of his non-restraint. Some said his practice would make the male nurse's position humiliating and drive him out of the service.

Retraint is defined by the Board of Lunacy as follows (see 49th Report, p. 16): "Whenever a patient is made to wear an article of dress or is placed in any apparatus which is fastened so as to prevent the patient from putting it off without assistance, and which restricts the movements of the patient or the use of hands or feet, the case should be recorded as one of restraint, irrespective of the reasons which may have led to the use of such restraint or of its having been used in accordance with, or contrary to, the wish of the patient."

Seclusion is defined: "Whenever a patient is placed by day in any room or locality alone, with the door of exit either locked or fastened, or held in such a way as to prevent the egress of the patient, the case should be recorded as one of seclusion, irrespective of the reason which may have led to the use of such seclusion or of its having been used in accordance with, or contrary to, the wish of the patient."

It is, I think, claimed by the officers of the Stirling District Asylum that no case of restraint or seclusion had been used at Larbert during the five years, 1902 to 1906, inclusive. We learn further from the 49th Report of the Commissioners in Lunacy for Scotland (p. 59), that there are three other Scottish asylums in which no case of restraint or seclusion has been recorded for the five years from 1902 to 1906. The three other asylums classed with the Stirling District are the Dundee Royal and Dundee District (under one medical management), the Haddington District Asylum and the Westermains Private Asylum. This report does not show the relative amount of so-called "chemical restraint" used in different asylums, and without a complete knowledge of the amount and frequency of the use of hyoscin and all depressant drugs, comparisons of restraints and seclusions are incomplete and may be misleading. This should be said, however, that our observation at Larbert did not discover the frequent use of depressant drugs. This asylum was more completely dominated by women than any other Protestant hospital for the insane we ever inspected. A head matron had more authority than any resident officer except the superintendent. It was she who engaged and dismissed employees, usually with the approval of the superintend

ent, for the wards as well as for all the domestic departments. This head matron was a superior woman, a graduate of a general hospital training school who had demonstrated her superiority and been promoted from a ward matron. So generally acknowledged was her fitness that the assistant physicians enjoyed the situation. An assistant physician in another asylum, speaking of the organization at Larbert, remarked ironically, "We would have a sweet time, really, if our matron were given such authority."

In an after-dinner speech at Larbert on the occasion of the dedication of a nurses' home, Dr. Clouston, praising the results at Larbert and claiming credit because Dr. Robertson had been trained at "Morningside," said, in substance, with sly humor: "Dr. Robertson's signal success, to my mind, is due to his keen insight into woman's nature. He who best knows woman's heart obtains best results from woman's service." The laugh was on Dr. Robertson but we are inclined to think there was more than a grain of fact in Dr. Clouston's pleasantry. If such responsibility and authority as were prudently exercised by the head matron at Larbert were given to the wrong woman, there would certainly be a "hot time" if not a "sweet time" in the average asylum.

Through the courtesy of the Stirling District Lunacy Board and the superintendent we were furnished with keys and admitted to all the privileges of an assistant physician at Larbert and cordially invited to stay as long as we wished. We hoped to be useful as a substitute for an assistant during a vacation, but we were delayed past the vacation season, so that the only part we could play of real service to the assistants was that of proxy at chapel service on Sunday. This service was warmly appreciated and accepted as legal tender for all our obligations. We inspected the wards at different times alone as well as with officials. Each building was in charge of an assistant matron. We saw not the slightest evidence of seclusion or mechanical restraint and the hospital atmosphere was very pleasing. The sleeping rooms, when locked from the outside, could all be opened by turning a knob from within so that no patient could be locked in. Only two of the men's wards had men nurses and these were under supervision of an assistant

matron.

We had not been accustomed to see patients smoking in bed, but in the infirmary for men at Larbert it was no unusual thing

for the woman nurse to strike and hold a lighted match while the patient in bed would pull at his pipe. When the pipe was working well, she would deftly fit a perforated cap to the pipe to protect the bed and the old man would smile at the white-capped nurse as if she were an angel thinly disguised.

