Of treatment I say no word. It would often include much that you do rarely use, and to which I have already alluded. You may have many means and many helps which we cannot employ except for the amply rich. Years ago I tried in vain to talk certain boards into having convalescent seaside homes, not farms near the hospital; I utterly failed. Now, this is coming, but not as yet is the need felt to have those homes where the alterative change of air is complete, as by the sea.

There is a steward for purchases and for care of farm-garden and grounds. The senior physician with no business cares, a trained neurologist, living in the city, spends two-thirds of his day in the hospital; he has only consultations in town. Then there are resident physicians in charge, who shall live in the house. On the female side it is a woman helped by women. After three to five years these aids should be transferred under a new and reasonable State system to another hospital; or, in an endowed hospital, changed yearly from one ward or group of patients to another. Here, alone, is rotation in office valuable. Under the chief are young physicians, internes who serve two years, and both classes compete to win these places, which are paid-as to the younger internes but modestly. One resident is a pathologist. There is a bath master; but in rotation a resident sees and becomes familiar with this service. We have, too, a skilled electrician. The nurses are taught massage, but there is one person who is, as to this, an expert. I would also have on the staff a city oculist and gynecologist to be used on call, and above all, I would have once a week a long consulting visit from outside neurologists. For this visit the staff should select cases of doubt or difficulty, and this should be a serious and formal matter. The men chosen should be paid, and well paid, for I shall ask from them help in research and in the training of nurses. as to these latter aids, they should have very little pay the first year, and more and more as they elect to stay upon receiving their diplomas after two years.

And

Again I wish to emphasize the fact that the nurse is by far the most important part of my organization. How can you hope for the best help from the class we usually see in your wards? I could surprise you a little with the dismay and disgust expressed as to these agents by refined and educated men and women in their letters to me. A few minutes a day make your visits, and the rest of the time, where there is an attendant, is too often spent by your patients in society little above that of the cook or maid.

One wing of my control building shall have a good library of medicine, a laboratory, rooms for pathological research, and also (as we have in the Infirmary here) a room for the study of such phenomena as reflexes, reaction times, with chronographs and the like.

And now, the life, the soul, the driving power, shall be in the physician-in-charge. The training schools, the meetings for organizing combined or individual research shall have his eager care. He shall possess the ingenuity to point out paths untrodden by discovery, the energy to lead on these and to put life and vigor and sympathy into all the work. Above all, he must be gentle, refined and courteous and insist that good manners prevail. I have seen in asylum wards, and seen unrebuked, bits of discourtesy to a well-bred gentlewoman for which I would have dismissed a nurse on the spot.

Of the rest of this great, and quite possible organization, of the rewards for scientific work, of the extra compensations, or the medals for nurses who show courage or have exceptional success I cannot speak; nor of much else besides.

A good deal of this cannot ever be had in your State hospitals, for incredible folly has put most of them remote from cities. But suppose some great-souled man, or some State, decreed such a hospital as I have made a day dream of, would it not become radiant of useful example far and wide? I used to be hopeless that any board would ever rise to an intelligent apprehension of the splendid value of such a scheme. But already at Elwyn certain steps have been taken to secure outside counsel, help and criticism, and I trust scientific use of the nine hundred defective children. The plan as yet lacks the essential element of pay, but perhaps this will come. Watch it and see how it works. The day dreams of the thoughtful sometimes materialize as practical working things, and the years will surely bring something like, or far better, than what I have sketched. If it will be created by the generosity of a man, or the educated demands of the commonwealth I do not know. But it will come.

And now, a word more. I accepted this ungracious post from honest sense of duty. I have said no word of dispraise or critical annoyance that I did not eminently dislike to say. I may be wrong as to some men and to some hospitals. It would be strange if it But let me add this on parting. One preaches to a congregation. It is impossible to select individuals for blame or

were not so.

praise. Try not to be merely hurt or disgusted by the verdicts of my fellow neurologists and myself. If what we have said causes only bitterness and leaves you in thought, action and purpose where it found you an hour ago, then I have assuredly failed as I do not want to fail and had better never have spoken. If it should happen, please God, that my words bear fruit of good I shall get more happiness out of this occasion than I ever thought could come out of most distasteful task of a varied life. If I have hurt or personally annoyed any man here to-day I am, believe me, sincerely sorry. Perhaps many of you who do not feel vexed may yet rest sure that I am largely wrong in my censure and my theories; but fifty years hence, when we must all have been swept away, another will possibly stand in my place and tell your history, and to him and the bountiful wisdom of time I leave it to be declared whether I was right or wrong.

