Prom the Eighth Annual Keport of the State Board of Health of Massachusetts, 
DISEASE OF THE MIND. 
CHARLES F. FOLSOM, M.D., 
Secretary of the Board. 
BOSTON: 
ALBERT J. WRIGHT, STATE PRINTER, 
79 Milk Street, Corner Federal Street. 
1877. Jftd de 
c/ de dcJoci'id o/ cZ^^oee/y/d. DISEASE OF THE MIND. 
By CHARLES F. FOLSOM, M. D., 
Secretary or the Board. 
I.—Early Treatment of the Insane. 
ll.—Pinel’s Reform and European Progress. 
lll.—English Progress, and Conolly. 
IY.—American Progress. 
Y.—Modern Methods of Less Restraint, 
Yl.—Responsibility for Crime and Definitions of Insanity. 
Vll.—Massachusetts Statistics and Asylum Accommodation. 
Vlll.—Supervision by the State. 
IX.—Certain Asylum Needs. 
X.—Medical Education. 
Xl.—Summary. DISEASE OF THE MIND.* 
“ Other nations are making rapid progress; and if the States are to keep 
before them, or even to keep up with them, they must be anxiously looking 
around for suggestions, and ready to adopt improvements from all quar- 
ters.”—President McCosh in the International Review, March, 1874. 
“ It is manifest, that if we would hope to keep our institutions up to the 
recent level of those of England and France and Germany, it must be done 
by unremitting activity, by never being satisfied with present attainments, 
and by keeping the community well advised of the absolute necessity of 
liberal means to meet this great end.”—Dr. Luther V. Bell’s Report for 1853, 
Early Treatment oe the Insane. 
It is impossible to get any fair idea of the present status of 
the insane I and their treatment without reviewing briefly the 
history of the subject. Mental aberration has, of course, 
existed in some form from the earliest times. The ancient 
Egyptians had temples £ dedicated to Saturn (Seb) in charge 
* This term (on the whole, the least objectionable) is used as signifying a certain 
morbid condition of the brain, whereby the cerebral functions are impaired to a suffi- 
cient degree to seriously interfere with the ordinary relations of life, or render them 
impossible. Of course this “ certain morbid condition ” was arbitrarily limited in its 
application when little was known of the subject; it is meant to exclude a similar 
state of the mental, moral and emotional faculties often observed in many of the 
common fevers and other diseases. 
The writer desires to express his indebtedness to Rev. W. C. Gannett, Dr, D. F. 
Lincoln, and Dr. A. H. Nichols, for many valuable suggestions and criticisms in their 
careful revision of the manuscript or proof, and to Dr. Edward Jarvis for the use of 
his library of rare pamphlets, reports, etc., in preparing this paper. Several hundred 
books, pamphlets, reports, etc., have been consulted; but no attempt is made to give 
a bibliography of the subject, which, indeed, would constitute a large volume by 
itself. If any desire to pursue their investigations farther, the references in the text 
and in the foot-notes will probably be sufficient for their purpose. 
t The discussion of the subject here will be confined within its strictly practical 
limits. Those portions, therefore, which relate to the causes, prevalence, increase, 
prevention, etc., have been necessarily omitted, as involving a minute examination of 
statistics, and as demanding a separate consideration by themselves, 
% It is well known that the Greeks and Romans treated the sick, and probably 
some of the insane, too, in rooms adjoining their temples. Disease of the Mind. 
of priests, who "cured” the insane by amusement, occupa- 
tion and healthful habits chiefly, but with the pretended exer- 
cise of spiritual influence. In the early Greek writers, and in 
the Old Testament, we find delineations of mental disease, 
and in the later Greek tragedians, but without any apparent 
appreciation of its true character. The physicians were 
mystics : some of them recommended hellebore from Mount 
CEta, and others extolled that of Galatia or Sicily. Hippoc- 
rates first had a fair conception of the real nature of insanity, 
and treats of it, although briefly, on more rational principles. 
Some of his disciples had very clear ideas of its treatment by 
medical and moral means; but the Hippocratic oath bound 
them to a secrecy which prevented their knowledge from 
becoming at all general. Asclepiades, although differing 
with Hippocrates in many points of theory, had essentially 
the same views with regard to the nature of mental disease, 
—its dependence on bodily conditions, and its treatment by 
remedial agents. Plato thought that there were two forms of 
mania,—one of purely corporeal origin, and one an inspira- 
tion from the gods. 
The first insane asylum of which we have any definite 
knowledge was built by the monks at Jerusalem, in the sixth 
century, for their fellows whose reason had given way under 
the austere penances which had produced a St. Jerome 
and a St. Simeon Stylites. This was about two centuries 
after the establishment of the first public hospital, which 
w’as built by a Roman lady as a penance and a gift to her 
native city. 
In the seventh century, the insane began to make pilgrim- 
ages to the shrine of St. Dympna * at Gheel, near Antwerp, 
in the hope that they would there find restoration to health. In 
time quite a colony of them grew up, living in the houses of 
the peasants, to which others of the insane were sent, because 
they could be cheaply cared for there. Later still, it was 
taken in charge, and in 1851 organized by the State, still 
keeping up the daily visit to St. Dympna’s tomb, without 
* An Irish girl who fled thither to escape from a cruel father, and whose persecu- 
tions, when followed and found by him, became famous. We have become familiar, 
recently, with a similar movement in the “ miraculous appearance ” at Lourdes in 
France, and in the annual pilgrimages to that place. Disease of the Mind. 
5 
which the benefits from air, exercise and employment were 
thought of little account. 
At Fez, several asylums existed in the seventh century. 
At the beginning of the fourteenth century, one was built at 
Cairo, and Lecky thinks that " it is probable that the care of 
the insane was a general form of charity in Mohammedan 
countries.” * 
Among Christians, the first in Western Europe was founded 
by a monk in Valencia in 1409, and the same century saw the 
establishment of four others in Spain. The Moors were un- 
doubtedly in advance of the Christians at this time in all 
matters relating to health ; f and Desmaisons gives them the 
credit of this movement in Spain. An insane asylum was 
opened in Utrecht J in the fifteenth century, which remained 
in private hands until 1834. In the middle of the sixteenth 
century, the Spaniards erected an insane asylum in Rome, the 
year after the old hospital, now represented by Bethlehem § 
("Bedlam”), was opened in London, and about a century 
before the first|] in Paris. 
During the two centuries following the establishment of the 
first asylum in Spain, the monks, who were the principal de- 
positaries of medical knowledge, had the care of the insane in 
convents in Europe. Their treatment was, with few exceptions, 
ignorant and barbarous, until St. Vincent de Paul travelled 
from land to land proclaiming that the darkened mind, which 
was at that time looked upon and treated as if possessed by 
evil spirits, was just as much a visitation from God as the 
darkened eyesight. The Franciscan monks used then to whip 
daily those under their charge,—a means of discipline which, 
indeed, they used also upon themselves; and it would be idle 
to guess how many were burned, put to the rack, etc.,, 
* History of European Morals, 11., p 94. 
f Seventh Report of the State Board of Health, p. 276. 
% A Visit to Thirteen Asylums for the Insane in Europe. By Pliny Earle,*M. D.,, 
Philadelphia, 1841. Institutions for the Insane in Prussia, Austria, and Germany. 
By Pliny Earle, M. D., Utica, 1853. 
$ This was founded in 1246 as one of the religious houses of the Order of Beth- 
lehem. When these houses were suppressed in the time of Henry VIII, it became a 
small insane asylum for the corporation of London, although the insane had been , 
known to be received there for at least the previous century and a half. It was rebuilt 
in 1675, and again in 1814. The first medical attendant was appointed in 1632. 
|| This was really only a department of the Hotel Uien, where three or four were., 
sometimes placed in one bed. 6 
Disease of the Mind. 
under the theory of witchcraft and dcvilcraft. The Knights 
of Malta, at that time, received the insane with the other sick 
in their hospitals. 
In 1751, a few benevolent gentlemen in London established 
the first asylum in modern times (St. Luke’s) for the care of 
the insane exclusively. From the first, there were separate 
wards for the curable and for the incurable. 
At the very close of the last century, there were three cor- 
porate asylums and one public in the United States, and five 
public in England. The private asylums were also very few, 
that of the parson-doctor, Willis, in England, being the most 
celebrated. In fact, the reputation of Willis was so great that 
he was called to attend King George the Third in his second 
attack of mental disease in 1788. His treatment of even so 
exalted a personage was arbitrary and dogmatic in the ex- 
treme. Mechanical restraint was liberally used, and the 
strait-jacket was one of the common means of "discipline.” 
In his own asylum it must have been the same, although for 
his more quiet patients he was in advance of his day, and 
depended to some extent on an excellent table, regular habits, 
general good health and agreeable occupation; but he allowed 
his attendants to beat the more unruly * when they thought 
it necessary. 
The age was one of the most absolute dogmatism; but in- 
sanity and the phenomena of mind were thought to belong to 
the province of the theologian and the metaphysician, and their 
dogma was even more narrow than that of the doctors. 
Neither Hoffmann, Stahl nor Boerhaave had advanced the 
knowledge of insanity, Cullen in Scotland and Morgagni in 
Italy had begun accurate observations ; but not until John 
Hunter went to London, in 1748, was the inductive method 
of study in medicine fairly inaugurated, and he was so 
far in advance of his time that he never had an audience of 
tweifty persons in all the years of his lecturing. Although 
he was "a man, who, for comprehensive and original research, 
comes immediately after Adam Smith, and must be placed far 
above any other philosopher whom Scotland has produced,”! 
his principle of careful deductions from recorded facts had 
* This was also permitted by the regulations of “ Bedlam.” 
t Buckle’s History of Civilization, 11., p. 432. Disease of the Mind. 
7 
not been generally adopted in medicine, and nowhere had it 
been applied to the study of the mind. The regular physi- 
cians did not study mental diseases in the schools, and Warren 
and his illustrious compeers in London looked upon Willis, 
with his enormous fees, as only a charlatan. 
During the last quarter of the past century, the insane, 
when not entirely neglected, were almost universally confined 
in jails and poorhouses, and, of course, in chains. In Scot- 
land, a farmer, "as large as Hercules,” had a reputation for 
curing them by his severity. In England, the practice of 
making several hundred pounds a year, by exhibiting the 
inmates of Bethlehem Hospital to the populace for a small 
fee, was given up only in 1770. In France, asylums were 
considered only as receptacles for chronic cases, where the 
attendants (often convicts serving out their time) were allowed 
to whip them. Van Helmont had recommended sudden plung- 
ing of the insane into cold water and keeping them there for 
some moments, and that remedy was still used. In this country 
the treatment was no better. The Spaniards alone, accord- 
ing to Pinel,* especially in the asylum at Saragossa, where 
the inscription urhis et orhis was placed over the door, had a 
rational open-air treatment. 
It does not come within the scope of this paper to enter 
fully into the humiliating records of that age, nor to discuss 
the reasons why the intelligent views of the Egyptians, 
Greeks and Romans, so utterly lost in the darkness of the 
Middle Ages, did not reappear upon the revival of learning 
or during the splendid Elizabethan age. 
With their religion, the Hebrews transmitted to the Christ- 
ians of Europe their demon-theory of insanity; and it was 
considerably less than a century ago that the insane began 
again, by the efforts of Willis, Pinel, Tuke, Chiaruggi, Reil, 
Langermann and Rush, to be treated as sick people. Then, 
as Roller says, wurden die verierenen Menschenrechte wieder 
gevoonnen\ (the lost rights of humanity were regained). 
Up to that time no one had described the phenomena of 
mental disease so accurately as Shakespeare; no one its 
pathology and treatment better than Goethe. 
* Traite medico-philosophique sur I’alienation mentale. Paris, 1801, p. 250. 
t Psyclaiatrische Zeitfragen aus dem Gebiet der Irrenfursorge, Berlin, 1874. 8 
Disease of the Mind. 
Pinel’s Reform and European Progress. 
France. 
The Due de La Rochefoucauld, Tenon, and a few others in 
Paris took the first steps in the reform of the treatment of the 
insane which marks the present centenary, a matter to which 
their attention had been called by John Howard in his visit to 
Europe in 1780; but Pinel was the great man in that work. 
He was appointed by the government to examine and report 
on the asylums at Paris and Charenton ;* and afterwards, in 
1792, when a mature physician in middle life, and a member of 
the Royal Academy, he became superintendent of the Bicetre, 
the asylum for incurable males. Later still Salpetriere, where 
the female insane were confined, was placed under his charge. 
The events of the revolution had filled the wards with the 
most excited cases. They were usually sent first to Hotel 
Dieu, the general hospital, where they were bled, purged, 
and douched, and then afterwards to the insane asylum, if 
they were thought incurable. The asylum was not looked 
upon as a hospital, a place of cure. 
As soon as Pinel received his appointment, he repeatedly 
asked the Commune to allow him to remove the chains from 
all who wore them, or one-fourth of those confined. The 
idea was to them preposterous ; but finally, tired out with his 
importunity, they allowed Couthon to go with him to see what 
could be done. After looking over the patients, he said to 
Pinel, " Ah, ga! citoyen, es-iu fou toi-meme de vouloir de~ 
chainer depareils animaux ?” (citizen, are you crazy yourself 
that you would unchain such animals?) He persisted, how- 
ever, removed the chains from fifty-three persons in three 
days, beginning with that one who had been thought the most 
desperate, and sought to give them occupation, making one 
his servant, interesting others in attending to those more 
needing care than themselves, etc.,—apparently getting the 
hint from Thouin, of the insane asylum at Amsterdam, wTho 
employed the quiet inmates in taking care of others, as was 
then the custom generally in Holland. Pinel kept constantly 
before him his independent motto, " Chercher d eviter toute 
* Then established about a half-century. Disease of the Mind. 
9 
illusion, touteprevention, toute opinion adoptee surparole* (to 
seek to avoid all illusion, all prejudice, all opinion taken on 
authority). He still, however, held the strait-jacket {gilet 
de force) in high repute; and although, he was the first in 
modern times to adopt the "moral treatment”f in a public 
asylum, his practice may be inferred from his choosing large 
and muscular men for his attendants. 
Pinel knew almost nothing of pathology. He read Hip- 
pocrates, Aretseus, Galen and Celsus. The contemporary 
medical writers and their theories he cared little about. He 
believed chiefly in careful observation of the insane them- 
selves, and never for a moment countenanced the force, 
deception and ingenious tricks of surprise and terror in 
such general use at that time. Cullen, with his theory of 
three forms of insanity,— (1) mental, (2) corporeal, (3) of 
obscure origin,—he regarded as simply a little above the rest 
of the theorists. The German writers, generally, he con- 
sidered as even less practical than the English and Scotch; 
but excepts Greding, whose two hundred careful autopsies he 
speaks of with approbation as praiseworthy efforts, although 
denying that any relation could be established between post- 
mortem appearances and intellectual derangements observed 
during life. His knowledge of psychology he got chiefly from 
Condillac, Montaigne, Locke, Harris, Smith and Stewart. 
He had only five classes of mental disease: (1) melancholia, 
simple, or complicated with hypochondriasis ; (2) mania with- 
out delirium or incoherence ; (3) mania with delirium; (4) 
dementia; (5) idiocy. Still, even in this, he was in advance 
of his time; for, according to the Vienna school, there were 
only two divisions: (1) maniacal delirium, and (2) melan- 
cholic delirium. 
The reform was slow in its advances. Following Greding in 
Berlin, Pinel made careful autopsies and dissections and ex- 
aminations of the brain; but these were fragmentary bits ot 
evidence until Bichat appeared,! the greatest investigator and 
* A full account of this great work, by Pinel’s son, may be found in the Memoires 
de I’Academie Royale de Medecine, Tome Y. 
fThis term has been used since Find’s day to indicate amusement, occupation, and 
all generally elevating influences. •» 
t His Anatomic Generate was published in 1801, and the Rccherches Physiologiques 
in 1800. 10 
Disease of the Mind. 
generalizer of his age, whose researches and experiments in 
anatomy and physiology make an epoch in the history of 
science, and after whom came Louis and modern medicine 
based upon exact observation. One of his pupils, Esquirol, 
advanced the pathology of mental disease as Pinel had ad- 
vanced its treatment. He visited the colony of the insane at 
Gheel,* with his students, in 1821, and opened a discussion 
as to its merits, which was continued in nearly all the languages 
of Europe. Upon his return to Paris he established the farm 
in connection with the Bic6tre, which Pinel had attempted 
without success. He also devoted much attention to asylum 
construction, and for years after his time his plan of a large 
rectangular block with a court in the centre was the one 
O 
adopted. His Maladies Mentales, published in 1838, and 
based upon an experience of forty years at Charenton and in 
the Salpetriere, may be referred to for a full description of 
the historyf of asylums in France. In Esquirol’s. private 
institution for the insane (each one of whom had an attendant) 
the quiet patients dined with his family; the others were 
treated with a free use of the strait-jacket. 
Many years after Pinel’s death, chains were in common use 
in the treatment of the insane on the continent of Europe 
outside of the great university cities, and in Great Britain; 
but the work of careful research went on, while the labora- 
tories of Berlin, Paris, and later, Vienna, were busy with 
scalpels and reagents. The doctors were still disputing 
whether insanity were an affection of an immaterial mind or 
of the material brain; whether it arose from disease or vice. 
Germany. 
The first German asylum for the custody of the insane alone 
was ready to receive patients in Vienna in 1784. Its name, 
the Narrenihurm (fools’ tower), gives a fair idea of the views 
* Without entering upon the merits and faults of Gheel, or the question of the pro- 
priety of hiring out a helpless class to ignorant peasants, there can he no doubt that 
Griesinger was right in saying that the experiment has proved that the greater number 
of the insane do not require the confinement of an asylum; that many of them 
can be safely trusted with more liberty than these institutions allow, and that associ- 
ation in the family life is very beneficial to many patients. A good account of Gheel 
may be found in the Revue des Deux Mondes for January, 1857. 
fin general terms this presents nothing distinctive, farther than those portions 
already referred to. Disease of the Mind. 
11 
of its founders. Practices continued there which had been 
abandoned in "Bedlam” a dozen years before. 
About the beginning of this century, insanity began to be 
looked upon as curable in Germany, the Saxons taking the 
lead. They published the first journal exclusively devoted 
to psychological medicine, in 1805, and appointed Ileinroth 
their first professor of that branch at Leipsic in 1811. The 
psychic theory of insanity was then universally accepted by 
them, and Langermann was their acknowledged leader. 
Langermann’s project of asylums for the insane, embodying 
many excellent features, was adopted at Sonnenstcin, under 
Pienitz, and soon after at Waldheim and Colditz. These two 
men and Ileinroth developed Pinel’s treatment, with which 
they had become familiar. Their ideas may be inferred 
from the fact that Heinroth, who wrote a treatise on mental 
hygiene, thought that all insanity began in vice, and that 
Langermann said, "God only knows whether an insane per- 
son can be cured or not,”—an opinion which he afterwards 
modified. 
When insanity began to be generally looked upon as cur- 
able by the medical profession in Germany, asylums for the 
cure (heil-anstalten) as well as for the custody {pflege- 
anstalten) of the insane were established. Unfortunately, 
from motives of economy or from necessity, the two were 
soon united in practice, at first by having the two classes in 
separate buildings under one head, and later by placing both 
under one roof. From 1820 to 1849, fourteen more asylums 
were erected. 
The psychic theory held its ground pretty well until the 
time of Gricsingcr, although shaken by Jacobi in Germany 
and Yan der Kolk in Holland, both of whom did service in 
calling attention to the more material and practical ideas of 
the countrymen of John Hunter and of Bichat. The profes- 
sorship of psychology was established in Berlin about 1830, 
and the word seelensidrung (psychical disorder), as applied to 
insanity, gradually gave way to geisteskrankheit (disease of 
the mind), thus indicating something of a step forward as 
more clearly recognizing the purely physical character of the 
malady. 
The great advance of this age was made by Griesinger, 12 
Disease of the Mind. 
who, when twenty-two years old (1839), was an assistant 
physician in one of the asylums of Germany. His dis- 
tinguished services for the following twenty-nine years, to 
the time of his death, well earned for him his title of the 
"greatest of modern alienists.” Like Pinel, he was not, in 
the narrow sense, a specialist, for his contributions to general 
medicine alone would have rendered him famous. He first 
established the diagnosis of diseases of the mind upon an 
exact basis and by logical, methodical processes, a work in 
which he got great assistance from his illustrious contempo- 
rary, Virchow, the acknowledged head of the medicine of the 
present day as based upon scientific research and sound 
pathology, and as great in his time as John Hunter and Bichat 
were during the last half of the past and at the beginning of 
the present century. 
In 1845, Griesinger strongly recommended the introduc- 
tion of the clinical study of mental disease in the schools ; but, 
at Tubingen, where he was then lecturing, he had not facilities 
for carrying out his design. He began this kind of clinical 
instruction at Zurich in 1864, as had then already been done at 
Erlangen, Wurzburg, Munich and Gottingen. The same step 
was taken in Berlin* in 1865, by Ideler, whom Griesinger 
succeeded in the following year as professor of psychological 
medicine and physician to the department for the insane in 
the Charity Hospital. 
At the present time, in the study of the physiology and 
pathology of the brain, based upon exact research, j- Germany 
stands easily first; and the great universities of Berlin and 
Vienna, under Westphal and Meynert, take the lead in a 
work where there are so many distinguished investigators 
that it would be useless to try to even name them all. 
Most of the improvements in hospital-construction in Ger- 
many have come from England and the United States; but, 
just as the first permanent "American hospital” (the small 
separate buildings found so successful during our late war) 
was built in Germany, so is German science now constructing 
* In Vienna, also, about the same time. 
t It is not possible to consider this subject here, or to discuss the opposing theories 
held by Hitzig and Brown-Sequard. The present position of scientific men on this 
point may be found in articles by Prof. H. P. Bowditch in the Boston Med. and Surg. 
Journal, July 20 and 27, 1876; and in the British Med. Journal, Dec. 2, 1876. Disease of ike Mind. 
13 
tire first insane asylum* which embodies the present knowl- 
edge of the subject. 
English Progress and Conolly. 
lii 1796, four years after Pinel’s great reform, a Quaker lay- 
man, William Tuke, abolished the chains of the insane in his 
part of the world, in building the "Retreat” at York, Eng- 
land . 
After Pinel and Tuke, the next great step in advance was 
made by Conolly, a mature English physician of forty-five ; 
but, in order to understand his work, and the peculiar need 
in England of such work, it will be necessary to review the 
history of mental disease in that country, although very 
briefly. A full account may be found in the reports of 
the parliamentary commissions of 1807, 1815, 1827 and 
1844. 
In 1815 patients were chained to the walls of the best 
asylum in London; at Fonthill, thirteen out of fourteen were 
in chains or handcuffs, and in another asylum there was 
one towel to 170 patients. In 1822, in some counties, jails 
were converted into asylums for the insane without change 
of structure, and were so used as late as 1842. In 1827> 
at Bethnal Green, with its 500 patients, some were chained 
to their cribs and confined from Saturday evening till Monday, 
morning, in order to give the attendants their Sunday holi- 
day. No physician or surgeon was in charge, but an apoth- 
ecary visited two or three times a week. 
The first commission! to look after pauper lunatics was 
appointed in 1828, and that tor the metropolis of London 
only. Up to that time, the only Act in force enabled any 
two justices to cause them to be apprehended and to be locked 
up in some secure place "and there chained”; and if the, 
pauper’s settlement should prove to be in another parish, then 
he was to be forwarded thither, and " locked up and chained” 
by the justices of that district. 
In 1828 twelve counties in England had provided.asylums 
* See Professor Westphal’s letter, page 55. 
f The origin and duties of the office of Lord Chancellor’s Visitor are so admiral 
bly given in Df. Bucknill’s letter at a subsequent page, that only a reference to it 
is needed here. Disease of the Mind. 
for the insane, although the law requiring them was passed in 
1808. Six more had been built in 1841. Many of them had 
no physician in attendance ; in nearly all mechanical restraint 
and coercion were used to a great extent; and the only 
inspection got by those outside of London was from irregu- 
lar, uncertain, and often infrequent visits of magistrates or 
local officials, who were interested in keeping the taxes as 
low as possible. In the private asylums there was no 
inspection, and in the jails little better than none. 
From 1829 to 1831 over one-half of the patients at 
Ringraer were in restraint at once. In 1837 * many of the 
worst faults existed in asylums, and few had the confidence of 
the public; but it would be unfair to imply that there were 
not others where there were employment and other moral 
means of treatment, and tranquil wards, where strangers 
might ask with the statesman Burke, after his visit to a 
modern asylum, "Where are the insane?” as he thought he 
had seen none such. 
Coleridge probably gave the sentiment of the educated 
people of the time, and the doctors followed him rather than 
he the doctors. He says : f " Madness is not simply a bodily 
disease. It is the sleep of the spirit with certain conditions 
of wakefulness; that is to say, lucid intervals. During this 
sleep, or recession of the spirit, the lower or bestial states of 
life rise up into action and prominence. It is an awful thing 
to be eternally tempted by the perverted senses. The reason 
may resist—it does resist—for a long time; but too often, 
at length, it yields for a moment and the man is mad forever. 
An act of the will is, in many instances, precedent to com- 
plete insanity. I think it was Bishop Butler who said that he 
was all his life struggling against the devilish suggestions of 
his senses, which would have maddened him if he had 
relaxed the stern wakefulness of his reason for a single 
moment. . . . "When a man.mistakes his thoughts for 
persons and things, he is mad. A madman is so defined.” 
By 1840 there were many private asylums in London, and, 
in that year, it was found necessary to enact a law making it a 
* What Asylums W ere, Are, and Ought To Be. By W. A. Browne, Surgeon 
Superintendent of the Montrose Asylum, Edinburgh, 1837. 
t Table Talk, 1830 and 1832. Disease of the Mind. 
misdemeanor for a superintendent of any of them to keep a 
patient concealed from the commissioners for the metropolis. 
In 1842 there were 162 asylums, including those of a pri- 
vate class, and the abuses were so great and so frequent 
that the Lunacy Commission (previously the Metropolitan 
Commission, above referred to), composed of twenty lead- 
ing men, of whom seven were physicians, was appointed 
in that year to visit "all places throughout the kingdom 
in which persons alleged to be of unsound mind are con- 
fined.” They were required to visit, one physician and 
one lawyer together, the licensed houses in the metropolis 
four times a year; other licensed houses, twice a year; and 
county asylums, jails, and workhouses, once a year. It would 
be difficult to overestimate the good which they have done in 
advancing the knowledge of their specialty and in improving 
asylums directly in England, and indirectly throughout the 
civilized world. 
In 1847 there were 177 county asylums, hospitals, and 
licensed houses, 437 separate establishments for single pa- 
tients, and 596 workhouses, the inspection of which by the 
local authorities was very unsatisfactory. Six of the asy- 
lums had been visited twice in twenty months; eight, 
three times; nine, four times; and one not for two years. 
The evasions of the laws had been so numerous that a 
special Act had been passed in 1845, allowing the commis- 
sioners to enter and examine the asylums by night. 
It is not necessary to enter into details, or to narrate 
particular instances. Enough has been said to show that a 
third of a century ago the condition of the insane in England 
was such as to demand some radical change. 
Conolly’s interest in mental disease began while he was a 
student, and bis graduating thesis was on that subject. He 
early gained a high reputation, and was called to a professor- 
ship of clinical medicine in London, but his chief interest was 
in diseases affecting the mind.* His attention was especially 
directed to the needs of the insane in England by the work 
Conolhfs Work. 
• A Memoir of John Conolly, M. D,, D. C. L., by Sir James Clark, Bart., London, 
1869. 16 
Disease of the Mind. 
of E. Gardiner Hill, of the Lincoln Asylum. He learned 
that there, in 1830, an aggregate of 27,113|- hours had 
been spent in mechanical restraint by 39 of the 92 pa- 
tients ; and that in 1838, with a largely increased num- 
ber of inmates, namely, 158, not one had been put in 
restraint during the whole year. He heard, too, that this 
change in treatment had been adopted because the very 
means used to restrain the patients had been the direct 
cause of the death of two of them. 
Hill had became so unpopular with other physicians -and 
with the officials, by reason of this innovation, that he was 
compelled to resign his position ; and it is probable that the 
movement would have stopped there, had it not been taken 
up by a man who, like Pinel, thought independently, carried 
out his honest convictions, and did his work well. 
