NOTES ON SPANISH ASYLUMS FOR THE 
INSANE 
_ BY 
E. C. SEGUIN, M.D. 
CLINICAL PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM 
IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK, ETC. 
[Reprinted from the Journal of Nervous and Mental Disease, July, 1883] NOTES ON SPANISH ASYLUMS FOR THE IN- 
SANE. 
By E. C. SEGUIN, M.D. 
BEING in Spain during several weeks of the past winter 
(1882-3), and having occasion to pass through 
the cities having the majority of the insane, it occurred to 
me that it would be interesting to visit all accessible institu- 
tions, and take short notes of their condition. 
Wherever I attempted to carry out this intention I 
was received by physicians and other officials with even 
more than the proverbial courtesy of Spaniards. In 
every institution every thing was done to render my visit 
advantageous and agreeable, and I shall retain a pleasant 
recollection of my transient relations with these gentle- 
men. 
In several institutions I was shown every thing at once 
upon my (unexpected) arrival; and nowhere did I detect a 
desire to avoid the critical observation of a stranger, 
or attempts to lead me past certain wards or places. 
It is proper to add that if evidences of a knowledge of in- 
sanity appeared only here and there, in a minority of 
the medical men, there was also a promising disposition 
to admit the backwardness of the speciality in Spain ; and 
in several cities the physicians expressed themselves in 
strong terms against the neglect of the insane by the local 
authorities. 
Reprinted from the Journal of Nervous and Mental Disease, Vol. 
x. No. 3, July, 1883. 2 
E. C. SEGUIN. 
I purpose using my material as follows : 
1. Giving a brief account of each institution visited, 
from notes taken at the time. In this I follow the order in 
which I visited the various cities. 
2. Reproducing some of the scanty and nearly useless 
Spanish statistics of insanity. 
3. Expressing truthfully and as courteously as possible 
the opinions I formed as to the care and treatment of the 
insane I saw. 
4. Lastly, considering what means might be resorted to 
for rapid improvement. 
MEMORANDA OF VISITS. 
Asylums near Madrid.-Entering Spain by way 
of San Sebastian, and stopping one day at Burgos, I 
was deterred, chiefly by the extreme unpleasantness of the 
season (end of December, 1882), from seeing Valladolid and 
Salamanca, thus missing two important asylums. Near 
Madrid are three institutions, two private; one of the 
private I failed to visit. 
I. The government asylum at Legafies, known as" casa 
de dementes de Santa Isabel." This is the only institution 
in Spain controlled by the general government; it was 
founded in 1852. It is situated in a suburb of Madrid, four- 
teen kilometres (about eight miles) on a line of tramway 
which extends out of the city by the gate and bridge 
of Toledo. The buildings are very plain, but neat. They 
have the radical fault of being too small, and especially of 
being devoid of large airing courts. Sisters of Charity are 
in charge of all the departments, and one of them, a very 
intelligent and bright woman, showed me about. A visit- 
ing physician sees the inmates every morning, and often in 
the early evening. I did not have the advantage of meeting 
this gentleman, and so failed to obtain any purely medical 
information. SPANISH ASYLUMS FOR THE INSANE. 
3 
Both private and pauper patients are received ; the latter 
are clad in uniform and sleep in large dormitories. I found 
them badly crowded in small day-rooms and courts- 
all idle. Private patients of the first-class have the 
use of two rooms ; second-class patients of one. The 
clothes- arid linen-rooms were models of neatness, and 
showed even artistic taste in arrangement of contents. The 
good Sisters were also proud of their kitchen department, 
where a smiling Sister, nearly as broad as she was high, 
was superintending the production of dinner. A complex 
and showy hydrotherapeutic room, with marble tubs, 
douches, and jets of all varieties, supplied with an abun- 
dance of hot and cold water, was shown me. It was stated 
that during most of the year this was much used, partly for 
hygiene and partly for treatment. Per contra there were 
no evident means of employing or amusing the patients. 
There are about two hundred (200) inmates, two thirds 
of whom were males. 
Out of this number there was only one in restraint; 
a noisy female patient who had on an ordinary camisole. As 
well as I could understand, the Sister said that they use as 
little restraint as possible. I looked sharply for haematoma 
auris but saw none. 
II. Private asylum at Carabanchel, owned and managed 
by Doctor J. M. Esquerdo, who is considered one of the 
most eminent alienists of Spain. Most unfortunately, dur- 
ing my stay in Madrid he was away visiting his winter 
establishment at Alicante. Judging by the excellence 
of several pamphlets of his that were given to me, I feel 
sure that I thus missed most instructive conversations. I 
was received by his nephew, Dr. Santiago Esquerdo, who is 
resident physician and executive officer of the asylum. 
The institution (opened in 1877) *s situated in the village 
of Carabanchel, about three miles out of Madrid, on the 4 
E. C. SEGU/N. 
same line of tramway as that which leads out to Legafies. 
Here, in rather small grounds, is a series of one-story build- 
ings arranged to form a double square; one square for men, 
another for women. Each side of the house has its own 
gardens and yards (" patios," very much as exist in the 
ordinary houses of South Spain). The quarters for the 
various classes of patients are different. First-class patients, 
who pay $100 per month, have a parlor, bedroom, and two 
alcoves, in one of which the attendant sleeps. Those suites 
are furnished in red, yellow, blue, etc., and open directly 
upon comfortable piazzas and gardens. Second-class 
patients, paying $60 per month, and third-class ones, paying 
only $25 per month, have each one and two rooms, various- 
ly though plainly furnished. All the rooms I saw were 
clean and well-lighted, but heavily barred and locked. On 
the female side there is a piano in a common parlor, and on 
the men's side a smoking-room and a billiard-room. The 
buildings, originally cheap, were out of repair; the walls, 
floors, etc., need patching and painting. The beds and 
linen were good. 
The female patients have a dining-room for each class ; 
but a number of them eat alone. All the male patients 
who are able to be about, the majority, eat simultaneously 
in a long and not over cheerful dining-room. As I dined 
there, perhaps it would be interesting to relate what I saw. 
There were three tables, one on a slightly raised dais for 
the first-class patients and the medical officers; two others 
on one level occupied by second- and third-class patients. 
I sat at the raised table with six patients, Dr. Esquerdo, Jr., 
and two assistant physicians. The dishes and qualities of 
wine were different for the three tables, but the same bread 
was served out to all. The food was true Spanish, but 
good ; indeed at our table we had quite a series of courses 
and a complicated dessert (extra because of Sunday); the SPANISH ASYLUMS FOR THE INSANE. 
5 
red wine was substantial and strong, tasting a little of the 
classic skins of Spain. The service at our table was well 
and very quickly done by a small boy in uniform. He, and 
an attendant at each of the other tables, knew just how 
much wine to give to patients, and needed no supervision. 
My impression is that each patient's glass, holding perhaps 
two ounces, was filled three times. Coffee and cigars came 
after the dessert for first-class patients; the others had 
already begun to smoke cigarettes. Quite a number of 
second- and third-class patients were chatting among them- 
selves ; others went off quietly to their rooms. At our table 
all behaved perfectly, and were as polite as well-bred 
Spaniards invariably are. I was much pleased at thus 
seeing how comfortable the patients were in one way, and 
on what a footing of friendly equality they were with the 
medical officers. 
There are about sixty (60) inmates, of whom one-third 
(21-25) are females. 
I was shown several cases of general paralysis, one in a 
stage of depression. There was an unmistakable female 
case of this disease, with the well-known physical and 
psychic symptoms. A number of epileptics in the house. 
No haematoma auris seen. 
Dr. S. Esquerdo, no doubt reflecting his uncle's opinions, 
expressed great admiration for non-restraint, but had a doubt 
as to its absolute application. He asserted that they used 
the camisole and restraint in bed very rarely. He showed 
me a padded room, large and well-lighted, but it was not 
thoroughly mattressed. On the day of my visit there was 
only one patient under restraint,-a violent, biting woman 
with a camisole. 
Dr. Esquerdo, Sr., has translated Guislain's classic " Lo- 
gons," and is now actively engaged in securing legislation to 
protect insane criminals, especially those not insane in an 6 
E. C. SEGUIN. 
evident way. I very much regret not having had the ad- 
vantage of hearing his opinion and views on the administra- 
tive and medical questions involved in asylum manage- 
ment. 
III. Insane wards of the Provincial Hospital of Madrid. 
This large and venerable institution, nearly two hundred 
years old, has a number of rooms in its half-basement for 
the temporary (?) reception of insane patients, prior to 
their transfer to Legafiez. These rooms were dismal and 
crowded. I am sure many cases of dementia and epi- 
lepsy are here permanently, in vary bad quarters. The 
physician of these wardsnot being present at the time of my 
visit, I obtained no medical information. Restraint seemed 
freely used. 
Zaragoza.-The insane of this city, and of nearly all 
Aragon, are crowded into the Provincial Asylum, or, more 
properly, the insane department of the Provincial Hospital. 
A new, modern asylum is being constructed out in the 
country. 
