 11. Any marks, bruises, wounds, sores, local pain, evidences of disease of any kind, complained of by the patients, or noticed by the attendant during any of the bathing operations, to be immediately reported to one of the medical officers, and also to be entered in the daily report sheet. 12. Any deficiency in the supply of warm water, soap, towels, etc., to be entered in the daily report sheet. 13. The attendants are to bear in mind that, except under medical order, the baths are to be employed solely for the purposes of cleanli- ness. 14. Neither the cold nor the shower bath is ever to be employed, except under medical order, and then only in presence of one of the officers. When not in use the door of the latter is to remain locked, and the key to be kej^t in the dispensary. 15. It is the duty of the head attendant to be present at all baths employed under medical order, and to take care that the duration does not exceed the time specified in such order. He is also to supervise the whole of the ordinary bathing operations, to ascertain that the rules are rigidly carried out, and to report to the Medical Superintendent every infringement that may come to his knowledge. T. N. BEUSHFIELD, M. D., June, 1867. Medical Superintendent. 301 [Lunati(?8 1. (16 & 17 Vict.) Private Patient.] "Order" for the Eeception of a Private Patient. N. B. — Under all circumstances the "Order" and "Statement" below to be filled up by the patient's relatives or friends. — Sched. (A) No. 1, Sects. 4, 8. I, the undersigned, hereby request you to receive , whom I last saw at , on the (a) day of , 18 — , a (b) as a patient into your hospital. Subjoined is a statement respecting the said . Signed: Name, ; occupation (if any) ; place of abode, ; degree of relationship (if any), or other circumstances of con- nection with the patient. Dated this day of , one thousand eight hundred and . To the Superintendent of Bethlem Hospital, St. George's. Eoad, Lam- beth, S. " Statement." If any particulars in this State?nent be not known, the fact to he so stated. Name of patient, with Christian name at length, j Sex and age, ; Married, single, or widowed, ; Condition of life and l^revious occupation (if any), ; Eeligious persuasion, as far as known, ; Previous place of abode, ; Whether first attack, ; Age (if known) on first attack, ; When a&d where pre- viously under care and treatment, ; Duration of existing attack, ; Supposed cause, ; Whether subject to epilepsy, ; Whether suicidal, ; Whether dangerous to others, ; Whether found lunatic by inquisition, and date of commission or order for inquisi- tion, ; Special circumstances (if any) preventing the patient being examined, before admission, separately by two medical practitioners, ; Name and address of relative to whom notice of death is to be sent, . How many previous attacks ? ; Have any relatives of the fam- ily been similarly affected ? ; State in what degree of relationship, ; Has the patient been of sober habits ? ; Number of chil- dren ? ; Age of youngest ? ; Degree of education ? . Signed: Name, (e) ; occupation (if any), ; place of abode, Degree of relationship (if any) or other circumstances of connection with the patient, r. (a) Within one month previous to the date of the order. (6) Lunatic or an idiot, or a person of unsound mind. (e) The "Statement" must be signed, but "where the person signing the statement 19 not the person who signs the order, the following particulars concerning the pergon signing the statement are to be added." 302 [8 & 9 Vict., Cap. 100. Sec. slv.] N. B. — Medical certificates of patients' examination, and the signa- tures, are required by tke above statute to be dated within seven clear days of the patient's reception. In stating the residence, the number of the house must be specified when there is any. The medical men signing the certificates must not be in partnership, nor one an assistant to the other. By Order of the Commissioners in Lunacy. 1. — It is absolutely necessary that the medical men should write their certificates legibly, so as to aiford the opportunity of an exact copy be- ing made. 2. — "All alterations in the original certificates, unless by the certify- ing medical man, invalidate them; and the initials of the latter must be placed to every change or addition made." 3. — " If a registered medical man describes himself as ' a duly quali- fied registered practitioner,' it is not necessary that he should specify his medical qualifications in full in addition." Medical Certificate.— Sched. (A) Xo. 2, Sects. 4, 5, 8, 10, 11, 12, 13. 1, the undersigned, , being («) , and being in actual prac- tice as a (p) , hereby certify that I, on the day of. , 18 , at (c) [here insert the street and number of house, if any,] , in the County of , separately from any other medical practitioner, personally examined , of {d), [state address and occupation, if any,] and that the said is a (e) , and a proper person to be taken charge of and detained under care and treatment, and that I have formed this opinion upon the following grounds, viz: 1. Facts indicating insanity observed by myself (/) [some definite fact or facts must be specified,] ; 2. Other facts, if any, indicating insanity communicated to me by others (g), [state the name of the person giving the information,] . Signed: Name, ; place of abode, ; dated this day of , one thousand eight hundred and . [Here follows duplicate of above certificate.] _ (a) Here set forth the qualification entitling the person certifying to practice as a phy- sician, surgeon, or apothecary, ex gra.; Fellow of the Koyal College of Physicians in London. (6) Physician, surgeon, or apothecary, as the case may be. (c) Here insert the street and number of the house, if any, or other like particulars. {d) A. B., of , insert residence and profession or occupation, if an^'-. (e) Lunatic or an idiot, or a person of unsound mind. (/) Here insert the facts. Some definite fact or facts must be specified. Please to write the facts legibly and on the lines. (g) Here state the information and from whom received. 303 COMPLAINT AND COMMITMENT. State of California, County of To Honorable , County Judge of said county. respect- full}' represents that there is now in said county a person named , who is insane, and by reason of insanity dangerous to be at large, and is a proper subject for the Insane Asylum; and the said being duly sworn, deposes and says that the foregoing statement is true; wherefore he prays that such action may be had as the law requires, and that the said may be sent to the Asylum of California. Subscribed and sworn to before me, this day of A. D. 18G . . The foregoing application having been made to me, , County Judge of said county, and named in said application, being this day brought before me for examination on said charge of insanity, and having heard the testimony of and witnesses who have had frequent intercourse with the accused during the time of the alleged insanity; and doctors and graduates in medicine, after hearing the testimony of witnesses, and after a personal examination of the accused, having made the certificate by law required, and being my- self satisfied that the said is insane and dangerous to be at large, and is not a case of idiocity, or imbecility, or simple feebleness of intel- lect, or old case of harmless dementia, or of any class of old, incurable, and harmless insanity, nor a case of delirium tremens; and being further satisfied of the truth of all the matters set forth in the said physician's certificate; I do hereby order the said '— to be taken to and placed in the Insane Asylum at Stockton, and is charged with the execu- tion of^this order. As to the ability of the said or his kindred to bear the charges or expenses for the time may remain in the Asylum, as well as all other matters pertaming to interests or possessions, I find, after diligent inquiry the facts to be as follows: 1. The said is by possession of able to pay expenses in the Asylum. 2. I have appointed a guardian for the said and directed a quarterly payment in advance, and a supply of necessary clothing, together with the bond, to be forwarded to the Asylum with the said as by law required of paying patients. 3. The said has kindred in the degree, as by law defined, who are able to pay said expenses, and I have made the assess- ment as by law directed in cases of kindred able to pay. 4. There is due the said for and I have taken steps as by law required to be taken in such cases. 5. There money (in own right) on the person of the said and Witness my hand this day of A. D. 186 -, Judge. PHYSICIAN S CERTIFICATE. State of California, County of ' We, and being sworn, do depose and say that we are graduates in medicine; that at the request and in the presence of Hon. , County Judge of said County, we have heard the testimony, and 304 carefully examined the said in reference to the chaj-ge of insanity, and do find that is insane and by reason of insanity dangerous to be at large. The facts in support of this opinion (elicited by said exami- nation) are set forth in the answers to the following questions as nearly as can be ascertained: QUESTIONS. 1. Name? 2. Age? 3. Nativity? 4. Married or single? 5. If children, how many, and the age of the youngest? 6. If female and married, maiden name and name of husband? 7. What State last from and how long in California? 8. What occupation? 9. What evidence have you of the presence of insanity? 10. Is there a homicidal, suicidal, or incendiary disposition? 11. Is the case a recent one, having occurred within twelve months last past. 12. When did this attack first appear? 13. Is this the first attack? If not, when did others occur and what their duration? 14. Is the disease increasing, decreasing, or stationary? 15. Are there rational intervals? If so, do they occur periodically? 16. Is there any permanent hallucination? If so, what is it? 17. In what way is the accused dangerous to be at large? 18. Is there a disposition tp injure others? If so, is it directed especi- ally to relatives, and is it from sudden passion or premeditation ? 19. If suicidal, is the propensity noio active, and in what way? 20. Is there a disposition to filthy habits, destruction of clothing, fur- niture, etc.? 21. Any relations, including grand parents and cousins, been insane? 22. Any peculiarities of temper, habits, disposition or pursuits, before the attack — any predominant passions or religious impressions? 23. Been intemperate in the use of ardent spirits, wine, opium or tobacco in any form? 24. Suffered from epilqDsy, suppressed secretions, eruptions, discharges or sores, or injured on the head? 25. Any change in the physical health since the attack? 26. The supposed cause of insanity? 27. Of what class of insanity? 28. What treatment has been pursued, and with what effect? , M. D. , M. D. Subscribed and sworn to before me, this day of A. D. 186 . 1 . 305 DIETAEY OF THE INSANE ASYLUM OF THE STATE OF CALIFORNIA, FOR EACH PATIENT. Breakfast. One pint coffee, or more, to satisfy appetite; five ounces loaf l)read; one half pound thick mush, made with corn meal or cracked wheat, fla- vored with syrup. Dinner. One quart soup, made from good fresh meat and beans, rice or fresh vegetables; four and one half ounces meat without bone; five ounces loaf bread; one half pound potatoes; beets, carrots, miscellaneous vege- tables and fruits, grown on the Asylum grounds, are used when in season. Supper. One pint tea; five ounces loaf bread; three ounces gingerbread. The attendants are instructed to furnish as much bread and soup as the patient may desire, except in cases of dementia with morbid appetite. Patients employed on the farm and garden have a lunch of bread and butter at ten o'clock, a. m. and at four o'clock, p. m., in addition to the above. The diet of the sick is prescribed by their medical attendant. Different kinds ^f meats and fish are substituted for beef, and other variations made for a change occasionally, but not regularly, except Fridays, when fish is used as far as practicable. pjch:mond, keae Dublin. Ordinary Diet. — Breakfast: half pound of bread and a pint of tea, or eight ounces of stirabout with a pint of new milk. Dinner: ten ounces of bread to males, and eight ounces to females, with half pound of meat or a British pint of soup. Supper: half pound of bread and a j^int of cocoa. Extra Diet. — Breakfast, ordered by the medical ofiicers, an Qgi^. Din- ner: a pint of beer or porter, half pound of chops, or half pint of beef tea and eight ounces of bread. Supper: a British pint of tea and eight ounces of bread. Hospital Diet. — Beef tea, chops, eggs, wines, rice, arrowroot, etc. 39 306 < P O Q w p ^ Tea Butter. Bread. Coffee. Butter, Bread. Vegetables , Meat stew. Mutton broth. Plum pudding. Baked pie. Suet pudding. Uncooked meat. Irish stew Mutton Broth. Suet pudding or pie. Uncooked meat. Beer Bread or dumpling. Bread. Cocoa , Bread. 6 I Beer *3 P^ Bread and dumpling... a Vegetables I ^ Cocoa I p^ O O O lO o o ^^:^:^:^:^:^:^ <© CC CO -^ 'O CC 'Xi o X' X :c X -^ 00 1^ O -* C5 nil ill ^ 307 EDINBUEGH ROYAL ASYLUM. DIET TABLE. Breakfast for Males, Six ounces oatmeal or two pints of porridge, and three fourths pint of skimmed or buttermilk, or one fourth ounce of coffee; one half ounce of sugar; seven and a half ounces of bread, and one fourth ounce of butter. Females. Six ounces oatmeal or one and a half ounces of porridge, and three fourths pint of skimmed or buttermilk, or one fourth ounce of coffee; one half ounce of sugar; five ounces of bread, and one fourth ounce of butter. Dinner. Sunday — Four ounces of rice; one third ounce of sugar, and one half pint of sweet milk; seven and a half ounces of bread for males, and five ounces for females. Monday — Seven ounces of uncooked meat boiled in broth, with two ounces of barley; seven and a half ounces of bread, or one and one eighth pounds of potatoes, for males, and five ounces of bread, or one and one eighth pounds of potatoes for females. Tuesday — Seven ounces of uncooked meat, stewed or roasted, and eight ounces of vegetables, bread, or potatoes, as on Monday. Wednesday — Broth made with two ounces of meat boiled down in the broth; eight ounces of dumpling of flour, suet, and currants; bread or potatoes as above. Thursday — Seven ounces of uncooked meat made into L-ish stew; bread or potatoes as above. Friday — Pea soup made from two ounces of meat and four ounces of peas; bread or potatoes as above. Saturday — Seven ounces of meat and broth, as on Monday; bread or potatoes as above. Supper for Males, Six ounces of oatmeal or two pints of porridge, and three fourths pint of skimmed or buttermilk, or one eighth ounce of tea; one half ounce of sugar; seven and one half ounces of bread, and one fourth ounce of butter. Females. One eighth ounce of tea; half ounce of sugar; five ounces of bread, and one fourth ounce of butter. Luncheon for Workers. Bread, two and one half ounces; cheese, one ounce; beer, one half pint. 308 "fe' r- « M-i s ^ ss . o- < <» -^ e CK Vj O) o3 .t^ 5 G oT . d'" P, o 2 ^ ^^ rO.O W 53 d t. •2 2, • ^ jj VI ^ Ul O • CD COi-(,-(rH--\i-(.-(COi-(eOi-l O O O-H CO«r>QO "H " i= iS +j c 3 ^ = J. 2 2 a o G O O ft 5§.S§ S 2 2 o :3 ^ ^ ^ — — js . be. \Z-oX -Sr^ 1f^ 3^ ^^5e^ HOOOO » o *^ , fcH in u, ;- fc-J2 -^ O Oqt^CO rH ^ O S3 ft > \ 5 ' ooo o t- o*2 ^OiH' 309 GENEEAL EULES FOR THE SUEEEY COUNTY LUNATIC ASYLUM, AT BROOKWOOD, Pursuant to the fifty-third section of the Act 16 ayid 17 Vict. cap. 97. COMMITTEE OF VISITORS. 