As soon as Couolly was appointed superintendent at 
Hanwell (in 1839), he visited the Lincoln Asylum, at the 
request of one of his trustees, who had formerly held the same 
position there, and introduced the non-restraint system, a 
course which was even disapproved by the Lunacy Commis- 
sion ; but, in sixteen years, he could say that he was often 
unable to show his classes any extremely violent cases, 
whereas, in 1840, the asylum was full of them. He did not 
suppose, however, that mechanical restraint could be dis- 
pensed with in all cases and under all circumstances with 
benefit to the patient, as he testified in the trial of Hill v. 
Phelp. His system has spread over all England, and at a 
later day over Scotland, sometimes by the pressure of the 
Lunacy Commission against the wishes of the superintendent, 
and occasionally, it must be acknowledged, with some imme- 
diate bad results, but with ultimate good.. 
One of Conolly’s admirers says of him : "It appears to me 
that the fact that the principles laid down by him have been 
almost universally accepted and acted upon by a generation 
to whom he was personally unknown, is a far higher testimony 
to the sagacity of his judgment, than the adhesion to his views 
of those, who, knowing him well, w7ere influenced by his lofty 
enthusiasm and by the persuasive eloquence of his teachings.” * 
* Address of the President of the British Medico-Psychological Association, by Dr. 
T. L. Rogers, 1874. Disease of the Mind. 
17 
Meyer and Griesinger have introduced the non-restraint 
system in Germany, Van der Kolk in Holland, and Morel in 
France ; but it has not yet been entirely adopted in either of 
those countries. 
In 1854 the English commissioners say: "Asylums were 
formerly constructed as if violence were the rule in the con- 
dition of the lunatics. They are now constructed as if it were 
the exception ; and it is the exception.” Since that date, 
great advances have been made in that country, which will be 
referred to at a later page. 
American Progress. 
In this country, the province of. Pennsylvania was the first 
to recognize its duties to the insane. Some benevolent per- 
sons, headed by Dr. Bond, took steps in Philadelphia in 
1750 to establish "a small provincial hospital.” In 1751 the 
Legislature passed an "Act to encourage the establishing of a 
hospital for the relief of the sick poor of this province, and 
for the reception and care of lunaticks,” a considerable 
portion of the money being subscribed by private individuals. 
In February, 1752, the first patients were received in the 
hospital (extemporized out of a private dwelling), of whom 
three of the first four admitted were insane. In the first two 
years, eighteen suffering from the "disease lunacy” were 
admitted, of whom two were cured. The trustees com- 
plained, in their first report, that many were taken away by 
friends before the cure was established, and passed a resolve 
"to admit none hereafter who are not allowed to remain 
twelve months in the house, if not cured sooner, or judged 
by the physicians to be incurable.” As there had been con- 
siderable opposition to the project on the part of some mem- 
bers of the Legislature, on the ground of expense, the visiting 
physicians gave their services, and at first charitably supplied 
the medicines prescribed by them.* The insane were kept in 
cells in the basement of the building until 1796.f 
Dr. Benjamin Rush returned from his three years’ visit and 
* An Address on the Occasion of the Centennial Celebration of the Founding of 
the Pennsylvania Hospital, delivered June 10, 1851, hy Geo. B. Wood, M. D. 
f A separate building was erected and occupied in 1841, now, in many respects 
one of the finest in the world. 18 
Disease of the Mind. 
study in Europe in 1769. He began his visits to the insane 
in the hospital in 1783, treating them, in the main, with 
doses and bleedings, as he did his other patients, but still as 
sick people.* He of course knew little of exact science, and 
at that tijne nothing of the "moral treatment.” His "Dis- 
eases of the Mind,” for which we are indebted to this hospi- 
tal’s experience, is, according to Dr. Isaac Ray,f "the first of 
the kind in the English tongue, displaying thorough observa- 
tion and original thought.” Rush, the "American Sydenham,” 
is well called by Dr. Bowditch, in his centennial address at 
Philadelphia, one of the most noteworthy men of the past 
centenary, although essentially a medical-system maker. He 
soon saw the wrong of the whips and chains in use in the 
treatment of the insane in his time, and gave them up for 
other; namely, "mild and terrifying modes of punishment.” 
He thought it important, upon being called to see a patient 
suffering from mental disease, "to look him out of counte- 
nance.” He recommended low diet, consisting of vegetables 
only, bleeding, purging, emetics, blisters, salivation, dark- 
ness, cold baths, etc. Up to the time of his death, in 1813, 
there were four cells in the hospital "so formed that it was 
possible to make them dark with but little trouble.” In the 
later years of his professorship, he introduced the moral 
treatment of Pinel to some extent, and speaks of the advan- 
tages of music, employment, etc., although he did not give 
up his other remedies for the more violent cases. 
In 1773 the first state asylum in this country was established 
in Williamsburg, Virginia (including Kentucky, which was 
not made a separate State till 1792), Mr. James Galt having 
been appointed keeper, an office which he retained forty-nine 
years. The Act of the General Assembly, in 1769, stated the 
desired end to be for " effecting a cure of those whose cases 
are not become quite desperate, and for restraining others 
who may bo dangerous to society.” Dr. Sigueyra was 
appointed visiting physician when the asylum was opened. 
The first resident physician and superintendent, Dr. John M. 
Galt, Jr., was appointed in 1841. 
In 1769, Dr. Samuel Bard, in an address delivered in 
* Some Account of the Pennsylvania Hospital, Philadelphia, 1817. 
t Contributions to Mental Pathology, p. 6. Disease of the Mind. 
19 
Columbia (then King’s) College, New York, " so warmly and 
pathetically set forth” the need of a general hospital, that a 
subscription was at once set on foot, aided by friends in 
England. A building begun in 1773 was nearly destroyed 
by fire in 1775, and the war of the Revolution prevented its 
completion before 1791, when it was opened for general 
diseases. In 1797, two cases of mania were admitted, but, 
as one is reported as having died there in the same month, 
there must have been previous admissions, although there is 
no record of them. A separate hospital for the insane was 
finished in 1808, with the help of the Legislature ; and in 1821 
the still better Bloomingdale Asylum took its place.* 
The "Maryland Hospital,” the next in order, organized by 
two physicians, was established in Baltimore in 1797 for 
general diseases and insanity. It was enlarged in 1807, and 
remained a private institution until 1864. In 1828, the late 
Dr. E. S. Stenart was appointed visiting physician and pres- 
ident. Since 1836 there has been also a resident physician. 
In 1828 the hospital was organized for the exclusive treat- 
ment of the insane. 
In connection with the recent steps in England to introduce 
more refining influences in their male wards by having female 
attendants, one portion of Dr. Steuart’s work is of especial 
interest; namely, his exclusive employment of female attend- 
ants as early as 1835, even in the male wards. Rush had 
called attention in 1812 f to the fact that the insane in Java, 
who were able to do so, employed female attendants, and 
that under their "mild and soothing influence” the propor- 
tion of recoveries was large, but that treatment had not 
been adopted elsewhere. 
We began the century with four asylums, of which only 
one had been built entirely by the State. Private institu- 
tions were almost unknown, and the few that existed were 
only better than the jails and poorhouses, where many of the 
insane were kept. 
In 1813, some Friends in Philadelphia called the attention 
of their community to Tuke’s work in England, and, the next 
* History, Description and Statistics of the Bloomingdale Asylum for the Insane. 
By Pliny Earle,M. D., Physician to the Institution. 
f Medical Inquiries and Observations upon Diseases of the Mind, p. 178. 20 
Disease of the Mind. 
year, published " The Account of the Rise and Progress of 
the Asylum, with an Abridged Account of the Retreat, near 
York, in England.” After having purchased fifty-two acres 
of land at Frankford, near the city, they got money and 
began building a hospital, which w7as opened in 1817, that the 
insane might see that they were "regarded as men and 
brethren.” A resident physician was appointed, and, 
although a great deal of restraint was the rule, the patients 
did all the work on the farm. "Whether the symptoms wrere 
mild or severe, treatment the most soothing and gentle was 
uniformly extended.” In receiving patients, preference was 
given to recent cases, of which three were cured in the first 
year; there were nineteen admissions. In 1824, as some 
uneasiness was expressed lest the rule at this hospital, 
requiring security for the payment of damages done to the 
glass and furniture by the patients, should operate as a dis- 
couragement to the applications for admission, the trustees 
thought best to state that " the whole amount of charges of 
this nature against the patients, during the seven years since 
the asylum was opened, is $30.19 on account of glass broken, 
and $27.17 for damages done to furniture.” * Their example 
induced the giving up of chains, etc., at the State Asylum of 
Kentucky in 1826. 
In establishing the McLean Asylum at Somerville, adapted 
from a private residence, in 1818, f just three years after the 
opening of the Harvard Medical School in Boston, Massa- 
chusetts wTas the fifth of our States to provide for their insane. 
In their address to the public in 1814 and 1816, the trustees 
dwell on the curability of insanity and the importance of 
its proper treatment. 
The founding of this asylum marks an important era in the 
history of mental disease in this country. It established the 
character and principles of treatment which have become 
* Trustees’ Reports for 1818 and 1824. 
f Thomas Hancock left some money to the town of Boston for a small-pox hospital 
and lunatic asylum, between 1760 and 1770, and there were two more legacies in 1797 
and 1798 by Thomas Boylston and William Phillips. In 1810, Drs. Jackson and 
Warren appealed to the public so successfhlly that the Massachusetts General Hos- 
pital was chartered by the Legislature in the following year. In 1816, after the 
depression caused by the war of 1812, 1,047 persons subscribed to one or both depart- 
ments of the hospital. John McLean, by his noble donation in 1821, gave to the 
asylum his name. Disease of the Mind. 
21 
universal with us, and especially the principle of state super- 
vision. The trustees were men of broad views and high 
character. Part of them being appointed by the governor, 
the State has thus exercised constant supervision over the 
interests of the patients. In nearly sixty years, their faith- 
ful and careful weekly visits to the asylum have been only 
once omitted.* In advance of the usual practice at that 
time, too, a resident medical superintendent was appointed, 
Dr. Rufus Wyman, whose reports one need only read to 
appreciate how well he was fitted for this, a pioneer’s 
work. 
From October 1, 1818, to December 31, 1821, he reports 
121 patients discharged, of whom 32 were cured: 28 re- 
mained. In 1822, he says,f "In this part of the country the 
disease had been generally believed to be incurable ; ” " it is 
too true that such treatment [whips, chains, etc.] in time 
not long past, has been approved and often advised by medi- 
cal men. An entire revolution of opinion respecting the 
treatment of lunatics has been produced”; "kindness and 
humanity have succeeded to severity and cruelty.” The 
estimation in which the community held the asylum may be 
inferred from Dr. Wyman’s observation, that for the chronic 
insane "the establishment has been considered a comfortable 
winter residence, where the boarders would enjoy the benefits 
of apartments well warmed, well ventilated, and free from the 
dangers of fire.” 
In speaking of Dr. Wyman’s work, Dr. Bell said, in 1843, 
" To this day scarce any institution can be visited in the land 
where evidences of the operations of his mind do not present 
themselves on every hand.” 
The "Retreat” at Hartford, Conn., a corporate asylum like 
the McLean, and the State Asylum of Kentucky, were opened 
in 1824. The Kentucky Asylum was simply "for the comfort 
and safe-keeping of persons of unsound mind,” as stated in 
the Act. It was adapted from a building intended for an 
ordinary hospital (the Fayette). As the patients were put 
under the charge of a keeper, with the paraphernalia of hand- 
* History of the Massachusetts General Hospital, by Nathaniel I. Bowditch, with 
a continuation by George E. Ellis, H. D. 
t Report to the Trustees, pp. 24, 25, 27 and 28. 22 
Disease of the Mind. 
cuffs, shackles, strait-jackets,* etc., the word "comfort” in the 
Act could not have been used in its ordinary sense. There 
was no medical care until 1844, when a physician was 
appointed superintendent. 
Virginia with its second asylum, and North Carolina with 
its first, followed in 1828. In 1830, Massachusetts founded 
the Worcester Asylum "for the safe-keeping of lunatics and 
those furiously mad” in the words of the Kesolve of the 
Legislature, at last accepting the noble words of one of her 
most far-sighted legislators, the late Horace Maun, that the 
insane are the wards of the State, a principle which has 
become that on which all civilized nations now attempt to act. 
The hospital was open for patients in 1833. 
The other States of this country followed: Vermont in 
1836 ; Ohio in 1838 ; Maine in 1840; the first state asylum in 
Pennsylvania in 1841; New Hampshire, Georgia, and the 
State Asylum in Maryland in 1842 ; the first public asylum 
in New York in 1843 ; Ehode Island in 1845 ; Indiana in 1847 ; 
New Jersey, Louisiana and Illinois in 1848 ; Tennessee in 
1849 ; Missouri in 1851; California in 1853 ; Mississippi in 
1855 ; North Carolina in 1856 ; District of Columbia in 1858 ; 
Michigan in 1859; Wisconsin in 1860; Alabama, lowa and 
Texas in 1861; the first state asylum in Connecticut in 
1864 ;f Kansas in 1866 ; West Virginia in 1867 ; Minnesota in 
1870 ; Nebraska in 1871; and Oregon a few years later. The 
first asylum for the former slaves of our Southern States was 
established out of an impoverished treasury by Virginia, in 
1870, using a hospital formerly occupied by the Freedmen’s 
Bureau. It will be remembered that Virginia was the first 
of our States to build a public insane asylum. 
At the present time we have (1876) sixty-eight public 
asylums, accommodating, including those not yet occupied, 
about 30,000 patients. Dr. Conrad gives a list of nineteen 
private and corporate hospitals (not including those which are 
quite small), with a capacity for about 2,600 patients. This 
number, 32,600, is probably from one-half to three-fifths of 
our total number. There are probably considerably less than 
* Insanity in Kentucky, by Edward Jarvis, M. D.; Boston Medical and Surgical 
Journal, 1841, p. 165. 
f Previously, the state patients were at the “ Retreat ” at Hartford. On page 22, line 5, for North, read South. Disease of the Mind. 
200 in all the private asylums of the United States.* Fifty- 
five of these state asylums, accommodating 27,000 patients, 
cost $29,879,258.f 
Many of these asylums were built by the States almost 
wholly through the efforts of Miss Dix, whose philanthropic 
labors, begun a third of a century ago, have been the means 
of many great advances in the comfort of a helpless class, 
both in this country and in Europe. She visited the poor- 
houses and county jails, finding her way into hidden corners 
and tearing official tape, against obstacles which would have 
daunted a less heroic spirit; and thus thoroughly informed of 
her subject, she appealed so eloquently to our Legislatures, 
that many an asylum has been the direct work of her hand 
and brain. Her frequent visits to our institutions for the 
insane now, and her searching criticisms, constitute, of them- 
selves, a better "lunacy commission” than would be likely to 
be appointed in many of our States. 
Period of American Leadership. 
For about twenty years, represented roughly by the period 
when Dr. Bell was in charge of the McLean Asylum, and 
until about twenty years ago, this country in its state asylums 
was in advance of Europe. Dr. Browne of Edinburgh, in his 
lectures on "What Asylums Ought To Be,” said in 1837, "in 
some parts of America there appears to be an ample realiza- 
tion of all that I have wished to inculcate as necessary to 
place the lunatic in that condition which is most conducive to 
his happiness and recovery.” Writing in 1841, Dr. Edward 
Jarvis said, "most of the American asylums are doing more 
for the cure of insanity than any others in the world.” 
* It is impossible to more than guess at the number of the insane in nearly all of 
our States. By the United States census of 1870, for instance, there were 1,625 insane 
in Illinois, whereas the State Board of Charities found 2,376; and of these, only 721 
were in both lists. The United States census of 1870 makes the number of the 
insane in Massachusetts as 2,662, and the idiotic 778, whereas the state census of 
1875 makes the numbers respectively 3,637 and 1,340, which is probably not so far 
from the truth as the former number. By the census of 1860, the insane in the 
United States numbered 23,999, but Dr. Pliny Earle estimated their real number at 
40,000. By the same census, the insane in Massachusetts were stated to be 2,105, 
although Dr. Edward Jarvis had found, five years previous, that there were 2,632 
insane, and 1,087 idiots. 
f Insanity; Its Financial Relations to the States, with Statistics. By J. S, Conrad, 
M. D., Resident Physician to the Maryland Hospital for the Insane, 1876. 24 
Disease of the Mind. 
In 1838, Dr. Isaac Ray published his "Medical Jurispru- 
dence of Insanity,” a book far iu advance of Casper, Esquirol 
and Marc, and one which, after having passed through several 
editions, is still the first authority in the English language. 
It is not claiming too much for our country to say, that the 
great advance in the social position and legal status of the 
insane during the last third of a century has been due more 
to the teachings of our distinguished countryman than to any 
other one person. 
A pleasant picture of the asylum life at Somerville in 1839, 
just after Dr. Wyman’s death, is thus given by Dr. Lee, his 
successor: "The patients rise and dress about half an hour 
before breakfast, which is at sunrise iu the winter and at six 
o’clock in the summer. After breakfast they are taken out 
to walk or ride, or are engaged, as far as possible, in useful 
labor, as farming, sawing and splitting and piling wood, or 
assisting their attendants ; and a few are engaged in mechan- 
ical employment. A large number are occupied more or less 
in the amusements of bowling, quoits, throwing the ring, and 
in checkers, chess, backgammon, and other games; and in 
the interval of these amusements, reading books from the 
library, newspapers, and writing serve to fill up the time. 
After tea they are assembled iu the oval room for family 
worship, which consists in reading a chapter from the Bible, 
singing two hymns, and a prayer. . . . Our quiet and 
convalescent patients are also taken with us to church, to visit 
places of interest and amusement, are taken into our family, 
dine at our table, and sit in our parlors. . . . Personal 
restraint is iu no case made use of except with those disposed 
to tear clothing or other property, and with the vicious to 
prevent injury to themselves or others. The number is 
always small who require any personal restraint.” 
In 1841, Dr. Ray was appointed medical superintendent of 
the Maine State Asylum, at a time when Conolly had fairly 
begun his great work in England, and Miss Dix was going 
through the poorhouses, jails, etc., of this country to call 
the attention of our Legislature to the deplorable condition of 
the insane. Dr. Ray’s reports, especially that of 1844, give 
a fair view of the treatment of mental disease in our state 
asylums about that time. Disease of the Mind. 
25 
Dr. Luther Y. Bell was then superintendent at the McLean 
Asylum, Dr. Thomas S. Kirkbride at the Pennsylvania 
Hospital, Dr. Samuel B. Woodward at the Massachusetts 
Asylum in Worcester,* Dr. Pliny Earle at the Blooming- 
dale Asylum in New York, Dr. William M. Awl at the Ohio 
State Asylum, Dr. Amariah Brigham at the New York State 
Asylum, where, in 1844, he established the American Journal 
of Insanity, the first in the English language on that subject,f 
and which started with the position that insanity is purely a 
physical disease. Dr. Edward Jarvis had begun his statistical 
researches, and Dr. Samuel G. Howe was at the height of a 
career which has deservedly given him the name of the Massa- 
chusetts philanthropist. 
These were all marked men, who exercised a great in- 
fluence, and whose work has been as various as their talents. 
Dr. Bell and Dr. Woodward were men of wide general 
information, and eminently fitted for a work requiring breadth 
of grasp, keen observation, sound judgment, and independ- 
ent action. Dr. Kirkbride devoted himself to hospital 
construction with a zeal and practical sagacity which made 
the American asylums of that day absolutely without rivals. 
His work "On the Construction, Organization, and General 
Arrangement of Hospitals for the Insane ” (1854) is still 
thought by the Association of American Superintendents to 
cover the whole ground. Dr. Earle and Dr. Jarvis have 
placed our social and vital statistics of insanity on a par with 
those of any country. Dr. Awl was chiefly interested in the 
provision for the insane by the State, in which he did excellent 
work. Dr, Brigham gave his fine intellect to combating the 
old idea, then prevalent to a great extent even among doctors, 
that there can be a disease of an immaterial mind independent 
of its physical organs. Several years before (in 1832) he 
had published a treatise on the Influence of Mental Cultiva- 
tion on Health, in which he defined insanity as a disease 
*His kindly relation to his patients is illustrated by the fact that in taking the 
census of 1840, the deputy marshal says there were so many lunatics “ in the family 
of Samuel B. Woodward, in Worcester.” 
fThe Zeitschrift far Psychiatric was first published in 1845; The Annalcs 
Mcdico-Psychologiques in 1844; The Annales d’Hygicne Publique et dc Medecine 
Legale in 1829; The Quarterly Journal of Mental Disease (London) in 1852. There 
were several short-lived journals in Germany much earlier, the first in 1783. 26 
Disease of the Mind. 
"produced by morbid excitement of some portions of the 
brain.” Dr. Ray was without a rival in jurisprudence and 
the phenomena of mental disease. 
In 1844, also, three years after a similar society was formed 
in England, Dr. Awl, Dr. Kirkbride, and Dr. Woodward 
organized the Association of Medical Superintendents of 
American Institutions for the Insane; the first meeting was 
held in Philadelphia the same year.* 
Our medical treatment, too, was at least not behind the 
age. In fact, bleeding, as a remedy in insanity, was very 
uncommon in this country some time after it continued in 
general use in England. Our knowledge of hospital hygiene 
was shown by Dr. Bell’s address on that subject in 1848, 
an essay which would do credit to a much later day. Our 
"moral treatment” is testified to by the following extracts 
from reports of that time : f 
American Principles of Treatment. 
“In a word, we endeavor always to treat our patients as every 
honorable, well-bred man treats another in the common intercourse 
of society.” 
“ Generally speaking, the more they (the insane) are suffered to 
act like other men, the more they will strive to become like them.” 
“The idea of improving the mental faculties of rational people 
by confining them together in large numbers, without any means of 
bodily or mental exercise, would be not more absurd, than that of 
expecting to restore the minds of the insane by a similar treatment. 
Until recently, however, it was universally supposed, in practice at 
least, that the insane are incapable of any occupation but that of 
amusement. It was thought unsafe to trust them with edge-tools, 
and supposed that they had too little control of their delusions or 
passions to be able to work to any advantage. It was reserved for 
* History of the Association of Medical Superintendents of American Institutions 
for the Insane, by John Curwen, M. D., Secretary, 1875. 
f Probably this description of an English asylum in 1841 could not have been 
applied to any of ours at any time during the present century. Out of 530 patients, 
29 “ were wearing either hand-cuffs, leg-locks, or strait-waistcoats, exclusive of 
between 30 and 40 patients who were chained down during tbe daytime on seats 
so constructed as to answer all the purposes of water-closets, in rooms known by the 
appellation of ‘ warm-rooms ’; moreover, during the nighttime all the epileptic and 
violent patients were chained or otherwise secured in bed. It was also an established 
custom to place every case, on admission, under restraint during the nighttime for a 
longer or shorter period as might appear expedient.” (From the report of the lunatic 
asylum for the county of Lancaster for 1841.) Disease of the Mind. 
27 
oar own generation to establish the truth, that useful labor is safe, 
practicable, interesting, and remedial to a large portion of the 
insane. And why should it not be so? The most of them have 
their bodily powers unimpaired, and their minds being deranged 
only on certain subjects, mayl, feel no less interest than ever in some 
form of industry, nor less ability to engage in it personally.” 
“ Of the eighty-two patients that have been in the hospital in the 
course of the year, we find that fifty-one have worked regularly 
almost every day, and a few others have labored occasionally.” 
Dr. Isaac Day, 1841. 
“ Of all the remedies [for mental disease], none can compare 
with labor, wherein I include all useful employment. No other 
moral means is adapted to so large a proportion of the insane, and 
applicable to so many of the various forms of the disease. . . . 
In most highly excited patients the surplus nervous energy will be 
consumed, if no other way is provided, in mischief and noise ; but 
let it be expended in useful labor, and, although the work may not 
always be perfectly done, }’et the patient thinks it is, and he expe- 
riences that kind of gratification which springs from the conscious- 
ness of having done a good thing, and consequently, so far as it 
goes, is a sound and laudable feeling. This feeling the guardian of 
the insane cannot too carefully watch over and foster, for it directly 
leads to an increase of self-control and self-respect. Indeed, many 
a patient will refrain, for the first time, from destroying his clothing 
or abusing his attendants on being allowed the privilege of going 
to work. . . . Even some of the most deiqented will be found 
capable of doing something, and though it ma}T not be very profita- 
ble, yet it keeps them out of mischief, and contributes to the quiet 
of the house, . . . While writing this, there is not a single patient 
in this institution with any kind of restraint upon the person ; and 
this is often the case for many days together. Occasionally, the 
number under restraint may amount to four or five, but probably 
the number would not average more than two or three.”—Dr. 
Isaac Day, 1844. 
“ The application of the severe measures reported as discarded 
at Hanwell, never was heard of in our asylums,* and but a few 
even of the measures deemed so insignificant as to form no excep- 
tion, have ever been found necessarj' here.”t—Dr. Bell, 1840. 
“ Each year that I have passed in this extensive field has served 
to diminish my confidence in an active medical treatment of almost 
every form of disease of the mind, and to increase my reliance on 
moral means. . . . The practice of bleedings, violent purga- 
* Dr. Bell refers to our state and corporate asylums only, 
t Speaking of New England institutions after a visit to England. Disease of the Mind. 
tions, emetics, vesicatories, and derivatives, has passed away before 
the light of experience. A different and opposite mode of treat- 
ment by energetic sedatives, I am satisfied, is obnoxious to many 
objections, although far to be preferred to the last. ... A 
wise expectation and a cautious use of medical agents to meet symp- 
toms, comprise most of the aids that the pharmacopoeia is capable 
of affording. But in relation to the moral means, especially carried 
through as they can be only by the instrumentality of an appropriate 
institution, my annual experience has only exalted my confidence.” 
“ The general law, both as regards the curative treatment, or cus- 
todial comfort, is constant but varied occupation of body and mind. 
To ensure this requires every opportunity and aid of labor and 
amusement. The more perfect the system of an institution, the 
more ample will be the provision to secure these ends.”—Dr. Luther 
V. Bell, 1842. 
“ Fortunately, in this country there never have been in the insti- 
tutions any abuses, nor, under the thorough system of governmental 
inspection which all our public establishments have secured to them, 
is it scarcely possible that there ever can be any abuses in this 
regard requiring that the feelings of the community shall be propi- 
tiated by the affectation of disusing all forms of mechanical re- 
straint.”—Dr. Bell, 1843. 
Speaking of the McLean Asylum, Dr. Bell says: "For 
some years the average number of patients under the restraint 
of leathern mittens has not exceeded one per cent, [per year], 
and often week after week elapses without even a single 
instance.” 
In 1847, Dr. Bell says, "a number of mantel-pieces and 
open tiros have been arranged in the Belknap ward to the 
greatest comfort and satisfaction of its occupants.” In 
1848, he says, "personal restraint, as in some preceding 
years, has been used only in two cases, where the necessity 
could not bo avoided without risk to the patient”; in 1849, as 
in 1850, it was used in only two or three cases, and "all other 
forms of mechanical restraint [except the Wyman bed-strap] 
have been abandoned with us for a number of years, and 
with no reason thus far to regret their disuse.”* 
“ The executive officers of this institution have gradually aban- 
doned the most exceptional forms of restraint, and more rarely 
* Report for 1849, p. 19, Disease of the Mind. 
resorted to those of a milder character. They have never, how- 
ever, become proselytes to the doctrine of the absolutely entire dis- 
use of all restraining apparatus. There are exceptions to all rules 
which are not governed by the invariable law of mathematics or of 
moral right, and no argument, however subtle or specious, or, to 
appearances, however strongly based, theoretically, upon benevo- 
lence, philanthropy, kindness, and the golden rule of ‘ doing to 
others as we would, under similar circumstances, that they should 
do unto us,’ can overthrow our belief founded upon the observation 
of several years, that there are cases in which the welfare of the 
patient and the dictates of true humanity require a resort to some 
restraining means. . . . There was one period of thirteen 
months during which restraint was resorted to but in two cases in 
the men’s department. In one of these, the patient, while in a con- 
dition of typhoid delirium, wore a camisole three daj’s ; and in the 
other, the patient’s hands were similarly confined a few hours, to 
ensure the vesication of a blister.”—Dr. Earle’s report, 1848. 