I have been very long, and you as patient. I thank you.

PROGRESS IN THE CARE AND TREATMENT OF THE

INSANE DURING THE HALF-CENTURY.

BY EDWARD COWLES, M. D.,

Medical Superintendent McLean Hospital, Somerville, Mass.

On this fiftieth anniversary of our Association it is fitting to review the half-century's work in the care and treatment of the insane in this country. This is a time to take ourselves seriously to account, and if we have not made due progress in the great purpose of our organization, we should profit by a frank confessing of the things we have left undone; if, perhaps, some advancement has been made, we may take pride in it and thank those who have gone before us, and who led the way.

The limits of this paper permit the discussion of little more than therapeutics proper, with only such reference to questions touching the general care of the insane as will naturally arise in such a review as this must be. We must first note the conditions under which the founders of the Association began their work in 1844. It is needful to consider what was their understanding, and that of their time, of the nature of insanity, although it is but to recite well-known facts of history. Then we may review more justly what they did for the care and cure of those afflicted with this gravest of human maladies. We know that the rational doctrine of Hippocrates and the other founders of medicine, that insanity is caused by disease, was lost in the superstitions of the middle ages. In the revival of civilization in Europe in the eighteenth century, and even before that time, a number of men in its greater countries sought to ameliorate the condition of the insane. The stories of Pinel and Tuke, and what they did one hundred years ago, are our household words; for them it was reserved to make the beginnings of a true reform, not only by taking humane care of the insane, but by treating them as subjects of bodily disease.

But it was twenty-five years later, in France, after Pinel's great triumph at the Bicêtre, that the next advance was made under the influence of his pupil, Esquirol, who began his lectures on the treatment of insanity in 1817. While Pinel had advanced the care and treatment of the insane he knew

little of pathology and got his psychology chiefly from the philosophers. Esquirol advanced the pathology of insanity, and was the prime mover in the second phase of the great reform. But progress in the hospital care of the insane was very slow in France, as in other countries. It was not until 1838 that Esquirol's labors secured the passing of the law by which the modern treatment of insanity in a humanitarian spirit was effectively organized in that country, on a sound basis. There followed then the building of new asylums, with proper treatment by physicians in charge, and better food and attendance.

In Germany, early in the century, Heinroth and others developed Pinel's treatment, but taught the psychic theory of the common origin of insanity and sin. But Reil had then freed psychiatry from the theory of Locke, that there is nothing in the insane but a change in the working of the intellect. In the third decade Jacobi (and Van der Kolk, in Holland) opposed Heinroth's theory, and sought to establish the relations of mental to bodily disease, advocating the material and practical ideas of John Hunter and Bichât. But Jacobi did not regard the brain as the organ of mental activity, and believed the causes of insanity were to be found in the disorders of the organs of respiration and circulation, and especially of the large intestine. It remained for Griesinger to demonstrate the inadequacy of these views, in 1845; and as the 'greatest of modern alienists," he first established the diagnosis of diseases of the mind upon an exact basis of scientific research and sound pathology. The teaching of Pinel and his pupil, Esquirol, were received by the civilized world with enthusiasm. The development of "exact medicine" through the introduction of natural science in the third and fourth decades, both in Germany and France, contributed greatly to the establishment of the new science of psychiatry, and its emancipation from the bonds of the metaphysicians, who still claimed all knowledge of mental physiol

ogy. The Germans interested in mental science went to Esquirol and his disciples, and there got the instruction and inspiration that promoted the building of hospitals for the insane in Germany, according to the modern ideas which Griesinger first clearly taught. He was greatly aided by his illustrious contemporary, Virchow, the acknowledged head of exact medicine of the present day. That this great leader is still living, points the interesting fact that psychiatry is one of the youngest of the medical sciences.