1. The Committee of Visitors for the time being, shall meet for the first time at the asylum within a fortnight after their appointment, and shall then (after electing a Chairman), appoint five members of the Committee of Visitors to be a House Committee for the purposes after mentioned, of whom three shall be a quorum. They shall continue their meetings at the asylum throughout the year, by adjournment to Buch times as they shall consider most convenient. 2. At their first meeting, and afterwards as occasion shall require, they shall make such appointments and perform such duties as may be necessary for carrying into full effect the various Acts of Parliament relating to lunatics (16 and 17 Yict. c. 97; 18 and 19 Yict. c. 105; 25 and 26 Yict. c. 111). 3. Minutes of the proceedings of the Committee of Visitors shall be kept and entered by the Clerk to the Visitors, and the same shall be read at the following meeting and signed by the Chairman. 4. The Committee of Visitors shall make, from time to time, such "regulations and orders " as they shall see fit, not inconsistent with the "general rules" for the time being, in force for the management and conduct of the asylum. 5. No general rule for the government of the asylum shall be rescinded or altered, except at a meeting of the Committee of Visitors specially convened for the purjDose; and no alteration in the general rules shall take effect until it has received the approval of one of Her Majesty's principal Secretaries of State. 6. They shall cause all moneys received from every source to be paid to the account of the asylum at the bank of their Treasurer, and they shall make all payments by checks, to be signed by three of their body. 7. A special meeting of the Committee of Visitors may be at any time convened in the manner pointed out by the Act 16 and 17 Vict, cap 97, sect. 25, notice being given of the particular business to be transacted thereat. 8. They shall in addition to the report required by the Act 16 and 17 Vict. cap. 97, sect. 62, present at every General Quarter Sessions of the Peace for the county a summary of their transactions during the preced- ing quarter; and at every Easter session they shall present a report on the state and condition of the asylum, with an audited account of the whole of their receipts and expenditures for the year ending on the pre- cedin^thirty-first day of December. 310 HOUSE COMMITTEE. 1. The House Committee shall visit the asylum twice in the course of every calendar month, and their duties shall be as follows: 2. To inspect the food and see that all contracts are performed; also, to see all the patients and all the wards and premises appropriated to their use, and also to inquire and examine as to the convalescence and improvement of particular patients, and as to the treatment, health, and general condition of the whole establishment, and to perform the general duties imposed on them by the Act 16 and 17 Yict., cap. 97, sect. 61. 3. To audit all the accounts of the asylum, to superintend the farm and garden, to examine all bills due by the asylum, and recommend the same when correct, for payment; to examine all accounts for the main- tenance of patients and for repairs previous to their being sent to the several parishes or to the County Treasurer, and to consider all applica- tions for additional stores and for advances to the Steward for current expenses before they are submitted to the Committee of Visitors, and also to make orders for such advances, not exceeding one' hundred pounds sterling. 4. To give orders, in all cases of emergency, for such works to be per- formed or such goods to be provided as shall be absolutely necessary for the service of the asylum, reporting such orders to the Committee of Yisitors at their next meeting. 5. To keep a record of all their visits and proceedings, and to make such reports or recommendations as they may see fit; all of which are to be read and confirmed at the next meeting of the House Committee and of the Committee of Visitors, respectively. CLERK TO THE VISITORS. 1. There shall be a Clerk to the visitors, who shall be considered the law officer and adviser of the Committee of Visitors, and shall prepare all contracts and legal documents. He shall convene and attend all general meetings of the Committee of Visitors, and also the meetings of the House Committee when required, and shall take minutes of all orders and resolutions, and take such steps as may be necessary for car- rying them into effect. 2. He shall assist the visitors in their examinations of the asylum books of accounts, the quarterly abstract of expenditure or mainte- nance, and the accounts of the Treasurer, and in preparing the visitors' annual report for publication. 3. He shall furnish to the Superintendent a copy of all orders made by the committee relating to the institution or its inmates. 4. He shall transact all the ordinary duties of Clerk to the visitors as prescribed by the statute, and as may be directed by the committee. RESIDENT MEDICAL SUPERINTENDENT. 1. There shall be a Medical Superintendent, who shall be a physician or surgeon and a registered medical practitioner. He shall be resident in the asylum, shalf give up the whole of his time to the duties of his office, and shall not attend to or engage in any professional or other business or employment except that of the asylum. 2. He shall have paramount authority in the asylum, subject to that of the Visitors; shall have control over all the officers, attendants, and 311 servants and '.hall superintend and direct their duties as prescribed bj the reo-uhitions and orders of the Committee of Visitors. He shall be empowered to hire, suspend, or discharge all attendants and servants, subject to the approval and confirmation of the House Committee at their next meeting, when such hiring, suspension, or dismissal shall be reported. ^. , ^ . ^. ^ ^ r 3 He shall be responsible for the condition of the patients, and lor the'management of the establishment, and shall have the full direction of the medical, surgical, and moral treatment of the patients, and of all general arrangements within the asylum. 4. Should any case of difficulty or danger arise, he shall have authority to call to his aid in consultation any registered medical prac- titioner. . , . T ^ 5. He shall visit the wards and offices daily, making occasional night visits also, and report to the House Committee any serious irregularities which may fall under his notice. 6. He shall examine every patient shortly after admission, and shall cause proper entries relative thereto to be made in the books kept for that purpose. i • ^ 7. He shall regulate and determine the diet of the sick and mtirm,^ and shall also from time to time examine and report on the quality of all provisions furnished for the use of the asylum. 8. He shall regulate and determine the bedding and clothing of the patients. , 9. In all cases of fatal or dangerous accident, or other emergency, he shall immediately communicate the fact to the Chairman of the Com- mittee of Visitors. . , r. .u 10. He shall not absent himself for more than one night from the asylum, without the previous written consent of one of the Committee of Visitors; nor for more than one week, without the sanction of the Committee of Visitors or the House Committee; and on no occasion shall he leave the asylum unless in charge of the Assistant Medical Officer, or of some other properly qualified medical substitute. 11. He shall have power to exclude from admission into the asylum persons affected with cholera, or any disease or malady which may be considered cootagious or infectious, and persons coming from any dis- trict or place in which any such disease or malady may be prevalent. 12. He shall keep a journal, in which he shall record the name of every attendant and servant whom he shall hire, suspend, or dismiss, together with the date and cause of such hiring, suspension, or dismis- sal. Also the name of every patient fit to be discharged, or likely to be benefited by being allowed a period of absence on trial. Also the case of every escape, death, and inquest, with such particulars as may be necessary for the Committee of Visitors to be made acquainted. Also all such other facts, observations, and suggestions as he shall deem important, relative to the condition or management of the asylum or the patients therein. And all such entries shall be read as part of the proceedings at the next meeting of the House Committee, or Committee of Visitors, respectively. . . 13. He shall make a yearly report of the number of admissions, dis- charges, and deaths during the year, and shall, in the same report, describe the general condition of the patients, the state and manage- ment of the asylum, and such other matters as he shall deem necessary or the Committee of Visitors may direct. 312 ASSISTANT MEDICAL OFFICER. 1. There shall be an Assistant Medical Officer, who shall be a member of the Eoyal College of Surgeons of London, Edinburgh, or Dublin, and a Eegistered Medical Practitioner. He shall be nominated to the Com- mittee of Visitors on his api^ointment by the Medical Superintendent, under whose control and direction he shall perform his duties. He shall be resident in the asylum and shall give up the whole of his time to the duties of his office. 2. He shall not leave the asylum when the Superintendent is absent, at which time he is to be held responsible for the management of the Institution. In his own occasional absence, he shall conform to the directions he may receive from the Medical Superintendent, as to its duration and the period of his return. Should, however, he desire to be avv-ay from the asylum for more than one night, the written consent of some member of the Committee of Visitors must also be obtained. 3. He shall exercise a general control over the conduct of the attend- ants and servants, and immediately report any misconduct, irregularity, or neglect of duty on their part to the Medical Superintendent. 4. He shall have charge of the dispensary, and shall be responsible for the safe and proper custody of the drugs, surgical instruments, and appliances. CHAPLAIN. 1. There shall be a Chaplain, who shall be a clergyman of the Church of England, in priest's orders, and shall be licensed by the bishop of the diocese. He shall devote the whole of his time to the duties of his office, and not hold any other engagement. 2. He shall perform divine service, according to the rites of the Church of England, in the chapel of the asylum, every Sunday, Christ- mas day and Good Friday, preaching short sermons on each occasion. 3. He shall administer the holy sacrament to such of the officers and servants as may be desirous of receiving the same, at least four times in • a year, and to such of the patients as he may think advisable, with the approbation of the Superintendent. 4. He shall consider all the household under his spiritual care. • 5. He shall attend daily at the asylum, and administer religious con- solation to the patients, subject however to the directions of the Com- mittee of Visitors and of the Medical Superintendent. 6. He shall read morning praj^ers daily at such hours as the Commit- tee of Visitors and the Medical Superintendent may direct. 7. He shall, under the general control and with the cooperation of the Medical Superintendent, organize and direct the schools for the patients of both sexes, and also classes for instruction in the Bible and in singing; and shall take charge of the library, and control the issue of books and periodicals. 8. He shall keep a daily journal in which he shall enter the hours of his attendance, and such other particulars as it may be desirable for the Committee of Visitors to know, which jourjial shall be laid before the Committee at every meeting. 9. He shall never absent himself from his duties on any Sunday, or for more than two days during the week, without leave in writing of one Visitor, and on providing some other clergyman, to be approved of by such Visitor, to supply his place. 313 10. He shall present an annual report to the Committee of Visitors, stating the result of his attendance on the patients. TREASURER. 1. There shall he a Treasurer, to whom all monies shall be paid. He shall keep accounts of all monies received and paid by him and make them up to the thirty-first of December, annually, and state the balance (if an}^) then in his hands. 2. He shall give security for a sum to be named by the Committee of Visitors. CLERK AND STEWARD. 1. There shall be a Clerk of the Asylum, who shall act as Steward. He shall perform all the duties of both those offices, under the control and direction of the Medical Superintendent, to whom he shall imme- diately report whatever he may know to be improper or contrary to the rules in the economy of the house or conduct of the servants. He shall be resident in the asylum and shall give up the whole of his time to the duties of his office. 2. He shall make all the necessary returns to the Commissioners in Lunacy and other authorities, as prescribed by the various Acts of Parliament relating to lunatics. 3. He shall take care of all the books and papers (except those relat- ing to medical duties), and of all the stores, and shall be responsible for the quality, quantity, and safe keeping of all the articles received. 4. He shall examine and superintend the weighing and measuring of all the goods and provisions furnished to the establishment, and imme- diately report to the Superintendent any failure in the quality or quan- tity thereof, and take his instructions thereon. He shall order nothing except under the signature of the Superintendent, and receive nothing into the asylum without an invoice, which must be signed by himself in token of its correctness, and then filed. 5. He shall superintend the weighing and measuring out of the pro- visions so as to suit the diet tables; he shall take stock once a quarter and keep quarterly accounts of all moneys received of and paid to the Treasurer, and also of all goods ordered and payments made for the same, in such form as the Committee gf Visitors shall direct. 6. He shall distinguish the building account from the maintenance account, and the accounts of the county from those of the unions and parishes; and shall lay an abstract of the accounts before the next meeting of the House Committee and of the Committee of Visitors, after the termination of each quarter, showing the moneys received and paid and the unions and parishes in arrear. 7. He shall keep all such books of accounts, and in such forms as may be ordered from time to time by the Committee of Visitors, so as to show the true state of the accounts. These books shall be kept in his office and be subject at all times to the inspection of any member of the committee and of the Medical Superintendent, to whom he shall supply such financial and other information as he may from time to time require. 8. He shall conduct such correspondence as the Medical Superintend- ent may direct, to whom he must submit all letters received by him 40 314 relating to the asylum and its inmates, all of which letters are to be considered the property of the institution. He shall keep copies of all correspondence, whether replies to letters or otherwise. 