The sanitary improvements and the simplicity of procedure for the admission of inmates tend to produce these favorable results. Delay no longer stands in the way of charitable aid which serves the double purpose of bringing humanitarian assistance to the sufferers at the very beginning of their mental disorder, thus avoiding the loss of health produced by their being secluded without assistance, and a prey to poverty in apartments which are deplorable on account of their lack of hygienic conditions; and their arrival at this charitable institution when it is already too late, converted into spectres, and sometimes with traces of cruel treatment, is also prevented. We have indeed witnessed during this year two cases in which the patient died a few hours after being admitted, but those cases are rare. In past years they were so frequent that it became necessary to take active steps for the suppression of their growing frequency.

The authorities now provide against the treating the insane as if they were criminals or prisoners, and have them taken to the asylum by proper and prudent means.

New wards in the male department, provided with modern drainage, constitute a noteworthy means of security and hygiene.

All of these noteworthy advantages so evident to all the Porto Ricans who have visited the various departments of the Insane Asylum show the evolution brought about by the Americans in the several branches of charities, and are most pleasing to their hearts. I am pleased to affirm this before you.

VILLAGE CARE FOR THE INSANE.

BY JULIA C. LATHROP, HULL HOUSE, CHICAGO.

We have seen set forth here to-night a broader, more highly differentiated, more economical, and more humane general plan for the public care of the insane than is anywhere in complete operation, although our greatest encouragement for its realization lies in such instances already apparent as the Kalamazoo Colony for chronic cases, the simple rural freedom of some of the Wisconsin county asylums, and the few special hospitals and special hospital wards for acute cases existing or proposed in various states.

I want to bring forward and to illustrate in some detail a kind of care for the insane whose limitations are admitted at the outset, but which I believe to be well worth our serious attention as offering a modification and enlargement of our present methods. This is family care for certain classes of quiet patients, already practiced in various European countries and notably growing in popularity abroad. It is said to exist in Russia, Spain, Norway, and Holland, as well as in Germany, France, Belgium, and Scotland. Technical discussions of the classes of patients to be thus cared for will be found in the annual reports of Dun-sur-Auron and of Ainay; in the writings of Dr. Peeters, director at Gheel, and of Sir John Sibbald, former member of the Scotch Lunacy Commission; and in the annual reports of that commission.*

We have heard many times in this Conference of the classic example of family care for the insane in the Belgian village of Gheel. It was for a long time believed that the inhabitants of this village, with their inherited generations of training, with their pious tradition of Saint Dymphna, were necessarily unique in their ability to care for the insane. And, indeed, for these reasons, Gheel might hardly seem to form an argument, convincing as are the freedom, the comfort, the order, the medical supervision, when personally seen and examined. The village of Lierneux, which lies at the other end of Belgium from Gheel, does, however, furnish an argument. It was felt in the early '80's that some provision for patients of the types cared for at Gheel was necessary in Southern Belgium, and after much consideration Lierneux was chosen for the experiment. The effort was to create deliberately such village care as was the growth of centuries at Gheel. The burgomaster protested, and is reported to have said, "Nothing is so contagious as insanity, and while I am burgomaster no insane person shall ever enter Lierneux.” Nevertheless, four patients were sent in 1884 with a nurse, who instructed the villagers in their care. The new boarders were welcomed, and were so much liked that applications to the medical authorities for patients to be taken as boarders came in with almost embarrassing rapidity. In 1896 there were 420 patients

A Congress on l'Assistance Familiale was held in Paris during the Exposition of 1900 to discuss the family care of the insane, of children, old people, and certain classes of invalids. A journal devoted to the consideration of this subject is published under the editorship of Dr. A. Marie, who installed the colony for the insane at Dun-sur-Auron. It is entitled L'Assistance Familiale, and is published at 58 Rue de Douai, Paris.

at Lierneux, and the undertaking has continued to prosper. The reports of the superintendent show the same features of simplicity, freedom, comfort, and adequate medical supervision as at Gheel. It is evident that in this instance there was nothing to depend upon but the actual experience of those who took patients to board, and that, as the burgomaster's opposition showed, there was much scepticism and disapproval to overcome. The Belgian asylums are under state control, and the inspector-general has the same supervision over Gheel and Lierneux as over the closed asylums. Each colony has a local board corresponding to a board of trustees. At the head of the colony is a superintendent who is a physician, with a staff of assistant physicians, and gardes who correspond to our hospital supervisors. The staff physicians and gardes are engaged in constant visiting of the patients in their boarding-places. In the centre of each colony is a small hospital to which new patients are brought for observation before being assigned to homes, and to which patients who become sick or unfit for family care can be taken at once. Curiously enough, while the family care of insane is many centuries old in Gheel, the beginning of this present careful administrative system in Belgium dates from the Napoleonic occupation in 1800.

