'*% %$ y- v\' O0 x *■ * »<*. ^* v ** % V°°x a- &, i A. o\ ■^% ^ -> V- • / . ^> ^ v^ ■> O o N **■ +, V v ^ 0° \^ 1 « ,, \ & ^ ^ ^ \ ^. A c, v>- **b o o ^ -n*. >4> *r> J 1 • * J- V *> -% \»°*. " • «• • f Of CONTENTS CHAPTER I. INTRODUCTORY. Powers, Duties, and Appointment of Commissioner — Importance of the Commis- sion — Asylums Visited — Number 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 1 CHAPTER II. INSANITY A DISEASE OF THE BRAIN. "What is Insanity? 8 CHAPTER III. INSANITY AS IT NOW EXISTS. The Subject Generally — Insanity in England — In Scotland — In Ireland — In Prance — In Italy — In Prussia — In Austria — In German States — In Bavaria — In Switzer- land — In Belgium — In Holland — In Denmark — In Sweden — In Norway — In New South Wales — In the United States — In California 8 CHAPTER IV. CAUSES OF INSANITY — SOME OF THE INFLUENCES OPERATING IN ITS DEVELOPMENT. General Observations — Assigned Causes — Physical Causes — Moral Causes — Observa- tions upon Assigned Causes — Principal Assigned Causes — Insanity Pound in all Countries — Enumeration of the Insane — Tables Kelating to Enumeration — Enu- merations Imperfect — Difficulties in the way of a Perfect Enumeration — Influence of Age — Influence of Age in the Different Eaces — Influence of Sex — Influence of Marriage ~ 32 CHAPTER V. INFLUENCE OF SOCIAL DISTINCTIONS. Diseases of the Brain Peculiar to no Class in Society 49 IV CHAPTEE VI. APPARENT INCREASE OF INSANITY. Increase of Insanity Demonstrated 54 CHAPTEE VII. INSANITY IN PRANCE. General Statistics of the Insane from 1854 to 1866 — Doctor Motet's Analysis of Le- goyt's Work 6Q CHAPTEE VIII. INSANITY AMONG THE ANCIENTS. In the time of the Ancients — In the Middle Ages — In the Eighteenth and Nine- teenth Centuries — In England — In France — In Rome — In the Germanic Con- federation — Observations upon Foregoing Subjects — Cruel Treatment the Result of Ignorance — New 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. INSANE ASYLUMS, LOCATION, SIZE, SITES, ETC. Location — Influence that Distance ought to have on Location — Effect of Multi- plying Hospitals — Effects of Railroads and other Facilities of Travel — Hospitals Better Known to Neighboring People — Observations on Foregoing Topics — New York State Lunatic Asylums — General Suggestions — Propositions relative to the Structure 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 Necessary — Comments upon Kirkbride's Views 108 CHAPTEE X. INSANE ASYLUMS— DOCTOR MANNING'S REPORT. Synopsis of Doctor Manning's Report — Comments upon the same 144 CHAPTEE XL CRIMINAL INSANE. An important question connected with the care of the insane should not be passed by without notice •• 161 CHAPTEE XII. CHRONIC INSANE. Provisions for Curables and Incurables in Separate Institutions 164 CHAPTEE XIII. TREATMENT 0E INSANITY. Treatment in English Asylums — Mania — Epilepsj 7 connected with Insanity — Paraly- sis connected with Insanity — Melancholia — Observations on present Treatment of Insanity 165 CHAPTEE - XIY. INSANITY IN GENERAL. Increased attention to Insanity — Growth of Hospitals in United States — Increase of Hospitals in United States — Increased Accommodation — Hospitals exhibit Insan- ity — Non-residents — Should other States send their Insane to California — Insanity in other States — Results of Treatment — Curability of the Insane — Effects of Early Treatment — Good-Hospitals necessary to Favorable Results — Results in our Asy- lum — Doubtful and Hopeless Cases — Economy of Early Treatment — Probable Duration of Life in Chronic Cases — Increase of Patients in our Asylum — Causes tending to this Result — 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 Subject of Insanity — Psychology recommended to be Taught in Medical Schools — Effect of the Liberal and of the . Economical Plan of Care and Treatment 188 CHAPTEE XY. .ECONOMY 0E PROVIDING AMPLE CURATIVE ACCOMMODATIONS. The Economy of Restoration, and the Amount Saved the State by the Cures already Effected in our Asylum 218 CHAPTEE XVI. PLAN BEST ADAPTED TO CARE AND TREATMENT OE THE INSANE. General Observations — Cottage System — Farm Asylums — Close Asylums — Pavilion Plan 222 APPENDICES 231 INDEX. Page. Asylums visited 2 Acknowledgements 7 Asylum at Stockton overcrowded 136 Asylum at Stockton should be finished 137 Asylums. New one needed 137 Asylums. Results in California 194 Asylums. Increase of patients in ten years 197 Asylums. Duty of State 212 Asylums. Manning's Report 144 Attendants 187 Asylums in process of erection 190 Asylums. Good ones necessary to favorable results 194 Asylums. Location, size, etc 108 Asylums. Influence V)f distance 109 Asylums in New York 117 Asylums. Propositions relative to the structure 121 Asylums. Best plan 222 Asylums. Growth of. 189 Asylums. Should be in healthy locality 138 Asylums, Quantity of land necessary 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 VI 11 Duration of insanity 196 Enumeration of the insane 40 Enumeration. Difficulties of. 40 Enumeration imperfect ' 40 Effect of multiplying hospitals 112 Effect of railroads 115 English Lunacy Commissioners 124 Economy of early treatment 195 Effects of liberal treatment 215 Economy of cure 218 Establishment of asylums in the British Provinces 190 General results 205 Introductory I ' 1 Importance of the Commission 1 Insanity a disease of the brain 8 Insanity as it now exists. Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity .Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity Insanity 8 9 10 12 14 in England , n Scotland in Ireland in Prance in Prance. Motet's Analysis 66 in Italy 15 in Prussia 16 in Austria 17 in the German States 19 in Bavaria 20 in Switzerland 21 in Belgium 22 in Holland 23 in Denmark and Sweden .■ 25 in Norway 26 in New South Wales 27 in the United States 28 in California 30 Causes and influences producing it 32 Assigned causes 32 Observations 34 Insanity. Comparative view of assigned causes 36 Influence of age 41 Influence of sex 46 Influence of marriage 47 Influence of social distinction 49 Insanity. Apparent increase of 54 Insanity among the Ancients 86 Insanity in the Middle Ages 93 Insanity. Condition of in England 94 Insanity. Condition of in Prance 97 Insanity. 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. Restraint and seclusion lOG Insane. One to four hundred and eighty-nine 13Q Increased mortality in Stockton 137 Insanity. Treatment of. iq*, Insanity in general 188 Insanity. Duration of the disease 193 Information. Sources of 7 APPENDICES. Appendix A — Statistical tables of United States 238 List of Asylums in United States 234 List of Asylums in Canada 246 Appendix B — List of Asylums in England 247 List of Asylums in Scotland 257 List of Asylums in Ireland 262 Appendix C — List of Asylums in Belgium 268 List of Asylums in Holland 272 List of Asylums in France 279 List of Asylums in Italy 280 List of Asylums in German States and Switzerland 282 List of Asylums in Germanic Confederation 284 Appendix G — Appendix G 289 List of Asylums in France 291 Appendix H — Opening of the Sussex Lunatic Asylum 294 The Asylum Bootham, York 294 Night Attendants 296 York Asylum 298 Missing List 299 Brookwood Asylum 299 Complaint and Commitment 303 Physician's Certificate 303 Dietary 305 Richmond, near Dublin 305 Sussex County Asylum. Diet scale 306 Edinburgh Royal Asylum. Diet table 307 Quartres Mares, near Rouen 308 General Rules for the Surrey County Lunatic Asylums 309 Proposed Case Book. (English History) 318 State on admission more fully arranged 318 Plans, etc., of the Boston Hospital for the Insane, at "Winthrop 339 County of Surrey Additional Lunatic Asylum 342 INSA^ITl 7 T AND INSANE ASYLUMS. CHAPTEK I. INTKODUCTOKY. Powers, Duties, and Appointment of Commissioner — Importance of the Commission — Asylums Visited — Number of Patients in Asylums Visited — Other Institutions Vis- ited — Plans of Asylums — Statistical Tables — Meetings of. Superintendents Attended — Importance of such Meetings — Books Obtained for the State Library — Sources of Information — Acknowledgments. POWERS, DUTIES, AND APPOINTMENT OF COMMISSIONER. An Act authorizing the appointment of a Commissioner to visit the* principal Insane Asylums of the United States and Europe, approved February eighteenth, eighteen hundred and seventy, directs the Com- missioner to visit such asylums as soon as possible, and to collect and compile all accessible and reliable information as to their management, the different modes of treatment, and the statistics of insanity, especial attention being called to the asylums of Great Britain, Ireland, France, and Germany. He is further directed to make a written report to the Governor, in which he shall embody at length a history of the manage- ment adopted at such asylums, a statement of the different modes of treatment in use, and such statistics as he may deem reliable. The Governor conferred the honor of this appointment upon me, and being in entire accord with my tastes and desires, having for a long time felt a deep interest in the subject to be investigated and an earnest sympathy for that class of our fellow beings in whose behalf the inves- tigation was ordered to be made, I entered at once upon the duties assigned me. IMPORTANCE OP THE WORK. Appreciating the importance of the subject, and feeling that the peo- ple, and especially those whose duty it is to make our laws, protect our citizens, and provide for the care and maintenance of our unfortunates, should have all the light that the wisdom and experience of the learned men in other States and countries could shed upon a subject about which so little is known by the great mass even of the reading public, the work was entered upon with some misgivings, but a sincere hope that the laudable object of the mission might be crowned with success. The law is a comprehensive one, and opens a wide field for interesting investigation and extensive research; one in which many an eminent man has spent a lifetime of labor and of thought, which it has been our object to search for, to find, and to appropriate. We have not gone forth with the expectation or even the hope of originating anything upon the subject, but rather to collect the accumu- lated truths gathered by the wisdom and experience of other men in other lands, that we might bring them home to California and strew them broadcast before our people. We did not for a moment suppose that a tithe of this information could be embodied in a report, however elaborate. The diversity of subjects necessarily touched upon would render it impossible to enter fully into the consideration of any; yet it is hoped that the attention of those who desire further light on a matter of so much interest to the State, the citizen, and the philanthropist may be directed to the channel where it exists in abundance, and where it may be found by a little patient and careful research. To all such, therefore, who can find in the accompanying report only a fragment of what they desire to know, let us say, look to the shelves of our State Library, recently replenished with a liberal list of the most valuable works ever contributed by the mind of man to the science of psychol- ogy, and you will find nearly all that exists on the important subject to which we desire to attract your especial attention. Having spent a sufficient length of time at Stockton to become thor- oughly informed with regard to the condition, construction, and require- ments of our asylum, its general management, good features, and glaring defects, we started out to compare them with what could be found in other States and countries. These comparisons have in some respects been in our favor, and, as might naturally -be expected, against us in others — in what particulars we will endeavor to point out in due time, and trust, while we commend our virtues to our brethren for their adop- tion, we will with equal alacrity and liberality give up our defects and substitute them with some of the excellent features of other institu- tions. ASYLUMS VISITED. During these investigations, one hundred and forty-nine Insane Asy- lums in complete working order have been visited, making an average of two each week during the whole period. Forty-five of these were in the United States, one in Canada, fifteen in Italy, three in Bavaria, seven in Austria, eleven in the German States, two in Switzerland, thir- teen in France, eight in Belgium, three in Holland, twenty-four in Eng- land, ten in Scotland, and seven in Ireland, the names, locations, and names of the Superintendents of which will be found in the table fol- lowing: Name of Asylum. Name of Superintendent. United Statj:s: Insane Asylum of California , Alameda Park St. Vincent State Lunatic Asylum St. Louis County Asylum Eastern Asylum Western Asylum : Central Lunatic Asylum Maryland Hospital Mount Hope Retreat Eastern Lunatic Asylum Western Lunatic Asylum Tennessee Hospital North Carolina Insane Asylum South Carolina Insane Asylum Government Asylum State Lunatic Hospital Pennsylvania Hospital Insane Dep't Philadelphia Almshouse . Eiiends' Asylum State Lunatic Asylum State Lunatic Asylum Kings County Lunatic Asylum Bloomin gdale Asylum .' New i'ork City Lunatic Asylum Willard Asylum BrighamHall State Criminal Asylum General Hospital for the Insane Retreat for the Insane Vermont Asylum for the Insane Maine Insane Hospital New Hampshire Asylum for the In- sane , Butler Hospital for the Insane State Lunatic Hospital State Lunatic Hospital State Lunatic Hospital McLean Asylum lor the Insane Boston Lunatic Asylum Michigan Asylum Iowa Hospital for the Insane Illinois State Hospital for the Insane. Indiana Hospital for the Insane Longview Asylum Southern Ohio Lunatic Asylum Canada: Provincial Lunatic Asvlum Italy : Provincial Lunatic Asylum Capo di Chino Asylum (private) Morotrofio Santa Maria di Pieta Santa Margherita Bonifazio (provincial Insane Asylum) Provincial Asylum , San Servalo St. John and St. Paul Senavra Insane Asylum Dufour , Colombo Rossi Asylum Presso San Celso Stockton, California Alameda, California St. Louis, Missouri Pulton, Missouri Near St. Louis, Mo Williamsburg, Va Staunton, Va Near Richmond, Va Baltimore, Maiyland ... Near Baltimore Lexington, Kentucky... Hopkins ville, Ky Near Nashville Raleigh Columbia Near Washington, D. C Harrisburg, Pa Philadelphia, Pa Philadelphia. Pa Philadelphia, Pa Trenton, ]Sew Jersey ... Ltica, New York Platbush, Long Island.. Bloomingdale, N. Y Blackwetl's Island Ovid, N. Y Canandaigua, N. Y Auburn, N. Y Middletown, Conn Hartford, Conn Brattleboro ... Augusta G. A. Shurtleff. Euston Treanor. C. H. Hughes. Charles W. Stephens. D. R. Brower. P. T. Stribbling. D. B. Conrad. R, F. Steuart, William H. Stokes. John W. Whitney. James Rodman. J. H. Callender. Eugene Grissom. J. F. Ensor. Charles C. Nichols. John Curwen. Thomas G. Kirkbride. D. D. Richardson. J. H. Worthington. H. A. Buttolph. John P. Gray. Edw. R. Chapin. D. Tilden Brown. R. L. Parsons. J. B. Chapin. George Cook. James W. Wilkie. A. M. Shew. John S. Butler. William H. Rockwell. Henry M. Harlow. Concord ., James P. Bancroft. Providence, R. I John W. Sawyer. Worcester, Mass I Merrick Bernis. Northampton, Mass J Pliny Earle. Taunton, Mass j William W. Godding. Somerville, Mass i George P. Jelly. Boston, Mass j Clement A. Walker. Kalamazoo i E. H. Van Deusen. Mount Pleasant ' Mark Ranney. Jacksonville j Henry F. Carriel. Indianapolis | Orpheus Everts. Longview, Ohio 0. M. Langdon. Dayton, Ohio R. Gun dry. Toronto Joseph Workman. Genoa Naples I Dr. Avesa. Aversa •. Antonio Ratfo. Rome ; Joseph Girolami. Perugia [ Cav. Guiseppe Neri. Florence ] Dr. Cardini. (?) Bologna ' Fiances Foucarti. [rio. Venice ! P. Prosdocimo, D. Sale- Venice i Antonio Berti. Milan ; Mombello Milan Milan Milan Milan Rinaldo Gectano. F. Franceso Corbetta. Achille Colombo. Antonio J. Bonfanti. Serafino Biffi. Name of Asylum. Location. N ame of Superintendent. Bavaria: Royal District Asylum.... District Lunatic Asylum. District Lunatic Asylum , Austria: Tyrolese Provincial Asylum Institute for Care and Cure of the Insane Royal Institute for Care and Cure of Insane Private Insane Asylum Asylum for Chronic Insane District Lunatic Asylum Royal Bohemian Asylum Saxony and German States: Sonnenstein Private Asylum Asylum for Chronic Insane ... Charity Hospital District Lunatic Asylum District Lunatic Asylum Thonberg Asylum District Lunatic Asylum District Lunatic Asylum District Lunatic Asylum Illenau Asylum Switzerland: Public Asylum . Public Asylum . France : Department Asylum. Antiquaille ......... St. Jean de Dieu St. George Chartreuse Asylum. Asjdum for Insane of St. Yonne St. Anne La Saltpetriere Doctor Blanche's Asylum. National Asylum , Colony Fitz James Quatre-mares St. Yon St. Yon Belgium: Asylum of Ansard Glaine Liege Hospital Colon} 7 at Gheel Insane Asylum Guislain Asylum St. Joseph Sts. Julien and Michael Du Strop (private) Munich Irsee Diggendorf Hall Linz Vienna Dobling Klosterneuberg.... Brunn, Moravia... Prague, Bohemia. Sleep, Bohemia.... Sonnenstein, Saxony Pirna, Saxony Hubertusburg, Saxony. Berlin Neustadt, Prussia Halle Thonberg, near Leipsic. Gottingen- Frankfort Heppenheim Aciiern Zurich Waldau, near Berne. Stephansfeld (Strasb'g), Lyons L3^ons Bourg. Dijon . Auxerze Paris Paris Passy, Paris. Charenton.... Clermont Aug. Solbrig. J. M. Kiderle. Dr. Ast. Joseph Stolz. A. Knorlein, Director, Dr. Schasching, Phy'n. Dr. Spurzheim. Dr. Leiderdorf. Dr. Mildner. Dr. Langer. Dr. Fischel. Dr. Kratochril. H. Lessing. O. Lehman. George Ehrst. Dr. "Westphal. Dr. Sponholz. Dr. Koeppe. E. W. Guntz. Ludwig Meyer. H. Hoffman . Dr. Ludwig. C. Roller. D. Gudden. Dr. Fetscherin, Phy'n, Dr. Schaerer, Direct'r Dr. Hildebrand, Phy'n, R. du Matey, Director J. Arthaud, Director and Physician. Dr. Carrier, Physician, J. de Matha, Director. Rouen Rouen Dr. Bruno, Director and Physician. Dr. Ceilleux, Director and Physician in Chief M. Bayent, Director ; M. Dagonet, Phy'n. M. Phelip, Director. Dr. Blanche. Dr. Calmeil. Gustave Labitte, Phy'n, M. J. Labitte, Direct'r Dr. Ed. Dumesnil. Dr. Morel. Liege ! Dr. C. Anten. Liege . % Gheel Dr. Bulckens. Antwerp T. Targue. Ghent i B. Ingels. Ghent j Dr. Nermenten. Bruges Dr. Van den Abeele, Ghent i Dr. Nermenten. or Name of Asylum. Location. Name of Superintendent. Holland : ReinierVan Arkel Eois le Due Meerenberg Asylum. Citv Asylum England: Royal Infirmary County Lunatic Asylum. St. Luke's Madhouse Bethlem Hospital Grove Hall, Bow County Lunatic Asylum. Near Haarlam Rotterdam Liverpool Rainhill London London Bow, London. Han well County Lunatic Asylum Colney Hatch Surrey County Lunatic Asylvm Sussex County Lunatic Asylum Essex Lunatic Asylum Bristol Borough Asylum Glamorgan County Lunatic Asylum- County Lunatic Asylum Barnwood House Buckingham County Pauper Lunatic Asylum Borough Lunatic Asylum County of Warwick Pauper Lunatic Asylum Derbyshire County Pauper Lunatic Asylum West Riding Pauper Lunatic Asylum Friends' Retreat York Lunatic Asylum Newcastle-upon-Tyne Borough Lu- natic Asylum Cumberland and Westmoreland Lu- natic Asylum Littlemore Asylum Brookwood Hay ward s Heath Brentwood Stapleton Bridgend Wotten, n'r Gloucester. Gloucester T. Frybouh. (?) B. H." Everts. G. Yrolck. Dr. Stockwell. T. L. Rogers. Dr. Eager. AY. Rhys Williams. Dr. Stocker. W. C. Begley, Male Dep't; J. M. Lind- say, Female Dep't. Eagar Sheppard, Male Dep't; AY. G. Mar- shall, Female Dep't. Thomas N. Brushfield. S. AY. D. Williams. D. C. Campbell. G. Thompson. David Yellowlees. E. Toller. A. J. AYood. Scotland : Edinburgh Royal Asylum Saughton Hall (private) Fife and Kinross District Asylum The Colony of Kennoway Royal Asylum Hall Cross Asylum District Asylum District Asylum AYhite House Asylum (private) .... Stone-* ; John Humphrey. Birmingham j T.Green. Hatton, near Warwick.' W. H. Parsey. Mickleover | John Hitchman. Wakefield j J. Crichton Browne. Near York J. Kitching. York | F. Needham. Newcastle j R. H. B. Wickham. Near Carlisle ! T. S. Clouston. Littlemore, Oxford I R. H. H. Sankey. Mornin erside ' David Skae. Near Edinburgh Near Cupar, Co. Fife... Kennoway Dundee Musselburgh Inverness Stirling Musselburgh Dr. Low. John B. Tuke. James Rorie. Royal Asylum Royal Asylum Ireland : District Asylum Richmond District Asylum, Bloomlield Retreat Thomas Aitken. F. W. A. Skae. Mrs. Thompson, Sup't; Dr. Thompson, Phy'n Glasgow j Alexander Mackintosh. Perth ; Lander Lindsay. Maryborough District Asylum. Belfast Dublin County Dublin Maryborough Robert Stewart. Joseph Lai or. H. A. Lodge, Sup't Male Dep't; Alarv Prvor, Female Dep't; J. H. Wharton, Physician. J. H. Hate-hell. Cork District Lunatic Asylum Cork Thomas Power. Killarney Asylum Killarney Central Asylum for Criminal Luna- tics Dundrum W. AY . Murphy. NUMBER OF PATIENTS IN ASYLUMS VISITED. The number of patients treated in these asylums during the last year was seventy-six thousand six hundred and seven, or an average of five hundred and fourteen for each institution. In addition to the asylums mentioned, a number of asylums in process of erection, lunatic wards of Poor Houses, Idiot and Deaf and Dumb Asylums, ordinary hospitals, penitentiaries, and other governmental, State, county, and city estab- lishments have been visited and examined, and such features noted as appeared might at any time be of interest or importance to the State. PLANS OF ASYLUMS. A large number of plans of asylums, rules, regulations, etc., have been procured, a portion of which will be found in the appendix, and all are at the service of the State. STATISTICAL TABLES. The statistical tables have cost much time and patient labor, and are believed to be as complete as any ever published on this subject, and the facts set forth in them have been gathered from the latest and most reliable sources known to exist. MEETINGS OF SUPERINTENDENTS ATTENDED. It has been our good fortune to have attended the meeting of the Superintendents of American Institutions for the Insane at Hartford last year, and those of a similar character for France, in Paris, and of Great Britain, in London during the present year. It is needless to dilate upon the high character and intellectual capacity that distinguish the men who compose these associations, nor upon the great service they have rendered to humanity by sending forth the results of their individual and collective experiences to enlighten mankind and relieve the distresses of their fellow men. They are the rays of light that dispel the mists and drive away the thick clouds by which the mind of man is enveloped when the brain is diseased. " Their's, indeed, is a mis- sion of mercy, and verily they shall reap their reward." IMPORTANCE OF SUCH MEETINGS. So important do these annual meetings appear to our mind we do not hesitate to express the opinion that it should be made the duty of the Superintendent of every asylum, or an assistant, to attend each meeting, feeling assured that the opportunity presented for an inter- change of opinions with those engaged in a like calling could not fail to be both agreeable and instructive to himself, but beneficial to those com- mitted to his care and the State in whose service he is engaged. We feel under especial obligations to them, and to all others who have con- tributed to our pleasure or added to our stock of information. BOOKS OBTAINED FOR STATE LIBRARY. A large number of books, reports, and essays on insanity and State medicine have been obtained for the State Library by purchase or dona- tion from various sources and countries, comprising in the list nearly all of the standard works of the most celebrated authors who have written upon the subject of insanity, and the most recent and reliable informa- tion on the statistics of lunacy that could be found. Among these are the works of Allen, Anderson, Arlidge, Bingham, Browne, Bucknill and Tuke, Burrows, Conolly, Crowther, Dunn, Ellis, Gall, Hill, Hills, Hoods, Jacobi, Morrison, Prichard, Seymour, Sieveking, Williams, Winslow, including Journal of Psychological Medicine, 1848 to 1863, and the more recent productions of Yan Der Kolk, Brown, Sankey, Mandsley, Blan- ford, Fry, Casper, Griesinger, Davis; translation of Pmel, Cox, Liddell; translation of Esquirol, Mayo, and a set of the Journal of Mental Science from commencement of volume two to the present time. Also, very nearly a complete set of the Reports of the Commissioners in Lunacy, and other valuable documents presented by Mr. Wilkes, one of the Com- missioners; a j)artial set of the Reports of the Scotch Commissioners, and other documents presented by Sir James Cox and Dr. Sibbald, of that Board; the last Report of the Commissioners for Ireland; special reports of all the asylums visited, where these were published and attain- able; essays on a variety of subjects; rules and regulations of asylums, general and special; descriptions of asylums by sundry persons; reports of Special Commissioners, and many other documents of more or less interest. Among the French works will be found those of Foville, Dag- onet, Calmiel, Faivet, Morel, Mundy, Motet, and others. From Prussia, a volume of general statistics for eighteen hundred and sixty-seven; a valuable treatise on construction and plans of asylums for the insane, containing the opinions of many of the most eminent psychologists of that country, and a brief account of all the asylums of the German Confederation in eighteen hundred and sixty-five, by Dr. H. Laeur, together with a few other documents of minor importance. Besides the reports, more or less complete, of all the asylums visited in the United States, a variety of documents, including statistics of the insane and idiotic for eighteen hundred and seventy, essays, lectures; reports of Commissioners sent into other States and countries, and those of a local character; reports of Boards of Charity of New York, Massachusetts, Ohio, and Pennsylvania, of the Cities of New York and Boston, and a number of other documents of interest and importance, and from most countries plans of asylums, more or less complete, of some of the best institutions known to exist, embracing every variety, from the palatial hospital to the modest cottage. The professional man will find much that is trite and familiar in this report, but it must not be forgotten that it is not so much for him as for the public that it has been prepared. SOURCES OF INFORMATION. The information which it contains has been derived from various sources. The work of other men's brains has been freely appropriated. Their experiences we have endeavored to use to the best advantage; and even the errors committed by some of them have taught us valuable lessons, as it is sometimes as necessary to know what to avoid as what to adopt. ACKNOWLEDGMENTS. Much has also been learned from personal intercourse with men of ability in all the countries we have visited, and we can never forget nor 8 ever cease to be grateful for the many acts of courtesy, kindness, and attention that we have received at their hands. To Drs. Shurtleff, Strib- bling, Kirkbride, Gray, Buttolph, and Walkar, in each of whose estab- lishments we spent several days in the early part of our investigations, we are especially indebted for the kind manner in which they took us by the hand and started us "right foot foremost" in the path of our duty. Nor have we forgotten the attentions and courtesies of a single Superintendent whose asylum we visited in America or Europe. CHAPTER II. INSANITY A DISEASE OF THE BKAIN. What is insanity? This question has been often asked, but perhaps has never been satisfactorily answered, for the simple reason that insanity assumes so many forms and differs so widely in different per- sons that no definition can possibly embrace all of its phases. Many persons have given definitions of this subtle malady, but not one has met with that universal concurrence necessary to render it the true and only or even the generally received definition. We do not propose to enter this list, but as much must be said on the subject in the following pages it is best, perhaps, that a selection should be made. In a lecture delivered before the Eoyal College of Surgeons, March first, eighteen hundred and sixty-one, by David Skae, M. D., F. E. C. S., Physician to the Eoyal Edinburgh Asylum, he defined it to be " a disease of the brain affecting the mind." We accept this definition as the best of all, because it is the most simple. It makes but little difference how the brain becomes diseased, whether primarily or by reflex action from the disease of some other organ of the body, so the fact as stated be true that the brain must be diseased ere the mind is affected. 