(5) his disease is of such a nature or in such a stage as to require for his recovery care and treatment while under legal restraint."

It seems to me that the language of this section makes further comment as to the nature of the statutes governing the commitment of the insane unnecessary, and also shows clearly the absurdity of the claim that the law, and public opinion which sanctions the law, recognizes that insanity is a disease; and not only that, beside leaving to laymen, without training, knowledge or experience, the determination as to whether or not an insane man should be placed under treatment. The statutes further imply that the medical men placed in charge of the patient are not competent to determine as to the insanity of the individual committed to their care or his disposition in the future, so that, while he is not committed to the hospital for a definite period, like an ordinary criminal, he has a sort of indeterminate sentence, the conditions of his release not being fixed by the medical man who attends him, but by laymen, who, however good their intentions, can hardly be said to be competent to determine the disposition of the insane man if his insanity is a disease and not a crime.

The construction of the statute shows quite plainly that more restrictions are placed in the way of discharging a patient from the hospital than in committing him to its care, and it is to this fact we owe the dread of these institutions so strong in the public mind, and the determination of the relatives of the patient to keep him at home just as long as possible; whereas, if there was no legal interference, and insanity was looked upon and treated as are other diseases of the human organism, no stigma would attach to the individual suffering from its effects, and he would go to a hospital for treatment just as he would for a surgical operation, because the facilities for care and treatment are better there than they can be at home, except among the very wealthy. Even as it is, I am constantly receiving requests from people who feel that they are breaking down mentally, and would like to place themselves under my care, if they could do so voluntarily.

The remedy I would offer for this anomalous condition is this: All statutes governing the commitment of the insane should be repealed, and such hospitals placed under the same conditions that govern general hospitals. Then patients would come to these hospitals for treatment voluntarily. This they would do if no restraint be placed upon them; and not only that, but as I have abundant evidence out of my experience, they would come for treatment early in the manifestation of the disease, and consequently with better chance for recovery. Let no restraint be placed upon them on account of their mental condition, but give them the same freedom to go as to come. If they are dangerous to themselves or others, and insist on leaving the hospital, let them be dealt with as anyone else would be. I can assure you that very few patients would insist on leaving the hospital, to run the risk of public exposure and a criminal trial. You never hear of the insane man who is taken care of at home or in a general hospital making any complaint about his detention, and only one per cent of those confined in our state institutions under present conditions ever complain or insist upon being allowed to leave before they are sufficiently recovered. Another important change of method is also necessary. If insanity is a disease, who is so well qualified to determine its existence and need of treatment as the physician, and especially he

by training and experience, has become fitted to recognise and treat t should, as does the physician in the general hospital, determine not only long the patient should remain under treatment, but also whether or he is a suitable subject for treatment. The most of the trouble occuring Lospitals for the insane arises from the sending to them of a class of ple who do not belong to them, whose condition can in no wise be bette Ded by treatment, and whose proper place is either a criminal asylum or a ace of detention, where they can be kept permanently secluded. I quote from a paper read by me before the second conference of charities and cors rection in this state:

"I believe that this is partly due to the old superstition that looked upon the man or woman suffering from insanity as a being possessed by the devil. or else as a criminal. Then, too, people's opinions have been formed, and they are most prejudiced, by the history of such institutions and their manAnd this feeling growing out of agement during the last century. the superstition before referred to, that the existence of insanity, in any form. in any member of the family, attached a stigma to the family in which it occurred, injuring their social status and interfering with their relation to their friends and neighbors. Consequently, whenever insanity has occurred in a family, the member so afflicted has been secluded from the public gazo, kept at home as long as it was possible to do so, and when his condition mado it necessary that he should be transferred to the care of an institution, this fact has been hidden, and the feeling engendered that it was a shame and a disgrace to have such an affliction enter the family; therefore, it should be hidden away from the world's knowledge, and not even spoken of at home, *** Then, again, the public admits the fact of insanity without appreciat ing the conditions involved or realizing that the relation of the insane individual to his fellows is changed by his condition; therefore they are disposed to accept his statements as if they were those of a sane person, and to be influenced by what he says, accepting his statements as facts to the discredit of the humanity, and sometimes of the honor, of those who have him in charge."

Here lies the difficulty in dealing with this question. It seems to be im possible for the average man, either layman or physician, who has not lived with the insane, to clearly comprehend that a man may be able to answer ordinary questions and converse fairly intelligently, and still be insane, or that his mental perversion can be, and often is, in abeyance, except in the presence of the conditions which gave rise to it; also, that this perversion, while only affecting his relations markedly in one respect, necessarily indirectly influences all of his conceptions with regard to his environment, and places him out of normal relation to his fellows; while the morbid selfconsciousness which dominates all of his mental processes makes unduly prominent the relation of his environment to himself, and confuses or completely annuls his appreciation of his relation to his environment. Then, again, as a result of the old superstition of demoniac possession, there persists the notion that insanity exists apart from the individual affected; that it is an entity superadded to his mental make-up, arising either de novo or as the result of some injury to or disease of the brain. The fact is "silently passed over,” that there is no manifestation of mental activity in the insane which differs in the least particular from a similar manifestation in a sane man, nor does the insane man do or say anything that he has not done or said before; also, that thousands and thousands of people suffer from injury

and disease of the brain, but do not become insane.

