PROGRESS IN THE CARE AND 
TREATMENT OF THE INSANE 
DURING THE HALF CENTURY 
READ AT THE 
Semi-Centennial Meeting of the 
American Medico-Psychological Association, Philadelphia, 
May 15, 1894 PROGRESS 
IN THE 
CARE AND TREATMENT OF THE INSANE 
DURING THE HALF-CENTURY 
By EDWARD COWLES, M. D. 
Medical Superintenden^>»S>4be>'M61^ Hospital 
Read at the Semi-Centennial Meeting of the American Medico- 
Psychological Association, Philadelphia, 
May 15, 1894 
Reprinted from the American Journal of Insanity 
CHICAGO 
Rand, McNally & Company, Printers 
1894 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 pur- 
pose 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 Bicetre, 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 
♦Read at the semi-centennial meeting of the American Medico-Psychological Associa- 
tion, held at Philadelphia, Pa., May 15-18, 1894. 2 
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 183S 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. Tn 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, advo- 
cating the material and practical ideas of John Hunter and Bichat. 
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 teachings of Pinel and his pupil, Esquirol, 
were received by the civilized world with enthusiasm. The develop- 
ment 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, accord- 
ing 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. 
In Italy, at the end of the eighteenth century, Morgagni, the 3 
originator of scientific pathology, had taught that the brain was the 
seat of mental diseases and proposed a mild and rational treatment. 
Chiaruggi also had undertaken the reform of the Florentine asylum 
by substituting a humane and judicious treatment in place of that 
based on superstition and cruel ignorance. After that a few 
asylums were built in Italy, but it does not appear that any 
important influence was exerted by Italian teachings as to the 
nature and treatment of insanity and the care of the insane, before 
the beginning of the half-century that is now ending. 
In England, after William Tuke had built the Retreat at York, 
in 1796, progress was very slow in mitigating the severity of the 
confinement of the insane in jails and alms-houses. Up to 1828, 
when the first commission was appointed to look after pauper 
lunatics in London, the only act in force provided for their being 
"locked up and chained" in secure places. In 1837 Doctor 
Browne wrote that many of the worst faults existed in asylums, and 
few had the confidence of the public. In 1842 there were one 
hundred and sixty-two asylums, public and private, in England, 
and the abuses were so great and frequent in them that the Lunacy 
Commission was then appointed which has accomplished so much 
for England and the whole civilized world. But the great advance- 
ment of the reform was due to Connolly, who, inspired by Hill's 
attempt at Lincoln Asylum, began his work at Han well in 1839, 
with the introduction of the non-restraint system. 
The foregoing summary will serve to indicate the ideas of the 
nature of insanity that were held by enlightened physicians and 
philanthropists in civilized foreign countries, during the half-century 
preceding 1844. That the advanced views of these reformers were 
only exceptionally in effect, is amply shown by the general continu- 
ance in those countries of the deplorable lack of humane hospital 
care. The prevailing ideas of the treatment of insanity, especially 
outside of the asylums, were equally unsatisfactory, although it had 
then come to be generally accepted by medical men that mental 
disorders are symptoms of bodily diseases. Pinel and Tuke had 
learned that the insane require " supporting treatment," and set 
themselves against the abuse of depletion by blood-letting, evacua- 
tion, and low diet. Esquirol, writing in 1816, describes in the 
strongest terms of reprobation the excesses to which this practice 
was carried, not only by physicians in general, but in the asylums in 
France. But while he agreed with his master that irritation is not 
inflammation, and that blood-letting is not necessary in the treatment 4 
of insanity, he still held that it is indispensable in plethoric subjects 
when the head is strongly congested, and hemorrhages or habitual 
sanguine discharges have been suppressed*. Broussais, in 1828, 
held that insanity being an inflammatory irritation requires sedatives, 
counter irritants, and revulsion. He wrote that " profuse bleeding 
has been too much declaimed against since the days of Pinel, and 
his school has been too parsimonious of the blood of the insane.'^ 
In the time before the adequate provision of special hospitals for 
the insane, many were treated in the general hospitals. The theory 
of depletion was the common one; and the practice of bleeding, 
vomiting, and purging pursued at Bethlem as late as 1815, revealed 
by Crowther, Haslam, and Munro, has been characterized by 
Doctor Earlef as absurd, and as a remarkable example of the adher- 
ence to traditional custom. But Morison, in 1826, and Prichard, in 
1837, though disapproving of indiscriminate blood-letting, regarded 
it as serviceable or absolutely necessary in some cases of insanity. 
