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The Committee proposes the classification of the 2000 insane of a single district into three groups: the acute and curable; the chronic infirm, dangerous, and custodial; and the chronic harmless and able-bodied. These should be in separate buildings, the distance might vary from a few hundred feet to many miles, and they would be designated, respectively, the hospital, the asylum, and the colony. The hospital should receive all patients for observation and examination and retain the curable; it should be the centre of the higher medical and scientific work, under the direction of an expert psychiatrist, with a staff of physicians and laboratory workers and a training school for nurses. The asylum would receive the infirm, dangerous, and untrust-worthy, and its main purpose would be safe custody and palliative treatment. The colony would take the harmless patients and establish them in small, homelike groups, according to their condition, and reeducate them in industrial activities. But a considerable portion of the harmless chronic class might be placed in the private care of families and supervised from the central institution, as is done in Massachusetts.

Besides this comprehensive scheme for combining the large institution under centralized control with thorough classification and the essential features of the colony, there are two special aspects of the care of the insane which have lately been strongly emphasized. American physicians trained in Europe where clinics in psychiatry have long been established, have felt the need of separate hospitals for the observation of acute and incipient mental diseases. Dr. J. Montgomery Mosher describes the complicated legal procedure for commitment of an insane person in New York and says: -

"In brief, a patient who is suffering from a disease of the mind, the most threatening calamity of life, must be so far advanced in the disease and so disordered in action or in speech as to satisfy a lay tribunal of the necessity or the justification of the forcible deprivation of his liberty, must be told that he is 'insane,' must be 'adjudged insane,' and committed by a court to an institution for the insane before he can receive the treatment best adapted to the restoration of his health." (151)

The demand for a hospital for the mentally disturbed, where they may be properly observed and cared for pending a decision as to the necessity for commitment, has been met by the establishment of different types of psychopathic hospitals. In New York, the psychopathic hospital is located at one of the State asylums and serves for all; in Michigan, it is located at the State University and is a central institution for the State asylums; and in Albany it is a department of a general hospital for mental diseases, known as Pavilion F. The report of five years' work at Pavilion E illustrates the humanity and the economy of the system. (152)

If this special provision had not been made, 905 of these patients would either have had to be treated .at home or would have been committed after a probably harmful development of the disease. All alienists are agreed that early recognition of the disease and treatment are most important in insanity, and Dr. Barnett of Michigan urges that the character of psychopathic hospitals should be such that patients, after recovery and return to civil life, should feel no more embarrassment than if they had been ill in a general hospital. Dr. Adams, superintendent of the Westboro, Massachusetts, Insane Hospital, to which patients have long been admitted by voluntary application, is heartily in favor of the system as a measure for preventing the accumulation of incurably insane in asylums by securing treatment early enough to bring about recovery. (153)

Not less important than the provisions for incipient insanity is the care of insane persons upon their discharge as recovered. Although, societies for the after-care of the insane have existed in Europe for three-quarters of a century, the first society of this sort in this country was organized by the New York State Charities Aid Association in 1906. It is believed that from 10 to 25 per cent of patients need friends, guidance, and assistance upon their discharge, and that such help promptly given will prevent the relapse and recommitment of a considerable number. (154)

No mention can here be made of the improvement in the treatment of the insane which comes only through an improvement in the personnel of the institution, through freedom from spoils politics, through the introduction of civil service reform, through the activity of clubs of men connected with each institution organized for their mutual improvement, and through the development of training schools for attendants upon the insane. It is by these and other agencies that the present great advancement is being made along the lines of greater wisdom in treatment, greater kindness in control, and greater freedom within the bounds of safety for the insane.