charge in these cases should always be a judicial act, the medical officers informing the committing anthorities of restoration to sanity. In case of remote districts, away from medical men or from a judge having power to commit, and in order to provide for the insane needing immediate care, it is quite important for the local authorities to have power to bring persons of unsound mind before the proper officer, who should also be able to summon them at his pleasure. It is proper, too, that in some cases at the discretion of the asylum authorities, where a certificate of insanity is not desirable or not legal, individuals should be allowed upon their written application to become voluntary patients, to be permitted to go away within three days after signifying their desire to do so, the three days' provision being made with their consent upon entrance, and being intended to prevent a person, quiet at first, but afterwards become violent or dangerous, from suddenly bursting out upon the community without warning to those whose duty it would be to secure at once a proper commitment.

The question would naturally arise, What security have the insane against too long detention, the medical men who see them every day not having their attention directly drawn to that point as often as might be desirable? The difficulty may be partially met by having every commitment paper valid only for a definite period of one, two, or three years, at the end of which time the medical superintendent should be required to examine his patient carefully, and certify anew to the central board as to his insanity, and as to the propriety of further detention. The board, as expert, too, should be constantly making investigations with regard to that point, and the rule should be followed of allowing the safe patients to try outside life too often rather than not often enough.

The lunacy commission or commissioner, having the right to discharge any insane person upon inquiry, should also be empowered to transfer paupers from one institution to another without obtaining fresh commitment papers.

III. While in the asylum or elsewhere the insane should always have the right to consult the central board, and to that. end must be allowed to send to the board, and to receive from it unopened letters by mail, without the delay caused by the periodical emptying of locked letter-boxes. Letters sent to others than State officers should be indorsed and kept for the relatives or inspectors, as in England, or disposed of as the judg.

ment of the superintendent dictates, according to Scotch law; the nearest relative, and as many others as is proper in each case, of course having the right of unrestricted correspondence. The admission of friends must necessarily be under the control of the medical staff of the hospital, a list being kept of those refused entrance, and there resting with the central board power to authorize any person for sufficient reason to have permission to visit any inmate upon its written order.

IV. Especially, as it is well to encourage the greater use of private asylums in this country, the board should be required to see that means are taken to sufficiently guard the property of all the insane under confinement, and whenever one of them is not receiving the benefit of a fair proportion of his estate, to report the facts in the case to the attorney-general, whose duty it might be to direct inquiry for the purpose of securing justice in the matter. As a rule, such a regulation would probably result in an agreement being made between the parties interested, with the consent of the board. Too many of the insane live without the comforts to which they have been accustomed, the property rolling up for their heirs, when the legitimate use of their income might make them incomparably less wretched.

V. The board should have authority to visit at their pleasure, and fully inspect all places in which an insane person is confined, seeing personally each patient at definite intervals of time, and with proper safeguards examine all places where one is alleged to be under detention, the overseers of the poor being required to report to it all persons in their town or city known by them to be of unsound mind. It should have such direction and regulation of all matters relating to lunacy as each State might think best to give it, a great deal being left to harmonious co-operation with it on the part of the asylums rather than to legal enactment, for it is much easier and more disastrous in its possible results, to place too much power than too little in supervisory hands. The board should be enabled to ask for any facts, to make inquiries, summon witnesses, examine on oath, require records of mechanical restraint, seclusion, and general matters of management, give and renew licenses for private asylums, receive notice of all deaths, accidents, escapes, or maltreatment by attendants, and make an annual report of all its doings. It should see that penalties are enforced for noncompliance with the laws for the protection of the insane, for neglect of duty, or abuse of patients, and should keep a list of

all discharged officers to be furnished to the several institutions. The laws regarding settlement of paupers, so far as the insane are concerned, should be enforced by the board, and all questions regarding them should be decided by it under the statutes. VI. Perhaps not the least valuable work to be done by a lunacy commission would be the proper classification of the insane, and by more promising treatment, by establishing a separate asylum for criminal lunatics, another for idiots, still another for paralytics, insane epileptics, and dements, and a self-supporting institution for dipsomania and allied forms of drunkenness, by removing suitable persons to those few almshouses and private dwellings which are adapted to their proper care, and, most important of all, by insisting upon well appointed. hospitals, in the strict sense of the word, with all the best resources of our skill, and the most approved appliances of art for treating curable mental disease. By tact and wisdom an incalculable amount of good might be done in this direction, which would finally reach out so as to embrace every question involving the welfare of the insane, and the duty of society to that unfortunate class.