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 Switzerland — In Belgium — In Holland — In Denmark — In Sweden — In Norway — In New South Wales — In the United States — In California. THE SUBJECT GENERALLY. In considering the subject of insanity, it is proper first to inquire to what extent it exists in the world and in our midst. To do this we have prepared tables exhibiting the population of various countries, divided into self supporting and pauper classes (where these have been sepa- rated), and in all cases the total population, number, and distribution of the insane at the latest dates at which these facts could be obtained; the proportion of the insane to population, the ratio per thousand, the proportion of pauper insane to pauper population, the proportion of insane under treatment to population, the number in hospitals and asy- lums at latest date; numbers admitted, cured, died, and treated during the year; the number of asylums in each country; the principal assigned causes of the disorder and of death; together with the numbers resident at beginning of the year; numbers admitted, cured, and died during the year, and the percentage of recoveries and of deaths to admissions and to numbers treated in the asylums visited in different countries; to which we have added similar facts for Norway, Sweden, and the Colony of JS~ew South Wales. INSANITY IN ENGLAND. Population, 1870. Self supporting classes Paupers Total population.., 21,006.631 1,083^532 22,090,163 dumber and Distribution of the Insane, January 1st, 1870. Private. Pauper. County and Borough Asylums Registered Hospitals Metropolitan Licensed Houses , Provincial Licensed Houses jSaval and Military Hospitals and Royal India A sy lum Workhouses With relatives or others '. Broadmoor Criminal Asylum Totals 259 1,969 1,666 1,478 198 356 354 6,280 27,721 400 1.034 726 11,358 7,086 108 48,433 Totals. 27,980 2,369 2.700 2^204 198 11,358 7,442 462 54,713 Proportion of insane to population, one in four hundred and three; or, ratio per one thousand, two and forty-seven one hundredths. Propor- tion of pauper insane to pauper population, one in twenty-two; or, ratio per one thousand, forty -four and sixty-nine one hundredths. Proportion of insane (under treatment) to population, one in six hundred and fifteen; or, ratio per one thousand, one and sixty-two one hundredths. The number of Insane in Hospitals, Asylums, and Licensed Houses, January 1st, 1870 35,913 Admitted during the year 11,462 Cured 3^955 Died 3,790 Number treated in 1870 47,375 10 Per cent of recoveries on admissions 34 Per cent of recoveries on number treated 8 Per cent of deaths on admissions j 33 Per cent of deaths on number treated i 8 Number of Asylums, etc., for the Insane in England and Wales. County and Borough Asylums Registered Hospitals State A sylums Metropolitan Licensed Houses Provincial Licensed Houses Total number of Institutes for the Insane 50 16 4 41 65 176 The average weekly cost per head in County Asylums is nine shillings five and one eighth pence, or two dollars and twenty-eight cents. The principal assigned causes of insanity are: hereditary, intemper- ance, domestic trouble, epilepsy, mental anxiety, puerperal condition and critical period, paralysis. The principal causes of death are: general paralysis, diseases of the lungs, diseases of the brain, epilepsy, debility and old age, apoplexy. In twenty asylums visited in 1870, the number of patients resi- dent was Admitted dumber treated Cured Died 12,116 . 3,670 15,786 1,369 1,220 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 8 33 7 INSANITY IN SCOTLAND. Population, January 1st, 1870. Self supporting classes Paupers (May 14th, 1869) Total population 3,142,503 80,334 3,222,837 11 Number and Distribution of the Insane. Private. Pauper. Totals. In Poyal and District Asylums 914 249 3,547 54 553 574 49 30 1,469 4,461 In Private Asylums 303 In Parochial Asylums 553 In Lunatic Wards of Poorhouses 574 In General Prison 49 In Training" Schools for Imbeciles 83 49 1,295 113 In Private Dwellings 1,518 Totals, January 1st, 1870 6,276 7,571 Besides the number of insane given above, it is estimated that there are about two thousand unreported, making the total number nine thou- sand five hundred and seventy-one. Proportion to the population, one in three hundred and thirty-six; or, ratio per one thousand, two and ninety-six one hundredths. Proportion of insane (under treatment) to population, one in six hundred and six; or, ratio per thousand, one and sixty-four one hundredths. Proportion of pauper insane to pauper population, one in thirteen; or, ratio per one thousand, seventy-eight and twelve one hundredths. Number of insane in asylums, January 1st, 1870. Admitted during the year Cured Died JST umber treated in 1870 ". 5,317 2,015 832 491 7,332 Per cent of recoveries to admissions Per cent of recoveries to number treated. Per cent of deaths to admissions Per cent of deaths to number treated 41 11 24 7 Number of Institutions for the Insane. District Asylums Poyal Asylums Private Asylums Parochial Asylums Total Asylums Lunatic Wards of Poorhouses Total 10 7 9 5 31 15 46 12 The average weekly cost of maintenance of pauper lunatics in Royal and District Asylums is nine shillings and nine and one fourth pence; in Private Asylums, ten shillings and two and a half pence; in Parochial Asylums, eight shillings and five and a half pence; making a general average cost of nine shillings and five and three fourths pence, or two dollars and twenty -nine cents. The principal assigned causes of insanity are: climacteric changes, old age, intemperance, child bearing. # The principal causes of death are: consumption, general debility and old age, organic disease of brain, inflammation of lungs, general" paral- ysis. In six asylums visited in 1870, the number of patients resident was : Admitted. . . . Treated Cured Died 1,995 1,030 3,025 365 206 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 12 20 6 INSANITY IN IRELAND. Population, 1870. Total population 5,195,236 Number and Distribution of the Insane, December 31st, 1870. Private. Pauper. Totals. In District A sylums 122 638 6,533 6,655 In Private Asylums 638 In Jail 1 2,754 43 167 1 In Workhouses 2,754 In Lucan 43 In Central ' 167 Lunatics at large 6,936 7,696 6,936 Totals 9,498 17,194 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 j or, ratio per one thousand, one and thirty-seven one hundredths. JSTumber of insane in asylums, January 1st, 1870 7,121 Admitted during the year 2,532 Cured 1.088 Died 708 dumber treated in 1870 9,653 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 43 11 27 7 Number of Establishments for the Insane. District Asylums 23 Private Licensed Houses 20 Asylums for Criminals ■ 1 Total '' 44 t The average weekly 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 causers 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 in 1870, the number of patients resi- dent was •. 2,437 Admitted. Treated . , Cured , Died 1.206 3^643 457 256 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 37,988,90.5 Number and Distributio?i of the Insane, 1866. Insane. Idiots. Totals. In asylums At home Totals 31,992 18,734 50,726 3,980 35,973 39,953 35,972 54,707 90,679 Males. Females. Totals. Insane Idiots.. 24,190 22,736 26,537 17,217 50,726 39,953 Proportion of insane to population, one in seven hundred and forty- seven; or, ratio per one thousand, one and thirty -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 37,170,942 Number of insane in hospitals and asylums, January 1st, 1860. 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 Number 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 patients resident was Admitted (in eleven of these) * Cured (in eleven of these) Died (in eleven of these) 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 26 7 38 11 INSANITY IN ITALY. Population, 1864 22,291,181 Ev the addition of Yenice, in 1866, the population was increased to 24,263,320. Number 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. • Number in asylums, January 1st, 1867. Admitted Discharged Died Number treated during the year Number remaining January 1st, 1868. 8,191 4,909 3,210 1,504 13,100 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 5,316 764 621 Per cent of recoveries on admissions l 38 Per cent of recoveries on number treated '• 13 Per cent of deaths on admissions | 31 Per cent of deaths on number treated I 10 The average weekly 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 IN PRUSSIA. Population, 1864 19,252,363 Number of Insane Under Treatment. In Public Asylums . In Private Asylums Total 4,796 944 5,740 Proportion of insane (under treatment) to population, one in three thousand three hundred and 'fifty-four; or, ratio per one thousand, twenty-nine one hundredths. Number of Asylums. Public Asylums.. Private Asylums Total 32 27 59 Expenses of Public Asylums, six hundred and fourteen thousand six hundred and sixty-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 population, one in six hundred and thirty-one, or ratio per one thousand Proportion of insane to population, one in fourteen hundred and sixteen, or ratio per one thousand. 1.58 .70 INSANITY IN AUSTRIA. German Austria, exclusive of Hungary. Population, 1864 13,000,000 Number of Insane in Asylums. 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 Admitted Cured Died Number treated 2,302 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 give's 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 Hospitals. In Public Asylums... In Private Asylums. Total 9,962 633 10,595 Proportion of insane (under treatment) to population, one in twelve hundred and ninety-seven, or ratio per one thousand .77 Number of Asylums. Public Asylums... Private Asylums. 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. They were as follows: Admissions Cures Deaths Number treated. 4,086 1,570 597 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 Number 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 .38 Number of Asylums. Public Asylums.. Private Asylums. Total. 9 2 11 In 1861 the population was The total number of insane Proportion to population, one in nine hundred and fifty-seven, or ratio per one thousand 4,689,837 4,899 1.04 In the six District Lunatic Asylums the number of patients 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 Asylums was, in 1865-6, two dollars 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 was 658 A dmitted 324 Cured 112 Died 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 17 5 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 Waldau is as follows; Number resident. Admitted Cured Died Number treated.. 295 83 32 19 378 22 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 8 22 5 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 31st 7 1865. Private. Pauper. Totals. In hospitals and asylums % 1,579 2,000 3,579 3,852 5,431 Estimated number at large who are supported by their families Totals 3,852 7,431 Proportion of insane to population, one in six hundred and seventy one, or ratio per one thousand Proportion of insane (under treatment) to population, one in nine hundred and seventeen, or ratio per one thousand 1.49 1.09 Number of insane under treatment in hospitals, January 1st, 1865. Admitted during the year Cured Died Number treated in 1865. 5,441 1,851 642 595 7,292 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 8 32 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 five 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 was f 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 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 per one thousand .88 Number of Lunatic Asylums 12 Cost of Maintenance. At Reinier Yan Arkel: First class, 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 Rotterdam (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 '. Pied 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. 2,605,024 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. Totals. 1861 f. 1864 j. 186711. 469 553 630 530 598 641 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 Report of Asylum, at Linz, published in 1866, p. 78. fHelso och Sjukvarden, 1861, pp. 30, 31. JHelso och Sjukvarden, 1864, pp. 26, 27. Q Helso och Sjukvarden, 1867, pp. 14, 15. 26 Number of insane in asylums and Houses for the Insane, January 1st, 1864 Admitted during the year Cured and improved 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 Number of in sane Proportion to population, one in nine hundred and thirty-five, or ratio per one thousand 3,641,011 3,893 1.06 INSANITY IN NORWAY. Population, 1864 1,6 68,254 Number of patients in asylums January 1st, 1864 557 A dmit t e d 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.... .34 Number of asylums 8 According to census of 1855 the population was ! 1,490,047 Total number of insane , I 1,329 Proportion to population, one in eleven hundred and twenty- one, or ratio per one thousand .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. Number of asylums in 1867 9 Number of patients in asylums January 1st, 1867. Admitted Cured Died Number treated Number in asylums January 1st, 1868. 667 423 140 41 1,090 727 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 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. Totals. At Tarban 397 347 744 223 189 412 620 At Parramatta 536 Totals 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 Black 1,605 Mulatto 169 Chinese 35 Indian , 13 Total 37,382 Number of Idiots. White 21,324 Black 2,743 Mulatto 445 Chinese 5 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 population, one in fifteen hundred and sev- enty-two, or ratio per one thousand Proportion of insane and idiots to population, one in six hundred and twenty -three, or ratio per one thousand .97 .63 1.06 Number 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 j 15,792 Admitted during the year f ! 10,229 Cured f ! 3,357 Diedf ! 1,851 Number treated f ! 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 6Q The principal assigned causes of insanity: ill health, spermatorrhoea, intemperance, domestic trouble, physical disease, religious excitement, epilepsy. Principal causes of death : exhaustion (from various causes), epilepsy, general paralysis, and consumption. * As nearly as can be ascertained from returns. t Keport for forty -nine asylums. Keturns could not be obtained from the others. 30 In thirty -nine asylums visited in 1870, the number resident was. Admitted 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. ffio o • co Uh £3 • p CD co HH ►d p ►-•CO 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 18,865 24,527 31,397 42,864 61,909 28 46 66 4,730 *8,500 17,735 30.30 35.42 47.44 INSANITY IN CALIFORNIA. Population, 1870 560,247 Native population .. Foreign population. Total. 350,416 209,831 560,247 Number of Insane. Males. Fem'les Totals. White 789 15 304 2 1,093 Black 17 Mulatto 29 2 835 4 1 311 33 3 Totals 1,146 * See Journal of Insanity, Vol. XVIII, p. 2. 31 Number of Idiots. Males. Fem'les 48 29 2 1 1 4 1 1 56 31 Totals. White Black Mulatto.... Chinese.... Indian Totals 77 2 2 5 1 87 Insane and Idiots classified as Native and Foreign. Insane. Idiots. Totals. 408 738 70 17 87 478 Foreign 755 Totals 1,146 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. CHAPTEK IV. CAUSES OF INSANITY, AND SOME OP THE INFLUENCES OPEKATING IN ITS DEVELOPMENT. General Observations — Assigned Causes— Physical Causes — Moral Causes — Observations upon Assigned Causes — Principal Assigned Causes — Insanity Found in all Countries — Enumeration of the Insane — Tables Relating to Enumeration — Enumerations Imper- fect — Difficulties in the way of a Perfect Enumeration — Influence of Age — Influence of Age in the Different 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 supersti- 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 will 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. Phrcenitis. 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 lawsuit. 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. Rheumatism. Bilious rheumatism. Suppression of hemorrhoids. Suppression of perspiration. Suppression of secretions. Suj)pression of eruption. Suppression of tumor. Suppression of fistula. Smallpox. Varioloid. 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. 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. Reading 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. Reverse 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. Exposure 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 derangement. 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. Yice. Immorality. And winds up by saying: "These are not all the diseases, accidents, events, etc., that can disturb the regular action of the brain." 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. Remorse. Millerism. Mormonism. Struggle between the religious prin- ciple and power of passion. Epidemic influences. 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; 35 that predisposition must exist, and that the form is only the effect, not the cause." We 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 Dr. 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 hst was inserted as a matter of general interest. The following table comprises the principal assigned causes of insanity: 36 m H M tf H 55 P O Sh < O m « m < o © M M o 55 M H ft o I 8 s jjjp *® PQ "as S CO S3 <4 St Hi o (3 «3 Hi T5 Pf 03 P? 05 O o CO n3 Pi as -5b G G hi ::::::::: .-§ p. • : : : : : : : : : ■gap : I. : :. : : : : : S-g es :::::::: : M£ ^::?::^ I « -i : : : I . « A o»« : : : : §5 g S § g g g*§ : : : : CM £ Q ft : : : : h. I I I I 11 11 C3 03 CD ».,.«».. *,Sg* ': : : r : : : : f- 1 — < i : i i ° «$ k* : ; : : Hi ......... -S S^S : : : : : : : .: : Khj ::::::;:: H, \ : I \ t I ': I I h t* ::::::::: Cv i> ......... ."S ft • 'gSS :::::: = :: Sufi ::::::::: S-s *::::::::: >*■ S - i 3 ® 53 : : : _g p^^ cd +3 c - : : Ssa o ® pj^ g £ cj : : : CD p+0-£ «3 > ^ pfi £ CD g CD P! H«M Q> Jh^ ©^ WO Hi AW ^H CO CD CD " &J0 CD <0 ft^«^ § S * S 2 2 6i PlrG_- CD Pi.'S C «3 cd '"' ft 2 ® ivL' OS P!.2 3.S.-S .«! 2 >> s|la8.-S|tsilg CD "g 03 O -M ft © .h 3 O OS ft tj w ft W^ Hi Hi O CD .^ 2^^.^S2b 1*5 SrC! CD s ft Pi S 2 ® §*SW So. 03 O-^ ^ 03 CD P Ph « 3 'ft 37 INSANITY FOUND IN ALL COUNTRIES. As the causes enumerated in this Chapter operate with more or less power and energy 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. Williams, 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." Captain 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 in 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. For the present we desire to exhibit their combined effect upon those subjected to their influence. ENUMERATION OF THE INSANE. Most nations in their enumerations take account of the insane; thus we find their numbers as seen in the following tables: 39 Table 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 Scotland 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 4,984,451 37,382 24,527 61,909 54,713 9,571 17,194 90,679 37,960 7,431 1 in 1,031 1 in 1,572 1 in 623 1 in 403 1 in 336 1 in 302 Ireland 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 France 1 in 950 i 1 in 418 Prussia 1 in 1,139 1 in * 31 1 in 6vl | Total 136,008,912 279,457 1 in 486 Table. f Countries. Census ta- ken once in : o 3 O Populat'n. Number of Insane. Males. Feml's Proport'n to Totals. 1 Populat'n Ireland England and Wales.. Newfoundland Nova Scotia Prince Edward's Island- United States Prance 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 * Calculated population. t From Vital Statistics of Ireland. 1861 1861 1857 1861 1861 1860 1856 1861 1856 1859 1861 1858 1861 1861 1861 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 1,720,708 856,907 287,163 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 35,031 310 4,017 2,139 3,084 2,323 648 1,559 4,899 1,338 508 2,592 1,995 710 954 5,135 3,893 1,329 1,750 m 821 in 824 in 1,394 in 973 in 546 in 1,310 in 1,028 1 in 1,750 1 in 1,128 1 in 1,547 1 in 612 1 in 1,427 1 in 957 1 in 1,286 lin 301 1 in 507 1 in 935 1 in 1,121 1 in 2,881 40 Table • 1844.* 1850.f 1857.J 1860.§ 1867.1! Countries. Population Insane. Eatio. Eatio. Eatio. Eatio. Eatio. Srtain 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 '37,583 569 3,441 3,763 2,300 32,000 17,457 130 1,535 16,222 10,059 3,652 1,909 488 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 977 1 in 932 1 in 846 1 in 807 1 in 774 1 in 648 1 in 551 1 in 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 244 1 in 341 1 in 339 1 in 446 lin S6VA 1 in 7,181 1 in 3,785 1 in 1,667 1 in 3,690 1 in 816 1 in 1,223 1 in 1,773 ifaly France 1 in 1,000 1 in 795 lin 444 United States. Malta & Gozzo "Westphalia... 1 in 577 1 in 700 1 in 2,125 1 in 513 1 in 550 1 in 666 1 in 432 1 in 325 Scotland 1 in 400 1 in 531 lin 368 Brunswick 1 in 551 Cities. Petersburg ... Naples Milan Florence Brunswick 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. VII, p. 286. J Bucknill & Tuke on Insanity, p. 47. \ Journal of Insanity, Vol. XVII, p. 348. j| Manning's Eeports, p. 109. 