9. He shall keep inventories of all the household goods, furniture, farming and artisans' implements, of&cial books, medical instruments, and other property of the institution. 10. In his occasional absence from the asylum he shall conform to the directions he may receive from the Medical Superintendent as to its duration and the period of his return. Should, however, he desire to be away from the asylum for more than one night, the consent of some member of the Committee of Visitors must be obtained. 11. He shall give satisfactory security by such sureties as the Com- mittee of Visitors shall from time to time require. HOUSEKEEPER. 1. There shall be a housekeeper, who shall perform her duties under the control and direction of the Medical Superintendent, to whom she shall immediately report whatever she may know to be improper or contrary to the rules in the economy of the house or conduct of the servants. She shall be resident in the asylum, and shall give up the whole of her time to the duties of her oflSce. 2. She shall have charge of the entire kitchen and laundry depart- ments, the officers' and servants' apartments, and central offices, and be responsible for their cleanliness and good order. She shall use her utmost endeavors to prevent waste, and to check any misapplication of stores. 3. She shall have authority over the female servants, directing them in their several duties; and be responsible for the safety and conduct of all patients employed in any of the departments over which she has control. 4. She shall suj^erintend the preparation of the meals for the patients, officers, attendants, and servants, and shall see that the articles of food are properly cooked, and served with neatnesi and punctuality at the appointed hours. 5. She shall superintend and be responsible for the washing, airing, and regular distribution of all articles sent to the laundry department. 6. She shall receive from the steward once weekly all necessary materials to be converted into clothing, bedding, etc., for the establish- ment. She shall cut out and supply to the wards, through the head female attendant, all needlework necessary for the employment of the patients; and when made, return all the articles to the steward, stating their number, with a detailed account of the conversion of the raw material. 7. In her occasional absence from the asylum she shall conform to the directions she may receive from the Medical Superintendent as to its duration and the period of her return. Should, however, she desire to be away from the asylum for more than one night, the written con- sent of some member of the Committee of Visitors must also be obtained. HEAD ATTENDANTS — MALE AND FEMALE. 1. There shall be a head male and a head female attendant, who shall perform their duties under the control and direction of and as prescribed by the Medical Suj)erintendent, to whom they shall immediately report 315 whatever they may know to be improper or contrary to the rules in the economy of the house or conduct of the attendants. They shall give up their whole time and attention to the duties of their oflSce. 2. They shall instruct the attendants in the performance of their duties, and shall at all times require the strictest obedience to any orders which they may give. GENERAL MANAGEMENT. 1. The male and female patients shall be kept in separate wards, and no male attendant, servant, or patient shall be allowed to enter the female wards, nor any female to enter the male wards, except in dis- charge of their duty, or with adequate authority. In visiting the female patients, the medical oflScer shall be accompanied by the head attendant, or some other female officer, and no male shall enter the female wards, unless accompanied by a female attendant. Any male attendant or servant found in any portion of the women's wards, unless he can give a satisfactory explanation for his being there to the Superintendent, may be immediately dismissed. 2. There shall be such a number of attendants as shall be sufficient for the effective supervision of the patients, both by day and night; and no ward shall at any time be left without at least one attendant. 3. During the day the patients of both sexes shall be employed as much as practicable out of doors; the men in gardening and husbandry, the women in occupations suited to their ability; and as a princij^le in treatment, endeavors shall be continually used to occupy the minds of the patients, to induce them to take exercise in the open air, and to promote cheerfulness and happiness among them. 4. The male patients shall be encouraged to follow their particular callings, and to learn shoemaking, tailoring, and other common useful trades. Needlework, strawwork, and other suitable employments shall be provided for the female patients. And they shall be rewarded by such indulgences as the Superintendent may deem compatible with their welfare and encouragement. 5. An ample supply of books, and cheap publications of a cheerful nature, in addition to Bibles and prayer books, shall be provided, and replaced in case of destruction; and various methods of in and out door amusements shall be placed at the disj)osal of the patients of both sexes, and they shall be encouraged to have frequent recourse thereto. 6. Ample and special provision shall be made for the effective watching of the asylum and attention to the patients during the night. 7. 1^0 patient, on any account whatever, shall be struck, or threat- ened, or vspoken harshly to; and no patient shall be placed in restraint or seclusion, or be subjected to any bath (except for the purpose of cleanliness), except by the authority of one of the medical officers. 8. All the attendants shall be responsible for the safety, cleanliness, and general condition of the patients, and for the ventilation, proper warmth, and good order of theii* respective wards. 9. No officers, excepting the Treasurer and the Clerk to the Visitors, shall have any occupation unconnected with the asylum, nor shall they have any interest, directly or indirectly, in any other establishment for the reception and treatment of lunatic, imbecile, or idiotic patients. 10. No officer, attendant, or servant shall, directly or indirectly, take any fee, reward, or perquisite of any kind from any tradesman, patient, or other person, on pain of immediate dismissal. 316 11. Eelatives and friends of patients shall be allowed to visit them once in every week, between the hours of ten and four o'clock, and on such other days and hours as the Superintendent shall in special cases permit; but no visitor shall be permitted to see any patient if the Super- intendent shall state in writing that the visit will be injurious to the patient or otherwise inexpedient. 12. Patients shall be at liberty to hold private conversation with those who visit them, but no male visitor shall remain in a room with a female patient, nor a female visitor with a male patient, except in the presence of an attendant or other third person. 13. The person of every patient shall immediately after admission be carefully examined by the head attendant, who shall at once personally report in writing to one of the medical officers the bodily condition of the patient, and especially of any mark, bruise, or injury of any kind, bedsores, ruptures, or the slightest symptom of disease or disorder of any kind; and it shall be the duty of one of the medical officers, upon receiving notice of the existence of any injury or apparent bodily dis- order, at once himself to make a personal examination of the patient; and no relieving officer or other person bringing a j^atient to the asylum shall be allowed to leave the premises until such report or examination shall have been made. 14. All parish officers shall be encouraged to visit the patients be- longing to their union or parish once in every three months, or oftener, on a week day; and to make particular inquiries from time to time as to the treatment experienced by the patients, and their fitness for dis- charge. 15. [N'otice shall be given to the nearest relative in the case of serious illness to any patient, and especially where a fatal termination is autici- pated. On the death of a patient, notice shall be immediately given to the coroner of the district, the parish officers, the registrar of the dis- trict, and the nearest relations of the deceased (if their address be known), and the body shall be delivered to the latter if requested. If the body be not removed early on the fourth day after death, it shall be buried under the direction of the Superintendent, who shall have power to order an earlier interment, if from any particular circumstance he shall consider such to be necessary. 16. Such patients as the Superintendent may direct shall in such number and at such times as he may think fit, be allowed, under proper care, to take walks or excursions beyond the grounds of the asylum; and he shall also be empowered, at his discretion, to permit patients to spend the day with their friends. Approved. (Signed) GATHOPtNE HAEDY. Whitehall, 28th October, 1867. 317 PEOPOSED CASE BOOK— (ENGLISH). Name. Admitted. Age and Sex. State as to Marriage. "Where from. Occupation. Mstory: Education. Eeligion. {Previous attacks. Hereditary history. Predisposing. Exciting. Duration of Disease. First f Mental. Symptoms. | Bodily. Recent \^^^^[ Symptoms. U^-.^^l^i^ Where treated. Disposition and habits in health. Dangerous. Other facts. State on Admission. ' Exaltation. Depression. Excitement. Enfeeblement. IND. Memory. Coherence. Can answer questions. Delusions. ^ Other abnormalities. ■ Appearance. Color of hair. Color of eyes. Muscularity. Fatness. Nervous system. Eeflex action. Pupils. Special senses. Eetina. ODY. -l Lungs. Heart. Pulse. Other .organs. Tongue. Appetite. Urine, specific gravity. Urinary deposits Menstruation. Temperature. .Hight. Weight, Name of Disease. General Bodily State. 318 Date. Temperature. Pu Ise. Weight Morn'g Even'g Morn'g Even'g Progress of Case. [Memoranda to be put in beginning of Case Book.] HISTOEY. Previous Attacks. Hereditary History. Predisposing Causes. Exciting and Proximate Causes. Number, character of each. Age of parents, relationship of parents or grand parents, health of same, family dis- eases or peculiarities — consumption, epilepsy, drunkenness. Drunkenness, overwork, character of vocation or habits. Food, tobacco, tea, infantile dis- eases, adult diseases. Catamenial irregular- ities, marriage, children, difficult labors, mis- carriages, lactation, etc. Disease of brain emotions — blows on the head, drinking bouts, fever, poisons, over-sexual excitement, childbirth. STATE ON ADMISSION MOEE FULLY AND SYSTEMATICALLY AEEANGED. . — Bodily Condition. a, Hight. b, Weight. c, Temperature. d, Color of hair (baldness). e, Muscularity. /, Fatness. g, Expression of face and general appearance h, Any special injuries or wounds to be noted *. — Vegetative Func- a, Digestive — Tongue, stomach, appetite, con tions. dition of bowels. b, Dermic — Conditions as to moistness, erup- tions, and other abnormalities. c, Circulatory — Pulse, cardiac murmurs, flush- ing of face, or inject of conjunctiva. C. — Eeproductive Fung. TIONS. 319 d, Eespiratory— State of lungs, breath, rapid- ity of respiration. e, Glandular — Exam, of urine, state of liver, spleen, thyroid, etc. a, X). — Nervous System. a, b, Abnorm. of penis or testes in men — mas- turbation, syphilis, etc. In women — Catamenia, discharges, syphili, pregnancy, nursing, etc. Paralysis, epilepsy, catalepsy, hysteria, and other abnormalities unconnected with the special senses or mental functions. Special senses — 1.- -Sight — a, b, c, d, e, A 9^ Color of iris. Shape and size of pupils. Condition of retina. Vision. Knowledge of color. Hallucinations. Illusions. 2.- -Hearing — a, External ear. b, Deafness. c. Hallucinations. d, Illusions. 3. — Smell — a, Any abnormality of nose. Sense of smell. Hallucinations. Illusions. 4. — Taste — a, Sense of. b, Hallucinations. c, Illusions. 5. — Touch and Nervous Sensibility — a, Sense of pain. b, Eeflex action. c, Hypersesthesia. d, Illusions and hallucinations, in- cluding those of internal or- gans. J7. — Mental Symptoms, unconnected with the special senses. a, Apparent consciousness. Identity. Attention. Coherence of language. Memory — a for recent events, b for past ditto. Exaltation or depression of spirits. Excitement of manner. 320 A, Habits and propensities (filthy, dangerous, suicidal, destructive, indecent, etc.) i, As to sleep. j, Delusions— not being hallucinations or illu- sions. A*, Other abnormalities. NOYA SCOTIA CASE BOOK. Eegistered Xo. Previous :N"o3. ^N'ame Admitted — "Where from Brought by Order of Maintenance Certificates Age last birthday Sex state as to marriage Occupation I^atural disposition Habits in health Education Eeligion Address of nearest friend HISTORY. Age at first attack First I Bodily Symptoms J Mental No. and duration J of previous attacks | Where treated f Hereditary history Causation -j Predisposing ( Exciting Duration of present attack Becent ) Bodily Symptoms ] Mental Suicidal, and how Dangerous, and how Other facts 321 Name, Date. Temperature. Morn'g EA-en's Pulse. [Weight Morn'g Even's Progress of Case. MICHIGAN ASYLUM FOE THE INSANE. SITUATION. The Michigan Asylum for the Insane is situated at KaLamazoo, upon the Michigan Central Eailroaci. The location is probaby as central and convenient as any that could have been chosen, having reference both to the present means of communication with the various parts of the State, and to any other routes of travel likely to be projected hereafter. The site selected for the building is upon an irregular eminence, about one mile from the village, and sufficiently elevated above the valley of the Kalamazoo Eiver to secure an extensive prospect, and yet is well sheltered and easy of access from the plain below. The location is in every respect healthful and desirable, and well adapted to the purposes and objects of an institution for the treatment of mental diseases. /ARM. The amount of land originally purchased for the use of the asylum was one hundred and sixty acres, but to secure a more desirable site for the buildings, an adjacent tract was subsequently added, making the whole amount of land in the possession of the institution one hundred and sixty-eight acres (167 7G-100). Most of the land is finely timbered with the original growth of oak, hickory, and other trees, aifording every facility which could be desired for beautifying the grounds. That in the rear of the building is broken, and falls, by a series of ravines covered with trees, about eighty feet to the valley below, through which flows a small but rapid stream of pure water. The buildings themselves will cover an area of one and one third acres. It is designed to preserve about fifty acres in groves and woodland, with walks and drives, and the remainder will be devoted to ordinary agricultural pur- poses. 