With all this, the excited insane were found by a committee 
of our Legislature, in 1848, to be at the Worcester Asylum 
even in small rooms, "having the least advantages for light, 
none for ventilation, unfavorably located, dark, dreary, damp 
and uncomfortable to that extent as to aggravate rather than 
to assist the cure of the unfortunate beings placed there” ; the 
male violent insane at the McLean Asylum, then considered 
one of the best, were kept in stone cells in the cellar; and 
this simply indicates the general knowledge of the time. The 
position and condition of the more quiet of the insane in asy- 
lums were very much better, of course; but it was reserved 
for further study and experience to show that the most violent 
may be treated to a certain extent in a similar way. 
Later Progress. 
In 1863, six years before the establishment of our first 
State Board of Health, Dr. Eay published the first systematic 
treatise in the English language on mental hygiene.* How 
far the community, and indeed the medical profession, were 
from being ready for it, may be judged from the fact that in 
thirteen years the first edition has not been sold. 
In 1869, the Willard Asylum for the Chronic Insane was 
opened at Ovid, N. Y. It had long been a problem in all 
* Others had been printed under this title, but were really not such. Disease of the Mind. 
countries to provide for this large and helpless class at mod- 
erate cost; many plans and theories had been suggested ; the 
Gheel system, with all its faults, had been recommended; 
the village system of Scotland had been praised; but all 
ended in our building expensive asylums for a favored few, 
and leaving the rest of the chronic insane to lead miserable 
lives in county receptacles. In many respects, Dr. John B. 
Chapin, the medical superintendent at Willard, has succeeded 
in solving this difficult problem better than has been the 
case elsewhere. Beside his central buildings, he has three 
groups of brick cottages, each accommodating 200 patients, 
and built at a cost of $lOO,OOO each, or $5OO per patient. 
The furniture cost $B,OOO for each group. They have the 
advantage of using the common laundry, etc., and it was not 
necessary to buy land ; but these additional expenses would 
not amount to more than $5O per patient. The asylum was 
visited by the writer, December 8, 1876, and found to contain 
all that is necessary for the comfort of the patients. The 
separation of them from one another, even to this extent, had 
the effect of diminishing noise and excitement. Of course, a 
medical officer resides in the central building of each group. 
The building, "A,” was constructed for a school, but has 
been adapted to the purposes of a separate department for 
women. "B” is the workshop. The weekly cost of main- 
taining each patient is a trifle less than three dollars. The 
accompanjdng map is reproduced from Dr. Chapin’s by his 
kind permission.- 
In the same year, 1869, an important step was taken by 
Dr. John P. Gray of the New York State Asylum at Utica. 
Recognizing the great advances in knowledge, and the im- 
mense field opened in all departments by the introduction of 
the microscope, he appointed a special pathologist, Dr. Hun, 
to make investigations in the morbid anatomy of the brain. 
Dr. Gray’s example was followed the year after at Middle- 
town, Conn., in the appointment of Dr. Edward C. Seguin 
of New York as pathologist to the State Asylum. 
In 1870, upon the recommendation of the superintendent, 
Dr. Bemis, the trustees of the Worcester Asylum appointed 
a woman as assistant physician in the female department,—an 
experiment which was followed in the Maine State Asylum in WILLARD ASYLUM FOR THE INSANE. Disease of the Mind. 
31 
1873. Upon the resignations of these two ladies, a few years 
later, it was difficult to find thoroughly educated women, the 
experiment had not proved altogether satisfactory, and men 
were appointed to the vacant places. But in the future, 
when there are accomplished female physicians to fill such 
posts, as there are now in other branches of medicine, our 
State can claim to have taken the step in advance. 
Great changes have been made in old asylums ; and the 
personal comfort of the patients is more and more an object 
of solicitude from year to year. At Dr. Kirkbride’s, in Phil- 
adelphia, "during the past seven years, at one department 
(«. e., the ladies’ wing), for nine months of each year, 
there has never been a single evening in which there was not 
some form of entertainment, occupation or amusement. . . . 
A few attempts to introduce mechanical occupations among 
women have seemed to me quite successful enough to justify a 
moderate extension of them. . . . Whatever has banished a 
delusion from the mind of a patient for a single hour, has done 
a work whose value is not easily calculated.”* 
Of the Massachusetts State Asylum at Northampton, in the 
3’ear ending October, 1874, Dr. Earle reports that there were 
only twenty-one days in which there was no gathering of the 
patients in the chapel for religious exercises, recitation, etc. 
In the same year, with a daily average of 469 patients, there 
were 15,802 days’ work done by them on the farm, in the 
kitchen, in the sewing-room, and in the laundry. 
At the McLean Asylum, several carriages are kept for the 
exclusive use of the patients, and the pleasant rides and 
excursions constitute a large part of the treatment, while the 
excellent library furnishes abundant material for that kind of 
occupation. 
At Dixmont there is a book-case and library in nearly 
every gallery, and the daily gymnastic drill in a bright, 
cheerful hall, with the pretty costumes, adds an interest and 
zest to an otherwise monotonous afternoon. At this asylum, 
in 1876, with a daily average of 500 patients, there were 
70,933 walks taken; 10,157 attendances at magic-lantern 
exhibitions, 16,558 at church, 4,327 at parties, 2,972 at other 
entertainments; 2,984 rides; 3,928 calisthenic exercises [for 
* Report for 1875. 32 
Disease of the Mind. 
ladies] and 8,893 days of labor. In scientific work, full trials 
have shown " that colored light has no greater power in the 
cure of insanity than colored water in the treatment and cure 
of the diseased stomach of an inebriate.” 
At the Retreat, in Hartford, a delightful amusement-room 
is open to the patients through the day, and is often pleasantly 
filled in the evening. Within a couple of years, too, a chapel* 
has been built, through the munificence of friends of the asy- 
lum, a little way from the other buildings, and in every respect 
like those for "sane” people. The daily evening service and 
the Sunday exercises, with the walk in the open space, give the 
patients a feeling of self-respect which they cannot have when 
constantly reminded of their infirmities by guarded windows 
everywhere and other indications of their deprivation of free- 
dom. 
Present Condition. 
At the same time, in the words of one of our most distin- 
guished alienists, the general " propositions (of the American 
Association of Superintendents) in regard to the construction 
and organization of hospitals, and the general management of 
the insane (in the United States), have all, or nearly all, now 
stood the test of a quarter of a century’s trial,”f which is 
equivalent to saying that there has been little advance in that 
time. 
In construction and internal arrangement, the best Ameri- 
can hospitals for the insane are not excelled by those in 
any part of the world, with the exceptions that they usually 
have insufficient provision for the employment and occupa- 
tion of the patients; that they have no hospital-wards and 
nurses, where such patients as require them may get the 
benefit of quiet, rest, and the care and attention common in 
ordinary hospitals ; and that the restrictions upon the liberty 
of the inmates have not, in all cases diminished to corre- 
spond with our advance in knowledge and with improvements 
in other parts of the world. These defects we share with 
most of the countries on the continent of Europe. 
*This is, so far as known, the first in this country (i. e., the first like those in ordi- 
nary life) although they are not uncommon elsewhere. 
fit is interesting to compare this with the statement, in 1862, of Daracrow, the 
leader of the conservative party in Germany, that there is nothing further to be got 
in the future to improve the public institutions for the care and cure of the insane! Disease of the Mind. 
33 
In costly arrangements for " convenience of administration,” 
in the magnificence of their central or administrative buildings, 
O O 7 
and in the multiplicity of labor-saving machinery, where it is 
difficult to find enough for the patients to do, the new Amer- 
ican state hospitals for the insane are absolutely without 
rivals. 
Less than half a dozen* of our States are now providing 
properly for all their insane, the expensive buildings which 
have lately been thought necessary being absolutely beyond 
the means of many of them. 
The condition of our worst asylums may be inferred from 
the report for 1872 of one of our medical superintendents, 
who says : 
“ In the appropriate tabular statement accompanying this report, 
there are several colored people reported as having died from 
various forms of disease. To have been strictly truthful, that report 
should have read, ‘ died from want of proper accommodations ’; for I 
verily believe their lives might have been saved, if I could have had 
the proper facilities for their comfort and care at my command. 
Every one knows the inefficacy of medical attention in the treat- 
ment of diseases, where the patients are confined to such miserable 
cattle-stalls as are our colored patients.” 
In 1871, a newly appointed superintendent in Texas found 
restraint-chairs, dark rooms, iron handcuffs, locked boxes, 
and cold shower- and plunge-baths in common use. He 
thought it necessary to state his opinion " that the infliction 
of punishment for misconduct on the part of any patient is 
entirely out of place.” The records and journal were not to 
be found. 
In 1876, chains were still used in the department for the 
insane of the almshouse at Baltimore. 
*“ Of all spectacles of human misery which the light of day looks upon, we sup- 
pose that of the lunatics in American almshouses is the most pitiable. Unlike many 
sufferers under the great evils of society, they are often persons who have been in 
better circumstances, and who must, in their dim way, feel and see the abuses of 
their treatment. In the country poorhouses, they arc treated as lunatics were a 
hundred years ago in Europe. They are chained, put in cages, beaten, kept in dark 
holes, without fire, often naked, their food reached to them as to beasts, their clothes 
seldom changed, without bedding, except straw, left in their own filth, and eaten by 
parasites. This horrible treatment was (till within three years) common in many of 
our States, and is still the fact in the majority.” [The Nation, No. 560, New York, 
1876.] 34 
Disease of the Mind. 
The city insane asylums of New York and Philadelphia were 
fitly described in 1875, by a distinguished English visitor, as 
being a disgrace to our civilization.* He also found,f close 
to our largest and wealthiest city, in one ward, " a rampart of 
iron bars, strong enough to confine lions and tigers in a 
menagerie.” In some of our asylums, reputed to be among 
the best, there are still dismal corridors and gloomy wards, 
which, however, will probably be altered as fast as circum- 
stances admit. 
The Twenty Years’ Leadership. 
It is not difficult to see why our asylums for the insane were 
better than those of England for about twenty years, as men- 
tioned above.J Neither country had, in 1836, begun teaching 
medical disease clinically in the hospital and at the bedside ; 
nor was it the custom in either to make careful post-mortem 
examinations as a basis of study, as had been done for nearly 
half a century in Italy, France and Germany. Neither 
country had any association or inspecting officers (excepting 
the metropolitan district of London) to compare and report 
upon the progress of the different hospitals. 
So far we were alike. Our great advantages were two: 
(1) That the principle of supervision by the state of individual 
asylums had been adopted by us in 1818, while, throughout 
England, state supervision, although more efficient than ours, 
did not begin until 1842; and (2) that we had not a large 
number of old asylums, private and public, with traditions 
and usages of years to overcome. Everything with us was 
new, and the pauper and otherwise helpless classes were only 
beginning to accumulate. 
Modern Methods of Less Restraint. 
During the last twenty years or more, dating from the time 
when the first insane asylum was built with wooden sashes, 
large window-panes, and no iron guards, the English and 
Scotch asylums have advanced faster than any others ; so that 
* These have been improved since that time; but there are many others that are 
still worse. 
t Notes on Asylums for the Insane in America. By John Charles Bucknill, M.D., 
F. R. S., F. R. C. P. London, 1876, page 53. 
X Sec page 23. Disease of the Mind. 
35 
those people now stand at the head of the nations of the 
world in the provision which they make for the care of the 
insane. In accomplishing these desirable ends, they have 
three important advantages over us. 
Ist. There is a careful and critical examination by experts* 
of every asylum in the kingdoms at least once a year, from 
which public reports are published of the condition and prog- 
ress of the various institutions, whereby local authorities are 
forced to make adequate provision for their insane, and through 
which each superintendent may compare his work with that of 
others, and see whether he falls behindhand in the race. 
2d. Mental disease is taught clinicallyf at the bedside and 
in the sick-wards in every important medical school; careful 
post-mortem are the rule and not the excep- 
tion in their asylums, and, as a result, pathological investiga- 
tions are more common than with us. 
3d. The British Medico-Psychological Association, including 
in its ranks physicians interested in mental disease, whether 
superintendents of asylums or not, in their yearly meetings, 
bring out a broader view of the field than if participated in 
by superintendents alone. 
There are still, however, in England and Scotland, enough 
asylums which may well occupy the attention of their philan- 
thropists ; and, although there are many points in which 
we can learn from their best asylums to our advantage, Dr. 
W. Lauder Lindsay has testified,§ after a visit to this 
country, that, "so far from its being the case that we have 
to learn from the Americans in our treatment of the 
insane, I will, I think, have no difficulty in showing that in 
* These correspond to the inspecteurs des alienes dans les etablissements speciaux 
and to the inspecteurs des asiles publiques d'alienes of France. There are not yet any 
laws for the German Empire; but each state supervises its own insane, generally 
through the Provinzial-Verwaltungs-Rath, or under the direction of the Ober-Prctsident 
of the Verwaltungs Commission. 
fln 1837, Dr. Browne’s work, already referred to, called attention to the want of 
clinical instruction in mental disease, and it was then begun almost at once. 
+The commissioners say, in their twenty-fourth report; “With the all-important 
view of advancing the knowledge of the pathology and treatment of the various 
forms of insanity, we think that the practice of making post-mortem examinations 
should, as far as possible, be everywhere the rule, and not, as in many instances, the 
exception. It ought also, in our opinion, to be applicable, under the same conditions 
of consent on the part of the relatives, to all classes of patients.” The proportion of 
such examinations to the deaths rose from 40 per cent, in 1869 to 61 per cent, in 1873. 
§ Edinburgh Medical Journal, December, 1870. 36 
Disease of the Mind. 
not a few important respects, they are decidedly (to use one 
of their own characteristic expressions) 'ahead.’” 
There were in England in January, 1874,— 
72 pauper insane asylums, averaging .... 456 patients each. 
5 asylums for the better classes, containing over . 200 “ “ 
4 “ “ “ “ “ from 150 to 200 “ “ 
7 “ “ “ “ “ “ 100 to 150 
7 “ “ “ “ “ “ 75 to 100 “ “ 
9 “ “ “ “ “ “ 60 to 76 “ “ 
29 “ “ “ “ “ “ 25 to 50 “ “ 
80 “ “ “ “ “ less than 25 “ “ 
One of the most striking of the changes* brought about, or 
rather commenced, is the individualizing of treatment and the 
separating of patients as much as possible from morbid 
influences, by the increase in the number of small asylums,— 
a very wide departure having been made from the position 
taken by Dr. Bell a third of a century ago, that " experience 
shows that the very highest curative advantages are effected 
by the mutual action and attrition of diseased minds upon 
each other,”—a point upon which Griesinger says,f "Nowhere 
is there greater need of strictly individual treatment than 
with the insane; nowhere must we more constantly bear in 
mind the fact that not a disease, but a diseased individual, not 
insanity, but one who has become insane, is the object of our 
treatment”; and Roller, when speaking of those suffering 
from mental disease, states the principle more forcibly still: 
" JSfur von unkundigen wird es bestritten dass das zusammensein 
mit andern kranken \ die Heilung befordert” (only the ill- 
informed contend that congregation with others favors re- 
covery)^ 
A few of the asylums in England, of which Bethlehem 
was, I think, the first, have imitated the example of the 
* These will he illustrated chiefly by letters which explain themselves. Some of the 
best asylums, with their advantages in employment, personal freedom, etc., of the 
patients, have been described by Dr. H. B. Wilbur, superintendent of the Idiot 
School at Syracuse, who visited Europe by request of Gov. Tilden of New York in 
1875, in an interesting treatise on The Management of the Insane in Great Britain, 
Albany, 1876. 
fDie Pathologie und Therapie der psychischen Krankheiten, Vierte Auflage, 
Braunschweig, 1876, pp. 472 and 473. 
j This word kranken (the sick) is very commonly used now by German writers in 
referring to the insane. 
$ Op. cit. p. 4. Disease of the Mind. 
37 
metropolitan hospitals in establishing summer resorts and con- 
valescent homes for their more quiet patients, so as to get 
them away from the asylum influences, and with the best 
results. 
In Scotland,* there were in 1874, 8,069 insane under the 
care of the commissioners. In 1858, there were estimated to 
be 2,000 beside those known officially; but their present 
number, which does not appear in the reports, is probably not 
so great. Of these 8,069, 4,717 were in seventeen royal and 
district asylums, 338 in eight private asylums, 748 in six 
parochial asylums, 565 in fifteen workhouses, and 1,650 in 
private dwellings f and training schools. 
About four-fifths of those under the care of the officials, and 
known to them, about 70 per cent, of the whole number, 
were therefore in asylums and workhouses. 
According to the statistics and estimates of our Board of 
State Charities, about 60 per cent, of all the insane in Massa- 
chusetts are in public institutions, the preference being given 
to the severer cases; so that the average degree of severity 
of disease in our asylums, as compared with those of Scot- 
land, may be roughly estimated as 70 to 60 or as 7 to 6, not 
allowing for any difference arising from nationality or char- 
acter of disease, if there be such. 
Opinions and Letters 
Dr. Bucknill, after his long visit to this country, writes to 
Dr. Edward Jarvis, October 31, 1875 : "You have no idea in 
the States of the amount of freedom, under due supervision, 
which our lunatics get; and it is constantly being increased, 
* There has been little that is distinctive in the early history of the treatment of 
insanity in that country. The Scotch laws placed the rich insane in the hands of 
guardians as early as the thirteenth century; in modern times they have rather fol- 
lowed the precedent of England. The Commission in Lunacy was appointed in 1855. 
fit would carry us beyond our limits to fully describe this system of boarding out 
the insane in families in the villages of Scotland. It is done at a cheap rate, and the 
patients are reported, many of them, at least, as liking it better than asylum life. 
But any one who has endeavored to find a boarding-place for a single one of them can 
appreciate the difficulty, and often impossibility, of finding in this country suitable 
persons who are willing to undertake such care and responsibility for strangers. 
There is an objection, too, in placing a dependent class in the charge of such persons 
as are willing to take them. The best account of this Scotch system, “ Other famil- 
iale irrenpflege in Schottland,” may be found in the Archiv f. Psychiatric und Ner- 
venkrankheiten, Vol. Y., 1875, pp. 164-188. It has been said in England that these 
insane boarders are not always adequately looked after. 38 
Disease of the Mind. 
and with the best results. We are now pretty well rid of the 
old superstitious fear of the insane; and, where the bounds of 
insanity have been so much enlarged, it was time that this 
should be so.” 
Dr. Tuke and Dr. Fraser. 
One of the most interesting experiments has been made by 
Dr. Batty Tuke, and carried out by his successor, Dr. Fraser, 
whose letter, originally published in the Boston Medical and 
Surgical Journal, is so full of suggestive matter that a con- 
siderable part of it is given here. It should be said that the 
asylum is quite in the country, and that the patients are mostly 
of the quiet, agricultural class. Herbert Spencer considers 
this one of the most important steps of the day in the treat- 
ment of mental disease. Undoubtedly it is such; but it 
would not be fair to infer that all asylums and all the insane 
in all places can be treated in this way. 
Some of the windows open freely, others are so arranged 
that neither sash can be lowered or raised enough to permit 
the egress of a patient. The separate wards of the main 
building are semi-detached and of only two stories each. If 
Dr. Fraser had described his autopsy- and microscope-rooms, 
it would have been seen that he considers careful pathological 
research of the utmost importance. 
The cost of this asylum, without furniture, was a little less 
than seven hundred dollars per patient. 
“Fife and Kinross District Lunatic Asylum, ) 
“ Cupar, Fife, Scotland, January 28, 1875. £ 
“My Dear Sir :—I have the greatest possible pleasure in acced- 
ing to your request for a description of mjr asylum. 
“It is the district or pauper asylum for the counties of Fife and 
Kinross. The population of the two counties is one hundred and 
seventy thousand. The institution is capable of holding two hun- 
dred and eighty inmates. The present numbers are one hundred 
and ten males and one hundred and thirty-eight females, or about 
two hundred and fifty altogether. The yearly admissions are from 
eighty to ninety. There is one attendent for every twelve patients. 
The patients are classified, and each class has its own gallery; the 
highest number in any gallery is twenty-four ; the lowest, twelve. The 
female department has seven galleries, each complete in itself; that Disease of the Mind. 
39 
is to sa3r, each of them has its own day-room, dormitory or dormi- 
tories, single sleeping-rooms, lavaUny and conveniences. Four 
have two attendants, two only one. This divisional arrangement, 
though I believe it adds to the working expenses, admits, as I have 
said above, of classification of the patients. The day-rooms or 
sitting-rooms for twenty-three patients are thirty feet long, twenty- 
one feet broad, and eleven and a half feet high. The windows of 
these rooms are nine feet by seven feet, and the panes are twenty- 
two inches by eighteen. There are no window-panes smaller than 
twelve inches by ten and a half anywhere. The lower half of the 
windows has brass rods three-eighths of an inch thick running trans- 
versely across the panes and through the woodwork of the window- 
frame. I could wrench these rods out with my hands. There is no 
such thing as an iron bar across a window, and all our window- 
frames are of wood. 
“You ask me for the features which distinguish my asylum. I 
believe these to be: Ist, unlocked doors ; 2d, the great amount of 
general freedom ; and 3d, the large number on parole. In common 
with the Argyllshire asylum, airing-courts are not in use. The 
great attention given to the occupation of the patients and the large 
percentage of those employed are characteristics of this asylum as 
well as of two others in Scotland. 
“ First, as regards open doors. Here is a paragraph from my last 
annual report to the directors : 
“ ‘ I wish now to describe the peculiar feature of }'Our asylum ; 
namely, the open-door system. It was originated about three years 
ago by your former physician-superintendent, Dr. Tuke, and I have 
no hesitation in saying that the introduction of this system will 
mark an era in the history of the treatment of the insane. As you 
are well aware, there are no high boundary walls surrounding the 
grounds, and the entrance gates stand always open. To make this 
system as clear as possible, let me suppose that a visitor calls and 
wishes to see through the asylum. He is received at the front 
door, which will be found open; he is then conducted through the 
whole of the male galleries, containing over ninety patients, and 
thence, via the dining-hall, through five of the galleries in the female 
side, also containing over ninety patients, without once coming upon 
a locked door. Not only is there this free communication inside 
the house, but the outer doors of the main ground corridors, which 
open out on the terraces, are also unlocked. The male convalescent 
building, which contains from twenty to twenty-five patients, has its 
doors open from shortly after six a. m. till eight p. m. The inmates 
are, of course, on parole. Two galleries in the female department 
still remain under the old system of locked doors. Though not 40 
Disease of the Mind. 
necessary for the majority of their inmates, yet the erratic and mis- 
chievous tendencies, as well as the excitement of some three or more 
in each division, render locked doors necessary. Greater content- 
ment is, I believe, the result of the innovation I have just referred 
to; the sense of confinement, or in other words, of imprisonment, 
of which even a lunatic is conscious, is absent. The asylum is con- 
verted into a home and a hospital. A greater number of escapes 
and accidents would a 'priori be expected from this state of freedom. 
The escapes have been nine in number, and there are only two which 
can be attributed to open doors. Four accidents, none of any im- 
port, except the suicide previously detailed, have occurred during 
the year, but none in any way attributable to this s}Tstem.’ 
“ This bold advancement in the treatment of the insane, is, as I 
have said above, wholly due to Dr. Batty Tuke. It is to his orig- 
inal mind, to his enterprising spirit, to his confidence in a portion of 
afflicted humanity hitherto unconfided in, and to his faith in the 
adage, ‘ The more }rou trust, the more you may,’ that this new era in 
the life of the insane has been initiated. I must confess I shook 
my head when the doctor first proposed it, and our matron said she 
could not see ‘ how it would do at all.’ 
“ The history of this movement is interesting. At first a great 
deal of wandering about the house occurred, especially from the 
galleries to the kitchen. A number wandered outside, and some of 
course attempted escape. Gradually the patients were taught when 
they were to go out, and what parts of the house they were per- 
mitted to visit. Those who escaped were spoken to in presence of 
the others: they were informed of the inutility of escaping, of the 
certainty of their being brought back ; that they must remain in 
the asylum until they were better; that every kindness would be 
shown them; that everything they had to say would be heard and 
attended to; that when the time came they would go out by the 
front door, and that the doctor would be there to say good-by and 
wish them well. It was wonderful how the most determined bolters 
ceased from attempting to escape. I could quote a dozen cases 
where a remarkable change in this respect occurred. The most 
intelligent escapers were taken to the doors, shown their openness, 
and then informed that confidence was reposed in them, that escape 
was unproductive of any good, and that the way to get home was 
to show themselves worthy of trust. Not only with permanent 
residents did this state of imposed confidence have a beneficial 
effect, but also with transfers from other asylums. For example, a 
lady patient was admitted some time ago from another asylum. 
The account sent was that she was most determined in her attempts 
at escape, that she had broken the framework of her window and Disease of the Mind. 
41 
set fire to doors in order to escape. Her habits were said to be 
dirty. It was a case of moral insanity, and the intelligence was 
keen and clear. After admission, she was shown the open doors 
(one leading out to the terrace within ten yards of her sitting-room), 
and the freedom that existed. Confidence was preached to her, and 
she was informed that good behavior of every kind was expected of 
her. She now walks out daily on the terraces, unattended, when- 
ever she likes, yet there has never been the least attempt at escape. 
She has never been dirty in her habits. This patient has been in 
three other Scotch asylums, and she says that this is not like an 
asylum at all, that it is unlike any of the others she has been in, 
and that here she has no desire to run away. 
“ Your experience of the insane will cause you no doubt to say, 
4 But all cannot be treated in this wise.’ I grant that, but what I 
wish to impress upon }ou is the great number that can. You will 
see I have two departments on the female side under the old regime. 
An attempt was made to leave one of these off the lock, but the 
mischievous doings of three chronic maniacs, and the incurable 
wanderings of two or three demented and suicidal patients, pre- 
vented the open door from being persevered in. Excepting these, 
the rest, numbering from one to eighteen, wmuld be all the better for 
the unlocked doors. The other department is one of our new 
buildings, and is separate. From its situation and its inhabitants, 
chiefly chronic maniacs, it would be inexpedient to attempt the step 
there. 
“ I wish especially to describe our male convalescent building. 
It is a house capable of holding thirty-three patients, but at present 
there are only twenty-two resident there. Its doors are open every 
day.from seven in the morning till eight and nine in the evening. 
The inmates are all on parole. No one has broken his parole dur- 
ing the last two and a half years. An attendant and his wife have 
charge of the place. They have a little child five years of age. 
They all sit down to meals together, the patients, the attendant, his 
wife and child. The latter two mix with the patients at all times. 
This was also a step of Dr. Tuke’s, and admirable have been the 
results. When men associate only with each other, they are apt to 
degenerate; coarseness, swearing, and fighting predominate; but 
when a woman is present, and especially when a sweet little girl 
mingles with them, then swearing and angry passions cease ; at 
least such has been the effect in this department of my asylum. 
There are two dormitories upstairs, one in which no attendant 
sleeps (ten patients are left to themselves), and the other is in 
charge of an attendant who comes down from the main building fur 
the night. This place is our Gheel. 42 
Disease of the Mind. 
“ I believe that the conditions above described, coupled with con- 
stant occupation, result in (1) greater contentment and general 
happiness among the patients, (2) better conduct in every one, i. e., 
less excitement, (3) the preservation of the individuality of each 
patient, (4) less degradation, and (5) greater vigilance and care on 
the part of the attendants. As regards the fourth result, I believe 
it to be strikingly true. 
“ Occupation is what I have the utmost confidence in. Its results 
are most beneficial. Almost every male patient can fill and wheel 
a barrow, and the majority can use a spade. So almost every 
female patient can use a needle and thread or a knitting-needle. 
Constant supervision soon teaches one what is most suitable to each. 
I beg to refer you to Sir James Coxe’s report, which you will find in 
the annual report which accompanies this letter. Here is another 
paragraph from my last annual report: ‘ Attention is being con- 
stantly and increasingly directed toward the occupation of both 
sexes. At the present date, all male patients, with the exception 
of from five to eight, are sent out every day in parties arranged 
according to their capabilities for work. Attendants accompany 
each set of workers. The head and sick-room attendants are the 
only ones retained in the house. On the female side there are three 
workrooms, one devoted to the main sewing requirements of the 
house, and the others to the teaching and encouraging to work of 
the idle and demented. In these three rooms are above ninety 
patients. The laundry, the kitchen, and the house generally give 
employment to about forty more, so that the actually idle are 
reduced to a minimum. My desire and aim are to make your asylum 
a veritable beehive. The men work both forenoon and afternoon, 
but their hours are not long. The females, though kept at work in 
the forenoon, spend the afternoon in walking and out-door recrea- 
tion. lam at present dispensing with the use of airing-courts, but 
I shall make no comments on this step until after a year’s experi- 
ence.’ 