41 the insane in the State; distinguishing as accurately as may be between the insane, properly 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 physician 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 complete, able, and satisfactory report ever made of the insane and idiots in any State or country was the result. It was 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 OF 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 proportion 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 Asylum, 1868. Holland. 1844 to 1864. Total. 3 hj tszj hj 2| hj 3 Hd ^ ^ AGE. B o o B 1 P 2 °8« B 3 p*s a 4 CD P o J? J. CD 4 EL,o D -i a o O rt; cT 15 o 3 2". CD 4 4 P o B o r H CO © i-^t^cct-i-Hcq-Hb-sci-^ccooocNi 00 es •KHK'-Ksr r-xi»r^HN o g : ii ec so ■* ion oct-ao cn cq o t-L'M^-J : : : : :cnccft->-o(M : Si O : : CNrii-c : i> *3 3 . :ooctict-CMiffr^»Ttii^i-(^Hi>(M lO *3 : hlohoc<)i»ich>coh o H-*C0(MHH co O r-7 M H © :rt *3 i—l I-H 1—1 to H :»0!'-sommohwxc "3 iMOa^CiLOSOONtlM t- oo £ £ a © Em ; 1-1 CSllC rH CCO 1>1> CO C<) ■—I CO 1-1 . :sosH»-j;HL^f:'*HCO'*M 0B © ;CMCO00SO''T't~0000I^SOOir-( 00 t^ "3 CO S : cc f co 00 Si i— 1 S ; ©OOOOOOOOOOOOa. • |aaasaaaaaaaa§« ;3ooooooooppp p_^ "3 -t-3 H PEhPhEmEmEmEmEhEmE hEmErE M^P 46 The preceding table shows a most interesting fact, that may or may not be overthrown by further investigation and longer experience. It will be observed that while the general rule under discussion holds good with the Chinaman and the Indian, that both the black and mulatto are most liable to become insane between twenty and thirty, and that this is true with regard to both males and females. This may be the result of accident; but from our knowledge of the race, derived from a long resi- dence among them in the Southern States, we are of the opinion it is the result of a natural law. Their development, both intellectual and physi- cal, is of much earlier growth and maturity than that of the Caucasian, and as insanity seems to attack the human race most frequently at that age when all the faculties are in fullest maturity, and most powerful, energetic action, there would seem to be no reason why the negro should be an exception to the general law. These reflections, however, are made more to direct the attention of future investigation to the subject than with a view to the promulgation of a new theory or the enuncia- tion of a new idea. INFLUENCE OP SEX. The susceptibility of the sexes to insanity has been a debateable ques- tion from the days of Cselius Aurelianus to the present time, most of those participating in the discussion seeming to be guided by their indi- vidual experience or their immediate surroundings. Aurelianus, Pinel, Haslam, and their followers taking sides with the women, while Esqui- rol, Copeland, Browne, and others took the other side of the question. In our country, Doctor Rush was of the opinion that more women were insane from the fact that they are exposed to several exciting causes from which men are exempt, apparently overlooking another fact, that men are liable to many causes from the influence of which females are partially or entirely removed. Doctor Jarvis, one of the closest observ- ers and most thorough investigators whose writings have come under our observation, came to the conclusion some twenty years ago, after exhausting all the information that existed on the subject at that time, that a few more men than women become insane. (Jarvis on the Com- parative Liability of Males and Females to Insanity; see American Jour- nal of Insanity, Vol. VII, p. 142.) And from the following table of first admissions into the Asylums of England, Ireland, France, Belgium, Hol- land, and Bavaria, during the period specified, it would seem that the conclusion at which he then arrived still holds good; though according to the United States census for eighteen hundred and seventy the reverse of this would seem to be true in our country, as the number of male? was eighteen thousand one hundred and seventy-four; the number t, females, nineteen thousand two hundred and eight, or an excess of one thousand and thirty-four females. 47 Table, Showing the Influence of Sex. COUNTRIES. Period. Number of First Admissions. Males, i Females. Veals. England Ireland Franc e Belgium Holland Bavaria (Asylum at Irsee).. Totals 1870 1870 1853 1865 1844 to 1864 1858 to 1868 5,124 1,141 3,959 865 4,747 388 4,966 971 3,487 690 4,526 324 16,224 14,964 10,090 2,112 7,447 1,555 9,273 712 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, w T hile 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 percentage 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 epilepsy, palsy, and mas- turbation are more frequent causes among men, and are among the most incurable cases. INFLUENCE OP 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 « ?». Sk 1 ^ o 3 CO c_> •J si m CO K SQ o w CO . O fl 'St^ o .►S s.-s Ph ft-H PI oS t~ CO 00 ^-v ^00 0)0 O CO © o r— « © . ©co S3 ID 03 CO P r-t ft 03 ^co ^ CO © r-t Totals... Female. Male. Totals- Female. Male. Totals- Female. Male. Totals. Female. Male. Totals- Female. Male. H3 So M f Totals. Female. Male. T ° O OOHX 1- CO l- tO rH_^oq_Oi_ oTcO CO~CO CM r-( HHiOH CO -* tO OS rH_OS_l>^^ co"co"ofr-r OS OS CO l^ CO i— I tH CO OlOHTjt CO tO T* tO i— I CO lO to ^ ■* CO i-l 00 00 CO OHCO oq cm co Jh- CO CO -*COH lO O CO CO CO "-* OS tDNO COCS iH 00 CO ^ CO lO CO rj< r-l 00 CO OS CO i^ os i^ cm CD.Tf^CO^CO^ co""ao"of co* O COCO OS O -*00 CN 00 r* 00 CO CO 1>tH b- 1- •<* OS OS CM O^b- (N oTtjT of ■n3 fl CO of CO Tt M Bi o* $0 P P-i M o" Proportion of— V CO SO p CD CD 2 so (3 3 p^ &J Ojl— I o -• ►d p'm §2 p 3 Pj I— ( o* England Scotland Ireland. Belgium. Total . 22,090,163 3,222,837 5.195,236 4,984,451 54,713 9,571 17,194 7,431 48,433 6,276 9,498 3,852 88 per cent 65 per cent 55 per cent 52 per cent lin 456 lin 513 lin 546 1 in 1294 35,492,687 88,909 68,059 76 per cent 1 in 521 It has been explained elsewhere and must not be overlooked, however, that a large majority of these pauper lunatics are no more furnished by the pauper element in society in these countries than are the non-paying patients in our own institutions; most of them were self-sustaining and independent citizens till misfortune assailed them and deprived them of their reason and the power to labor. Yet all must admit that pauperism is one of the most prolific sources from which insanity is supplied. Here is a grave question for the consideration of those in authority, whether they may not, by providing means sufficient to accommodate and care for every one who becomes insane, thereby affording proper treatment in the early stages of the disease, restore most of these unfortunate victims of this direful malady to health, the power to serve themselves, their families, and the State, and whether this is not a duty which every commonwealth owes to itself and to its members? CHAPTEE VI. APPARENT INCREASE OF INSANITY. For many years it has been apprehended that this fearful malady was increasing, not only in our own country, but in all other civilized 55 nations; land as early as eighteen hundred and fifty-one Doctor Ja±'' read a paper on the subject before the Association of Medical Superin tendents of American Institutions for the Insane, in which he said: "It is a recent thing that any nation has enumerated its insane, and I cannot discover that any nation has ascertained and reported this twice, and thus offered us data for the comparison." Since tkat-time other nations have taken an account of their insane, and some of them several times, but only to prove that insanity has increased, at least apparently, and in some countries very rapidly, within comparatively a short time. Thus the following table, from official reports, will show the result in the countries named: UNITED STATES — TWENTY YEARS. Year. Population. « X amber of Insane and Idiots. Eatio per 1,000 to _ Population. Proportion to Population. 1850 1860 1870 23,191,876 31,443,322 38,555,983 31,397 42,864 61,909 1.35 1.36 1.60 1 in 738 1 in 733 1 in 623 e>; GLAND — TEN YI ,ARS. 1862 1865 1868 1871 20,336,467 20,990,946 21,649,377 22,704,108 41,129 45,950 51,000 56,755 2.02 2.18 2.35" 2.49 1 in 494 1 in 456 1 in 424 1 in 400 \ SCOTLAND TEN YEARS. 1862 3,083,989 6,341 2.05 1 in 486 1865 3,136,057 6,468 2.06 1 in 484 1868 3,188,125 6,931 2.17 1 in 459 1871 3,358,613 7.808 2.32 1 in 430 IRELAND — NINETEEN YEARS. 1851 6,552,385 15,098 2.0a 1 in 434 1856 6,164,171 14,141 2.29 1 in 435 1861 5,798,967 16,749 2.88 1 in 346 1870 5,195,236 17,194 3.39 1 in 303 56 FRANCE — FIFTEEN YEARS. 1851 1866 35,783,170 37.988,905 1 in 795 1 in 418 This shows that the ratio of insane and idiots per one thousand in the United States in eighteen hundred and fifty was one and thirty-five one hundredths, or one in seven hundred and eight, and in eighteen hundred and seventy, one and sixty one hundredths, or one in six hundred and twenty-three. In England, in eighteen hundred and sixty -two, it was two and two one hundredths, or one in four hundred and ninety-four, and in eighteen hundred and seventy-one, two and forty-nine one hundredths, or one in four hundred. In Scotland, in eighteen hundred and sixty-two, it was two and five one hundredths, or one in four hundred and eighty-six, and in eighteen hundred and seventy-one, two and thirty -two one hundredths, or one in four hundred and thirty. In Ireland, in eighteen hundred and fifty-one, it was two and thirty one hundredths, or one in four hundred and thirty-four, and in eighteen hundred and seventy-one, three and thirty -nine one hundredths, or one in three hundred and two. In France, in eighteen hundred and fifty-one, it was one and twenty -five one hun- dredths, or one in seven hundred and ninety-five, and in eighteen hun- dred and sixty-six, two and thirty-eight one hundredths, or one in four hundred and eighteen. But even these statements must not be taken as altogether correct. In the paper of Doctor Jarvis, already referred to, he shows how very carelessly the returns from France had been made, and so it may have been with those from which our figures were taken : Statistique de la France, 1866, second series, Yol. XVII. In the United States we have also shown that all of the insane and idiots have probably not been found. In England, Scotland, and Ireland, the reports are mainly official, showing the number in institutions for custody and cure, in pau- per establishments where they are kept merely for support, and those under the guardianship of the Lord Chancellor's Commissioners. It is probable there are many others who belong to neither of these categories. Nor must these facts induce the conclusion that insanity, if it has increased at all, has done so in anything like the proportion here indicated. The existence of a fact and our knowledge of it are two very different things. Electricity has existed for all time, but our knowledge of its properties and the purposes to which it may be use- fully applied is of very recent date. So it may be in many respects with our knowledge of the insane. We have already shown that many had existence in Massachusetts who could not or had not been found by one set of Commissioners who were found by another Commission whose method of search was different and whose work was more thorough. Nor must it be overlooked that since greater attention has been paid to the insane than formerly many more are brought to light and seek the benefit of asylum accommodation. Add to this the important fact that the duration of life among the chronic insane has been much increased by the greater amount of care and the more humane treatment which they receive, and we can readily account for at least a portion of the apparent increase. 57 It is exceedingly interesting to trace this apparent increase of insanity in the various countries of the world, and easy to show how much more rapidly the increase has been brought to light in those countries where the most humane and liberal provisions have been made for their accom- modation. We will show, however, that it is not confined to the present epoch, nor to any particular country; but that it has always and every- where come forth from its recesses and hiding places whenever suitable hospitals for the reception of its victims were provided. Thus Bucknill & Tuke state that " in the short space of nineteen years the estimated proportion of the insane in England rose from one in seven thousand two hundred to one in seven hundred and sixty-nine;" while on the first of January, eighteen hundred and seventy-one, there was one to four hundred. This is simply insanity revealed by increased attention. The following extracts from the paper of Dr. Jarvis on this subject will show the results in several States and countries at a former period: " Thus we find that whenever the seeds of this interest are once sown and allowed to germinate and grow, it spreads continually thereafter. Whenever the attention of the people of any country is called to this subject, and a hospital is built, there follows a remarkable increase of the cases of insanity revealed to the public eye and asking for admis- sion. " In the year eighteen hundred and thirty-two, when the McLean Asylum at Somerville, Massachusetts, contained sixty-four patients, the State Lunatic Hospital was established at Worcester for one hundred and twenty patients. This was as large a number as was then supposed would need its accommodation. In eighteen hundred and thirty-six one new wing, and in eighteen hundred and thirty-seven another new wing, and rooms for one hundred more patients were added to the Worcester Hospital, and at the same time the McLean Asylum contained ninety- three lunatic inmates. In eighteen hundred and forty-two the Worces- ter Hospital was again enlarged by the addition of two new wings, and now these are all filled to overflowing, having four hundred and fifty patients in May, eighteen hundred and fifty-one, while at the same time there were two hundred at the McLean Asylum, two hundred and four at the City Lunatic Hospital at Boston, and one hundred and fifteen in the county receptacles for the insane at Cambridge and Ipswich, beside thirty-six in the jails; making one thousand and fifteen lunatics in the public establishments of Massachusetts in eighteen hundred and fifty- one, instead of the one hundred and eighty-two which were there in eighteen hundred and thirty-two " — an increase of eight hundred and thirty-three in nineteen years. " Besides these there is now a great demand for the admission of patients who cannot be accommodated in these establishments already built, and there is so much interest elicited in their behalf, and the friends of the lunatics are so alive to the necessity of providing means of relief for all of these sufferers, that the Legislature has just now authorized the erection of a new hospital sufficiently large to receive two hundred and fifty patients. " The State Hospital at Augusta, Maine, was opened in December, eighteen hundred and forty, with only thirty patients. In eighteen hundred and forty -five it was so crowded that the Trustees asked for more rooms. In eighteen hundred and forty-seven the building was enlarged, and one hundred and twenty-eight patients were admitted. 8 58 In eighteen hundred and forty-eight the house was all filled, and more were offered than could be accommodated, and the Superintendent asked the Legislature to build still another wing, to enable him to meet the increased demand. " The New Hampshire Hospital was opened in eighteen hundred and forty -two, and received twenty -two patients; these were all that were offered. In eighteen hundred and forty-three these were increased to forty-one ; in another year, eighteen hundred and forty-four, there were seventy; in eighteen hundred and forty-five there were seventy-six; in eighteen hundred and forty-six there were ninety-eight; and in eighteen hundred and fifty they reached the number of one hundred and twenty. In the meantime additions have been made to meet this growing demand for more and more accommodations. " The number of patients in the Eastern Virginia Asylum at Williams- burgh has increased more than two hundred per cent in fifteen years — from sixty in eighteen hundred and thirty-six, to one hundred and ninety -three in eighteen hundred and fifty. " Those in the Western Virginia Asylum at Staunton, have increased more than eight hundred per cent in twenty-three years — from thirty- eight in eighteen hundred and twenty-eight, to three hundred and forty- eight in eighteen hundred and fifty. " The average number of patients in the Ohio State Lunatic Asylum at Columbus, was sixty-four in eighteen hundred and thirty-nine, and three hundred and twenty-eight in eighteen hundred and fifty — being an increase of more than four hundred per cent in eleven years. u JSTow, no one would imagine that the population of these several States has increased in these ratios of the increase of the lunatics in their asy- lums within these respective periods. But it will readily be supposed that the opening of these establishments for the cure or the protection of lunatics, the spread of their reports, the extension of the knowledge of their character, power, and usefulness by the means of the patients that they protect and cure, have created and continue to create more and more interest in the subject of insanity and more confidence in its curability. Consequently, more and more persons and families who, or such as who formerly kept their insane friends and relations at home, or allowed them to stroll abroad about the streets or country, now believe that the'y can be restored or improved, or at least made more comforta- ble in these public institutions, and therefore they send their patients to these asylums and thus swell the lists of their inmates. " For the same reason the people in the vicinity of lunatic hospitals send more patients to them than those at a greater distance. Thus the County of Worcester, Massachusetts, has sent one lunatic out of every one hundred and sixteen of its population, while the most remote coun- ties of the State have sent only one in three hundred and sixty-one of their people to the State Hospital since its first establishment. V. In New York, the County of Oneida has sent one in three hundred and sixty-one, and the remotest counties sent only one in fifteen hun- dred and twenty -three of their people to the State Lunatic Asylum at Utica. " In Kentucky, the people of Fayette County sent one in eighty-nine of their people to the Lunatic Hospital at Lexington, while the farthest counties sent only one in sixteen hundred and thirty-five of their popu- lation to that institution. "Similar differences in the use of the public hospital are found in 59 Maine, New Hampshire, Connecticut, Ohio, Maryland, Tennessee; and doubtless in other States the same will be found on investigation. " To infer the number of lunatics in the community from the number in the hospitals is about as unsafe as to infer the number of births from the number of children in the schools. The first element here is want- ing: that is, the proportion of all the children that are sent to school. Now, as this is very different in Massachusetts and England, and Spain and Egypt, no reasonable man would venture to compare the number of births in these several countries by the population of their school houses. The provision for the cure and custody of the insane in these countries differs as widely as their provision for the education of child- ren; and yet writers have given us the comparative numbers on this ground, as in London one in two hundred, because there were seven thousand in the metropolitan hospitals, and in Cairo one in thirty thou- sand seven hundred and fourteen, because there were fourteen in the hospitals of that city. " It must be further considered that many of these statements that were put forth as positive facts are given in such round numbers as to afford good reason for supposing that they or their elements are esti- mates rather than actual enumerations. " Thus, in some works on this subject, there are stated to be thirty-two thousand lunatics in France; sixteen thousand in the United States; seven thousand in London; four thousand in Paris; two thousand in Pennsylvania, and one thousand in Massachusetts. Millingen says the proportion of lunatics to the people is one in one thousand in England, and in France one in one thousand. " One department in France, Ariege, gives three hundred vagabond lunatics for four successive years, without change, but these suddenly, in the fifth year, diminish to two hundred and fifty, and in the seventh year disappear entirely. Another department, Seine Inferieure, reports two hundred lunatics for seven successive years, and another three hun- dred for three successive years in private families. Saone Haute reports none, either in private families or as vagabonds, for two years, when suddenly in one year there appears to be one hundred and ninety-three. Sarthe reports two hundred and seventy-three lunatics in families in eighteen hundred and thirty- seven, and then they all disappear and are reported no more. Mayence reports eight in families and as vagabonds in eighteen hundred and thirty-five. These are increased to two hun- dred and nine in eighteen hundred and thirty-seven, and diminished to twenty-one in eighteen hundred and thirty-eight, and to eight, the original reported number, in eighteen hundred and forty-one. There are so many of these apparent inaccuracies, such full and round num- bers, and such unvarying totals where there must be some change, and such sudden and violent changes, out of all relation to the ordinary cir- cumstances of society, that we are compelled to look with distrust upon the whole, and consider it as but little better than mere guess work, with more or less foundation in fact." As more attention has been paid to the insane within the last twenty- five .years than ever before, we may fairly conclude that their numbers have been more accurately ascertained and reported, at least in some countries. The foregoing extracts prove how rapidly this malady appeared to increase prior to eighteen hundred and fifty -two in all the States and countries where liberal provision had been made for its proper treatment. We have shown its increase in England and the 60 United States since that time, and the Chapter on insanity in France affords a comprehensive view of the disorder in that country. But let us see what has been the result in the several States and Territories of the United States, respectively, within the last twenty years. The fol- lowing table shows the population, the number of the insane, the num- ber of idiots, and the ratio of each to the total population, in eighteen hundred and fifty, eighteen hundred and sixty, and eighteen hundred and seventy. It will be observed that the ratio of the insane has increased from one in fourteen hundred and eighty -five to one in thir- teen hundred and ten during the first period of ten years, and to one in ten hundred and thirty-one in eighteen hundred and seventy; while during the whole period of twenty years the idiots are not so numerous in proportion as they were in eighteen hundred and fifty, being at that time in ratio of one in fourteen hundred and seventy-six, and in eighteen hundred and seventy, one to fifteen hundred and seventy-one. We have neither time nor space to analyze each State separately, but the curious can do so for themselves, as the facts appear in the tables. 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MOWOO LOIMNNXCOIN^CJ i-H~ -^r-Tcf CO i-T r-T r-T OX^HOOiC^OO wioccxoaosNxio i^COjX^i-^N ©_O_00 N © cq" ©" cT tjT r-T r)T o" r-T ©" co Tti co i— i co i-i cq © co cq 5R « 2 rl cc to C T/J TO • to sj aj o 22r2_d ^ M a cjcS^+S C cS c 'So Si H ^3 .5 C3r£j TO C 0{ i — i O s-i c? S3 O o3 o C a -'* cs a> CM eSi^i 1^,'^.y^ ^V ^ *> 53 O fj cj aj^ o a: ai «•>-•>-».>-». O f- O C3-— JS, 1 -! atients 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 patients, 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 Kailroads and other Facilities of Travel — Hospitals Better Known to Neighboring People — Observations on Foregoing Topics — New York State Lunatic Asylums — General Suggestions — Propositions relative to the Structure and Arrangements for American Institutions for the Insane — English Lunacy Commis- sioners on Sites, Construction, Size, etc. — Suggestions of the Scotch Board — Size of Hospitals — Quantity of Land Necessary — Comments upon Kirkbride's Views. 