Among the changes in systems of management of our State institutions suggested as worthy of consideration, is that which proposes to appropriate one institution for the exclusive use of recent and active cases; others to be set apart for the more passive and incurable classes, who constitute the large majority. By this plan the benefit of the largest medical care and treatment may be secured for those who require it most, while time and opportunity would be afforded for thorough investigation into the causes and best mode of treating the whole class of mental maladies; from which, valuable contributions to the present stock of knowledge might be expected. Much yet remains to be done to insure the highest standard of care and treatment for all of this unfortunate class, wherever they may be placed. The question is by no means settled, whether all cases still remaining in our county almshouses should be transferred to State institutions, or whether a numerous class already referred to may not with propriety be suffered to remain. In the large and wealthy counties, suitable buildings have been erected, provided with the necessary conveniences, and in which patients receive good ordinary care and medical treatment. The dissatisfaction of State legislatures at the number and cost of buildings for the care of this class (it cannot be denied) is not without just cause. The wisest judgment has not always been exercised. Errors in location, and in the magnitude of the buildings, have been committed in different States; one of the consequences of which has been that those easily accessible are unduly crowded, whilst others, at remote points, are only partially occupied. The remedy for questionable appropriations of this kind, on the part of the State, must be sought in the knowledge which is derived from a survey of the whole field. The opportunities for correct information afforded by the supervision by State boards of all the institutions, in all their details, conjoined with the system of quarterly reports, as arranged and practised under the direction of the Pennsylvania Board, bring every thing relating to methods of care, cost, numbers, and character of the occupants, distinctly into view. This cannot fail to exercise a most salutary influence upon the officers connected with the management, from which very decided benefits have already been realized. This remark applies not only to institutions established for the care of the defective classes, but to those for the pauper and criminal classes also. By this system, properly executed, little difficulty is experienced in obtaining the information which is essential in order that correct conclusions may be arrived at, not only with reference to the degree in which the State aid should be extended, but to every thing connected with the mode of conducting institutions. DEBATE ON INSANITY. REV. J. L. MILLIGAN expressed his approval of that portion of Dr. Luther's paper advocating the cottage system. A cottage could be built for a few hundred dollars, instead of the few hundred thousands that our large asylums cost. Small cottages could be grouped around the superintendent's building, so as to be light, comfortable, and of easy access and control from the officers' building. In such cottages the patients would feel more at home, an important feature in the cure of the insane. Of course, persons in charge of State institutions desire to appear well, to have a grand institution to look at from a distance or on paper. There is no necessity for such display, if we come down to the main point of curing the patient mentally and physically. What we need is scientific treatment. The food should be simple, pure, and clean, together with all the other things required to rehabilitate the insane in their mental and physical power. It is better to have eight, nine, or ten cottages, than one big asylum, with all the appliances of steam-pipes, machinery, &c., which are necessary to such an establishment, and so suggestive of prison confinement. The cottage plan, Mr. Milligan thought, would doubtless be a growing one, and he hoped his hearers would bear that portion of Dr. Luther's paper in mind when they returned to their homes. MR. W. P. LETCHWORTH (of New York) stated that the cottage plan for the care of the harmless chronic insane was about to be tried in Cattaraugus County, N.Y., and that the experiment was looked upon hopefully. He illustrated the plan of the buildings on the blackboard. The cottages were designed to accommodate thirty persons each; to be strongly built of wood, sheathed within and without with inch hemlock boards, and covered under the clapboards with felt paper. The lower floor would be double, with paper lining between; and the attic would be also laid with a double floor of rough boards, lined in the same way to secure greater warmth. The cottages were planned for two stories, the upper portion being designed for dormitories. Open corridors would connect them with the main dining-hall. A central cottage would accommodate the medical superintendent and family, and afford office-room. In the rear of the central cottage, and connected with it by a short corridor, would be a one-story building, containing the general kitchen and two dining-rooms, one for each The kitchen and dining-rooms it is proposed to build somewhat larger than necessary for present use, in anticipation of enlarging the plan hereafter by the erection of two additional cottages. sex. The entire cost of these buildings was estimated at fifteen thousand dollars, making a per capita outlay for shelter of $250. With the two additional cottages contemplated, the whole expenditure was computed at twenty thousand dollars, or a per capita expenditure of one hundred and sixty-six dollars and a fraction. But even allowing a still more liberal outlay, and making the cost for the shelter of one hundred and twenty patients to be twenty-five thousand dollars, it would be found a very moderate investment to attain so comfortable a provision for this class. In case it was desired, the lower story of the cottages could be used as dining-rooms. The corridors communicating with the cottages it was proposed to construct cheaply, and to make them attractive by means of vines and