“ Airing-courts are a mistake, especially for females. Not long 
ago I used to send out the demented, the chronic maniacs, and the 
idle to the airing-court of a morning. Of course, having nothing 
useful to do there, they did mischief, quarrelling among themselves, 
getting excited, and increasing their destructive habits. The pa- 
tients being safe within four walls, and out of sight, the atteujdanls 
were heedless, habits and pi’actices occurred which the attendants, 
for the sake of decency and for the respect of their sex, would have 
been active and vigilant to prevent elsewhere. Those who used to 
go to the airing-court in the morning are now collected around 
tables and set to work at knitting, sewing, darning, etc. The Disease of the Mind. 
contrast between the airing-court and this room is very striking. 
This very morning this workroom was quiet in the extreme. I 
went round them all, spoke to each, praised their doings, and en- 
couraged the idle, and there was not a word out of place. Had 
they been in the airing-court they would have been squatting in all 
the corners, rampaging about, holding forth in loud tones, etc. 
Occupation and the working together in the way described have a 
most decided inhibitory effect. The airing-court system permits 
every insane propensity to run to weeds. 
“ During the present year there have been two or three cases 
subject to paroxysms of great excitement, I have occasionally 
been present in the galleries when such outbursts have occurred, and 
have been witness of how the peace, quietude, and industry of the 
other inmates have been disturbed, and the excitable roused. Great 
destructive propensity is generally a feature of these attacks. In 
such cases, one of two things must be done : the patient must either 
be restrained by two or more attendants (the worst form of re- 
straint), or put into seclusion. The former plan cannot be carried 
out where there is a minimum staff, but even had I sufficient at my 
command, I believe seclusion to be the more beneficial mode of 
treatment in every way. There are cases,—at least this asylum 
possesses such,—in which great coarseness of language charac- 
terizes the paroxysms; and I maintain that such cases, in con- 
sideration of the feelings of the other inmates and attendants, 
demand their temporary seclusion. Constant supervision of the 
galleries has determined me in this opinion. Restraint I have 
not resorted to. 
“ As regards the chronic harmless insane, I here subjoin another 
extract from my report: ‘ltis my opinion that many chronic luna- 
tics do not require asylum treatment; they can be sufficiently cared 
for and guarded by their friends or others whom the proper authori- 
ties deem fit custodians. The chronic lunatic I refer to is one who 
is harmless, trained to be cleanly, and perhaps industrious, whose 
mental condition may be described as that of a premature second 
childhood, and of whose recovery no hope can be entertained. 
Such an one does not require constant medical supervision, the ex- 
pensive appurtenances of an asylum, nor the services of trained 
attendants. 
“ Dr. Arthur Mitchell’s book on the insane in private dwellings 
will give you a most graphic account of what formerly existed and 
what exists at the present day. 
“ I trust the foregoing remarks convey the information you de- 
sire, and I shall be only too happy to answer any further inquiries 
you may wish to make. If any of my professional brethren on 44 
Disease of the Mind. 
your side of the water desire to see this asylum, thejT will find me a 
most willing cicerone. 
“ With best regards, I am, dear sir, 
“ Yours most truly, 
“John Eraser. 
“ Dr. Charles F. Folsom, Boston.” 
Dr. Clouston. 
Dr. Clouston, well known in this country as the successor 
of Dr. Skae at the Royal Edinburgh Asylum, formerly medi- 
cal superintendent of the Cumberland and Westmoreland 
asylum, and co-editor with Dr. Maudsley of the Journal of 
Mental Science, has begun an interesting work at Morning- 
side, a description of which is best given in his own words. 
In 1874, he wrote as follows : 
“ Memoranda as to the Treatment of Insanity, etc., in the Royal 
Edinburgh Asylum, Morningside, Edinburgh, by T. S. Clouston, 
M. D., Physician Superintendent. 
“ I have been now for fourteen years engaged in this department 
of the profession, and have paid much attention to the various 
modes of treating the insane in this and other countries. 
“ My practice in regard to patients, especially of the higher class, 
is to allow them from the first, as much liberty as I possibly can, 
putting many of them on parole very soon, and trying to make 
them feel that they are here really as invalids and not as prisoners. 
Unquestionably, in those cases where I can thus trust patients, they 
are happier and recover sooner than they otherwise would. Of 
course, in some cases I cannot do so. Out of 77 patients of the 
higher class, over 30 are on parole, 22 of them living in cottages or 
pavilions where the arrangements are perfectly homelike. 
“ Throughout the whole department for the higher class lam 
substituting large plate-glass for small squares in the windows, and 
am trying to remove all prison-like arrangements. So far as we 
have gone yet, in the eighteen months since I came here, the effects 
have been very good indeed on the patients, and we have had no 
accidents. 
“ I send a short description of the cottages, with photographs. 
The main part of the house consists of three wards for gentlemen 
and three for ladies, with a few private rooms and parlors. Each 
ward contains about eight patients, and in some cases two, and in 
the case of one ward one, attendant. There is a parlor or corridor 
open and lighted on one side, and with a row of bedrooms on the Disease of the Mind. 
other. We are building two new dining-rooms, chiefly of glass, to 
look like conservatories, one for the gentlemen and one for the 
ladies, and we have already one very handsome dining-room for 
gentlemen who pay over £lO5 a year. There is a large drawing-room 
where the ladies and gentlemen meet in the morning for prayers, 
and in the evenings twice a week for cards, readings, dancing, etc. 
The gentlemen have a billiard-room. All these public rooms are 
precisely like those of a good house in their arrangements, the 
doors opening the same way, etc. 
“ As much as is practicable, I send my patients to walk and drive 
out be}Tond the asylum grounds, to town, to the museums, picture 
galleries, etc. 
“ Believing that the first object of the institution is to cure as 
many of the patients sent to it as possible, and to enable those who 
are incurable to lead as happy lives as possible, I deliberately run 
risks as to escapes, and even in some cases of mild melancholia as 
to suicides, with those objects. It is quite easy to arrange an 
asylum so that no escapes shall take place from it, but any such 
institution I should pronounce to be radically faulty in its prin- 
ciples. 
“ In the treatment of every case, it is of the utmost importance 
to find out whether the tendencies of the patient result from an 
incurable pathological condition of the brain, or from a curable dis- 
order in its working. I should not put a general paralytic or a bad 
epileptic on parole nearly so readily as a simple case of excitement 
or depression, though I have now mild cases of the two former 
diseases on parole. 
“ I do not believe that ‘ non-restraint ’ should be so elevated into 
a ‘ principle.’ that no departure from it is allowable. Diminish 
restraint and seclusion by all means to the utmost, but don’t sacri- 
fice a. patient’s life, or the lives of those about him, to any such 
principle. In practice, 1 have only used restraint once at night in 
the case of one patient, for suicidal tendencies of the most aggra- 
vated kind, and seclusion twice in a year and a half among my 
higher-class patients. I use seclusion rather more frequently among 
the pauper class of patients, from having fewer attendants in pro- 
portion to the number of patients. 
“ We take in all cases that apply when we have room. 
“ There are much fewer windows broken now than when the panes 
of glass were small and guarded by iron bars, and I think there is 
an improvement in regard to degradation and dirty habits in many 
of the worst class of patients. 
“ For painting, decoration and papering in the institution, I 
employ the best and most tasteful tradesmen in Edinburgh. 46 
Disease of the Mind. 
44 Description of the Photographs of the Cottages, etc., Royal Edin- 
burgh Asylum, Morning side, Edinburgh. 
“ No. 1* is the ladies’ 4 wing’ or pavilion, connected to the main 
part of the 4 East House ’ by a row of sleeping-rooms and passage. 
The 4 East House ’ is exclusively for private patients who pay the 
higher rates of board, and there is a corresponding wing for gentle- 
men. The wings contain eight rooms each, and usually accommo- 
date six patients. The gentlemen’s wing has a billiard-room behind 
it. The arrangements of the wings are precisely similar to those of 
private houses, the doors being unlocked, opening by their handles, 
the outer doors (glass) open, and all the windows consisting of 
large sheets of plate-glass. The patients in the wings form groups 
separate from the rest of the house. 
44 No. 2, 4 The Cottage,’ for ladies, containing eight rooms, and 
usually accommodating four or five patients. It has a dining- 
room, drawing-room and bedrooms. All the arrangements are 
those of a private house, unlocked doors, plate-glass windows, etc. 
The cottage is situated about twenty yards from the asylum. 
44 No. 3, 4 Myreside Cottage,’ for gentlemen, containing eight 
rooms, and accommodating five gentlemen, two attendants, a cook 
and an assistant cook, w7ho is an unpaid pauper patient. It is 
situated at the extremity of the Royal Edinburgh Asylum Farm, 
about a quarter of a mile from the asylum. Its arrangements have 
nothing supposed to be asylum-like about them. 
44 Altogether in these four buildings there are twenty-two patients 
out of the entire number of seventy-seven high-class patients in the 
asylum.” 
Two years later, Dr. Clouston writes as follows : 
“ Royal Edinburgh Asylum toe. the Insane, ) 
“Edinburgh, 28th Nov., 1876. ) 
“ Dr. Folsom. 
“ My Dear Doctor :—I duly received yours of the 13th, and I 
assure you I am only too glad to answer any questions you put. 
“As regards, any plate-glass experiments now universal in our 
East House for higher-class patients (containing ninety-two patients), 
I have the greatest reason to be satisfied with them. Only one pane 
of glass has been broken in the two and one-half years they have been 
in, and that by an attendant in cleaning it. To show that I believe 
in them, I may mention that in some cottage additions which we 
have lately built and occupied for twenty-four patients, there is 
nothing but plate-glass, each pane filling up a sash, and that the 
* Not shown in this place. Ut’lioty/'t' 
M i u esijj£ Lari a *JM- 
James R. Osgood Co. c* 
The Cottage. ManWAr;.sv/>k. 
«<) 
>S 
I 
§ 
? 
(> 
V Disease of the Mind. 
47 
outer doors have all plate-glass panels, and that each parlor has 
such a door opening into the garden. 
“ I have followed some of my Scotch brethren, too, and have done 
away with airing-courts, so that now we have absolutely no such 
walled court of any kind at our East House or at the male division 
of the West House (these two containing four hundred patients). 
I am sure the general result has been very beneficial, though, in a 
few individual cases, we miss the courts. 
“ As regards plate-glass windows in the West House, we have 
fairly begun the experiment, having fitted up three galleries, con- 
taining one hundred and forty patients, with them, one gallery being 
on the ground floor, the next on the second, and the next on the 
third floor. They are immensely more cheerful, and no bad results 
have followed during the three months they have been in. 
“ I think in our asylums here we have too few attendants for our 
patients to individualize them properly, so I am gradually increasing 
our staff. We ought to have one attendant to eight for pauper 
patients and one to three* for private patients, in my opinion, to 
do them full justice. lam carrying out this without reference to 
the plate-glass windows or open doors in some wards, etc., but in 
accordance with what I think is required for proper treatment. 
“The question that is bothering us most here now is that of dis- 
posing of our chronic, harmless cases. 
“ I am very7 truly yours, 
“ T. S. Clouston.” 
In Dr. Clouston’s East House, the same class of patients and 
the same character of disease are treated as in our corporate 
asylums. The West House is for non-paying patients. 
It cannot be said that Dr. Clouston has a mild form of dis- 
ease to treat; for, by his last report, it may be seen that, of 
310 patients admitted in 1875, 60 had attempted and 31 
others had meditated attempting suicide. Dr. Butler, for- 
merly superintendent at the Retreat in Hartford, thought, 
after visiting Europe, that the form and degree of severity of 
insanity in the Scotch and in New Englanders are about the 
same, although milder in the English. 
Sir James Ooxe. 
The following letter from Sir James Coxe of the Lunacy 
Commission of Scotland, gives a fair idea of the general treat- 
ment of the insane at the present time in Scotland : 
* This is about the proportion at the McLean Asylum. 48 
Disease of the Mind. 
“ General Board of Lunacy, 5 
“ Edinburgh, January 20, 1875. ) 
“ Dear Sib :—I have the honor to acknowledge receipt of 3rour 
communication of the 4th inst., requesting information on certain 
points in connection with the management of the insane in Scot- 
land. 
“ I have much pleasure in replying to your questions, which I 
shall do in the order you put them. 
“ It is the desire of the board of lunacy, that individual asylums 
shall not accommodate more than 300 patients. It is however im- 
possible to keep them within this limit, as they are built for dis- 
tricts and must be enlarged when demands are made for increased 
accommodation. At present three of the district asylums are built 
for less than 100 patients ; others accommodate from 200 to 300, 
and others again exceed 300. The older asylums, which were 
erected from legacies and charitable contributions, and which also 
serve the purpose of district asylums without being under the 
management of district boards, accommodate from 500 to 800 
patients. 
“ In none of the newer asylums are the windows fitted with bars ; 
on the contrary, the window-sashes are of the ordinary construc- 
tion, the frames being of wood and the panes frequently so large as 
to permit readily of the passage of the body of a patient. The 
only precaution taken is to restrict the opening capacity of the sash 
to a space of about 5 or 6 inches, and, when the panes are of un- 
usual size, to pass a brass rod through the astragals on the inner 
face of the glass. 
“ The commissioners look upon asylums merely as convenient 
arrangements for the disposal of patients. They attach no thera- 
peutic value to the agglomeration of the insane ; and, apart from 
the question of economy, would prefer to see them accommodated 
in groups of such a size as would ensure every patient being- 
individualized. 
“ It is the object of the commissioners to facilitate the removal 
of harmless and incurable patients from asylums and to dispose of 
them in private dwellings. Curative treatment in private dwellings 
they regard as surrounded by too many difficulties to receive official 
countenance. As a rule, the chronic patients removed from asylums 
are not concentrated in special villages, but are sent home to their 
parishes to live with friends. Occasionally, however, urban par- 
ishes, such as those of Edinburgh and Glasgow, resort to the prac- 
tice of placing their incurable patients in certain villages and 
communities of 10 to 50. This practice, however, arises simply Helioty/>i\ 
Montrose Asylum. 
James R. Osgood <V Co. Disease of the Mind. 
49 
from the difficulty of procuring suitable accommodation in towns. 
It has been found to give satisfactory results. Not more than four 
patients are allowed to be received into an}r one house, but the 
actual number rarely exceeds one or two. 
“ There is a growing difficulty in procuring and retaining the ser- 
vices of trustworthy persons of either sex as attendants, a diffi- 
culty which is owing to the increased facilities which the prosperous 
condition of the country affords in obtaining employment in almost 
every capacity. 
“ Our experience is, that in proportion as the restrictions on 
liberty are relaxed, the more easy does the management of asylums 
become. A movement to abolish walled airing-courts 'has already 
acquired considerable development, and, in addition to this, the 
experiment is being tried of doing away altogether with locked 
doors, except in one limited portion of the establishment. 
“ As a rule, mechanical restraint is entirely abolished in Scotch 
asvlums, except in the department of criminal lunatics in the 
central prison at Perth, where one or two patients are generally 
found with one or both hands restrained as a protection against im- 
pulsive violence. Occasionally, in ordinary asylums, a patient may 
be found wearing a strait-waistcoat to guard against sudden out- 
bursts of violence, or to prevent his injuring himself, but, as a rule, 
mechanical restraint will not be met with in more than one or two 
instances in making the whole round of our asylums. 
“ Trusting you will find that my answers to the questions you 
have asked will give you the desired information, 
“ I am, my dear sir, 
“ Yours very truly, 
« j)r Chas. F. Folsom, Sec’y of the State Board of Health, Boston, Mass,” 
“ James Coxb. 
The accompanying photograph of a portion of the Montrose 
Asylum, gives a fair idea of some of the later accommodations 
for the more quiet of the insane who pay either nothing or 
low rates of board. 
Dr. Rogers. 
The next two letters, from a physician of large experience 
and eminence in the treatment of mental disease, sufficiently 
explain themselves. 
“ County Asylum, > 
“ Rainhill near Prescot, January 18, 1875. \ 
“My Dear Sir :—This asylum, as originally built, was in blocks, 
three on each side, connected with covered passages, two wards in Disease of the Mind. 
each block, one above the other, and the largest ward only having 
capacity for 34 patients. With the great demand for increased 
accommodation, two new blocks were built, three stories high, hav- 
ing bedrooms on first and second floors and none on the ground 
floor. These blocks contain 124 patients each. 
“ It is obvious that the same amount of supervision and of indi- 
vidual attention cannot be bestowed on each patient in these large 
wards as in the smaller ones, and therefore they are only advanta- 
geous where a large proportion of the patients are chronic cases 
and fairly tranquil and orderly. 
“ A similar arrangement of large sleeping-rooms has been made 
over the laundry, but this is objectionable, in my opinion, and 
I would prefer that the laundry should be untenanted, except during 
the daytime. 
“ There never were bars to our windows, which are all of the 
same size, both for the quieter wards and those for the worst class 
of patients. Locked fire-guards were originally in use, but these 
have been removed for twenty years. A former superintendent 
even had all the Venetian blinds removed from the windows, but I 
have replaced of these for convenience and comfort’s sake. 
“ With regard to the number of windows broken, this depends a 
great deal on the propensities of individual patients. With some, 
the propensity is only transitory ; with others, permanent. I have 
now an inveterate window breaker—a woman. The moment any- 
thing occurs in the ward to call off the attendant’s attention, she 
takes the opportunity to break as many windows as she can ; in 
one month she broke 80. Her object is to get put in seclusion, 
where she is happy. I should not think of using restraint in this 
case, as a principle, if it be worth anything, is worth more than a 
few panes of glass; besides, the tendency to window-breaking is 
due to some condition of health which may be improved 
by treatment—most frequently a weak state of health with excite- 
ment. This is not so in the case quoted, who, although a phthisi- 
cal patient, is at present in very good health. 
“ I am decidedly of opinion that the use of restraint tends to 
confirm and strengthen degraded and animal instincts, and that 
treating the insane as rational beings has the tendency to develop 
self-restraint and decency. 
“ That this result is often very long in being produced, and that 
in some patients never is produced, is no argument against the gen- 
eral rule, and I hold most decidedly the opinion that there are no 
patients so degraded in habits but that are susceptible of 
humanizing influences, provided there is no progressively active 
brain disease present. Disease of the Mind. 
51 
“ I might add a few wrords on the subject of attendants. This is 
a fruitful source of complaint amongst English physicians and 
superintendents, and of late I have found the difficulty of securing 
and retaining the services of good attendants greater than ever 
before. 
“ I attribute this parti}’ to the hostile feeling which exists, and 
which constantly tends to break out amongst the superficially edu- 
cated, on the subject of asylum management, which was illustrated by 
sensational articles in many of the public papers (medical included) 
a few years ago. These had, as it appears to me, the effect of 
making present attendants shirk their responsibility and seek their 
own interests rather than that of their patients, and of preventing 
eligible men and women from undertaking an employment which 
was so calumniated. The great increase of wages throughout this 
country has, of course, also tended to make employment more easily 
obtained, as well as the shortening of the hours of labor to contrast 
unfavorably with the hours of an attendant’s duty. But of one 
thing I am convinced, that a mere advance of wages will, even if it 
induce a better class to undertake the duty, not ensure its being 
better performed. What is wanted is a training institution similar 
to what we have in London and Liverpool for hospital nurses, pro- 
vided by Miss Nightingale. 
“ Yours sincerely, 
“ T. L. Rogers. 
“Dr. Chas. F. Folsom.” 
“ County Asylum, i 
“ Rainhill near Prescot, December 1, 1876. \ 
“ Dear Dr. Folsom :—Our English county asylums are visited 
once a year by the commissioners in lunacy,—i. e., by two mem- 
bers of that Board, a medical man and a legal member,—and every 
two months by two or more members of the committee of visiting 
justices. These are all the statutory visitations, and the rules for 
visiting made by local committees vary greatly, from weekly visita- 
tions, as in Middlesex, to quarterly, as in Yorkshire. 
“ Here, We used to have a rule that a magistrate should visit be- 
tween each monthly meeting of the committee, but that has not 
been observed now for years, and only the statutory visitations are 
made. . . • 
“ I object strongly to any set of men arrogating to themselves 
the right to determine how another set should treat any kind of 
disease, and, although I certainly am of opinion that our system of 
treatment of insanity is better than yours, I have no right or wish 
to assume that yours is incapable of being defended. 52 
Disease of the Mind. 
“ By the way, Dr. of visited this as}dum a fortnight 
ago with an introduction from your consul in Liverpool, I was 
unfortunately away from home, but my deputy informed me that he 
had particularly wished to see the implements of restraint, and 
seemed incredulous when informed there were none in the establish- 
ment ; and this seems, from what I read and hear, to be the prevail- 
ing feeling in America; viz., that we do not really act up to our 
professions. If this were so, it would be far worse (at least in my 
eyes) than an open use of restraint. If, however, your countrymen 
would take the trouble to make inquiries, either through their con- 
suls, or, still better, by personal examination of our asylums (and 
I am certain they would always be gladly welcomed), they 
could satisfy themselves how far the system of non-restraint was 
actually in force in England at the present time. However, as I 
went rather fully into the subject in my presidential address in 1874, 
a copy of which I believe I sent you, I will not give you a second 
edition of it here. 
“ I am yours sincerely, 
“ T. L. Rogers.” 
The following notes by the writer in regard to Tue Brook 
Villa, near Liverpool, and the West Riding Asylum at Wake- 
field, England, illustrate some points which may be suggestive 
here : 
Tue Brook Villa* 
“ Reaching Liverpool, and not having much time to spare here, 
I at once called on Dr. Owen at his private asylum for the treatment 
of mental diseases. When I went to see him two years ago, I 
thought that by mistake I had strayed into some gentleman’s 
private grounds. The gate was swung wide open, there was not a 
fence in sight over which I could not have easily vaulted, the hospi- 
tal in the distance had an attractive, home-like look, and the 
well-trimmed hedges and newly mown lawn looked only the more 
picturesque with the herd of Ayrshires and occasional groups of 
men and women here and there. As I got nearer, I found in the 
faces of the people unmistakable evidences of mental disease. 
Some were strolling about, or sitting under trees, entirely alone, 
on parole, that is, having the liberty of the grounds, provided that 
they kept within certain limits. In other cases, one attendant 
looked after a group of cases or a single patient, according to the 
severity of the illness. Inside the hospital the pleasant sitting- 
* Boston Medical and Surgical Journal, August 26, 1875. Disease of the Mind. 
rooms with their cheerful open fires (which are really not an atom 
more dangerous than gas-burners, sharply-pointed scissors, knives 
and forks, and steep stairways) had a quieting influence which is not 
got from opium or chloral. Those of the fifty patients who could 
control themselves sufficiently dined with the doctor’s family, a 
privilege which they appreciated highly, and to gain which they 
exercised a great deal of self-control. This daily stimulus to their 
self-respect had a really wonderful effect; and as I sat at the table 
conversing with one after another, the windows wide enough open to 
throw out a wheelbarrow, and the doors all unlocked, I had time to 
prepare myself for Dr. Owen’s statement, based upon an experience 
of over twenty years, that in building a new asylum he would have 
only such doors and windows and fences as are found in a gentle- 
man’s private house and grounds. 
“ Dr. Owen has one assistant physician and twenty-five attendants, 
whom he can employ in case of necessity, although so many are not 
always needed ; that is, he treats individuals, and not wards or 
galleries.” 
West Riding Asylum.* 
“ Having a few hours to spare, a few day ago, while waiting for 
my train, I made an unannounced visit to the West Riding Lunatic 
Asylum, from which we have seen so many excellent papers in the 
medical journals, and whose yearly reports are so interesting and 
valuable to us. I was fortunate enough to find Dr. Browne at home, 
and was received with that cordial hospitality which I find so freely 
extended here to strangers. I have not seen an asylum, and I doubt 
whether there is one, where the modern treatment of mental disease 
is so well carried out in all respects as there. The directors pay a 
large salary so as to secure talent of the first order, and then leave 
the management of the asylum in all its details to their medical 
officers. The newer parts of the building were constructed with 
wooden sashes, and no iron guards of any kind were used. In 
some of the wards the panes of glass were so large that a patient 
might easily get out by breaking the glass, if no one were at hand 
to prevent it. Dr, Browne said that if he were now to construct the 
whole asylum anew, he should have all the windows made in this 
way. Even the ‘refractory’ wards have open fire-places, porcelain 
vases on the mantel-pieces, prettily decorated walls and nice furni- 
ture. 
“ Of the fourteen hundred patients, not one was undergoing me- 
chanical restraint in any form, and not one was in seclusion. 
“ Dr. Browne does not even use clothes of indestructible material 
* Boston Medical and Surgical Journal, September 9, 1875. Disease of the Mind. 
for his violent and “ tearing” patients, preferring to have an attend- 
ant close at hand until the destructive tendency has given way under 
medical treatment and occupation. There were no airing-courts 
in the old sense of the word; that is, bare yards with high walls ; 
but every patient who went out to walk did so in pleasant, tastefully 
decorated yards. I could not but admire the skill and ingenuity 
with which the older parts of the asylum had been made cheerful, 
light and airy. At the end of one rather dark ward, a pleasant light 
from several gas-burners shone through a beautiful stained-glass 
window during the day. One great secret of the quiet and order 
which prevailed was, I think, the fact that all the patients are kept 
employed as far as possible. Even the carpets, shoes, bedding, 
cloth, clothes, etc., used in the place were made by the patients. I 
found some old, demented men darning stockings. Some of them 
were even blacksmiths. About one-fourth are taught to work at 
their several occupations after entering the asylum. 
“ Of course, Dr. Browne has a large staff of competent attendants, 
one to every eight patients ; these attendants are carefully selected 
in the first place, and all unfitted for the work are unsparingly 
weeded out. The suicidal patients are watched day and night, and 
cannot even go to the bath-room without an attendant. We all 
know what good pathological work is done at this asylum ; I need 
not describe that department. As an illustration of the care which 
is used to keep the patients from disagreeable sights, I noticed that 
the two dead-rooms (one for the males and one for females) had 
been so placed that the hearse coming or going, could not possibly 
be seen. Many little things like that all over the asylum showed 
how fully the old theory had been abandoned, that the insane are 
indifferent to their surroundings. In fact, a great deal was expected 
in the way of treatment from making them as comfortable and 
happy as possible. A few minutes’ walk from the wards a pretty 
Gothic church stands out among the trees, to which the patients go 
with a feeling of self-respect; and there is nothing in it or about it 
which makes it look different from a church for sane people. 
“ I have not space to describe the department for experiment, and 
medical and pathological research. I am sorry to pass over the 
strictly medical treatment with simply a mention of their Turkish 
baths and vapor baths (a very important feature) and to say that 
only a very few patients, comparatively, were taking medicine (not 
more than five per cent, taking morphia in any form). 
“ I was very much struck with the good behavior of the patients 
and with the absence of noise and violence. I suspect that the 
whole treatment which has been so successful may be described in 
Dr. Browne’s remark to me: ‘ Treat them as men and women, and Disease of the Mind. 
55 
they will behave as such.’ I placed the aphorism alongside of my 
Scotch friend’s reply to my inquiry what his treatment was that 
made his patients so quiet, for I saw many open doors, large wooden 
window-sashes, no mechanical restraint, and very few prescriptions 
in the medicine-book. That reply was, ‘ I believe in a good cook 
and a big garden.’ 
“ It seems to be generally believed in our country that insanity is 
of a milder type in England, and that the insane are more easily 
managed. Of course I cannot say that such is not the case. I can 
only say that it does not seem to me to be true, and that I am sup- 
ported in my opinion by careful and competent observers. But the 
English and Scotch have a great advantage over us in a climate 
-which makes it possible to send their patients out-of-doors to walk 
or to work nearly every day throughout the year.” 
Prof. Weslphal. 
Prof. Westphal, the distinguished successor of Griesinger 
as superintendent of the department for the insane of Charity 
Hospital in Berlin, and professor of diseases of the mind and 
nervous system in the university, writes of Germany thus ; 
“ Deae Sik :—I am very glad to answer your questions as far as 
I am able. 
“ The English no-restraint system is, to my knowledge, carried 
out in Germany at Hamburg, Halle, Gottingen, Charite [Berlin], 
Hall (Tyrol), Heppenheim, Neustadt, Eburwalde. Of private asy- 
lums, I would mention Dr. Mendel’s and Dr. Levinstein’s in Berlin. 