41 322 GENERAL PLAN. The ground plan was furnished by Doctor John P. Gray, the accom- plished Superintendent of the New York State Lunatic Asylum at Utica, under whose directions the work was commenced. It might here be remarked that the principles laid down in a series of propositions rela- tive to the construction and arrangement of hospitals for the insane, unanimously adopted by the " Association of Medical Superintendents of American Institutions lor the Insane," have been fully carried out in the plans adopted by the Board. The form and internal arrangements of the institution will be readily understood by reference to the accom- panying ground plan. The asylum building proper, the main front of which has an easterl}-- aspect, consists of a centre and six wings. The centre portion of the main building is divided by the entrance hall into two nearly equal parts. That to the right contains, in front, the princi- pal oince of the institution, the apothecary shop, and an anteroom com- municating by a private stairway with the Superintendent's apartments above, and in the rear the matron's room and ladies' reception room; while that to the left contains, in front, the public parlor and officers' dining room, and immediately behind these the steward's office and men's reception room. The second floor is appropriated exclusively to the use of the Medical Superintendent. Upon the third floor are the apartments of the Assistant Phj^sicians, steward, and matron. The base- ment contains the laboratory connected with the apothecary shop, and the officers' kitchen and storerooms. Immediately behind the centre building is the chapel, aTid stiil further in the rear the engine and boiler house. Extending from the centre building tovrard the south for males, and toward the north for females, are the several wards of the institu- tion, nine on each side, including the infirmaries. MATERIALS. The material used in construction is brick, covered with Eoman cement, and sand, and finished to represent freestone. The window caps, sills, and brackets, belt courses, and capitals in front, are of white lim.estone from the Athens quarries, near Chicago. The division walls throughout are of brick. The xVsylum is built upon a system of fireproof construc- tion, nearly all the flood's being laid upon brick arches sprung from iron girders, which, beside providing against fire, give additional security to the building and insure its durability. ARCHITECTURE. The plans selected by the Board of Trustees were placed in the hands of A. H. Jordan, architcci, of Detroit, for the necessary elevations, details, etc. The style adopted is the Italian, it being the lightest, most cheerful, and least expensive for the eflect required in such an extensive range of buildings. REFERENCES TO THE PLATE. (A) public parlor; (B) general office; (C) Matron's room; (D) Stew- ard's office; (E E") receinion rooms; (F) officers' dining room; (G) apothecary shop; (H) anteroom, communicating by a private stairway with the Superintendent's apartments above; (I) Steward's storeroom; 323 (J J) matron's storerooms; (K) associated dormitories; (L) attendants' rooms; (M) ihi}^ and recreation rooms; (N) parlors; (O) dining rooms; ,(U) chapel, having below it the kitchen and storerooms; (1) boiler house; (2) engine and fanrooms; (3) laundry; (4) drying room; (5) ironing room; ^(6) work shops; (7 7 7) covered corridors. APPROPRIATION OF WARDS. The various wards in the institution are appropriated as follows: Nos. 1 and 2 3 and 4 5 and G 7 8 9 Classification. Number of bedi No. of ward^. Convalescent and quiet Less disturbed More disturbed Demented Demented and infirm Acute cases, etc., (Infirmaries) Total 18 Single rooms. Associated dorm it's. 80 56 60 20 12 12 16 32 240 96 88 60 20 12 12 288 The divisions for the sexes are equal. Eight of these wards, inclusive of the infirmaries, are upon the first fioor, six upon the second, and four upon the third floor of the transverse wings. It is considered that by means of these any desirable classification of patients may be carried out. ARRANGEMENT OF WARDS. Each ward has the usual arrangement of corridor, sleeping rooms, day rooms, and dining room, with two stairways, a clothes room, lava- tory, bath room, water closet, soiled clothes shaft, drying shaft, and dust flue to each. The corridors in the first, second, and third wings are, respectively, one hundred and fifty-five, one hundred and sixty, and sev- enty feet long, and in the third stories of the first and second transverse wings, one hundred and nineteen and thirty-four feet long. They are uniformly twelve feet wide, and, in common with all other roOms, sixteen feet in height upon the first and third floors, and fifteen upon the second. The dimensions of the single sleeping rooms are eight and ten by eleven feet, with an average cubic capacity of fourteen hundred feet. The associated dormitories are fourteen by twenty-one feet, and the parlors or recreation rooms, eighteen by twenty. Lateral recesses, extending into the projecting towers in front, form additional da}' rooms in the first and second wmgs on either side. The dining rooms are sufticiently capa- cious to accommodate the number for which they are intended, and are supplied with detached sinks, cupboards, and dumb waiters. ^ The clos- ets, bath rooms, lavatories, and clothes rooms open upon an adjacent and not upon the main hall, giving a very desirable privacy. The bath and closet fixtures are of approved construction, and, to prevent all possible 324 danger from leakage, the service pipes are conveyed in a separate pipe shailt — an arrangement which also facilitates and cheapens any repairs that may become necessary. Drying shafts, having lattice-Vork floors and communicating direct}}^ with the ventilating cupolas, furnish a ready ' means of drying mops, wet cloths, damp brooms, etc., and thus mate- rially assist in promoting the cleanliness and healthfuluess of the cor- ridors. To prevent exposure, the bathrooms and lavatories have communicating doors, in order that the latter may serve, on " bathing days," as dressing rooms to the former. INFIRMARIES. In a detached building, in the rear of the first transverse wings, but connected with the wards by means of a covered corridor, an infirmary is provided for each sex. Fitted up with every convenience, they provide a very desirable place for the treatment of acute cases, of those who are seriously ill, or of any requiring special care and Irequent medical attention. They can be reached at all hours of the night without dis- turbing any other portion of the house; they provide the means of isola- tion in case of the occurrence of any infectious or contagious diseases in the institution, and give to the friends of dying patients an oppor- tunity of administering to them in their last moments. WINDOWS. The windows are fitted throughout with a castiron sash, the upper half of which alone is glazed. Posterior to the lower half, and immedi- ately against it is a wooden sash of corresponding size and shape, moving free and suspended by a cord and weight; the former being attached to the bottom of the sash and passing over a pulley near its top, is always entirely concealed. The panes of glass are six b}^ nine inches in size.^ The windows, where deemed desirable, are protected by a shutter of framed wicker w^ork, sliding into the wall and retained there, as also in. its position, by one and the same lock. FLOORING. The floors in all uncarpeted rooms are formed of one and one half inch oak plank, grooved and tongued, and none of them being more than three and one half inches in width. The sleepers and the iron girders supporting the arches rest upon an offset in the wall, which, when finished, also forms the cornice in the room below. PROVISION AGAINST FIRF. The horrible sacrifice of human life on the occasion of the burning of an institution for the insane in one of the eastern States, and the pecu- liar liability of these buildings to take fire, as shown by the frequent occurrence of such accidents, determined the Board of Trustees, although it would somewhat increase the price of construction, to make the asylum fireproof. The more recent partial destruction by fire of another insti- tution has confirmed the wisdom of this decision. The use of iron gird- ers and brick arches as a support for the floors was consequently deter- mined upon, and to secure additional safety all connection between the wings and the center building is entirely cut off" by the interposition of 325 a verandah of iron and glass, with communication from one to the other only through fireproof doors. The location of the heating apparatus and the kttchen, in detached buildings, renders the institution quite exempt from danger of destruction by fire. CHAPEL. A separate building immediately^ in the rear of the centre building, seventy by forty feet in size, contains upon its first floor a room for chapel purposes capable of seating three hundred and eighty persons. It communicates with the different wards by means of covered corridors, is appropriately fitted up, properly warmed, and lighted with gas. KITCHEN. One central kitchen is intended to supply the whole institution. It is placed immediately beneath the chapel room, with storerooms near at hand, and communicates with the dumbwaiters of the difterent dining- rooms by means of a small car moving upon a covered railway. The building containing the chapel room and kitchen is surmounted by a bell and clock tower. WARMING AND VENTILATION. It is now admitted, as a principle, that the warming and ventilation of buildings corresponding in size and purpose with institutions for the insane should be efi'ected by one and the same process; and also that means should be adopted for expelling the foul air to the same extent and simultaneously with the admission of fresh. The fact is also estab- lished, and in many asylums has been confirmed by a costly experience, that the ordinary system of making the ventilation depend upon the spontaneous action of warm-air currents failed to give satisfactory results. A perfect and equable distribution of fresh air, either warm or cold, and the necessary rapidity in the discharge of foul air, under all circumstances and in all seasons, can be secured only by a system of forced ventilation. This is found to be most eflSciently and economically effected by means of a fan driven by a steam engine — effectual, because at all times under perfect control; and economical, because the warm air is more thoroughly and rapidly distributed. The primary cost is not great; it is not liable to get out of order, and the motive power is that required for other purposes. The system decided upon is a modifi- cation of that in use at the New York State Lunatic Asylum, the effi- ciency of which is shown by the fact that in five similar institutions in other States it has since been adopted in place of furnaces and other means of heating and ventilation already in operation. It consists of boilers, an engine, a fan, heating surface, and distributing ducts, and inlet flues, with exit flues, foul air ducts, and ventilating cupolas. The boilers are four in number; these, with the engine and fan (the latter peculiar from the circumstance of its delivering the air in the direction of its axis), and the heating surface, consisting of a series oi: wrought- iron pipes, are all in a separate and detached building. The air, after Its delivery from the fiin, passes directly forward beneath the chapel. The main duct conveying it gives oft" a small branch to the chapel, and another to the centre building; it then branches toward either wing, and ' another subdivision is made, one portion x)assing beneath the first longi- 326 tudinal wing, and the other, entering the proximal end of the second wing, passes on to the end of the extreme wing. The air passage beneath the building occuj^ies the middle portion of the basement, or rather the space immediately beneath the floors of the corridors, and the distributing flues pass up in the walls upon either side of them. Exit flues are carried up in the same walls, taking their departure from two points, one near the ceiling, and the other near the floor of the rooms on either side; these again conjoin in the attics to form the foul air ducts and empty out into the open air through the ventilating cupolas. Downward currents of air, for the ventilation of the water closets, will be secured through an arrangement of pipes terminating in the fire boxes of the boilers. LAUNDRY AND WORKSHOPS. The right wing of the engine and boilerhouse contains the washroom, drying and ironing rooms; and a similar wing upon the other side fur- nishes convenient rooms for the usual workshops. A close partition running from the rear of the chapel to the engine house, with a covered j^assageway on either side, provides ready and protected access to the shops and ironing rooms from the various wards in the house, and at the same time prevents all communication between the sexes. WATER. Water for drinking purposes is drawn from a well, while that for bathing and laundry purposes is forced up from a stream flowing in the valley, immediately in the rear of the institution. DRAINAGE AND SEWERAGE. Cast iron pipes will be used for connecting drainage in the rear of the wings, and will pass forward beneath the building at a single point only on either side. The drains and branch sewers will unite in front, and pour into the common sewer, which is of brick, egg-shf,ped, three feet high, and two feet wide. This runs down the ravine in front of the institution, and empties into a depot for the collection of solid material. ILLUMINATION. It is now universally conceded that gas is the only proper material to be used in lighting asylums for the insane. To obviate the only objec- tion to its manufacture upon the premises, the gashouse will be placed just below the depot referred to. The gas main will be carried up to the institution in the sewer, attached to its upper arch. The completeness of this description renders any further analj^sis of the internal arrangement of the institution quite unnecessary. To those familiar with the construction of asjdums for the insane a reference to the engraving and lithograph will supply any omission that may have occurred. The j^lans of the building, as given iu the preceding sketch, have been submitted to and received the unqualified approval of many of the more experienced physicians in charge of similar institutions; and from those most capable of judging, the Board have received the grati- fying assurance that their efforts to combine in one the acknowledged excellences of several recently erected establishments, with such 327 improvements as careful study and experienced assistance suggested, have not been unsuccessful. EXPLANATIONS OF THE PLATE. (App. F.) In the accompanying plate, all portions of the institution represented in shaded Imes are already built, with the exception of the " Infirmary for Males "and the chapel and kitchen. The portions represented in outline constitute, collectively, the north wing. "Hall No. 1" constitutes the portion known as the first longitudinal division. Adjoining it at the left is the first transverse division, which is connected with the second transverse division by the second longi- tudinal, designated as " Hall No. 3." " Hall No. 5 " and the wards beyond it are collectively known as the extreme wing. The transverse divisions are three and all other portions of the wing two stories high. The divisions of the north wing are the same. Eeferences.