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 fifty-eight each year, and the average annual increase has been sixty-seven. If we 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 we 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 who will be likely to require its use may be 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 some 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. n 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, Oswego, 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, Rensselaer, 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, Rockland, 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 of 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 twenty-three years — eighteen hundred and forty-three to eighteen hundred and sixty-five — 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 OP DISTRICTS. SUMMARY. Districts. I. Sum of the annual population for twenty- three years 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 2,292,643 827 99,680 36 2,772 II. 10,528,406 1,809 457,756 78 5,820 ill. 16,337,520 2,222 710,327 96 7,351 IV. 28,146,477 2,440 1,223,760 106 11,535 " 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, one thousand 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 enjoyed 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 hundred and fifty -five and eighteen Ill hundred and sixty-five show the number 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 population: POPULATION TO ONE LUNATIC IN NEW YORK. DISTRICT. 1865. First.., Second Third.. Fourth 1,300 1,611 1,396 1,904 " This diversity of advantage of an insane hospital enjoyed by the people of near and remote districts is not an accident, nor a peculiaritj^ 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 proportion 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 fill 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. STATES. Number of Years. Districts. I. II. in. IV. V. Maine New Hampshire .... Massachusetts Rhode Island New York New Jersey Pennsylvania East Pennsylvania . "West Pennsylvania Maryland Virginia North Carolina Mississippi Louisiana Tennessee Kentucky Ohio Illinois ..... Michigan Missouri Canada Nova Scotia 1840-65 1842-65 1833-53 1849-65 1843-65 1848-66 1850-57 1857-66 1857-66 1850-64 1828-59 1856-60 1858 1848-58 1852-59 11824-55 1838-66 1847-64 1859-65 |1851-64 1853-66 1858-64 2,835 2,440 2,229 3,094 2,772 2,253 6,061 5,884 3,650 7,034 5,472 4,875 f 15,0l8 6,653 3,923 3,198 5,060 3,306 3,162 5,910 3,184 467 5,171 3,470 3,872 5,279 5,820 3,714 10,793 10,497 10,585 10,122 10,314 6,433 7,026 15,235 8,318 10,670 7,304 7,865 9,229 12,553 7,227 1,023 5,630 6,280 4,953 7,351 5,905 17,686 17,414 22,382 23,009 21,570 9,707 13,290 16,645 13,164 12,964 11,712 9,317 11,089 13,989 7,744 1,768 7,890 11,535 23,748 53,629 24,433 10,982 16,151 21,399 20,440 24,132 28,873 11,753 14,208 15,983 12,608 3,057 25,105 45,779 21,276 25,822 : 15,826 27,801 15,585 58,039 26,933 14,582 " In all these States the privileges of the hospitals are offered equally to the people of the counties. The patients of Oneida and Allegany Counties in New 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 York, 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. f Excluding 1844, 1845, 1846, and 1847. t Excluding 1861, 1862, and 1863. 113 sent a few patients to the distant institution now sent many to the hos- pital which was brought to their 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 opened in Taunton, Bristol County, for the southeastern part of the State. The Worcester establishment continued to receive ail 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 use^ 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 number, 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. COUNTIES. 1845 to 1853. p m g.3 o o f V • o : >a : C hj CD CD C CD 1854 to 1862. p m _ c £3 o o o Pi ^ •a CD CD : o : 3 • CD w o Bristol Plymouth ... Barnstable ] Nantucket > Dukes J Totals... 151 132 104 669,581 493,215 429,319 387 1,592,115 4,434 3,719 4,118 324 204 118 810,903 565,981 421,662 2,194 2,774 3,573 4,111 646 1,798,546 2,784 102.1 34. 15.2 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 1W five persons, 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 period fifty-two, or one in two thousand four hundred and nineteen people, to Northampton. Berkshire County is geographically fifty miles nearer to Northampton 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 River Eailroad from Springfield to North- ampton. This practically reduces the difference of distance between the two hospitals to thirty miles. And many when 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 patients. Therefore the increase is less in BerkshireMJounty than in the others. Nevertheless, there was 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 Worcester, and after that they sent to Worcester and Northampton forty-seven patients, or an average in each year of one in four thousand seven hundred and fifteen people. 11 To the towns in the eastern part of Hampden County, Worcester is nearer and more accessible than Northampton. Most of tke people must necessarily use the Western Eailroad, whether going to Worcester or Northampton, and all must change cars at Springfield 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 vear. POPULATION TO ONE PATIENT SENT TO HOSPITAL BEFORE AND AFTER NORTHAMPTON HOSPITAL WAS OPENED. Western District. COUNTIES. 1855 to 1858, four years. 1859 to 1862, four years. Increase. hj w V g SB 5" o g V, o g-IL P trt- P o &.1L a> cd S-* 8 a> ca P «*• CO S-.B P rt- CD a ? p • 6,437 47 221,640 4,715 6,574 52' 125,830 2,419 4,008 85 151,897 1,787 2,185 3,717 116 230,784 1,988 300 730,151 2,433 sr.i-tf 2 <* p <-t » 2 p "* Berkshire ! 33 Franklin ! 19 Hampshire ! 37 Hampden 101 Total Counties 190 212,437 124,916 148,294 220,680 706,327 38.6 171.2 124.3 9.9 52.7 " The people 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 lunatics 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, public high- ways, public 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 tbe 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 presents 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 when any one of their family or friends become deranged the hospital occurs to them as a means of relief, and they look uj)on 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 places 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 which 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 sympathy 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 portion 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 conrpelled 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 any 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." OBSERVATIONS 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 corresponding 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 period 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 passed away. It is interesting to notice in this connection that since the publication of Doctor Jarvis' paper the State of New York has inaugurated an 117 entirely new policy, and we are informed by Doctor Charles S. Hoyt, Secretary of the 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 officers; and that bills have already been passed authorizing the 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 skoj)S, boiler and engine 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 OVTD. V This institution, designed for the chronic pauper insane, heretofore provided for in the county poorhouses, 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 far 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 central building for the Superintendant's residence and offices, and a north and a south wing, with 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 »ast. It is a plain, substantial brick struc- ture, in good preservation, and appears to be well adapted for the pur- 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) For the completion of the south wing, including the amount already expended (estimated) For the extension to the north wing, erecting a single group of detached buildings, furniture, fences, further water sup- ply, etc. (estimated) Total $446,998 44 81,728 67 200,000 00 $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 different 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 c£>st 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 affecting 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 INSANE Was established by the Legislature March sixteenth, eighteen hundred and sixty-seven. The site, previously selected by Commissioners ap- pointed by the Governor, contains three hundred (300) acres. Its loca- 119 tion is on the east bank of the Hudson Kiver, 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 full 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 completed according to the plans adopted 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 adaptations 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 : NAMES OF ASYLUMS. Cost of the buildings. The New York State Lunatic Asylum at Utica. The Willard Asylum for the Insane at Ovid.... The Hudson Elver State Hospital for the Insane at Poughkeepsie The Buffalo State Asylum for the Insane at Buffalo The New York State Homoeopathic Asylum for the Insane at Middleton Total $661,065 58 728,727 11 1,200,000 00 800,000 00 360,000 00 $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 sixty-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 wisely chosen locations in different portions 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 within easy reach of that city. At what particular lo- cality, must necessarily depend on many important circumstances and indispensable conditions; and 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^pby every State 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. IV. ]N~o 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. V. The highest number that can with propriety be treated in one building is two hundred and fifty, while two hundred is a j)referable 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. VII. 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. VIII. Each ward should have in it a parlor, a corridor, single lodgirig 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. JSTo 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. XL .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 by 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 ©ther 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 Physician and his family, in case that officer resides in the hospital building. XYL The wings should be so arranged that if rooms are placed at both sides of a corridor the corridors should be furnisked 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 hospital 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. XXL 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 expense 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 arrangement, 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 hospital 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 Superintendents 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, m conveniently accessible to all the people of such district, may properly oe 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. Resolutions offered in the same Association in 1870. Resolved, 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: First — 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 be 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 adopted, the following Superin- tendents voting upon the question: • Yeas — Doctors Ray, Butler, Kirkbride, McDill, Shew, Walker, Hughes, Parsons, Landor, Reidle, Compton, Gundry, Clopton, Grissom, Lewis, Bancroft, Curwen, Evarts, Dickson, Roy, Gray, and Read. • Nays — None. In the discussion upon their adoption, Doctor Ray 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, and 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 speaking upon them ai^present." In reply to a question asked by Doctor Cook, Doctor Kirkbride made these remarks: " Speaking for myself, I should say, without any hesitation whatever, that I do mean, as the fourth resolution declares, that 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, l 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. [Suggestions and Instructions in Reference to (1) Sites, (2) Construction and Arrangement of Buildings, (3) Plans of Lunatic Asylums, by the Commissioners in Lunacy for England and Wales.] JYo. 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. Proportion of Land. 2. The land belonging to the asylum should, when practicable, 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 position, 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 plateau of 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 patients. Locality. 5. The asylum should be as central as possible to the mass of po]DU- lation in the country or district for which it is to be erected, and should be convenient with respect to its easy access by public conveyance in 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 pipes and reservoirs, and also to ascertain, its fitness 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 per 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 of 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. Euildings 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 buildings 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 epileptic patients, 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 spacious 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. Proportion 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 Upper 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 boarded 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. Rooms 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- munication. 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 so hung that when open 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. Warming. 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 water joipes 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 connection with any shaft, furnace, rarifiying chamber, or smoke flue, must be constructed entirely of brick, stone, or other fireproof material. The rarifying 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 sufficient fall, so as effectually to carry off to a sufficient 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 water. Lightning Conductors. 32. Lightning conductors should be placed on the most elevated parts of the building, 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 pipes and lightning conductors. Farm Buildings. 33. Farm buildings, with suitable stables, etc., for visitors' horses, should be provided. No. 3 — Plans Bequired. 1. One or more sheets of the ordnance map containing the county, borough, or district, in respecb 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 basement, 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 j>rincipal 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 j-ooms 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 workmanship have been calculated in making the estimate. 8. The thicknesses of the walls, 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 plan 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 OF 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. No. 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 Epileptic 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. (Kemainder of description same as for England and Wales.) General Dining Hall, Library, and Beading Boom. 9. A general dining hall, conveniently situated with reference to the kitchen, should be provided 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 Bay Booms and Dormitories. 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 may 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., should be provided, and 133 also workshops, suitable for the employment of the patients according to the prevalent occupations 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 emergency they may be enlarged to contain six hundred to seven hundred patients without sacrificing the special characters which all modern asylums 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 effective 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 always 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 Coiney 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, would 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 efficient 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, worthy 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 elasped, 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, F 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 patients. 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 propriety, 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 written. 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 inoffensive 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 proportious 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 well 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 Wickham informed us that this was 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 B^y — 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 difficulties 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 wards about eleven hundred — or four hundred more than it can properly accommodate. Doctor Shurtleff tells us in his report, " that beside two patients in the rooms intended for but one, in eight out of the eleven wards, two 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 wards 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 we 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 surprise, and the untiring energy and constant watchfulness 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, we 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 whether Stockton is or is not the proper 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 were desirable. We therefore heartily indorse all that Dr. Shurtleff has said with regard to the necessities of the institution over which 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 privacy 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 OP LAND NECESSARY. While it is the duty of the State to provide for and take care of every 139 citizen who may be afflicted with 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 occupation "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 contraindi eating it should be employed in some way during a portion of every day. Hence every 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 which 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 effect 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 importance that the supply should be permanent and of the most liberal kind. The daily consumption for all purposes 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 placed 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 the 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. Inclosures. 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 it 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 effective. 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 — it 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 afford. 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 seated 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. All 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 iJMLt at no time should a larger number be admitted than the building is ^Rculated 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 course to the amount of personal attention required from the chief medical officer. 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 physicians who have had a large practical acquaintance with the insane, 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 to make a beautiful and picturesque exterior 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 was 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 friend|^ patients unim- portant. They cannot fail to see that neither labor nJJPkpense 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 should 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 physician, he should possess the mental, physical, and social qualities to fit 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, th& 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. YI. 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 the Superintendent, should have a general supervision of the domestic arrangements of the house, and, under the same direction, do what she can to promote 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. XI. 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 disposition; 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 we 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 weighed 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 OP 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. * Note. — See Kirkbride on Hospitals for the Insane. 145 2d. Non-pauper — supported by friends or from their own estates. 3d. Criminal. 4th. Idiots. 5th. Inebriates. He speaks 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). In a new country such a plan is altogether impracticable. Describes G-heel (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. Distance 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 asylum 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 patients by the attendants is more complete, ventilation is more easy, since the windows and doors of the sleeping rooms from which the patients 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 admirably, 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 l 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 supply; 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 method of opening; 3. Size of panes; 4. Guards and accessories, as shutters, etc. Page 52 — Yentilation, either artificial — by propulsion or extraction; or natural — by doors, windows, and fireplaces only, or by openings 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. Day 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, fittings, and furniture of rooms. Page 64 — Staircases and stairs, bells. Page 65 — -Treats of the different provisions made in asylums for con- valescents and quiet patients, for the sick and infirm, and for the violent and excited. " The proportion 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 part 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 opinion. 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. He 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 speaking of the use of the shower bath, he 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 while 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 pro- 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 public papers and by the existence of well conducted asylums, before the separate system is adopted. An attempt 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 New South Wales 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 Hobart 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 beneficial 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 whose minds are in a state to profit by such kind offices, 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 offer 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 bodily, of the inmates, as well as the cost of the institution and the whole workmg 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 affording 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 continues: "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 officials, medical officers, etc. 2. Diminished cost of conveyance of coal, 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 spoken of at considerable length. In reference to land, Doctor Manning recommends " the proportion 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 ci.n be so employed, it will be equivalent to the constant labor of ten healthy men; and what these are capable of effecting 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. working smoothly and well, with every care for the treatment of patiems, and effective supervision, are, as a rule, below this number; and" "for eco- nomical reasons, 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. Worcester County. Sussex County. Essex County Three Counties Ne w Surrey Middlesex County (Colney Hatch) Gloucester County Derby County Lancashire County Leicester County Stafford County (New) Stafford County (Old) Lincoln Coun ty Bristol Borough Cotton Hill Lunatic Hospital Northampton Hospital Retreat, York Elgin District Hospital Perth Hospital > Haddington Hospital Fife Hospital Montrose Royal Government Asylum, Washington. Pennsylvania State Northampton (Mass.) State New Jersey State New York Evreux, Departement Eure Quatre Mares, Departement Seine Inferieure Sainte Anne, Departement Seine..... Yille Evrard, Departement Seine.... Yancluse, Departement Seine Colony of Fitz James, at Clermont Meerenberg, Holland Guislain's Asylum, Ghent Hamburg Illenau Frankfort Gottingen 100 200 96 252 150 150 80 100 96 80 100 77 40 32 80 75 30 92 60 12 57 110 230 130 200 120 200 150 100 14 750 700 1000 70 35 65 42 40 20 20 30 10 20 80 10 50 25 15 17 10 14 10 15 28 12 2 7 30 105 18 4d 60 60 20 15 20 12 10 152 Table, Showing Number of Patients and Assistants in certain Asylums, with the Sala- ries of the Superintendents in certain of the English arid Scotch Asylums. [From Manning's Report.] ASYLUM. 