It is possible that there are still other German asylums with no 
restraint, of which I am not aware that they have carried out that 
system; but there are certainly not many, and it can still be said 
now that the greatest number use mechanical restraint, even those 
that are readily acknowledged to be model asylums, as for instance 
at Illenau in Baden. On the other hand, the no-restraint s}Tstem is 
extensively carried out in German Switzerland. 
“ Window-guards have never yet, to my knowledge, been removed 
from any German asylum, but I know of one in Denmark, at Roes- 
kilde (on the island of Zealand) in which there are no guarded 
windows. 
“ A new insane asylum has not yet been built in Berlin, and the 
city has lately given up the land which had been bought for that 
purpose. My advice has not yet been asked ; but I should recom- 
mend the purchase of a large piece of land to be cultivated by the 
“ Berlin, October 18, 1876. 56 
Disease of the Mind. 
insane; a small central building should be constructed, and the 
greatest part of the patients should be lodged in separate, simply 
constructed buildings. Such a plan is now being carried out in the 
province of Saxony, the land having been already bought, 
“ The no-restraint system was first practised in Germany by Prof. 
Ludwig Meyer, in the department for the insane of the Hamburg 
Hospital in 1862—the new asylum (Friedrichsberg) was not then 
built. Griesinger introduced it in the Charity Hospital (in Berlin) 
in 1866 ; but the system has been fully carried out only since Feb- 
ruary, 1867. There have been since that time no camisoles, etc., in 
the department of the insane of the Charity Hospital. (Compare 
the Archiv fur Psychiatric und Nervenkrankheiten, Vol. I, 243.) 
“ I am myself thoroughly convinced that the no-restraint system 
is the correct one {das richtige), and have never had occasion to 
depart from it. 
“ I think, too, that the guards may be removed from the windows 
provided certain patients (krarike) have their rooms on the lower 
floor; for the greatest number of the patients, in my opinion, there 
are no window-guards needed. 
“ Hoping these few notes may serve your purpose, 
“ I am very respectfully yours, 
“ Ch. Westphal.” 
Under date of January 6, 1877, Prof. Westphal informs 
me that a part of the asylum at Hamburg is without window- 
guards, and that the new asylum at Marburg is to be 
wholly so. 
Munich. 
At Munich some interesting work is done, as noted in the 
following description : *— 
“ The director has recently had one million guldens voted him, 
without a dissenting voice, for enlarging and improving and beauti- 
fying his buildings and grounds. In all his windows (which are 
guarded now) he is putting panes of plate-glass about a centimeter 
thick ; it cannot be broken by any ordinary blow. In fact, I could 
not break it with my fist. Each pane costs a gulden, an extrava- 
gance which the Geheimrath from Hildesheim said that he had not 
seen even in England. 
“ Another excellent idea which I noted was the building of large 
rooms for exercise during stormy weather. The southern sides 
* Boston Medical and Surgical Journal, October 14, 1875. Disease of the Mind. 
57 
were almost wholly of glass, and the rooms were not to be heated. 
The sashes are to be taken out during summer, and the space 
occupied with plants, shrubs, etc. The superintendent is carrying 
rather far the principle of decorating the grounds and frescoing the 
wards and other rooms which are for the most demented patients ; 
but he thinks his experience justifies him in saying that by such 
means he reduces his number of filth}’ patients 75 per cent.” 
Dr. Stearns. 
Dr. Stearns, the accomplished superintendent of the corpo- 
rate asylum at Hartford, gives this interesting account of his 
experience of British asylums. It is an important fact that 
his use of the non-restraint system for the past year has fully 
satisfied him of its merits : 
“Retreat roe the Insane, > 
“ Hartford, Conn., May 23, 1876. > 
“My Dear Doctor:—You may perhaps be interested to know 
that I visited Dr. Fraser’s institution two years ago and spent a 
day with him. Of course I need not say that I was greatty inter- 
ested. No one could fail to be so, with one having the enthusiasm 
he appeared to have in his work, especially as it extended quite as 
much to his pathological investigations as to the conduct of the 
other branches of his labor. The system of unlocked doors he 
explained to me, and judging by his letter to you the subject has 
increased in interest with him. I, however, felt then and do now 
that it is entirely impracticable with us, for reasons which I have 
not time to mention and which doubtless have occurred to your own 
mind. 
“ While abroad, I was specially impressed with the following 
points connected with the management of their asylums : 1, Occu- 
pation. 2. Non-restraint (so called). 3. Personal freedom. 4. 
Pathological investigations. I refer particularly to the Scotch 
asylums. It appeared to be the aim of the commissioners to stim- 
ulate in these directions, specially in those institutions 
where the superintendent had the requisite qualifications therefor. 
And here I think the beneficial influence of the system of commis- 
sions was specially apparent,—by counsel, advice, etc., helping the 
superintendents a little out of the beaten track and into new fields. 
I may say, in reference to the system itself, I think no one who saw 
the wonderful effects arising from the appointment of medical in- 
spectors in the army during the late war could doubt the beneficial 
effect of a commission of lunacy. The trouble, however, in this 58 
Disease of the Mind. 
country is to obtain one properly constituted. If the New England 
States would combine and appoint men of acknowledged eminence 
in the specialty, who should devote their whole time to the work, 
and clothe them with the requisite power, it seems to me such a 
commission would commend itself both to the public and to the 
institutions, and great good might come from it. . . . 
“ Very truly yours, 
H. P. Stearns.” 
Dr. Andrew McFarland of Illinois, a gentleman of many 
years’ experience as superintendent of insane asylums in two 
of our States, suras up his experience in 1876 in these words : 
Dr. McFarland. 
“We adapt our hospitals to the easy visitation of physicians and 
convenient administration of medicines, sacrificing, by so doing, the 
easy and most desirable freedom of action in the patient, which 
ought to be hampered as little as possible, 
“ Another of our inherited ideas, equally vicious, is, that the 
insane man is necessarily a ‘jail-breaker,’ and thus strength of con- 
struction is to be the universal feature of buildings for his use. 
My later experience with the insane has much disabused my own 
mind on this subject. The number who cheerfully and contentedly 
accept an asylum on the true principle as a fixed home, from which 
they are not tempted to stray, very much surprises me. The sight 
of means of restraint is, I am satisfied, a frequent temptation to 
break over them. I believe that more of the insane than we give 
credit for have a consciousness that they need a special home, that 
the outer world is no place for them, and, if such homes were pro- 
vided on the true principle of governing diseased minds, they would 
become more completely attached to them than we are apt to sup- 
pose in an experience of structures built to hold them in by physical 
force.” 
These opinions of men of large experience in the treatment 
of mental disease, and of eminence in their profession, are 
not quoted as indicating any arbitrary rules which should 
always be carried out under all circumstances, but to show in 
what a different light many of the first authorities now look 
upon mental disease as compared with the views held even 
twenty years ago. It is, moreover, evident, that for the last 
century the treatment of the insane has become annually less 
and less that of restraint. 
Less-Restraint Methods Considered. Disease of the Mind. 
59 
The climate of England is such that the patients may get out 
of doors nearly every day in the year, and that is considered 
by English specialists one of the most important features in 
their treatment; but in Germany the heat of summer is as 
intense and the winters are nearly as severe as with us. 
It is not possible to prove by statistics that a larger num- 
ber of cures can be got by this treatment. It certainly is 
reasonable that such should be the case; and it is thought by 
Dr. Clouston and others that more and speedier recoveries are 
the result. It is certain that there is no decrease of recover- 
ies and no real additional danger to the patients or to the 
community, whereas the comfort and happiness given to a 
large and unfortunate class more than compensate for the 
added feeling of responsibility and possibly anxiety on the 
part of the doctors, and for the increased watchfulness on 
the part of attendants. 
There are in most insane asylums patients so violent that 
all risks with regard to them should be assumed very cau- 
tiously ; others so absorbed in their own delusions as to 
scarcely notice their surroundings ; others too demented to 
perceive them; others still, too ill to do so, and a certain 
number who, well or ill, arc indifferent or superior to their 
associations. Granting all this, and, for the sake of the 
argument, that our insanity is more intense than that ob- 
served elsewhere, we still have a large class who are not 
"furiously mad,” who are thought to be best treated away 
from home and in an asylum, and who need everything in the 
scale turned in their favor in their struggle with a powerful 
disease. . Often with a diseased will and weakened powers of 
self-control, they need every strengthening help possible. 
For them, the influences ot multiplied restrictions and the 
inability to exercise what feeling of responsibility they have 
left, act simply as so many depressing forces. In their case, 
it is often really the safest to run some risk; and, in trying 
to be too safe, we should not infrequently, like an over- 
cautious surgeon, lose our only chance of ultimate success. 
In reference to this well-known fact, the late Dr. Bell said, 
in his report for 1853 (page 26) ; 
“It is said that the admission among the early inmates of this 
institution of one of extraordinary propensities and capacities of 60 
Disease of the Mind. 
breaking out of any place of confinement involved a useless outlay 
of thousands of dollars. It was naturally reasoned that, if among 
the first hundred admissions was included a man so dangerous and 
violent as to render his certain detention an indispensable duty, and 
who was yet capable of making his way through all ordinary obsta- 
cles, others of the same character would now and then occur. An 
entire building was erected predicated on such a possibility, but no 
parallel case has since [in 35 years] been received.” 
Management and Curability. 
It is the almost universal testimony that mental disease has 
been more easily managed in England by the less restricting 
treatment of it, and that the asylums have become quieter 
and more orderly. An illustration of this general principle 
has been so recently shown in one of our own asylums that a 
short account of it is given here. 
In 1874, one of the county asylums in Illinois was found 
to have six out of its three hundred patients handcuffed and 
chained to chairs or walls. Their actions seemed like the 
stories of sights in Bedlam and St. Luke a half-century ago, 
and which the writer had thought were not to be seen in these 
days. On representing the matter to the physicians and sur- 
geons of Chicago, made an examination and a report, as 
a result of which the whole evil was corrected and the asylum 
has been much improved in every way. One of the leading 
physicians writes, November, 1876, as follows: "I visited 
the insane asylum on Friday and examined every ward care- 
fully. I wish you could have been there with me, as it did 
not seem at all like the institution we visited together two 
years ago. 1 remarked to the physician in charge that I did 
not see any patients handcuffed or fastened to the chairs or 
wall.” Of the result of removing the chains and handcuffs, 
he writes : "The change was noted inside of twelve hours, 
and the patients who had been chained to their chairs made 
no more noise than the others ; the superintendent said that 
he had not used them (handcuffs, etc.) since the time when 
you were there. You said they would behave well enough if 
they were treated well.” 
Another striking case is the experience of Dr. J. S. 
Conrad, superintendent of the Maryland Hospital for the In- Disease of the Mindl. 
61 
sane.* In May, 1876, he put in practice the system of occu- 
pation for his patients; and, from then until October 31, 
there were 2,724 days of work with less than 200 persons, 
not including many times when they worked for only a few 
hours. With a view of extending his experiment, Dr. Con- 
rad purposes buying shoemakers and tailors’ tools, and those 
of other mechanical work. He says: "The amount of work 
done is really astonishing, and many patients have engaged in 
outdoor occupation who were never before outside the wcdls of 
the hospital since they came within them.” As a result, he 
speaks of his ability to very much reduce the amount of 
mechanical restraint used, " owing, doubtless, to the greater 
liberty that we have granted the patients, and also to the 
restraining influences of the system of occupation which we 
have adopted. There can be no doubt of the fact that with 
the insane, as with the sane, the more confidence you use the 
better.” He recommends smaller and separate buildings for 
purposes of classification. 
If our asylums were relieved of their overcrowded condi- 
tion, and if Dr. Conrad’s example, carried out indeed for 
many years at our state asylum in Northampton by Dr. Earle, 
were generally followed, might we not hear less of an "Amer- 
ican type of insanity” distinguished by greater severity, more 
violent excitement, more desperate melancholy, etc. ? 
In the report of the Connecticut Hospital for the Insane, 
for 1876, Dr. Shew says : 
“ In former reports I have alluded to various means employed 
to divert, amuse and occupy such of our patients as were not in a 
condition to engage in outdoor labor. Besides our regular enter- 
tainments of music, dancing, concerts, lectures, stereopticon exhi- 
bitions, readings, etc., which occupy four evenings each week, our 
male patients have found pleasure and profit in a systematic course 
of outdoor military drilling, which was conceived as a valuable 
training exercise for insane men, and has been carried into useful 
practice by our worthy supervisor, Col. Thayer. So far as I am 
aware, this is a new feature in hospital management. Early in the 
season walking parties were formed of from ten to fifty persons, who 
would leave the grounds and spend an hour or two, and sometimes 
a whole afternoon, in roaming about the hills, gathering flowers or 
* Report for 1876. 62 
Disease of the Mind. 
picking berries. As the season advanced, Col. Thayer gradually 
and almost imperceptibly formed those from the different wards into 
distinct companies, officered by their respective attendants. These 
companies would go out daily and practise at military evolutions. 
I am free to confess my surprise at the proficiency attained by many 
of the chronic insane, who had been turbulent, restless and noisy, 
or listless, desponding, and partially demented. These exercises 
were practised one or two hours daily by about 150. It should be 
borne in mind that these companies were formed of men who were 
not considered available for farm labor, or, in other words, of that 
large class of epileptic, maniacal, and demented patients found in 
every hospital who spend their time in the airing-courts or in the 
wards. 
“ About forty per cent, of all the men are regularly employed on 
the farm and grounds. One of the results of this form of military 
exercise and discipline was a steady increase in the number of those 
who wTere able to be employed on the farm, so that on pleasant days 
not more than half a dozen men, out of a total of 230, would be 
inside the building. Another pleasant effect of this form of amuse- 
ment and exercise was observable in the quietness and order which 
prevailed in the house. The universal quietness at night was equally 
noticeable. .Rarely was a sleeping dose of sedative medicine re- 
quired ; and from records accurate!}" kept, I am able to report the 
absence, for weeks at a time, of all forms of mechanical restraint.” 
Position of English and European Experts. 
It is not universally agreed, even in England, that mechan- 
ical restraint should be abolished entirely. Dr. Edgar Shep- 
pard, Medical Superintendent of the Male Department at 
Colney Hatch and Professor of Psychological Medicine in 
King’s College, London, says of his own practice : 
“Mechanical restraint is resorted to whenever it is thought 
necessary for the protection of the patient; but it is only necessary 
in rare and exceptional cases.* I believe its use to be neglected in 
many asylums to the detriment of the patients. All the windows 
in Colney Hatch are barred but there is no occasion for so prison- 
like an arrangement. English asylums have improved greatly since 
less restraint has been used, because of general attention being 
directed to their once neglected condition ; because of legislative 
enactments, better supervision, etc. Restraint was formerly resorted 
to in all cases to save trouble, and so it became wholesale neglect; 
* This was Conolly’s position. 
t Like our asylum windows. Disease of the Mind. 
63 
now it is resorted to in a few cases, and then only as the best means 
of treatment.”* 
Dr. Sheppard’s high position, and his experience and ability, 
entitle his opinions to great weight. By the reports of the 
Lunacy Commission for 1871, 1872, 1873 and 1875, it is 
found that less than one per cent, of his patients (averaging 
829 each year) wore mechanical restraint for those years,— 
much less of course than one per cent, at any given time,— 
and more than half of these were for surgical reasons ; although 
a very different interpretation of the meaning of those who 
agree with Dr. Sheppard is usually made in this country. 
Dr. Yellowlees, a well-known writer on psychology, for- 
merly physician-superintendent of the Glamorgan County 
Asylum, and now of the Loyal Glasgow Asylum, says :f 
“I never hesitate to use restraint when other means fail, if I 
think it for the patient’s good. The cases requiring it are very rare ; 
but it is as certainly right to use it when required as it is wrong to 
use it when unnecessary. To condemn restraint under all circum- 
stances merely because it has been or might }Tet be abused, is as 
unreasonable as to forbid all use of stimulants because they have 
been or may yet be used too freely. Unnecessary restraint cannot 
be too freely condemned ; but to reject its use when necessary for the 
patient’s welfare is to sacrifice the patient to a sentiment, and to 
degrade ‘ non-restraint’ from the expression of a great principle 
into the tyranny of a mere name.” 
A striking instance of the extent to which the non-restraint 
treatment has been raised to a principle in England, may be 
seen in the Criminal Lunatic Asylum at Broadmoor, of which 
we learn that in 1875, the daily average number resident was 
503, of whom 204 had been sent there for murder and 110 
for "attempt to murder, maim,” etc., and yet "no form of 
mechanical restraint was used in any part of the asylum dur- 
ing the year.” With all this, "there were no instances of the 
commission of premeditated acts of violence, and no attempt 
to escape was even partially successful.” There was only one 
suicide during the year, and no accident which could have been 
prevented by the use of mechanical restraint.^; 
* Dr. Sheppard’s views are given at length in his Lectures on Madness, London, 1873. 
f Asylum Notes, Edinburgh, 1873, page 13. 
+ Annual Report for 1875, by W. Orange, M. D., Superintendent. London, 1876. 64 
Disease of the Mind. 
As to the extent of the use of mechanical restraint in Eng- 
land, Mr. James Wilkes of the Lunacy Commission writes, 
under date of January 25, 1875, that it "is now very rarely 
employed in public or private asylums, and in many it is 
never used.” 
As to the amount of such restraint, where it is used, the 
commissioners, in 1873, when commenting on the fact that in 
800 patients treated in one year at a certain asylum, ten differ- 
ent individuals had worn restraint at different times during 
the year, say that such an amount of mechanical restraint was 
without parallel at that time in England. 
As to the character of the restraining means used, Dr. 
Yellowlees says : *— 
“I have only two appliances for this purpose, which it seems 
absurd to call instruments of restraint,—canvas gloves which 
envelop the whole hand, and a jacket such as that worn by all the 
patients, but of stronger material, and wdth the ends of the sleeves 
sewed to the pockets.” 
The benefits of the change in practice in England are well 
expressed in Dr. Sheppard’s letter.f The position of the 
superintendents themselves is well represented by the follow- 
ing extracts from letters from two of their leading men ; 
o o 
(1.) “Restraint in England has a strictly technical meaning, 
and means a restriction of personal liberty by some mechanical 
appliance attached to the person ; as a camisole, locked gloves, etc. 
In this sense I have no experience of restraint whatever. I believe 
I have seen cases that might, perhaps, have been benefited by it. I 
have never, however, had recourse to it, perhaps from a weak- 
minded fear of the name; but I believe because I objected to its 
moral effect on the other patients, on attendants, and even on 
myself.” + 
(2.) “ Some superintendents in this country have adopted the 
extreme view, that restraint should never be used ; for, even if a 
benefit to one special case, its introduction might lead to great injury 
in other cases. I think this view false in principle and wrong in 
* Op. cit., page 11. 
t See page 62. 
t Judging from the extensive correspondence printed in the eighth report (1854) of 
the Lunacy Commission, this is the position of the majority of English superin- 
tendents. Disease of the Mind. 
65 
practice. It is my province and duty as physician to distinguish 
between the use and the abuse, and there are rare and exceptional 
cases in which I deem it as much a duty to use some modified form 
of restraint as I deem it a duty not to use it in other cases. The 
good of the individual patient is the paramount consideration.” 
Another view is given by Dr. Sutherland, and is essentially 
the same as Prof. Meynert’s of Vienna, that "formerly the 
patient was strapped down to his bed and not allowed to 
move; the consequence of which was that the horizontal 
position favored the congestion of the brain and added to the 
development of the already superabundant nerve-force, thus 
producing greater and greater irritation, followed by collapse, 
typhoid symptoms, and too often death.” * 
In the second edition (1861) of his work on diseases of the 
mind, still the standard authority, Griesinger says : 
“When my first edition was published [1845], I agreed with 
German physicians generally in condemning the non-restraint 
system. I sympathized with the reform, but could not meet the 
objections made to it. Since that time, experience from one end 
of England to the other has answered these objections. I have 
seen the system in practice, and am convinced. . . . Let no one 
again say that it is impracticable, ... or more suitable to the 
English, because more manageable, than on the Continent, . . . 
or that the use of it is commendable and its abuse to be condemned. 
No one can say at what point in the use of mechanical restraint 
abuse begins ; it seems to be almost unavoidable.” 
He quotes Conolly, however, apparently with approval, as 
saying that there are rare and exceptional cases where 
mechanical restraint is best for the individual patient. 
It is only fair to say that a different conclusion was reached 
by Guislain of Brussels, whose work Brierre de Boismout 
compares with that of Pinel and Esquirol, and who was the 
best-informed man of his time in regard to the various 
methods of treatment, having visited the asylums of Italy, 
Switzerland, Holland, Germany, France, and England, and 
having, like Griesinger, seen the non-restraint system in 
practice at Hanwell. He gave Conolly full credit for his noble 
* Non-restraint System of Treatment of Insanity. By R. Gardiner Hill. London, 
1857. 66 
Disease of the Mind. 
work, but thought with Ray and Bell, that there were some 
patients, about one or two per cent., who were better off for 
some form of mechanical restraint. He said, with Baglivi, 
" All ter enim, in morbis curandis, traciandi Itali, 
aliier Galli, Hisjpani, Angli, Germani.” . . . (Italians, 
Frenchmen, Spaniards, Englishmen and Germans, all require 
different kinds of treatment.) 
However decided one own’s opinion may be on this point, 
and however honest one’s convictions, it must be acknowledged 
that humane, able and well-informed men still differ as to 
what is best in individual cases. 
Substitutes for Restraint. 
It has been thought that there must be some substitutes 
in England for mechanical restraint,* in wet-packing, etc. ; but 
we find that the Lunacy Commission, in speaking of one asylum 
where this was used, simply as " medical treatment,” say, 
"This packing should be recorded in the medical journal, and 
under the head of restraint.” 
Whether more drugs are used or not, as less physical 
restraint is resorted to, is chiefly a matter of individual 
practice, some going so far as to class all use of powerful 
sedative drugs as "medicinal restraints” to be avoided, and 
others saying that more narcotics are employed. 
It is generally agreed that it has been necessary to have 
more and better attendants. 
Accidents Considered. 
The result in England has not been to increase the number 
of accidents; and it has been stated by Dr. Conolly-j- and 
others, although I have been unable to find statistics on the 
subject, that they have decreased. As compared with our 
own country, it is found that they have fewer fatal casualties, 
as the following table (including suicides) shows. 
Deaths from a suicidal act committed before admis-sion, 
Sudden deaths from natural causes, as heart disease, epilepsy, 
etc., are not included. 
* Superintendents of asylums and physicians, in like manner, formerly often went 
to Hanwell to ask Conolly what he used in its stead. 
f Eighth report of the Commissioners in Lunacy, pp. 171, ct seq. Disease of the Mind. 
67 
The quiet insane in the workhouses of England, 10,307 in 
1866, and 15,409 in 1875, are also not counted. There are 
almost no fatal accidents among them. 
Table showing Fatal Accidents for Ten Tears in Asylums for the 
Insane. 
H 
O' CO LO *—1 O GO ~J Ci 
w 
t> 
S3 
m 
t—l H—1 >—* k—* ►—* 
4-41- CO —* •—1 €D “-4 CO “-3 
Inmates of asy. 
o« t-: o< 4- co b go b 
lums. 
d 
COtOc5bcOtOO'CC4-*4* 
w 
Fatal casualties 
0 
1 
CO 1C to to >-* M KJ to to «-J 
4- 0« tO O' C2 4- O tO 
during the year. 
m 
H 
> 
Rate per 1,000 pa- 
W 
M 
tOMMMUMHCOtOl-1 
tients of fatal ac- 
GO 
iw<ib'bowO'Mb^oi 
C)tiU<0'000*4(»-4 
cidents. 
4^4^COCOCOCOCOCOCOCO 
Inmates of public 
W 
*2 
and private asy. 
o 
1 
GO M 03 OU-O ffi 05 w to lO 
O' O CO CO O' CO CO --J to o 
lums. 
0 
Fatal casualties 
!> 
1 
v£-tOO'0'v£*C04-kfc.v£‘tO 
LO O O GO I—1 »—1 tO 4— GO 05 
during the year. 
« 
Rate per 1,000 pa- 
>- 
l_a 
OOH-*H-«!-JOMl—‘»-JO 
tients of fatal ac- 
b 
CO 
b io O' b GO ►-* to 00 
CD tO Oi O O i(- GO CO 05 tO 
cidents. 
oa 
Inmates of royal 
Cn0'0'0'0'4^4i*4^4^ 
and district, pri- 
GO -lb4-W®b050' 
vate and paro- 
1 
OJOtOHOCWi^W© 
chial asylums. 
W 
Fatal casualties 
O 
H 
1 
| 0O4^4-a>t0O3t0CO4^ 
during the year. 
> 
5! 
0 
Rate per 1,000 pa- 
>~it0t0l0l0l-j|0>-‘0 
tients of fatal ac- 
b 
| CO -I 'O IO k) O' M OO 
-44^.000'^tOOitOCO 
cidents. 
* The figures Include 29 asylums in 1866; 33 in 1867; 27 in 1868; 32 in 1869; 37 in 1870; 33 in 
1871; 37 in 1872; 41 in 1873; 42 in 1874; 40 in 1875. The records were not counted, as there 
were no statistics, of five asyiums each in 1868 and 1869; of 4 in 1866, 1867 and 1870; of 3in 
1871, 1872, 1873, 1874; and of 1 In 1875. 
f Not including six lost by the destructive fire at one of the asylums. 
11l preparing the table in regard to this point, the records 
for the past ten years have been consulted. For this country, 
reports (380 in all) of the various asylums (51 in num- 
ber) have been examined through the kindness of Dr. Edward 
Jarvis, who offered the use of his library. The superintend- 
ents, also, were addressed personally, with a view to obtaining 
reports for those years which were wanting. For Scotland, 
the suicides and fatal accidents are reported in the tables 
published in the reports of the commissioners. As it was 
not entirely clear whether all fatal accidents were reported by 
the English commissioners, a letter of inquiry was sent to 
Mr. James Wilkes, who very kindly sent the following' 
reply 68 
Disease of the Mind. 
Office of Commissioners in Lunacy, ) 
19 Whitehall Place. S. W., 26 April, 1876. £ 
My Dear Sir :—I have been away from London on circuit for 
nearly a month, and have not been able to reply to your inquiries 
earlier. 
All suicides, both in public and private asylums, are recorded 
in the tables published in our reports showing the admissions, dis- 
charges, deaths, etc., which take place in each. They are also 
subjects of special investigation by the board, and in most cases 
copies of the evidence given before the coroner are procured. 
Fatal accidents are not included in this table; but all are equally 
the subject of special inquiry, and, when necessary, of personal 
investigation by the commissioners. They are always mentioned 
by the commissioners in the reports they make upon their visits 
both to county and private asylums, and are also commented upon 
in the annual reports they make to the Lord Chancellor. . . . 
I am, dear sir, faithfully yours, 
C. F. Folsom, Esq., M. D. 
James Wilkes. 
The result of the comparison is to show that Dr. Bucknill 
is right in saying* "that non-restraint does not encourage nor 
restraint diminish or prevent the occurrence of injuries from 
violence,”—at least if the non-fatal accidents are in the same 
proportion as the fatal. This point cannot be ascertained 
with certainty for American asylums, as records are not 
published in all cases, as they certainly should be. In 
England it is shown by statistics that the non-fatal accidents 
have very much diminished in the last fifteen years, while the 
non-restraint system has been more fully carried out. 
If we examine the character of the fatal accidents, we find 
that there are almost none in our best asylums (and the same 
holds true of the best English asylums) except those which 
were due to the patients themselves. In the case of all our 
county asylums, a few of the city asylums, and the depart- 
ments for the insane in poorhouses, all of which are under 
the care of men not members of the Association of Amer- 
ican Superintendents, and in a few of our state institutions, 
which are the least creditable to us, either there are no 
* Op. cit. Disease of the Mind. 
69 
reports or we have been unable to consult them, so that the 
apparent result is more favorable to us than if all classes of 
asylums were included in the account. 
In the British asylums, too, careful autopsies and inquests 
are required in all doubtful cases, of which the records are 
kept and published by the Lunacy Commission ; so that we do 
not find the euphemism of" autochiria ” for suicide, as occurred 
in one of our asylum reports; and they are also complete. 
