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the fifty millions who now inhabit our country, and he will confirm me, if right, or correct me, if wrong, in saying that throughout the older communities of the northern and eastern States we have already at least one insane person to every 400 inhabitants. In Massachusetts, for some reason or other, the proportion is even greater than this, since nobody now estimates the whole number of our insane at less than 5,000, while the population of the State does not much exceed 1,800,000; which would give a proportion of 350 sane persons to one insane person. And the most painful fact is still to be stated, namely: that the proportion of the incurable and the dependent insane is much greater in Massachusetts than it appears to have been twenty years ago, and is steadily, if not rapidly, increasing from year to year. Every other condition of pauperism in Massachusetts, except insanity, has been mitigated within the past three years; but this most perplexing element, instead of being less apparent, as the times have improved, has become more manifest and more embarrassing. We have scarcely been able to build hospitals and asylums fast enough to receive the accumulation of our chronic insane, while the records of our criminal courts have shown a marked increase of those crimes which are excused from punishment on the plea of insanity. At one such crime, peculiarly heinous by reason of the complete innocence and the lofty station of its victim, our whole nation has lately shuddered; but the madness or the guilt of the wretched assassin, Guiteau, differs in nothing save its consequences to the people of America, from many acts of which those persons on the borderland of insanity and crime are responsible. This national tragedy, therefore, casts its sinister light on many another and more private tragedy, for which insanity has furnished the occasion, the provocative, or the palliation. Look, then, at the wasted lives, the severed families, the ruined hopes, the broken estates, for which hopeless insanity is responsible, and consider whether there is any malady in the whole circle of human ills from which we ought to pray more fervently for deliverance. Yet this very disease proves to be, just now, that which is least amenable to science for its cure, or to a wise and humane system for its prevention and practical treatment. It has increased, is increasing, and ought to be diminished,-yet what are we in fact doing to stay its progress or alleviate its miseries? Upon us and upon those who work with us or against us, in the medical profession and in the framing and administration of the

laws, rests now the responsibility of a remedy for this unhappy state of things which seems to have no parallel in the case of any other disease..

Fortunately we can discern, even in the year since we met at Cleveland, some indications of a better state of things. Not that anything has yet been done toward the prevention of insanity, nor very much toward its wiser and more systematic treatment; but we can observe that the persons who deal most directly with the disease and its victims, are coming, since our Cleveland meeting, to a clearer perception, and a better understanding in regard to the measures that need to be taken; have ceased to dispute with each other so constantly, and are beginning to apply themselves, in practical effort, to the problem before them. The medical profession, and especially that branch of it which has made a specialty of insanity and its treatment, has begun to recognize the fact, long obvious to others, that the public authorities have a right and a duty in regard to the supervision of insane asylums, which only becomes more exacting the more its performance is resisted. And on the other hand, the authorities, the State legislatures, and the general public, are coming to understand better what the enormous difficulties are in the way of preventing, curing, or even measurably relieving the insanity that finds its way into our asylums and poorhouses and prisons. And no one person has contributed so much, it seems to me, in this enlightenment of the specialists and of the public, as a veteran among those specialists (Dr. EARLE) whose good gray head I recognize in this audience, and who, as we hope, will give us the opportunity to hear today some of those wise counsels to which in former years we have all been so much indebted. Still greater would our debt have been to this Nestor of his profession if we had known better how to follow the good advice he gave us.

Nor can I refrain from mentioning two special circumstances of the past year, which, in my opinion, have promoted the favorable change of opinion on this subject of insanity. I am aware that some will think otherwise; but it seems to me that the formation of the National Association for the Prevention of Insanity and the Protection of the Insane, which took place last summer at Cleveland, has to some extent operated in the direction that its enthusiastic founders intended. Its task is a hard one, its methods are not yet perfect, nor is the experience of its members so great as it will be

a few years hence; but it has made its mark on the public sentiment of the country, at least in this section, and so far as I can see, has done no harm to any one. We have with us today some delegates from the new organization who desire to be heard in our debates, and to whom, no doubt, you will readily accord the opportunity.

The other circumstance to which allusion has been made is the increased power in the treatment of insane women, given during the past year to physicians of that sex. It is only since we adjourned at Cleveland that the feminine wards in two large hospitals in the State of Pennsylvania have been put under the independent control of experienced women, educated as physicians, and with something of that special training which such responsible positions require. I have visited one of these hospitals within a few weeks, and have received trustworthy information from the other. In both, so far as I can judge, the experiment has had unexpected success, amidst many and obvious difficulties. It is too early to say that the course there adopted, under peculiar and rather fortuitous circumstances, is the best course to follow in all hospitals, I have serious doubt if it is, for reasons soon to be given, but it is important to know, as I think we do know, that an experiment so interesting has been tried in perfect good faith, and upon a large scale, in a State where the example will be so conspicuous, whether it shall be followed or avoided in future. It is to be hoped we shall hear from one of these physicians, a delegate to this Conference (Dr. CLEAVES), concerning the results observed by her in the State hospital at Harrisburg.