trellis-work; while the cottages themselves, standing apart from each other, having light and air on all sides, in the midst of lawn spaces, and embellished with shrubbery, might, with interiors neatly furnished, and made cheerful so far as compatible with their uses, be made to suggest home life, rather than the prison-like character so often a prominent feature in these institutions. Each of these cottages is to have several strong-rooms, in case it is necessary to restrain patients. The more violent and disturbed cases it was intended to consign to State care in the Willard Asylum at Ovid. But, out of the fifty for whom the provision was being made, only four were regarded as belonging to this class. Whatever might be the merits of the different opinions entertained, as to whether the chronic and acute cases of insanity should be treated together or separately, the question in New York would seem to be practically solving itself, by the providing of separate institutions for the treatment of each class. MRS. STARRETT (of Missouri) referred to an instance which had recently come under her observation. A young girl of her acquaintance had exhibited signs of a deranged mind; left her occupation of seamstress, became melancholy, and manifested other DEBATE ON INSANITY. GENERAL LIBRAR Waiversity o CHIGAN 99 peculiarities. It was decided that she was insane, and that under the circumstances it was the proper and benevolent thing to put her under treatment in the early stages of her insanity, and, if possible, effect a cure. She could not be taken to the asylum of her own free will: so she was taken there by strategy. We went there on a visit; and as we passed out of a ward, while she remained behind a little, the door was locked on her. When she realized what had happened, she became almost frantic, refused to eat or drink for three days, and in that period was reduced almost to a skeleton. When she understood that nothing could be done, she quieted down, and wrote letters to different parties, in which she said, "I am not insane, but if I remain here undoubtedly I shall soon be." She is now insane to some extent; but it is perfectly evident to my mind that if she remains among those insane people she will become hopelessly insane. Now, what ought I to do in this case? DR. BYERS called attention to the fact that in Ohio the introduction of patients into hospitals by stratagem was almost impossible; it was necessary that their friends and relatives should all be aware of the fact, and there must be a preliminary inquiry. MRS. STARRETT. In this case no complaint is made of the stratagem used, but of the fact that she is compelled to associate with the insane. She says, "If I am insane, I am only partially So. Let me have a place by myself; give me my books and sewing, and I will remain quiet. If I remain here I will certainly become insane." cure. C. S. WATKINS. In Iowa we have a committee of supervision to see that all patients are humanely treated. Stratagem is injurious in the introduction of patients into hospitals; its discovery by the patient creates a spirit of resistance which retards his The physician should endeavor to gain the confidence of the patient. As soon as that is secured, a cure is in recent cases half accomplished. Mr. Watkins expressed his hearty approval of the cottage system, which he had taken occasion to examine. In 1868 Iowa had begun to build an asylum which was intended to accommodate 400 patients, be completed in four years, and cost $400,000. After ten years' work the asylum is only twothirds completed, and instead of $400,000 they had already spent $800,000 on it. By the adoption of the cottage plan new additions and accommodations could be added, as they were needed from time to time, to keep pace with the growth of the country; and it was not necessary, when they were crowded, to wait until a new large asylum could be obtained. Mr. Watkins favored the non-restraint system of treatment, but particularly objected to the copious use of drugs as a substitute for mechanical appliances. DR. I. W. ANDREWS, President of Marietta College, Ohio, said that not long ago he had asked a builder who had a contract for the erection of a State institution, for its actual cost, and the number of persons it would accommodate; and then he ascertained what was the average cost of a family residence in that county. The house accommodation of an inmate of that asylum cost just ten times the average house accommodation in the county. He would venture to assert that in the whole State the actual house accommodation of each inmate of one of the asylums cost not less than seven times the average house accommodation of each citizen of the State. MRS. DALL (of Boston). They talk about cottages costing $20,000 to $25,000, when they ought not to cost more than $5,000. I have had a large and varied experience in visiting insane-asylums, and I know that in those asylums where the restraints are fewest, the most cures are effected. The insane should be allowed to write to their friends what nonsense they please, and to receive replies, if it is three times per day, and have all intercourse that they possibly can with their friends. The restraints, if there are any, should be invisible. The restraint should consist in the care, and not in high walls, locked doors, and barred windows. These things remind the patient that he is insane. The idea should be to inform him that he is sick, but not hopeless and forsaken. There was a time when if a person was insane, no one in the family spoke of it; it was considered a disgrace, a visitation of God: but that is past. The more the habitation of the sick person is made to compare with the best habitation of that class of healthy persons, the nearer we shall approach to a normal administration of such institutions. I desire to mention another matter. I think every man who has visited these institutions is at once aware of a sickly smell that seems to pervade the building. It is like linen which has been badly washed by your washerwoman; it has what some call an odor of poverty about it. Dr. Willard of New York made the soap for his own institution, taking the fat of his own meat for the purpose. He used this soap; and the result was, his dish-cloths, cloth |