Still more significant for us is the opening in 1892 by the French of a colony for women at Dun-sur-Auron, and the opening in 1900 at Ainay, a neighboring village, of a colony for men patients. This was only undertaken after the French had studied what is known as the Berlin system,* as well as the older Belgian and Scotch plans.†

As to the Berlin system, it may suffice here to say that in 1888, after some years of effort on the part of Dr. Sander, superintendent of the Dalldorf asylum, official sanction was given to a system of urban family care under the immediate supervision of the asylum physicians, to be employed for patients who were in a state to be benefited by removal from the asylum, but unfit for absolute discharge.

We are now specially interested, however, in the methods of permanent care practised in Belgium, France, and Scotland.

L'Assistance Familiale Urbaine pour les Aliénés Inoffensifs (Système Berlinois). MM. A. Marie et Manheimer-Gommes. Reprinted in L'Assistance Familiale, July 31, 1902.

† Memoire, Dr. A. Marie, presented at Congrès International d'Assistance Publique et de Bienfaisance Privée, Paris, 1900.

Dun-sur-Auron is a village in the middle of France, about thirty miles from Bourges, and was carefully selected as a favorable place for an experiment in sending elderly women patients out from the overburdened Paris asylums. It was begun in 1892, when a few quiet old women were sent there to board. The villagers were glad to receive them; and, although later groups showed more eccentricity, they were still desired as boarders.

At Dun on Jan. 1, 1900, there were 654 patients, of whom four were men; but all the others were old women, for which class the colony was designed. I saw the village in June, 1900, eight years after the first patients were sent. An old inn opened off the main street, whose row of dwellings was broken on the opposite side by the church and a pretty open square. This inn had been turned into a superintendent's house and a little hospital. In the big gardens beyond, another hospital for the care of patients who should become too feeble or too demented for family care was nearly completed. One assistant physician was with the superintendent: the other was stationed at one of the outlying hamlets where patients were boarded, and from which he could more easily supervise his district. As we walked down the village street toward dusk, we met a woman leading a little child, who hopped contentedly along by her side. The woman was a boarded-out patient; and she explained that a neighbor was ill, and she was helping by caring for the neighbor's child. Notice that the patient was not the compelled nurse of her own hostess's child, but that she was lending her friendly aid to a sick friend.

We called at various houses, and had such a glimpse of the life as was possible in a very brief visit. Usually, the patients had the best room in the house. Sometimes there was one patient in a house. Where there were two, they usually shared one room. All the rooms seemed comfortable. Some were adorned with photographs of relatives, and expressed by sundry little touches the occupants' tastes and individuality. Some of the women worked in the sewing-room in which the clothing of the patients was made. There was the neighborly surveillance unavoidable in village life of any type, and the constant supervision of the physicians and attendants going about and in and out of the house.

In 1900 it was determined to open at Ainay, a village contiguous to Dun, a colony for men. The report of the director, Dr. Lwolff, covering the installation and the first year of the colony, and

describing the life as the number of patients grew to one hundred at the end of the year, is so interesting, and is written with such candor, that we would gladly quote it in full; but some brief extracts will serve to give an idea of the simple beginning. He says:

On taking possession of my post, June 1, 1900, I found at Ainay, which was then an annex of the colony at Dun, 29 women boarders and I man. An attempt to install a colony for men was to be made, and I was to send all the women to Dun. But I knew that it was important as well from the financial as from the medical standpoint to have shops in which the patients should work, and at my request the administration authorized me to retain a certain number of women (15) in order to open a sewing-room with their aid. I will say at once that the simultaneous presence of women and men in the colony does not present any difficulty and has occasioned no annoyThis has long been the common experience, however; and all the foreign colonies are mixed colonies. . . .

ance.

:

The first question which proposed itself was the following: Would the population of Ainay receive men patients? Protestations had been many they were afraid of men, they thought them intractable, violent, dangerous, etc. It seemed especially that it would be absolutely impossible to place them in the households of widows. Thus at that period it required a certain courage to accept our patients. We had chosen among our guardians (nourricières) two widows more intelligent and having more initiative than the others; and, after long discussions and veritable conferences upon insanity, we were able to persuade them each to take a male patient on trial. The experiment once tried, all fears vanished; and now we have among our nurses nineteen widows with or without children.

At the time this report was written there were 100 patients at Ainay, so that it will be seen that nearly one-fifth were domiciled under the care of women only. Dr. Lwolff adds, with what we trust is an exaggerated enthusiasm for his men charges:

Women have become much more difficult to place. They are charged with being meddling, gossiping, difficult to please, indiscreet, interfering in houshold affairs.

But he concedes that

Certain nurses possessing a little means ask by preference for quiet women patients to keep them company. These quiet women make their beds in the morning, go to work during the day in the sewingroom, return at meal hours, and pass their evenings in the house. This sort of existence suits their guardians, who thus avoid entire solitude ...