3 p o o o •is Salary interi hi B co co CO CO rt- pa co of Super- 206 342 1 391 1 £500 469 1 502 1 650 510 1 550 534 1 550 540 1 600 554 1 800 590 2 500 650 1 600 836 2 600 962 2 750 1,124 2 2,026 2 600 220 1 350 213 1 300 380 1 400 ASYLUM. 3 O o Bristol Derby Leicester Stafford Lincoln Sussex Three Counties Worcester Essex Gloucester New Surrey Lancashire, Lancaster Lancashire, Prestwich York, West Riding Colney Hatch Perth District Cupar Montrose Quatre Mares St. Yon St. Anne Ville Evrard Evreux Guislain's Asy., Ghent Meerenberg Hamburg Frankfort Gottingen Illenau Washington New 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 principle 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. Recent 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 asylum the maximum population of which is never to exceed two hundred, the modified cottage plan is the one to be most recommended. For an asylum 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 plan 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 may 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 Eesident 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 se23arate 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 passing 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 numler for which it will serve will not be greater than can be contained in one dormitory floor; but if the dining room accommodation is provided 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 space 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 asylum 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, i £ * See Appendix F, plates 5, 6, 7. 20 154 and no site should be chosen where this cannot be obtained. If the asylum be near the town, the town supply 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 per diem. For safety in case of fire, Dr. Manning says: "Keliance 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 which attendants and patients should assist, should be practised at fixed intervals, and the hose and other appliances kept always in order. In asylums in which force of water sufficient to play the hose cannot be obtained, ordinary hand fire engines should be kept 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 effective mode of lighting. If gas cannot be conveniently obtained from a company's works, it may be made on the premises without difficulty, 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 every 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 ail 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 ceiliugs. There is but little necessity for oiling or polishing the floor except in rooms devoted to dirty patients. The walls 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 simple railway key will serve for each attendant to turn on or off water, gas, or to chock the window sashes, close or open shutters, 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, officers, 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 chapel in the well ordered institutions of all countries. For minor amusements, the day rooms of the institution are sufficient, 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 provide a special room for a library. The building for the reception 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 appointed 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 paid, and such remuneration made to the professional members as may be deemed fair, but the other members should not receive salaries, the position being entirely 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 reap- pointment. 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 Housekeeper, sub- ject to the approval 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 patients, 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 examine the patient and affix 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 conti ol 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 approved, by the General Government; whilst minor alterations, which are not contrary to their general spirit, may be made by the Superintendent or Board of Control. Financial Administration "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 what 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; the number 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 ground of insanity or found to be insane, in prison; and the direction as to their maintenance 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. Superintendent. 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. Assistant Medical Officers. The Assistant Medical 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 asylum 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 population 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 Physician, and that an asylum of five hundred patients should be pro- 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 effects of such policy are ever appa- rent. We 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 JSTew South Wales, through Messrs. Triibner & Co., No. 60 Paternoster Eow, London, may 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 appears 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 possible manner 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 provided 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 pleasant 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 by the Superintendents in the United States; eight 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 where 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 ineonvenier.ee 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, with very rare exceptions. The 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 Patients ivho Pay. . Some eminent men in all the countries we have visited have given as their decided opinion, that patients who pay and those who 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, while the necessities of a crowded asylum often enforces associations that would 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 different propositions, and in a majority of cases we have to accept the latter. If it were possible, however, 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 sufficient 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 be free to every person belonging to the State who might elect to enter them, without the payment of 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 be sufficient 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 jDrofit by its operations save and except the patients 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 affixed 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. Wi'th 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. * Note. — Statement of the Number 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 New Brunswick 1 1 11 8 11 3 22 11 Totals 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 few 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 public Treasury. Until the system suggested can be carried out, we think it would be far better to abolish all charges, so far as they relate 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 nouses, amusement halls, theatres, dances, employes, attendants, airing courts, keys, etc., as we have done so to a sufficient 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. CHAPTEK 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 continental countries, and in New 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 of 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 who 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 different. 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 are often whetted by insanity, and exhibited in an intensified degree. They have no power to conceal the real hideous- ness of their 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 recovery. 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 hospital, 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 light 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 maybe an obstacle to their restoration, and prevent some, perhaps many, from 8ver 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 various 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 intense 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, when they are proper, but always with tenderness, and that everything should be done to encourage his self respect. Among the patients in the hospital fere 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 villainy — 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 responsibility that, look- ing for the highest good of the community and the moral and spiritual welfare of all its 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 with 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 afflicted 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 take 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 way, 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 California 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 CHAPTEE XII. CHKONIC Jj^SANE. Provisions for Curables and Incurables in Separate Institutions. v 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 cashes 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 who 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 atjOvid, 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 Utica because he was considered curable, and that one in Utica should be sent to Ovid because the reverse of this was 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 elicted arc altogether in favor of non-separation; the percentage of cures being less and that of deaths greatest in those countries where the system of separation is most generally pursued. CHAPTEE 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 (1847) 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 especially to the treatment adopted: First — In mania. Secondly — In epilepsy connected with insanity. Thirdly — Paralysis connected with insanitv. Fourthly — In melancholia. Replies were received from fifty-three physicians in charge of these establishments, from which we extract the following as a fair specimen of the whole, 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 sleep, 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 symptoms 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. Remarks. 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 nape of the neck. In inflammatory diseases within the chest, I find that free cupping 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 incipient 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 purgatives. 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, oj^ium 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 warm 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. Antispasmodics. 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 tbe 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. Iconics. Vegetable bitters, with ammonia and aromatic stimulants, or with mineral acids, or with liquor potassae, or with small doses of iodide of potassium, are frequently used; also, chalybeates, in the form of steel wine 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 which 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. Stimulants Are frequently used medicinally. Those preferred are aether and ammo- nia, strong beer, porter, and wine. They are mostly given to patient 3 who are admitted in a reduced condition, or to those whose 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 Summer 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. Vapor Jbaths 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 Hanwell) 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, provided 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. I 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 appeared 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 auxiliaries 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. Nauseating 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 sufficient 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 effect 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 upon 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 ehemata 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 aether. 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. amnionise, acet. vin. antimon., pot. tart., tinct. hyoscyami, potassae nitras, and mixtura camphorse) 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 in 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, patients who are laboring under much excitement are not restricted to the ordinary dietary, bufr 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 even 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 by 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- tion to the state of the skin and bowels, the maintenance of a warm at- 172 mosphere in the sleeping apartments, a plain and nutritions diet, and the use of much exercise, unattended with violent bodily exercise. Remarks. We have found it impossible to comprise 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 adopted 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 purgatives, early rising, and active exercise, with a prolonged separation 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 asylum, 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 apprehension of apoplexy, and never for the purpose 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 permanent fatuity. We have found general bleeding useful in some cases of melancholia. In most forms of insanity, we find benefit derived by the local abstrac- tion of blood from the head or nape of the neck; in some cases, by the application 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. We consider that the use of purgatives is indicated in almost all forms of insanity in the incipient stages, and we find them especially 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, we quote: Remedies used in Cases of Epilepsy at Devon County Asylum, as described by Dr. 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 spt. 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 (hycl. chloria. is preferred) have apparently effected cures. Remedies used in Cases of Epilepsy at the Middlesex (or HanwelV) 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. Remedies 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. Remedies 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 which 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 assafcetida. 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 Brislington House, by Doctors F. and C. 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 appears 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 opinipn 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 applied for three or four hours every second day. Remedies used in Cases of Paralysis at the Middlesex (or Hanwell) County Asylum, by Doctor Conolly. The paralytic complication (paralysie generale 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 reduction nor excite- 175 ment; even baths are scarcely to be recommended. Leeches and aperi- ents are sometimes 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 ineffectual as regards a cure. Many of the miseries of the malady, as uncleanliness, ulceration, and fits of violent anger, are prevented or long retarded by 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. D. 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 Mr 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 hoj)eless 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 beyond the influence of medical treatment. Remedies used in Cases of Paralysis at Brislington House, by Doctors F. and V. 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 effects upon the mental disease. These cases are rarely presented to our notice- in a curable state. 176 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 assafcetida, 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. potassae 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. Remedies used in Cases of Melancholia, at Middlesex {or HanwelV) Asylum, by Dr. Conolly. The attention is first directed to any manifest bodily disorder, or to existing debility or plethora, often with the effect 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 effect. 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. When plethora is manifestly present, daily saline aperients are generally useful. Remedies used in Cases of Melancholia in the Surrey 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 improve 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. Remedies used in Cases of Melancholia at Stafford County Asylum, by Mr. James Wilkes. 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 asylum 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 constipation 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 great 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 so 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 saphaena, 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 by others, and therefore not so generally emjDloyed. 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 Yienna, 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 weeks, "an til a new cuticle had formed over the entire body. The patient recovered without inconvenience. This case was not one of insanity, and has been introduced to show how much endu- rance is possessed 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 Borne, and St. Ann at Paris, are fitted up 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 barrel. 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 patients we infer it was regarded in the same unfa- vorable light by them. At the Asylum San Ton, at Eouen, presided over by Doctor Morel, a writer well known 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 employed, and especially in the treatment of epilepsy. The shower bath is used twice a day in these cases, after Avhich 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 the 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 powerful agents they are liable to abuses, by which they are brought into disfavor. Doctor Blanche, of Paris, and Doctor Skae, of Edinburgh, 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 had 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 applicable 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 einjDloyed 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 were 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. None 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 some, and greatly abused in other instances. Dr. Maudsley, the President of the Psychological 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- ically, 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 being tabooed by public opinion, was not to be thought of ten or twenty years ago. It would have cost any Superintendent in England his official 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 health and mental integrity. Attendants, unfor- tunately, are not always tdessed with that amount of sweetness of temper, of untiring patience, 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 fol- lowed the reading of Doctor Maudsley's address revealed the fact that all did not agree in the views he had expressed; but, on the contrary, many 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 potash, chloral hydrate, and, in some instances, a mixture of two or more of these drugs, was given prefer- ence. But the most remarkable and varied views were entertained with regard to the effects and efficacy of the hydro-chloral. It is thought, by Doctor Phys Williams and a few others, to be of little consequence either one way or the other. Doctor Browne, of Wakefield, has rej)orted three cases of death from it in the asylum under his care — two of these having occurred the same day, and within half an hour after taking thirty grains of chloral. While Doctor Clouston, of the Cumberland and Westmoreland Asylum, near Carlisle, and many 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 Neri, of Perugia, Dr. Serafino Biffi, of Milan, Dr. Poller, of Illenau, and others, have also used it, and express the highest opin- ion of it as a quieting, sleep-producing agent. Dr. Poller thinks, when long continued, it has a tendency to produce congestion of the skin; while 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 very 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 we 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 upon 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 especially 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 when the end to be accomplished 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 given 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 muff is the only kind of mechanical restraint that should ever be emj)loyed under any circumstances, except for surgical reasons, and these only by the order and in the presence of the physician. In these views 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 believe 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 advocates of the non- restraint system with whom we met in all France. He had paid a visit 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. Having imbibed Dr. Conolly's views, he made to his Government one of the ablest reports on the subject that we have read, and so thoroughly was he convinced of the j)ropriety and practicability of the system that he at once put it in practice in the asylum over which he presided, nor did he abandon it, even in surgical cases, until a deformity in a case of fracture of the leg demonstrated the absurdity of treating 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 have been avoided, 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, but under no circum- stances does he permit an attendant to employ it without his direction. The chemical restraint, opium, morphine, chloral, etc., are prescribed by the physician only, and so should it ever be with mechanical restraint, the camisole. . Epilepsy. We have seen that the remedies employed in this fearful disease were principally the metallic salts — nitrate of silver, oxide of zinc, citrate of iron, bichloride of mercury, etc., assisted by setons, blisters, cups, pur- gatives, and antispasmodics — and that all were equally unavailing. The disease is still considered incurable by almost all who have 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 supervenes on a previously existing epilepsy, it is not necessarily incu- rable, and that, in a large majority of cases, the frequency and severity of the attacks may be lessened, thus modifying the disease and amelio- rating the unhappy condition of the patient. We have already stated the treatment by shower bath pursued by Doctor Morel, at San Yon, and given the results. Similar claims have been made by different persons in favor of each of the remedies above enumerated. Thus, Doctor Deiderdorf, of Dobling, near Vienna, reports one case, cured with ox. zinc; another, when there was a syphilitic taint, with iod. pot. Doctor 183 Fischel, of the Koyal Bohemian Asylum at Prague, attributes the cure in one case 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 profession 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 twenty 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 affections, while it is the only neurotic medicine employed 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 galvanic 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 effects have been accomplished by its use, but sufficient time has not yet elapsed to test its efficacy. 