Separate Provision for the Re- 
cent, the Curable, and the 
Appreciative Insane. 
BY 
J. P. BANCROFT, M. D., 
CONCORD, N. H. 
FROM 
American Jfournal o£ E-nsnmti?, 
October, 1889. 
UTICA, N. T.  t/ie Y/ulci. SEPARATE PROVISION FOR T1IE RECENT, TIIE 
CURABLE, AND THE APPRECIATIVE INSANE * 
J. P. BANCROFT, M. D., 
Concord, N. H. 
For convenience in presenting the views proposed in this paper 
I will separate the insane requiring special care and treatment 
away from home into three divisions. In doing this it is not 
claimed that any inflexible or unchangeable lines can be drawn 
making divisions permanent, or that the same person may not, for 
special reasons, be found now in one and then in another. 
No arbitrary or fixed classification of the insane is possible if 
due regard be had to the endless complexity of symptoms, and 
variety in personal states and characteristics. 
In the first division I will place those who are financially inde- 
pendent, and on that account have the benefit of a greater range of 
choice in the particular methods of care and treatment which may 
be adopted in a given case. 
For this class the State need have little concern except in the 
direction of exercising vigilant supervision over all places where 
persons deprived of the power of self care may be in the custody 
of others. Persons in this division are not limited by financial 
necessities. If the family object to treatment away from home, 
hospital adjustments and service can be extemporized in the home. 
Under some circumstances this can be done with satisfaction and 
the best results. Yet the circumstances requisite for the success 
of this method exist in but a small proportion of cases. 
For others of this division there is no lack of provision away 
from the home, and somewhere among these every variety of 
preference can be satisfied. To an increasing extent, in the United 
States, establishments are springing up under private enterprise, 
many of them most liberally equipped; and prepared to cater in 
detail to every preference of patients or friends. There is nothing 
in the way, under wise administration, of affording to the affluent 
classes everything in the way of remedial treatment for the curable, 
and every comfort and attraction for others which the most exact- 
ing could expect. 
Then, for still others of this division, those who prefer the less 
♦Read at the annual meeting of the_Association of Medical Superintendents of 
American Institutions for ttjb Jijaje*IjSy R. I., June 18-30,1889. 2 
private form of care, there are the larger corporate asylums with 
more liberal outfit, service and cost than States provide. These 
afford all desirable facilities for care and treatment, and it may be 
contended with reason that they can offer some conserving moral 
influences, not so easily available in more private establishments. 
These varying resorts for treatment being accessible, the affluent 
classes have within easy reach all needed provision for the care or 
mitigation of the evils of insanity, and that without being sub- 
jected, while under treatment, to embarrassments which are not the 
necessary product of their disease, but of the circumstances under 
which treatment is attempted. What the nature of the embarrass- 
ments here referred to are will be apparent further on. 
With these remarks we may dismiss this division and pass to the 
next to be considered. It is far the largest in numbers, and most 
varied in conditions. It contains the largest proportion of chronic 
disease, though not all are of this class, and it contains a larger 
representation of the pauper class than the division to be men- 
tioned last, although not confined to it. We may include in this 
division most of those subjects of chronic mental disease whose 
welfare will not be compromised by more simple and less expensive 
adjustments than are required for those who will constitute my 
third division. 
The line separating this from the third division is not one simply 
between dependence and self-support, but conditions of disease, 
—mental and bodily states; the distinction resting upon the 
radical difference in the legitimate demands of the two as to 
methods of care and treatment. This is overwhelmingly the largest 
of the three divisions in numbers, and most rapidly increasing in 
comparison. 
There are many reasons why this division of the insane should 
accumulate in greater ratio than others. It must necessarily 
embrace a much larger ratio of the pauper class for the obvious 
reason that poverty is fruitful in insanity, and insanity is often the 
cause of poverty. One condition favors the other whichever may 
precede. 
