With the progress of our knowledge of pathological conditions, especially as related to nervous diseases (in which is included insanity in all its modes of expression), happily, this objective is often reached. Thus, the State has surrounded these unfortunates with the best possible skill, and most favorable conditions for a return to health, happiness, friends and occupation. Midway between these places of forcible detention is the hospital. Your Conference considers all these conditions and institutions. You have, in the main, pleaded for those conditions which shall ameliorate the surrounding of persons incarcerated, of either class, with such result as add lustre to our own land and teach a genuine philanthropy. In my observation, during many years of service as Surgeon of the Detroit House of Correction, I have often had cause to reflect upon the necessity for the presence of some capable physician in attendance on primary criminal courts, to determine the condition of accused prisoners; often, the incarceration of a prisoner is clearly indicated, but the place and the character of the incarceration, require the best diagnostic skill. I know that expert testimony is not held in so high esteem as I think it deserves, owing in great part to the methods of securing it, which I need not explain here. In criminal cases of persons at bar I have formulated this general classification:

1. Innocent persons. Of this class, but few are found in court, for society is very tolerant of wrong-doers, and except in grave cases, arrest seldom follows the first offence.

2. Those persons who elect to follow a life of crime, taking all the chances involved in such a course. This class includes healthy, often educated men, and women of all trades and professions.

3. Those who adopt certain specialties in crime as a means of livelihood.

4.

Unfortunate persons, to wit: (a) Insane; (b) Epileptics; (c) Sick; (d) Incompetents.

I desire to write of this last class, because, on the one hand, their condition affords scope for trained skill, and, on the other, demands in equity all the aids our civilization can render. Criminals admit the justice of punishment for crime, but the "moral sense" is debased when one is condemned for mere misfortune.

As to insane persons: It is well known by physicians, especially those having in charge large hospitals, prisons or asylums, that many diseases, both acute and chronic, are preceded

by insanity; and that, during these primary stages, those acts are perpetrated which are considered criminal or disorderly.*

I need but mention puerperal mania, during the existence of which the patient, modest, industrious wife becomes a kleptomaniac, vulgar and obscene. Although this is an extreme instance, and although such patients have usually good attention, cases are not infrequent where these unfortunates are even sent to prison. Stealing and untruthfulness are often the symptoms of general paralysis. Business failures are often intimations of paralysis or insanity; the order of sequence being generally inverted, and insanity predicated of embarrassment, when embarrassment should be predicated of insanity or general paralysis. A citizen honored and trusted, conducting a successful business, quite without warning, failed; he has since that time been a paralytic. A person well known as a man of honor was caught stealing a boxof cigars; this first theft was excused, but a second was committed very soon; arrest followed, and he was sent up for larceny. He was then a general paralytic, with no notion of meum and teum, and almost his first act was to jump from the gallery of the prison and break his thigh. He is now in the asylum hopelessly insane; had he first been sent there, his friends at least might have been saved the chagrin of having a relative in prison.

As to epileptics: Epilepsy is congenital or acquired, and in either condition is an indication of serious pathological changes, tending in many cases to insanity and death; in others, especially with women, to dementia and prostitution. Some of these cases are curable; many are not. Some States have asylums especially for these, but my State, so far, has made no special provision for this particular class. I estimate that, in the Detroit House of Correction about twelve per cent. of the prisoners are epileptics. No class deserves more attention and sympathy, and no class receives less. This is especially true of epileptic women and girls, who fall an easy prey to lechery.

As I have written above, many diseases are announced by insanity; hence those persons, so insane, are liable to arrest,

*Walter C., aged about thirty, pilot; stole a horse and buggy, but was acquitted on my statement that he was insane. Being arrested again within a week for larceny, I advised the judge to send him to the House of Correction for treatment. By examination I found consumption indicated when he came to the prison; he lived but ten months. I regard this as a case where kleptomania can be predicated of the physical disease, the incipient stages of which may have lasted some years.

especially as disorderly persons. Such persons come often to our clinics held for the treatment of "out patients." A prisoner was brought to prison from a distant city with acute cerebretis (inflammation of the brain), comatose, supposed to be in a drunken stupor. He never spoke, was placed in hospital, — and I wish to say, in passing, that the city of Detroit has in its House of Correction one of the best hospitals I have seen, where he soon died, and the autopsy revealed a traumatic inflammation of the right hemisphere. Other instances of disease announced by insanity are given below.

CASES IN POINT.

O. M.; age, 61; American, farmer, from Texas; sent in from United States Court, charge not noted; admitted to Detroit House of Correction, October 12, 1877. He was suffering from chronic inflammation of both lungs. He was at once placed in the hospital, where he was treated until his death (October 17), just six days after he was admitted. I do not predicate his crime of his sickness, but should not this man have been sent to a hospital?