Burrows, writing as late as 1828, stated that " copious abstractions- 
of blood are almost universally adopted in cases of insanity attended 
with symptoms of violence, and sometimes when the patient is tran- 
quil. The practice has received the sanction of ancient authority, 
and is at present very universal." But he says, further, that having 
followed that example for a number of years, he modified his prac- 
tice. Connolly, while he became convinced at Hanwell that "great 
blood-letting is rarely advisable, and generally dangerous in insan- 
ity, still believed that local bleeding, by leeches, is safe and service- 
able in most cases?' 
German writers of the earlier decades of this century express like 
differences, and a gradual change of opinion, on this subject; and 
Zeller, in 1840, stated that " the idea of irritation has taken the 
place of that of inflammation," and that " topical bleeding as a 
revulsive is better and safer." In Italy the older ideas prevailed 
in the period of medical decadence of that country, even until its 
political regeneration. It is significant that the most distinguished 
personality of that epoch, the great Cavour, was a sufferer from 
nervous exhaustion, and died in 1861, after repeated blood-lettings. 
No one incident of the time did so much as that in arousing scientific 
medicine from its apathy. 
The importance of this question of general depletion in insanity. 
*Dr. Hack Tuke. The Insane in the United States and Canada, 1885, p. 22. 
+Dr. Pliny Earle. "Examination of the Practice of Blood-Letting in Mental Disorders,"' 
Am. Jour, of Ins., Vol. 10, p. 379. 5 
by venesection and otherwise, justifies its being so fully noted here. 
The crucial question of its time was upon this practice, which 
greatly flourished before the first half of this century, and lingered 
even later than 1850; the battle was fought over it by rational med- 
icine against ignorance and empiricism - of insanity as a disease 
of weakness of body against the lingering of the conception of 
some invading evil that must be heroically routed, as were the 
obsessions of an earlier age. The part it played in American med- 
icine shows the influence of European teaching in one respect, and 
the independence of it in another, to the lasting credit of American 
alienists. This brings us to the consideration of the conditions in 
which the fathers of our Association were placed just preceding its 
foundation. 
Rush was the "American Sydenham"; to mention his name is to 
recall to every physician the profound impression made by him not 
only upon general medicine in America, but upon the treatment of 
the insane. His professional career covered the period from 1769 to 
1813, when he died; and among his extensive medical works the 
last one published was the " Observations upon Diseases of the 
Mind," in 1812. This great work is said by Ray to have been "the 
first of the kind in the English tongue displaying thorough observa- 
tion and original thought." 
Rush treated the insane in the Pennsylvania Hospital, and it is 
not necessary to repeat the well-known history of his faith in the 
lancet. He soon discarded the classification of diseases of his 
Scotch preceptor, Cullen, and made one of his own, including insan- 
ity. He lamented the slow progress of humanity, and most in 
behalf of the insane; he refers to the "humane revolution" in 
Great Britain, and states that a similar change had occurred in the 
Pennsylvania Hospital. " The clanging of chains and the noise of 
the whip are no longer heard in their cells. They now taste of the 
blessings of air and light and motion, in pleasant and shaded walks 
in summer, and in spacious entries warmed by stoves in winter." 