In the above table of statistics, it is known that all our fatal 
accidents are not included,* although it is not certain how 
many omissions there are. The results do not, therefore, 
possess entire completeness ; but it is thought that, especially 
for the later five years, they are pretty nearly correct for most 
of the asylums. 
Ten years ago there were many injuries in English asylums 
attributable to rough handling by the attendants, apparently 
in some cases such as might have been avoided by the use of 
mechanical restraint or better attendants. The number has 
been diminishing, however, and is now very small indeed. 
But there are still reported in England accidents of a kind 
and with a frequency said to be entirely unknown in the 
asylums under the charge of members of the American Asso- 
ciation of Medical Superintendents of Hospitals for the Insane. 
If we had any means of getting at the statistics on this point 
for all our county and city asylums, and so could include the 
good and the bad, as is done in England, we probably should 
not have good reason to be proud of the result. A careful 
comparison of English with American state and corporate 
asylums leads the writer to the conclusion that there is not 
less personal kindness and care on the part of the doctors and 
not less gentle treatment on the part of the nurses in the lat- 
ter. The accusation that the use of restraint in our best 
asylums is on any other than humane grounds is certainly not 
based upon adequate knowledge of the true facts. 
* In one of the asylums included in the table on page 67, it has been lately ascer- 
tained that there were four fatal accidents which did not appear in the reports,'and 
which are not counted. 70 
Disease of the Mind. 
Question of Escapes. 
Another matter is worth considering, and that is whether 
the system of more freedom permits more escapes. On this 
point Mr. Wilkes says: "During the year 1875, I find that 
376 escapes were registered, and on the Ist of January, 1876, 
there were 40,261 patients in public and private asylums in 
England and Wales.” He further says that the great majority 
of the patients' who escape are returned very shortly (or 
return themselves), sometimes in a few minutes; and the 
instances are very rare in which they are not retaken. 
In looking over all the reports for that year of American 
asylums, of which I have copies at hand, I find that among 
15,407 patients in 34 asylums, there were 38 escapes, none 
of whom were returned or came back themselves. Those who 
escaped and did come back are not recorded in the reports ; 
so that, in this point also, the system of more freedom appar- 
ently has no disadvantage. 
Dangerous persons should be carefully watched, and not 
allowed to escape; but the moral effect of occasionally allow- 
ing a harmless patient to wander away, and find out for him- 
self that he must go back, is certainly not a prejudicial one. 
Summary of Restraint Question. 
This subject of mechanical restraint has been dwelt on at 
some length, because it has lately excited a great deal of 
attention. Both here and abroad, a great many exaggerated 
and untrue statements have been made, and these have 
been copied and commented upon, giving rise to a great 
deal of misunderstanding; a matter which cannot be put in 
better form than by quoting from a recognized English 
authority, who says, in a private letter recently received : 
"I received the Journal of Medical Sciences, and have no 
reason to complain of being misquoted, but the gist of my 
argument, the writer failed to appreciate. I took up my 
parable against the intolerance of non-restraint advocates 
certainly, because they are in the majority in this country, 
but I meant it equally to apply against intolerance on the part Disease of the Mind. 
71 
of advocates of restraint. Now, that article is as intolerant on 
one side as anything that has ever been written or said on 
the other side in this country, and the writer omitted to 
state that I, who had never employed restraint, was the 
advocate of tolerance towards those who are opposed to me. 
Moreover, the arguments in favor of restraint are only a 
rechauffe of what used to be said in this country by the 
opponents of the abolition of restraint. 
"I admit some amount of force in the argument about the 
American people being less easily controlled, or, I should 
say, less amenable to discipline, than the inhabitants of this 
country ; but, for that reason, I should apprehend they would 
feel the degradation of restraint all the more keenly. On the 
subject of American patients, I am not speaking without some 
knowledge, as I frequently have them in this asylum; and, 
what is still worse, according to my experience, Irishmen 
who have returned from America, and who, as usual, have 
acquired the vices (if I may so term a repugnance of disci- 
pline) of the people amongst whom they have lived, without 
acquiring their virtues. 
"I have been in the habit of thus classifying, mentally (i. e., 
in my own mind), my Irish patients: (1.) The recent im- 
ports, who are generally docile and manageable; (2.) Those 
who have lived some time in Liverpool or other manufactur- 
ing towns, and who have lost all their native docility and 
acquired the vices of their Saxon neighbors without having 
also developed their self-reliance; (3.) Those who have re- 
turned from America, who kick against discipline of any 
kind To return to the subject of restraint, I 
think I may assert that if it can be dispensed with in this 
asylum, it can be anywhere ; for a more degraded, lawless 
class than are sent here, are not to be found in this country. 
. . . . Ido not think that the leading superintendents in 
this country favor restraint; no doubt sentiment leads many 
men very far in theory, but I really believe that, in England, 
the restraint men are in a small minority.” 
In our country, alienists look upon the use of mechanical 
restraint as a purely medical question; but there are so 
many other interests, social and moral, connected with it. 72 
Disease of the Mind. 
that Dr. Bucknill is undoubtedly right in saying that "it 
is a matter upon which persons who are not scientific will 
eventually insist upon having much to say, unless it be defi- 
nitely settled beforehand.” In some of the best English, 
and also in some of the best American, asylums, the prin- 
ciple is essentially alike ; namely, to use mechanical restraint 
only when the interest of the patient demands it. 
The practice is widely different in the two countries in this 
respect. One physician in England, for instance, who treats 
about forty patients of all degrees of severity in his asylum, 
and who uses mechanical restraint when he deems it best for 
the patient, wrote February 6, 1875, that he was then using 
it for the first time in twenty years, and oddly enough in two 
cases. Generally speaking, the amount used in that country 
is very small indeed.* In the United States, there has been 
a progressive improvement in the last five years ; nor can there 
be any doubt that there will be a still less amount of restraint 
used, and that the methods found so successful elsewhere 
will be more generally adopted after they have become fully 
known. At the present time, the use of mechanical restraint 
in some of the American asylums is excessive, but not more 
so than is common on the continent of Europe. 
This marked difference of interpreting the needs of each 
case, with reference to the requirements of humanity in the 
use of mechanical restraint, has caused a great deal of mis- 
understanding, in this country, of the position of English 
superintendents; so that they have been thought by persons 
not thoroughly informed, to say much more than they really 
mean when recommending mechanical restraint where the 
necessities of the case demand it. In the same way, our 
superintendents are thought in England to use it more than 
they really do. 
The English county asylums, filled with inactive paupers, 
cannot fairly be placed in full comparison with our state 
asylums, overcrowded, insufficiently supplied with attend- 
ants, and provided for a less manageable class of patients ; f 
* Compare the statement of Mr. Wilkes, page 64. 
t It should be remembered that the asylums at Perth and Broadmoor for the crim- 
inal lunatics remove that class, which (except in New York) must be treated in our 
ordinary asylums; that the large English asylums are mostly for paupers; and that 
the more intelligent classes are generally treated in private asylums. Disease of the Mind. 
73 
but this fact of itself does not render the non-restraint system 
inapplicable to us, nor prove that it is not the best. Perhaps 
we shall find the " golden mean ” somewhere between the 
practices of the countries, but nearer the English side. 
An illustration of the principle of non-restraint was shown 
at one asylum in England, where there were padlocked guards 
over the fireplaces, which also had been covered with wire 
netting, through which a patient, in the absence of attendants, 
passed a long taper, lighted it, and killed herself by setting 
fire to her clothes. The superintendent had all the fireguards 
taken away, the attendants found that they must look after 
the patients, and no similar accident occurred again. 
Responsibility for Crime,* and Definitions of Insanity. 
It would be an interesting study to follow the gradual 
development of rational views on the part of the community 
with regard to mental disease, but it is not necessary here. 
It corresponds very nearly with general intellectual develop- 
ment. 
Until about the beginning of the present century, Lord 
Hale’s principle was held by the courts, that to be exempted 
from punishment on the ground of insanity, a man must be 
deprived of all memory and understanding, and no more 
know what he is doing than an infant, brute, or wild beast. 
Delusion, of which the criminal act was the direct offspring, 
was the next test; and then the general power of distinguishing 
right from wrong. A little before the middle of this century, 
the particular knowledge of right and wrong at the time the 
criminal act was committed was laid down by the judges as 
the criterion of responsibility. Under this decision, an in- 
sane man would be held exempt from punishment if he killed 
another man whom, by virtue of his delusion, he supposed to 
be making a mortal attack upon himself; if he supposed that 
some great injury only was to be done to him, murder com- 
* This is touched upon here only very briefly, as a matter of necessity. The general 
reader is referred for further information to Ray’s “Medical Jurisprudence ” and 
“ Contributions to Mental Pathology,” to Maudsley’s “ Responsibility in Mental 
Disease,” and to the last edition of “ Casper’s Forensic Medicine.” Disease of the Mind. 
mitted under this delusion would render him liable to punish- 
ment, while, at the same time, he could not legally make 
a will. This illogical position is not now generally held in this 
country, and some recent decisions have been made in con- 
formity with more rational views; but that criminals should 
occasionally be acquitted on the ground of insanity, and that 
persons evidently insane should suffer judicial murder, may 
be unavoidable so long as there can be no definite line drawn 
between sanity and insanity. The recent decision by which 
Kullmann, who attempted to assassinate Prince Bismarck, 
was acquitted of deliberate attempt to murder, on the ground 
of limited responsibility arising from hereditary defect,— 
although he was in no sense insane,—may be fairly con- 
sidered far in advance of any other judgment of modern times. 
In striking contrast with this, is a late English decision.* A 
patient, an insane epileptic in one of their asylums, killed an 
attendant. At the trial, the judge held that— 
“ Where a man committed crime for some supposed grievance, 
if he knew that what he was doing was contrary to law, he was to 
be held responsible for his actions. If a man killed another while 
under delusion that he himself was about to be killed, and that he 
was acting in self-defence, he would not be punishable; but if a 
man did so for some supposed injury to his character or fortune, 
then the man would be responsible. ... If the jury were sat- 
isfied that, although Fordham was suffering from delusions, he knew 
what he was doing, and was not merely taking life under an erro- 
neous impression that he was defending his own life, but killing 
because he felt himself injured in some form or other, it would be 
their duty to find him guilty.” 
Ford ham was declared guilty and sentenced to be hanged, 
but there was afterwards commutation to penal servitude for 
life. The superintendent of the asylum in which Fordham 
was confined was one of those who thought him respon- 
sible. The question of self-control apparently was not con- 
sidered. 
The Commissioners in Lunacy (a board in which there are 
three physicians and three lawyers who visit the asylums) 
* Thirtieth Annual Report of the Commissioners in Lunacy, London, 1876, pp. 40 
and 41. Disease of the Mind. 
75 
recommended, in 1873 (and there is no dissent expressed in 
their report on the part of any members), that a patient in 
one of their insane asylums, who had committed murder 
while there, should sulfer the full penalty of the law.* Some 
years before this, an attendant was convicted in court and 
sentenced on the sole evidence of an insane patient. 
In this connection, it is proper to say that the English 
criminal code is very much more severe than ours ; and it is 
natural, therefore, that their limitations of responsibility 
should be less favorable to all offenders against society, f 
Regarding the criminal, insane or not, from the humane 
point of view, our own country, during the past century, 
has made greater progress than this, as have also France and 
Germany. 
So long as insanity was considered a disease of an imma- 
terial mind, a seelenstdrung, the greatest confusion existed in 
defining it. One of Esquirol’s pupils it in 1817 
as " a want of control of our feelings and propensities.” 
Haslam, in 1832, testified in an English court that he had 
never seen a sane person; saying, too, "I presume the Deity 
is of sound mind, and he alone.” 
A little later, the capability of repeating the multiplication- 
table was gravely propounded in an English court as a 
test of insanity in a case involving a large sum of money. 
In 1837, Browne, in his lecture on What is Insanity, says 
that its definition is an enigma which CEdipus could not 
have solved. 
With the clinical study of mental disease in the European 
schools, and with the impulse given to scientific research by 
careful autopsies, the immaterial theory of insanity has dis- 
appeared. In 1854, in an essay on Unsoundness of Mind in 
* Twenty-eighth Report, 1874, page 2. 
f In Blackstone’s time, for instance, there were one hundred and forty capital offences. 
Judges now sentence hoys of twelve to a dozen lashes for such offences as throwing 
stones at railroad trains. The penalty for unlawfully destroying or damaging “ any 
statue or monument exposed to public view ” is whipping, if the offenders are under 
sixteen years of age; for highway robbery with violence judges may, at their discre- 
tion, and often do sentence to imprisonment, with or without a certain number of 
lashes in addition. 
+ Management of Lunatics, with Illustrations of Insanity. By George Parkman, 
M. D. Boston, 1817. 76 
Disease of the Mind. 
Relation to Criminal Acts, to which the first Sugden prize 
was awarded, Dr. Bucknill describes insanity as " a condi- 
tion of the mind in which a false action of conception or 
judgment, a defective power of the will, or an uncontrollable 
violence of the emotions and instincts have separately or con- 
jointly been produced by disease.” Two recent definitions 
illustrate still greater advance, and the difference in twenty- 
two years is well worth noting : 
“ Insanity is, in fact, disorder of brain, producing disorder of 
mind; or, to define its nature in greater detail, it is a disorder of 
the supreme nerve-centres of the brain,—the special organs of mind, 
—producing derangement of thought, feeling, and action, together 
or separately, of such degree or kind as to incapacitate the indi- 
vidual for the relations of life. . . . Mind may be defined 
physiologically as a general term, denoting the sum-total of those 
functions of the brain which are known as thought, feeling, and will. 
By disorder of the mind is meant disorder of these functions.” * 
“ Insanity consists in morbid conditions of the brain, the result 
of defective formation or altered nutrition of its substance, induced 
by local or general morbid processes, and characterized especially 
by non-development, obliteration, impairment, or perversion of one 
or more of its psj’chical functions.” | 
" Disorder of brain ” and " morbid conditions of the brain” 
are such general terms as to include all conditions, even 
those usually called reflex, giving rise to insanity; but the 
definitions also embrace too much, for they clearly include 
the delirium of starving, drunkenness, and of many of the 
acute febrile conditions as well of the brain as of other 
organs. No one, for instance, would be justified in calling 
the raving of brain fever or pneumonia insanity, and yet the 
conditions (as defined above) of irresponsibility exist. It 
has been proposed to get over the difficulty by limiting the 
word insanity to permanent disorders of the cerebral facul- 
ties, carefully avoiding even the expression in transient at- 
tacks. If this could be done, a great gain would be got in 
* Responsibility in Mental Disease. By Henry Maudsley, M. D. International 
Series. New York, 1874. 
t Dr. J, Batty Tukein the Edinburgh Medical Journal, November, 1874. Disease of the Mind. 
many ways; for there are many forms of mental disease of 
short duration, pursuing a definite course and self-limited, 
like typhoid fever, in which the recovery is complete, and in 
which the purely physical symptoms are very slight. Again, 
in the recurrent forms of " insanity,” with entirely healthy 
intervals, there are many reasons for supposing that we 
deal with successive attacks of a malady, where, as in 
bronchitis, the diseased organ recovers wholly its tone, 
rather than with a fixed malady like syphilis, where, even 
with quite long intervals of apparent health, the disease can- 
not always be said to be cured, beyond possibility of reap- 
pearance or of transmission to offspring, until death. 
Still, if the above definitions, unsatisfactory as they are, 
could be insisted on, many of the disputes between the law- 
yers and the doctors would settle themselves. Men trained 
in medicine and in exact scientific observation would then 
testify as to the pathological condition of a given individual 
wffiose sanity is questioned, and other men, trained in a dif- 
ferent way and accustomed to take a broader view of social 
questions, would decide as to the limitation of responsibility. 
Massachusetts Statistics and Asyeum Accommodation. 
The number of the insane known to the officials and under 
the care of the State increases from year to year in all 
countries. We have no absolute statistics, by which we can 
say how far this increase is apparent and how far it is real; 
that is, whether the actual proportion of recent cases to the 
population is greater from year to year. The life-saving 
influence of better medical skill, and the more humane views 
of the people at large, have undoubtedly tended to very much 
prolong life in chronic diseases. We do not now leave the 
sick and the lame by the wayside to die. The natural result 
is, that there are more invalids ot all classes, many of whom 
marry unwisely and beget debilitated offspring to still further 
increase the number. 
The following table shows the number of the insane in our 
asylums in Massachusetts at the end of each year since 1820, 
and the rate per 100,000 of the population for the census 
years:— 78 
Disease of the Mind. 
CCCOOOCOCCCOCOOOGCOOCOOOOOCOCCCOOOOOCC 
COCOOOCOCOCOCOCOCOtOtCtOtOlOtOlOtOtObO 
a)HoiC'^WLOMOoa)<ic50'>F‘0:L'iHO 
• 
Years. 
WWWMMM 
HHC0050)l--4-a)0 0'0'-10<^MtM'OCCO 
Patients at end 
of year. 
9.55 
11.34 
1 
Patients per 
100,000 of the 
population. 
1839, . 
1840,2 
1841, . 
1842, . 
1843, . 
1844, . 
1845, . 
1846, . 
1847, . 
1848, . 
1849, . 
1850, . 
1851, . 
1852, . 
1853, . 
1854, 
1855, . 
1856, . 
1857, . 
Tears. 
'o'o'o'o COCOGCCOGO— 
CO CO to *•! -1 -1 to M OT tv Oi W CO O -1 -icnw 
totocono-iaia'OtcoJHiooo'rfi-GH-i 
Patients at end 
of year. 
61.99 
84.97 
90.87 
Patients per 
100,000 of the 
population. 
1858.4 
1859, . 
1860, . 
1861, . 
1862, . 
1863, . 
1864, . 
1865, . 
1866.5 
1867, . 
1868, . 
1869, . 
1870, . 
1871, . 
1872, . 
1873, . 
1874, . 
1875, . 
Years. 
M K-i M W-» M 
co'bo -i'os 
4-C'4iw0^tDODCW 
O' cn to w m one w to w -i -4 oj h o> p—* 
Patients at end 
of year. 
110.55 
111.44 
130.44 
132.88 
Patients per 
100,000 of the 
population. 
1 Worcester Asylum opened. 2 South Boston Asylum opened. 3 Taunton Asylum opened. 
4 Northampton Asylum opened. 5 Insane department in almshouse at Tewksbury opened. 
The next table shows for each year since 1832, the number 
of admissions to our asylums (excluding transfers) and the 
number of acute cases; i. e., those who had been ill not over 
a year. This latter division is not perfect, but is sufficient for 
HMMMMMMMMMMMMuiki 
GO GO OO CO GO GO CO GO CO CO CO CO CO CO GO 
05 O' W K) M o O CO H 05 o< w to 
*• * 
Years. 
rfx^^COOOCOv^WCOKJtOMtOtO 
05 w lO CO H a 'r4 M CO W CD CO O' o 
«0&3^CO^HWH‘CJ'COi-i05HQlti 
Admissions. 
kOWlOWUlMMMMM k-J M 
OC0 4-COC005 
CO O K) O' 05 t-o O' tn O H CO rfk. O' M 
Acute Cases. 
1847, . 
1848, . 
1849, . 
1850, . 
1851, . 
1852, . 
1853, . 
1854, 
1855, . 
1856, . 
1857, . 
1858, 
1859, . 
1860, . 
1861, . 
Years. 
CO CO H Ol C3 O O' O' kt*. 19 
' CD CO 
05MOWLO-403W^O>©HHO(» 
Admissions. 
v^^WCOCOCOtOCOl'DbOlOhDtOfcOtO 
H W -1 *“1 O' GO O L\) Oi Oi O) O' -I 
tOCOCO^SbOOOSO'lCHHSCn 
Acute Cases. 
HMMMMMMMMMMMMU 
GO GO GO GO GO CO CO GO CO GO GO GO CO GO 
O' CO w M o '■•O GO <1 OJ O' W lO 
* 
Years. 
'h-*'h-‘'o'h-‘T-‘T-I CDCDCDCOOJC5C3C5 
OJi>C0C0l0O03t0*'lt0HCCCO 
Wt^aicoHCccoooio^OJHW 
Admissions. 
03C0C0 
HOiCOOOMMHO'CObGtf-CO^^ 
Acute Cases. 
our present purpose. The years in which new asylums were 
opened are marked with an asterisk. For the eight succes- 
sive quinquennial periods, beginning with 1836, the propor- 
tions of acute cases to admissions have been 44.42, 53.28, Disease of the Mind. 
79 
53.29, 49.74, 53.54, 49.42, 47.96, 56.34. The acute cases 
from the South Boston Asylum are not included in the last 
twenty years, as there were no records by which they could 
be readily got; they would make the percentage of acute cases 
slightly greater for the last four quinqennial periods. 
We cannot, indeed, say definitely just how much influence 
this conservation and prolongation of life has in increasing 
the number of our insane; and the cure-rates in asylums are 
estimated on such different bases by different individuals, and 
our statistics are otherwise so incomplete, that we should not 
learn much from considering them with reference to this 
point. But it is clear that the number of curable cases exist- 
ing in the State is less in proportion to the whole number 
from year to year. On the other hand, under the influence 
of increased confidence on the part of the public, a larger 
part of the insane of all classes are admitted to our asylums 
each year, while the incurable cases accumulate, so that the 
ratio of recoveries seems less; and this fact explains many 
otherwise puzzling statistics of our insane asylums.* 
If this view be correct, the annual rate of increase must at 
some time diminish and finally cease to be anything; and "it 
is worthy of remark that the total increase of the past year 
[1875] over the preceding one has been less than in any other 
year” since 1859 in England,f covering the period (eighteen 
years) during which full statistics have been kept. Perhaps 
the extreme point has been reached there. 
According to Dr. Jarvis’s accurate and exhaustive report to 
the Legislature in 1855, there were then in Massachusetts, 
O 7 
2,632 insane and 1,087 idiots, with a population of 1,132,369. 
By the census of Massachusetts, in 1875, there were 3,637 
* A good illustration of this fact is found in the statistics of the only insane asylum 
in Maine for the three decades and a half of its existence, from 1840 to 1875, where 
the increasing death-rate and diminishing cure-rate indicate the change in the charac- 
ter of the patients admitted and treated:— 
Time. 
Number of 
Patients 
Admitted. 
Proportion 
of Cures to 
Admissions. 
Proportion 
of Deaths to 
Admissions. 
First decade, 
1,064 
42.10 
7.80 
Second decade, 
1,185 
40.75 
17.80 
Third decade, 
1,374 
40.32 
23.28 
Fourth period, one-half decade, .... 
093 
36.41 
25.81 
f Thirtieth report of the Commissioners in Lunacy, page 2. 80 
Disease of the Mind. 
insane and 1,340 idiotic—with a population of 1,651,912. 
During the year 1875, there were about 3,800 insane reported 
to the Board of State Charities, so that the numbers in the 
census returns must fall somewhat short of the truth. 
By Dr. Jarvis’s statistics there was one insane person to 
every 430 of the population; by the census of 1875, not so 
many ; namely, one in 454. If the ratio were the same as in 
1855, our present number of the insane would be 3,842. It 
can hardly fall far short of 4,000. 
September 30, 1875, there were 2,722 under the supervision 
of the Board of State Charities : 
In state hospitals, ........ 1,842 
corporate and private and county hospitals, . . j 441 
the workhouse, ........ 46 
the state prison, 2 
At Monson, ......... 1 
In the care of overseers of the poor outside of hospitals, . 390 
All of our state hospitals are crowded, and considerably 
less than half of our insane can be treated in them, even in 
that condition, while we are building two new asylums, 
which will, by crowding, accommodate at most 1,000 more. 
When these are finished we shall have provision by the State 
for about 2,600, or nearly two-thirds of our insane, without 
overcrowding. The McLean Asylum and the City Asylum 
at South Boston will accommodate together nearly 400 ; so 
that, if hospital provision is needed for three-fourths* of our 
insane (or 3,000), the State really needs to provide for 2,600 ; 
to do which, even if we do not allow for any increase in the 
numbers to be cared for in institutions, the old asylum at 
Worcester and at South Boston will probably be needed, 
unless we adopt some new plan of provision for the insane. 
Otherwise, the wards of our asylums will soon be filled to 
overflowing; and this overcrowding, to be found pretty much 
over our whole country, increases excitement in the patients, 
and renders their classification and management much more 
difficult. Massachusetts is as well provided as any State, 
probably, in this respect; and yet there are now in our 
* This is somewhat less than are provided for in Scotland and England in asylums 
and departments for the insane of workhouses. Disease of the Mindl. 
81 
asylums 500 more patients than can be properly accommo- 
dated in them. 
Yery fewr of our States, indeed, have provided sufficient 
hospital accommodation for their insane, and we may well 
take a lesson from their experience. In regard to this point, 
Dr. Mark Ranney, the well-known superintendent at Mount 
Pleasant, lowa, writes : 
“In every State in the Union, the attempt or prevailing custom 
of keeping the common or ordinary pauper and the insane in the 
same poorhouse, with the prevailing want of proper separation and 
classification, has been a scandal and a reproach. 
“ The fact that the two hospitals for the insane in this State, with 
a capacity suitable for only 550, contain to-day about 865 patients, 
while there arc at least, or not far from, 1,200 insane, is of itself 
sufficient evidence that there are not adequate provisions for the 
insane in this State. In this particular, however, Ido not suppose 
we are much behind many or most other States, the newer as well 
as the older. Like some other States, lowa has provided for the 
building of a very expensive hospital,—unnecessarily expensive in 
my opinion,—now about half completed, which will cost about 
$1,000,000, or about $2,000 per patient. 
“ I apprehend that this great outlay wdll have the effect, as similar 
outlay elsewhere has had, in the opinion of some, to prevent ade- 
quate provision being made of a cheaper but in every way suitable 
character. It has long seemed to me very inconsistent to provide 
so expensively for one-half of the insane and doom the other half, 
equally deserving, to poorhouses or receptacles that at the best are 
no better than they should be, or to severe struggles with want and 
privation in the hands of their friends. I have }Tet to see reason 
to believe that a hospital costing $2,000 per head will be more con- 
ducive to the recovery of patients from insanity than one costing 
only $l,OOO, or even less.” 
Dr. Andrew McFarland of Illinois, an alienist of large ex- 
perience, says:— 
“ The history of the relation of the State to the insane here is 
soon told, and probably has its counterpart in most other States. 
In 1847, Miss D. L. Dix, after extensive exploration, drew a most 
appalling picture of the condition of the insane in the State, which 
she embodied in a memorial to the Legislature. The establishment 
of a state hospital followed, which was opened in 1851. But it filled 
up at once, with no perceptible relief to the accumulating mass. 82 
Disease of the Mind. 
The State was slow in proceeding further, and soon the picture of 
1847 might have been drawn in even darker colors. By 1867 the 
accommodations were doubled, and still no relief. We now have 
three state hospitals, first-class in size, with a county asylum near 
Chicago, equal in capacity; yet with all this, we get no apparent 
relief. It is not surprising that intelligent legislators ask, ‘ How 
long is this to go on, and are you sure your lead is in the right 
direction ? ’ ” 
Dr. C. F. McDonald, superintendent of the asylum for 
the criminal insane at Auburn, N. Y., writes : 
“ ‘ Overcrowded’ seems to be the fixed condition of almost every 
insane hospital in the country. In looking over the reports of 
American institutions for the insane, one is struck with the fact that 
in almost none is the subject of overcrowding not considered. In 
fact, allusion to the topic is so common, that I have come to doubt 
if we shall ever see the time when we can say, ‘ Our provisions for 
our insane population are adequate.’ ” 
And Dr. A. Reynolds, of the state asylum at Independ- 
ence, lowa, adds : 
“No state west of the Alleghanies has adequate hospital capacity 
for her insane. Until hospitals are built at a less cost per capita 
than $l,OOO, it is useless to talk of providing for all the insane of 
the State.” 
Supervision by the State. 
Committal to Asylums. 
The late Dr. Samuel G. Howe, after twenty years’ official 
relation with some of our public establishments for the insane, 
and after ten years’ experience as visitor to all the state hos- 
pitals of Massachusetts, said : * "All human institutions are, 
of course, liable to abuse, but our Massachusetts hospitals for 
lunatics are as well guarded against them,as any public estab- 
lishments with which I am familiar”; and again, "there are 
rather too many than too few difficulties in the way of commit- 
tal” of patients to insane asylums in our State. 
Although a different position is held in the report of the 
commissioners of lunacy, appointed for a single year, who 
* Boston Daily Advertiser, March 22, 1873. Disease of the Mind. 