Bad heredity goes largely with the two, and these generate 
defective heredity; and altogether gravitate heavily towards 
chronic and hopeless states of disease—mental and physical decay. 
Then again, while under the ordinary action of the laws of life in 
a stable population, we must expect an accumulation of the chronic 
insane, we have had extraordinary causes of accumulation in the 
enormous influx, by reason of almost unrestricted immigration of 3 
both bad constitution and developed insanity. The normal opera- 
tion of physiological laws could never have increased chronic and 
incurable insanity and taxed our charity at the existing rate, had it 
not been for the indiscriminate importation of all the most fruitful 
elements that produce both insanity and pauperism. 
Without these the several States would have had ample time to 
provide tor the legitimate insane of all classes, and without undue 
pressure, as last as the disease would have arisen among a native 
population. It requires only a glance at most large State asylums 
to show how much the country is indebted to foreign sources for 
the populations which throng their wards and swell the proportions 
of those for whom all the appliances of remedial treatment offer 
little or no relief. 
A lai’ge majority of these are both incurable and dependent on 
the public for support, which terminates only with life. The per- 
centage of this class is constantly running higher in most State 
asylums, even those not denominated chrouic, but those still per- 
forming the functions of hospitals, while under this load of embar- 
rassment of providing for patients of all classes, and in all stages and 
conditions of disease in common. Thus it turns out that under 
the pressure of the great chronic and almost hopeless division the 
hospital is compelled, in a great degree, to merge itself in the 
asylum, and thus modify its work as a hospital; for it is unavoid- 
able that the vast majority under care should give shape to usages 
and methods of care, even if it is at the expense of the smaller 
fraction—the curable and those who are their fit associates. In seven 
of the most prominent and best equipped and managed State hospi- 
tals for the insane an average of over eighty percent are paupers. 
This fact does not show that all of this proportion are in chronic 
stages of disease, but a very large proportion are; and it. could 
not be far from correct to assume that seventy-five per cent of the 
population at any one time had reached the period of disease 
beyond which special remedial treatment could not promise success. 
Whatever may be the exact proportion of the chronic classes, the 
point of emphasis is that the remedial function of the institution 
is overshadowed by the custodial, always an embarrassment to that 
important minority still in the hopeful stage of disease, since all 
the circumstantial influences are unavoidably adverse. These in- 
fluences will be referred to more particularly further on. 
I will now turn to those who constitute the remaining division 
and inquire into their characteristics as insane persons, and name 
some of the points in which they differ radically from the division 4 
just described. Generally they are persons in the more recent 
stages of mental disease, or if not that, in its milder and less 
destructive forms. Pecuniary considerations shut them out from 
our first division, and thus they are unable to choose their place of 
treatment. They cannot extemporise a hospital at home or resort to 
any of the elegant private retreats which can cater to every want 
and every shade of taste; and surround remedial or mitigating 
treatment with every adornment, not, however, on account of char- 
acter, but pecuniary necessity. 
There is a wide range of persons, condition and character 
embraced in this division; it is composed of those who belong to 
all stations in society, not excluding persons dependent on the 
public for support, needing the ministrations of a remedial or 
sustaining hospital. These come from all trades, callings and 
professions, and belong to classes in the community not wanting 
in character, consequence or self-respect. In health they bear their 
share of responsibility and public burdens, and exert their share 
of influence. In a word they are the average people, the stock 
out of which the future is to spring, worth curing, if possible, and 
restoring to society. These are not the people who have contrib- 
uted unduly to swell the army of the chronic insane in the coun- 
try, but those who will promise the best results of remedial 
treatment. 
For this reason this is the division to which we are to look 
principally for restorations to mental health, home and usefulness. 
If anywhere there is a hopeful field for mental medicine it is found 
among those I include in this division, and a moment’s considera- 
tion gives the reason. 