— A, Trustees' room; B, general ofiice; C, Matron's room; D, Steward's office; E, E, reception rooms; F, dining room; G, medical office; H, safe on the left and water closet on the right; K, associated dormitories; M, recesses; N, day rooms; O, ward dining rooms ; U, chapel and kitchen; 1, boiler room; 2, engine room; 3, laundry; 4, drying room; 5 and 6, ironing and distributing rooms; 8, fan room. PENNSYLVANIA HOSPITAL FOR THE INSANE. The Pennsylvania Hospital for the Insane, as now constituted, con- sists of two distinct buildings, each complete in itself, having separate pleasure grounds and inclosures, both situated, however, on the same tract of one hundred and thirteen acres of land originally purchased by the institution. The hospital just completed is styled "the Depart- ment for Males," and that which has been in use during the last nine- teen years, " the Department for Females." Both departments remain as heretofore under the charge of a Physician in Chief, and who now has as associate officers one or more assistant physicians, a steward, and a Matron in each building. This new hospital faces to the west, and consists of a centre building, with wings running north and south, making a front of five hundred and twelve feet; of other wings, connected with each of those just referred to, running east a distance of one hundred and sixty-seven feet, all three stories high, and these last having at their extreme ends communications with extensive one-storied buildings. All the exterior walls are of stone, stuccoed, and the interior are of brick. This arrangement gives provision for the accommodation of sixteen distinct classes of male patients in the new building, as the same num- ber of classes of females are now provided for in that previously in use. Each one of these sixteen wards has connected with it, besides the corridors for promenading and the chambers of the patients and attendants, a parlor, a dining room, a bath room, a water closet, a urinal, a sink room, a wash room, a drying closet, a storeroom for brushes and buckets, a clothes room, a dumb waiter, a dust flue, and a stairway passing out of doors, if desired, without communication with. 328 the other wards; and every room iu the buikling, almost without excep- tion, has a flue communicating with the fresh air duct for warm or cool air, according to the season (and hereafter to be referred to), and with the main ventilating trunks which terminate in the various ventilators on the roof of the building. The centre building is one hundred and fifteen by seventy-three feet. It has a handsome Doric portico of granite in front, and is surmounted by a dome of good proportions, in which are placed the iron tanks from w4iich the whole building is supplied with water. The lantern on the dome is one hundred and nineteen feet from the pavement, and from it is a beautiful panoramic view of the fertile and highly improved surround- ing country, the Delaware and Schuylkill Elvers, and the City of Phila- delphia, with its many pi;ominent objects of interest. In the basement or first story of the centre building 'is the main kitchen, forty-two by twenty-four feet, in which are improved arrangements for cooking — a scullery, twenty-four hy eleven; two storerooms, each about twenty by twenty-two feet; a trunk room, twenty-four by twelve feet; a general clothes room, a bread room, a dining room for the officers, another for the domestics, a lodging room for the seamstress, another for the super- visor of the basement, a stairway to the main story, and a dumb waiter leading from the kitchen to the cellar, and another to the upper rooms of the centre building. The cellars under the centre building, besides containing the hot air chambers for that division of the house, have three distinct rooms for storage, which are ventilated by means of flues leading out through the roof of the house. In front of the basement and under the steps and adjoining roadway are the vaults for coal for the kitchen and bake room, and the ice house, the latter being ventilated as mentioned for the cellars; and carts unload into both, through open- ings in the blue stone flagging, which forms the roadway upon the arches below. Adjoining the ice house is a small apartment with stone shelves, for keeping food cool in Summer; and alongside the coal vault is a space for the oflal from the kitchen. There is also a small kitchen near the scullery, and intended for the Superintendent's family, whenever it is required for the purpose. In one of the storerooms is a dark apartment, and in another the tanks tor the oxygen and hj^drogen gases used in the dissolving apparatus. On the second or principal story is the lecture room, forty-two by twenty-four feet, in the lecturer's table of which, water, steam, and gas, for experimental purposes have been introduced. It also contains com- modious cases for apparatus, a blackboard running on a track behind the cases, and a smooth surface twenty -four by eighteen feet, at its eastern end, on w^hich the dissolving views are shown. On the opposite side of the main corridor is a reception room for visitors, and a room for visits to patients b}' their friends, each being twenty-four by twenty- three feet. There are also on this floor two small rooms for more pri- vate visits, the medical office and library, which is also the Assistant Physician's oflice, twenty-four by fourteen feet, with a small storeroom, containing a sink, etc., adjoining; the lodging room for the Assistant Physician having charge of the medical office, with which it communi- cates; a general business office, which is also that of the steward, twenty- four by twenty feet; a numager's room, twenty-four by nineteen feet, which is also the Principal Physician's private office; a parlor twenty- four by nineteen feet, for the use of the officers of the house, and a fire- proof, eleven by nine feet, in connection with the general business office. In the third story front are four fine rooms, each twenty-four by twenty- one feet; a corridor, forty -two by sixteen feet, shut off from the adjoin- ing portion by a ground glass partition; a batliing room, water closet, and clothes closets, intended at some future day for the use of the family of the superintending physician, whenever such an officer may be specially connected with tluit department. There are also on this floor, chambers for the Steward and Matron, for the Senior Assistant Physician, three others that may be used as deemed expedient, and a room twenty-four by eleven feet, lighted from the roof, and intended for a general storeroom for the bedding and other dry goods not actually in use. The corridors of the centre building, running east and west, are sixteen feet wide; those running north and south, in which are the stairways, lighted from the roof, are twelve feet wide. The height of the ceiling of the basement in the centre building, and of all parts of the wings', which is one foot more, is twelve feet. The ceilings in the second or principal and in the third story of the centre, are eighteen feet high. TheVings on each side of the centre building are almost exactly alike, except that on the south side in front, in the basement immediately adjoining the centre, is the ironing room, twenty-eight by eleven feet, with a drying closet, eleven by eleven feet, attached, and in the rear the small kitchen already referred to, and the lodging rooms of the female domestics; while on the north side in corresponding positions, are the bake room, the baker's store and lodging rooms, and the lodging room of the hired men not employed in the wards. On this floor on each side of the centre is also a museum and reading room, forty-two by fourteen feet, and accessible either from the grounds or from the inside of the building; two work rooms for the patients; two lodging rooms for per- sons employed in the Avork rooms; a bath room for the officers, and another for the domestics; two water closets, etc. The portion of the wing just described is shut off from the adjoining part (which constitutes the fifth ward) by a thick ground glass partition; this ward having in it a large room, twenty-nine by twenty-four feet, with a bath tub and water closets in a recess; another twenty-four by fourteen feet; a third twenty-three by eleven feet, and five rooms eleven by nine feet, a bath room, drjdng closet, and all the other conveniences already mentioned as forming a part of each ward. These apartments and arrangements are all intended for patients who are particularly ill, and who require special quiet and seclusion, where they may be visited, if deemed expedient, by their friends without annoyance to others, or interfering with the dis- cipline of the house. Besides the fifth ward, just described, and which is on the first floor, there are, on each side of the centre, two other stories, each of which constitutes a ward, and with all the conveniences already referred to. The rooms are arranged on both sides of the corridors, which are twelve feet -wide, and have their extreme ends mostly filled with glass; while, wherever one wing joins another, there is entirely across it an open space for light and air eight feet wide, glazed with small sash from near the floor to the ceiling; and in the middle of each ward, on one side, is a similar open space, all of which may be used for keeping flo\yering plants, birds, etc., for having small jets of water, or any other object of interest, and which, in excited wards, may be guarded by ornamental wire work. Each story of the return wing makes a ward similar to those just described. Passing from the return Avings into the Super- 42 330 visor's office, the one-storied buildings are reached. Each of these has provision for twentv-six patients and six attendants, and every arrange- ment for their comfort. The rooms are here on one side of a corridor ten feet wide, and at the end of each of those running towards the east is a cross hall, in which are three roonis intended particularly for pa- tients who from any cause ma}^ require special seclusion. One of the main halls is used for dining, and the other as a sitting room. Between the dining halls of these two wards (the seventh and eighth), and made private by sliding doors, are four rooms intended for excited patients who have special attendants. Opposite these last is a room one hun- dred and ten by fourteen feet, with an arched ceiling fifteen feet high, with skylights and windows out of reach, intended to be used as a kind of gymnasium, and accessible either from the adjacent garden and j^ards, or directly from the wards; and in the story below this is a room of the same size, in which are two fine bowling alleys, with reading tables, etc. Both these rooms may be well lighted with gas, and warmed by steam pipe, so that they can be comfortably used in the evening as well as by day, and in all kinds of weather. The arrangement of these one-storied buildings makes for each two very pleasant yards, in size one hundred and ten by fifty-four feet, sur- rounded by broad brick pavements, and having grass in the centre, with an open iron palisade in front, giving a distinct though sufficiently dis- tant view of two of the most traveled roads in the vicinity. There is also a yard, three hundred and forty -three by seventy-two feet, adjoin- ing each sixth ward, fitted up as the others, and planted with shade trees. Brick pavements also surround the entire building, making, with those just referred to and those in front, a continuous walk of six thou- sand one hundred and fifty-two feet. ENTRANCE. The entrance to the department for males, as before mentioned, is from Forty -ninth street, between Market and Haverford streets. The gatekeeper's lodge has two comfortable rooms on the north, while on the opposite side of the gateway is a dead room and another for tools used about the grounds. Brick paths on either side of the main road- way lead 'to the centre building, and the space in front, planted with evergreen and ornamental trees, and having a fountain in the central grassplat, is three hundred and twenty -five by one hundred and seventy- five feet. From the front platform, eight steps lead uj) to the vestibule and seven steps inside of the building to the level of the principal floor. Visitors passing into the centre building may go out upon a pleasant balcony* on its eastern side and overlook the improvements in that direction, but they cannot pass through the grounds. Ten steps descend from the roadway to the pavement around, the basement, which, except immediatel}^ at the front of the centre, where it is surrounded by a wide area with sodded banks, is everywhere above ground. There is also a gate on Market street, near the engine house, used for bringing in coal or other heavy articles, and another on the eastern side of the grounds, for the use of the officers of the hospital only. ENGINE HOUSE AND LAUNDRY. The engine house, seventy-one feet from the nearest jDoint of the hos- 331 pital building, is a substantial stone structure, seventy by sixty-four feet, and two stories in heigdit. The character of the ground is such that carts drive into the second story to discharge the coal directly into the vaults below, and the level of the railroad in the cellar of the hospital brings it upon the second floor of the engine house. The first story, on the level of the ground on its southern and eastern side, contains vaults capable of containing near five hundred tons of coal. Adjoining these vaults is the boiler room, thirty by seventeen feet, and opening into the engineer's work room, in which will be placed lathes, grindstones, pipe cutting machines, etc., driven by the engines which are in the engine room, twenty three by nineteen feet in size, and separated from the last by a glass partition ; while further west, also separated by glazed windows and doors, is the fan room, and the tower for supplying fresh air to the main duct, which leads from it through the entire building. The height of ceiling in this story is seventeen feet, and it is arched over the engine room and the engineer's work room, so as to give a proper support to the stone floor of the room above. In the second story of this building, into which the railroad passes, is the wash room, twenty-seven by twenty-four feet; the room for assort- ing and folding clothes, twenty-four by fourteen feet; the mangle room, forty-three by eight and a half feet; the drying closet, occupying a space twenty-six by thirteen feet; a water closet, and a large room over the coal vaults and boilers, surrounded by movable blinds, and intended for drying clothes without the use of artificial heat, for making soap, etc. The carpenter shop, thirty-six by fifty feet, is of frame, two stories high, and forty -five feet from the engine house, from which steam may be taken for warming it in the winter. It has two rooms below, and a single large one above. The carriage house and stables make a neat stone structure, fifty seven by thirty-six feet, and two stories high. It has accommodations for six horses and as many cows, and the carriages required for the difierent purposes of the institution. The lower floor is of «ement, brick, or blue stone. The j^iggery is in the yard in the rear of the stables, and there is a carriage yard in front, both being surrounded by a stone wall. SIZE OP ROOMS. The height of the ceilings throughout the building, and the size of the parlors, and of all the rooms in the centre of the building, have been already given. The ordinary size.of the patients' lodging rooms is nine by eleven feet, while there are some in each ward of a much larger size, many of which have communicating doors and are intended for patients who desire a parlor as w^ell as a chamber, or for