care of the insane. With the incoming of a new era in the construction of hospitals there is already established a new movement for the perfecting of their use. This is animated by the spirit that leads us to keep in view the broadest principles of moral treatment, with all that this implies.

There is one other subject that has a large place in our history of the care of the insane, and is destined to have a more potent one. The problem of the nursing of the insane arose with Pinel. Tuke trained attendants at York at the beginning of this century. Jacobi at Siegburg, in the third and fourth decades, described the kind of attendance he wanted for his patients as probably not to be had unless it was iuspired by religious motives. Pastor Fliedner, at Kaiserswerth, in 1836, revived the Protestant nursing sisterhoods. Wyman, and Lee, and Bell described the humane service upon the insane.by New England young men and women. Ray wrote of the ideal attendant, and Curwen published rules for their instruction. Kirkbride, in 1845, recommended the giving of systematic instruction to attendants. All this was before the middle of the century. In 1854 Browne lectured to his attendants at the Crichton Institution; yet later it was still doubted by many most thoughtful minds if the humane aud sympathetic service required for the insane would ever be gained except it is prompted by the religious spirit. But Samuel Tuke had already, in 1841, expressed the doubt that there could ever be an adequate supply of such service.

Then came another noble woman-Florence Nightingale—who raised up one of the greatest reforms of our time-the reform of nursing in the general hospitals. The alienists had striven for this reform long before in the asylums, and now they strove the more. The recent work of Clouston and Clarke is now a matter of history; and for the last decade of the century, which Pinel and Tuke began, it was reserved to effectively establish a considerable number of organized schools for the training of both men and women as nurses for the insane. In 1892, the centennial of Pinel's great year, there were nineteen such asylum training-schools in America, all established within the previous ten years.

That this is but the beginning of as great a revolution in work for the insane as the like one is now coming to be in the general hospitals, no well-informed observer can for an instant doubt. Progress in our special work has been retarded, and in some vital particulars made impossible, through the lack of intelligent and

faithful attendance. Now it is the nurses of a new order in our hospitals that make possible the new and better modes of treatment. We are stimulated to apply these better methods by having the means for applying them. This movement is filled with the largest promise of good to come by the multiplied power and inspiration it brings to physician and nurse; and it is big with blessings to the sick in mind who, even in their weakness, may know and be uplifted by the intelligent and sympathetic interest of those in whose care they are.

DISCUSSION.

Dr. A. B. RICHARDSON: Such a valuable contribution should not pass unnoticed. We are all under obligations to Dr. Cowles for his resumé of the therapeutics of insanity during the past halfcentury. We are only sorry that the Doctor was not able to give us a more complete review of the general care of the insane, but in the brief time allotted to him he was necessarily restricted to certain portions of the treatment and he handled it in the satisfactory manner customary with him. It is interesting in this connection to notice how truth stands out in this as in everything else and how we cannot from the very fact that truth is truth, get far away from a certain few fixed principles in the treatment of this disease any more than we can in the treatment of any disease. The fact is, as the Doctor says, that the treatment of insanity is the same in its essence, as it approaches correct principles, in every age and under all conditions. And it has been demonstrated by the experience of alienists during this past halfcentury that the treatment of insanity must have in view the fact that the disease is a disorder in the nutrition of the elements in the brain and that there exists a disturbance in the proper balance

between the supply and the demand. On the one hand, in many cases, the ability of the brain elements to take nutrition and properly utilize it is limited. In the next there is an inability to secure the proper amount of nutrition because of conditions in the environment of the organization. Again, there is an overstrain upon the individual which has unduly taxed that particular organization. So the entire treatment of insanity must be a readjustment of this balance which has been lost, by a diminution of the demand upon the organization, upon the brain, by rest, by proper regulation of environment, and by increase in the capacity of the

organization to take nutrition, and a proper regulation and supply of this to it. The Doctor's remarks demonstrate this point clearly, that as far as the treatment has approached correct principles all the way through this half-century it has been directed to this one. point. In the place of taking away good healthy blood or the best elements of the blood as well as the worst elements, the directions now is toward removing the diseased and damaging elements on the one hand and increasing the good elements on the other. It is quite an instructive review and teaches us that we have not got so many principles to keep in consideration in the treatment of insanity, but we must multiply methods of applying these few principles.