IV. The Provincial Asylum (or Manicomio) of Zaragoza 
is one of the oldest in Europe, having been founded in 1425, 
or only sixteen years after the first of Spain's remarkable 
series of charity foundations in the fifteenth century.1 It 
was, for a long time, one of the model institutions of Europe, 
praised by Pinel, Foder£, and other writers on insanity. In 
August, 1808, during the celebrated siege by the French, 
the entire hospital was burned. New buildings were soon 
erected in another part of the city, one for general hospital 
purposes, the other as an asylum, in the same grounds. I 
was shown through by Dr. Vicente Almenera, the physician- 
in-chief. He is in reality a visiting physician ; but several 
internes reside in the institution. 
Rooms for single patients are numerous, but there are 
1 Asylum of Valencia, 1409. SPANISH ASYLUMS FOP THE INSANE. 
7 
also dormitories for large numbers of patients. All the rooms 
are very gloomy, ill-ventilated, and with heavily-barred 
small windows. A wing accommodates some thirty epilep- 
tics. Paralytics (ordinary ones, I mean) are numerous (re- 
ceived for dementia ?). Dr. Almenera condemned the build- 
ing in strong terms, and expressed the hope that some of 
the pavilions of the new asylum would before long be ready 
for occupation. 
There are here four hundred and thirty patients (430); 
proportion of sexes not obtained. 
In 1846 there were two hundred and forty-two inmates ; in 
1852 there were two hundred and seventy-three, and the 
same number in 1859. 1 1880 the number had increased 
to three hundred and ninety-eight. 2 
Owing to the fact that none of the physicians spoke 
French, I was unable to obtain any purely medical data. 
It was, however, evident that the recognition of general 
paralysis was not the rule. 
Restraint is little used; I saw none. Dr. Almenera 
assured me that, from time immemorial, with members of re- 
ligious orders in charge of patients, kind treatment had been 
the rule. Noisy and violent patients are isolated in small 
rooms which are ill-lighted and wretched, but not filthy as 
described by Dr. Desmaisons 3 in 1859. Patients are never 
tied in chairs. 
V. The new asylum. A private citizen gave a large 
piece of ground a short distance out of the city for this 
purpose, and the provincial authorities not long after voted 
a credit of a large sum, for Spain, viz.: twelve million reales, 
or about $600,000. It is said that careful studies were 
made prior to the adoption of a plan. One pavilion of the 
new manicomio is finished and nearly ready for occupation. 
1 Desmaisons, " Das asiles d' alienes en Espagne," p. 82, Paris, 1859. 
2 Official Report of Senor D. Castor Ybanez de Aldecoa, 1880. 
s Op. cit., p. 79. 8 
E. C. SEGUIN. 
It is a quadrilateral building of three stories, very much 
like a wing of an ordinary hospital; only the entrances are 
in the centre instead of at the ends. The lower floor con- 
tains dining- and day-rooms ; the other floors are for general 
dormitories. Large windows open on either side and direct 
ventilation is thus obtained ; ventilating apertures have also 
been made in the walls. The windows are lightly and 
pleasantly barred. The attendants' rooms are in the centre 
of each floor (except the first), and have one window opening 
into the dormitories at either end, to secure free super- 
vision of patients. There are no rooms for single patients. 
There is a bath-room in the building. Each pavilion is 
intended to accommodate one hundred patients ; each 
will have its own large airing-court, and the ground- 
floor next the court opens upon a large, well-protected 
piazza, or walk. The workmanship was good. 
It is intended to erect eight of these pavilions, and the 
necessary building for executive purposes. A medical 
director with full authority will probably be appointed. 
If this plan is well carried out, it will give Zaragoza the 
best public asylum in Spain, and restore to it some of its 
old philanthropic prestige. 
Dr. Don Joachim Gimeno, Professor of General Pathology 
in the University, drove me out to the new asylum, and 
showed me every courtesy. 
Barcelona.-In this prosperous and progressive city 
there are three private institutions for the care of the insane, 
and a part of the general Provincial Hospital is also set 
apart for them. 
VI. The Provincial Hospital, Santa Cruz, within the 
city, was erected more than two centuries ago, and is, con- 
sequently, very defective. In its insane department some 
changes have been made, but the day-rooms and " cells" are 
dismal; many still retain the original low-arched ceilings. SPANISH ASYLUMS FOR THE INSANE. 
9 
All are, however, clean. There are no grounds for the 
exercise of patients, only small inner courts. 
The visiting physician is Dr. Pi y Molist, a gentleman 
who has held the position for nearly twenty years, and is 
one of the corresponding members of the M£dico- 
Psychologique of Paris. 
He has about three hundred patients under his care, 
more than half of whom are males. In 1855 it contained 
two hundred and two insane, of whom one hundred and 
nine were males, and ninety-three females.1 
There are very few simple acute cases, mostly chronic 
dements and epileptics, no female case of general paralysis. 
Saw one haematoma auris in a male patient having chronic 
mania. 
The doctor considers general paralysis as not very fre- 
quent. Between Dr. Esquerdo's estimate of 8 to 10 
and Dr. Mendez' {vide infra) 20 %, he would keep nearer 
the former figures. Can recall only two or three female 
paretics in his long experience. 
There are no malarial or typhoid fevers, and very little 
phthisis among the patients. No clinics are held, which is 
all the more surprising, as students daily crowd the hospital 
to receive clinical instruction in other branches. The doctor 
was evidently deeply sensible of the defects of the building, 
and lamented the lack of occupation for the patients. 
Restraint. In the last century and during the first part 
of this one, patients here were chained, and some wore iron 
collars. None of these contrivances have been preserved as 
relics. I saw one chain in use, however: a patient lay in 
bed with leather manacles and ankle-rings, and a cloth 
tightly bound across his chest; the two ankle-rings were 
connected by a short strap, and this in turn was fastened to 
the foot of the bed by a chain. Patients are not, however, 
fastened in chairs, and " cribs " are unknown. 
1 Pi y Molist, cited by Desmaisons, op. cit., p. 98. 10 
E. C. SEGUIN. 
VII. Manicomio of Nueva Bethlen. This private institu- 
tion, opened in 1857, owned by its medical director, Dr. 
Juan Gin6 y Partagas. It is admirably situated, just beyond 
the suburb of San Gervasio, on a rise of ground terminat- 
ing in a large hill. The grounds are quite extensive and 
the gardens very fine. Camelias and roses were in bloom, 
and oranges dotted the trees at the time of my visit (Jan- 
uary 7th). From the house, one has a beautiful view of Bar- 
celona, of the hill and fortress of Monguid, and beyond, of a 
great stretch of the calm, blue, inland sea. In the absence 
of Dr. Gin6, I was courteously shown about by the chaplain, 
a clever young priest who spoke French. The buildings 
face southeast, and are protected from east winds by the 
hill referred to. 
The first-class patients, paying thirty-six dollars per 
month, have each a very neat, comfortable room. Some 
of these chambers open directly upon a pleasant garden, 
others on "patios" (courts) which are neat and comfortable. 
Second-class patients (twenty-five dollars per month) sleep 
two in a room; and third-class patients (eighteen dollars 
per month) are three in one room. The dining-rooms are 
common for all classes, seated at different tables, however. 
On the male side, the resident physician, Dr. Ribas, and 
often Dr. Gin6 himself, sit at the head of the first table; the 
chaplain at the second. This room is decorated and cheer- 
ful. Noisy and violent patients are in small, dark, but 
well-ventilated rooms in a sort of wing, all opening upon a 
" patio." There are parlors, a billiard-room, and a sort of 
gymnasium in a court. The female side of the house is 
like the male, except that the parlors are more pleasant. 
The men have boy attendants, the women are taken care 
of by Sisters of the Order of St. Vincent de Paul, but are 
also allowed boy attendants if desired. 
The patients of both sexes had really free access to SPANISH ASYLUMS FOR THE INSANE. 
11 
the gardens, with apparently little supervision (they were 
watched, however). The majority of them go to chapel 
twice a day, from choice (and for lack of any thing to do ?). 
I met Dr. Galceran, who holds the position of consulting 
physician. He considers that from two to four per cent, of 
all the cases received at Nueva Bethlen are paretics. In a 
long time only one female case has been observed. He 
claims that they have cured two cases of this disease ; one of 
them has now been well four years; his improvement 
accompanied and followed a severe attack of pneumonia. 
General paralysis is rare in Spain because there is less 
alcoholism. 
Through some inadvertence I failed to learn the number 
of inmates. In 1880,1 there were 102 patients: 59 males and 
43 females. 
Restraint is employed, though sparingly.2 Camisoles and 
leather muffs are used; some patients are tied in their beds 
while camisoled. No case of haematoma. Everywhere I 
saw evidences of humane treatment and of personal kind- 
ness. 