83 
reported to the Legislature, January, 1875, there are no facts 
given there in support of that opinion ; but recent investiga- 
tions at Tewksbury and at Westborough seem to indicate that 
there is fault either in the laws or in their execution. 
Improper Committals. 
It has been urged before our legislatures, that many persons 
insane and not insane are improperly confined in our asylums, 
and that many complaints are made by patients which could 
best be attended to by an impartial commission. 
As to improper confinements, our superintendents have 
testified that they are rare, soon discovered, and promptly set 
right. They must occur occasionally, so long as human judg- 
ment is fallible, but no wisdom or foresight can always prevent 
them. The very professor of mental disease, some years ago, 
in one of the first German universities, with the benefit of a 
consultation of the hospital staff, was committed to an insane 
asylum when suffering from typhoid fever. 
In looking over a pile of American reports, the first two in 
which I find any mention of this point are from Utica, N. Y., 
and Dixmont, Penn., justly considered as among our best 
institutions. In the asylum at the former place, of 11,831 
patients admitted from 1843 to 1875, 175 were found not to 
be insane. Of 2,981 consecutive admissions at Dixmont there 
was no insanity in ten cases. But in all these cases, which 
included dipsomaniacs, opium-eaters, and others suffering 
under some form of delirium, there was not one of intentional 
deception or illegal committal. 
In some forms and degrees of mental disease, no more per- 
plexing questions come before the expert than whether to send 
to asylums, when to send to asylums, and when to advise 
removals; and here there is room for very wide differences 
of opinion. The only thing we can do is to provide as many 
safeguards as possible, the greatest of which is in the high char- 
acter of our superintendents. These men should have large 
powers, duly guarded, should be held to a strict accountability, 
and should be trusted by the officers of the State, in order 
that they may get the confidence of their patients. 84 
Disease of the Mind. 
More or Better Supervision Needed. 
Without maintaining that, with all the supervision now got 
by the patients in our Massachusetts asylums, there is need 
of another commission to still further protect their rights (a 
need which is now urgently felt in some of our States), it can 
hardly be doubted that great benefit would arise from more sys- 
tem and better methods in such inspection. The advantages 
of well-organized supervision cannot be better stated than in the 
experience of a State which has already tried the* experiment. 
By a law passed in 1876, all the asylums (of all kinds) in Kan- 
sas were placed under one board of trustees; and in their 
report on the insane asylum at Ossawatomie, they say,— 
“It gives a uniform direction to their management; ... it 
enables them to compare the advantages and disadvantages of the 
different systems of management, and to abolish the evil and in- 
graft the good features thereof into each to their benefit; it occa- 
sions a close scrutiny of the condition and requirements of each, 
and it has resulted in a large reduction of the expense” * 
One of the most distinguished alienists in England said, 
after carefully visiting thirteen of our asylums, and studying 
our customs pretty thoroughly,— 
“Unless I am much mistaken, the superintendents of asylums 
in America have a heavy task before them, which will indeed require 
a determined effort before they can say that they possess' the confi- 
dence of the public in the same degree to which of late years it has 
been extended, in England, to the management of our county asylums 
and hospitals for the insane. With us, the management of our &sy- 
lums is open and patent. Abuses occur, as the}7' will occur every- 
where ; but they are remedied, and, if need be, punished in the most 
public manner, and the records of them are displayed to the world.” f 
There are many particulars, indeed, beyond protection of 
the rights of the insane, in which a properly constituted com- 
mission, if wisely selected, might be of use, especially in 
collecting facts and diffusing information for the use of the 
Uses of a Commission. 
* The asylum now building at Topeka for tha insane will cost less than one-fourth 
as much per patient as sonic of those recently built in other States. 
f The Lancet. London, 1876. Disease of the Mind. 
85 
public; for insanity is, as Sir James Coxe says, a disease of 
ignorance; and our chief reliance in arresting its progress 
must be in an increase of knowledge among those who may 
be considered liable to it. The public has the right, too, of 
knowing just how asylums are conducted; and the fact that 
the affairs of all of them were to be open to inspection, would 
tend to increase popular confidence in their management. 
False Position of American Association. 
The American Association of Superintendents have opposed 
lunacy commissions. They refer to the humiliating story of 
our Indian commissions, etc., and think that such a body as 
is likely to be appointed at Washington would be of negative 
use, or do at least as much harm as good,—an argument 
which, unfortunately, must be acknowledged to have very 
great weight. They assume, too, that the State would do 
unwisely to interfere with the absolute control, which they 
think superintendents of insane asylums should have over 
those committed to their charge. They say :*— 
“ If the time shall ever come when the Legislature, in its zeal for 
the public good, shall establish a board of officers to supervise the 
medical practice of the State, with power to enter every sick man’s 
chamber, to inquire respecting the medicine and diet prescribed, and 
any other matter connected with his welfare, and report the results 
of their examination to the constituted authorities, then it may be 
proper to consider the propriety of extending the same kind of 
paternal visitation to the hospitals for the insane,” 
Whatever opinion we may have as to the necessity of 
governmental supervision, there can never be any analogy 
between the two cases until our laws are very different from 
those now in force. A sick man, in his chamber, is sur- 
rounded by his dearest friends and relatives, who sacrifice 
their own comfort to his needs. In the asylum, his wants are 
administered to exclusively by those who are paid to do so; 
he cannot select his physician, he cannot change his nurse, 
he cannot order his food or discharge his cook, and often 
does not communicate with his friends for many weeks. 
It is difficult to conceive that such a position could be taken, 
except from a very narrow standpoint, and with an undue 
* Resolutions, 1874. 86 
Disease of the Mind. 
sensitiveness as to public opinion. It would not be likely, 
for instance, in a society like the British Medico-Psychological 
Association, composed of medical superintendents, assistant 
physicians in asylums, physicians in general practice, .justices 
of the peace, and lawyers. 
Complaints of Discharged Patients. 
The complaints of discharged patients and of patients in 
asylums, if investigated by a fair commission, might be more 
satisfactorily disposed of than at present, and would often 
relieve the superintendents of undeserved censure. To give 
full and not undue weight to such complaints would require 
an intimate knowledge of mental disease, and a familiarity 
with the history of the complainant which the public cannot 
get. They are often plausible, frequently trivial, and arouse 
the sympathies of philanthropic people to a degree not al- 
ways proportionate to their importance, although sometimes 
far otherwise. The really sensible criticisms which one gets 
on our asylums come chiefly from persons who have recov- 
ered, and who avoid rather than seek notoriety. 
For the purpose of considering the bearing of this ques- 
tion, discharged patients may be classified as follows: Ist. 
Those who have recovered, and whose minds were clear 
enough, during a considerable part at least of their illness, to 
have received clear impressions of what was going on about 
them, and who have remembered with tolerable accuracy,— 
by no means an insignificant number. 2d. The same as the 
above, except that they have not remembered. 3d. Those 
who have recovered, and whose minds were absolute blanks 
during the time of their severe illness, so that they remember, 
absolutely nothing of that time, and more or less imperfectly of 
their period of convalescence. 4th. Those who have recovered, 
and whose impressions during a large part of their residence 
in the asylum were more or less tinged by their own delu- 
sions ; of whom some finally recognize the delusional char- 
acter of their previous ideas, and others never do so, although 
in other respects perfectly well. 
There are four other classes corresponding to these, with 
the single difference that they have never recovered. Disease of the Mind. 
87 
It would be very unjust and untrue to say that there are 
not many discharged patients from insane asylums whose 
testimony and general statements are fully as trustworthy as 
those of other people. But there are many others also, 
from whose minds the false impressions once made are not 
removed, and it is often a matter of the greatest difficulty for 
even an expert to decide between the two. 
The superintendents of the asylums might easily dispose of 
many loud accusations and complaints by publishing a few 
pages from their records, and showing to the public the real 
facts in such cases. This, however, their sense of honor 
forbids their doing, for their patients’ secrets are held by 
them as a sacred trust. 
The impression which is sometimes given, that the mere fact 
of a discharged patient’s making complaints or criticisms in 
regard to asylum management is ipso facto evidence of incom- 
plete recovery, and that those entirely well always speak 
favorably of everything that happened to them during their 
illness, does not need consideration here. 
Best Supervision. 
The best supervision consists in frequent visits of friends 
of patients, and this has lately been done to a great extent, 
particularly in asylums of the McLean type, although begun 
and extensively adopted nearly twenty years ago under Dr. 
Walker at the South Boston Asylum, and now considered by 
many of our superintendents as one of the most important 
points to be thought of in locating new asylums. Dr. Clous- 
ton of Edinburgh thus speaks of this important matter in 
his report for 1875 ; 
“ We are in this peculiar and almost unique position in Scotland, 
that while our number of yearly admissions increases, our numbers 
left at the end of the year have diminished for the past three years* 
There are several causes for this. Our recoveries are very numer- 
ous, and a large number of unrecovered but quiet cases are removed, 
at my advice, by their friends. Our proximity to town and the 
extraordinarily ready access provided by the tramways are circum- 
stances which most people, and among them many high authorities 
in lunacy matters, would consider great disadvantages. Their effect 88 
Disease of the Mind. 
is to bring the relatives of our poorer patients out to the asylum to 
visit them, to an extent quite unknown in country asylums. In this 
way, an interest in them is kept up, and very few of them indeed are 
forgotten and neglected their kith and kin. This is an influence 
•which often saves them from falling into incurable insanity; it 
gives many of them unbounded pleasure, it keeps alive home feelings 
and associations, and it brings a direct public opinion of the most 
unsleeping and critical kind to bear on the officers and attendants 
of the institution—all matters of incalculable importance and much 
difficulty of attainment, 
“ When the relatives see that the acute symptoms have passed 
off, they are often disposed to take them out for a day or two to see 
how they get on. If this succeeds they try them at their usual 
employments, and, if they do well, are often anxious to have them 
home altogether. It is by tins most natural of all means that any 
undue accumulation of the incurably insane has been avoided for the 
past three 3mars, and the problem of how to provide for such, which 
is so urgent in many parts of the kingdom, has been solved 
for us at no cost to the rates whatever. I And from the report of 
the commissioners in lunacy that Edinburgh is the only county in 
Scotland the majority of whose population is urban, where the 
numbers of the registered insane, whether in asylums or not, have 
absolutely diminished for the last three years.” 
Another beneficial result of this frequent visitation is noted 
in higher standards of excellence, and consequently increased 
confidence of the community. In commenting on the fact 
that 1,026 patients were treated in the year passed (1875), 
without the occurrence of a single suicide, untoward accident, 
or case of epidemic disease, although extensive alterations in 
the asylum were making, the report continues;— 
“In addition to the requisites of a good ordinary hospital, in 
the way of light and air, ventilation and cheerfulness, sanitary 
apparatus and baths, and convenience of administration, we require 
extended and varied means of occupation and amusement, day- 
rooms, dining-rooms, and workshops of all kinds, extensive gardens 
and farms, pleasure-grounds, and billiard-rooms, etc. The extreme 
importance of the curative aspect of the institution, as distinguished 
from its boarding-house character, is amply attested by the enormous 
and increasing number of admissions of recent cases.” 
This statement may well be considered carefully, where 
decreased confidence on the part of the community is com- Disease of the Mind. 
89 
plained of as a cause of fewer admissions of acute cases.* 
Can we not, too, in some such way, reduce the accumulation 
of chronic cases in our public institutions and diminish that 
unfortunate class described by Maudsley as " asylum-made 
lunatics ”? 
The first patient admitted to a Massachusetts insane asylum 
was a person brought by his own father, who thought the 
young man to be possessed of a devil, and whose treatment 
consisted in whipping him. From that day to this, although 
the ideas of the people have very much changed and more 
enlightened views prevail, no one familiar with the insane 
can, I think, for a moment doubt that they often are treated 
with more uniform consideration and kindness in our best 
asylums than by their own friends in their own homes. Indi- 
vidual and striking illustrations of this statement are con- 
stantly brought under the observation of the officers of 
asylums. 
It is the opinion of asylum superintendents, too, almost 
universally throughout the country, that, taking all things 
into consideration, treatment in an asylum gives the most 
chances of a cure f in the majority of cases, in spite of the fact 
that, as they are now constructed, the good of the individual 
must be occasionally sacrificed to conform to requirements 
deemed necessary for others, but not needed by him. 
We must not think, however, that an asylum, as now exist- 
ing, is the only thing possible or the best thing practicable in 
Good Asylums, as a Rule, Better than Homes. 
* The fact is that the two are not necessarily at all connected. If the community 
simply learn to trust asylums more, they will send more of their friends to them, 
until they are full;.if they learn, also, that the chief object of the asylum is curative, 
that the wards are not crowded to excess with inmates who would be better off else- 
where, and that the idea in treatment is to keep people out of asylums, as far as is 
practicable, they will act accordingly. 
f This opinion is, of course, entitled to great weight; but the statistics upon which 
it is sometimes based do not prove the fact. It is stated, for instance, that of those 
who enter an asylum early, from seventy to ninety per cent, are cured, and in a short 
time; while the others are incurable just about in proportion as their friends delay 
sending them to asylums. If, in similar way, we grouped all pulmonary diseases 
together, we might prove that a large proportion of cases of pleurisy and lung fever 
get well because the symptoms in those diseases are early severe enough to make 
hospital treatment or rest in bed necessary, and that consumptives never get well 
because they never seek hospital treatment until progressive weakness compels them 
to do so, or until the disease is far advanced,—a manifest reductio ad absurdum. 90 
Disease of the Mind. 
all cases. Florence Nightingale, in 1876, summed up her 
great experience in these words, " Hospitals are but an inter- 
mediate stage of civilization. At present, hospitals are the 
only place where the sick poor can be nursed, or, indeed, 
often the sick rich. But the ultimate object is to nurse all 
sick at home.” Sir James Simpson devoted the ripest years 
of his life to opposing the agglomeration of disease of all 
kinds. Sir James Coxe, after forty years’ active work in the 
medical profession, and nearly twenty years on the lunacy 
commission of Scotland, attaches no therapeutic value to 
insane asylumus, but regards them simply as conveniences. 
Professor Meynert tells the physicians from all parts of the 
world, who listen to his lectures in Vienna, that something is 
lost in all cases although more is generally gained, in sending 
an insane person to an asylum. Maudsley, Blandford and 
others treat even some of the most violent forms of mental 
disease in private houses in those rare cases when the circum- 
stances, surroundings and associations of their patients are 
such that they can command anything that is needed for their 
proper treatment; and cures are often more rapid thus. The 
cases are decidedly the smaller number, however, where home 
treatment of insanity can be recommended, and the points in 
which our asylums excel are growing more from year to year. 
Project of a Law. 
The American Association of Superintendents, a half-dozen 
years ago, prepared a project of a law, which has become a 
statute in Pennsylvania, giving their views upon this general 
question. So far as they go they are admirable, and are 
given here entire as dealing‘with an important subject:— 
“ The Association of Medical Superintendents of American Institutions 
for the Insane, believing that certain relations of the insane should be regu- 
lated by statutory enactments calculated to secure their rights and also 
the rights of those intrusted with their care, or connected with them by 
ties of relation or friendship, as well as to promote the ends of justice, and 
enforce the claims of an enlightened humanity, for this purpose recommend 
that the following legal provisions be adopted by every State whose existing 
laws do not already satisfactorily provide for these great ends:— 
“1. Insane persons may be placed in a hospital for the insane by their 
legal guardians, or by their relatives or friends, in case they have no guar- 
dians ; but never without the certificate of one or more reputable physi- 
cians, after a personal examination, made within one week of the date Disease of the Mind. 
91 
thereof; and this certificate to he duly acknowledged before some magis- 
trate or judicial officer, who shall certify to the genuineness of the signa- 
ture, and to the respectability of the signer. 
“2. Ins,ane persons may be placed in a hospital, or other suitable place of 
detention, by order of a magistrate, who, after proper inquisition, shall find 
that such persons are at large, and dangerous to themselves or others, or 
require hospital care and treatment, while the fact of their insanity shall 
be certified by one or more reputable physicians, as specified in the pre- 
ceding section. 
“3. Insane persons may be placed in a hospital, by order of any high 
judicial officer, after the following course of proceedings, viz.: On state- 
ment in writing, of any respectable person, that a certain person is insane, 
and that the welfare of himself, or of others, requires his restraint, it shall 
be the duty of the judge to appoint, immediately, a commission who shall 
inquire into and report upon the facts of the case. If, in their opinion, 
it is a suitable case for confinement, the judge shall issue his warrant for 
such disposition of the insane person as will secure the objects of the 
measure. 
“4. The commission provided for in the last section shall be composed of 
not less than three, nor more than four persons, one of whom, at least, shall 
be a physician, and another a lawyer. In their inquisition they shall hear 
such evidence as may be offered touching the merits of the case, as well as 
the statements of the party complained of, or of his counsel. The party 
shall have seasonable notice of the proceedings, and the judge is author- 
ized to have him placed in suitable custody while the inquisition is pending. 
“5. On a written statement being addressed by some respectable person 
to any high judicial officer, that a certain person, then confined in a hospi- 
tal for the insane, is not insane, and is thus unjustly deprived of his liberty, 
the judge, at his discretion, shall appoint a commission of not less than 
three, nor more than four persons, one of whom, at least, shall be a physician, 
and another a lawyer, who shall hear such evidence as may be offered touch- 
ing the merits of the case, and, without summoning the party to meet them, 
shall have a personal interview with him, so managed as to prevent him, if 
possible, from suspecting its objects. They shall report their proceedings to 
the judge, and if, in their opinion, the party is not insane, the judge shall 
issue an order for his discharge. 
“6. If the officers of any hospital shall wish for a judicial examination 
of a person in their charge, such examination shall be had in the manner 
provided in the fifth section. 
“7. The commission provided for in the fifth section shall not be repeated, 
in regard to the same party, oftener than once in six months; and in regard 
to those placed in a hospital under the third section, such commission shall 
not be appointed within the first six mouths of their residence thei’eiu. 
“8. Persons placed in a hospital under the first section of this act may be 
removed therefrom by the party who placed them in it. 
“9. Persons placed in a hospital under the second section of this act 
may be discharged by the authorities in whom the government of the hospi- 
tal is vested. 
“ 10. All persons, whose legal status is that of paupers, may be placed in 
a hospital for the insane by the municipal authorities who have charge of 
them, and may be removed by the same authority, the fact of insanity be- 
ing established as in the first section. 
“ 11. On statement in writing to any high judicial officer, by some friend 92 
Disease of the Mind. 
of the party, that a certain party placed in a hospital under the third sec- 
tion is losing his bodily health, and that consequently his welfare would he 
promoted hy his discharge, or that his mental disease has so far changed its 
character as to render his further confinement unnecessary, the judge shall 
make suitable inquisition into the merits of the case, aud according to its 
result, may, or may not, order the discharge of the party. 
“ 12. Persons placed in any hospital for the insane may be removed there- 
from by parties who have become responsible for the payment of their 
expenses; provided that such obiigation was the result of their own free 
act and accord, and not of the operation of law, aud that its terms require 
the removal of the patient in order to avoid further responsibility. 
“ 13. Insane persons shall not be made responsible for criminal acts in a 
criminal suit, unless such acts shall be proved not to have been the result, 
directly or indirectly, of insanity. 
“14. Insane persons shall not be tried for any criminal act during the 
existence of their insanity ; and for settling this issue one of the judges of 
the court by which the party is to be tried shall appoint a commission, con- 
sisting of not less than three, nor more than five persons, all of whom shall 
be physicians, aud one, at least, if possible, an expert in insanity, who shall 
examine the accused, hear the evidence that may be offered touching the 
case, and report their proceedings to the judge, with their opinions respecting 
his mental condition. If it be their opinion that he is not insane, he shall be 
brought to trial; but if they consider him insane, or are in doubt respecting 
his mental condition, the judge shall order him to be placed in some hospital 
for the insane, or some other place favorable for a scientific observation of 
his mental condition. The person to whose custody he may be committed 
shall report to the judge respecting his mental condition, previous to the 
next term of court, and if such report is not satisfactory, the judge shall 
appoint a commission of inquiry, in the manner just mentioned, whose 
opinion shall be followed by the same proceedings as in the first instance. 
“ 15. Whenever any person is acquitted in a criminal suit, on the ground 
of insanity, the jury shall declare this fact in their verdict; and the court 
shall order the prisoner to be committed to some place of confinement for 
safe-keeping or treatment, there to be retained until he may be discharged 
in the manner provided in the next section. 
“ 16. If any judge of the highest court having original jurisdiction shall 
be satisfied by the evidence presented to him that the prisoner has recov- 
ered, and that the paroxysm of insanity in which the criminal act was com- 
mitted was the first and only one he had ever experienced, he may order 
his unconditional discharge ; if, however, it shall appear that such paroxysm 
of insanity was preceded by at least one other, then the court may, in its 
discretion, appoint a guardian of his person, aud to him commit the care of 
the prisoner, said guardian giving bonds for any damage his ward may com- 
mit : provided, always, that in case of homicide, or attempted homicide, the 
prisoner shall not be discharged unless by the unanimous consent of the 
superintendent aud the managers of the hospital, and the court before which 
he was tried. . 
“ 17. If it shall be made to appear to any judge of the supreme judicial 
court, or other high judicial officer, that a certain insane person is mani- 
festly suffering from the want of proper care or treatment, he shall order 
such person to be placed in some hospital for the insane at the expense of 
those who are legally bound to maintain him. 
“ 18. Application for the guardianship of an insane person shall be made Disease of the Mind,. 
93 
to the judge of probate, or judge having similar jurisdiction, who, after 
a hearing of the parties, shall grant the measure, if satisfied that the per- 
son is insane and incapable of managing his affairs discreetly. Seasonable 
notice shall he given to the person who is the object of the measure, if at 
large, and if under restraint, to those having charge of him; but his pres- 
ence in court, as well as the reading of the notice to him, may be dispensed 
with if the court is satisfied that such reading or personal attendance would 
probably be detrimental to his mental or bodily health. The removal of 
the guardianship shall be subjected to the same mode of procedure as its 
appointment. 
“ 19. Insane persons shall be made responsible, in a civil suit, for any 
injury they may commit upon the person or property of others; reference 
being had in regard to the amount of damages to the pecuniary means of both 
parties, to the provocation sustained by the defendant, and any other cir- 
cumstance which, in a criminal suit, would furnish ground for mitigation 
of punishment. 
“ 20. The contracts of the insane shall not be valid, unless it can he 
shown either that such acts were for articles of necessity or comfort, suit- 
able to the means and condition of the party, or that the other party had 
no reason to suspect the existence of any mental impairment, and that the 
transaction exhibited no marks of unfair advantage. 
“ 21. A will may be invalidated on the ground of the testator’s insanity, 
provided it be proved that he was incapable of understanding the nature 
and consequence of the transaction, or of appreciating the relative values 
of property, or of remembering and calling to mind all the heirs-at-law, or 
of resisting all attempts to substitute the will of others for his own. A will 
may also be invalidated on the ground of the testator’s insanity, provided 
it be proved that he entertained delusions respecting any heirs-at-law calcu- 
lated to produce unfriendly feelings towards them.” 
Dr. BucknUVs Letter. 
There is another point in regard to the supervision of the 
insane, which has not been considered by the writer, but 
which may become of importance, as our communities grow 
in wealth, if indeed it is not such already. It is a matter 
which the customs of England made necessary in very early 
days; and, although we should not be likely to adopt precisely 
the same method to accomplish such an end, it has seemed 
best to give an account ot what has been done there in the 
following interesting and important letter from Dr. Bucknill, 
for many years Lord Chancellor’s Visitor, and still earlier a 
superintendent of large experience : 
“39 Wimpole Street, W. London, ) 
“ November 28, 1876. 5 
“ My Dear Sir :—You have set me by no means an task, but 
I will endeavor to give you at least a sketch of the function of the 
Lord Chancellor’s Visitors of Lunatics. 94 
Disease of the Mind. 
“ It seems quite correct to say that the charge and control of 
the Lord Chancellor over lunatics is derived from feudal custom, 
under which the Crown assumed, as part of its prerogative, the care 
and custody of those who from want of understanding were incapable 
of taking care of themselves. This rojal prerogative existed before 
the statute of 17 Edward 11., called Prerogativa Regis, which is 
declaratory only. [See Elmer’s Practice in Lunacy.] And although 
Elmer thinks that the sovereign acted in this matter as parens patrice, 
it seems more probable that this power was assumed as the head or 
chief of the military force. A lunatic vassal not being able to render 
that service upon which the tenure of his land depended, in conse- 
quence of his being non compos mentis, the sovereign assumed, for 
the time being, the direct control of his property, most property in 
those ages being in the form of landed possessions. 
“I do not think that I need trouble you with any account of the 
manner in which the Crown deputes its authority over lunatics, under 
the sign manual, to the Lord Chancellor, assisted in later years by 
the Lords Justices of Appeal, nor with the somewhat nice and 
difficult question of the point where matters in lunacy cease to be 
under the royal prerogative and come under the ordinary jurisdiction 
of the Court of Chancery. 
“ The control and custody of lunatics the Lord Chancellor 
under the.sign manual, is now regulated by several Acts of Parlia- 
ment, called the Lunacy Regulation Acts. The earliest of these is 
dated July 24, 1833; the second, August 15, 1853; and the third 
and last, August 7, 1862. 
“ The most important officials whose powers are created and 
defined under these Acts are the masters in lunacy, whose duty it is 
to preside, as judges under the great seal, at all inquiries as to the 
soundness or unsoundness of mind of any person alleged to be of 
unsound mind and incapable of taking care of himself and his affairs. 
This inquiry is called an inquisition, and takes place in consequence 
of an order to that effect of the Lord Chancellor, which order is the 
result of a petition from some person or persons interested, or of 
information given to the Lord Chancellor, that a certain person, be- 
ing of unsound mind, has property which is not properly protected. 
“ In the initial stage, all these proceedings have reference to the 
care of the property, rather than to that of the person of the lunatic. 
After the person has been found lunatic by inquisition, the master 
has to ascertain what property he possesses, and who are interested 
in it as the heir-at-law and the next of kin. They have to devise a 
scheme for the proper care and expenditure of the property, and for 
the proper care and treatment of the lunatic, and fur this purpose 
they nominate two very important officials in each case, who are Disease of the Mind. 
95 
respectively called the Committee of the Person and the Committee 
of the Estate. As a general rule, the Committee of the Person is 
the next of kin or some one who has an interest in the continuance 
of the life of the lunatic, while the Committee of the Estate is the 
heir-at-law, who naturally has a strong interest in the protection of 
the property, and, as may be expected, these interests very frequently 
conflict. 
“ The Committee of the Estate receives the proceeds of the prop- 
erty, hands over to the Committee of the Person so much of it as he 
ma}r be ordered to do by the court, for the maintenance of the lunatic, 
and accounts for the whole to the Master in Lunacy. 
“ The Committee of the Person has the charge and care of the 
lunatic and of his treatment. He ought to expend upon his care, 
treatment, comfort and pleasure the whole of the moneys he receives 
for that purpose. He enjoys a very wide liberty and choice as to 
the manner in which he discharges the duties he has undertaken, 
and he is exertfpted, in many important respects, from the operation 
of the lunacy laws as they apply to persons who are of unsound mind, 
but have not been so found by inquisition ; for instance, he has the 
power of placing the lunatic in any asylum without medical certifi- 
cates. It is the main function of the Lord Chancellor’s Visitors to 
ascertain the manner in which the Committee of the Person dis- 
charges his duties and to report them to the Lord Chancellor. 
“ The appointment and powers of the Visitors were first enacted 
in 1833, 3 and 4 Guilielmi IV., under which, section second, 
two physicians and one barrister were appointed for the purpose of 
4 superintending, inspecting and reporting upon the care and treat- 
ment of all persons found idiot, lunatic, or of unsound mind by 
inquisition.’ 
“The visits under this statute were only once a year, and the 
superintendence, therefore, could not be very stringent. 
“Twenty years afterwards another statute, 16 and 17 Vic., cap. 
70, further defined the duties of the Visitors, and constituted them 
into ‘ a board for their mutual guidance and direction in matters 
connected with the visitors of lunatics,’ and at the same time 
subjecting them as to the times, rotation and manner of their visita- 
tions to the general orders of the Lord Chancellor, which general 
orders, often having been laid before Parliament and not having 
been objected to by Parliament, then acquired the force and 
validity of law. 