Dr. HURD: I regret very much that Dr. Cowles did not have time to elaborate some of the other points which he undoubtedly had mind. I think the past fifty years have shown in the care of cases of insanity a great advance in a variety of directions. We probably have done as much in the treatment of insanity, as in the treatment of ordinary diseases, by learning what not to do, what things are harmful and should be avoided and how to assist nature. Another matter which has been thoroughly demonstrated by the experience of the past fifty years, is the importance of prompt treatment. When institutions were first opened they treated largely cases of maniacal excitement. When the patient's excitement had subsided he was thought to be well and was called recovered. We now know that in some instances the mere quietness of the patient was not a cure but that he may have suffered from circular insanity or possibly after an attack of mental excitement, he passed into a state of dementia and remained there. The old records regarded those patients as cured. They were cured of excitement, of noisiness and that was all. We have found that other conditions are necessary to effect a cure. The past fifty years have demonstrated that the stage at which mental disease can be successfully treated is its earlier stage, and that conditions which terminate in chronic insanity or dementia or degenerative disease may easily be arrested when the fault is originally with nutrition, When, however, the difficulty has gone farther and the nerve cells of the brain become degenerated no amount of treatment seems to be of any great service. I believe if we have done no other thing during fifty years than to establish the principle that all forms of mental disease must be treated as early as possible, much has been accomplished.

Dr. C. G. HILL: This paper of Dr. Cowles' embracing as it does a review of a half-century of psychiatry in this country is something that we would all like to have in our libraries. It would be of great value to the young practitioner to prevent him from moving in a circle, and passing over the ground that has been already traveled. The paper suggests still another agency for producing insanity-a question that we are just entering upon,--the possibility of auto-intoxication, by some toxic element, either produced by a want of proper elimination of effete tissues from the body or else by the growth of bacteria in the various tissues of the body. It would seem that there is a very strong probability of our entering upon a new era and making a new advance in the line of treatment. The history of the past would seem to confirm this. We know that we are constantly environed by elements of destruction, by germs and agencies of various characters, which we breathe into our lungs, take into our stomachs and which get into our tissues in various ways, and our only antidote is a good state of resistence, in other words, a prime state of health. One deduction that might be drawn from this paper is that while there are no specifics in psychiatry, yet there is one essential in all treatment and that is the maintaining of the tissues at a very high point of resistance.

The paper suggests also, that our forefathers (some of us would call them contemporaries) builded better than they knew, and even when they bled and used derivatives and various reducing agents, they sometimes, though acting upon a false theory entirely, accomplished great good. We are taught by modern pathologists that nature constantly makes an effort to throw off diseased tissues and diseased conditions, to eliminate various morbific products and germs productive of disease. Now, in drawing blood from the arm who can measure the number of germs of disease that were eliminated and who can estimate the advantages that might have occurred in so reducing the colony of germs with which the blood was freighted; possibly it allowed the individual an opportunity to gather his strength and make another effort to throw off the remaining causes of disease. Then we all know the value of free purgation. Very probably this had the same effect.

DEVELOPMENT OF THE PRESENT HOSPITAL FOR

THE INSANE.

BY W. W. GODDING, M. D.,

Medical Superintendent Government Hospital for the Insane, Washington, D. C.

Will you pardon the egotism of one moment of reminiscence? Ten years ago I stood here, at the parting of the ways between the old ideas and the new respecting hospital construction, to say what I honestly thought of the progress that had been made in forty years in provision for the insane in America. In speaking, I was turning from the lessons of the past to the promise of the future. It was an attentive audience, of whom some are here to-day, but so many gone! Two who had been my teachers in the study of mental disease, C. H. Nichols and the elder Bancroft, sat here. Pliny Earle, one of the "original thirteen," was presiding, and John P. Gray, who had just quitted the chair, was listening to my words.

Only ten years, and what I said at that time, intended to be conciliatory but possibly considered somewhat radical, would be regarded as conservative, perhaps behind the age now. For the moment had come, and the time was ripe for the change.

But the success or failure of that hour has passed into history, and the shadow on the dial has moved on. To-day has its own lessons, and yet,

'For the touch of a vanished hand,

And the sound of a voice that is still,"

I would gladly stand ready to be offered now, as I stood then.

"Soul-like were those hours of yore,

Let us walk in soul once more."

This means nothing to the younger members who hear me; but there are some listening now who listened then who will appreciate the feeling, pardon the digression, and join with me, as, standing and in silence, I drink in the memories of the past and salute its illustrious dead.

I have been asked to present to the Association "The Evolution of the Present Hospital for the Insane" in twenty minutes. Either this is too much or not enough time. The most wonderful evolu