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Taking into consideration the current beliefs with regard to insanity, what I have said may appear startling, and be considered sensational and visionary. But I can remember when the idea of doing away with mechanical do it restraint and the utilization of the trained nurse in the care of the insane was considered visionary. I do not anticipate that the changes I have outlined will come soon or all together, for superstition and prejudice are hard to overcome, and the education of public opinion is a slow process. The first reform to be accomplished is the removal of the opprobrium of over-crowding. from our state hospitals. Then will come the recognition of the fact that the institution owes its first and greatest consideration to the recent case and his treatment; whereas now, every question is discussed and determined from the standpoint of the chronic insane, their detention and maintenance. When these reforms are accomplished, I believe that the transition to the practical recognition of insanity as a disease will follow as a matter of

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DISCUSSION.

MR. ALBERT, Stillwater: Doctor, suppose you were to take a vote this morning, and ask these people whether, if one of their friends were insane, they had any idea that this process involved criminality on their part?

DR. TOMLINSON: The point I would make is this: If you said so, they would say no; but in point of fact they do, because it is a stigma.

MR. ALBERT: Does that not arise from the fact we all feel there is some family tree affected by that, rather than a crime?

DR. TOMLINSON: Whenever a newspaper speaks of the insane man, whenever anybody speaks of him in public, they always speak of him as being "arrested on the charge of insanity," and of those connected with the hospital as "guards" and "prison keepers." Insanity is never spoken of in any other way than in the language of the criminal law or criminal procedure when it is discussed in public.

MR. HOULTON: Doesn't the feeling prevail that a trace of insanity being recognized in a family has its relation to some previous condition existing in that family, and a sort of taint?

DR. TOMLINSON: Yes, that is true; but what has fastened this feeling on it is that the law takes cognizance of it. The saine feeling would exist in regard to consumption, or any other disease, if the law took cognizance of it, because that is just as much a family taint as insanity.

DR. CLARK: How are you going to distinguish between these different. classes unless you have statutes to do it by?

DR. TOMLINSON: If a man should refuse to go to the hospital, and his conduct was such as to make him dangerous, arrest him as you would any other criminal, and try him according to law, and I will guarantee that he will not make any objection. Just arrest him as you would anybody else. Then, if his friends wish to enter a plea of insanity as against his crime, well and good. The trouble is, we have tried to ignore the insane condition of the patient. His friends do not tell him he is insane. They try to avoid that fact in dealing with him. They do everything else but that. Whereas, if they were perfectly frank with him. the question would very seldom arise, and if it did arise, it could be dealt with as in any other procedure.

MR. FAULKNER: I would like to ask a question: Whether there have come under your observation any cases where persons had a knowledge or sort of premonition in their own mind that they were becoming insane and were anxious to put themselves voluntarily, without any ceremony or process, under hospital care? I have had many such cases.

DR. TOMLINSON: I refer to that in my paper-that not a week goes by but that I have just such applications.

MR. FAULKNER: That is in accord with my experience.

DR. TOMLINSON: In Massachusetts, in one hospital with which I am familiar, sixty per cent of all the adinissions are voluntary. In other words, when people do not have to do a thing they will do it, but just as quick as they have to do it, they don't want to. You can sit down in this room all day, and be perfectly satisfied; but if somebody locked that door, it wouldn't be half a minute before you would want to get out. That is the whole point But what lies at the bottom of the whole thing is this that you have got to educate out of the public mind the idea of criminality and vagrancy in connection with insanity.

Now, as to the commitment of people not insane, and the danger of their being kept in a hospital when they are not insane. That I dwelt upon in my paper. This involves the belief that persons in charge of our insane institutions are not competent to tell whether a man is insane or not, and that they Would keep a man there who was not insane. There never, has been in the history of the institutions of this country an authenticated case of a sane man ever being kept in a hospital for the insane against his will. But there are lots of insane people who are considered sane.

A MEMBER: Ought there to be any more trouble in this matter than in enforcing the health laws?

DR. TOMLINSON: No. A man is found in a boarding house or hotel suffering from smallpox, and a health officer sees him. He is directly taken to the pest house without any legal proceeding whatever. And yet that man is deprived of his liberty without due process of law. Why? Because his remaining in the boarding house or hotel interferes with the personal convenience of the other people there. The insane man appeals to the public sympathy, with the incompetent and the inefficient. The public always takes the side of the incompetent and the inefficient. They are like the Irishman who landed in Philadelphia, and was asked by one of his friends to what political party he belonged. He said: "I don't know, but I'm agin' the government."