Levi Shafer; age, 27; a colored man from Grand Rapids, Mich. ; admitted September 26, 1877; charge not noted; by trade a barber. Shafer had an enlargement of the femoral artery (traumatic aneurism), and was sent to hospital, where gangrene of the foot set in; his leg was amputated November 28; he died December 4, 1877. This patient was a proper person to be sent to the hospital, where an earlier operation might have saved his life.

Milo Monroe; aged 50; American, farmer; admitted January 17, 1878; had consumption of the lungs; charge not noted; was sent to hospital February 4, 1878. It is well known by medical men that incipient consumption is often announced by a disturbed insanity, which may account for certain actions of this prisoner which caused his arrest and conviction.

Thomas Goodwin; aged 68; an Englishman; admitted April 16, 1878, with cancer, -epithelioma involving the entire lower

jaw, and very offensive. As his presence was very offensive, he was transferred to the county hospital, July 12, 1878, with no hope of relief. The case was too far advanced to admit of an operation, but, for many reasons, the patient should not have been sent to prison, but to a hospital.

E. H.; aged 45; an Englishman; at one time a successful busi

ness man, came in under sentence from the Police Court, having acute mania a potu. He was in a most filthy condition, so filthy that I could not properly diagnose his case. I ordered a warm bath to cleanse him, but the bath was scarcely complete when he died.

G. G.; aged 30 (woman); had been handsome, now demented; having syphilis, and scattering the loathsome disease among young boys; was pronounced insane by competent authority, and yet was allowed to go on the street, powerless to resist wrong. She has finally been sequestrated in our insane asylum, where she should have gone years ago, as a matter of public hygiene.

I have omitted some cases in order that I might here suggest the appointment of a proper medical adviser for the primary courts having jurisdiction over criminal cases. To this may be made objections more or less valid. Malingerers will be ever ready to try their arts of deception, and are often familiar with all subjective symptomatology. The "insane dodge" will be (and is) often

tried.

While this paper is far from exhaustive, and based wholly upon my personal experience and observation, I hope it may be at least suggestive, and so add somewhat to your valuable deliberations.

DEBATE ON THE INCREASE OF INSANITY.

The PRESIDENT (Mr. Lord): The remarks submitted by Dr. Yeamans are based upon his experience not only as a prison officer but as a medical man. The paper is now before you for discussion, if it should occur to any one in the audience to remark upon the subjects that Dr. Yeamans has laid before you.

Mr. SANBORN: I would make a single remark concerning one of Dr. Yeamans' introductory observations in regard to the increase of insanity. I think Dr. Yeamans did not express himself as he meant to in that matter, for there is no doubt whatever, with any person who has examined the statistics, that insanity has increased in the older States. I presume he meant there was no increase of recent cases, for the chronic insane have very much increased in the last ten years in the older States; whether so much in the newer States, I cannot say. My impression is, that the new national enumeration, of which Mr. Wines has charge, will show a great increase of insanity throughout the country, even as compared with population.

However, if Dr. Yeamans should say that new attacks of insanity do not increase throughout the country, I should agree with him that they have not increased out of proportion to the population. In this connection I would cite Dr. Earle, of Massachusetts, one of the best authorities in regard to this matter; he says he has never seen any sufficient evidence that there is an increase of new cases beyond the increase of population. My own opinion is that such an increase, if any, is very slight.

Dr. HoYT: Will Mr. Sanborn explain how there can be an increase of chronic insanity without an increase of new insanity?

Mr. SANBORN: If other diseases were of a similar nature to insanity in their result, there could not be,-but in this respect insanity differs from most other diseases. One hundred persons are attacked with insanity in a given year, we will say; if all those persons recover, there is no increase of insanity; there is even a slight decrease, for some will die; but such a state of things was never known. Now, if, among that hundred, thirty or forty recover (the latter would be about the usual fact), and ten die,-I am merely using these figures for illustration,-then there are of that number about fifty left who at the end of the year, or the middle of next year, will be added to the chronic insane. The reason why chronic insanity increases is, that the recoveries and deaths in any year are not able to keep pace with the attacks of insanity, while the diminution of recoveries and the decrease of deaths (the latter being due to the better care of the insane) have also caused the chronic insane disproportionately to increase. Now, also, there is a stricter classification than formerly, and persons are called insane who would not have been so called thirty years ago. Every insane case is called chronic if it has continued more than a year; consequently the unrecovered cases pass rapidly into this class.

Dr. LUTHER: There has been much speculation about the increase of insanity, some estimating it at one in 1,500 of the population, others at one in 2,000, and another estimate makes it one in nearly every 3,000 population. Now, in considering the subject in reference to the conditions which are to be provided for the insane, we are in danger of running into errors. Allow me to refer to a few statistics upon that subject. Be the number of new cases larger or smaller, one thing cannot be disputed, that, in regard to increase, it will be necessary to provide in the asylums only for the difference between the yearly admissions and discharges; what that is can be