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Having massed numbers, the next step would be a redistribution such as experience has proven will provide the best advantages for the greatest number at minimum cost; and this, of course, will be found in separating trainables from untrainables.

As an asylum requires a different régime and can be run on a more economical basis, there is nothing gained by hampering with profound idiots or with untrainable epileptics the training school; for this with its custodial and non-custodial cases, its high, middle, and low grades of both sexes, each and all requiring separate and distinct methods, has its energies taxed to the utmost with the material in hand to build up defective minds and bodies, and to make their labor reduce the cost of maintenance. Once protection be assured by means of a system of prolonged apprenticeship, industries already proven could be extended and others introduced, bringing in time this reduction to a maximum. Many of these industries can be profitably carried forward by the incorrigible or moral imbecile; and the custodial buildings now largely filled with untrainable epileptics and idiots, if fitted with shops, might become veritable hives of industry.

The low-grade, or any, early reaching their limit in the schools, might be drafted off to the idiot or epileptic asylums, where they would make useful aids; and in this way, by separation and redistribution may the helpless become helpful, and the utilizing of waste products be made to serve the double purpose of eliminating from society in large degree the criminal element and converting it into an aid in caring for its weakest members, thus in two ways relieving the burden upon the tax-payer.

Later, as sequestration gradually becomes law, there will be de-. mand for yet larger outlet; and the scheme will attain its full development only in a colony giving changed environment with greater freedom to trained artisans completing apprenticeship.

Such a colony, giving a stimulus to training as well as offering permanent outlet to the institutions of the country, might be established on a liberal scale by the national government, which would thus set its seal to the work of maintaining the integrity of the state and the purity of citizenship.

VI.

The Insane.

THE ESSENTIALS OF AN ADEQUATE SYSTEM OF CARE FOR THE INSANE.

BY FREDERICK PETERSON, M.D.,

PRESIDENT OF THE NEW YORK STATE COMMISSION IN LUNACY.

Twenty-three years ago I was a resident physician in a general hospital in a city of perhaps 200,000 inhabitants. The nearest asylum for the insane was two hundred miles away. As a consequence, acute cases of insanity had to be placed in police stations or in the general hospital, pending arrangements for their removal to the asylum. On inquiry you will find that in nearly all the cities and towns of this country at the present day the acutely insane receive their first therapeutic ministrations, such as they are, in a jail or station house. In some cities a general hospital is made use of to a certain extent. For instance, during my residence in the general hospital mentioned, an average of two or three mental cases per month was received, the majority of which were there cared for and treated for a few days or weeks and discharged recovered or improved, while a small number were transferred to the asylum. We had, however, no special provision for these cases; and they had to be taken into the wards or private rooms together with all other classes of patients. If we had had a separate pavilion, we might easily have received all the mental cases of the city without the intermediary of the jail; and immediate medical care and nursing, so important in early cases of insanity, could have been supplied for as long a time as was judicious previous to a possible transfer to an asylum.

We have emergency hospitals for broken bones or acute fevers; but, when the most important organ of the body, the brain, becomes. affected with an acute disease, the emergency hospital is the jail.

This deplorable condition of affairs has led to a steadily increasing agitation of the subject of emergency hospitals for the insane. It is an axiom among physicians versed in psychiatry that early diagnosis and speedy treatment are of paramount importance in nearly all acute cases of insanity. Surely, nothing could be worse for a delirious mind than the sight of police officials and prison walls I advocate, therefore, as the fundamental basis of a system of care for the insane, the establishment in all large towns and cities of emergency pavilions or independent hospitals for the reception of the insane. These need not be isolated special hospitals. Two small wards in a general hospital, or a pavilion in connection therewith, will suffice for the early treatment and humane care of the insane in the larger towns. In cities of considerable size, say with a population of 100,000 or more, provision should be made for the insane in independent psychopathic hospitals. The hospital for the acutely insane should be located in the most populous portion of the city in order to afford convenient and speedy access from every quarter. The same rules that guide us in selecting a site for a general or emergency hospital should aid us here. Since the acutely insane are usually put to bed or restricted to single rooms or wards, situation in the heart of the city is of no greater disadvantage to this than to other hospitals.