I called on Dr. Gine the same evening, and again in a few 
days. He is Professor of Clinical Surgery in the Medical 
Department of the University, and author of quite a number 
of medical text-books; one of them, a volume of six 
hundred pages, entitled "Tratado teoretico-practico de 
Frenopathologia." He speaks French well, and his opin- 
ions had all the clearness and force which come from large 
personal experience. I greatly enjoyed these conversations, 
and highly appreciated the courtesy of his reception. The 
following are the main points of his remarks:- 
General paralysis has greatly increased in Spain during 
the last fifteen years. This is owing partly to the greater 
1 Official Report. 
2 In the Official Report cited, the management is claimed as on "non- 
restraint principles." 12 
E. C. SEGUIN. 
abuse of alcoholic liquors (alcoholism a predisposing cause), 
but also because of the increased severity of the struggle for 
existence. He does not believe that sexual excesses are a 
frequent cause of the disease. Syphilitic general paralysis 
(or a condition resembling it) he considers very grave-has 
never known it to get well. On the other hand, he has 
notes of four or five cures of the non-syphilitic form of pa- 
resis; some of these have been published in his journal, 
Revista Frenopatica Barcelonesa. Dr. Galceran's two cases 
are probably included in these. The melancholic and 
hypochondriacal forms or styles of general paralysis, so fre- 
quent in France, are here very rare. Formerly, most of the 
acute cases were simple ones of mania and religious melan- 
cholia, allowing of many cures. 
As regards restraint, Dr. Gin£ is quite advanced. He has 
great admiration for Conolly and Charlesworth, and thinks 
" non-restraint " is an ideal to be always aimed at. Still, in 
practice he finds some cases requiring mechanical restraint; 
and he sanctions the use of camisoles, soft wristlets, belts, 
and muffs. He thinks that manual contention by attend- 
ants causes much more irritation to the patient, and tends 
to give rise to a feeling of rancor or hatred toward the 
nurses. 
VIII. Asylum of San Baudilio de Llobregat, usually 
called " San Boy," founded in 1854. Permission to inspect 
this large and important private institution was readily ob- 
tained by means of a card of introduction to Sefior Don 
Roman Rodriguez de Lacin, the President of the Board of 
Trustees. I was received with genuine Spanish courtesy, 
and indeed Sefior Rodriguez insisted upon going with me 
to the asylum. Accordingly, on the morning of January 9th, 
we drove out in company with two other members of the 
Board of Trustees, young gentlemen who appeared inter- 
ested in the work. SPANISH ASYLUMS FOR THE INSANE. 
13 
San Boy is at a distance of about nine kilometres (nearly 
five miles) from Barcelona, near the line of railway between 
that city and Valencia. It is also possible to go to the asy- 
lum by taking a train as far as the hamlet of San Baudilio, 
about a mile from the house. The property is quite large, 
but is unfavorably situated in a low valley near the bank of 
a wretched, muddy stream called the Llobregat, which often 
overflows a large piece of bottom-land, and occasionally cuts 
off communication. I might here state that I was shown 
one case of remittent fever in the infirmary. The view from 
the house is limited to the garden and some distant moun- 
tains. 
The grounds and gardens are extensive and well laid out; 
they must be very pleasant at the favorable seasons of the 
year. Some farming is done by poor patients. 
The buildings, as in some other institutions visited, are of 
two stories. As a rule, the upper floor is used by night, and 
in the daytime the patients are on the ground-floor and out- 
of-doors, in the garden, or in large " patios." The various 
dining-rooms, billiard- and reading-rooms are on the ground- 
floor, as are also some of the apartments for first-class pa- 
tients. Around the "patios " or courts are the well-sheltered 
piazzas so common in Spain. The rooms for private patients 
of these classes are very much like those at Nueva Belen, 
but less handsomely furnished. In the second and third 
classes, from two to four patients sleep in one room, with 
an attendant. The dormitories for poor patients contain from 
ten to thirty beds. The tiled floors were absolutely clean, and 
the pillows and sheets white. All the sleeping-rooms, with 
the exception of one ortwo occupied by filthy patients, were 
remarkably sweet and clean. The beds were doubtless too 
close together, but it must be borne in mind that they are 
used only in sleeping hours, and that their direct ventilation 
by windows and doors is enforced. The quarters for vio- 14 
E. C. SEGUIN. 
lent and wholly demented patients were very dark and 
small. 
Before leaving the subject of the building it may be well 
to state, that in the entrance court is a fine marble statue of 
Brierre de Boismont, erected by Dr. Antonio Pujadas, the 
founder and first medical director of the asylum, who had 
been a pupil of the great French alienist. Over the outside 
door-way is a bust of Pinel. 
Dr. Caballero is the present medical director or physician- 
in-chief. He resides in the institution, as do a sub-director 
and several assistants (including an apothecary). 
The total number of cases now in San Boy is nearly seven 
hundred (700), of whom two hundred and sixty (260) are fe- 
males. These patients come from various sources. First, 
private patients of three classes from any part of Spain, 
though naturally mostly from Barcelona and vicinity. Sec- 
ond, the poor insane of the province of Barcelona, who are 
paid for by the local government. Third, soldiers from 
all parts of Spain, under a contract with the general 
government. Fourth, patients may be sent by any of the 
provinces. 
According to one of the trustees, the actual average cost 
of maintenance per capita (exclusive of physicians' salaries 
and interest on capital engaged) is about 75 centimes, or 
nearly 15 cents per diem. 
There are all possible forms of mental diseases here, of 
course. The percentage of general paralysis is "large." 
Many epileptics. No female paretic now in the house. 
Dr. Caballero has seldom seen a case. 
One case of haematoma auris seen ; unilateral, in a pa- 
retic. 
As many patients are employed as will work. A good 
many are on the farm, and in the gardens; some in shops. 
A number of female patients were sewing, washing, and SPANISH ASYLUMS FOP THE INSANE. 
15 
ironing: not many, however. Probably many patients lack 
the ability to do any thing useful, besides being unwilling. 
The idea of absolute non-restraint is not accepted here, 
but in practice is approximated. On the day of my visit 
there was no one in restraint. Camisoles, sheets, and pieces 
of cloth are employed as means of restraint. Wristlets 
and anklets are not used. Tying in chairs is not done, and 
" cribs " are unknown here. 
IX. Institute Frenopatico, situated at Corts de Sarrid, 
N. E., a suburb of Barcelona. It is owned and managed by 
Drs. Dolsa and Llorach. The former gentleman received 
me, and showed me about. Opened in 1867 or 1868. 
The " institute " is nearly as well situated as Nueva 
Bethlen. The gardens, though smaller, are more open and 
more free to the patients; the rooms of all manageable 
patients (who are a majority) opening directly upon gardens 
in which they may wander, of course under surveilance. The 
grounds are surrounded by high walls. The rooms are on 
very much the same plan, and quite as comfortable as those 
at Nueva Bethlen. The first-class patients eat with the 
physicians in a separate dining-room. There are billiard- 
and reading-rooms; not much frequented. A room with 
baths and a variety of douches and sprays was shown ; there 
was an abundance of hot and cold water under proper 
control. The douches are used for moral and also for 
strictly medicinal effects. Throughout the building are 
many piazzas where patients can walk in wet or excessively 
hot weather. 
Noisy and filthy patients are in a separate building, with 
an enclosed court or " patio." There are here some dozen 
narrow dark rooms; two of them,which are padded, have 
deep bunks instead of bedsteads. Quite a number of these 
patients were tied in bed. 
There are one hundred and ninety (190) patients in this 16 
E. C. SEGUIN. 
institution ; about two thirds males. Many are epileptics 
with psychical symptoms. 
The attendants appeared kind and intelligent. 
Dr. Dolsa considers general paralysis as now much more 
frequent than fifteen years ago. He would give at 20 % or 
25 % the proportion among his admissions. Has seen some 
three hundred paretics, and recalls only two or three female 
cases; none now in the house. He is of the opinion that 
the chief cause of the increase of paresis is the greater 
intellectual strain and the fierce competition now required 
in the struggle for existence. This theory he thinks applies 
well to the province of Catalonia, all the more as he does 
not think that there has been much increase in the consump- 
tion of alcoholic beverages. 
Dr. Dolsa has never tried non-restraint, and does not be- 
lieve it to be either practicable or desirable. 1 There are 
cases in which mechanical restraint is imperative, and it 
causes less irritation and anger on the patient's part than 
restraining by hands. 
No case of haematoma. Dr. Dolsa considers this lesion 
as evidence that the ear has been pulled or boxed, though 
he admits that very rarely it may arise spontaneously. 
Before leaving Barcelona I sought an interview with Dr. 
Rafael Rodriquez Mendez, Professor of Hygiene in the 
University, and for several years (until last year) Medical 
Director of San Boy. His conversation was fully as inter- 
esting and instructive as Dr. Gina's. 
Dr. Mendez thought that nearly 20 % of all cases at San 
Boy were paretics. Has seldom seen the disease in a female. 
He considers alcoholism to be the chief and best demon- 
strated cause of general paralysis ; syphilis comes next in 
1 Drs. Dolsa and Llorach in their description of the institution and pros- 
pectus published in 1874, are Stillmore outspoken. " Non-restraint, considered 
from the point of view it is represented, is an absurdity." " The practice of 
non-restraint must be illusory if not highly pernicious and criminal " (!). pp. 8 
and 9. SPANISH ASYLUMS FOR THE INSANE. 