“Such general orders were made and issued on the 12th of 
January, 1855, by Lord Cranworth, the then Lord Chancellor, with 
the advice and assistance of Lords Justices Knight, Bruce and 
Turner; and notwithstanding the important alterations made in 96 
Disease of the Mind. 
lunacy regulations by the statute of 1862, these general orders of 
1855 still form a main part of the law under which the visitors must 
act. 
“ The second and third of these general orders are the most im- 
portant, and are as follows : 
“ * 2. That the medical visitors of lunatics do on each occasion of visit- 
ing any lunatic, inquire and examine whether such lunatic is maintained 
in a suitable and proper manner, having regard to the then existing 
amount of the allowance ordered to be paid, and the then existing scheme 
approved of for the maintenance of such lunatic; and also, whether hav- 
ing regard to the then fortune and income of such lunatic it appears 
expedient that any, and what, addition should be made to his comforts, 
or any, and what, alterations should be made in the scheme for or manner 
of his maintenance. 
“ ‘ 3. That if the said visitors shall, on such inquiry and examination, con- 
sider that the lunatic is not maintained in such suitable and proper manner 
as is aforesaid; or that the allowance provided for his maintenance is not 
duly applied; or that any provision in the scheme for his maintenance, 
either for his personal comfort or enjoyment, or otherwise, is not duly 
observed; or that any addition to the comforts, or any alteration in the 
manner of the maintenance of the lunatic should be made, to which his 
then fortune or income is capable of providing, they shall forthwith make 
a special report, stating such their opinion, and the grounds thereof to 
the Board of Visitors.’ 
“ The fourth order directs that the Board of Visitors shall consider 
the report made to them by the individual visitor, and, if they think 
fit, refer it to the masters, ‘ or take such other steps therein as may 
appear to them to be expedient.’ 
“ The fifth order directs that the masters may investigate any such 
report, and make such report to the Lord Chancellor as they ‘ may 
deem proper.’ 
“In 1862, a new Act of Parliament was passed, under the old 
title of Lunacy Regulations, 25 and 26 Vic., cap. 86, by which the 
visitations to Chancery lunatics living in private houses were 
increased from once to four times a year, the duties of the visitors 
being left otherwise very much as they were fixed by the earlier 
statutes and defined by the general orders which I have quoted. 
“ These duties, as fixed by the statutes, by the general orders, 
and by the direction of the Board, may briefly be defined as follows : 
England and Wales are divided into three districts, each of which is 
taken by each visitor in rotation ; that is to say, for two consecutive 
visits to patients living in private houses. 
“ Each patient living in a private house is visited once in each 
quarter of a year, each patient living in an asylum is visited once a Disease of the Mind. 
97 
3'ear. This distinction is made by the .statute of 1862, no doubt, 
on the ground that all lunatics residing in asylums are also visited 
by the commissioners in lunacy and in the provinces by justices of 
the peace, acting, either as visitors of licensed houses or as visiting 
justices of county asylums, whereas lunatics residing in private 
houses are visited only by the Lord Chancellor’s visitors. 
“ The visitors have to inquire and report upon these several 
heads: 1. The state of mind of the lunatic. 2. His bodily condi- 
tion. 3. His care and treatment, having regard to the due provision 
of comforts ordered for him by the court and to the amount of his 
income. 
“ If everything is satisfactory on these heads, they have to report 
thereon to the Lord Chancellor direct; but if on the contrary, they 
have to make what is called a special report, which is made, in the 
first instance, to their board, by whom it is dealt with either ; (1) by 
calling the committee before them, to whom the fault found is com- 
municated, and by whom, in manj’ instances, amendment is promised 
and carried out; (2) by referring the report to the masters, who 
have large powers of control over the committees, deputed to them 
by the Lord Chancellor; (3) by reporting directly to the Lord 
Chancellor himself. 
“ In the great majority of cases the special reports of the visitors 
have reference to some neglect of duty on the part of the Committee 
of the Person by which the lunatic suffers ; and, in the event of the 
committee proving refractory to the reasonable demands of the 
visitors, the Lord Chancellor may, as a dernier ressort, dismiss him 
from his office. In a smaller number of cases the special report has 
reference to an inadequate allowance made from the estate for the 
maintenance of the lunatic, and in another class of cases the special 
reports have reference to the recovery of the lunatic, in wffiich case 
the former lunatic has to present a petition to the court that his 
inquisition majr be superseded. Such is the system which j’ou ask 
me to explain,—not a very simple one I fear you will think,—but 
upon its merits or demerits I do not feel that I am in a position 
to offer an opinion. 
“ I am, my dear Doctor Folsom, 
“ Yours very sincerely, 
“John Charles Bucknill.” 
Certain Asylum Needs. 
It is a common opinion that purely mental exertion is the 
most common predisposing cause of disease of the mind, 
Education in Hygiene. 98 
Disease of the Mind. 
especially when joined with any of the three " causes ” most 
frequently assigned in the reports of our insane asylums; 
namely, heredity, intemperance, and ill-health. The first 
authorities, however, consider that such is not entirely the 
case; that emotional excitement, disappointed hopes, or some 
form of egoism are more frequently at fault, and that the best 
preventive of mental disease, even in those predisposed to it, 
is education, or wisely directed intellectual activity, leading to 
a knowledge of the proper ways of living. 
Although essentially a disease of high civilization, and not 
prevalent largely where there is little competition for the 
prizes of life, or where the struggle for existence involves the 
exercise of muscles rather than of brains, insanity prevails 
most, other things being equal, where thought stagnates. 
Even Pinel speaks of its rarity among those professions 
giving exercise to the intellectual and not the emotional 
faculties. 
"The more joints, the more rheumatism,” was the apt 
criticism on one of those marvels of workmanship that lately 
came from the hands of one of our microscope makers. In 
like manner, as our civilization becomes more complex, as our 
capacities for enjoyment intensify, so is the keenness of our 
suffering sharpened, so do the requisites for moral, mental 
and physical health become more numerous; and, unless a 
sound education gives us a correspondingly greater knowl- 
edge of that wonderful mechanism, the human body, disease 
of all kinds must increase. 
If, therefore, the mere healthy development of the brain in 
itself conduces to preserve its health, how doubly important 
that education becomes when it is made to teach general laws 
of nature, and the special course to be taken in each individ- 
ual case to preserve bodily and mental health. But what is 
done in our high schools, our colleges, our medical schools, 
or even in our asylums, to accomplish such a desirable result? 
We must answer, almost absolutely nothing. 
Even in our asylums, where the medical staff are busied 
with a multiplicity of routine duties, and have time for little 
else, the convalescents and sufferers from chronic illness not 
only do not get that information which many of them would 
gladly receive, and which would help them to maintain their Disease of the Mind. 
99 
health to a sufficient degree to remain at home when dis- 
charged, but they are not even taught the evils of persisting 
in a diet which surely adds to their chances of a relapse, or 
in habits as regards exercise, clothing, ventilation, etc., which 
certainly do not promote health. As a natural consequence, 
it often follows that they go home, refuse advice, continue in 
their erroneous methods of living, follow a course whoso log- 
ical result is a relapse or recurrent attack and return to the 
asylum with diminished chances of a permanent cure. 
Of course, it is not meant to say that there are not many 
who will neglect all advice, others who are mentally incapable 
of sufficient persistent effort to follow wise counsel, and a 
certain number whose predisposition to disease is so great as 
to render them unable to bear the trials common to the lives 
of most people without breaking down ; but experience justi- 
fies the statement that even with those who have had one 
attack of mental disease, a second may, in some cases, be 
warded off by wise methods of living. 
Better Hospitals and Trained JVurses. 
We recognize the fact that insanity is a disease of a purely 
material organ, and yet we go on building our hospitals for 
treating it essentially on the same plan as when they were 
simply regarded as prisons for confining persons dangerous 
to society; we do not provide a single ward* for the care ot 
those who need to be removed from the boisterous noise, 
occupation, and amusement, which are the only salvation for 
others to prevent their relapsing into incurable insanity ; and 
more important still, although we have many excellent attend- 
ants, of whose faithfulness and intelligent devotion to their 
work it is impossible to speak without some degree of enthu- 
siasm, we lack some system of training them for their work.f 
*- This is considered of great importance elsewhere. We find the following criti- 
cism by the Commission in Lunacy on an English asylum in 1875: “In connection 
with matters relating to the treatment of the sick, we desire again to draw attention 
to the want of a ward set aside as a hospital, and furnished with proper furniture and 
appliances for the patients laboring under bodily disease.” 
f In many establishments in France, as early as 1837, the attendants were required 
to have undergone a system of training previous to their appointment; and attend- 
ants were trained for other asylums at the retreat in York, forty years ago. In 
Scotland, the commissioners keep records of all attendants who have been discharged 
from any asylum for any gross fault, so that they cannot be employed again else- 
where, in ignorance of that fact. 100 
Disease of the Mind. 
In many of our asylums, we have not a single educated nurse* 
who knows how to care for any severe illness confining 
patients to their beds. 
This difficulty of getting trained nurses and attendants is 
one of serious moment. A dozen years ago it was nearly 
impossible, and the systematic and thorough education of them 
for their work began only since the Crimean war. Dr. Bell’s 
" Directions for Attendants ” is the earliest treatise which 
I have been able to find devoted to this important subject. 
Dr. Woodward published a similar one for the Worcester 
Asylum in the same year (1839) several years before Con- 
olly’s "Teachings for Attendants on Lunatics,” and a dozen 
years before Dr. Kirkbride’s and Dr. Curwen’s. Florence 
Nightingale’s "Notes on Nursing” came much later. It is 
not likely that these books have been heard of by many of 
our attendants, and it is possible to count on the fingers of one 
hand the places where this matter is arranged on a generally 
satisfactory basis. 
In two of the large hospitals of England (the London and 
St. Bartholomew’s) the nurses have only lately been relieved 
of the scrubbing. In our asylums we expect one person to 
be nurse, attendant, night-watch, companion to the patient, 
and wash the windows and scrub the back-stairs, all for a less 
sum than we pay to a second-rate cook. 
Dr. Maudsley and Dr. J. Crichton Browne have lately set 
on foot a plan for female nurses in male wards in insane 
asylums, and it is said " the presence of women nurses in the 
male wards is found to be much more effective in restraining 
outbursts of violence, abusive language and offensive habits 
than the presence of male nurses.” 
At the Mt. Hope Asylum, near Baltimore, the patients, 
nearly three hundred in number, are managed entirely by the 
sisters of charity. Physicians make regular morning visits, 
but none are resident. In each male ward there is one male 
attendant, subordinate to the two sisters in charge of that 
ward. The sisters say, themselves, that they have no serious 
trouble even with the most violent patients, and that, indeed, 
excitement in the men is even more readily quieted by them 
than by the male attendant. When visited, without warning, 
* In many European hospitals there arc both nurses and attendants. Disease of the Mind. 
101 
by the writer a few months ago, the wards were in excellent 
order, quiet, and without that untidiness which is usually 
found where men have sole charge. 
There are some admirable features about the asylum, which 
are certainly not common in this country. Some of the 
rooms of the convalescents and quiet chronic cases have win- 
dows without guards, as is the case in the passage-ways, in 
the pleasant chapel, entries, and in the cheerful entertainment 
hall, where patients likely to harm themselves or others never 
go without having attendants close at hand, if at all; a 
prison-like appearance is thereby avoided, wherever it seems 
easy to do so. The sisters devote themselves so closely to 
their charge, that they consider high fences and " airing- 
courts ” also unnecessary. We might well learn an important 
lesson from their work, which has been going on quietly for 
nearly half a century, since it was begun under the wise and 
thoughtful direction of the late Dr. Steuart.* 
In providing for the chronic, incurable insane, separating 
them from society, which is strong, and from the actually ill, 
who are weak, the Willard Asylum has proved a success; but 
nothing satisfactory has yet been done by us for those of 
the curable who are depressed by their ordinary surroundings 
in our asylums, as at present managed. Classification does 
not accomplish the desired result, where one roof covers such 
a diversity of disease and of mental condition ; but it would 
be a great error and injustice to make curability alone the 
basis of division ; for many of the chronic insane maintain 
their intelligence and self-respect, often help and cheer the 
curable, and would suffer if placed with dements. Those who 
are so far demented as to have lost their human identity 
should manifestly be kept away from the rest, just as much 
as from children or any others likely to be unfavorably influ- 
enced by association with them. With the comparatively 
small number whose condition is for a while a matter of some 
question, it would not be difficult to give them the benefit of 
the doubt. 
* See page 19. The Mount Hope Hospital was built by the sisterhood who 
were originally in charge of the Maryland Hospital under Dr. Steuart. 102 
Disease of the Mind. 
Medical Education. 
The matter of medical education is with us,*at the present 
time, a most pressing one. Its importance has long been 
recognized. Governor Adair in his message to the General 
Assembly of Kentucky, in 1821, urged as one reason for the 
establishment of a state insane asylum, that it "would prove 
highly beneficialto the medical school, which would, in time, 
repay the obligation by useful discoveries in the treatment of 
mental maladies ”; a prophecy which it is needless to say has 
not been fulfilled. 
Thirty years later, Dr. Pliny Earle, after his return from 
Europe, urged strongly the necessity of establishing pro- 
fessorships of mental disease, and finally that has been done 
in a few of our leading medical schools ; although, in one of 
the best, the lectures were first delivered in private parlors, 
as the faculty did not deem them of sufficient importance to 
be given at the college. 
In none of our medical schools, however, except in New 
York, is disease of the mind taught clinically by observation, 
although there is not one of importance in Europe where it is 
not so taught. As has been well said by Dr. Gray of Utica, 
"the evils of this lack of attention to the pathology of insan- 
ity, and want of knowledge of the true character of the 
disease, are much greater than the public are aware of. If 
the result was only an indifference to the whole subject by 
medical men, it would be bad enough, but it is far worse. It 
is the application of a false theory, which not only deprives 
the sufferer of proper treatment, which he has the right to 
claim, but subjects him to wrong and injurious treatment, 
and especially to neglect of remedies in the beginning when 
the disease is in its curable stage.” 
Formal lectures on such a subject are of just as much prac- 
tical use as in any other disease, and of no more. Without the 
hospitals of Paris, Vienna and Berlin, and the instruction at 
the bedside and in the dispensary all over the civilized 
world, Louis, Laennec, Oppolzer, Skoda and Traube might 
almost as well not have lived; their brilliant discoveries in 
the detection of the different forms of thoracic disease would 
have scarcely helped the world at large, and we should Disease of the Mind. 
103 
have gone on treating the cough which needs rest in bed 
in the same way with that which warns us to drive our 
patients out into the open air, thereby sacrificing many a life 
which we now save. 
The vague nomenclature, the supposed difficulty of diag- 
nosis and treatment, the assumed ground that insanity can be 
treated only by persons peculiarly gifted, and in nearly all of 
its forms in buildings specifically constructed, has conduced 
to this omission on the part of our universities. We have 
learned that nature makes no leaps, and that there is no pos- 
itive line of demarcation between sanity and insanity; that 
about one-half of the recent cases get well, of whom a little 
less than half remain so; that hallucinations of sight and 
hearing may be the genius of inspiration in 'Joan of Arc and 
a conclusive evidence of insanity in somebody else; that 
Julius Caesar, Mahomet and Napoleon suffered from a mental 
disease, by virtue of which persons are held not accountable 
for murder in modern courts ; that a false belief is not neces- 
sarily a delusion; that Martin Luther was not insane; that 
the Agrippinas, Neros, Caligulas and Tiberiuses of history 
were probably only the monstrosities which occasionally 
appear in modern times ; that insanity was increased by the 
Crusades, the Reformation, the American and French revo- 
lutions, the Retreat from Moscow, the Commune, the religious 
revival in Edinburgh, and diminished in the manufacturing 
districts of England when the "hard times” compelled the 
laborers to drink less gin. 
But how does all this interesting information help us, when 
the ink on our diplomas is scarcely dry, and we are called 
upon to sign a paper* which will send a woman to an insane 
*ln New York State there is a restriction, whereby only those physicians thought 
to be qualified to do so, are allowed to sign certificates admitting persons to insane 
asylums. The law on the subject is as follows : 
Section 1. No person shall be committed to or confined as a patient in any 
asylum, public or private, or in any institution, home or retreat for the care and treat- 
ment of the insane, except upon the certificate of two physicians, under oath, setting 
forth the insanity of such person. But no person shall be held in confinement in any 
such asylum for more than five days, unless within that time such certificate be 
approved by a judge or justice of a court of record of the county or district in which 
the alleged lunatic resides, and said judge or justice may institute inquiry and take 
proofs as to any alleged lunacy, before approving or disapproving of such certificate. 
Section 1, 2, 3, of Chapter 446 of the Laics of 1874. 104 
Disease of the Mind. 
asylum for life, or deprive a man of the power to make his 
will, when we cannot for our lives tell the difference between 
folie circulaire and general paralysis, when we cannot recog- 
nize many of the simplest forms of mental disease in their 
early stages, and when we do not know whether the best 
treatment consists in sending our patients to the inactivity of 
an asylum or for a tramp among the hills, or whether he can 
as well or better be cared for at home ?—an uncertainty which 
deprives many of the benefit of early treatment. It is cer- 
tainly as rational to treat common cold and consumption alike 
because they affect the same organ, as to say that the manifold 
forms of mental disease should all be subjected to the same 
general rules. 
Insanity, in tlxe reports of our asylums for the insane, is 
the disease of which so many recover, so many do not, and 
so many die ; but it would be fully as rational to say the same 
of all patients entering our general hospitals with " cough ” 
and " pain in the chest ” ; for insanity is really only a symptom 
of disease, or perhaps a combination of symptoms ; and the 
disease underlying it is often incurable from its very nature, 
and often readily yielding to treatment. The different forms 
often require as different treatment as brain fever and pul- 
monary consumption. 
This confusion of names and of things, has undoubtedly had 
a seriously prejudicial effect on medical education, and is in a 
large degree the direct result of this very want of adequate 
instruction in our medical schools. 
It cannot be denied that the sciences are each year claiming 
a greater part of the student’s time, already too short for the 
and said judge or justice may, in his discretion, call a jury in each case to determine 
the question of lunacy. 
{2. It shall not be lawful for any physician to certify to the insanity of any person 
for the purpose of securing his commitment to an asylum, unless said physician be 
of reputable character, a graduate of some incorporated medical college, a permanent 
resident of the State, and shall have been in the actual practice of his profession for 
at least three years, and such qualifications shall be certified to by a judge of any 
court of record. No certificate of insanity shall be made except after a personal 
examination of the party alleged to be insane, and according to forms prescribed by 
the State Commissioner in Lunacy, and every such certificate shall bear date of not 
more than ten days prior to such commitment. 
§ 3. It shall not be lawful for any physician to certify to the insanity of any per- 
son for the purpose of committing him to an asylum of which the said physician is 
either the superintendent, proprietor, an officer, or a regular professional attendant 
therein. Disease of the Mind. 
105 
work he must do ; but, in adding to our requirements for grad- 
uation, we have only begun to drop the lumber which medicine, 
as a dogma, had to carry. Of what importance is it, for 
instance, to the busy physician, to know that the morphine 
which he injects in his patient’s arm, is from the palaver 
somniferum, and not from some other papaver, and to be able 
to give all the complex processes by which it is prepared for 
use? What cares he from which one of the scrophulariaceoe 
comes the drop which quiets the too rapid pulsation of the 
heart? These things are all very well—the expert must know 
them ; but are they of sufficient importance to exclude a prac- 
tical study of vitally important problems which meet every 
physician face to face in every year of his practice ? 
If we have time for only the necessary and fundamental 
branches, why not recognize the fact that the physician simply 
begins his education in the medical school and leave out 
many of the details which only a specialist is required to 
know, to be filled in by reading afterwards ? With four thou- 
sand people in our State suffering from mental disease, and 
with the superintendent of every insane asylum in the country 
complaining that curable insanity is almost universally neg- 
lected in its early and curable stage, are we wise to exclude 
its careful study from our list, in order to have more time to 
investigate the action of digitalis and belladonna on rabbits 
and guinea pigs, or to learn difficult surgical operations which 
many will not see and only a few experts will ever perform? 
"Taking the word hygiene in the largest sense,” said the 
late Dr. Parkes, "it signifies rules for perfect culture of mind 
and body,” In this maxim, and in its observance, we must 
look for our greatest help in convincing the community that 
insanity, like other diseases, is to a great degree preventable, 
and that to cure or to prevent it, we must first study it. 
It is gratifying to find that such a serious defect in our 
medical education is attracting the attention of thoughtful 
people. In a recent report by one of our most distinguished 
sanitarians, we find these words: " A third branch of medi- 
cine, which is not taught in our schools, is the diagnosis, 
treatment and jurisprudence of insanity. Ido not know if 
it will be possible to deal with this subject in this university, 
but I would keep this urgent want in mind, and the possibility 106 
Disease of the Mind. 
of making connections with some public or private establish- 
ments devoted to the care of the insane, which can supply 
the necessary facilities and receive more than a corresponding 
benefit.” * 
No truer word has been spoken than that " Insanity is part 
of the price that we are paying for the imperfection of our 
civilization and the incompleteness of our education.” f 
Summary. 
If our century’s work seem to any to offer not enough to 
say in favor of our past, when we have been spending mill- 
ions in the construction of asylums, without diminishing the 
amount of insanity or increasing our cure-rate, the present 
offers many signs of encouragement. We have made mis- 
takes, it is true, and we are still in doubt as to many impor- 
tant points ; but earnest people are at work over the whole 
civilized world, and more and more certainty is reached every 
year. 
That we have started from as small beginnings, and have 
made no more progress in other branches than in insanity, 
may readily be seen by consulting John Howard’s account of 
prisons, hospitals, etc., in Europe, published in 1789, and an 
excellent treatise on "A Century of Nursing,” by a member 
of the hospital committee of the State Charities Aid Associa- 
tion of New York, issued during the past year. 
If we go beyond this century, we shall see that there have 
been in modern times four great epochs in the history of 
the treatment of insanity. 
(1.) The abolition of the theory of possession by evil 
spirits—a work of humanity, in which St. Vincent de Paul 
was the great mover, two centuries and a half ago. 
(2.) Pinel’s reform—also essentially humanitarian. 
(3.) The adoption of the idea of the curability of insan- 
ity ; the establishment of the heil-anstalten in Germany; 
Esquirol’s visit to Gheel and his theories of asylum construc- 
tion ; the laws in England compelling the several counties to 
* Johns Hopkins Hospital, Reports and Papers relating to Construction and Organ- 
ization, No. I. By John S. Billings, Asst. Surg. U. S. A. 
f Relation of Education to Insanity. By Edward Jarvis, M. 1)., in the Report of 
the United States Commissioners of Education for 1871. Disease of the Mind. 
provide for their pauper insane, and establishing a lunacy 
commission; Rush, Wyman, Bell and Kirkbride in asylum 
construction and management; Ray and others in the juris- 
prudence of insanity; the reduction of mechanical restraint 
in the United States forty years ago to a point below that in 
vogue elsewhere; and finally, the abolition of mechanical 
restraint begun by Hill and made a principle of treatment by 
Conolly. This may be called the practical movement, arising 
in England, France, and later in Germany, for a while reach- 
ing its highest point in the United States, now best in Eng- 
land and Scotland. 
(4.) The general acceptance of the somatic and rejection 
of the psychic theory of insanity, by establishing psychology 
on the basis of physiology and pathology—a scientific move- 
ment anticipated by John Hunter, begun by Bichat and Es- 
quirol, carried out by Griesinger and Virchow. 
Humanity is now the basis of treatment everywhere, no- 
where more laboriously and studiously sought for than in the 
best asylums of our own country. 
The work of the future, the rational movement, will be 
for each nation to contribute its best, and for all to unite 
humanity, science and art in solving problems now satisfac- 
torily met by none. 
The history of mental disease shows a steadily progressive 
development of rational views in its treatment. So long as 
divine inspiration was thought to be its cause, the insane were 
treated as seers and prophets ; and, as such, their influence on 
society has been a potent one. Under the later theory of the 
Middle Ages, they were burned or hanged by the courts, and 
whipped by their custodians, the monks. After St. Vincent 
de Paul, violence and force in their treatment gradually gave 
way to deliberate imposture. For a while, the satirist might 
have said that their care under the doctors consisted in show- 
ing that what was good for a sane man was bad for one insane ; 
and it used to be taught, even from the professors’ chairs, 
that patients were benefited by continual morbid surround- 
ings, while the doctors must make a special exertion under 
the same circumstances not to become insane themselves ; that 
asylums for the chronic insane would be fatal to the reason 108 
Disease of the Mind. 
of tho curable cases which would be inevitably placed with 
them, but that it did no harm to subject acute cases to their 
daily influence in large asylums, and that the insane have a 
peculiar exemption from diseases and influences ordinarily 
affecting well people. 
It was a long time before we made our practice at all corre- 
spond with our knowledge that insanity is a disease, and we have 
by no means done it fully yet; but now physicians know that 
they must gain the respect and confidence of their insane, just 
as they do with their other patients ; and Dr. Farr, after thirty- 
eight years’ experience in the science, which he made, of san- 
itary statistics, says, in his thirty-sixth animal report, "In 
fact, as far as is known, a lunatic remains as subject to zymotic, 
constitutional and various local diseases as sane people.”* 
In the majority of cases, a well arranged asylum is a better 
place for an insane person than his home ; but the asylums 
might be made much better than they are, if we used a small 
part of the money now expended to gain a questionable archi- 
tectural magnificence in providing more attendants and in 
improving our facilities for medical treatment. 
To get tho benefit of such improved asylums in properly 
selected cases, our general practitioners must understand 
mental diseases, as the majority of patients come under their 
exclusive observation in the early and more curable stages. 
When our medical schools have given them this knowledge, 
may we not fairly expect an improvement in the results of 
our treatment, corresponding with what has taken place in the 
early stages of pulmonary consumption and Bright’s disease, 
especially when the superintendents, who are now overbur- 
dened with routine work, have more time to devote to their 
strictly medical duties? 
It cannot be said that this is a subject which interests com- 
paratively few persons. Such is the general impression, with- 
out doubt, and most people look upon insanity as something 
"hereditary,” to which not many are liable. On this point, 
our highest authority said to the trustees of a new asylum :f 
"From the sad disorder which is to be treated within these 
walls, no one has any privilege of exemption. No accident 
* Registrar-General’s Report for 1873, page 221. 
t Address at Danville, by Isaac Ray, M. D., 1869. Disease of the Mind. 
109 
of fortune or birth, no measure of strength, no exercise of 
prudence may be able to save you from the fate of others once 
as little likely to meet it as you. Or, if you escape person- 
ally, the stroke may fall on child, parent, or neighbor with far 
more sorrow than if it fell on yourself. You, therefore, are 
deeply interested in having it perform its allotted service suc- 
cessfully, and are bound, as far as in you lies, to promote this 
end,”—an opinion fully sustained by Dr. Kirkbride, who says,* 
"Insanity is a disorder of the brain, to which, under certain 
contingencies, every one is liable.” Hagen, too, after exhaust- 
ive researches extending over a period of twenty-five years,f 
has concluded that the influence of heredity, although consider- 
able, is still much less than has usually been supposed. The 
very large number who marry wisely, and do not transmit 
their infirmity to their offspring, do not usually appear in our 
statistical tables. 
Some of our most experienced and best-informed alienists 
consider the manifold diseases of the mind no more likely to 
be transmitted to offspring than Bright’s disease and pulmon- 
ary consumption. The evidence is strong, also, that they 
may be as readily eliminated from families by wise marriages 
and judicious modes of living. In either disease, of course, 
there are cases where any marriage must be looked upon as 
unwise; but they are not so universal as has been sometimes 
supposed, and the transmission to descendants of what has 
been sometimes called the insane temperament has given to 
the world many men and women of genius, whom we could 
ill have spared. 
Even as late as the time of the Ptolemies, the plague was 
unknown in Egypt.;j; One hundred years ago, it was thought 
a necessary part of modern civilization, and now, under a still 
higher civilization, the area over which it may be feared is 
narrowing from year to year. A similar result may be fairly 
expected with regard to disease of the mind. 
* Report for 1876. 
t Statistische Untersuchungen aber Geisteskrankheiten. Erlangen, 1876. 
X Uebcr den Hungcrtyphus and einige verwandte Krankbeitsformen, von Rudolph 
Virchow. Berlin, 1868, p. 53.