Finally, every officer of the central lunacy commission should be required, as in Scotland, to take an oath to keep secret all such matters as might come to his knowledge in execution of his office, except when required to divulge the same by legal authority, or as far as he should feel called upon to do so for the better performance of his duty.

In the necessarily brief time which I have felt justified in occupying, I have endeavored to give an outline, in as concise a manner as possible, of what I conceive the simple duty of the State to the insane to be, in a most important matter, touching the direct interests of most-at least the sympathies-of all of us here. Where so much demands accomplishment, cannot our noble profession inaugurate measures to bring about the changes that are required, and help to guide a movement which, with fewer or more mistakes as we co-operate or not, an enlightened public opinion must sooner or later set in motion? The superintendents of our asylums are doing a vast deal in the direction of improved methods for the treatment of the insane, for which they deserve the gratitude of the profession and of the public. They will be only too glad to co-operate in any wise way for carrying that work still further.

THE NATIONAL BOARD OF HEALTH AND THE INTERNATIONAL

SANITARY CONFERENCE OF WASHINGTON.

By J. L. CABELL, M.D., LL.D.,

UNIVERSITY OF VIRGINIA.

WHEN the Chairman of this Section requested me to prepare and read at this meeting a paper in relation to the operations of the National Board of Health, my first impulse was to decline the proposed task, on the ground that, that subject having been treated by my colleague, Dr. Billings, at the last annual meeting of the Association, it was not probable that a further consideration of the same general questions would prove to be acceptable to the same class of hearers. After some reflection, however, and in deference to the reiterated requests of the chairman, I was induced to believe that a brief statement of the salient features of the discussions of the International Sanitary Conference, recently held in the city of Washington, might be of interest to sanitarians in general, and especially to those who may be charged with the duty of protecting our seaports against the introduction of contagious and infectious diseases from foreign countries.

And in connection with this general topic, it will not be inappropriate to allude to the practical results of recent illiberal legislation on the part of Congress, in wellnigh nullifying the efforts of the National Board of Health to render effective aid to the local authorities of our seaports in the execution and enforcement of the regulations which they have framed or adopted, with the view of preventing such importations. It is hoped that at some future session wiser counsels will prevail, and the national legislature be induced to recognize the truth of the adage that prevention is better than cure. As a means to bring about such a result, it is desirable that sanitarians should exert their legitimate influence in the way in which it is most likely to tell with practical effect. How this may be done without

taking any individual physician from his home has been shown in a letter on the "Power of the Medical Profession in Legislation and Public Affairs," addressed to the editor of the Medical Record, in June, 1880, by Dr. Stephen Smith, of New York. The details of a plan of procedure by means of which the previously oft-defeated Bill for the Establishment of a State Board of Health was at length quietly carried through both houses of the New York Legislature are succinctly stated, and the result well illustrates the influence which the medical profession can exert in legislation when that influence is properly exercised and concentrated. It is an example worthy of study and imitation. One feature of the plan may be cited verbatim, as especially indicating the mode of individual action on the part of physicians at their respective homes: "Immediately," says Dr. Smith, who, by the way, devised the plan, and was very largely instrumental in its execution, "immediately after the election last fall, the name and post office address of every member elect was obtained. With the aid of the Transactions of the State Medical Society it was not difficult to locate an influential physician in the immediate neighborhood of each elected member. Correspondence was immediately opened with these medical men, and each was requested to take an early opportunity to explain to his representative the necessity of establishing a State board of health, and to urge him to support such a measure if introduced into the legislature. The response to this appeal was unanimous and most cordial, and before the meeting of the legislature a large proportion of the members elect had expressed themselves favorable to the measure."

Thus the battle had been more than half won before the meeting of the legislature, in preparation for which, however, petitions had been circulated throughout the State, which were very extensively signed by the leading citizens of each locality. For further details let me refer the members of the Section to Dr. Smith's admirable letter, as published in the Medical Record of June 19th, 1880, vol. 17, No. 25. The result was the passage of the bill in the senate with but a single dissenting vote, and in the house by a vote of eighty-two to six, to the extreme "surprise of those who did not know the secret but all-controlling influence which governed the actions of individual members of the legislature. It was wholly the work of the medical profession of the State, each man acting in his own circle of influence