The psychopathic hospital should have much the same administrative arrangements as any general hospital. There should be a medical superintendent with experience in the care of the insane, and a staff of internes, together with a corps of consulting physicians representing the various specialties of medical and surgical practice. All the nurses should be graduates of asylum training schools. An outdoor department or dispensary should form a part of the organization, in order that cases of incipient insanity may be seen at the earliest possible moment. Such a plant as this would afford abundant opportunity for the medical schools to conduct clinics and provide medical men with a knowledge of psychiatry before they go out into practice. It is probably not familiar to you that little or no instruction in insanity is given in the majority of the medical schools. in this country. A general diffusion of knowledge of the methods. of diagnosis and treatment of the insane would be achieved through the instrumentality of the psychopathic hospital, and early attention insured more frequently than is now the case to these unfortunates.

The laws relating to the insane should be so changed that patients could be admitted as emergency cases for a period of, perhaps, ten days. Due regard must be paid to the preservation of personal rights; but legislators have seemed too often to regard the insane as malefactors or delinquents, and too seldom as sufferers from serious illness requiring immediate nursing and medical attention.

From the standpoint of humanity and from that of economy, we should establish these reception pavilions or psychopathic hospitals wherever there is sufficient population to warrant it. Let it be remembered that the acute cases are those which will always require our greatest care and attention and the largest per capita cost for construction and maintenance. This is true economy, for it has been estimated that each patient not cured becomes an ultimate cost to the state of $6,000.

Thus far we have considered the reception hospital as the foundation of any adequate system of care of the insane. We must now proceed with the development of such an ideal system from the foundation described. It is unfortunately true that insanity is prone to run a chronic course. Disorders of the delicate mechanism of the brain, unlike diseases affecting other tissues of the body, are usually tedious in their progress and all too frequently permanent in their effects. In the State of New York, for instance, the excess in the number of patients received in asylums above the number discharged is between six and seven hundred every year. There is, then, an accumulation of chronic and incurable patients with an average duration of asylum life of twelve or thirteen years. The proportion of acute and curable patients who are to be treated in the psychopathic hospitals to the vast aggregations of chronic and incurable patients is exceedingly small. The proposed ideal system of care of the insane, then, must provide for enormous numbers of the latter class; and it is to these we must now direct our attention. The chronic and incurable class is made up of a great variety of types, of sick, aged, and infirm, excited, quiet, dangerous, harmless, paralyzed. The word "chronic" does not mean incurable, but merely long-continued; and many of this type recover in time. A very large proportion, perhaps 70 to 80 per cent., of these chronic and incurable insane, are physically strong and well, and are able to work. Their work has an economic value; and occupation is, moreover, one of the best remedial agents at our disposition in the treatment of the insane.

The kinds of labor best adapted to their needs are of a simple sort, preferably out-of-door work. Hence agriculture, gardening, roadmaking, quarrying, and brickmaking have been found to be the most useful employments for men; housework, sewing, laundry work, kitchen work, light gardening, weaving, rug and basket making, for women. Now, in order to properly classify and segregate these numerous types of the chronic insane, a considerable number of different kinds of buildings is required; and, in order to provide the occupations above described, a large and fertile tract of land is essential. The location selected must be near a centre of population and on some railway or waterway; for ease of access is a prerequisite to economy in the transportation of supplies, to speedy transfer of patients to and from the cities, to visitation of relatives and friends, and, in short, to the success of the system. These premises lead to but one conclusion; viz., that the institution in the country for the mixed classes of insane should be organized on the colony or village plan. It is a system of segregation, and is directly opposed to the old scheme of immense aggregations of insane persons under one roof. This old scheme still so generally in vogue had its origin at the period in the history of the insane when they were first separated from the criminal classes in the prisons, and for economic reasons were transferred to abandoned convents and monasteries. By a process of evolution the abandoned monasteries gave rise to the more or less ornate corridor style of asylum architecture with which we are so familiar, for every state and country has numerous exemplars. To this order of institution various names have been given, such as the monastery style, corridor style, cathedral style, and the barrack system. The block or pavilion system is a mere variation of the scheme, with surface or underground corridor connections.

Before outlining the details of the cony or village idea, your attention must be called to one cardinal fact in relation to every asylum, whatever be its situation in the city or in the country; and that is that all types of insanity will inevitably gravitate to it from every direction within the radius of easy access. The psychopathic hospital in the city, designed though it be for acute cases only, will attract to it the chronic and incurable insane of the community as well; these will be transferred to the colony immediately after admission. But the colony in the country will also afford to the surrounding country districts a ready means of disposition of acute