It is not composed of the world’s drifting, unstable, ill-condi- 
tioned populations, including the modern tramp, but of the settled, 
industrious, home-loving and stable classes; often of slender 
means, it is true, but generally means of their own producing, the 
fruit of their own industry. The classes here referred to represent 
more nearly than any other general one of the present time among 
us, the average population of half a century ago, before the great 
influx of foreign blood and character, often bearing the germs of 
weakness, poverty and disease. It is therefore characterized by a 
higher average of good and sound heredity and power of resist- 
ance to disease, as well as freedom from the vices and habits 
which are demoralizing both physically and mentally. Even the 
industry which their more moderate fortune demands may contrib- 
ute not a little to the power to resist mental disease, or to recover 
from it when it occurs. 5 
Indeed it is not unlikely that in this power of resistance, the 
constitutional resiliency resulting from their manner of life, the 
classes we are considering excel the seemingly more fortunate of 
whom our first division is composed. I do not attempt to settle 
this question. Without remarking more at length on the charac- 
teristics of the insane whom we place in this division, it is manifest 
that it includes a large majority of those in whose behalf remedial 
treatment is the most important; not only as regards the interests 
of the subjects themselves, but in the ultimate interest of the 
public as well. 
Assuming this to be correct the country cannot afford to with- 
hold the best possible means for their restoration to mental health, 
thus retaining the largest practicable fraction of them among 
the productive aud burden-bearing portion of society. Public 
policy would indicate this course independently of the dictates of 
humanity and charity. In the midst of the many modern influ- 
ences calculated to deteriorate the quality of the population, it 
is wise to be economical of the old and the best stock. 
In view of the warnings of students of social scieuce that the 
stock of the country is deteriorating, it is wise as far as relates to 
the insane to give remedial medicine its best chance of success; to 
put in operation the most carefully and wisely studied plans, 
methods and influences preventive of mental disease, and all that 
knowledge and experience can do to apply remedial agencies 
where it already exists. 
It has already been remarked that in this division is found the 
vast preponderance of recent and hopeful cases, while in the other 
great division described, the immense majority are the chronic and 
unhopeful. This fact alone is just ground for a distinction in care 
and treatment. Many things are essential for the former which 
are of little or no value to the latter; and it is no invidious dis- 
tinction against the great chronic division to recognize this fact in 
making provision for the two divisions. 
It has been the uniform opinion of alienist observers that insanity 
is curable in proportion as it falls under proper early treatment, 
and this undoubted fact attaches great responsibility to provision 
for the classes containing the cases of recent origin. Success in 
curative agencies is confined mainly to this field, and to give early 
curative measures their full force, the situation itself should, above 
all things, contain no obstructing influences. Here psychological 
study and practice must find its test and main field, reap its main 
rewards, and render its best service to the public. Here too it can 6 
make its strongest resistance to the increase of the helpless burden 
of chronic and incurable insanity; since it is a well known fact 
that among those constituting our great chronic division a recovery 
is of rare occurrence. 
On a large analysis of statistics in promiscuous asylums, with 
patients of all classes, and in all stages of mental disease, it appears 
that the results reached are a little over thirty per cent of recov- 
eries. Considering that a recovery very rarely occurs in asylums 
devoted exclusively to the great chronic division, it is plain 
where the field of an aggressive remedial practice lies. I use 
the word aggressive advisedly, believing that many cases may 
be saved under early active measures, combative of special symp- 
toms, which, under a more hesitating and less personal management, 
would and do slide into chronic disease. I believe that under 
improved provision the percentages of recovery would be increased. 
This view gives great significance to all questions relating to the 
care and treatment of the hopeful and sensitive classes. If then, 
among these lies the whole field of preventive and remedial work, 
no question is so small as to lose its importance, whether it relates 
to the original organization of institutions, or the minutiae of treat- 
ment. 