17 
importance. Such conditions as anxiety, overwork, grief, 
etc., he would relegate to the rank of uncertain and unim- 
portant causes. He recognizes the great increase of paresis 
within the last ten years, and considers this increase to be 
as marked in the country as in cities. Sexual excesses are 
not a cause of general paralysis, but may be of tabes. 
Myelitis is rather common in Spain; hysteria is frequent 
and severe. Within the last eight years has twice known 
public church ceremonies held in Barcelona in cases of 
demoniac hysteria ; the patients being brought to church to 
have the Evil One exorcised. Chorea not very common and 
seldom severe. Is fully satisfied with results of arsenic 
treatment (which he carries out in thorough style). 
Dr. Mendez does not think that any of the Spanish 
statistics of insanity are reliable. He gave me a copy of 
his pamphlet on the subject, and further on I give an abstract 
of it. 
Valencia.-The phrase " the first shall be last," is 
sadly illustrated in the history of the asylum of this city. 
Here in 1409, with the most philanthropic and God-serving 
intentions, was opened the first asylum of Western Europe, 
organized by the efforts of Joffre Gilaberto, of the order 
of our Lady of Mercy. It was patronized by King Don 
Martin I. Dr. Desmaisons1 admits the creation of this 
pioneer institution under the immediate influence of char- 
itable Catholicism, but also, and very justly, points out 
the fact, that in Cairo and in Fez asylums for the insane had 
existed for one or more centuries, and as the members of 
the Order of Mercy had for their chief object the relief and 
ransom of Christian prisoners in Mussulman countries, they 
thus were likely to have known of these " infidel " charities. 
The building having been greatly damaged by fire, the in- 
1 Op. cit., p. 41, et seq. This historical sketch is taken from Desmaisons. He 
did not see this institution, or any south of Barcelona. 18 
E. C. SEGUIN'. 
stitution was reorganized and annexed to the general hos- 
pital of Valencia in 1512. This seems to have checked its 
course of development and progress. As will appear from 
the notes of my visit, it is now a blot upon the fair name of 
Spain, and a surviving specimen of mediaeval cruelty in the 
midst of our modern human development. It ought to be 
reformed radically, and at once. 
X. " El manicomio de Jesus" is situated on a flat piece 
of land only one kilometre south of the city, beyond the 
gate of San Vincente. Formerly the insane occupied a part 
of the Provincial Hospital within the town, but twenty-two 
years ago the patients were removed to the present building, 
an altered convent. 
The physician-in-chief, Dr. Juan Ortiz Company, a very 
courteous gentleman, who speaks a few words of French, en- 
tered the asylum as " interne " twenty-two years ago, and 
has thus been in the new buildings since their completion. 
He admires March's work on insanity, and has visited only 
the asylums at Barcelona. 
The building is exceedingly plain ; built in pavilion style, so 
combined as to form a double quadrangle, one for each sex. 
All the rooms, day-rooms and dormitories are dark and 
dreary, but perfectly clean. There are a few rooms for pri- 
vate patients. Airing-courts or " patios " much too small. No 
grounds. The parts reserved for epileptic, violent, and 
filthy patients were very bad. The kitchen, clothes-rooms 
etc., under the care of Sisters of Charity, were good and neat. 
Nothing of value could be learned of the forms of insanity. 
There were many epileptics, and Dr. Company estimated 
that among his men he had five per cent, or six per cent, of 
cases of general paralysis, and three per cent. (?) among the 
women. From this statement and others, I inferred that the 
diagnosis of paresis was not here understood. There seems 
to be no special treatment carried out. SPANISH ASYLUMS FOR THE INSANE. 
19 
There are five hundred and thirty (530) inmates, of whom 
some three hundred and thirty (330) are males. 
Restraint is greatly abused here. Indeed, this asylum 
takes the lead in this matter, and is a century behind the 
age. Camisoles and ordinary muffs, wristlets etc., were em- 
ployed, but there was something worse. This was an iron 
belt, made in two segments connected behind by a hinge, and 
closing in front by a nut and screw ; the belt is two inches wide 
and one eighth inch thick. On either side, screwed by a rivet, 
is a single oval chain link, two inches long, supporting a mana- 
cle or bracelet of the same iron as the belt (a trifle less wide), 
opening with two hinges and closed also by a screw and nut. 
The bracelets give play for the arms (in semi-flexion, as the 
wrists are kept at waist) only on a radius of some three 
inches. And to cap the climax, these iron parts are not 
lined or protected in any way. The apparatus weighs from 
four to five pounds. Many of these were in use on 
male and female patients, and there were others hung up 
in a store-room. During our visit, a number of the patients 
came forward, half holding out their hands, begging piteously 
to be released. The good doctor smilingly replied, " Yes, 
by and by," or " Yes, to-morrow." The most astounding part 
of this barbarity was Doctor Company's satisfaction with 
the irons, and his assurance that they were " so secure." 
He showed me how they were managed, and took consider- 
able trouble to procure me permission from the general 
authorities to take one away with me " as a model," which 
he supposed I would introduce to a grateful circle of alienists 
in America. 
But the worst thing of all, a thing almost incredible at the 
present day, was the way in which the filthy demented pa- 
tients were herded (and that is a mild word). In one long, 
narrow, dismal room, I found between thirty and forty 
women squatting nearly naked on a wooden platform, about 20 
E. C. SEGUIN. 
six by twenty-five feet, and raised one foot from the floor. 
On this platform was straw, and on this sat, or kneeled, or 
sprawled, or squatted, these women, with only a coarse shift, 
open in all directions, exposing to view wrinkled and dirty 
arms, backs, bosoms, etc. Some were howling, others 
moaning, some singing, many rocking to and fro. They 
were so crowded as almost to touch one another. On the 
other side of the same hall, a yard away perhaps, was 
another wooden, raised, sloping platform, extending the 
whole length of the room, covered with straw and corn husks. 
Upon this the wretches were to lie down side by side to 
pass the night. A bad-looking man had charge of this 
crowd, assisting a woman. No doubt sometimes extra 
muscular strength was required. The filthy male patients 
were treated in much the same manner, only they were al- 
lowed to go about their "patio," some with irons on. They, 
like the women, had almost no clothing, and like them they 
slept promiscuously on straw. 
In these and other departments I noticed patients with 
bare extremities visibly suffering from the cold ; it was a 
damp, chilly air, and I was glad of my winter underclothing, 
and a heavy autumn overcoat. Dr. Company said of these 
unfortunates, in a half apologetic way, that they were per- 
fectly demented and unconscious. He added that restraint 
was always ordered by himself or his assistants. 
I must confess that my blood boiled at these sights in a civ- 
ilized city, in an asylum founded for humane purposes, and for 
so many years leading the world. Had I been able to speak 
Spanish or had Dr. Company understood French well, I 
should certainly have told him exactly what I thought. As 
it was, I could only swallow my painful indignation, and 
smile or bow. 
I saw no haemktoma auris. 
In this, as in some other asylums in Spain, the patients SPANISH ASYLUMS FOR THE INSANE. 
21 
take their meals according to the old conventional way ; i.e., 
narrow tables arranged near the walls, the patients sitting 
only on one side next the wall, thus leaving the whole interior 
of the room for the service. Not a bad plan as regards 
watching and serving, but a dismal one for the patients. 
Intercurrent diseases quite rare ; only three patients in 
the infirmary. 
There is no opportunity for farm-work, and only a few 
patients assist in the labors of the household. No trace of 
diversion or amusing occupation in-doors. 
XI. Malaga.-About three miles from the centre of 
the town, to the westward, across the rio guadal Medina, 
on quite a hill commanding a beautiful view of the sea- 
coast and city, is a small convent more than three hundred 
years old. Its single " patio " is surrounded by some dozen 
most elegant arabesque columns of white marble, and in its 
centre is a single-stone well-curb, deeply grooved by the 
friction of ropes, for centuries. Yet the place is wretched ; 
the rooms small, dismal, and out of repair. There is no 
ground whatever outside, and the patients can only exer- 
cise by walking in this " patio," or in a perfectly bare sort of 
yard adjoining the men's quarters. This asylum is within 
the jurisdiction of the hospital, which is a mile nearer the 
town-quite a fine modern structure, built after the plan of 
Lariboisi&re, in Paris, and well appointed. There is no 
resident physician (I think). 
There are now fifty (50) inmates; more than half males. 
This number is believed to include all the insane in Ma- 
laga (?)-(94,000 inhabitants). 
Many are now " discharged cured," as I saw in the books 
shown me by the intendant. Some years ago, when, 
by a special contract, the insane of Malaga were sent to the 
asylum of San Baudilio, at Barcelona, very few were saved. 
The sea-voyage killed some. «• 22 
E. C. SEGUIN. 
There are neither means of occupation nor amusement for 
the patients. 
Restraint moderately used. There is only one apparatus 
of iron in the house, which was on a " furious " patient at 
the time of my visit. He had on anklets of iron, joined by 
a chain, like a galley-slave. Usually, the camisole and soft- 
leather manacles are employed. The patients seemed de- 
pressed and untidy, though the building itself was clean. 