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 which 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 head are as varied as the diseases leading to or the symptoms developed 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 more 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 asylums 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 flowers 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 system 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 coming under the head of moral treatment or manage- ment may be properly 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 so 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 patients 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 day 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 and 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 A versa, near Naples, 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 3d — 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 have 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 Richmond Asylum, at Dublin. The system has been completely established, and the organization as perfect as any schools in the country. The able Superintendent, Doctor Lalor, has taken great interest in and paid particular attention to the subject, demonstrating 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 whom attended school. In the school for males we saw one hundred 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 places 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 on the continent of placing a Director at the head of the institution. Its gen- eral management, the power 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 powers 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 officers, and selects his attendants. He is paid a liberal salary, and given one month's leave of absence each year for recreation; and after serving fifteen years is alloAved 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 prepare themselves for the position of Superintendent, and being under a local Board of Managers, 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 own local affairs 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 coDverse 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 j)hysieal character than 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 effects upon the patients of too much indiscriminate visiting by families or friends, but the propriety 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 by our friends in Ire- land. The last reason referred to is of still less weight. We cannot comprehend how any physician who does not thoroughly understand the pathology and treatment of physical diseases can successfully treat persons 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 possessed 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. Reasonable 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 well 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 properly 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 infirm men, and learned from the Superintendents who 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 w T ere as apparent 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 any time 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 hope 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 asylum 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. CHAPTER XIV. INSANITY IN GENEKAL. Increased attention to Insanity — Growth of Hospitals in United States — Increase of Hos- pitals in United States — Increased Accommodation — Hospitals exhibit Insanity — Non- residents — Should other States send their Insane to California — Insanity in other States — Results of Treatment — Curability of the Insane— Effects of Early Treatment — Good Hospitals necessary to Favorable Results — Results in our Asylum — Doubtful and Hope- less Cases— Economy of Early Treatment — Probable Duration of Life in Chronic Cases — Increase of Patients in our Asylum — Causes tending to this Result — Will the Chil- dren of Foreigners be as liable to Insanity as their Parents — Observations upon Phys- ical and Moral 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 — Psychology 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 which 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 was curable in any considerable degree. The doctrine, however, made very slow progress 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. Hence, hospitals began to be built for the twofold purpose of custody and curability, for beside the difficulty of managing and taking care of lunatics 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 'demand for their accommodation, and though their numbers have multiplied with astonishing rapidity, 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 piteous appeals seek admission for the treatment they afford and the benefits they are known to confer. At the beginning of this century there were only four receptacles for the insane in the United States, and only one of these, that at Williamsburg, 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 Baltimore, and the Bloomingdale Asylum, at ISTew 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, with 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, Va., 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 Lexin gt on, Ky 1 824 Hartford, Conn 1824 Staunton, Ya 1828 From 1830 to 1840. Worcester, Mass 1833 Baltimore, Md.. 1834 Brattleboro, ¥$.. 1837 Columbus, Ohio, destroyed by fire 1839 Boston, Mass 1839 190 From 1840 to 1850. Nashville, Tenn 1840 Augusta, Me 1840 Philadelphia, Penn., Hospital for Insane 1841 Concord, K H 1842 Milledgeville, Ga 1842 Utica, N. Y .-...1843 Insane Department of Phila- delphia Almshouse 1845 Flushing 1846 Providence, E. 1 1847 Indianapolis, Ind 1848 Jackson, La 1848 Trenton, K J 1849 From 1850 to 1860. Jacksonville, 111 1851 Fulton, Mo 1851 Harrisburg, Pa 1851 Stockton, Cal 1852 Longview, 1853 Madison, Wis 1854 Taunton, Mass 1854 Hopkinsville, Ky 1854 Jackson, Miss 1855 Flatbush, L. 1 1855 Canandaigua, N. Y 1855 Dayton, 1855 Washington, D. C 1855 Dixmont, Pa. 1856 Baleigh, K C 1856 Auburn, N. Y 1858 St. Vincent, Mo 1858 Northampton, Mass 1858 Kalamazoo, Mich 1859 Troy, R Y 1859 Newburgh, O 1859 From 1860 to 1870. Kellyville, Pa. ^....;. ;.1860 Tuscaloosa, Ala..... 1861 Mt. Pleasant, Iowa 1861 Blackwell's Island, N. 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 Eetreat, 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, N. S 1859 During the next ten years, eighteen hundred and twenty 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 Hill, 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 from 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. hj % * % > Hd o p h 3 P P < 5*^ 3 '' h 3 p 4 c-t- B a> ja CD H B CD 3p 3 rj; o P o O o Hi ^5. p YEAK. M 3 w P P P •rt- 3 2. ■Z.P'o 3 tlJi-l P P O «. < o p CD p e-t- P W CO ►cs p O co go CD w 00 o p £■ . CO 1 1 I 1844... 17,069,453 23,191,876 31,443,322 38,555,983 #17,457 23 2,561 ] 4,730 ] f8,500 ] - 17,735 S 11 14.67 1850 15,610 23,999 37,382 28 50 .68 70 30.30 1860 35.42 1870 '.. 6Q 168 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, Vol. XVIII, p. 2. 192 Table, Showing the per cent of the Insane provided with Hospital Accommodation in the United States and England at different periods. UNITED STATES. ENGLAND. K} H >zj hj ^ fcj hj CD P 4 nr m- a p JO a* a P J o J ropoi sane tiospi mod? CD SO H. a' 22 3 ropoi sane hosp mod a a o 2 -i- o a^'w -! o 2 o 2: org: -- — o O O H- O „?~ a p M SO CH -i *> l — IS SO CO -*JT 50 O *» S0O •8113 Jt *- cri oa o m bi GC I-" Si 4- ^ OS I— ' I— ' o I— 1 -~T ES CO S l ••a^era^ octo I— I K-J> O rt-&0 t" 1 ■ pnox en hmhm j; C7» I— sa so >+- so ►*- o t-4 — I CO SO . OOOOl- COrf*. KOHOR' •-> O I— I O OS SO CH 4- CO mox GO : bo m : : cti co o *- : -s : i— is, to : ccccocico -T • m i-* ij- so , _ O : i-i tc : i— ■ co -a to o . C l h- ^ SO -I OS : m ~ co so -t — : osbscoos-i ■et«K •81BUI8J 'I«}°X •ai«H ••8[ttuia L ;j I B 1<>I • 8 I«lt 8J13UISJ 'Woj •ai*RT •9IBUI9J Wx CO 73 > •ST O _ I I— /- ^ J CJip<< £ 5. -a tr H- C t— ' M " to tr IS 1 o o Cs.< • o ^ « ^2 o ^ ^s O OS as Si- 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 cfcsease, 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, with 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 early period because it is not only known that they will be received, but kindly and skillfully treated, and that the chances of recovery are greatly in their favor. The very 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 they are sent to the asylum, fortunately for them, in time to be treated while there is yet hope of recovery. Under 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 many 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 scribe for, a much larger number would recover. Abundant evidence has been adduced in another place 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 establishments for the treat- ment of the insane, DOUBTFUL AND HOPELESS CASES. We are fully aware that many cases of insanity are incurable from the beginning. The very causes producing it places recovery beyond 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 have forfeited their best chances of recovery and gone within the limits of chronic insanity, from which but few return with mental 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 numbers 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 hospitals. Men of dis- ordered mind, when they need a change of air or scene, cannot go to a hotel or private boarding house, or even to the house of a friend, when 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 prepared 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 poor 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 effected 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 ns 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 who recovered in the Worcester Hos- pital from 1833 to 1848. 3 Total Duration Average Dura- Total Time in Average Time B of Insanity. tion. Hospital. in Hospital. Duration of In- cr 1 CD sanity previ- ous to Admis- O *4 K b H B u l-d K b K d CD o SB CD o p CD c p CD o p sion. a 53 p VJ SO p V) P <0 P 3 ^ SO H CO CD CO CO co hJ -1 CO tr 1 p" 1 iO CD w oa en ■ CO : CM One year or less. More than one 1,179 855 6 ?5 8 ?1 523 10 ?o 5 10 vear 201 41 1,181 2 6 5 10 12 173 33 1 6 7 2 10 9 10 Unknown ?4 Duration of Insanity of those who Died. No. Cases. Years. Months. Days. Years. Months. Days. 272 1,171 5 29 4 3 i 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 16.74 29 years. • 197 PROBABLE DURATION OF LIFE IN THE CHRONIC CASES. This table 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 j)resent time, as well 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 were 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 appointed by that Government to make an investigation similar to the one in which we have been engaged in behalf of California, made to his Government one of the most able, complete, 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 asylum walls, and reach by accumula- tion to that number of old, chronic, and incurable cases with which 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. Upon the whole, then, though the con- templation of this mass of suffering humanity must occasion deep sorrow, the Col'ony 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. With 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 spirits 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 Br. 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 — The 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 operating, 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; while 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 eighteen hundred and seventy; the next to show the percentages of these ele- ments; the next table shows that more than sixty -two per cent of the population of California in eighteen hundred and seventy were 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 who 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, operating 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 CO i< t-o ^ © CO CO Q i»o © o « CD ^ ss © co *~* S£ Sn. « © co ^ ^ ^ £ c6" ^ S5 "< 1 "- co o .8 "♦-* ^ 8 §s .^> CS~> CO 'orei Fot *, CO ~ -to EH 53 «» < H Ul Nat porti oo <0 A W to O CO H _~» r~o ^o « hH S £ £ gT © P *■§ "§ •w h«3 ■J3 s §.$ Ps co -» -B .*>•£ s | © sp ^ £ ^s £ ss •«• « -fo> © to ^ 8 •^o s © r< CO H t-5 PO < H • Proportion of Foreign Insane to Native Insane Proportion of Foreign Insane to Foreign Population Proportion of Native Insane to Native Population Proportion of total In- sane to total Popu- lation Foreign Insane. Native Insane. Total Insane. Foreign Population. Native Population. 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"aving considered the subject of the treatment of insanity and the rapid growth of hospitals, and having shown how rapidly insanity itself has apparently, if not actually, increased in all countries during the last forty years, let us consider the far more important subject of the results of treatment in the various countries under consideration. The first of the accompanying tables shows the number resident at the beginning of the year, the admissions, numbers treated, recoveries, and deaths, with j)roportions of recoveries and deaths in the asylums of the several coun- tries from which returns could be obtained and of the latest dates that could be procured: While the last table sets forth similar facts for one hundred and thirty- six of the one hundred and forty-nine asylums visited, the results as exhibited in this table are for the year eighteen hundred and sixty-nine in the United States and Canada, and for eighteen hundred and seventy in the other countries. Though these tables differ in results in some respects, they agree in showing that the largest proportion of recover- ies to numbers treated and the smallest percentage of deaths to numbers admitted are in the United States. This, of course, may be the result of accident, as it requires a series of years and a knowledge of all the facts to enable us to draw positive conclusions in matters of this character. The average per cent of cures to admissions in all the asylums visited was thirty-four, while in the United States it was thirty-seven. The average of deaths to admissions in all was twenty-seven, and in the United States only seventeen. This we believe to be owing to the fact that the patients in our asylums are allowed a more liberal diet than in any other country, and that the debilitating effects of the continued bath so commonly used on the continent are entirely ignored in this country. There may be other causes operating to produce this remarkable differ- ence (sixty -three per cent) in the mortuary lists of all other countries, as compared with our own, though the two above cited seem fully adequate to the result. As already seen in the foregoing table, of all the patients admitted during the year, in the one hundred and thirty-nine asylums under con- sideration, thirty-four per cent were cured, and twenty-seven per cent died, leaving thirty-nine per cent, most of whom must be added to the chronic list, and thus swell the number of the insane. This is doubtless as favorable a showing as could have been made had all the institutions in the world been comprised in the list, as many of these are considered among the best asylums ever established, and are conducted by as able and learned men as have lived in any age. Well may we inquire, then, " if this is a necessary part of our natural condition or our civilization, to make this annual sacrifice of regiments of men and women on the altar of mental destruction, can the causes producing these effects in any way be avoided, and some of this sacrifice be prevented?" We will permit others of more experience and wiser heads to answer the question. CURABILITY OF THE INSANE. " In a perfect state of things, where the best appliances whi ch the science and skill of the age have provided for healing are offered to tho lunatics, in as early a stage of their malady as they are to th ose whe are attacked with fever or dysentery, probably eighty, and possibly 203 ninety, per cent would be restored, and only twenty, or perhaps ten, per cent would be left among the constant insane population." — Dr. Jarvis. Referring to this assertion, it is stated, in reference to the Utica Asy- lum, that " its influence has been such that every acute case happening in the county is at once placed under hospital treatment. The result is that 00 1^ 1> CM tH 00 00 CO CO OS cm CO OOM^NOOMOQN r-l CO CM CM rj< CO CO CO CM © CO 00 i— 1 rH r->< vi rH rH rH -t— »O5 0^H r-i r-i CO M-^HCOO ■h- T* 00 CO OS CO CO CO -* tHOi— IOOOt^iCOOi— IrH inocsoNooiiO'*© 00^1-^ -f I> OS_i©_iO CO i-Tco" "*~r-T Recoveries. 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No. Asylums visited from which Reports were ob- tained m M O IQ jtNtNHCOCOClMNHOOO CO :Hi-lr-ICqiHr-(THrH «©= : N^NCNHCOOOMOiOOOO tH r-l >— I N CO M O H CO N N H H M O lO iHCOCO fccc d CI— IM d o to C ©T>j • O • 3 rd 03 jj? ° ^ CS •§!§ to«2 O "Id d 03 1— IH- 1 • Q3 ■-;.- B= <0> Ul ' a H* oT r/* to <-< 03 C3 rd d •+J I — 1 tj. r*i ^d 03 ^ d £3.3 r— I o_( tO 03 O ^ rd (-■ © ^ 03 ^ *d > r G3 O «3 > 03 03 -m Aa.A Sf|^££o£^Mc£wM 207 w < V co o jo -io ■to o cj §< ft o CO 55l ■o., co r*o o p*H ^o -< -t— « *K CO o C H S o £ -«o ^. o So §< ^ ft ■ts CO "-iS ~ ^ .° ■— ~ to g ^ to K| •o .^ to to C5 5 50 &H ^T c>-| O 5>. -jo W ►< ^ -t~ * O to **» CI ^ ^s 53 Jo CI CO 5-. ►? CO «l -o S? co Ch Co s— CO ^3 ^3 s ^o e CO S ~ .« Jo >s» -to "^ CO S -+— 53 CO s CO ■to -~ ^ •o > CO to t— <4i © ~< « ^ -to t^ ^ O) CO r-^ CO to co ^Q Proportion of the For- eign Insane to the Native Insane co ot 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 EH w. Q !— I 5 Foreign Insane. Native Insane. Total Insane. Foreign Population. Native Population. Total Population. co Co O -1-3 o CM O CM CM CO co CM GO co~ CO LO CO co CM~ CO CO GO to go" CO oi < a i— i - O 2 Lh c5 O O o +3 c5 O pH So • r-l o O Cm O .2 *-3 o CO CM CO CM GO GO O CO GO' GO O 208 Table, Showing the Population and Numbers of Insane and Idiots in 1850, 1860, and 1870, with the proportion per one thousand of Insane and Idiots to Population, and the Annual Bate of Increase of Insane, Idiots, and total Population. CALIFORNIA. hi o S3 3 3 o c-t- s» Batio per 1,000 of— Annual Increase of— H P cr 1 4 a- H S3 i i— i M M HJ H ^ p i— i o o O P S3 W o §Ts» YEAR. M M o o* ^ 2 3K.T7fi 1860 456 1,146 1870 408 738 | 1 35.60 | i 64 f 39 1 to 858 1 to 284 209 Table, Showing the total number of Idiotic, with Native and Foreign Idiotic, and proportion of the Native and of the Foreign to the total Idiotic, and of the Foreign to the Native Idiotic. -9 ^ ^ hd * 1 ►d * Hd K> o a O ^5 2o ?sj o o -1 2. ^2 » 2 g$ o'o 2j c4- 1—1 erf < <+ (-+■ o' ° 5* °o j YEAKS. 2: "5 3' 5" o' c-t- l-»5 n of diotic. ^ 2 hj2 1 ~> : » i * 3 ^ 3^ E*0 . • o O p §2. : Cg i i ; : O o ' c5 : ctq" Q 3 ^5 ; H . : •— i : o i i ° 1 O i i : & 1850 1 \ 6 1 8 5.71 14.28 1 6.66 1 to 11,723 I860..., 4 1870 £ 7 < 1 '0 17 8 0.45 19.54 2 4.28 1 to 5.005 1 to 12,343 CALIFORNIA NO EXCEPTION. This shows that California is not an exception to the general rule; for while the insane have increased within her borders more rapidly 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 down in health, or enter upon a course of reckless dissipation that leads them to insanity and to our asylum, 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 prepared 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 equivocation 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 proper 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 who 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, so 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 are the only causes of prominence f In Italy we find pellagra (disease of the skin peculiar 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 we 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 effect, 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. With 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 wiser 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 of 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-producer for seventeen years. We must either provide hospitals 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. No other State, so far as our knowledge extends, has done so much j 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 Shurtleff in his report 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 proportions 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 expenditure 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 Shurtleff 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 respects, in the location of a hospital for the insane. Officers' fees and travelling expenses, which depend 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 Shurtleff, 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 provisions 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 words, 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 will deny these facts; every person who has written or spoken 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, Virginia, 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, reports 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 New York. The States of Maine, Iowa, Illinois, and others are no better off. 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 l 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. While 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 support. They cannot afford to send this afflicted member of the family to a private asylum — it may be in another and distant State — nor can they afford 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 walls. 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 Wfore 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 justify 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 in 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 sixty-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- portion 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 public hospitals 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 COTinection that the reports of admis- sion into the hospitals of Massachusetts include both the foreign or State paupers who are admitted free, and the American paying patients 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 the readiness with which people avail themselves of hospital privilege for the cure 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 h*ave 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. £Tow, no one will suppose that the hospitals of Ohio are managed with more skill than those of this State. But the difference in the result of their labors is due to the difference in the proportion of patients sent in the curable stages of their disorder. " Looking upon 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 plain 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-supporters, 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 proportion 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 been sent at as early a stage of their dis- ease, and as large a proportion 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 world, 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 people. Here it is imposed upon tl^pse 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 people 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 property and income of the Commonwealth." Any attempt to save money by failing to provide 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 who may be so unfor- tunate as to require their use and need their healing influence. In this connectiou, we deem it of some importance to introduce the following extract from a Message from Mr. Seward (when Governor of New York) to the Legislature : " I cheerfully express 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 proclaimed 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 people/' 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 Kepublican 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 apd 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. CHAPTEB XV. INSANE ASYLUMS — ECONOMY OF 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 effected 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 eral prosperity. If, more than this, lie loses power to provide for his own w an ts, his support becomes a charge upon property that he or others have created, or are at the time creating. If his own means or those of his family are insufficient 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 incurable 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 supporting 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 add 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 and ten cents ($83 10) for six months, and one hundred and sixty-six dollars and twenty cents ($166 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 up 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 ,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 hospital — 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 ($3 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 otherwise have been paid to the public treasury on this amount of property, are properly 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 ^nay be considered as an annuity, or so much annually contributed to the commonwealth. Accord- ing to the best European 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 ($1,208). 