to the door of the police authorities, but the city should be blamed for permitting such an inadequate system for the care of these cases.

The time has come when the question of the proper disposition of these cases can no longer be evaded. Cases of delirium tremens and doubtful mental disease are irresponsible to a great degree, and the law makes no provision for them.

A special reception hospital has been advocated. Such an institution under proper management and with constant medical supervision would be an ideal arrangement. Necessarily the establishment of this hospital would mean the expenditure of a large sum of money in the first instance, and a yearly appropriation for its maintenance afterwards. For these reasons the immediate establishment of such hospitals would, perhaps, be considered Utopian in most cities.

But in all cities it would be possible to have a ward or pavilion in connection with the city hospital set apart for these cases. The city hospitals are instituted by the people for the care of the sick whether deserving or undeserving, and are supported by the public moneys.

Attention should be called to the fact that cases of delirium tremens and of doubtful mental disease which come to the official notice of the city authorities are a limited class, so that were this small number added to the number of disturbed cases that always exist in any general hospital, the additional burthen would not be grievous. Against the objection that has been urged that such cases require specially constructed buildings and apparatus, specially skilled physicians and attendants, it may be said that many such cases are now well taken care of in general hospitals and private houses without these so-called essentials. It can hardly be believed that these desiderata are to be found in prison cells or penal institutions. At the present time most hospitals have a neurological staff, and it would be an advantage to house officers, nurses, and students to have larger opportunities to observe mental sickness. Many hospitals object to the admission of these cases because they fear that their admission may be the entering wedge which will open the door of the hospital indiscriminately to all cases of alcoholism and insanity.

It is undeniable that the cases that should be under medical observation in large cities much exceed those which are under discussion. In Bellevue, for instance, 5205 patients were admitted to the alcoholic wards in 1900 and 2425 to the insane pavilion.

According to the statement of the superintendent of the hospital, patients remain in the insane pavilion for about five days or until it is determined whether or not they are insane. They are then discharged or transferred to other institutions. Alcoholic patients remain about three days. They are then discharged, or, if suffering from other ailments, transferred to the medical or surgical wards of the hospital. Patients suffering from the effects of morphine, epileptics, and hysterical patients are put in the alcoholic wards.

Aside from the humane standpoint and on purely economic grounds, the establishment of separate hospitals or of special wards in connection with general hospitals for observation cases would, in most instances, cost less than the present system. Were there such a place provided, many persons who are allowed at large because the police know of no place to which they can be sent would come under early observation and their condition be determined in time to prevent crime. According to the attorney-general, the cost of one murder trial in Massachusetts may reach $15,000.

The first movement tending to proper care of these unfortunate people must be made by medical men. Without earnest and continuous effort upon our part there is but little hope of improved conditions.

DISCUSSION.

DR. CARPENTER: While the care and treatment of the insane has progressed along general lines, this paper is suggestive of steps which should be now taken up by us along special lines. This is a most appropriate subject, inasmuch as it suggests to us the necessity of receiving cases early in order that treatment be applied, and the earliest convalescence be inaugurated. It is a fact that in many of the large cities, no early provision is made for this class of cases. To be sure, acute inebriates are unwelcome guests at the hospitals. We have little sympathy with them inasmuch as they are self-constituted sufferers. We must all agree with the idea the gentleman has advanced, that aside from the cause they are afflicted ones, and frequently in a condition dangerous to life. It occurs to me, after some consideration of the subject, that in every district there ought to be provision

made for a receptive test or temporary hospital, call it what you wish, and we should endeavor to relieve this class from that old idea of stigma which painfully clings to many cases when committed to an insane hospital. I hardly think that such a provision would relieve a person from such a stigma by having it separated from the regular government institution, unless the commitment feature be removed. The fact that one has been committed to such a hospital is the same whether it be within the city limits or in the environs. I think voluntary commitment should be a feature of them. Certainly the general profession would come in better contact with the subject; at the same time the officers and medical staff of the government hospital or state hospital would have the opportunity to early initiate a line of treatment, and at the same time closely observe and investigate each case.

