A VISIT TO THE PSYCHIATRIC CLINICS AND

ASYLUMS OF THE OLD LAND.

BY EDWARD RYAN, M. D., KINGSTON, Ont.

Any opportunity of adding to our store of knowledge is welcome indeed, and especially so if it takes the form of a long looked-for break in the round of arduous professional life. But when it takes us away to the old land, and brings us in contact with an older civilization, in close touch with other ideas of life, and within the portals of educational institutions time-honored and revered, then truly it is an event in one's life, of more than ordinary importance.

In Ontario, more particularly for the past few years, educational affairs have been much in the public mind. In this connection the administration of hospitals, especially in university centers, would naturally claim attention. The wisdom or want of wisdom exhibited in the care and treatment of the insane has been openly and freely discussed. By some it was held that the present system, which meant little beyond care and restraint, should cease to exist, and that for acute cases, at all events provision should be made in harmony with modern hospital ideals. So many perplexing problems intrude in a question of this character, that, for their solution, it was thought well to seek light where already hospitals for the insane, or psychiatric hospitals, had passed beyond the experimental stage. Germany has given to the world in recent years a remarkable example of industrial expansion. Technical education has found a field or created one for its own development. But it is perhaps in medical science that Germany has made her greatest advance. To Germany, therefore, we went to see what was being done in the world of psychiatry. Of course it could not be expected that anything like a critical study could be undertaken, in the time at our disposal.

In Germany all roads lead to Berlin, and therefore Berlin was the first objective point. It is a beautiful city, though unfortu

nately too little time could be given to a study of its architectural beauty, and artistic advantages.

The hospital "La Charite" is the center of university medical life in Berlin. The psychiatric clinic is a department of the hospital in connection with the University of Berlin, and bears the same relation to the University as do the departments of medicine, surgery and obstetrics. The term "clinic" is applied to all those various hospitals. The psychiatric clinic is presided over by Professor Ziehen, who is appointed by the University of Berlin. The clinic is supported entirely by the university funds and by the fees of the patients.

We were very courteously and kindly received by Professor Ziehen, who personally conducted us throughout the institution, entering fully into every detail of administration, of treatment, and also into the methods of scientific investigation. There are two departments, one for the study and the treatment of the insane, and the other for neurotic diseases, organic and functional. Exception has been taken to the method of thus combining these two classes of patients. It does seem, however, that in a clinic where educational and scientific advantages are important, the wide pathological field afforded by the various neuroses ought not to be neglected.

In the psychiatric clinic there are 160 beds, and in the clinic for nervous diseases about 70. The institution is conducted purely on the hospital system. It is well equipped throughout with modern hospital appliances for treatment and research work. There are laboratories for gross and microscopic anatomy, experimental physiology, micro-photography, neurological research, and so on. It is supplied with electro-therapeutic and hydro-therapeutic apparatus, the various forms of hot air baths, sand baths. and other therapeutic necessaries. Every department, whether clinical or scientific, is under skilled expert directors, aided by a capable staff of assistants. All assistants do clinical as well as laboratory work. The physicians are appointed by the State, on the recommendation of Professor Ziehen, the director. Besides the physicians holding official positions, there are many clinicians, and laboratory workers from the University, and others doing voluntary duty. The patients are kept in bed, carefully nursed

and attended. During the day there is one nurse to every four patients, and one nurse to six patients at night. This number may be increased at any time should necessity demand. For the more disturbed patients single rooms, four in number, are provided, and where required deep padded beds are also used for this class. I cannot say that these beds commended themselves very highly to our judgment. Padded beds, padded rooms and all such, should follow stone walls and iron bars to the limbo of forgotten things.

Small wards, from seven to ten beds, abound throughout, thus affording better opportunity for classification and for clinical purposes. The patients are retained in this institution so long as they are of scientific interest, or respond to treatment, and no longer. The chronic insane patients are then sent to the many asylums in and around the city. The neurotic patients, if chronic, are sent to the institutions for the care of these chronic maladies. Twenty-five hundred patients pass through the clinic in one year.

We visited the asylum at Daldorf, near Berlin. There are 1200 patients in this institution. These patients are received, some from the psychiatric clinic and others direct from the city of Berlin and the towns adjacent thereto. There is a staff of 14 physicians for the 1200 patients. For asylum purposes the staff of attendants is quite ample, in the ratio of one to every five patients. The criminal insane are confined in separate buildings.

We visited the asylum at Buch, which is also situated near the city of Berlin. This institution is built on the cottage system and was erected last year. The buildings are of magnificent architectural design, and occupy a very desirable locality. The buildings number some twenty in all. The interior of every department is well lighted and the space allotted to each patient is particularly commendable. There are 14 physicians on the staff, and one attendant to every four patients. Some distance from the other cottages is situated the building for the insane criminals; they are not allowed to mingle with the other patients in any way; they are, however, kept employed and their life is made tolerably happy. In fact the German method of dealing with the criminal insane, and the insane criminal is worthy of mention. For six weeks they are kept under close observation and subjected to the

most searching examinations. In this way it is quite impossible that deceptions can be carried out, or that mistakes in diagnosis can be made, at all events in either case such an incident would be quite rare. The importance of this method in criminal proceedings must be obvious to all. The unseemly wrangling and contradictory evidence of opposing physicians in criminal trials. is entirely wanting in Germany. "Justice is best served by those who can serve justice best."

The patients in this institution are received from the psychiatric clinic, from the city of Berlin, and from the surrounding districts.

Of course the greatest possible interest centered in our visit to Munich. So much had been said and written regarding the famous clinic of Kraepelin, that we were naturally anxious to come within its sphere of influence. Our anticipations were high, yet we were not disappointed. The Munich clinic marks a departure in psychiatry. It is an entire breaking away from our previous point of view with regard to the insane. Here insanity is regarded as a disease, that should come under the earliest possible treatment. This treatment should be carried out in properly equipped hospitals, with an ample and well-trained nursing staff. As a disease it should receive the same clinical and pathological observation and study as are awarded to the other departments of medicine.

Prof. Kraepelin received us at the clinic with the utmost personal consideration, and one of his staff was in constant attendance during our visit.

The building was erected in 1905, by state funds, and is most modern in every respect. The site was given by the city of Munich. The psychiatric clinic is closely associated with the University of Munich, in fact is one of its most important sections.

Prof. Kraepelin is dean of the medical faculty, and his first assistant, Dr. Alzheimer, is assistant dean. The exterior of the building is of modest though pleasing design. The interior is well arranged, fitted and equipped with all the modern accessories for the treatment and study of the various forms of insanity. Conveniences and appliances for hydro-therapy, hot air baths, vapor baths, electro-therapy, abound throughout. On the scientinc side the institution is particularly strong. Well-equipped