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 occupations 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- port, 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 unciired patient a total expenditure for sup- port Add the loss of the value as a producer Showing a total loss of. $3,490 83 1,208 00 $4,698 83 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 by 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 each; 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 persons in the asylum at Stockton. This calculation presupposes 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 222 average, and their years should be deducted. This would reduce the sum, but would still leave a very great amount lost by uncured insanity. CHAPTER XYL INSANE ASYLUMS— PLAN BEST ADAPTED TO CAEE AND TREATMENT OF THE INSANE. General Observations — Cottage System — Farm Asylums— 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. We have already shown why they cannot be properly 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 wing 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 otner 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 with 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 asy- lums in vogue in several countries, in our sketch of the report of Doctor Manning. What 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, Moreau, Parigot, Bulckens, DeMundy, Duval, Boiler, 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 experiences 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- p not 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 Hosjntal Beport 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- nal, 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 we find in our notes, would constitute a volume, and must therefore be omitted, however agreeable it would be to us to give our exj)erience of each institution visited. We must therefore be content with descrip- 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, with its colony of Fitzjames, 224 about 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 are 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 work 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 who 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 m 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 lauudry 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 othQr 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 work 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 rej)orted 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 peculiar 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 asylums in the United States have nearly all been constructed on the corridor plan, with centre building and wings. The plans of the proposed asylum at the City of Boston, the Pennsylvania Hospital for the Insane, and the Michigan State Asylum, though differing 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 ~New Kirkbride Asylum — with all of its appurtenances would probably cost two thousand dollars per patient. It is a corporate 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- nish many advantages, comforts, and luxuries, and sources of amuse- ment and diversion, that would be beyond the reach of institutions intended mostly for the accommodation of indigent or non-paying patients. Its caj^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. Descriptions 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 wide, 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 ward 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 at 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 building.. 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 especially 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 as 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 asylum 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 tresj>ass 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, with few 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 Utile 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 rooms 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 be made with advantage — that there might be one large dining hall, not for all, or for three fourths, but for one fourth of the patients 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 clone, 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 fifty 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 completed, or in process of construction, and of which the asylum at Auxerre (see plan App. 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 adopted this plan to some extent, by supplementing 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' Retreat, JSTewcastle on Tyne, Cumberland and Westmoreland, Morningside, Cupar and Fife, Glasgow, the Richmond Asylum near Dublin, Cork, Quartre Mare, and the new Asylum San Yon at Rouen, 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 asylum 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 system, 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 Science, for January, eighteen hundred and sixty-seven, an interesting paper ~by Doctor Lockhart Robertson, read at the annual meeting of the Medico-Psychological Association, held in Edinburgh, July thirty-first, eighteen hundred and sixty-six. Doctor Robertson is the able and well known editor of the Journal of Mental Science, ex-President of the Medico- Psychological Association, and for mstay years Superintendent of the Asylum at Hay- ward'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 Reports 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 satisfaction 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 beatiful in design and elegant in structure, can never afford. It may be well in this connection to state that no asylum in Great 9 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. ' JSTo ward should be built without a wide stairway of iron or stone at either end, that free escape 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 few 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 sj)eak 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 any 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 non-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 t>e wished for but not of absolute and press- ing necessity. CONCLUDING EEMAEKS. In our introductory 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. Wilkes, in addition to valuable 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 numfcer of the most able and learned men in the country, and enabled us to exchange views with and obtain the exj>erience of such men as Doctor Bucknill, the accomplished author and Chancery Commissioner in Lunacy; Doctor Lockhart Robertson, also a Chancery Commissioner, and editor of the Journal of Mental Science; Doctor Tuke, the Secretary of the Associa- tion, and Doctors Arlidge, Blandf'ord, 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 Hanwell; Hoctor Marshall, at Colney Hatch; Doctor Ehys Williams, at Bethlem; Doctor S. W. D. Williams, at Hay ward's Heath; and that noble trio of genial gentlemen, Doctors Yellowlees, 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 own 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 others 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 Superintendents of all the asylums visited, for similar favors. Doctor Stewart, of the Belfast Asylum in Ireland; Doctor Lalor, of the Richmond 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 Eome, 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 were studying the diseases of the brain that affect the mind. Doctor Cardini, of Florence; Doctor Fouscartfof 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, who 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 possible 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 rejmtation, such as Doc- tors Bay, Jarvis, Earle, Gray, Butler, Kirkbride, Stribbling, Nichols, Bancroft, Bead, Buttolph, Gundry, Curwen, 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 w T ays. 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, w T e 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. Showing 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 troubles Intemperance Religious 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 ^7.96 13.32 10.23 10.23 9.91 6.71 Showing, also, the Deaths, with principal 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 tv ere: 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 a^e 162 111 107 51 40 38 16.08 11.02 10.62 5.06 3.97 3.77 30 234 Cost of Maintenance. Number of Patients. Cost of Building. Material Ml pq < Capacity "When Opened. Acres of Land. Character P P £ fl CD • f- i c3 1— 1 co r—t -U O O --■•,-■ ce GOtE m eg <» © g l-H +i +i O •"Ci ^"s £*> ^a M as ^3 -m om ^>> 9^ o'S seven do lars. fifty to ten fifty to five ^ -M «M .M Cm « m'O 0> rO^,Q ■** a _2 03 03 £^3 r9 k c; s M ;,_ Jj r O 03 03 P .. 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Oi • . CO GO. : oo B ■ rH t> cS ; -n c3 Hi 0-2 P : <$ '- Is a) HH O P ^^ o M V-^i <4 E r— < 11 c ! 4- r= * I. et < g 1 c c i p c IIS c ?- .c +: H > c a c 1 — c hi 1 P M Mt. Pleasant, Kansas H- C c +a '=J a hi 243 CO t> CO : m : . OS . : *• : ■^(MHCON^ONMMHkO • t>-^O"^Q(Mi©r|J!MC0H0Q . i>^o6i6i6o6c6^c6o6rHrHi6 : t— i t— i : ©q GO 1—1 I- OS 1—1 : ^ : : oo : : °^ : OCOCOCOOsOCO^OOt-COO '• O'OHM^OH'O^'OCOO ; ©It— IHHH^r 1 r- It— 1 NH ; O £-; CO ©q ©q : oo : : t- : : ©q : OOONt> ' o l- t- ©q : o o ^ oo : rH ^h th t- ©q co ©q m io co tr- t- co ©q : oo ©i t^ cd os co os : rH t— 1 rH r-i ; CO rH ©q o oc cc : ©q : os '. CO CO rfi CO iO COH00N rH t-5 os -HH rH t- CO CO CO CO CO £- £~ OS lO O iO CO lO rH OS lT3 GO O lO ©q th ©q co o co ©i rH 00 ■ )0 : co os ©q to O CO o -H CO T)H CO 00 iO CO O CO CO MhOOOOiO ©q rH co ©q rH co ©q ' ©1 : <** H- 1— : co ■^^oococo©i©qcoiocO"^oo .©qCOC0C0T}H-COHHCOHH '. ©1 CO OS ta rH OS CO : co ©q tr- : b- : co : oooo^oi>mco^iflcoco ;COI>J>COi©o:M»OCOHCOm ' 00 : co ; CO : CO : ^ : ^ : i— i co co co 1>CO>OHO TP CO CO 00 OS , r-i r-i ©q CO OS rH : co : os . : ©q : : ^ : CO CD 00 t- : CO 00 CO lO : i—i co co ©i ' O O CO : t- co t> • rH rH ©1 OS 00 CO rH : ©q : os ; rH T- i '• o ► '. CO • T— ( ''OTtii0©TC0i005-t | C0i— IG0O :N00NOC0OI>H^C0G5N • i— i co co ©q ©q i— i coh nh : co ■ rH rHC0fc~^OCDC0©qt-©q^0SrH'*00C0OC0 OCOCOrHOSt-GOOCOrHOO©qCOlOCOi— ILOlO C0rHC0rHrHCOC0^©q©lrH©qrHrHCO©qCq©l M ® r* o § W4 2^ +3 o3 © © :« :-> co d d.d d c3 rH o ^ W CD GO 03 00 M so -^ PH rH "*d d~£ * OS CO 00 GO rd CO O C3 ^3 d o ro^i p==i^ o ^ S3 f-i c3 © ^ r^ H £ H PQ 02 W QQ O c3 d += d ^ °? ^ c r^ O £ d o CD H5^ o - d fH © |.s hh!> o © d +Jh o 244 Zfl < zn P i— i P 73 • I— ( o O rH W O oo g «0 .CO 05 Proportion per cent of Deaths on number treated Proportion per cent of Deaths on number admitted Proportion per cent of Cures on number treated Proportion per cent of Cures on number admitted Number Eemaining.. Number Died. Number Cured. r& 05 Total. Female. Male. Number Admitted. Number Kesident co i-l < OHWOi rH 05 00 lO id co t^ co rH C5 rH t- £- ©q OOiflCOO CO lO O CO rH rH b- rH H 00 lO H 00 O Oi CO OC5N CO CO CO tH »o o t)'CO©qrHTtlirH lO CO CO rH r- ' rHr-i ©q CO CO iO f» -H r^03 PH -^ .oT ^ J°r3 HfH .^^r-s Sfc*i fc pa rH t> P3 £ rd •r-< bJ3 c3 O Hp^pq^pqfHEHOpq i>. rfl tO CO CO >0 CO CM o rH CO C5 O0 rH CO I rH O O O b- OO O C5 b- 0 CO rH CM CM CO CO CO "f rH CM I rH CM CM 00 rH CO 00 OO CO CM rH : (M^H • O O COffiiOOb-O '• CO cm rn : CO CO O : Ci rf< rH O 00 O O CO I o i-i co : Tfl rH : ^ O CM CO rH CM oo : cm" r-i NiOHCOQOO : CM rH O t- 00 O rH CM rH r-i HMO CO CO ; rH CO rH rH rH rH CO rH O . T— 1 CO T-T N tH J> lO O O : -^ co O CM CO CO CO CO OO b- CO OS rH t— I CO co : co cm 00 CM CM rH O CO o r- 1 CO oo" CO^OIHCOM : O CM rH OO 00 O rH CM 0C rtH 00 t- CO Ci t- co : co cm 00 1- 00 00 rH 00 rf CO HlflH lO O : cm co CO CM CO rH CM O CO °i. i-T CM O o : b- : co : MCOHiOOOiON l : b- o : ■70 '. rH '. O rH t- C5 CM CO O i CM CM *. rH : CO rH rH rH CM r- ; OS ' T— 1 lO : CM CM ; cooNiacoNr- C5 . "* CM : cm co I CM OO rH CO rH (O C: < CM CO ; rH O0 rH CM rH CM rt j >■ "c ■1 i-H K \r<£ | c 11 ► - i c 2 ^H I A'* : ^ i> i i c > r- 11 •4P i r & 11 5 a c- || : 5 : c 5 r IS at* - +^ •I 1& > 2 Of !! ! f] i 1 1 Q a 2 s > 246 CANADA. Table 5. tzj > < 3 1 3i tz{ ^d 3 *d Hd ( ; 5 & IB Zu 3 : I \ D 2j M 4 t o o ( ASYLUMS. ^o 4 t> CD rt- O ■D 2j 3j 3 c-t- is /J e-t- 2.5* 1 o o *?. ! >-s o CD h+j < a O o 3 c 5*o p ° r§ CD p pj £ CD C Pj - pj \ 4 ^3 CD E?" © cd CD CO : co CD X e+ • rt- i->' : t^ co O : o CO : co 1869. 216 518 238 11 '9 J •7 J 50 ( 53 ] 55 i 32 J L3 26 50 295 595 368 41 45 47 11 5 16 16 33 23 4 4 Provincial Asylum, Frederickton 8 31 i 25 ] L7 2 66 68 30 8 3 1870. 245 509 li 239 12 ro s 21 < 24 ' 16 J 14 J 25 $7 56 315 630 363 84 38 35 7 7 12 35 30 29 7 5 Provincial Asylum, Frederickton 9 247 P P <1 Average capacity NXHHO rH Tft CO CO — i CO CO 1 of Asylums LOH CM r-{ M OCOCOlOO ^ i- i-{ : CM 0B C5 i— 1 C5 00 CO rH o co • QO r- Total iO cm "# CI CO C5 COCO • O CO 'tcqiMH rH o co : ! OS GO t— 1-* y- i co : OS O CO . ■>* aC Pauper patients co^co o co : C5_ lo" co^o_ : cTco" : cm" -•-> -. lums -7f< rH rH CO rH -+j .^ Average capacity Moomc CO rH !>• CO CC CO cq m of Asylums CO iH r- T—i 1 CO C5 rH b- CO C~ •* or- ; 1—i O CO N OS t^ <* o •* : Ol Total o; w o o r- co_ oo^co_ : co"ifi" ." co" .r3 r-i cq CO 0D o OlOCiN t~ O l- • ■* oi C5 t— Ci CO lO o ci : IC T3 00 Pauper patients GO co" oq^ : co"tfT '. co"" o B rH rH 1—1 CM 1 o co co C5 r-i cr t- :© : w o CD h ic n h ?; GO • o • CO Private patients.... (NlCO^lOr- r-TrH r-T CO : >-h : 00^ ^" 'cl rH S 1 l_3 Number of Asy- N O N a r os pq lums CO rH CO l^ CO rH p£ Average capacity HHHCC< co o co ^ cc C5 IMH CN co h n n c: cq 1> lOCSJ CO OD n3 GO rH CO CO C CO OS lO CO 7—( Total •"*! r-H-- CO CC GO 1^00 lO > OH(MCO co" rH I>T}< co" CM CD N ■* i* N C ^ t^oo : : CD 00 ^00 CO CO tJ CO o i-h : Pauper patients Pica cq^co^r- lO" rH~Cq~ CO 1= (MH^O rC -»-3 CO n co • © : o 2 « t o < -t-i -j © i >> O cc S t? C/ CO < QJ3— rH Cr - 2 5? 0J • CO • :^5 : : o : Ji CD CD c and Boroi ed Hospit litan Lice ial Licens 5 'c o khouses... latives or CD PI S3 :/) l-H |>TfH fe^&g' * 1 > 53 f-. <£ co O r<^J o QO Ph ~g^ B'l o o «■§ gr 3r3^< 5 ' 1 In W With In Ja EH O CD M > m 248 00 o 00 ^8 <» •w cq H co in" g M -< CO EH ^ < CO r-o 5» ^ ^ 'K o CO to Per cent of Deaths on No. Treated.... Per cent of Deaths on Admissions Per cent of Cures- on Number Treated.. Per cent of Cures on Admissions Numbers Died. Numbers Cured. Numbers Treated Numbers Admitted. Total. Pemales Males. m < "^CiCii-Hco>OTjHC^ocdcdi>^cdo6T}Hci NcoHooHO^tomaicooiOiMN T^THTjnc^foo6^oit^ ^ HCO^^rHOOMMNCOH^ Hl>cq0005C0C000TH»0ON»0I>«0 odidi>^(roco»diOi>t>od(>iiOT-ir>o6 rH r- 1 03 rH r-K ocqiOb-HHoqoqi>»ocqC)Oit-iO d H n ci d oo ci co co' Tji d th 6 d ©4 T^r^OO^r-ICvlOqCOCOCCCOCvl^CO^H rji COCOOOOOOOiOiOtMCCX) lO ^iCuCCOMGiiflMHOOOiOHOOCO N C5 H 'O 00 t- l»OCOCO'OHiOb.CO^ b»l>C0 00iO(MHOH03C0N00Or0 NN^OHiOOOOOb-W^OHiO cI>fOOOHOOO(M rHr- lOrHCOr- 1 Gi GO OOOCOCOlMHHiM o o __, o ^ CD A pi S3 c5 ^3 X CD co bJD 3 3r> O CD CD CD 3 O s ° o a o o o g 5* g "S J © co t3 ^b ° c3 o o cq CO CO 1-i -* CD o Q co Jh o| o ~P c3 Pi WW 249 cdc6odj>cdidciT**ci 10 ONCOOOCOCCNCON o CO oqoo^coHcoooit* c j> 6 n »6 n to h 6 l— 1 rH r- 1 t-H r- 1 CO 00 OOOOrljNfOO^HO co' rH id id co* o ci cd -h4 CO CO OOCOOiOHCQMcOO T— 1 iCMOHOOWNOO 00^ OH H H CO!> oq CO r-4 Hl>CO00^!>Oi00CO J>Or)OCO T-l GO co~ 1— 1 ^coocoiONOoa OJOOH^HCOOOfOO I—I HtJ r-l r-i r-» CO CO a £~"H/<00NI> co oq r-t co Hcq WHMMO(MiMC5CO t-N 00 CI iQ O 00 C5 IM (MCqHlQ rH HM k HC0 >-P ^4 •£ ^3 P-2 « S rS © % O a +3 © P ^ EH ^ ^ p^£ o § * &< O P T3 . © p ~£ o3 © © ,£2 © f-J © r-t o © +3 c3 32 250 P P CO M EH O EH Total CO CO 10,090 1,372 11,462 47,375 3,955 2,759 3,790 10,504 36,871 13.5 Females .. CO CO oo" 1— 1 CO i—l CO CO Oi co^ 2,172 1,298 1,683 5,153 : fr- Males 00 CM rH H^ 1—1 OJ HH i—l CO co b^ 10" 1,783 1,461 2,107 5,351 > OJ P5 H Ph Total cq oq °^ of -r= o3 PM <+H o CD rO ft * ct E • r— -r= +i ae *• r- a ■+: -r= '£ < • : > • r— ■ ■+: C H-3 P CD £ += c r-l += rH CD ^C P P rH CC rC f r- K H^ c E- *6 g Si •r- P 1 ■ S : •rH ■ -+^ ; o : p : Tj ; P ■ c3 : T3 : CD ' 2 : Ph a • rH CD rH C c3 > rP C O r- co C p _i a P cc 03 rr c b r- ci rC c 'ci C o fr- ee r^ r-i CO e CD P F 'p °1 c s Proportion per cent of readmissions 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 tr eat e d 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- pers 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 ENGLAND. Table 4. Showing the ratio of total number of Lunatics, Idiots, etc., to population 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, workhouses, etc. ^ i-3 &d Number in private Number in asylums, a JO e-t- otal ofluna iots, et uary 1 e-t- P *& O O bouses. poorbouses, etc. YEAR. O »0 rt-0 P ^d hj Hi hi : *-*? $ Ef". M < c t3 P £ ^ co T5 Z~~ ._. CD CD Mm 4 J ■5 a «H^CD § P ^ a £lo I 1— HI, P O P 4 C4 £ o a ^ o p o ^a s-^a Pop CD tJ £ © CD ^ C5 3) a -IT a-i o a °w- o o a ►a a? — >a i-i a a o O I I <-i O ' p 1862 1863 1864 1865 1866 1867 1868 1869 1870 1871 946,166 1,142,624 1,011,753 974,772 924,813 963,200 1,040,103 1,046,103 1,083,532 1,085,661 35,709 37,611 39,190 40,076 41,548 42,943 44,876 46,j953 48,433 50,301 3.77 3.29 3.87 4.11 4.49 4.45 4.31 4.48 4.46 4.63 1.75 1.82 1.88 1.90 1.95 2.00 2.07 2.14 2.19 2.21 26.6 26.7 26.9 27.9 28.7 28.6 28.3 28.4 28.4 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 ft 3 o b- 00 OS ICO 00 5^. 00 CO g ^ CO ^ CO ^ M So (_3 O 1-J w OD «i 03 S^. H CD o 03 CO 00 •S © CD ^ s o © rH CO CO iO CO t* OS 10 JlC CON 00 CO iO M 00 OS V »OOiCOH O5H00 CO «i CO 00 CM CO rH rH CO co os co co co io cm -* © 00 O 00 N Ol M (M r-i 00 cooHdboqod TjH rH co -c« oq cq th co CO . OcON(MO 00 CO CO -h4 CO id tJH GO CO 02 rH COCONMH CO OiN-*HCOCO^ 1 CO <4 CO r-i CO CM r-i CO CO CO co GO co n h th" ci d 6 c6 Pi r- 1 CO CO CM CO CM CO HOiOkOCDiOO 1 CM CO CO 00 b; b- h q w q lO lO 00 CO CO lO CO OJ CM © Pf o o i— < CO ^* CM CO T-i r-i CO OOH^Q-f HH 1 CO +J lO CO OO M O H Q H CO 10 00 OONOO^cONoi t-5 CD > o «H CO CO CM CM r-i 00 rH O CO CM CO b- b- 1 b- 03 CO HHOliOiOON 00 P3 00 b- CO O OS OS CO CO -* T3 I— 1 CO CO CO CM r-i 00 ■+j «3 . CO lO rH b- ^H rH CM . T^ cc CO OS OS O O OS »o 00 «M oo CO OS M CO b- rH OS »d o I— I CO CO CO CO r-i CO 00 rH lO CM CM r-i 1 r-i § CN cm b- 00 co r-i. ; t-* CO CO fe oo OS b- OS CM rH CO %2 CM CO CM Or J CO 1— 1 1—1 CO CM CO OS O CO OC 1 r-i 7-H- CO Tf CM CM N rH cc r-i 00 lO CO CO rH CO id tH »— t CO Hh CM CO rH CO OS OS CO CO CO © CO qciNiOH 00 d lo 00 co ' -t- r-i I— t CO CO CO CO CM 00 Hj ifj ^ CO P- Proport gate r aggre ! 255 £ to S3 <^ ca 5^ ^> ^rs S3 S-, so b- £> « ^ W Jxi iP « M ^ «5 o 1-o H CO ■to ^ £ o o "to s o © Jffl O lO W l> ifl ^ co Jjfi co o co •* a ro ^ CO V ONOOdoNiO o <1 rH t— 1 rH *-" H M 00 C5 r(f b- !M Ci © CO CO ^ t-H mh CO O CM 00 ONCJOONii o T— ( rH t-H t-H rH WNQ^HCOO CM -4-3 C* to H H tO 'O H O N l> fl 00 HG5ClOHCO^ o* "cc ; f-{ 00 O l> O Q Q H lO OS r& tH rH n CD )> lO CO (O r-l -f Oi J>* CD COiONOiOCCN CM 00 OOOHCOQNifl o f-i > e3 i— ( . rH rH rH co b- b- cm CM CO " © CO o o rH rH rH rH tH b- CO o 00 OhHhO to oi ^ T— 1 tH tH tH CO CO O CO CO (M CO rH CO o ro to b- H t> CO £ 00 Hb-OtOH CO o r— 1 rH rH rH T-i tO lG> T* tO rH cc CO O* CO Hr^OiON cc CM 00 CM to t-h 00 tJH cc T-H rH tH tH tH tH iocohc^ ' cc o q" (M lO ^ tO C3 oc Ci 00 © to CM t^ CO IC C5 1— ( rH rH tH 1 ^ 1 O ' \ 2 ^ «8 o3 "^3 © % r-H P ^ m W o 5 Of 5M ^^ k 1 1 3 ■H H fl < bD R P £ P P fn at O C P 1? CP CO M HO d 83 f . p c *-r= a. * c °-§| ■^ CH P Cm » § ° ^ 1 t, "m r-l g OS D ^g © s g^ ! .2 P bS) >■* a p.2 P 6» o 1 O a: "H l> £ P ! R 1 > ( T— 1 r- >p- > t © r c PhcS bJDri 256 ENGLAND. Table 8. Showing Length of Residence in Sixteen English Asylums of Patients who Died therein or were Discharged therefrom Recovered in 1870. DIED. Discharged Kecovered. LENGTH OF RESIDENCE. cd" o B CD w o 80 CD w CD 3 SO 9 o £1 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... Two vears and over 173 287 236 105 92 */ Totals 532 422 954 399 519 918 Table 9. Showing Proportion per cent of Numbers Died and Discharged Recovered the following 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 £ \ Over 1 and under 3 months Over 3 and under 6 months PI o ^7«.55 Over 6 and under 12 months Over 1 and under 2 years J ||} 21.45 Two vears 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/or Ten Years, 1861-1870. PATIENTS. Number; *-i «rf- S o n-» >3 P^ 3 ° t a o5 5 O Numbers resident January 1st, 1861 24,989 Admitted ■ 101,927 Treated 126,916 Discharged cured 34,716 Discharged not cured 22,826 Died 32,087 Total discharged and died 89,629 Remaining 37,287 34.05 27.3 SCOTLAND. Table 11. Showing number of Patients resident, number treated, admissions, recoveries, and deaths, with 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. fcj z B _) & ^7* o B *-i -i 1 a O Zu r/3 Pi O rjf Ej T> -<- ^ 1 CD CJ ^ Proport'n pr centum of recover's to Proport'n pr centum of deaths to 5 P > &■ o 4 Eoyal Edinburgh. Eife and Kinross... Dundee Eoyal...... Inverness District. Stirling District Glasgow Eoyal Total. 754 227 190 279 545 1,995 265 70 59 58 252 326 1,019 297 249 337 252 871 118 35 25 26 14 147 1,030 3025 365 67 13 13 26 16 71 206 44.52 25.28 11,57 50.00 18.57 11.78 42.37 22.03 10.04 44.82 7.71 44.82 5.55 6.34 5.55 45.09 21.77 16.87 35.05 12.06 20.03 6.57 4.37 5.22 7.71 6.34 8.15 6.80 33 258 * P EH O O © t^- OO Q £ so o CJ CO co CO < Co •0 CO of o T— 1 CO m CO g **j 73 H ^ to •fO c0 Oq CO CO t- CO lO t> © t- 00 CO Tff lO © U0 CO !>• lO t>- t>^© 1>^C0 c © PI feJDg Pi c; CD 75 CD w CD > O CD CD H -P o r-J 75 75 3 75 75 ®75 I£ CD a-M +3 c3 u u CD CD © 3 S g P! PI ~ o o -1-3 +3 +3 co .2 .2 & © ® J£ > £ 7; o o Boo © CD CD CD *h ^ ®«h Cm Poo 75 ■+3 CD '2 "^ -§ 2 Cv -+3 U w CD CD S B Pi PI o o •+3 -M CO CO -M -M c3 rt CD CD 75 75 Cm Cm o o CD CD bo be ° ° "S r-Ai rA Wd CD p. 2 o -4-3 M o •4-3 o Ph Pt| Ph Ph o o o o M M M M ^5 <^ H P P P Ph Ph f^ Ph PM . ^ t^ CO CO "^ b- oq oq o -t-3 CO CD CO pj O co go 75 c5 Art CD 2 2 * OQ tl CO CD CD C3 ^ O -Pi rO CD Pi Pi .2 S 43 43^ C3 fl fl d Q..M -M r •S "Sr "S ® C3 C3 C3 CD C fl fl co s ^ 2 2 ^ ^ ho CD CD CD . «3 5 5 'S PhPhPho Cm Cm Cm O O o CD CD m CificjOg 03 03 «r-( -)J -t-3 p Pw o Pw Cm o p o ■4-3 +3 O CD Pi O O O M M m CD CD U PMPhP^Ph o P4 o 259 o CO =o CO © co ^3 so » S ^s SS « co" £■» ss f-O p CO £ CO ~«o T 1 o 5 O 05 1§ 1-3 o ft I £3 03 02 3 !<1 !> o Ph Total Females .. Males Total Females .. Males Total Females .. Males Total Females Males Total Females Males oo coco noiH CD lO -* O Tt< ©HXOO i— I © CO CO MMOOHM iH l— I Tt< CO 04 tH CM ■* CO i-l I— I-- 00 no 00 © CO CM CM o SO (M00HOO O CO i— I i— I lO CO tH co 01 O O C W N LOt^ tH OJ CO CO CD CO nO !>• CO t* CD CM Ol 00 CI CO CM tH h<^ cm go no nOCM i-H LO CO coco t^ CO CO rf !>• -* CO CO tH CO CM CO © UO CO HOlOCOH CM rH CO I- CS) 00 © CO 1— i-H CO CO CD CM CM iH ONtCNN CM © (N CO iH CO HO y-t CO CO CO CM CO uO © • tJH no CO tH CO SS © cm' © -HH^CO no CO H rJH CM ^H ■* © CM 00 CO CM iH CO CM © 00 co cq CO* l> CM no t>- CO ^ I~- CO CO T* co© ** COCM iH CO cq CO CO lo-r—cMLOiH ih © © CO©©©© • ■ • csjcocmcsicm r* rj co #-. CO *=T» CM o g 3 02 O ^£ C5 I 02 03 ft CO C Cj B w *w'o2 © co 05 > *3 ^ O M r*-i <- ^ 2 H S *3 02 02 C3 CSr^ CJ 05 " H g oS » hIPQ O C3 H P j-i O C as o-S o-g o a S C5 g O g P Ph Ph rg O * i-i "^ fii — OgOf) Ph 260 SCOTLAND. Table 14. The ratio per one thousand of the total number of Lunatics, Idiots, and persons of unsound mind, to the population in each year from eighteen hundred and sixty-two to eighteen hundred and seventy-one, both inclusive. TEAR. hi o ►d c Total nu lunatic etc., Ja » o <*■ d" B '-" a'di o 3g? 8# Number in Asylums and Poorhouses. P+- p mbe s, id nuai 2* CP5 B* tn p : d C "d ,-> o 2 1 : -*=e £ S lO ^ r-i S © H ^ co h3 eo~ § W < « r^> H « £ js's © ■«- fcu ~ CD *^3 ^ co S3 to <4i *3 ►.«- bi co 5^. p.8 s § <^3 to CO £ £ s © ^ CQ Pt ft *-• ^ P « a a H Total. Female. Male. Total. Female., Male. Total . Female. Male. Total , Female. Male. Total, Female- Male. Total. Female., Male- Total. Female- Male. Total . Female- Male. CO i— IC5 00 ?i •*NN 0 r-i COOO^f i-OiO(M 18 M< rfio T-ICOiO rtiCOlO 00 NMN r-l >nt-t- >-< OCOCO i> : : to«i_j • : to 3 '£ s ^ ."is CO 1 to ' §<§ ^^ %s ■ t<> §£ J". or Ss. <^> <43 P^ CO "^ S © © -^ "S3 tg co ^ | I 31 *© ©> © Proportion per cent of deaths to num- ber treated Proportion per cent of deaths to admis- sions Proportion per cent of recoveries to num- ber treated Proportion per cent of recoveries to ad- missions Died.". Kecovered. Number treated. Admissions. c3 . «M 03 fn *« © 03 rO ft Total Females Males < O 00 O CO OS rH CO co ci or CO o b^ tH rH o co co oq CO o co CO c/co gf'So •|o 5S I — a ^ =2 co -io 1< C3 C3 c? O CO CO P3 co -lo CO ft S ^ ^ CO 00 CO t-5 t> o t> OOHHH CO CO lO rtl id r-5 oq i^ t~ Oi CO rH t^ t}5 C © CO CO CO © id t- CO CO CO Tf lfl H ION CO CO O CO o © CO > <1 02 CD bl) d PQ tJ PI +3 w. c5 i— i o CD o CD Cj m ,2 P, ^.^S -g d p— I .r— I •!— I ^-, DQ CO OQ.h O O O o3 o3 -(J O 269 BELGIUM. Table 2. Charges in Belgium Asylums Visited. First Class. Second Class. Third Class. Fourth Class ASYLUMS. Francs Per "Week. Francs Per Week. Francs Per Week. Francs Per Week. L/iege, St. Ans 38 to 76 7 to 11 23 to 28 6 2 to 15 5} Colony at Gheel 5.00 centi. Asylum at Antwerp 6.86 centi. Guislain Asylum, Ghent.. 