On a certain morning's visit to a men's receiving ward we were interested to watch a muscular young Scot held in bed by four comely young women nurses. He was a mild "manic case and the expression on his face resembled a grin more than fear or rage. After watching the struggle for a time, we could not escape the impression that his desire to get out of bed might not be so great as his desire to be restrained. Be this as it may, we may safely assume that, when fully recovered, memory of his asylum experience will not be associated with any great dread of another commitment.

In the congregate dining-room, the men and women were not separated, even by screens or banks of flowers, as we have seen in our own country, but were seated at the same table, a man between two women or a woman between two men like guests at a banquet. There was method and a purpose in all this-the purpose being to re-educate and strengthen self-control under natural conditions.

When Dr. Rutherford resigned the superintendency of the Crichton Royal Institution at Dumfries in the summer of 1907, to retire on a pension of 1500 pounds a year, there were half a dozen strong men thoroughly fitted for promotion in the public asylums of Scotland. The chief executives at Ayr, Bangour, Larbert and Perth District Asylums were each and all particularly able, ambitious and progressive men. One was the author of a scientific work on psychiatry of exceptional merit; one had won a wide reputation as a champion of non-restraint and women nurses on men's wards, besides being an able teacher of clinical psychiatry. One had proved his ability by building a large institution on unusual lines and solving difficult administrative problems with signal ability, and one had built an exceptionally good hospital for acute cases and had done much to popularize the open-air, bed treatment of both acute and chronic cases. These were but a few of the props on which honorable reputations had been builded, but to mention these serves our purpose. It was an interesting and

evenly balanced competition. There were also competitors from England. "The remarkable thing about it is," remarked Dr. Clouston, in speaking of the candidates for the superintendency at Dumfries," that I haven't an idea which one will win, although each one of the candidates was formerly my assistant." It was not till after we reached home that we learned that Dr. Easterbrook had been appointed at Dumfries. Shortly after this came news of Dr. Clouston's resignation and the appointment of Dr. Robertson of Larbert to the superintendency of the famous "Morningside Asylum," Dr. MacRae having been appointed superintendent of the District Asylum at Ayr.

Since the summer of 1907, Great Britain has lost the active services of two strong men: Rutherford, preeminent as an administrator, and Clouston, as a teacher and writer, the peer of any man.

We made no attempt to make an exhaustive study of the asylums of Scotland. Some of them we did not even visit. We saw no evidence that hydrotherapy was much esteemed there, but we feel sure that an adjunct found so useful in Germany and America will not long be neglected. For the spirit of progress prevails in Scotland even as the spirit of liberty was dominant in the days of Wallace and Bruce.

NOTES ON THE TREATMENT OF ACUTE INSANITY.*

BY SANGER BROWN, M. D., CHICAGO, ILL.

So far as its treatment is concerned acute insanity may be defined as a disease which impairs or destroys the patient's capacity to co-operate with, and indeed not infrequently prompts him to vigorously oppose, those who seek to institute measures intended to promote his cure or comfort; it also disqualifies him from conforming to the conventionalities of social, civil or family life so that some special provisions have to be made for his proper care throughout the course of his disorder; practically this usually requires the exercise of such arbitrary authority as can best be applied in an establishment specially equipped for the purpose. In reference to their treatment, patients suffering from acute insanity may be divided into two classes. In the first may be included those in whom there is a morbid excess of bodily and mental activity and in the second those in whom there is a pathologic deficit in these particulars. The former may be boisterous, boastful, blasphemous, obscene, violent and homicidal, the latter apprehensive, silent, hopeless to the point of despair and suicidal. These two characteristics may alternate, if indeed they be not occasionally combined in the same individual. Either excessive or defective activity may be so pronounced, accompanied as they frequently are with persistent refusal of food and insomnia, as to excite serious apprehension of fatal exhaustion.

Acute insanity, aside from that which accompanies general paresis or those cases which from the first show pronounced signs of mental deterioration, tends strongly toward recovery, and the indications for treatment are, therefore, to assist and not retard nature in her restorative efforts.

Treatment in most cases of acute insanity can only properly be carried out in an institution specially adapted to that purpose, and what I have to say is intended to apply to measures therein employed.

* Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.