XII. Granada.-An old convent, built by Ferdinand 
and Isabella, has long been used as a manicomio. It offers 
wretched accommodations ; dismal rooms, small stony air- 
ing-courts, horrible cells for violent patients. However, the 
worst cases were not inhumanly treated as at Valencia. 
Dr. Enrique Guerrero Ortega is the visiting physician ; 
no resident. He sees the patients once a day, and gives 
clinical instruction to a few students. There are no regular 
lectures on insanity at the university. 
There were one hundred and fifty-seven (157) patients in 
the place; ninety (90) males and fifty-seven (57) females. 
For the male patients there were two attendants and a 
"chief," or superior, in each of the two divisions. On the 
female side there were a number of Sisters of Charity ; and 
they also had charge of the economy of the house. 
Not much could be learned of the forms of insanity. 
There were many epileptics; and it was stated that there 
were only five or six (?) cases of general paralysis. Dr. Or- 
tega considers alcoholism as the chief cause of paresis. Re- 
ligious melancholia, with erotic excitement, frequent. He 
told me of a case of nymphomania, with dementia, cured 
by cold douches to the spine, and monobromide of camphor. 
It is said that there are some cretins in the region round 
about Granada, but I saw none. 
Restraint, apart from isolation in cells, was not much 
used. There were no chairs, or iron manacles, etc. SPANISH ASYLUMS FOR THE INSANE. 
23 
Leather ones and camisoles were used. I saw no haema- 
toma. 
Dr. Ortega seemed fully aware of the shortcomings of his 
" asylum," and he criticised freely the parsimony of the 
provincial government with respect to the insane. He has 
all the insane of Granada, (67,300 inhabitants), and a few 
from Malaga. 
Dr. Ortega, besides showing me every possible courtesy, 
gave me a copy of the recent official report on insanity 
{vide infra). 
XIII. CORDOBA.-An old convent is appropriated to the 
use of male patients, while the females are housed in a part 
of the general (provincial) hospital near by. These insane 
are two in a room, or alone. 
There is no resident physician. Dr. Luis Fuentes visits 
the two sections every day. Not finding the doctor at his 
house, I was obliged to go through the institutions with 
the Sisters in charge. 
There are here thirty-two (32) male and twenty-seven (27) 
female patients; a total of fifty-nine (59), which is thought 
to include all the insane of the city, and province of Cdrdoba 
(population of the city alone is 42,000). 
In a conversation with Dr. Fuentes, later in the day, he 
complained bitterly of the buildings and general manage- 
ment. He expressed the hope that before long a special 
asylum would be erected for two or three adjacent prov- 
inces. In spite of difficulties, he claimed some cures of 
simple forms of mania and melancholia. He could give me 
no definite data as to general paralysis; its diagnosis was 
evidently uncertain. 
There were very few patients in restraint. One, a furious 
woman, was tied down in bed. The means of restraint are, 
however, barbarous; unlined iron wristlets and anklets are 
employed. Saw one room fitted up in ante-Pinel style : 24 
E. C. SEGUIN. 
near a bed made on the floor of a dismal cell was a chain 
riveted to the wall; its other end was to be fastened to the 
iron anklets of a patient. This under good Sisters of 
Charity ! 
XIV. SEVILLA has no separate building for its insane. 
They are lodged in several altered wards of the Provincial 
Hospital (h. de las cinco Llagas) on the northern outskirts 
of the city-a huge building erected in part during the 
reign of San Ferdinand. There is more or less open coun- 
try behind the hospital, but it has no "grounds." The 
rooms are for one or two patients, poorly lighted, closed by 
a heavily bolted door with a small grated window. Some 
of these rooms are suggestive of cages for wild beasts. 
There is one large dormitory, which accommodates fifteen 
or twenty quiet patients. The courts or " patios " are small 
and cheerless. 
The physician in charge of these wards, Dr. Jos£ M. Baca 
Santiago, visits the patients daily, in the same manner as 
other visiting physicians. Several internes look after the 
service at other times. Dr. Santiago expressed himself in 
strong terms as to the inadequacy of his wards, and the 
want of grounds. He has only seen one other asylum, viz., 
that of San Baudilio at Barcelona. 
There were at the time of my visit seventy-seven (77) 
male and fifty-one (51) female patients; a total of one 
hundred and twenty-eight (128), which the physician thought 
included all the evidently insane in the city and province 
of Sevilla (population of city 118,000). 
The attendants seemed few in number but kind, espe- 
cially the women. 
Not much seems to be attempted here in the way of 
classification and study of cases. There were many cases 
of erotic melancholia and mania, often associated with 
religious ideas. There seemed to be little general paralysis ; SPANISH ASYLUMS FOR THE INSANE. 
25 
but it was impossible to estimate their number or to learn 
any thing about it because of loose notions as to its diag- 
nosis. There were many epileptics with various mental 
symptoms. Some, much dreaded by the staff, were danger- 
ous after their seizures. 
Treatment seemed nil. Indeed, Dr. Santiago expressed 
his disbelief in medicinal treatment. He would use occu- 
pation, diversion, and moral treatment in general, if he had 
the means and space. 
Restraint was moderate in amount and humanely done. 
No male was in restraint at the time of my visit; several 
women were isolated in cells, and two tied in chairs (the 
only ones seen in Spain). Restraint is usually by cami- 
soles; but soft leather wristlets and anklets, as well as a 
broad strap for the body (for confinement to bed), are also 
employed. Restraint is applied by attendants, but the in- 
ternes see how it is done. The gentlemen of the staff were 
much surprised when I mentioned the irons I had seen in 
other cities of Spain. No haematoma auris. 
XV. Cadiz.-" Casa de los dementes." This is an exten- 
sion of the convent of Santa Catalina, in the chapel of which 
are the celebrated Murillos, including the altar-piece upon 
which the painter was at work when he fell and sustained 
fatal injuries. It is a wholly inadequate building, very 
dreary, with heavily barred cells, and is crowded. There 
are two visiting physicians: Dr. Henrique Rocafuel, 
and Dr. Carlos Borga. The former gentleman very kindly 
showed me over the asylum, and also took me to the 
hospital and school of medicine. In the asylum there 
is also a resident physician. 
There were one hundred and seventy-four (174) patients, 
about two thirds males. As usual there were many epilep- 
tics. (Cadiz has 71,500 inhabitants.) Nothing learned of 
general paralysis. 26 
E. C. SEGUIN. 
Restraint is rather too freely used; it is done by means 
of camisoles, leather wristlets, and I regret to add some iron 
manacles. No haematoma seen. 
Toledo.-Hospital provincial de Inocentes, commonly 
called " El Nuncio." Although I was in Toledo, circum- 
stances prevented me from visiting the asylum, and I was 
unable to make a second visit for the purpose. I owe the 
following details to the courtesy of the medical director, 
Dr. Fernando Sanchez y Mercander, who very kindly 
answered my letter of interrogatories, as follows: 
1. The asylum was founded in 1493, by the Papal 
Nuncio, Cardinal Francisco Ortiz. 
2. There are now in the asylum sixty-five (65) inmates, 
forty-two (42) males and twenty-three (23) females. 
3. There are five (5) male attendants, two (2) female 
nurses, and besides six (6) Sisters of Charity. 
4. General paralysis occurs in the proportion of 7 $ of 
all admissions. Would estimate at 4 / its prevalence 
among females. 
5. In Dr. Sanchez' opinion the most potent cause 
of general paralysis in Spain is excessive cerebral activity, 
more especially in the shape of intellectual exertions. 
6. Restraint is employed in very few cases; many 
days pass without any one being restrained. Camisoles and 
belts are used, and the latter are so devised as to leave 
the arms partly free and the hands wholly so. 
7. Nurses are permitted to apply the camisole at their 
discretion, but this is closely watched by the medical director. 
8. Doubts if the English system of non-restraint would 
be practicable with the class of patients he has. 
I may add that this asylum receives many patients from 
Madrid, which is less than three hours' distance by rail. It 
probably has, besides, nearly all the insane of Toledo, whose 
population is 17,600. SPANISH ASYLUMS FOR THE INSANE. 
27 
DOCUMENTS AND STATISTICS. 
Apart from what is to be found in Spanish books and 
pamphlets relating to the history of hospitals and other 
charities, very little has been written about the insane. 
Few travellers have visited Spanish asylums and have 
made public their impressions. It is singular that John 
Howard in his celebrated work on prisons and hospitals1 in 
1791, makes no mention of asylums in Spain : he simply re- 
fers to certain rooms allotted to the insane in the general 
hospitals of Madrid and Cadiz ; and this after having made 
extended observations upon asylums of various countries. 
Dr. Desmaisons, medical superintendent of the asylum of 
Castel D' Andorte, near Bordeaux, visited the hospitals and 
asylums in the north of Spain in 1858-9. His pamphlet of 
177 pages was published in Paris in 1859, was written 
chiefly to answer a circular of the then Spanish Minister of 
the Interior, Don Jos6 de Posada Herrera, calling for plans 
and proposals for a " model " insane asylum to be erected 
near Madrid. Dr. Desmaisons writes in a diffuse sort of 
way, and his essay is mainly valuable for historical data. 