And then another thing: Insane men are restrained in their own houses, and in sanitariums, and in general hospitals, just as much as they are in hospitals for the insane, but nobody says anything about that. It is only complained of when they have to admit before the public that they are insane. What actuates people is not the feeling for the patient, but the feeling for themselves.

MRS. DUTCHER: Doctor, what would you do with periodical insanity? I have been at homes where the mother and her little children have been turned out of doors by the father and husband at two o'clock in the morning. The man came home drunk-insane. What would you do with that kind of insanity?

DR. TOMLINSON: Arrest him, and try him as a criminal. I have lived with them for fifteen years. My personal experience covers the care and ob servation of more than ten thousand of them, and what I have said in this paper is based on that experience; and I would say, further, that the same ideas are practically held by all those men who have written upon the subject and who speak of it from the medical standpoint.

A MEMBER: Might you not succeed in changing the laws? It is my experience that people let things go because they think there is no other way. We are educating them.

DR. TOMLINSON: That is true. You know Pinel struck the chains from the patients in France. He did not wait until people were educated to his ideas. And yet Pinel was hounded through the streets of Paris, and threatened with assassination.

MR. FAULKNER: Are there not a number of states which commit through a lunacy commission?

DR. TOMLINSON: In Rhode Island and in Pennsylvania the procedure is such as I have described, except in Pennsylvania the physicians have to certify to their findings before a court of record. The State of Alabama has probably the simplest procedure of all. Their procedure was formulated by

medical officers of the hospitals of the state.

In Rhode Island, since the adoption of their statute, there has absolutely disappeared the idea of illegal restraint, or of persons being sent to the insane hospital who should not be.

MR. GATES: Following up your suggestion, that nothing radical can be

accomplished, I should like to ask what you suggest in the way of remedying the laws?

DR. TOMLINSON: I do not think it is practicable to present anything to the legislature.

MR. FAULKNER: I don't agree with you on that.

DR. TOMLINSON: I think, as Dr. Clark does, that it is a matter of public opinion.

MR. GATES: Doctor, I think you said two or three weeks ago that your paper would not be particularly interesting. Now, you see it has proved to be most interesting.

DR. TOMLINSON: I said I didn't think my paper would do any good; nor do I believe it will.

A MEMBER: It has already.

ANOTHER MEMBER: Doctor. you want to have faith in your works.

DR. CLARK: I want to say, in justice to Dr. Tomlinson, that I think every educated physician will agree with him on the points in his paper. This criticism is not against his admirable paper. I simply disagree with him in regard to the fact that every insane person recognizes his insanity.

DR. TOMLINSON: What I meant to say was this: that I have never known an insane man, who was not demented, who was not amenable to reason, and who did not have a sufficient sense of responsibility to govern his conduct to gain certain ends.

MRS. COE: My mind is not quite clear in regard to leaving the matter to be decided by the individual. Should not the friends of the person be the ones to decide whether he ought to be sent to the hospital?

DR. TOMLINSON: Yes, that is what they do now. You see, every day such patients sent to private hospitals. Dr. Whetstone spoke of one of her patients who was taken to a general hospital when she became insane. When a person is in the delirium of typhoid fever they do not stop to ask them whether they shall be placed in bed and under treatment. Insane people should be dealt with and treated just as other sick people.

A MEMBER: Then your idea is that we should have no machinery in this matter except the boards of health?

DR. TOMLINSON: No machinery except that supplied by the common law. As I said before, there are some things about this subject which, unless you have lived with the insane people, are pretty hard to understand; and I have never met anybody who had not lived with them that did understand them. When a new assistant comes into the hospital he always tells me very frankly, in a few months, that he has had to unlearn all that he ever was taught or thought about insanity.

MR. FAULKNER: Now, Mr. I'resident, just one word. I am heartily in accord with Dr. Tomlinson's views, except in one point, and with reference to that he is a pessimist. I don't believe in that. I believe that something can be done. I believe that if the superintendents of the hospitals of this state and the state board of charities and other people, could get an audience with the justices of the supreme court, and go over this thing carefully, they might be able to get from them some modification of that arbitrary decision which classes an insane person as a criminal. I believe there can be a revision of the law, under the guidance of the justices of the supreme court, which will enable us to avoid this miserable process; and, if that cannot be accomplished, we shall have to go to the fundamental constitutional provision, and revise that. Now, this waiting to educate public sentiment is all nonsense. I have been trying to do that for twenty-five years ou this very line. We cannot pass resolutions here, but we can resolve that we will coöperate with these superintendents and with the State Board of Charities to get an audience with the supreme court, or enough of the legal fraternity, to get at a plan and present that plan to the legislature. We can no doubt get a better process for the committal of the insane than that which disgraces the statute books of Minnesota at this time.

DR. MARY S. WHETSTONE: Mr. President, I heartily thank you and the members of the executive committee for granting me the privilege of presenting a matter for your consideration that comes under the head of the "Ounce of Prevention." You have been hearing about places for the keeping of the hopelessly or the chronic insane; that is, the subject of "Detention Hos