those having special attendants. The parlors in the first and third wards are thirty-three by twenty-four feet, and in the second, fourth, and sixth, they are twenty- three by thirty feet. The dining rooms are generally twenty-three by seventeen feet. The bath rooms are mostly nine by eleven feet. Six- teen rooms in each one-storied building have water closets in them, firmly secured, and with a strong downward draught. The sides of doors and windows in patients' rooms are generallj- rounded, by being built of brick made expressly for the purpose, and smoothly plastered. WINDOWS AND WINDOW GUARDS. The windows in patients' rooms are almost universally six feet by 332 two feet Dine inches, having twenty lights of glass, six by seventeen inches in each. In the front wings adjoining the centre, and in the third story of the return wings, both sashes are of cast iron, secured in wooden frames, so arranged as to balance each other, rising and falling only to the extent of five and a half inches, and doing away with the necessity for guards. In the other parts of the return wings, and in the one-storied buildings, the windows are of the same size, having the upper sash of cast iron and immovable, the lower being of wood, rising to its full extent and protected by an ornamental wrought iron guard, securely fastened on the outside. A few rooms in each one story build- ing have small windows out of reach of their occupants, and intended for the temporary seclusion of very violent or mischievous patients. In other parts, as well as in this, wire screens inside of the rooms are occa- sionally used to protect glass, and ornamental wire work is adopted in some of the parlors, at the ends of corridors and in other similar posi- tions, as a guard outside of the windows. DOORS. The doors throughout are made of the best white pine lumber. In the wards the}^ are one and three fourth inches thick, six feet eight inches high by two feet seven inches wide. Each door has eight panels in it, one of which makes a hinged wicket, and what is commonly known as bead and butt, very substantially put together, and wherever special strength is required it is obtained by transverse pieces of iron let into the wood, or by plates of boiler iron screwed on and painted so as to resemble an ordinary door. Each door has a good dead lock to it, and occasionally a mortise bolt is added. Over each door is an unglazed sash, thirty-one by seventeen inches, covered with fine wire on the inside, or a space thirty-one by five inches, which can be filled up at pleasure by a tight board or by wire. Lift hinges have been used for all these doors, whidi for patients' lodging rooms always open into the corridors. FLOORS. The floors throughout are of the best yellow pine, cut to order in Florida and piled up on the grounds two years before it was used. The boards are one inch and a quarter thick, varying in width from two and a quarter to four inches, and put down with secret nailing. Counter ceiling is everywhere used. The onlj^ exception to this kind of flooring is in the two kitchens, the scullery, a sj^ace in the basement hall in front, the bake room, all the sink, water closet, and wash rooms, the line between different wards, the entrance to the stairways, and the main wash room in the engine house, which are of brown German flag- stones laid on brick arches; the engineer's work room, which is paved with brick; the front of the boiler room, which is of iron and blue stone flagging; and the engine room, one sink room, and all the ward stair- ways, which are of slate, admirably adapted to such a j^urpose, and. which has also been used extensively for window sills, stairways, and other purposes. STAIRWAYS. All the stairways in those parts of the building occuj^ied by patients are fire proof. The framework i§, of cast iron, built into the brick work on each side and covered with slate, which has many advantages. The 333 rise of these steps is only seven inches, and there are pLatforms every five or six steps, with convenient handrails on botli sides from top to bottom. They are all well lighted by windows by day and by gas at night. The well around which the stairs wind is used for hat or coat rooms for the different stories. PLASTERING. The inside plastering is what is called hard finish, composed of lime and sand, without plaster of Paris, except for ceilings, and well trowelled. This fihish admits of being scrubbed for years without injury, and is at all times ready for painting. The outside of the building is rough cast, the material used being the pulverized stone of which the house is built and lime, to which an agreable shade of color is given by sand. Hy- draulic cement is used near the ground in certain j^ositions, in many of the sink and wash rooms, in the kitchen and scullery, in the main wash room, and as a substitute for the ordinary wash boards in many of the ward corridors and patients' chambers. ROOFING. The roof is of Pennsylvania slate, fastened on lath, and plastered with hair mortar on the under and upper edges, and on the joints of the slate. The pitch is one fourth of the span. The water from the roof is carried off through four inch cast iron pipes, inside of the building, and easily accessible, into large drains leading into the main culvert. SEWERAGE. The main culvert is two thousand and thirty-two feet in length. It is thirty-five inches from top to bottom in the clear, built of brick laid in hydraulic cement, egg-shaped, the smaller part being at the bottom. Beginning near the intersection of the north return wing and one-storied buildings, at which point it receives various pipes from the adjacent wards, it passes under the main chimney, by the engine house and barn, and extends to Mill Creek, into which it discharges just before it reaches Market street. Through this culvert all the drainage from the building and much of the grounds is carried off, being intersected by branch culverts at various points in its course. BATH ROOMS, WATER CLOSETS, ETC. There are twenty-one bath rooms and as many water closets in the building, in addition to those in the patients' rooms. Sixteen are in the wards. Each bath room has in it a cast iron bath tub, covered with zinc paint, and with improved arrangements for the admission and dis- charge of water through the bottom. In addition to the ordinary hot air flue, there is a coil of steam pipe for direct radiation in each, so that when hot baths are used the temperature of the room may be made so high as to prevent the sensation of chilliness when coming froni the water. The water pipes in these rooms arc generally of galvanized iron, left exposed, so as to be readily accessible, and passing from story to story through castings made for the purpose, so that in case of leakage the ceilings may not be injured. The water closets are of cast iron, enameled, have no traps, but are 334 open, so as to have a constant downward draught of air tlirongli them into the main chimney, as have all the sinks, bath tubs, etc., in the whole establishment. The water is let on by the opening of the door. The wash basins in the wash rooms are of marble, with strong swing cocks. The sinks are of cast iron, and have hot and cold water at each. There is also an iron hopper to each, and into which the slops, etc., are emptied. There are permanent fixtures for securing the towels m each wash room. The di'ying closets are sufficiently large to contain a bed, and like the closets for buckets, etc., have fines leading into and from them, and thus secure a direct communication with the fan belo.w and the ventilating ducts above. All these arrangements in each ward are clustered together, and have scarcely any wood in any part to absorb moisture or retain unpleasant odors. SUPPLY OF WATER. The new hospital is suplied with water from a well twenty-five feet in diameter, containiDg fifty thousand gallons, and into which, as meas- ured at the dryest period of the last year, is a daily flow of thirty thou- sand gallons of excellent water. There is also a constant stream of spring water passing near the well, which can at any time be turned into it. By means of one of Worthington's combined direct acting steam pumj^s, capable of raising ten thousand gallons per hour, this water is forced through seven hundred and eight feet of six inch cast iron pipe into the four boiler iron tanks in the dome, and from which it is distributed through the entire building. These tanks are one hundred and three feet above the well, and contain twenty-one thousand gallons. The}' are so arranged that one or all may be used at pleasure; have overflows and pipes through which they may have the sediment washed out whenever deemed desirable. The elevation of these tanks is suffi- cient to secure the feeding of the steam boilers when carrying a pressure of forty pounds to the inch. These tanks were made at the works and put in place before the roof was on the building. It is intended that they shall always be about full of water, and a small pipe leading from them to the engine house tells the engineer on duty when that is the case. There is also in the engine room a single ^Yorthington steam pumj:*, capa- ble of raising five thousand gallons per hour, and intended to prevent any possible deficiency of water should an accident happen to the larger engine. The rule is that both should be used some part of every day, so that in case of emergency there may never be a doubt of their being in working order. The tank for su2:)pl3ing the centre building with hot water is twelve feet in length and twenty-three inches in diameter, and is i^laced above the cooking range, the heat being supplied through circulating pipe from a waterback behind one of the range tires, and is abundant for all purposes. The supply of hot water for the wards is derived from six iron tanks placed in the most convenient points in the cellar, in which situations they are easily accessible, and leakages can do little injury to the build- ing. The heat is derived from steam coils coming from the summer pipe (as it is called) used for cooking and all other purposes except warming the building. The large steam boilers at the engine house are supplied with hot water by the condensed steam used in heating, which ordinarily returns to them by gravity, but when it does not is received into an iron tank and forced into them by a small steam pump. The laundry has hot water from a large tank placed in the oven^ which 335 covers the boilers, and tlirongh which the exhaust steam from the engines and pumps can be made to pass whenever desired, and which nnty be also used for feeding the large boilers. There are three wells of excellent water besides, at convenient points near the building, and which supplied all the water required in its erection. A fourth is now beini»- sunk near the stable. -'to LIGHTING. The hospital is lighted by gas from the city works. The fine meter is placed in the engint room, and a record is made every morning of the consumption during the preceding night. Stopcocks are placed at con- venient points for checking the flow of gas through the main pipes, and the ordinary kinds of fixtures have been adopted throughout the build- ing. The gas is also used for experimental purposes in the lecture room, and for boiling water, etc., in the medical office. FURNITURE. The furniture is intended to be neat and plain, but of a comfortable and substantial character; the amount in the various apartments being in a great measure dependent on the character of the patients occupying them. Carpets of some kind generally cover the parlors, and some por- tions of the corridors and chambers. Wardrobes, tables, mirrors, and other conveniences are frequently added to the bedsteads, which are of various kinds, mostly of wood, but many are of wrought or cast iron, painted of a light color, a few of which last are secured to the floor. HEATING AND VENTILATION. There is no fire used in any part of the hospital for heating, although provision for open fires has been made in all the parlors and in many of the other large rooms, should such an arrangement ever be deemed desirable. The only fires kept up in the building are those in the kitchens, bake and ironing rooms. In the boiler room at the engine house there are three large tubular boilers. Each of these has a furnace five feet three inches wide by five feet three inches long and seven feet four inches high. The shell is seventeen feet eight inches long by four feet six inches in diameter. Combustion chanlber four feet long, and ninety-eight tubes two and a half inches in diameter and eleven feet long. The total heating sur- face for each is seven hundred and forty-four square feet. The grate surface is twenty and a quarter square feet. The escaping gases enter a common flue, and the draft can be regulated by a damper at the back end of each boiler, or the supply of air graduated by a register in the ashpit door. These boilers furnish steam for warming the entire hospital, and for driving all the machinery, pumping water, for ventilation, washing, cooking, etc. They are so arranged that one or all may be used at pleasure, either for heating or driving the machinery. The steam is carried from them in a five-inch welded iron pipe, and after reaching the hospital building, it is distributed in eighty-three air chambers, placed in its cellar, with direct flues leading from them to the apartments above. The gases from the boiler fires pass through an underground flue, four feet wide and six feet high, a distance of five hundred and fifty-seven feet, rising thirty-one feet in its course, till it comes to the foot of the main chimney, which is seventj-eight feet above the surface of the ground. The chimney is built double, the interior being round, formed of hard brick, without pargeting, six feet in diameter in the clear from bottom to top, the latter being formed of cast iron, while the foun- dation is of pointed stone work to a height of eleven feet, and the re- mainder of pressed brick. The underground flue alluded to contains the main steampipe until it reaches the nearest point of the building, and also that portion of it which is carried to the north section of the hospital, and is immediately over the main culvert. This chimney is made the ventilating power for securing a strong Jownward draft of air through all the water closets, urinals, sinks, and bath tubs in the entire establishment, and for this reason is placed in a central position on the eastern side of the building. The coils for heating are composed of welded iron pipes, three quarters or one inch in diameter, and are in two sections m all the air chambers, so that one or both may be used, according to the severity of the weather. In the engine room are two horizontal high pressure steam engines of fine finish. They are exactly alike, each having a cylinder ten inches in diameter and a stroke of twenty-lour inches. The}^ are so arranged that either may be substituted for the other, and one may be made to do the work of both in case of emergency. Ordinarily, one drives the fan, and is therefore a part of the ventilating apparatus, while the second drives all the other machinery. The fan is of cast iron, its extreme diameter being sixteen feet and its greatest width four feet. It is driven directly from the shaft of the engine, and its revolutions vary from thirty to sixty per minute, according to the