If practice in mental diseases possesses a real remedial possibil- 
ity, it is manifestly for the public interest to give that power its 
best opportunity; it is not economy to hamper it in the outfit 
for its activity. That would not be good financiering any more 
than sound social science or humanity. This brings us to the 
main point of our subject, “ provision for the recent, the curable, 
and the sensitive classes of the insane.” Has provision, including 
building and the details of care and treatment, yet reached the 
best that is attainable in results to the subjects of mental diseases 
themselves, or in the interest of the public at large ? Must we rest 
satisfied with present rates of recovery, or the present degree of 
satisfaction experienced by appreciative inmates of asylums ? If 
so we can only do with diligence what the hand now findeth to do. 
To aid in settling, to our own satisfaction, the question whether 
the best attainable provision for the classes to which my subject 
pertains, has been as yet reached, let us briefly look at the situa- 
tion. Where and how are they now provided for ? 
But an insignificant comparative number are in strictly private 
institutions. A larger, but still small number, gain admission to 
corporate hospitals occupied mainly by the more fortunate finan- 
cially, these institutions extending their charities to some of the 7 
less fortunate. Those patients of our group who can secure 
the advantages of these institutions, enjoy the best that is avail- 
able for care and treatment at the present time in the country. Of 
this class are the McLean, the Butler, the Retreat, Bloomingdale and 
the Pennsylvania, and in all these may be found patients from the 
classes under discussion. Still, this is but a very small fraction, 
and the vast majority remain to be provided for elsewhere. This 
large majority, containing the most hopeful subjects for remedial 
management, are mainly provided for in the large State hospitals 
and asylums, or more rarely in municipal asylums. These institu- 
tions now vary somewhat in plan of construction and organization, 
but agree in being large in plan, and growing rapidly larger in 
population. They agree in providing in the same establishment, 
in the same group of buildings, and often in the same wards, for 
all classes of the insane; whether they may be receut and hopeful 
cases, demanding special remedial treatment, or those needing only 
ordinary care. These institutions have generally been planned, and 
thus necessarily organized on a grand scale, divided into large 
wards, accommodating from twenty to forty or more in a single 
group or family. This feature has rendered necessary the massing 
of large numbers of patients, and generalizing treatment and 
service, whatever may be the individual needs of particular per- 
sons ; and this massing does not end with physical conditions, but 
the very organization compels also the pooling of moral methods 
and instrumentalities. It embarrasses attempts at individualized 
measures and usages, and tends ever towards the adoption of a‘ 
general routine service. It creates a strong leaning to wholesale 
dealing in management, which passes lightly over individuality of 
symptom and want in the particular patient, each falling into the 
established order. It tends to the neglect of the sound doctrine 
that prescription should respond directly to special diagnosis and 
not to a house rule. This doctrine is as true in moral treatment 
as in medical. 1 am not claiming that no individualized service 
is rendered under this wholesale adjustment, but that the pressure 
is all against it, and obstructive to it; nor do I say that a degree 
of success in moral treatment may not be achieved, but that it is 
much less marked than might be gained under changed relations. 
It cannot be doubted, that under the prevailing promiscuous 
plans, and in the midst of the mixed multitudes, the best medical 
ability and the most enlightened and faithful nursing service work 
under perpetual embarrassment, to say nothing of the adverse 
influence of the environment upon the subjects of their efforts at 8 
curative treatment. I cannot doubt that the experience of my 
brethren will confirm these general statements, that the immense 
wards, filled with a miscellaneous population of many shades of 
character and condition, are powerful obstructives to the successful 
application of their best ideas in the treatment of the hopeful and. 
sensitive insane, and that they could work with greatly increased 
efficiency in a narrower and more diversified field. At least no one 
will question that all the adjustments and instrumentalities for 
aggressive treatment of the hopeful classes can be much more suc- 
cessfully organized under more select conditions. 