He had enlightened views of the importance of labor and diversion 
of the mind thereby, while he regarded insanity as sickness. But 
he had peculiar views as to its nature; he believed that its primary 
seat is in the blood-vessels of the brain. He employed bleeding in 
melancholia, and as the first remedy in mania, it being, as he 
believed, " an arterial disease of great morbid excitement or inflam- 
mation." In most cases he also prescribed blisters, issues, saliva- 
tion, emetics, purges, and a reduced diet. Then after reducing the 6 
action of the blood-vessels to a par of debility with the nervous 
system, he allowed stimulating food, drinks, and medicines, and a 
change of company, pursuits, and climate. He extols opium as 
" that noble medicine which has been happily called the medicine of 
the mind." He believed also that venesection was necessary in con- 
sequence of there being " no outlet from the brain to receive the 
usual results of disease or inflammation, particularly the discharge 
of serum from the blood-vessels." 
These teachings of Rush long controlled the treatment of insan- 
ity by general practitioners in America. But these depletory and 
reducing means were practically discarded by the earlier alienists 
who came after Rush; The Frankford Asylum, opened in 1817, 
employed the mild method of the York Retreat in England, and 
exercised a most salutary influence by its example. At the McLean 
Asylum, in 1818, Doctor Wyman adopted the system of Pinel and 
Tuke, and was opposed to depletory treatment; and Doctor Bell in 
1841 wrote that " the practice of bleeding, violent purgation, emetics, 
vesications, and derivations has passed away before the light of ex- 
perience." In the earlier years of the Hartford Retreat, which was 
built in 1824, Doctor Todd insisted upon generous diet, and recom- 
mended a frequent resort to tonics and narcotics in the medical 
treatment of the insane. He found that it required considerable 
boldness and address to introduce this plan of treatment, contrary 
to the teachings of Rush. These rational views were advocated by 
Brigham, Ray, Bell, Kirkbride, and Curwen, and many others. But 
Earle, as late as 1854, found occasion for a strong protest [1, Op. 
Cit.] against the general practice of blood-letting in insanity as an 
error then generally prevalent. 
The practical therapeutics of that time, from 1840 to 1850, may 
be summed up, truthfully perhaps, as follows, both for England 
and America: With the discarding of the theories of inflammation 
and depletion as the prime indications in insanity, the practice of a 
"supporting treatment" had come into favor, with medication 
aimed at meeting the symptoms as they appeared. About 1840 it 
was with many the rule of practice to regard it as an important first 
indication to meet the symptoms of local congestion, especially 
when there was evident determination of blood to the brain. But 
in the treatment of this condition only local bleeding was approved 
in the best hospitals, and that under many cautions against exhaus- 
tion or collapse. Emetics were regarded as useful in torpid states, 
as in melancholia with dyspeptic disorder. The best method was 7 
to use tartrate of antimony, which was found most efficient often 
in mania. But care was to be taken not to be misled by the calm- 
ness thus produced, which arises from exhaustion. 
Purgatives, laxatives, and enemata were used with much of the 
careful discrimination taught by modern therapeutists, the less dras- 
tic remedies being best approved. Preparations of mercury were 
used with more care than before that time. Opium, narcotics, and 
sedatives were in general use; these included hyoscyamus, bella- 
donna, and conium. They were used to allay excitement or agita- 
tion, or as hypnotics. Opium and morphia, while their use was 
regarded as requiring discrimination, were believed to be liable to 
cause phrenitis in cases of cerebral congestion and great vascular 
action. When indicated, opium was given in large doses; but it 
was often contra-indicated for sleeplessness, if after taking it the 
patient should awake with increased excitement. Camphor was 
much used, and often combined with liquor ammonias acetatis, and 
was regarded as a valuable remedy. 
Counter irritation was still prescribed to some extent. It is to be 
presumed that some in America followed an English authority of 
the time, and regarded blisters as beneficial in mania as revulsives, 
and as useful in melancholia by their irritation serving to divert the 
mind from its morbid train of thought. It was considered injuri- 
ous to apply them to the head, as they increased the excitement of 
the cerebral membranes and interfered with the application of cold. 