requirements of the house. The fresh air is received from a tower forty feet high, so that all surface exhalations are avoided, and is then driven through a duct, which at its commencement is eight and one half by ten and one half feet, into the extreme parts of the building. From "the cold air duct openings lead into the difterent warm air chambers, which in the one stoned buildings are covered with slate; but in all other parts of the hospital these chambers and air ducts are arched with brick laid with smooth joints. The warm, air in nearly all cases is admitted near the floor and the ven- tilators open near the ceiling always in the interior walls. The only exception to this arrangement is in the one storied buildings, in which, in the patients' rooms, the warm air is admitted above and the venti- lators are taken off near the floor. All the ventilating flues terminate in the attic in close ducts, either of brick or wood, smoothly plastered, increasing in size about thirty per cent more rapidly than the capacity of the flues entering them, and by which, through the different belvi- deres on the roof, they communicate with the external atmosphere. In the centre building the ventilation is through the main dome. There is no leaden pipe used in the building. COOKING AND DISTRIBUTION OF FOOD. All the cooking is done in the central kitchen, which has in it a large range with two fires and three ovens, a rotary roaster, a double iron steamer containing ninety gallons, a smaller one — iron outside and cop- per tinned on the inside — containing forty-five gallons, and six of tin for vegetables, besides the vessels for tea and coffee. The food prepared in this room is put into closed tin boxes, which are lowered by a dumb waiter to the car standing on the track of the railroad, where it passes 337 under the kitchen, and is thus conveyed to the bottom of the various dumb waiters which lead directly to the different dining rooms above, of which, as before remarked, there is one for each ward. Each dining room has a steam table with carving dishes on it, and abundant provis- ion for keeping meats and vegetables warm as long as may be desired. The dumb waiters are all controlled by the person having charge of the railroad; they are moved by a crank and wheel, and wire rope is substi- tuted for that commonly adopted. The railroad is an indispensable part of the arrangements for distributing food. By its use a meal may be delivered in all the ward dining rooms (eight in number) on one side — the extreme ones being five hundred and eighty feet distant — in ten minutes after leaving the kitchen, or for the whole sixteen in twenty minutes. It also forms a very convenient mode of transporting articles from one section of the building to another, carrying clothing to and from the laundry, and gives a protected passageway in going from the centre building to the engine house, barn, and workshoj), and for persons visiting their friends in the room set apart for the purpose between the sixth and seventh wards. PROVISION AGAINST FIRE. As already mentioned, no fires are required in the building for warm- ing it, and gas is used for lighting. Wherever one wing comes in con- tact with another, or with the centre building, all the openings in the walls, which extend up through the slate roof, have iron doors in addi- tion to the ordinary wooden ones, and which may be closed at pleasure. The floors of the kitcl^en and bakeroom, in which alone tire is used, are of German flagstone laid on brick arches, and all the stairways in the wings are fireproof. It is intended that there should always be about twenty thousand gallons of water in the tanks in the dome of the centre building, and fifteen thousand gallons per hour may be placed there by the pumping engines. A standpipe connected with this reservoir j^asses into every story and into every ward, in all of w^hich it is intended to have a piece of hempen hose constantly attached, so that by simply turning a stopcock water may be put on a fire almost as soon as discov- ered. A steam pipe also passes up into the attic of each wing, and as one of the large boilers is constantly fired up, steam may at any moment be let into the building by simply turning a valve in the cellar. Hose is also kept near the steam pumps, so that it may be promptly attached and water thrown on the barn, carpenter shop, engine house, and contiguous parts of the hospital. A watchman is constantly passing through the house at night, and by means of two of Harris' watch- clocks, as made by H. B. Ames of JSTew York, there is no difficulty in ascertaining not only how often each ward is visited, but almost the moment the visit was made, and of course the time taken in passing from one ward to another. LAUNDRY ARRANGEMENTS. The clothing, bedding, etc., collected in the different wards, after being sent to the cellar, are conveyed from that point by the railroad to the room for assorting clothes in the engine house, and thence into the largo wash room, in which, besides the usual washing, rinsing, and blue tubs 43 338 and soap vat, is one of the valuable Shaker washing machines, in which six different kinds of clothes can be washed at the same time, and a cen- trifugal wringer, both of which are driven by one of the steam engines. From the wringer the washed articles are taken to the drying closet, in which by means of the heat derived from* the exhaust steam from the engines passing through a large amount of cast iron pipe, and fresh air from the fan, they are in a very few minutes made ready for the mangle (also driven by steam power), or folded and taken by the railroad to the ironing room near the centre building, to which they are raised by the dumb waiter alread}^ referred to, or are sent directly to the principal clothes room, from which they are distributed by the same route as they may be required in the wards. All the divisions of the washing machine, of the rinsing and washing tubs, have hot and cold water and steam introduced directly into them, and the water from them all is carried otf under the stone floor of the room to one of the iron columns below, through which it passes into the culvert on the outsi-de of the building. PLEASURE GROUNDS, GARDENS, AND YARDS. This new hospital is situated in the midst of its pleasure grounds, embracing about fifty acres, and from most parts of which are fine views of the surrounding country; the boundary wall being so arranged, from the natural character of the ground, or made so by excavations, that little of it can be seen from any part of the building that is occupied by patients. There are two pleasant grovps of natural forest trees v/ithin the inclosure, and several hundred others, evergreen and deciduous, that have already been planted or collected for the ^purpose, will give an ample amount of shaded drives and walks. A carriage road has already been made on the inside of the wall throughout its extent, and winding by the gardens and terraces around the buildings will ultimately be two miles long. The foot walks are not to be less extensive, and the brick pavements about the building have been already mentioned. There are also, as may be remembered, three pleasant yards on each side of the building, and connected directly with the adjacent wards. The vegeta- ble garden will contain about eight acres, and is in full view from the north side of the building. Flower borders have been made near to and around the entire structure. The only fences inside of the inclosure are to give privacy to the patients in the yards, or to prevent those walking about the grounds from approaching certain parts of the building. COST. Without a statement of the cost, no account of such a building and such arrangements as have been described would be at all complete, and especially not of one like that under notice, which is entirely the offspring of the benevolence and liberality of a community, a result of practical Christianity, and a generous recognition of the paramount claims which such afliictions of our fellow men have at all times upon our interests and our sympathies. The style of architecture is plain, and all useless ornament has been studiously dispensed with; but whenever the comfort and welfare of the patient were concerned, everything has been done in a thorough manner. The amount of money paid on account of the new building and its varied fixtures and arrangements, up to the present time, is three hun- dred and twenty-two thousand five hundred and forty-two dollars and 339 eighty-six cents, and a further sum of about thirty thousand dollars will be required to meet the other liabilities that have been incurred. Of this total sum, twenty thousand two hundred and seventy-six dollars and twenty-eight cents have been for the boundary wall and gate house; two thousand two hundred and forty-one dollars and forty-six cents for the carriage house and stabling; eight hundred dollars for the carpenter shop; four thousand four hundred and tifty-six dollars and three cents for machinery of different kinds; twenty-three thousand six hundred and twelve dollars and thirty-seven cents for heating and ventilating appa- ratus; fifteen thousand two hundred and one dollars and forty-seven cents for grading, for building, planting, and improving the grounds; and ten thousand four hundred and forty-one dollars and seventy-three cents for furniture. PLANS, DESCEIPTIONS AND ESTIMATES OF THE BOSTON HOSPITAL FOE THE INSANE AT WINTHEOP. Boston Lunatic Hospital, . \ Boston (Mass.), September 28, 1867. j To the Board of Directors for Public Institutions: Gentlemen: Three months ago the committee on the proposed new ''Hosj^ital for the Insane " referred the '-j^lans" to the architect (N. J. Bradlee, Esq.) and myself, with the request that we would give them a thorough revision. That has been done and the result is before you. While not doubting that experts of larger experience niixy discover defects and suggest improvements, we are at a loss to see how, without great expense, the plans can easily be materially improved. Such a hospital structure, containing no provision that can well be dispensed with, and requiring not a dollar for mere ornamentation, will be no discredit to the humanity, intelligence, and good taste of Boston. These j^lans have my hearty and unqualified approval. Yery respectfully, CLEMENT A. WALKEE, Superintendent. construction of the building. The exterior walls will be of brick, with granite trimmings, sur- mounted by a brick cornice and French roof. The grouping of the several wings, falling back as they do from the centre and from each other, with their several projections and bays, will give a very pleasing effect to the whole. basement. This story, which will be from four to six feet above the level of the ground, will contain five hundred and four hot air chambers, each being two feet by five feet, for the pipes to heat the building. The basement 340 of the rear centre building will contain store rooms and vegetable cellars. • PRINCIPAL STORY. The general plan of the building consists of a centre building, three stories high, sixty feet by ninet^^-two feet, a building in the rear of the centre, two stories high, forty-nine feet by one hundred and fifty-six feet, and two wings of three sections each, two being three stories high. The first section on each side is fifty-six feet by one hundred and fifty- four feet; the second section, fifty-six by one hundred and forty-five feet nine inches; the third section, two stories high, fifty-seven feet by one hundred and twenty-one feet nine inches; one being at each side of and at an angle of forty-five degrees to the second section. This gives eight distinct wards for each sex, the ininimum required (by unanimous vote of the Association of Medical Superintendents of American Institutions for the Insane) in a hospital for two hundred patients; this designed for three hundred. The principal story of the centre building contains Superintendent's room, twenty feet square; private room, seventeen feet by twenty feet; Assistant Superintendent's room, seventeen feet by twenty feet; apoth- ecary's room, twelve feet by seventeen feet; library, twelve feet by seventeen feet; dining room, twenty feet by forty feet; pantry, seven- teen feet by twenty feet; and six large closets. The rear centre building will contain: reception rooms, twelve feet by eighteen feet; attendants' dining room, eighteen feet by forty feet; store room, eighteen feet by twenty-six feet; kitchen, twenty feet by forty- two feet; laundry, twenty feet by forty feet; ironing room, twenty-two feet square; pantry, six feet by fifteen feet; bakery, fourteen feet square; bread closet, seven feet by twenty -three feet; tin closet, six feet by fifteen feet; oven, ten feet by twelve feet; drying room, ten feet by eigh- teen feet. The first section on each side of the centre will contain fifteen single rooms, eight feet six inches by fourteen feet; sitting room, twenty -two feet by thirty feet; bay window, eighteen feet by twenty feet; reception room, thirteen feet by twenty-one feet; attendants' room, thirteen feet by twenty-one feet; bath room, nine feet by fourteen feet; storeroom, nine feet by fourteen feet; dormitory, seventeen feet by twenty-seven feet; dining room, sixteen ieet by thirty-four feet. The second section on each side will contain sixteen single rooms; general store room, twenty feet by twenty-three feet; the other rooms are the same as described for first section. The third section will contain twelve single rooms, eight feet six inches by fourteen feet; open corridor, twenty-eight feet by sixty -two feet; dining room, seventeen feet by twenty feet; storeroom, ten feet by seventeen feet; attendants' room, fourteen feet by seventeen feet; bath room, ten feet by seventeen feet. SECOND STORY. The second and third stories of the first and second sections are divided the same as the first story of said buildings, and the second story of the third section is also like the first story of the same. The attics of the first and second sections will furnish pleasant and desirable infirmaries. The attics of the third section will aff'ord ample and con- venient room for the isolation of small pox and other contagious diseases. 