He only gives the number of patients in asylums he 
visited; there are no purely medical observations in 
the work ; and as he did not see the worst Spanish asylums, 
he is unable to give any thing like a complete picture of the 
condition of the insane. 
A French physician, Dr. Rey, has visited asylums in 
South America, Spain, and Portugal, and has placed his ob- 
servations on record.2 
Dr. Donald Frazer has also published some notes on 
Spanish asylums.3 
1 "An Account of the Principal Lazarettos in Europe." Cited by Dr. Des- 
maisons, p. 33. 
9 Rey : Notes sur quelques asiles de 1' Amerique du sud, de 1' Espagne, et 
du Portugal. Annales Medico-Psychol., Sept., 1876, p. 236. 
' On Spanish Asylums. Journal of Mental Science, 1879-80, vol. xxv. 28 
E. C. SEGUIN. 
These essays I have not had the opportunity of read- 
ing. 
I only know of the following recent Spanish publications 
on the subject. 
1. Dr. Don Pedro Maria Rubio. Estadistica de las de- 
mentes que existare in Espana d islas adjacentes, desde 1846 a 
1847, formada por el excelentissimo, Sehor Don Pedro Maria 
Rubio, con los datos ojiciales que se le han facilitado por el 
Minister™ de la Gobernasion del Rcino. Madrid, 1848. The 
statistics of this report, together with various ministerial 
orders upon the subject, were published in the Gaceta de 
Madrid, for Oct. 7, 1848. I know its substance by citations 
made in the following : 
2. Memoria acerca del re suit a do que ofrcce la estadistica 
de los manicomios ; censo de poblacion acogida en ellos durante 
el aho econdmico de 1879-80. Madrid, 1880. This paper is 
signed by Sefior Don Cdstor Ybanez de Aldecoa, Director- 
General of Charities and Health. 
[I am indebted to Dr. Ortega, of Granada, for a copy of 
this report]. 
3. Dr. Rafael Rodriguez Mendez. Estadistica de los Mani- 
comios Espaholes {ano econdmico de 1879 a 1880). Barcelona, 
1880. This essay contains little that is original, or of 
strictly medical interest. It is a re-statement of the con- 
clusions of the official report (No. 2), and a correction of 
some errors of calculation contained therein. 
The only valuable part of these publications is the census 
of Dr. Rubio. It may have been quite incomplete, espe- 
cially as it is stated that it was made up from " datos 
oficiales," and not after a special or personal canvass. 
However, he estimated the total number of insane in Spain, 
which had never been done before, and has not been at- 
tempted since. I quote from the citation-the official re- 
port of 1880. SPANISH ASYLUMS FOR THE INSANE. 
29 
Dr. Rubio found that the confined insane were distribu- 
ted in the following institutions : 
Four buildings having the special attributes of asylums. 
Thirty-two general (provincial) hospitals. 
Ten hospices, or houses of refuge. 
Two infant asylums or foundling asylums. 
Fourteen public jails. 
Two penitentiaries (casas galer as). 
One convent of monks. 
One presidio (state prison where labor is enforced). 
The number of insane he found to be : 
Men. 
Women. 
Total. 
Insane in above institutions .... 
" kept in their families .... 
" whose sex is not stated .... 
912 
3.148 
714 
2,077 
1,626 
5.225 
426 
Total 
7,277 
[Dr. Desmaisons omits these patients unclassified as to 
sex, and thus makes Dr. Rubio estimate the number of in- 
sane at 6,851 1; an error of nearly 6 %]. 
The population of Spain is not mentioned in the official 
report, but the proportion of the insane was calculated by 
Dr. Rubio as one in every 1,667 inhabitants, or six per 1,000 
-certainly a very small proportion, especially if as many 
epileptics were included then as now. 
In consequence of Dr. Rubio's report and suggestions, a 
number of laws were made and royal orders issued, looking 
to a serious and intelligent reform ; but the frequent politi- 
cal revolutions which have since distracted the kingdom 
have naturally prevented their realization. The only re- 
sults which followed were the withdrawal of insane from 
jails, etc., and their aggregation in provincial asylums and 
hospitals ; the authorization of several private asylums ; and 
1 Op. cit., p. 36. 30 
E. C. SEGUIN'. 
the erection of the government institution (far from a model 
one) of Santa Isabel at Legafiez. 
The report of 1880, in spite of its imposing tables, is 
nearly useless. It bears the marks of also having been 
compiled from " datos oficiales," and contains gross errors 
of calculation. Its radical fault, however, is that it only 
gives the number of the insane who are in institutions, and 
makes no attempt to estimate the total number of insane in 
Spain. Consequently, the report is useless to the general 
statistician, to the physician for etiological studies, etc., and 
to the government, general or local, as an aid in making 
provision for the insane. I shall quote but little from it. 
First, a table showing the number of insane of both sexes 
who were in asylums and hospitals at the close of the year 
i878-'8o, (month not given). 
Institutions. 
Men. 
Women. 
Total. 
Badajoz (Merida), Provincial Asylum 
84 
28 
112 
Baleares (Palma), Provincial Asylum .... 
32 
28 
60 
Barcelona, Dept, of Hospital Santa Cruz . 
177 
136 
313 
" Private Asylum of Nueva Bethlen 
59 
43 
102 
" " of San Baudilio 
378 
247 
625 
" " at Corts de Sarria 
69 
37 
IO6 
Cadiz, Provincial Asylum ..... 
96 
73 
169 
Cordoba, Dept, of Provincial Hospital 
27 
21 
48 
Gerona, Provincial Asylum ..... 
3i 
22 
53 
" Private Asylum, Lloret de Mar 
9 
1 
10 
Madrid, Government Asylum at Leganez . 
125 
72 
197 
" Private Asylum at Carabanchel-Alto. 
24 
16 
40 
" " at Ciempozuelos . 
25 
25 
Malaga, Dept, of Provincial Hospital 
23 
12 
35 
Murcia, " " " ... 
3° 
23 
53 
Oviedo, Provincial Asylum ..... 
23 
21 
44 
Salamanca, " " . 
40 
25 
65 
Sevilla, Dept, of Provincial Hospital 
45 
28 
73 
Soria, Provincial Asylum ...... 
3 
2 
5 
Teruel, " " 
46 
44 
90 
Toledo, " "...... 
33 
19 
52 
Valencia, " "...... 
294 
165 
459 
Valladolid, " " 
308 
155 
363 
" Private Asylum of Dr. Rodriguez 
22 
5 
27 
Zaragoza, Provincial Asylum ..... 
244 
154 
398 
2,366 
1.424 
3,790 
Of these 3,790 " insane," nearly nine per cent, are epileptics. SPANISH ASYLUMS FOR THE INSANE. 
31 
As remarked, the " census " is of very little use. How- 
ever, by comparison with the census of 1848, certain inter- 
esting suppositions may be made. For example, in the 
enumeration we calculate that of the 7,277 in Spain, only 
22-j- % were in institutions. If now we assume the same pro- 
portions to have existed in 1880, as there were then 3,790 
patients in institutions, the total number of insane in Spain 
may have been not far from 17,000 (.223 : 100:: 3,790: 17,000). 
The population of Spain in June, 1880 1 being 16,638,938, 
the proportion would be very nearly one insane per one 
thousand inhabitants, which is still far below the proportions 
in " civilized countries." 
Second, a table exhibiting a "classification" (sic) of the 
insane in various institutions. 
Classes. 
Men. 
Women. 
Total. 
Tranquil patients ....... 
I,no 
566 
1,676 
Semi-tranquil " ....... 
442 
268 
710 
Violent " ....... 
218 
170 
388 
Filthy " ....... 
238 
203 
441 
Epileptic " ....... 
216 
117 
333 
Unclassified " ....... 
142 
TOO 
242 
2,366 
1,424 
3,790 
Third, a table purporting to give the number of " cures " 
in the five years ending in 1880. 
Men. 
Women. 
Total. 
Cured after less than one year of treatment 
654 
336 
99° 
" " more than one year and less than five 
297 
160 
457 
" " " " five years and less than ten 
48 
20 
68 
" " " " ten years .... 
16 
12 
28 
1.015 
528 
1 >543 
What is remarkable in this showing, if its data are reliable, 
is the number of tardy cures; insanity being seldom recov- 
1 Dr. Mendez, op. cit., p. 9. 32 
E. C. SEGUIN'. 
ered from after five years. This is, however, useless for 
calculations, because the total admissions for the period of 
five years are not stated. 
Fourth, a table giving the number of re-admissions in the 
same period. 
Men. 
Women. 
Total. 
Re-admitted within one year ..... 
" " " and less than five . 
99 
52 
157 
76 
36 
112 
" after five years ..... 
28 
15 
43 
203 
103 
306 
It would thus appear that only about 25 % were re-ad- 
mitted; which, of course, would not, by any means, include 
all the relapses, as many such cases would be retained at 
home, etc. 
CONCLUSIONS. 