Tartar emetic ointment, and the like, were used to maintain a 
steady counter irritation on the back of the neck in recent cases of 
insanity. Cold to the head, the douche for the same purpose, the 
warm bath, with friction of the lower extremities, were prescribed 
in appropriate cases. But the use of cold water was regarded as 
requiring caution, and unjustifiable as a mode of punishment. 
In the search for data as to the practice of American alienists in 
the use of medicines during the last half-century, the case-records 
for seventy-five years of the McLean Asylum have furnished a mine 
of information. The general results of their examination in detail 
will be given here, as probably affording a fair example of American 
practice, and showing the changes in it. 
In the period from 1840 to 1850 these records confirm the indica- 
tions of the foregoing summary of the therapeutics of the time, 
except that there is proof, by negative evidence, of Doctor Bell's 
statement, already quoted, as to the disuse of " violent derivations." 
Tartar emetic ointment, applied to the spine, is once mentioned. 8 
A common tonic was " red mixture " (conium and carbonate of iron). 
Quinine, arsenic, port wine, "brandy and bark " were prescribed. 
Chloric ether was sometimes given in agitated melancholia. Tincture 
of opium in one drachm to three drachm doses was prescribed for the 
excitement of mania, and sometimes in melancholia. It is noted in a 
case of puerperal insanity that " a previous attack seven years before 
had doubtless been prolonged by depletory treatment - bleeding, 
blistering, salivation, and starvation." It is interesting to note the 
use, in a number of cases, of inhalations of ether and chloroform to 
allay excitement and promote sleep. " Supporting treatment," with 
nutritious and liberal diet, was the regular practice. The writer 
recalls with interest his personal experience in the preparing and 
dispensing, as a junior officer at the Hartford Retreat, about 1860, 
of a very similar list of medicines. The terms " red mixture," 
"elixir pro," and " nux and gentian," are vividly remembered, as 
well as the consistent teaching and practice of the " supporting 
treatment." 
Moral treatment was regarded in all the asylums as of the great- 
est value. Taking the practice of the McLean Asylum as an 
example of the views prevalent from its beginning, in 1818, to 1850, 
its records show that great attention was paid to occupation and 
recreation. Doctor Bell gave interesting accounts in his reports of 
the means for inducing patients to take exercise, in manual labor 
on the farm and in the carpenter's shop, walking in the gardens, 
excursions, in-door games, entertainments, etc. These methods 
were not unlike those employed in hospitals of the same class at 
the present day. 
At the McLean Asylum, up to about J 865, there is little change 
noted in the records beyond the introduction of new preparations of 
iron, the occasional use of strychnia, etc. But in that year bromide 
of potassium appears as being prescribed for melancholia. The 
use of opium and morphia at that time had notably diminished to 
small doses, often combined with hyoscyamus; and these prescrip- 
tions were much less frequent. Chloral hydrate appears among the 
drugs given in 1871; but before 1890, this and the bromides were 
practically no longer prescribed. Cannabis indica was given for a 
time about 1880, but was quite abandoned, along with all prepara- 
tions of opium, except codeia, which was used in the restlessness of 
elderly people to allay distress, and in some cases of melancholia. 
During the later period the newer preparations of iron, quinine, 
strychnia, etc., were commonly given. A rather increase*?! use of 9 
stimulants at one time yielded to the more common practice of 
frequent feeding, especially at night. 