My doubt respecting the practicability of introducing in all insane hospitals the special organization for the women's wards which now prevails at Harrisburg and at Norristown, does not arise from any skepticism about the ability of the right woman in the right place to perform toward the insane of her own sex the duties of a good physician. But a hospital, like every other establishment or sovereignty, should have one head and not two, still less three; while it is not easy, in fact, to give to a woman, under the direction of a masculine superintendent, that complete responsibility for the care of her patients which her assumed experience and their manifest need requires. There are objections, readily occurring to any one familiar with the daily administration of a hospital, to the maintenance of a mixed staff of physicians, some

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men and some women,-and it has therefore occurred to me, whether it may not be expedient, in some cases, to establish separate hospitals for insane women, under the exclusive care of their own sex, as are the women in our reformatory prison at Sherborn, which you will visit on Thursday. This notion has led me to correspond or confer with several eminent hospital superintendents,-whose opinions may be cited without their names. Suffice it to say they are all persons of high reputation and long experience. One of these, upon the general subject of employing a woman as first or second assistant in a hospital with no very large number of patients, writes as follows:

"Situated as we are, I think we have done better than have one on our staff. I have called in a recognized female physician from the city, for cases with gynecological complications, and she has attended to any examinations and topical treatment for which a nurse was not competent. This plan has worked very well, and has so far been satisfactory. For this institution I am disposed to continue this plan in preference to the introduction of so new an element in the domestic organization. I have no prejudice against the plan, but in the present state of female medical education and the supply available, I think the chances of a happy result are greater on our present plan than they would be with the changes of one of our own present assistants for a woman. I can imagine a situation in which the right sort of a female physician would be an improvement on any other plan, but confess to doubts whether, at present, a general change of that kind would be an improvement, all things considered. I think it is one of the things which will work itself out in due time, and the best will come to be seen. But it will turn out, I think, that success in the innovation will depend more on the personal traits of the imcumbent than on any general principle. So I should not be surprised, by and by, to find here a physician of one sex and then one of the other, just as the professional and general character of the one or the other should have commended itself to the trustees of different institutions."

Another superintendent with views somewhat different writes as follows: "The propriety of women engaging in the practice of medicine is now but little mooted. The action of the most civilized communities has given such sanction to the custom as to make its growth inevitable. For some time in the past I have been convinced that, for various reasons, it would be better for females to be treated by physicians of their own sex. My only hesitation upon the point was due to the fear that it might be difficult or impossible to find, in very many instances, thoroughly competent physicians of that sex. I still have my doubts, because it is certain that the great majority of women, whatever the opportunities offered them

for preparation for professional life, will be content to devote themselves to domestic duties, - the care of their houses and children. The numbers, therefore, who devote themselves to physic must ever be far less than those of the opposite sex. Even, therefore, admitting an equal original competency, it is evident that the number of thoroughly skilful female physicians will necessarily ever be less than male physicians.

"Every argument which is of weight in preferring female to male physicians for women in ordinary diseases has many times its weight when applied to the consideration of women as physicians in hospitals for the insane. The reasons of this are so obvious that I will not trouble you with their rehearsal. Yet there are such inevitable evils connected with a mixed medical staff in hospitals, that I have not employed a female physician in any capacity about the establishment of which I have been superintendent for more than twenty years. All the difficulties inevitable to mixed staffs would of course be avoided in a hospital for women under the superintendency of a woman. I am, therefore, as you may readily infer, greatly inclined to favor such superintendency. Any misgivings which I have in the matter originate in the fear that it may be impossible to secure a woman thoroughly competent, intellectually and physically, to fill the place. The duties of such a position are very onerous, and ought never to be undertaken by any one who does not combine with intellectual training and capacity for the treatment of disease, thorough business qualifications. You know the opinions of the American medical superintendents upon the point of lessening the labors of superintendents by a distribution of responsibilities - unqualified disapproval. I heartily concur with my brethren in their position in this matter, and could not, therefore, give any countenance to the appointment of a woman to the office of superintendent unless such woman were as competent to administer the various business affairs of the institution as to preside over its remedial province. The difficulty of securing such a woman must be very great, for reasons given above. With this single exception, I am disposed to lend a hearty approval of the plan proposed."

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This plan was that already suggested, of establishing separate hospitals for insane women, not merely separated on the same estate, as in Dr. Kirkbride's admirable hospital at Philadelphia, but situated on separate estates, and managed, as the above letter implies, by women at the head and throughout the establishment. The two superintendents just quoted live a thousand miles apart, and have viewed the question presented to them from the experience of their own States and sections. Another superintendent of still longer service, in the largest State, Dr. John P. Gray, of Utica, N.Y., recently gave me in conversation the conclusions at which he had

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