THE DUTY OF THE STATE TO THE INSANE. 745 



ties are very sick people indeed, for, in the first place, they are in 

 danger of their lives ; and, in a second, they are in imminent dan- 

 ger of lapsing into that living death, terminal dementia. Each 

 case, under circumstances of curative rest and calm, requires 

 special hospital treatment, conducted on identically the same 

 principles as those that regulate practice in our general infirm- 

 aries, and conducted under similar conditions as regards rest, 

 nursing, and therapeutic agents. The existing system of asylum 

 structure, management, and treatment makes this almost unat- 

 tainable. No class of cases requires the attention of trained 

 nurses more than subjects of recent insanity." 



Can the present State hospitals provide such accommodations 

 and give such care as Dr. Tuke claims the acute insane for their 

 proper treatment need ? I believe they can, and also that the ac- 

 commodation and care there provided could be made far better 

 than any that might be furnished in an institution established 

 exclusively on the lines of a general hospital. 



Unfortunately, Dr. Tuke's charge that " the existing system of 

 asylum structure, management, and treatment makes the medical 

 care of the insane almost unattainable," is alas too true. The 

 erection of palatial buildings, which would be grand and magnifi- 

 cent monuments to an architect's skill, a State's pride, or a physi- 

 cian's ambition, has too often predominated over modest, simple 

 structures, which could be rendered homelike and natural to the 

 inmates. The fact is that though millions of dollars have been 

 appropriated for the care of the insane, and thousands of capable 

 men have spent their lives in this line of work, very little has 

 been discovered in America about the real nature of insanity, and 

 to-day the whole subject is a terra incognita whose shores have 

 scarcely been touched, and which furnishes a number of the most 

 difficult but yet the most intensely interesting problems to be 

 solved. This condition is the result not of a want of ability or 

 investigating spirit among asylum physicians, but is the natural 

 outcome of a system which so handicaps them with extraneous 

 duties as to render long-continued original medical work almost 

 impossible. 



A physician has under his care on the average more than two 

 hundred patients, both acute and chronic. The desire to get as 

 many of these as possible engaged in suitable occupation, the 

 wish to make the unhappy lot of the chronic insane a little 

 brighter by entertainments of various kinds, the routine history- 

 writing, the correspondence, the attention to the visits of the 

 friends of this large number of patients — all of which, needful and 

 necessary in their way, make so many demands on the physician's 

 time that medical work becomes necessarily secondary and the 

 administrative duties the more important work. 