The therapeutic history of the last five years or more, of this 
hospital, shows an extension of the indications just noted; there 
was also a marked lessening of the use of hypnotics. Paraldehyde 
and urethan were not long used. Sulfonal then came in vogue, 
but after three or four years was practically disused as unsatisfactory 
because of its possible after-effects; it still appears to be used in 
many hospitals but there is evidence, in cases that come to them, 
that this and other like drugs are employed to excess. Then came 
chloralamid and trional, and these last are still prescribed for brief 
periods in severe cases. Hyoscyamine and the like were never used 
here beyond a few experimental doses. The same is true of hyoscin, 
although it is perhaps generally regarded as a useful drug. But grad- 
ually the practice has come to be the dependence upon food as the best 
tonic, and the best hypnotic, frequent feeding by night-nurses, with 
the warm bath as an adjuvant. A few sleepless nights were not 
regarded with anxiety, nor even a long continuance of small amounts 
of sleep nightly, as long as nutrition is maintained, as it more surely 
is when no poisons are given that impair the digestion and aggravate 
irritation by their after-effects. 
After 1880 there was noted the increasingly diligent use of mas- 
sage, sometimes faradism, and gentle gymnastics, with increasing 
amounts of exercise as it was borne. Absolute rest in bed in 
appropriate cases was prescribed, except when unendurable, 
because of distressing restlessness; but such rest was insisted upon, 
and modified to suit the case - till after midday, or after breakfast. 
The practice of this later period may be summed up as the further 
development of the "supporting treatment" that our fathers began 
early in the century. It became rational and scientific under the 
precise methods of the " rest treatment," with which the name of 
our illustrious countryman is always associated. The proof of the 
prevalence of these principles in the past practice among the insane 
is not wanting. A remarkable article was written in 1868 by Doc- 
tor Van Deusen, the superintendent of the Michigan Asylum for 
the Insane at Kalamazoo, entitled " Observations on a Form of 
Nervous Prostration (Neurasthenia) Culminating in Insanity." He 
wrote that his observations had led him to think that there is a 
disorder of the nervous system, the essential character of which is 
expressed by the term neurasthenia, and so uniform in development 
and progress that it may be regarded as a distinct form of disease. 10 
He drew a graphic clinical picture, with a completeness of detail 
and an analysis of symptoms, that exactly accords with our present 
knowledge. He applied the term " neurasthenia " as an old term, 
taken from the medical vocabulary, and used simply because it 
seemed more nearly than any other to express the character of the 
disorder, and more definite perhaps than the usual term, " nervous 
prostration." The transitions from neurasthenia to melancholia 
and to mania were well described, with a clear insight into the 
concurrent bodily conditions; the motor and the sensory changes 
were noted, and differentiations were made between the various 
groupings of mental and bodily symptoms. The principles of the 
treatment of neurasthenia could hardly be better stated to-day, in 
the light of the present greater knowledge of these conditions. It 
is known that these views of Doctor Van Deusen's grew out of clin- 
ical observations at Utica Asylum some years before. It is inter- 
esting to note that they were published in 1869, before the appear- 
ance of Beard's original paper on neurasthenia; and that even the 
neurologists are not yet agreed as to the existence of such a 
disease. 
It was the common teaching ten years ago, and by some even to 
the present time, that neurasthenia, as a distinct disease, rarely 
passes into melancholia. In this view it was hardly believed that 
the neurasthenic condition is the very soil out of which insanity 
grows. Hence there is progress made when it is shown that all 
insanity being nervous weakness somewhere, the fundamental prin- 
ciples of the treatment of the insane are included in the "rest 
treatment." Thus it has come to pass, at the end of the century 
since Pinel's and Tuke's " milder treatment," the great contribu- 
tion to rational therapeutics, in the formalizing of the " support- 
ing treatment," has aided in making a finality to the demonstration 
that acute insanity is a disease that presents various manifestations 
of pathological fatigue and should be treated accordingly. And as 
we change with the changing times, so " time brings in his 
revenges." A hundred years ago Rush contended against the 
humors in the blood which, being pent up in the brain, disordered 
the mind; and he sought to let them out with his lancet. Now we 
are beginning to believe that various toxaemias work derangement 
of nervous and mental function; and against the depletion so 
largely prescribed during the first half of our century, we set up 
the principles of elimination in the treatment of acute insanity. 