341 The second and third stories of the centre building are arranged to accommodate the Superintendent and his family, with his assistants. The second story of the rear centre building contains a chapel, forty-five feet by seventy-five feet; domestics' room, fourteen feet by twenty feet; billiard room, eighteen feet by forty -five feet; storeroom, twelve feet by twenty feet. The main centre building and the first section on each side, also rear centre buildings, are connected by corridors ten feet wide. THE ENGINE HOUSE Is located one hundred and three feet distant from the rear centre building, and is forty-seven feet by seventy-four feet, containing a boiler room thirteen feet by fifty-seven feet; engine room, fourteen feet by twenty-four feet; fan blower room, thirty-two feet by fourteen feet; fuel rooms, fourteen feet by twenty -three feet, and fourteen feet by thirty-four feet; connected with this house is the large chimney, fifteen feet square at the base by one hundred and eighty feet in height. CONSTRUCTION. The outside cellar walls are to be two feet thick of stone laid in cement mortar; the wails above are of brick twenty inches thick, laid hollow, the outer walls being twelve inches, an air sj^ace of four inches, and the inner wall four inches thick. The interior walls on the side corridors will be also twenty inches thick, so as to leave room for the ventilating and heating flues to pass through them. To render the building as nearly firei:)roof as possible without going to the expense of brick arches and iron beams or girders, all the plastering will be done directl}^ upon the brick walls without furring; the floors will be plas- tered between the floor boards and the base or plinth around the rooms, and corridors will be of face brick, painted; all the inside partitions will be also of brick. To give some idea of the size of the building, it may be stated that it will require one thousand seven hundred and seventy-five perches of stone for the foundation. Seven million seven hundred and fifty thou- sand two hundred and fifty bricks will be used in the walls; sixty-two thousand eight hundred and twenty-nine yards of plastering; three thousand two hundred and twenty-four feet of gutters, with two thou- sand twenty-two feet of conductors; eighteen thousand two hundred and fifty feet of gas pipe; one million two hundred and eighty-nine thousand four hundred and eighty-eight feet of lumber; one thousand two hundred and thirty-eight windows; fifty-nine thousand four hundred and twenty-four lights of glass, and nine hundred eighty-nine doors; five hundred and four being required for the pipe chambers in the base- ment. HEATING AND VENTILATION. The building will be arranged so as to hereafter decide upon the best method of heating, whether by hot water, high or low pressure steam, all of which systems have their strenuous advocates. The ventilation of all the waterclosets will be effected by the downward draft to the heated chimney; the ventilation of the wards will be likewise arranged for the downward draft; there will also be j^rovided in the boiler house, a fan blower upon the Doctor Nichols plan, to be used as occasion may require. ,342 The high chimney will be so constructed as to form a large ventilating flue entirely around the boiler flue, to assure a steady draft. The under- ground air flues will be eight feet in diameter, diminishing in size as they approach the third section, with small branches to each of the several hot air chambers in the basement story. COimTY OF SLTEPtEY ADDITIO:NrAL LUNATIC ASYLUM. At Brookwood, near Woking. The additional asylum for the pauper lunatics of the County of Surrey is designed to accommodate six hundred and fifty patients, and stands on an estate of about one hundred and fifty acres in extent, at Brook- wood, about three miles from the Woking station on the South Western E ail way. The site is bounded on the south by the Basingstoke Canal, and on the east and west by the high roads to Guildford and Chertsey. Few sites could be found in the country better adapted for such an institution. The soil, a primary consideration, is a dry sand, with occasional veins of gravel, loam, and clay. The ground rises gradually from the south and west about seventy feet above the level of the canal, and the buildings are erected on a plateau of some extent, with a fine range of views and southern aspect. The plan of the building gives to every part uninterrupted views of the surrounding country, and free access to light and air. The principal entrance with the visiting Justices', Superintendent's, Porter's, Steward's, and waiting rooms form the central portion of the north front of the main building. To the west of the entrance block is the laundry wing, with the rooms for the female working jDatients and their attendants. On the east side oi the entrance block corresponding to the laundry wing just described, are the workshoj^s and the apartments appropriated to the patients engaged in them. In the centre are placed the kitchen, offices and stores, so arranged that the service on the male side is perfectly separated from the female side. The apartments for the Assistant Surgeon and the matron, vv^ith dis- pensary and stores, are grouped together in the centre of the south building, near the wards for recent cases, which with the infirmaries form the rest of the south front of main building. The height of the rooms occupied by the patients on the ground floor is twelve feet, and on the upper floors eleven feet. ^ Fifty superficial feet, or nearly six hundred cubic feet, are allowed to each patient in all dormitories, except those in the infirmaries, where the cubical contents exceed seven hundred feet per patient. The smallest separate sleeping room is nine feet by seven feet, which gives seven hundred cubic feet; in the infirmaries they vary from eleven feet by eight feet seven inches to fourteen feet by ten feet. The day rooms, except one on each side of the wards for recent and acute case, are all on the ground floor. 343 Lavatories, water closets, baths, slop rooms, store rooms, and closets are provided iu all the wards. To the east and west of the main building are placed detached blocks with associated day rooms and dormitories for the accommodation of ninety patients in each building. These blocks are connected with the main building by covered passages. The buildings are constructed in stock brickwork, relieved with a few coloured brick dressings and sailing courses. The stairs are of stone in all parts occupied by the patients, with the well holes built up. The floors of all day and slee])ing rooms and of the south corridors and corridors in infirmary wings are boarded. The sashes generally are of wood, double hung with locks and keys, to prevent their being opened beyond a certain height. The doors to all patients' rooms have solid panels, and all angles are rounded. The day rooms and corridors have open fireplaces, in which are warm air grates, so constructed that warm air is admitted either into the room wdth the fireplace, or conducted to the chamber above. Provision has been made for the introduction of warm water pipes in case any auxiliary heating power should be required. In both day rooms and dormitories ventilating Aujcs for the extraction of foul air are formed, having sectional areas, in proportion to the sizes of the rooms, connected wath the towers by large air shafts formed in the roofs. The sew^age is conveyed from water closets, sinks, etc., by means of pipe drains to filtering tanks, so placed and constructed as to permit of the distribution by gravity of the filtered water over a considerable por- tion of the land under cultivation. The Superintendent's house is a dctatched building placed to the southwest of the main building, near the boundary of the airing, grounds for the female patients. Plans of the floors of this house are given, and show with sufiicient clearness the arrangement and accommodation provided. The house for the gardener, in which accommodation has been pro- vided for twelve of the more quiet patients, is situated in the east of the main building, about tw^o hundred yards from the entrance to male airing grounds, and near the kitchen garden. The farm baililf s house, in which accommodation has alsO' been pro- vided for tw^elve patients, adjoins the farm buildings. The gas works are placed to the northwest of the main building about sixty-five yards from the laundry block. The chapel is a detached building, designed to accommodate three hundred and forty-three persons, very simply constructed,, with plain gothic headed windows and doors. Ventilating dormers are provided in the roof, and the building is heated by Haden & Son's apparatus. There is a chancel with vestry to the north. From the entrance of main build- ing to the south porch of chapel the distance is about two hundred yards. The detailed statement of the accommodation provided for the patients in the several parts of the building is as foUow^s, namely: RECENT CASES. Female side — Ground floor: Single rooms, eight. First floor: Single 344 rooms, eight; dormitories, twelve. Second floor: Dormitories, forty- five. Total, seventy-three. Male side — Ground floor: Single rooms, eight. First floor: Single rooms, eight; dormitories, twelve. Second floor: Dormitories, forty- five. Total, seventy-three. INFIRMARY. Female side — Ground floor: Dormitory, six; single rooms, three. First floor: Dormitories, twenty-four; single rooms, four. Second floor: Dormitories, thirty-four. Total, seventy-one. Male side — Ground floor: Dormitory, six; single rooms, three. First floor: Dormitories, twenty-four; single rooms, four. Second floor: Dor- mitories, thirty -four. Total, seventy-one. SOUTH FRONT. Female side — Second floor: Dormitories, thirty-two. Male side — Second floor: Dormitories, twenty -two. NORTH FRONT. Female side — First floor: Dormitories, twenty-five. Second floor: Dormitories, twent}^ Total, forty-five. Male side— First floor: Dormitories, five. Second floor: Dormitories, eighteen. Total, twenty-three. LAUNDRY BLOCK. First floor: Dormitories, sixteen; single rooms, two. Total, eighteen. WORKSHOP BLOCK. First floor: Dormitories, sixteen; single rooms, two. Total, eighteen. DETACHED BLOCKS. FEMALE SIDE. MALE SIDE. Ground Floor. Dormitories 20 2 68 Ground Floor. Dormitories 20 Single rooms Single rooms ... 2 First Floor. Dormitories First Floor. Dormitories r>8 Total Total 90 90 licceiit cases.... Infirmary Soiitb front North front.... Laundry block. Detached block Total 3 SUMMARY 45 OK TOTALS. Kccent eases 1 73 71 32 45 73 Infirmary South front 71 22 North front 23 18 90 Workshop block Detached block IS . . 18 Bailifi"s house Gardener's house 12 12 j Total 329 321 The buildings, with all the necessary work and fittings having been completed, the institution was opened in the Summer of eighteen hundred and f?ixty-seven. The cost of the buildings, exclusive of fittings, and engineers and ga§ works, amounted to the sum of sixty-one tliousand nine hundred pounds sterling. C. H. HOWELL. Architect. 44 EKRATA. .Page thirteen, tentli line from bottom, for '"eleven " read "seven." Page fort^^-seven, nineteenth line from hottom, for "excess " read "sexe?." Page iifty, fifth line of second paragraph, for " courses " read " causes." Page eighty-eiglit, ninth line from top, for " seventeenth " read "nineteenth." The tables of " Results of Treatment," on pages two hundred and live, two hundred and six, and two hundred and seven, should come immediately after "Results of Treatment," . »n pagi^ two hundred and two. Page sixty-four, Mrst column ligures. fifth line, for "260,247" read "560,247." m mQMm^ Appendix F.- PI. 1 WARD BUILOiNC SO. Hot Air Chambers. | 31 32. Serving Roo Nath't J. Bradlee, . CENTRE 8UILD1NQS H'tll. rwridor Sitting Rooms. Store-Roovis Pantry. Kitchen. Laundri). Drying Room. Railroad. Serving Room- Workshop. CMar. 35. Medical Stores BASEMENT m Appendix K.- I'l. •^^'^'tz;|>t^ 4^'^-' l't?rniVr-t!./i'i:iJ SlM m -\pi>(Mi(lix p. — PI WA 1. J tall. 2. CorrUlnr. «. Bay Windoii-. 4. Sitting- Room. f>. Heccption Room fi. .Ut''/id'a)itx' Rooi CEN TRE BUILDINGS. 1. HaJL 1 Ki. Libyan/. 2. 6'o?-rirf(>r. 1 17. Pantry. S. Jieception Room 1 IS. Kitc/ieti. 7. IHuiny Room. ]<>. Bakcrv. 10. Store- J:«om. 20. tf/-ertc/ C7o.5ef. 12. Mater- Clo.sft. I'l. J'in Closet. i;j. Svpf.-^ Ro,;,,. 22. Ove/i. u. Ass't Snpft: Roi Hi. 2.-;. Laundry. J 5. Apothecary's. 24. Tro7iing Rnom •Ih. Dry; >fl Hoo'ii. FIRST STORY. kppi-ii'lix I-'.— PI. xxV <^ V ^1 " ^' ' ' " ''"■■'"'« Appendix F.— PI. 3- ^ J jKgSIrTTTXIJTTTXg^fj FOR THE INSANE. PUT — f T-™ Ttrn I 1i : m i .JfoiiniI>iniEti ill F^ fir FhAhT OF THE r'KNNKYlLVANlA miSiriTAIi, FOH. TME IINHANE. Appendix FPi. ^, TTTTT1 m (NriMARY^OR FEM/ALES. "i'iiim[ _«' .RCS fOR FEIVdALE PATIENTS. ULAMAZOO. Appendix F. Pi. -^ '^'^^^^SfMOTlfefS ^^^.IWI] pTTTTTl im [TTTTn MICHIGAN ASYLUM FOR THE INSANE, KALAMAZOO. Al'.V-PI...^ < (;KOrXl) PLAN. PL, 7 yxy.^.>ixi(^ ^' COlNrV Ol SlKIiKY m:w rorATY lixai u asym m J S.ali- Ktr.rl I.. |Ih-1ii^ A-^M^' f>S$-/^ 'i^'!^^/ /- a / ...^ m U : f^^p^ ^-■a rrx; / / PLAN 1)1 1 IHSI 1 l,()()M CH)l T» CX)I XT AP.F- PL.T Scale 1 , AP. 1 - 1'I..7 COl'XTV OF .sriiUKV XKW (X)rXTY U XATK^ ASVU'M . S(-;«l<> lO 1I H) Ihc Iiic h ' I V'^ T-.r--' V I "iT=7.°ri tiir — " 1 — ■^ ,.C..,0„.| IM AN or SKCOM) I'l.OOH AP. IWh.H. Ht AHOIT X 77.700 y A(:( ((ALMOHAIKS .iHo PAl'l'lOK PATIKMS Day Roomp. Altendiim's Rooms. DreBsing Rooms. Sculleries. Central Public Booms. Medical Soperiatendeofi! Room. Kotrnnce lo Med. Siiperinteudent's HouBe. 'S'iBUing Room. Porter's Room. Entrance to .Assistant Med. Officer's Roonn. Chaplain's Room and Library. Committee Room. Do. Retiring Room. Department, Officers, etc. V St™ t J § Aiv 1- . rr.s. COST AIM) IT X 77.70 Detached Buildings and Tard. B . Steward's Honse. C . Housekeeper's Rooms k Rooms for Domestic SetT^ne. . Lanadry Block with Ward attached, a . Sorting and Receiring Room. b . Washing Hoase. C . Do. for Fool Linen, d. Drying Ground. 6 . Drying Clo.=et. f . Ironiug Room. £ . Workshop Block with Ward atfRohed. a.a . Tailor a aod Sboemaker'ff, b.b . Maitress Makers. C.C . CarpcDter'a. d.d . Painter's. e.e . Y&rd for Workshops. F. Engiaeer's Yard, including Engine Honse. Plumber's and Smith's Shops. Gasworks. Steam and Hot Water Boilers, Steam Engine and Well. Stable Yard wiih Shod. Do. Med. ! Cliurch. Entrance Lodge. Female Airing Court! Male Airing Courts. Kitchen Ganlen. PLAN OF FIRST FLOOR OCCUPIED ENTIRELY BY SLEEPINQ ACCOMMODATION AND THE NECESSARY CLOTHES STORES. LAVATORIES. ETC.. ETC Reference I*. Dormitories. 2. Sinffle Rooms. 3. Attendantt. 4. StOTM. 5. Bath. 7. Lavatories. 10. Head Attendant's Rooms. (6. Assistant Medical Officer's Room/. A. Medical Superintendent*! House. B. Sieward^s JJousp.. C. Houaekeeper and Domtttic Servants F. Engineer's Bouse. [inn [^feai^LFg-fe^;^ -t Soa/e of f'ff/. AF. F - I'L.ll ^ LIWATU^ ASYLl >r. MKKHKNUKIU;. XKAU lIAAltl.KM (.lioiiml Plan and Klovation. B Ar. I- - I'L.ii ;3^j-T^T:Trrr-^?"rHP^fE['f?T-|-7r-:-T-yT±Tj r-TTl'-—^—-'- •'—".-'•" — -;—- -r+-t-r-'-L-J--J--i — -U---X- + 4-r;Tn b±t+^-\--'—- '"Id tar r"' p=i ^^M E 11-^ I ^s , , ! I l._L!IIIhK--iIifflio;ii--ni£I!l rK ' br^ 1-1-4 ^ 7? L _L j_ _i. 1 — I T:n _ J. J. — J lULCLJLnj] n n n J, n n i 1 1. ^^r^-r-T-iT , ■■ ■■ : ■ ,^ ; : i ill n n n n n_n,n7nrff ni nilMfl.D.iiiinii-r '' C ASYLLl IG, NKAR HAA ri-' : '— .U*.F. PL.l^ LUNATIC ASYLUM. MKEllENUKKi;. NKAR HAAHI.KM . Plan of iho Hrsl Slor\: .U».F. PL. 12. fiw:r AP. 1\ VVAll. Officer's Buildings, lirA'ATK ASYH'M IX A'IKXNA. M 1 ^nwvwwwww^vwwwviX^ nr [e^.Tin.-Erji!i;aj Female Dmsions, >„< Bath Roomst Tor let a Bedroom for 3d CIuss Pali Harloi- ami Dining Rnoine Bedroom for 3d Cla«8 I'alii Economic Department. ninnn > ti _ T I — i n \}\ V PI. i;i. Officer's Buildings. d fiath Room fur Ut and 'i e First Steward's Room / Kitchen for WaTming W •J Pasteboard and Straw W k Billiards and Dining Kooni^ Paper banger SUop Cabinet Maker and Tumet Shop , Bedroom for M Class Patients ^^il 1,^., Ss^ (..ii.U'ii 'E r— m^. j^-^ — lE-^L. t^: U-L iti^i t?^ SSI.:! ^i--da HW.~ , u'r^i |t- j4'jx\.u:ou T 1T-T— V*- ^ ^^ r^CFt ZLT GENERAL PLAN. M''II SOIIIEK, SupcriiilPiident, l)o( loi I'OHKT, Mpdical Direclnr. Descrixrlion of Plan ftnlml 'Utiildiitq Ibrt/cui'itil Vsc . Tr--J^i *^- L-rl. '/ G leth,- mehc l.iO.mV) . ](alf Side 2 Chiipi-I. 'A Sitf)nt'nft1fntUtits 'JitiittlOnf. .'» . liittrtitiitttsoi' the Stntvnt. 8 Wmiiiams,-. 3 BnlUHaus, 10 'HiiiMiiul Ihr llif i/iiirt'lUlunt!: 11 'Jinitifniil lorllii luilf'tfliiff. \i Clhlhrl/i, i.whiU. lilnlilm.in- U) W///«/. iii/,'/i.