It occurs to me that the best procedure would be for the legislature to provide a receptive hospital somewhere on the grounds of the regular state hospitals, and there receive all such questionable cases, and be authorized to detain them from five to ten days. The local officers should be required to notify the magistrate that such persons are in durance, and on this order such persons should be admitted to this tentative hospital for examination. From there they may be released when recovered, or regularly committed to the state hospital. In this way many cases would go through the sifting process of the reception hospital. As a result many of the old people, many of the transitory psychoses, as well as many alcoholic and drug habitues, might be returned to their friends instead of augmenting the numbers in the already crowded hospitals.

DR. BROWER: The method as pursued in Chicago is, in my judgment, both economical and judicious. For many years, I should say probably twenty years, since the establishment of our Cook County Hospital, these cases of delirium tremens have been successfuly taken care of there. The Cook County Hospital is an institution that contains a number of pavilion wards and attached to each one of these wards there are from three to five or six private rooms, and these cases of delirium tremens begin their treatment in these private rooms away from the ward patients, so that they do not become objectionable in the wards. I am very certain that our results from treatment there are satisfactory and, as I have already stated, much more economical than would be the establishment of any special hospital for this particular kind of delirium.

DR. A. B. RICHARDSON: Mr. President, I simply arise to make one or two remarks about the practice in the city of Washington, inasmuch as that was referred to by the essayist. I am sorry to say that the practice there is not by any means yet what it ought to be. I saw two or three days ago in the public press an announcement of a case that had been taken to one of the hospitals and was refused admission because cases of acute alcoholism were not admitted to the hospital; then the patient was returned to the prison cell, because of the failure to admit him to the hospital, and the next morning he was found dead in the cell. It was shown that the man had been at one of the hotels of the city and had been seen in

a sober condition one or two days before; he was about the streets later in a condition of intoxication and then later in a condition of helplessness. When refused admission to the hospital he was returned to the prison cell and he must have perished, largely at least, from not having received proper attention in this acute stage. The essayist has brought before us a subject that is very interesting and very important, and it is a subject that is certainly too much neglected in many of the cities of the Union. We neglect not only these cases of acute delirium tremens but we neglect cases of alcoholism in general. I don't know a more helpless class and a class that it seems to me is more neglected than the cases of alcoholism. They are just as helpless as any class with which we have to deal. We know this condition often has its origin in forms of defective mental organization and defective physical development, and that being the case, we certainly ought to keep presenting to the powers that be the necessity for treating the defects in these individuals, and ask that some proper attention be given to their care.

We have in the city of Washington just now a police judge who does quite a good deal for this cause; he keeps advocating that something be done for this class, which is a prey upon society and a burden to all their friends. It seems to me that this Association can do nothing more worthy of its calling than to assist in every manner possible, not only with the proper care of the cases of acute delirium but also the proper care of those that are showing the inability to control themselves through a defective organization in this matter of acute alcoholism.

SOME OBSERVATIONS ON THE TREATMENT OF ACUTE INSANITY IN GENERAL HOSPITALS.

By Daniel R. Brower, M. D., LL. D.,

Professor of Nervous and Mental Diseases, Rush Medical College, Chicago.

As we look back over the history of medicine, we marvel at the wonderful advancement in psychiatry. In nothing else has the century just closed shown such mighty strides, and it is with commendable pride that we, as Americans, can claim that here the insane were first elevated from the position of victims of diabolical possession to the dignity of sufferers from disease; that here their hospitalization first began. In the year 1752 Pennsylvania provided accommodations for the insane in a hospital where other patients were admitted, but to Virginia belongs the credit of having organized the first hospital for the insane, and I had the special privilege of taking a somewhat active part in the celebration of its centennial, November 10th, 1873.

It was twenty years after this Virginia hospital was established that Philip Pinel became physician to the insane at Bicêtre, and striking off their chains, placed them under hospital care, and twenty-three years afterwards, when William Tuke opened the York Retreat.

The progress in these early days was very slow. The Eastern Lunatic Asylum, of Virginia, did not become a hospital in fact until Dr. J. M. Galt became its superintendent in the year 1841; and the insane were incarcerated in cages in France as late as 1834.

The great work cannot stop; advancement must continue. The foundations were laid by Pinel, Tuke, Esquirol, Chiarruggi, and Galt, and upon them a mighty structure, as is the hospital for the insane of to-day, has been built. But it needs much to make it a perfect edifice, and we, their successors, must see that