The alienists all through the century have held the advanced and 11 
enlightened views of their times. They were leaders in their com- 
prehension of nervous weakness, and in withstanding the evils of 
the depletory theories; they have kept pace with the logical 
advancement of the " supporting" method. We have now come to 
face with our modern problems: not only must we study the 
chemistry and physiology of nutrition and body weight, but the 
revelations of blood analysis are of vital importance as guides to 
treatment; and the study of the influence of infectious diseases, and 
the chemical pathology of diathetic disorders, point directly to the 
rational treatment of the mental derangements that depend upon 
auto-intoxication. The "new psychology " now presents itself as 
one of the newest of sciences for us; the beginnings of the adapta- 
tion of its precise methods to clinical purposes in the laboratories 
of our hospitals are only yet being made in Italy, Germany, France, 
England, and America, but they are full of encouragement. It is 
on these lines that there appear the most hopeful signs of progress. 
The advancements that have been made in the pathology of the 
nervous system have been very great in some directions, but the 
aid that was expected from anatomical pathology, in the treatment 
of mental diseases, has so far been disappointing. This subject, 
however, is not germane to the present discussion. 
This review has been quite strictly limited to the therapeutics 
proper of our special work. But it has of necessity touched upon 
one of the burning questions of the whole century in the humane 
care of the insane, that of mechanical restraint. We have seen 
that our American alienists of the first half of the century were 
able to begin with the methods of Pinel and Tuke. Our first 
asylums were new then, and in them there was little to reform. In 
1844 there were twenty institutions for the insane in the United 
States - nine of these were founded in the preceding five years. 
Doctor Bell then contended that, as compared with the European 
asylums of that time, no such abuses ever existed in American 
asylums that called for the great reform of non-restraint. It is not 
the place here to review that controversy of eighteen years ago. 
The truth lies somewhere between the opposing extremists among 
English and American alienists. Folsom has shown the fact of 
American leadership by the grand men who were numbered in the 
"original thirteen" of the founders of our Association; and that 
this leadership may be accounted as continuing about twenty years, 
covering the careers of Ray, Bell, Kirkbirde, and others. But in 
the half-century of events that we are now recounting, one hundred 12 
and twenty-five institutions for the insane have been added to the 
twenty that before existed. In the marvelous growth of our coun- 
try, with the immense influx of foreign population, and the rapid 
multiplication of the insane in hospitals, it has been an age of con- 
struction. Our States, municipalities, and asylum officers have been 
often overwhelmed with the problems of the mere housing of the 
insane. It was a question of great poverty in some of our States. 
We never fail to honor the noble woman, Miss Dix, when we think 
of the time of preparation that led to the building of our many great 
hospitals. We will all agree that in the struggle with the problems of 
construction, there were the inadequate provision of asylum accom- 
modations that left the insane in alms-houses and jails, the slowness 
sometimes with which the legislators were enlightened, the interfer- 
ence of political interests that sometimes worked disaster and is still 
obstructive of progress. We will agree that there were many 
lamentable shortcomings in the care of the insane of our country. 
Doctor Tuke has done us the justice to say that the proper persons 
to be blamed are not the body of alienist physicians, but the mass of 
the people themselves. It is doubtless true that, so far as medical 
restraint is concerned, its use has been greatly lessened during the 
past ten years; by many it is practically not employed, and there 
has been a large growth of the humane spirit that surely comes 
with the knowledge gained through the greater experience in the 
care of the insane. 
Moral treatment is better understood; it is being more generally 
recognized that everything available which includes healthful occu- 
pation for body and mind is a most salutary medicine for the mind 
diseased. While we have to lament that true progress is still sadly 
retarded in some of our Slates, where the best interests of the insane 
are sacrificed to political greed, there is growing evidence that our 
country as a whole is entering upon a new stage of progress in the 
care of the insane. With the.incoming of a new era in the con- 
struction 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 13 
attendance he wanted for his patients as probably not to be had 
unless it was inspired 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 instruc- 
tion. 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 and 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 estab- 
lished -vithin 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.