DEBATE ON INSANITY.

Thursday Morning, July 1.

The PRESIDENT: An opportunity will now be offered to members of the Conference for discussion of the papers read this morning, under the five minute rule, which the chair will observe.

Mr. WINES: I should like to say one word in regard to this general subject, which has been presented in the Report of the Committee on Insanity, and the Paper by Dr. Gundry.

I always approach the subject of insanity with some diffidence, in consequence of my consciousness that one not practically connected with the administration of an insane hospital can scarcely know, understand and realize the very great difficulties which are encountered by men who occupy the position of medical superintendent of a hospital or asylum for the insane. And I feel that great respect is due to the medical superintendents of the insane, for the noble work they have accomplished for the cause of humanity. I give them credit for all honesty, ability and sincerity in the discharge of the duties confided to them; and I feel that, while they have not made the progress many of us desired, their shortcoming has been largely due to difficulties insuperable, or at least considered insuperable in our present stage of knowledge of insanity, and its treatment as a disease. When I was in Europe, some two years ago, and inspected many of the insane asylums of Scotland, France, Germany and Sweden, I found that our institutions are not in sympathy with many in England and upon the continent, and the points of difference are partly with respect to the construction of the hospital, and partly with respect to the administration of the hospital, and the means relied upon for the care and treatment of the insane. Many of these differences, and the one that stands out the most prominent, is the emphasis and importance which is given, both in England and upon the continent, to the labor of patients. I found in the French hospitals that a workshop for patients was just as much a part of the organized system for the care of the insane as was the laundry, or drug-store. I found in England that while they were very much opposed, and I thought unreasonably opposed, to the use of mechanical restraints in cases where mechanical restraints might be

of material service, and where a good, sound medical service would, in my opinion, warrant and recommend their use, yet one reason why they dispensed with mechanical restraints to a greater extent than we have in this country is, because they depend upon this principle of labor in the care of the insane. I spoke upon this subject at the last meeting, and need not here allude to the views I gave at that time. I listened to a very interesting paper in Philadelphia, which took the ground that restraint in the care of the insane was absolutely necessary; that is a proposition to which I think we all agree, that is, with persons who are disposed to commit suicide or violations of person or property. But there are three forms of restraint, viz.: manual restraint, which is the practice of the English asylums; medical restraint, as by the use of drugs, such as hydrochloral; and mechanical restraints, as by the use of straps or other mechanical contrivances. I find that the English physicians say there is another form of restraint upon which they mainly rely, and that is exercise, occupation and labor. They say there is no necessity of either manual, mechanical, or medical restraints in the case of patients to whom a sufficient amount of exercise and of useful occupation can be furnished. I believe that principle is sound, and that it has not received sufficient consideration at the hands of superintendents of asylums in this country. It appears to me that this is an important question, to which our attention should be called.

I am sorry I cannot speak longer, because there are one or two things I wished to say. [Voices, "go on," &c.] I have not signed the Report of the Committee, although a member of it; because I am not thoroughly satisfied with some of the positions taken, and the expression of them; neither do I join in the protest of Dr. Chapin and Dr. Gundry, because I do not agree with the sentiments of Dr. Gundry. I do not, for one, feel satisfied that the principle of the care of all chronic insane in asylums, as distinguished from hospital care and treatment, is the correct principle. I think that is a question to be left very largely to the determination of individual States, according to their condition and circumstances; and that the principle upon which the insane should be separated, is not their condition in respect of curability, but their condition in respect of the amount of restraint and personal care they require. Some incurable patients require as much restraint as those who are curable, while on the other hand some

curable patients require very little of the form of treatment customary in hospitals for the insane; and so I do not believe that is the point upon which the separation should turn. Again, I do not think the separation should depend upon the pecuniary condition of the patient. I do not agree with Dr. Gundry; I do not believe that there is any difference in the demand made upon the public or the alleged necessity for equal care and equal expense in the treatment of the chronic pauper insane. I do not believe, and I think that is one position to which our Conference should give its adhesion firmly, that it is necessary, or practicable, or just, to provide for all our chronic pauper imbeciles the same luxurious and magnificent accommodations which we are in the habit of providing in all hospitals for curable cases. I think, as expressed, I believe, in the Report, that the State often makes an unnecessary and extravagant appropriation for the erection of an insane hospital to accommodate a limited number of patients, and that every dollar that is unnecessarily expended upon that hospital is so much taken from the comfort and well-being of the great mass of the insane, who are scattered through the community, in our poorhouses and private houses. I take issue with superintendents wherever and whenever they justify and advocate such extravagant expenditures upon a portion of the insane, to the neglect of the interests of the entire body of the insane of a State.