11 19 to 57 19 to 57 7 1 5.60 centi. Female Asylum, Ghent... Du Strop Asylum, Ghent. St. Julian Asy., Bruges... 7 5.88 centi. 2.00 centi. Table 3. Showing the Number of Patients in Lunatic Hospitals, the Admissions, Dis- charges and Deaths, and the Per Cent of Recoveries and of Deatlis to Admissions, and to Number Treated for the Year 1865. p CD o p o CO B P o p -f- o CO p ►— < CD o Number of patients January 1st, 1865. Admissions for the first time Eeadmissions Total admissions Total number treated during the year. Discharged recovered Relieved Not improved Died Total discharges and deaths Remaining January 1st, 1866 325 126 239 341 317 99 160 254 642 225 399 595 2,663 865 174 1,039 3,702 1,031 2,671 2,778 690 122 812 3,590 830 2,760 5,441 1,555 296 1,851 7,292 1,861 5,431 270 BELGIUM. Table 3 — Continued. K p cd CD 3 p i — i CD 31.2 39.0 8.7 8.8 32.8 31.2 9.2 7.0 ►3 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 34.6 8.8 32.1 8.1 Table 4. Belgium, 1863, 1864, and 1865 — Fifty-one Asylums. H i-3 H ri H H H »-3 Number Eesident. o e-t- JO p IS- » P go P JO w p «*-2. o g* 3 a> si ' 11 y B n p> P'CD P. CD 5 © ^^T p © YEAE. CD to CD B P CD o P o. Adn 2^ O CD cr* CD o CD P. 3 ^ TO CD TO CD 00 p P o CD CD 4 s CTCD 2 P to P Q O M 2. TO ^ H 2. i-* >-is c-t- CD e-t- CD H hi o : ^ : Q : cd CD *-*» J"~ ' : P. ►J CD : cd : p . CD p i P? • 1 • aa • TO • TO ' TO 1863 2,587 2,583 5,170 1,694 6,864 % 605 373 l 320 35.50 30.51 8.81 7.57 1864 2,673 2,693 5,366 1,669 7,035 577 427 390 34.57 35.35 8.20 8.38 1865 2,663 2,778 5,441 1,851 7,292 642 624 595 34.68 32.14 8.80 8.15 Total- 7,923 8,054 15,977 5,214 21,191 1,824 1 ,424 1,' ros 34.98 32.70 8.60 8.04 271 BELGIUM. Table 5. Increase of Insane Persons in Belgian Asylums for Ten Years (1856 to 1865), and Annual Increase. TEAES. Number of Insane. Increase. In 1856. In 1857. In 1858. In 1859. In 1860. In 1861. In 1862. In 1863. In 1864. In 1865. Total for ten years Annual increase 4,278 4,431 4,508 4,677 4,882 5,033 5,170 5,366 5,441 5,431 49.217 153 77 169 205 151 137 196 75 10 less 115 Number 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 j)ay patients only For paupers only Number of patients 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 patients under their care, as follows: NUMBER OF PATIEXTS. Francs. In an asylum of 50 patients In an asylum of 100 patients T t PiKA *• 4. f Head Physician , In an asylum of lo0 patients j ABBiBtan £ In an asylum of 200 to 250 patients -! » e . , ^ In an asylum of 250 to 300 patients < » . , ? 1,460 2,500 2,500 700 2,800 850 3,500 1,200 272 O W ^ o ^3 ^ SS to 53 CO CO fo co ^> co ^ CO o co 53 CO "53 s\) CO Ss, r< ^S to se ^ 53 CV r-o: to CO CO CO CO to CO l" *cO o CJ> "53 f< to P Number Gooid ci r-« CO a p r— 1 p 53 r-t O §■# o • r-l CO ££ O00H i-H Pj Admissions.... ifliOCO o g^S CO LQ Ttl ■^ Ph S-3 CD Number CO CO i> CO o o ^ co ocoj> i-l t^ 9. cS P>S H .2 © •+J o rH CD co ©q co CO O H PsM Admissions.... o od co CO p o rtl CO CO co Ph fc- CO lOlOH 1 CO i—l CO CO o CO Numb (N C<1 C ) PC JS p: s w O q=l CM CN t3 CD Cm CD O o epl co C3 "=Pl c3 co CD §>> ^^ ct3 CD crt P. .3c3 MCE) CC CD <=> s o o co ^ co~^ co P< H ^ ^ 02 <2 "3 o •PI P O M qp CP ^•^ O -^ o o ^ co > co i — i ci co -£ £ CD 1*2 C3 o • co o CD C5 CD Ph O O qp P ^ O rt Ph '* CD -P P co CD "ta'cDrS S+* « •r-l cO-rn CD.fc! H rO C> I ; « 12 g ! CD Is «.2 ■ rl l»K+ ) HOLLAND. Table 7. Showing number of Patients in Lunatic Hospitals, with Admissions, Discharges, Recoveries, and Deaths for the Year. o B Cd" Total a> B CD o 1,521 500 2,021 1,658 494 2,152 3,179 994 Treated during the vear 4,173 Discharged during the year recovered 177 36 35 193 203 33 36 165 380 69 71 358 Relieved Died 441 1,580 437 1,715 878 Number remaining January 1st, 1869 3,295 • ST 1 CD 3 p CD 1 Total 35.4 8.7 38.6 9.5 41.0 9.4 33.8 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 HOLLAND. Table 8 . ADMITTED. AGE. From 1844 to 1854. From 1854 to 1864. Totals. cd w cd B P a> o P SO CD VI CD B P cd' CO o e-r- P GO CD CD CD P >— ' CD Go H3 o Ct- P CO Less than ten years Ten to twenty years 13 142 551 672 564 303 135 47 7 94 490 569 462 382 198 101 2,303 20 236 1,041 1,241 1,026 685 333 148 27 255 788 888 692 490 242 79 19 162 852 916 652 497 46 40 417 397 1.640 1,339 1,804 1,560 1,344 l-25fi 26 256 1,342 1,485 1,114 879 490 241 66 653 Twenty to thirty years Thirty to forty years 2,681 3,045 2,370 1,672 867 367 Forty to fifty years 987 793 377 126 Ov^er seventy years 292 | 534 140 1 219 Totals 2,427 4,730 ^ 3,461 3,530 6,991 5,8S8 5,833 , 11,721 Married Unmarried Totals ., 1,040 1,387 927 1,376 1,967 2,763 1,334 2,127 1,274 2,256 2,608 4,383 6,991 2,374 3,514 2,201 3,632 2,427 2,303 4,730 3,461 3,530 5,888 o,833 4,575 7,146 11,721 Relapsed cases 1,985 442 1,790 3,775 513 955 2,762 699 2,736 794 5,498 1,493 4,747 1,141 5,888 4,526 1,307 9,273 2,448 Totals 2,427 2,303 4,730 3,461 3,530 6,991 5,833 11,721 Hereditary Not hereditary. Totals 366 2,061 457 1,846 823 3,907 4,730 1 879 1,039 2,582 2,491 1,918 5,073 1.345 4,643 5,888 T.496 4,337 2,427 2,303 3,461 ; 3,530 6,991 5,833 2,741 8,980 11,721 From intemperance 307 2,120 53 2,250 360 4,370 4,730 586 2,875 109 3,421 695 6,296 893 162 1,055 4,066 4,995 5,871 Totals 2,427 2,303 3,461 3,530 6,991 5,888 5,833 11,721 Mania Monomania- Melancholia. Dementia Idiotisme Epilepsia .... Totals ... 871 981 1,852 1,554 1,574 3,128 2,425 2,555 436 331 767 212 221 433 648 552 322 434 756 635 883 1,518 957 1,317 507 391 898 622 554 1,176 1,129 945 98 70 168 162 99 261 260 169 193 96 289 276 199 475 469 295 2,427 2,303 4,730 3,461 3,530 6,991 5,888 5,833 4,980 1,200 2,274 2,074 429 764 11,721 275 HOLLAND. Table 8 — (Continued.) AGE. CUBED. From 1844 to 1854. From 1854 to 1864. Totals. © B p i-3 c p © CD © 3 ©* CD 2 1 1 83 87 59 415 313 •419 466 312 437 358 246 267 249 184 164 94 80 76 28 14 18 1,605 1,237 1,441 o 3 p H3 o Less than ten years Ten to twenty years Twenty to thirty years . Thirty to forty 3 7 ears .... Forty to fifty years Fifty to sixty years Sixty to seventy years... Over seventy years Totals Married , Unmarried Totals Insane for the first time Relapsed cases Totals Hereditary Not Hereditary Totals From Intemperance Not from intemperance. Totals Mania , Monomania Melancholia , Dementia Idiotisme Epilepsia Totals 1 44 188 222 182 110 45 6 798 1 39 227 244 176 139 49 22 2 146 732 749 513 348 156 32 2 131 501 534 428 294 125 20 2 98 646 681 443 303 125 40 897 2,678 2,035 j 2,338 4 229 1,147 1,215 871 597 250 60 4,373 393 405 407 490 800 895 533 j 704 798 897 1,695 1,237 614 827 1,147 926 ! 1,021 1,531 I 1,109 | 1,317 1,441 2,678 2,035 2,338 1,947 2,426 4,373 611 187 640 257 1.251 444 905 332 997 444 1,902 776 1,516 519 1,637 701 798 897 1,695 1,237 1,441 2,678 2,035 2,338 124 674 164 733 288 1,407 338 899 437 1,004 775 1,903 462 1,573 601 1,737 798 897 1,695 1,237 j 1,441 2,678 2,035 • 2,338 135 663 798 21 876 156 1,539 1,695 231 1,006 50 1,391 281 2,397 366 1,669 71 2,267 897 1,237 1,441 2,678 2,035 2,338 425 515 940 782 818 1,600 1,207 1,333 154 135 289 84 79 163 238 214 132 198 330 260 442 702 392 640 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 3,153 1,220 4,373 1,063 3,310 4,373 437 3,936 2,540 452 1,032 275 15 59 4,373 276 HOLLAND. Table 8 — (Continued.) AGE. Less than ten years Ten to twenty years .... Twenty to thirty years . Thirty to forty years Forty to fifty years Fifty to sixty years Sixty to seventy years... Over seventy years Totals Married Unmarried Totals Insane for the first time. Eelapsed cases Totals Hereditary Not hereditary Totals From intemperance Not from intemperance. Totals DIED. From 1844 to 1854. From 1854 to 1864. Totals. CD CO B SB CD t» 2 28 7 107 70 216 120 258 133 170 150 88 111 48 102 917 693 i-3 o CD B go 2 7 35 35 177 183 336 308 391 317 320 261 199 146 150 81 1,610 1,338 4 34 107 211 204 204 213 173 1,150 c *4 CD 3 11 9 4 69 63 41 290 290 177 519 524 331 521 575 337 465 431 354 359 234 324 254 129 375 2,488 2,255 1,843 i-3 o 13 104 467 855 912 785 558 404 437 480 265 428 702 908 557 781 378 772 935 1,553 994 1,261 643 1,200 917 693 1,610 1,338 1,150 2,488 2,255 1,843 815 102 618 75 1,433 177 1,186 152 1,006 144 2,192 296 2,001 254 1,624 219 917 693 1,610 1,338 1,150 2,488 2,255 1,843 100 817 87 606 187 1,423 230 1,108 252 998 482 2,006 330 1,925 339 1,504 1,843 917 693 1,610 1,338 1,150 2,488 2,255 91 286 15 678 106 1,504 190 1,148 31 1,119 221 2,267 281 1,974 46 1,797 917 693 1,610 1,338 1,150 2,488 2,255 1,843 1,637 2,461 4,098 3,625 473 4,098 669 3,429 4,098 327 3,771 4,098 247 124 70 358 40 78 186 88 89 245 29 56 433 212 159 603 69 134 400 77 182 414 63 202 348 77 200 368 42 115 748 154 382 782 105 317 647 201 252 772 103 280 536 165 289 613 71 171 1,181 Monomania 366 Melancholia 541 Idiotisme 1,385 174 451 Totals 917 693 1,610 1,338 1,150 2,488 2,255 1,843 4,098 277 X3 cp *d PJ A O £3 fc O <1 U . -< i A no o H ►h «! H rH CO 00 rH A O -t-s W rH « Hi CO |3 rH o £ o co X rH lO CO rH CO rH rH X Pn Totals.. Females Males. Totals. Females Males. Totals.... Females Males. o ^ rH Hi CO rH rH CO i—l g 3 £-4 Totals.... Females Males. Totals- Females Males. Totals- Females Males. tHCC©©©©GOCOiOCO CN i^ © CO rH rH © © O © C5-*»CiCM(M(NHHM NCSONOOXOHON OOOM^iCNMONX rH rH CS CN rH rH rH rH i—( © © © rH r- I rH CO CN © r- © CN CO CO i— I rH i— I i- © O OJ i-C X O H H 00 M i> rH © CO rH CN CN rH i— I OLOOOYCXNO^H Hi 1- CO CO Hi rH CO rH CN CO ©XHIMffiHCIMHO CO rH rH CO i> © rH CO CN 1>- CN rH rH rH CO © Hi CO LO CN CO CO CN CO "CCOOil^XOOlMHH © rH rH © rH rH rHCOrHCOCO©WrH©© 1^ O C C O N CO (M rH rH © © CO CO CO co^ of ocorH©r^oqc5i>.©co 1— CO CO CN GO CO CN rH id to CO Hi CO ©^ of ©©COt^COCOrHlOI>aO iC©rHrHrH©rHrH © 1> i> rH rH 00 ©_ of ©COCOCO©rHCNCNCOCO COGOOCOOrHCNrH CN CO rH CN rH rH r£ r-T ©rH©rHi>©©COrH© OS CN CO CO Hi rH rH CM CO CO rH CO N r-T rHl~-CNrH©©©CO©© ©CN©©©COCNrH rH COrH rHCN Hi © CO r-T ifliCCOiOOCOOWN © rH lC CN CO CN rH CN CN CN rH © GO ©CN©©©CO©rHCNCO GO rH © CO CO rH rH rH CM rH rH 00 CS ;r rr OB DQ ,£3 H o o £ 5 © > © r>5 o CD k, CD CD CD - -> aj +J +J CO fl2 H CD CD © A -i-> a. o +j +J +j ssgas CO o □ o © u Fh — fn H CO u f-> - Fh c3 c3 : si © © ._ £kr»2 ^£© £"co'©^3 £ S S g o o c g o 278 HOLLAND. Table 9. Admitted. Cured. Died. 1844 to 1854 1854 to 1864 1844 to 1854 1854 to 1864 1844 to 1854 1854 to 1864 41.6 58.4 37.3 62.7 39.4 60.6 47.2 52.8 42.8 57.2 45 55 42.9 57.1 37.3 62.7 40.1 59.9 Insane for the first time 100 79.8 20.2 100 78.6 21.4 100 79.2 20.8 100 73.9 26.1 100 71.2 28.8 100 72.6 27.4 100 89 11 100 88.1 11.9 100 88.6 11.4 100 17.4 82.6 100 27.4 72.6 100 22.4 77.6 100 17 83 100 28.9 71.1 100 22.9 77.1 100 11.6 88.4 100 19.4 80.6 100 15.6 84.4 100 7.6 92.4 100 9.9 90.1 100 8.8 91.2 100 9.2 90.8 100 10.5 89.5 100 10.3 89.7 100 6.6 93.4 100 8.9 91.1 100 7.3 92.7 100 39.2 16.2 16 19 3.5 6.1 100 100 44.8 6.2 21.7 16.8 3.7 6.8 100 42 11.2 18.8 18 3.6 6.4 100 55.3 17.2 19.3 6.1 0.4 1.7 100 60 6.1 25.8 6.5 0.4 1.2 100 57.7 11.7 22.5 6.3 0.4 1.4 100 26.9 13.1 10.2 37.2 4.3 8.3 100 30.1 6.2 15.5 31.5 4.1 12.6 100 28.5 9.7 12.9 34.3 4.2 10.4 100 100 100 100 100 100 100 100 279 CO co co s*» S3 o J"» O to CO to ^ *§ CO £ <* CO CO CO eo to SS ,«o to co -O §5 © - ia co r-5 Oi Ol lO id ^ t-5 Ol CO CO N © ifl co oi oi lOCOH co oi b- Oi rfH CO t* i£> CO co co 01 CO OS CO oq b- Oi b- CO 01 »ft t}< CNJ h o ci r> co" oo tjh ^ oq oi © oq t> *a os od o oi co h io 6 CO t^ CO CO -^ iO 01 oq co co l>t>HC0®OO oi Tji CO* 00 CO CO CO b^ Tf< b- CoifliS iS 00 Oi rf< ^f Oi lO CO Ol CO Ol OiOJiO^riOOO 00 Ci I> i> Tt lO CD i-l Ol Ol Oi Ol (M N CO O O M H CO t> 00 CO 00 IM CO O b- co oc (MNiOCOHCOO i* Tf O C 00 CO N b- CO CO o ^ »o CO © o oi co oo © 92 N ^ O C5 OS Oi V, Ol TJH T-H i-H ^ O b- CO 00 i£> CO^H Ol CO OOCOiOO OrlCMO Oi Ol Ol CO H^GOOrHOiOM^ COHOTO^COCOOH CO O CO \H »o CM b- CO od 7^3 03 S SO 53 2 Hi fV-+3 fl +3 H 03 © o Ph +3 PW feO- CD - S3 o OlOO b- i-H O HNCO O o +3 pq C3 Ah Q CD §•§ CD a 6 <3^ o CD . 03 03 rtj ?h CD O +3 Ol CO Ol Ol co^ coT HHOOO'f'OCONCOCOCOOO 00 OOHCOO^CHOHOOO^O CO b-rHCOTtliO ifl ^ CO Oi CO -* CO Oi co co co 00 CO 03 t-3 o EH oi o p oi o 92 eS CD s I— I >i 03 280 Hi i — i CO to co co* co io* • cq° © io* cq hh" ©* io : . CJ rH (M rH . rH rH rH i— 1 (M rH | CO* ■ rH Per cent of deaths • CO* © C* l>* CO *0* OS OS GO l> CO GO rH : . NWlMmHCOCONiTOH CM . rH CO Per cent of cures on •1>*tJ* CC : ©cq ic • CO GO 1> : coi- o o" id co' o h5 th oi o* t-" • l^COCq^COCOrHCOH^-'*! . 00* CO ISTumber Died. Total COCN[lOCO©C5C0 1>>COCO • cs co tji cd co co oq : I— t rH cq CO Female- : : : ih : : : : : : ^ : : : o cq cq co CO >0 rH : : :co : : :co : r>- £ o "- 1 £ o 1— 1 Total . . : co co : rH rH ' CO O lOGO : (M I"- rH CO 00 rH © © ' rH rH rH I © cq cq Female... :i> : 00 CO ■ HH GO ■ ; r- 1 i— 1 t— 1 © Female... : c: : o : : : : : "^> : : : o co io co o : : io co : ; Male..., :© too : : : ■* ico^ihos : : : cq : o> : ; : t- : ■* rt ; : ft ; Total :n(Noonio '.i^coc&rHTticcio : : o n oo io io "Oicoocoi— icoi— i • I ; r-i t* CO CN GO : IO •* CO 00 rH i-H : © rH CO iO Female... • U0 • uO • •' • : co : CD a> a- Total t CO tO CO lO lO CO O CO O rH CO »o CO " : Ttl CM CO GO "* C5 CD IO CN CD ■* CO CO : j rH CM CO CM rH rH CO co os Female... ; CO : (N : : I> : rH : rH : : CO : : ■— • : : »- 1 OJHHCqN • • IO OS CO rH rH '. '. rH rH • • Male. ,.. • O • rH • ' Ci O : co : io : : o co : : rH ; ; rH rH © © rH CO • cq co co rH : : rH • ; ,0 CD rt CO Total O H MO (N O INOOOHCONH COCOHHCMl'^rH :cOCOCO©t-COl-~l> lO COCCrHiO : -^ CO CO CO __!__ Female... lO 0^ 1> CO •' •' ' ■*(Mhh : : : cn cn co ; ; : c © © ^H rH IO CNI CM rH •'© : ^ Male lO (M O rH rH : 1 : • "*i i : »o : % P Hi H «! PR o m T^rnnfi : : : c : : : « C3§|^ h ors i" CPr-5 O K a "B a t> 5 P- CC 1 P % -J I « E 1 Eg c E c r- P c 1 C •6 '■ S :"8 \m : o • -*-> : a : * "«2 IS o .3 Phco O EH 281 ITALY. Table 12. General Movement of Population of Lunatic Asylums — 1867. Number of patients in asylums January 1st, 1867 ... Number of patients 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, in the Lunatic Asylum at Florence. Admitted. Cured. Kemaining. CASES. CD B o Q 1 CD B CD H3 O rt- P i — i p CD - * CD B CD H3 o P 1— ' 67 44 62 41 55 45 108 99 107 28 18 26 17 24 16 45 42 42 80 104 142 2 102 110 167 182 Hereditary tendency not admitted.... 214 309 2 72 Tota 1 . 173 141 314 57 129 328 379 707 36 282 Hi M CQ Q W Eh PQ EH «o •> •co J S^ £ « ^ CO ?g s S o — s >i ?. 1/J o ^ "A, cv ^> 4; IO S K? 5S to *cO H ss s?> ^ s? co Kg 9 SS o 03 r-o R| ^ ts co Sg to « sg CO CO *"0 ^ v» en ,!s CO P3 bn !k CO sg © CO KS co CO £ g <0 ■^3 Kg ^ to ^ **° to ^3 S3 Sg r>* J5 « 1 *g "l"? ^ -2 ^ id co -T5 ?g 2 ©. to !1 « co S3 £>- co r-i © Proportion per cent of deaths to num- ber treated Proportion per cent of deaths to ad- missions. Proportion per cent of recoveries to number treated... Proportion per cent of recoveries to admissions Died Cured Treated. Admitted. e*% o £ Total. Female. Male , m 1-3 m «o io «q tjj t> tij 5D lO W O lO O* OS i-j ©'©* cq cq iMHiO © -* cq # -th cq cq id tj" i> id os rH lO-* (M CO r-( CO GO CO CO CO © CO iH CO CO iO iO T^CO r-t cq © Ci i— I "# 1^ CO U5HH IO© LO IO i> oq co cq c^ i^ cq* co cqcq co co 1> rtj 00 # © ©* ^"cd ■* lO© T(H © lOHOJH CO CO CO CO cq co ■* CO © lO CO HHWH rHO cq cq oo © >-o co co cq cq © ■*cqi'^ cq co © cq cq © © io lO I"- iC iO Cq rH iH io io cq © cq iogo co 1> rH GO © cq cq © © H o M K ■sofa's J? 5^ § P. 283 CJ UO rHCO rH iO *■**! 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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 Religious 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 BKOOKWOOD ASYLUM. BATHS — REGULATIONS TOR THE GUIDANCE OP 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 the 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 kept 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. BKUSHFIELD, M. D., June, 1867. Medical Superintendent. 301 [Lunatics 1. (16 & 17 Vict.) Private Patient.] "Order" for the Eeception op 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 Statement be not known, the fact to be so stated. Name of patient, with Christian name at length, ; Sex and age, ; Married, single, or widowed, — j Condition of life and previous occupation (if any), ; Religious persuasion, as far as known, • Previous place of abode, j Whether first attack, ; Age (if known) on first attack, ; When and where pre- viously under care and treatment, ; Duration of existing attack, j 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, j 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), j place of abode, Degree of relationship (if any) or other circumstances of connection with the patient, . (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 is not the person who signs the order, the following particulars concerning the person signing, the statement are to be added." • 302 [8 & 9 Vict., Cap. 100. Sec. xlv.] . N. B. — Medical certificates of patients' examination, and the signa tures, are required by the 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 or the Commissioners in Lunacy. 1. — It is absolutely necessary that the medical men should write their certificates legibly, so as to afford the opportunity of an exact copy be- ing made. 2. — ff 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 l 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) No. 2, Sects. 4, 5, 8, 10, 11, 12, 13. I, the undersigned, , being (a) , and being in actual prac- tice as a (b) , 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. Pacts 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 (#), [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 Eoyal College of Physicians in London. (&) 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 any. (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- fully 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. .86 . . 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 pertaining 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 charge 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 to 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 now 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 epilepsy, suppressed secretions, eruptions, discharges •r 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 . . 305 DIETABY OF THE INSANE ASYLUM OF THE STATE OF CALIFORNIA, FOR EACH PATIENT. Breakfast. One pint coffee, or more, to satisfy appetite; five ounces loaf bread; 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 of 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. BICHMOND, NEAE 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 pint of cocoa. Extra Diet. — Breakfast, ordered by the medical officers, an egg. 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 Hi o P <1 p O O H P ^oo C3 PR © ^ Tea ... 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Hot Air Chambers | 31. Railroad 32. Serving /looms. Nath'l J Bradlee. Arch't. CE nnf UILIMNUS Hull. . Corridor Silling Rooms . Store-Rooms P.i, itry Kitchen \i j:f Laundry. | '.'5. Dri/ing «.ir» l 81. Railroad. J 82. Serving Boo I 33. Workshop. I I 84 CeKar. BOARD OF DIRECTORS FOR 185)7 36. Medical Stores Moses Kimball, J. Putnam Bradlee, Jonas Fitch, Amos A. Duimels, Franeis 0. Manning, tlenrv A. Drake. jfclvnnus A. Denic Avery Plnmcr, William Cumston, Clms. S. liuigess. Lewis Rice, Sam'l W. Hodges. .1 Putnam Bkai President- William Willmt, Olerk. SL'fEKl.NTKNOLKT Of HOSPITAL Clement A. WaUtir M. D. p p p p T six, on ] P : F.— Pi. 2. 1. Hall. 2. Gon-ido 3. Bay Wi 4. Sitting-i 5. RecCptit 6. Attendu f FIRST STORY. Appendix P. pi, 2 ENRINt HOUSi. i|S- S:^"»' 28. Fan Room 36. Chimney. WARD BUILDINGS. 1. Hall. 2. Corridor. 3. .Spy Window. *. Sitting-Room. 5. Reception Room. 6. dttentfttnts' Room. 7. Dining Room. 8. Patients' Room. 9. Dormitory. 10. Store-Room. 11. Rath-Room. 12. Water Closet- Niith'l J. Bradlec. Aren't. in BOARD OF DIRECTORS FOR I86T. Moses Kimball. J. Putnam Briuilee .Jonas Fitch, Amos A. Dunncls, I'm Dels C. Manning Henry A. Drake William Willktt, Clerk. S.vlvanns A. DeDio, Avery Plumer, William Cumston, Chas. S. Burgess, Lewis Rice, Sam'l W. Hodges. Putnam Bkadlbk, President. CENTRE BUILDINGS 1. Hall. 2. Corridor. 5. Reception Room. 7. Dining Room. 10. Store-Room. 12. Water-Closet. 13. Supfs Room. U. Ass't Supt'l Room 16. Apothecary's. 16. Library. 17. Pantry. 18. A'itcften. 111. Bakery. 20. Bread Closet. 21. 7Y)i CTosef. 22. Oven. 23. Laundry. 24. Ironing Room. Drying Room. SUPK«INTKM>K: ACCOMMODATION h Vmnlt; Sul r Hnria ( iixftit /"? //!/;>;/ ,nrv 71 Sim ih /-rmi/ :t:> Ahrf/t MmiJ f.i Ifiiwrtry/J/tJiA- IS 1)rfrlr/irr/ /HrJC/t •'■"' /„/,,/ :;■!<> GKOl'XD PLAN. on .F -PL. 6. OF SIJRR1 LUNATIC et to the Incli COUNTY OF SURREY. NEW COUNTY LUNATIC ASYLUM. Scale 40 feet to the Inch AP.F- IM..C). SIS on i TTSm?I rrric Je 40 I AP.F- PL. 7 AP.F- l'L.7 ft COUNTY OF SFRREY :nt:w county lunatic asylum Scale 40 feel to the Inch.. > ♦ % o WJ m PLAN OF SECOND FLOOR. S13 on I .r.PL.8 -r K t (;lamokoax county asy1um ACCOMMODATES 365 PAUPER PATIENTS Wards. 1 . Day Rooms. 1*. Dormitories. 2 . Single Rooms. 3 . Attendant's Rooms. 4 . Store Room. 5 . Batb Rooms. 6 . Dressing Rooms. 7 . Lavatories. 8 . ScullerieB. 9 . Padded Room. 10 . Head Attendant's Rooms. Central Public Rooms. 11 . Surgery. 12 . Medical Superintendent's Room. 13 . Entrance to Med. Superintendent's House. 14 . Visiting Room. 15 . Porter's Room. 16 . [in trance to Assistant Med. Officer's Rooms. 17 . Chaplain's Room and Library. IS. Committee Room. 19 . Do. Retiring Room. Economic Department, Officers, etc. L t0. Kitchen. ^ 5 S 21 . BeaUwy. 22 . Dining Hall. 23 . Attendant's Malt. 24 . Kitchen Stores. 25 . Kitchen Yard. 2B . Steward's Stores. 27 . Steward's Office. 28 . Housekeeper's Store und Cutting out Room. 29 . Wood and Coals. 30 . Dead House. AP.I.PL.8. COST ABOUT % 77,700 Detached Buildings and Yard. Medical Superintendent's House. Steward's House. Housekeeper's Rooms & Rooms for Domestic Servants. Laundry Block with Ward attached, a . Sorting and Receiving Room. b. Washing- House. C . Do. for Foul Linen. d . Drying Ground. 6 . Drying Closet. f , Ironing Room. . Workshop Block with Ward attached. a.a . Tailor's and Shoemaker's. b.b . Mattress Makers. C.C . Carpenter's. d.d. Painter's. e.e . Yard for Workshops. . Engineer's Yard, including Engine House, Plumber's and Smith's Shops, Gasworks, Steam and Hot Water Boilers, Steam Engine and Well. . Stable Yard with Shed, i . Do. Med. Superintendent. . Church. ; . Entrance Lodge. . , Female Airing Courts. H. Male Airing Courts. i. Kitchen Garden. sis on m fm9m .,. iWWBHI A]>. F._ 1M. 9. w r 3 rORES. LAVATORIES, ETC., ETC J * ^1 r i : PLAN OF FIRST FLOOR. OCCUPIED ENTIRELY BY SLEEPING, ACCOMMODATION AND THE NECESSARY CLOTHES STORES. LAVATORIES. ETC., ETC.. -M223 : l./.J Reference |». Dormitories. 2. Single Rooms. 3. Attendants. '4. Stores. 5. Bath. 10. Head Attendant's /.'cow.*. 16. Assistant Medical Officer's Rooms. A. Medical Superintendent's House. B. Steward's House. C. Housekeeper and Domestic Servants F. Engineer's Bous*. AP F. PI. 10. whim. *--■£. Perth District Lunatic Asylum. . si: on ^-~-"\ 4 EMTT \S9 E LUNATIC ASYLUM. MEEBENBERG, NEAR HAARLEM. Ground Plan and Elevation. a AP. F -PL. II irOTziZE si: on P.F.PL.12 ASYLU NEAR HAARLEM first Stoxv 2 Z4 ^w^ * * 2* Z-'A 2.3 S* h i. ■■ w II ■ II J 3 , f I rn m |-iiia E^i^fflSL riE LUNATIC ASYLUM. Meerenberg, near haaiu.km Plan of fixe first Story AP.F. PL. 12. : !L. ITTOATIC ASYLUM IN VIENNA. GKOXT3TD 1'LAaV . fl (: / \ II. its. Iff. ss: de, <0> ilium. Znlnk, I. Piaidtvilrir XV I'll lid. Fig '.' EXPLANATION OF TABLE NUMBEE TWO. Figure 1. Plan of situation. Parterre and first story of Institution. I. Building of administration. II. Section of quiet patients. III. Section of less quiet patients. IY. Section of idiotic (unclean) patients. Y. Section of raving patients. YI. Church. YI. Household building. YIII. Coach room. IX. Ice cellar. a. b. c. d. e. f 9- h. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Day room; Kitchen for dishwashing; Eoom of attendants; Sleeping apartment, third class; Isolating room; Eoom, first class; Eoom, second class; Garderobe room; Announcing room; Yisiting room; Medical office; Medical office; Store room for material; Eoom of the office porter; Dispensary; Eoom of the porter; Sleeping room of the porter; Office of the Administration; Magazines ; Lodgings of Assistant Physic'n: Eoom of accountant; i. Depot room ; k. Eoom for somatic patients ; I. Cell; m. Drying room; n. Bath room, third class; o. Dressing room; p. Bath room, first and sec'nd class; q. Single bath room. 14. Sewing room (on the other side, lodgings of kitchen servants) ; 15. Kitchen for cooking; 16. Adjoining rooms thereof; 16' Formerly provisory kitchen; 17. Kitchen for washing; 18. Adjoining rooms thereof; 19. Eoom for washing machines; 20. Eoom for steam boiler; 21. Engine room; 22. Eoom of machinists; 23. Yentilation tower. I -Lb N '08 i I ^■B , * .A +<* ■ 1 '-*>

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