I. The number of insane persons in Spain. I have 
already (p. 409) made a calculation of the total number 
of insane that there may have been in 1880. In the 
asylums which I visited I found an increase of population, 
as shown in the following table: 
INSTITUTIONS. 
1880. 
1883. 
Men. 
Women. 
Total. 
Total. 
Barcelona, Hospital Santa Cruz .... 
177 
136 
313 
300+ 
" San Baudilio . .... 
378 
247 
625 
700 - 
" Corts de Sarria ..... 
69 
37 
106 
190 
Cadiz, Casa de dementes ..... 
96 
73 
169 
174 
Cordoba, Dept, of Provincial Hospital . 
27 
21 
48 
59 
Granada, Provincial Asylum. .... 
119 
47 
166 
147 
Madrid, Government Asylum at Leganez 
125 
72 
197 
200 
" Private Asvlum at Carabanchel 
24 
16 
40 
60 
Malaga, Dept, of Provincial Hospital 
23 
12 
35 
50 
Sevilla, " " " . . . 
45 
28 
73 
128 
Valencia, Provincial Asylum .... 
294 
165 
459 
530 
Zaragoza, " " .... 
244 
154 
398 
430 
[Toledo, " " reported by letter] 
33 
19 
52 
65 
1,654 
1,027 
2,681 
3,033 SPANISH ASYLUMS FOR THE INSANE. 
33 
Thus, in thirteen asylums which in 1880 contained 2,681 
inmates I found 3,033 ; an increase of 13 per cent, in less 
than three years. 
If we suppose that this represents an equal increase in 
the total number of insane in the kingdom, there would be 
(on the same basis as the former calculation) about 19,000 
insane altogether. I do not believe this to be true, because 
it seems to me much more likely that the increased asylum 
population in both enumerations (1880 and 1883) was much 
more due to greater readiness on the part of families to 
send their insane to institutions for treatment, and to 
greater care in collecting the pauper insane, than to a posi- 
tive increase. If one may hazard a guess in such an im- 
portant matter I would place the total number of insane in 
Spain at the present time, at not more than 15,000. This 
would include cretins, idiots, and many simply weak-minded 
epileptics and paralytics. 
2. The question of general paralysis, or paresis. In the 
absence of classification and statistics not much can be 
said of the prevalence and recent increase of this fearful 
disease. The percentage of cases was most variously 
estimated by different physicians. 
Dr. Galceran, of Barcelona, 2 % to 4 
Dr. Sanchez, of Toledo, about 7 % to 4 % (in women !). 
Dr. Pi y Molist, of Barcelona, 8 % to 10 %. 
Dr. Esquerdo, Jr., of Madrid, 8 % to 10 %. 
Dr. Mendez, of Barcelona, nearly 20 %. 
Dr. Dolsa, of Barcelona, from 20 % to 25 %. 
These conflicting estimates are not so very different from 
those we find in books, and hear specialists of other coun- 
tries express. 
What is more interesting, is the emphatic testimony of 
the experienced physicians above named, that general 
paralysis has greatly increased within fifteen years. As to 34 
E. C. SEGUIN. 
the causes of the affection and of its increase they expressed 
themselves as follows: Dr. Galceran blamed alcoholism; 
Drs. Dolsa and Sanchez think the cause is excessive in- 
tellectual exertion caused by the greater competition of 
modern life; Dr. Mendez considers alcoholism and syphilis 
to be the chief causes; Dr. Gin6, while recognizing alcohol- 
ism as a predisposing cause, thinks that the anxiety and 
mental strain attending the increasingly severe struggle for 
existence is the chief cause. 
3. The state of psychiatry in Spain. If we except per- 
haps half a dozen, the physicians I found in charge of the 
insane had but little knowledge of the subject, and were 
apparently unable to recognize general paralysis in its early 
stages, or in its peculiar forms. They were, almost without 
exception, unable to read the large and invaluable literature 
of insanity which is German or English ; and beyond a 
vague and sceptical knowledge of " non-restraint " they 
knew nothing of the admirable management of the insane 
in countries beyond France. Several of these gentlemen 
read French and had a fair knowledge of its psychiatrical 
literature up to ten years ago. Never had I so fully real- 
ized how men of industry and talent may be baffled in 
their work, and made to appear ill-trained by the want of 
modern linguistic knowledge. More especially is it true of 
this specialty in medicine, which since the days of Pinel has 
progressed almost equally by contributions in the three 
great modern tongues. 
Many of the physicians I met had never been of 
Spain, and had, consequently, never seen with their own 
eyes the practicability of non-restraint, the wonderful in- 
fluence of occupation, etc., so well shown in English and 
Scotch Asylums. 
In only a few universities is clinical instruction in mental 
disease given to medical students. SPANISH ASYLUMS FOR THE INSANE. 
35 
An association of alienists does not exist, so that these 
gentlemen have no opportunity of comparing means and 
results, and of exchanging ideas. Each one (with few 
exceptions) goes on alone in his routine work, ignorant 
of what his Spanish confreres are doing, and also of what 
is being accomplished and planned in other countries. 
Dr. Gine, who is a distinguished exception to the above 
criticisms, has invited physicians of asylums and others 
interested in psychiatry to hold a meeting or reunion at 
his asylum, Nueva Bethlen, in September next. Prizes are 
offered for essays on certain subjects, and a general dis- 
cussion will doubtless take place. This may prove the 
beginning of a medico-psychological association, which 
would, indirectly, perhaps, prove of great and lasting benefit 
to the insane of Spain. I hope that this meeting will prove 
a success, and that it will be followed by results which shall 
reward its large-minded and generous originator. 
4. The buildings. No very special fault is to be found 
with the best private asylums except this: in none of 
them are the violent and filthy patients treated with enough 
patience and humanity. They are in worse quarters than 
are the poorest patients in many public institutions; in dis- 
mal dark rooms, with small, perfectly cheerless airing- 
courts. In this matter, I think that improvement should 
soon be made, as it simply needs a few more attendants, 
and more vigilance on the part of the physicians. In 
reality, these unfortunates need more active care, and should 
have it, than the quiet, orderly patients. The general man- 
agement of the private asylums is fairly good ; especially 
to be praised is the proximity of gardens and pleasant 
" patios." In none of them, however, are the reunion rooms 
for male patients attractive and cheerful. It would be 
invidious, and is unnecessary, to compare the various pri- 
vate asylums, but I cannot help remarking that, consider- 36 
E. C. SEGUIN. 
ing the class of patients it is intended to receive, and the 
price asked for board, the asylum at Carabanchel is poorly 
equipped ; it almost needs re-building and furnishing. 
The provincial asylums are all bad; several unfit to 
receive any but criminals. Indeed, until the new institu- 
tion at Zaragoza is opened, Spain cannot be said to 
have one proper provincial asylum. 
The government asylum at Legafiez is not as bad, but 
still it is far from what it should be. 
The following are some of the most striking faults in 
these public institutions:- 
a. Want of ground, of large gardens or farm-land. Con- 
sequently, it is almost impossible to occupy the inmates and 
to give them proper exercise. 
b. Small size and utterly cheerless aspect of the airing- 
courts or yards (" patios "). Some of these are unfit for human 
use. 
c. Absence of attractive (warmed, for Northern Spain) 
reunion rooms or parlors. Want of materials for amus- 
ing or instructing patients. 
d. Want of sufficient extent of buildings to allow of classi- 
fication and separation of patients. Many of the airing- 
courts now almost resemble Kaulbach's celebrated cartoon. 
5. The management. I did not inquire into the questions 
of food and general economy, but simply observed the man- 
agement of patients. It seemed to me to be kind, as a 
rule, but very imperfect. The physicians and patients 
were on friendly terms. I detected no signs of hatred of 
nurses on the patients' part, and the evidences of humane in- 
tentions were all around me. I was unfavorably impressed, 
however, by the prevalent notion that many patients 
were "utterly demented," unconscious of comforts or 
discomforts, and indifferent to their surroundings. This 
false idea led to much unintentional neglect and harshness. SPANISH ASYLUMS FOR THE INSANE. 
37 
Another idea incompatible with progress was the fear which 
the attendants (and apparently some of the physicians as 
well) had of violent patients. That such a patient was very 
furious, very dangerous, etc., was an exceedingly frequent 
apology for isolation in dungeon-like rooms, for tying down 
in bed during the day as well as night, and for the use of 
other means of restraint,-yet it might be difficult to con- 
vince the physicians that ceasing the use of restraint would 
diminish the "fury" wonderfully, as demonstrated by 
Pinel nearly one hundred years ago. 
Nowhere was a systematic attempt made to employ 
patients. In some asylums a few are employed in the 
laundry, kitchen, etc. (at San Baudilio I was pleased to find 
quite a number of inmates gardening and farming). Of 
course in private asylums the feelings or notions of patients 
and their families must be consulted in this respect; but 
occupation for the insane does not necessarily mean manual 
labor. This is perhaps best, but there are many things 
which can be given to ladies and gentlemen to do in-doors, 
which will pass the time, and demand some concentration 
of the attention, or something objective and tangible. Even 
for pauper patients valuable productive labor is not what is 
needed ; it is the labor itself, the physical exercise, the 
effect on attention, and the sedative action of fatigue 
which are sought by the alienist ; so that labor which 
the administrative head of an asylum would smile at, is of 
as much importance, medically, as the steady, valuable work 
of some of the patients. 