I have said enough, but I will simply speak of one matter further and I am done. I do not believe, as was indicated in the Report, that it is wise and expedient to relegate the insane, or any portion of them, to the care of almshouses. I have seen insane persons in almshouses who did well, but have also seen many cases of neglect in almshouses, so shocking that I have no confidence in almshouse keepers. Some of them are men of intelligence, and of large and warm sympathies, and care for all paupers under their charge in a manner agreeable to humanity and the humanity of the public at large; but they are liable to be displaced at any time through the political change which results from a change of the board of county control. Many almshouses are not properly equipped; and by that I do not mean with the best of furniture, elegant rooms, and magnificent grounds, but that they are not properly provided with medical care and attendance. The very moment an insane person becomes troublesome, the only means of restraint almshouse keepers have is to shut him up; and I have also seen many, many

insane patients, men and women, shut up in rooms of private houses for years at a time. I knew one man, in the State of Illinois, to be shut up for sixteen years in a room, because the almshouse keeper did not know what to do with him. I have seen almshouses in which there was no door to go into the room where the patient was confined. The whole front of his cell was a cage, and there was no entrance to clean his room or take any care of him. As long as these things exist, we ought to take the ground that we are opposed to the almshouse treatment of the insane, and that all the insane requiring personal care and attention, should receive it in establishments well furnished, equipped and manned under the charge of State authorities; and that, in large counties, like many where there are large cities, with establishments under their charge, the county authorities do wrong in trusting their insane in these almshouses under any circumstances whatever.

Dr. ROGERS: Mr. Chairman, I deeply regret that Mr. Wines did not submit a minority report. I have been exceedingly pleased and edified with the points which he has treated upon. He is a member of this Committee, and I believe it only justice to this Conference that he should have submitted a minority report. Upon the Committee's Report there are points with which, like him, I do not coincide, but on the whole, the report is a very beneficial one, highly interesting, and I think will prove of great profit to our Conference and the institutions at large. With Dr. Gundry's paper I was also exceedingly pleased; however, I should like to ask him one question: Dr. Gundry, will you be so kind as to inform me how often you would require the superintendent of an insane hospital to visit the wards of his institution? [Applause.]

Dr. GUNDRY: As often as is necessary.

Dr. WILBUR: Is it possible for any human being to visit thoroughly the wards of an institution that numbers six, seven, or eight hundred patients?

Dr. GUNDRY: That is a question simply of capability and endurance; a man may visit a part himself and may visit the rest by agents. I am only saying that the trustees should visit the wards as often as practicable. If you have capable assistants you can surely intrust them to visit the medical apartments; but do the best you can under all circumstances. One man may sit in his room and supervise his house better than another man could do by going through the house. [Applause.]

Dr. WILDUR: But our hospitals are often too large for a man to do this and do justice to his patients. At an investigation that took place at Washington, with reference to the Asylum in the District of Columbia, there was the testimony of numerous witnesses that Dr. Nichols was in the habit of visiting his wards, some witnesses said but once a week, and some said only once a month. Superintendents of asylums from different parts of the country were examined in behalf of the superintendent, and I think it is on record, and seemed to be manifested by that testimony, that if the superintendent visited his wards once a week, that was sufficient; and this weekly visit, in this case, was usually on Sundays, and was rather a dress-parade on the part of the patients. It appeared that Dr. Nichols, accompanied by some members of the board of trustees, visited the wards, and the patients were brought into line, and, like any other inspecting officers, these gentlemen deliberately marched in front of the line and behind it, and inspected it, and at that investigation it was decided that this was a proper inspection of the asylum.

Dr. NOLAN, of the Northwestern Ohio Asylum, was called upon and said: As a superintendent of an asylum, I am a novice; I am only superseding one who originated an idea, Dr. Wright. In 1869, the Legislature of Ohio passed a law making it obligatory upon each county to take care of its own chronic insane. At that time there were about forty lunatics in the Lucas county poorhouse. A few of the best class of citizens met at the building, and found a most deplorable condition of things there; males and females were in the same building, and perhaps in many cases no door to separate them. The commissioners immediately commenced the construction of a hospital for the insane, to accommodate perhaps one hundred patients. It was constructed at the cost of about $18,000, or perhaps a little more; and immediately after its completion, and after our own county insane were safely immured in the building, the Newburgh asylum burned, and eighty Newburgh patients, the chronic portion, were transferred to the Northwestern asylum. From that time, a year ago last April, it was under the control of Dr. Wright. His success in the treatment of the chronic insane was, doubtless, equal to that in the better class of hospitals, and I attribute it mostly to outdoor work. I went further than he did in employing the insane. I rented more land adjacent to the hospital, and opened two wards for the convalescent insane.