Amusements. In the private asylums there were reading- 
and billiard-rooms, but I saw no one using their contents. 
One reason was the unattractiveness of the rooms, but the 
most important cause was indifference on the part of 
physicians and attendants ; it seemed no one's business to 
induce the patients to read, play games, and be sociable. 38 
E. C. SEGUIN. 
Lectures and theatricals were rarely given. The public 
asylums had no sort of amusement provided. The life of 
their inmates was one long monotonous, idle, cheerless 
existence-enough to cause dementia in a sane person. 
6. Restraint. On re-writing my memoranda I am 
struck by the moderate use of mechanical restraint in 
Spain. Of course the provincial asylum of Valencia is an 
exception : its barbarous practice ought to be wiped out 
very soon. In many of the asylums there were very few 
patients restrained on the day of my visit, and that by the 
milder means, such as the camisole, or soft leather 
manacles or wristlets. Though I saw one wall-chain, and a 
number of iron manacles, I did not find one " crib." I 
must add that if I compare the impression made upon me 
by seeing the Spanish restraint (always excepting Valencia), 
and that produced by seeing a nearly naked, urine-stained 
woman struggling like a caged wild beast in a " crib " at the 
asylum at Danvers, Mass., in March, 1880, I am obliged to 
admit that the latter was the more painful, the more revolt- 
ing sight of the two. And, if we remember the amount and 
nature of the restraint employed in asylums in the 
eastern part of our country prior to the recent agitation 
for asylum reform, we will not feel so very superior to 
our Spanish confreres. Dr. Gin6's opinion that non-restraint 
is a noble ideal to be aimed at all the time, is a more 
advanced view than most of our asylum superintendents 
would have accepted five years ago. And the opposite 
opinion of Drs. Dolsa and Llorach, that non-restraint is 
absurd, and may be highly pernicious and criminal, would, 
I venture to assert, please more than one of our alienists. 
It seems to me, from the generally benevolent manage- 
ment of the patients, and the naturally kind disposition 
of Spaniards, that non-restraint, in a general and practical 
way (if not in an absolute sense), will be the rule in Spanish 
asylums before a generation has passed. SPANISH ASYLUMS FOR THE INSANE. 
39 
In connection with this I might state that I saw only 
two (2) cases of haematoma auris, though I looked about 
sharply. 
Is it proper for a stranger and a passing observer to offer 
any suggestions for reform ? I may be allowed to do so, 
because I am not a hostile or prejudiced critic in this case. 
In the much-lamented fact that Spain has no worthy 
public asylums, I see an opportunity for much more com- 
plete and rapid reform than has been possible in other civi- 
lized countries, burdened as they were (and are still) by 
costly " tolerable " establishments which it would have been 
waste to pull down, and yet which barred the way to prog- 
ress. How much we in America suffer from this evil, as 
embodied in " palatial asylums," more especially! Every 
thing is to be done for the poor insane of Spain, and it 
may be well done from the start. 
It seems to me that the following movements for reform 
might be begun simultaneously. 
a. To make a special and actual census of the insane of 
the kingdom-separate lists to be made of idiots and 
cretins on the one hand, and of epileptics on the other. 
The mass of simply foolish, helpless paralytics (hemiplegics 
mostly), which are now included under the term " de- 
mentes," should be excluded. The enumeration should, of 
course, be made on one day, simultaneously, throughout 
Spain. Upon the data thus obtained, making allowance 
for the probable increase of insanity in the next thirty 
years, plans zfor asylums might be intelligently prepared. 
b. New buildings will have to be erected, and this is a 
question involving many problems, and provoking many 
conflicting views. I would suggest the following general 
plan :- 
1. To build in every principal centre of population a 
small thoroughly-appointed hospital for acute cases. It 40 
E. C. SEGUIN. 
might be designated in Spanish, " Hospital de Enage- 
nados." 1 The meaning of the term acute cases should be 
further defined as including all simple forms of insanity ; 
the psychoses, which are usually curable ; and other cases 
in which the diagnosis is for a time uncertain, or in which 
it is hoped that treatment may cause remissions or inter- 
missions. On no account should such an institution be 
crowded with cases of general paralysis, on the pretence 
that they are " acute cases." These hospitals would be 
relatively costly, in order that nothing in the way of foods, 
medicines, hygienic and moral treatment shoufd be wanting. 
For is not a curable insane, who may continue a useful 
citizen for years afterward, as deserving of as expensive 
treatment as a man who breaks his leg, or contracts a 
pneumonia ? It has always seemed to me that this view of 
the case was not correctly appreciated as a matter of politi- 
cal economy and of ethics. With the curative idea em- 
bodied in the name and practice of such institutions, the 
people of the city and surrounding country would soon be 
educated to sending their insane for early treatment; thus 
greatly increasing the chances of cure. As the salary of a 
competent resident physician, or medical superintendent, 
would be a considerable item of expense, it might be well, 
for small hospitals, either to have a visiting physician and a 
resident pupil, or to allow the medical superintendent to 
practice outside the hospital. 
2. To erect, in a few accessible localities, large asylums, 
or " casas de dementes." Perhaps four or six would at 
present suffice for all Spain. The new institution at Zara- 
goza might be one of them, though it is much too expen- 
sively built.2 The buildings should be very plain, of great 
extension, and (as now is the rule) of only two stories, one 
1 The present title of the Toledo asylum. 
2 Yet, unless altered in some of its parts, it will be unfit for a hospital for 
curable cases. SPANISH ASYLUMS FOR THE INSANE. 
41 
to be used solely at night. Each institution shall have a 
large farm with its stock, workshops of various kinds. 
The " patios " should be shaded and pleasant. These asylums 
might be made to receive from 500 to 2,000 of the chronic 
insane. As all the cases admitted would be incurable 
(upon any unexpected indications of improvement,1 patients 
would receive special attention, or be sent to one of the 
hospitals), there would be no medical objection to such 
large numbers, while from an administrative point of view 
there would be the advantage of extreme economy. The 
population of these asylums would include cases of primary 
and secondary dementia, of systematized mania or mono- 
mania, of general paralysis (just as soon as the diagnosis 
became certain), and of epilepsy. After awhile the out- 
door or shop labor of the inmates would prove remunera- 
tive, as it has done in many asylums,2 and the patients 
might be paid a trifle to enable them to procure extra 
comforts. 
3. To erect two special institutions for the training, edu- 
cation, and guardianship of idiots (not young dements) and 
cretins. One of these schools might be in the north, 
another in the south, of Spain. 
4. One or two special asylums for insane criminals will 
be necessary in time, as it is manifestly unjust and unwise 
to mingle these lunatics, or quasi-lunatics, with others. 
c. Young physicians, if possible such as have served as 
internes in general hospitals, should be sent on a tour of 
study in France, England, and Germany. These gentle- 
men would doubtless be made very welcome everywhere in 
their search after knowledge. They would return with a 
fair reading knowledge (at least) of the three languages, 
1 See table 3, p. 409. 
* At the asylum of Rome all the cloths used for clothing (including uniforms 
of attendants), shoes, etc., are made in the asylum by patients who are paid a 
little and have bank accounts. 42 
E. C. SEGUIN. 
with a practical belief in the practicability of non-restraint, 
and with a fund of valuable ideas relative to the employ- 
ment and amusement of patients, to the medico-legal rela- 
tions of the insane, and to more purely medical and scien- 
tific points. If the States or provinces, or benevolent 
individuals, defrayed the expenses of these travelling schol- 
arships, it would be only just to require the incumbents to 
bind themselves to serve the insane for a given number of 
years after their return. 
Quite a small number of men thus educated, would exert 
an extraordinary influence on the progress of psychiatry in 
Spain. They would train attendants, educate other phy- 
sicians, infuse life into the specialty, and in many ways con- 
fer great benefits upon the nation. 
d. The physicians who are now in charge of asylums, 
should, in justice to their patients, and to themselves, en- 
large their knowledge and experience. They, nearly as well 
as the young men, can learn to read the modern languages 
if they will; and many of them can visit asylums outside of 
Spain. They can also co-operate in a medico-psychological 
association. 
e. Lastly, some supervision or inspection of the asylums 
becomes necessary. This might be done by means of medi- 
cal inspectors reporting to some department of the govern- 
ment ; or, perhaps better, by means of the English plan, of 
a Board of Commissioners in Lunacy, with critical and ad- 
visory privileges, but not executive powers. THE JOURNAL OF 
NERVOUS AND MENTAL DISEASE 
EDITED BY 
WILLIAM J. MORTON, M.D., New York. 
PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM, UNIVERSITY OF VERMONT; ASSOCIATE PROFESSOR 
OF DISEASES OF THE MIND AND NERVOUS SYSTEM, AND OF MEDICAL ELECTRICITY, 
NEW YORK POST-GRADUATE MEDICAL SCHOOL. 
ASSOCIATE EDITORS: 
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