Sufficient has already been said of the embarrassments of the 
mixed provision for all classes of the insane to authorize the 
assumption that this method of organization is not the best attain- 
able ; that it does not afford the division under consideration the 
kind and degree of curative and sustaining influences to which they 
are justly entitled ; neither does it sufficiently protect them from 
influences which operate advei’sely to their comfort, happiness and 
final recovery. This brings me to the main purpose of this paper, 
to contend that separate provision should be made for these classes. 
In adducing special reasons for this contention it must always be 
kept in mind, as already stated, that substantially all the curable 
and hopeful cases are included in this division, that this is, par 
excellence, the remedial field. 
Among the more specific reasons for separation of this gi'oup 
from the larger chronic and demented classes is incompatibility in 
personal condition and chai’acter. Their habits and wants are 
materially unlike, so much so as to make them xinfit associates. 
What is vitally essential for the welfare of the one may be useless 
for the other; and methods of care entirely suitable for one are 
out of place for the other. 
This difference in demand for care will hold true of nearly all 
the items of hospital service. So diverse are the indications for 
care in the two divisions, that the attempt to generalize practical 
measures is a perpetual embarrassment both to administration and 
the more intelligent patients. Such attempts almost necessarily 
end in a compromise of personal interest and privilege, and the 
losers in the compromise are the least damaged patients; for 
while the hopelessly demented pei*son suffers no detriment from 
contact with his more intelligent and appreciative associate, the 
resxilt of the association is sadly otherwise on the latter. 
This one, who needs above all things a corrective environment, 
lives perpetually in a disturbing one. The moral and social 9 
atmosphere is necessarily gloomy, distracting, depressing. But 
not only is the personal contact adverse, even the style of service 
tends to sympathy with the majority, and to drop to a lower level, 
for in such a presence no zeal or skill can avail to impart reassur- 
ing aspects to the mixed society. So the best devised corrective 
measures are sadly hampered, for with the intelligent and sensitive 
contingent the evidence of the senses is a perpetual negative to 
all healthy moral stimulants resorted to. 
Thus it turns out that, at the very threshold of positive moral 
treatment for the hopeful classes, the situation itself is at once 
unavoidably obstructive to the best success, and wasteful of the 
curative instrumentalities of an administration. 
I use the term “best success,” for I w7ould not imply that success 
has not followed the curative work done, even in the midst of the 
obstructing influences of promiscuous association, but I mean to 
contend that what is accomplished is done against great hindrances, 
and that success is less in degree than is attainable under changed 
conditions. 
Neither should success in the care and treatment of the insane 
be measured simply by the number of recoveries, but beyond this, 
by the well being, the comfort, and the degree of happiness 
secured to the sensitive insane who may not be restored to reason. 
Of this class there must always be many in the hospitals, and 
they deserve much sympathy from the public. They are persons 
in whom mental disease has suspended the power of self-guidance 
and consigned them to the care of others; and yet they are left 
intelligent and sensitive to all external influences; they enjoy and 
suffer, appreciate order and beauty, good and bad in a perfectly 
normal way, and in many of the aspects of life they scarcely differ 
from their normal condition. These, though chrouic on the score 
of time, should be classed for association with the recent and hope- 
ful, both in their own interest and that of their associates; for 
their influence for good on the curable is often very salutary. 
So the conditions under which this portion of the insane live is no 
small matter. 
Another reason for separate provision for the two great 
divisions of the insane is a financial one, a question having an 
important place in the original organization, and the adjustment 
of all the details of current institution life. The line that divides 
these people into two sections for care is degree of disease, and 
this calls for a distinction in the details of care. The needs of the 
most advanced in mental disease are more or less narrowed in 10 
variety, and mucli that is important and even essential for the 
less advanced is of little avail for these. It is no unjust dis- 
crimination to recognize this in the style and variety of equip- 
ment and service, and this can be readily done under separate 
provision, and with no inconsiderable financial saving, both in 
construction and running operation. 
The rate which will supply amply all the legitimate needs of the 
least hopeful, whose wants are mostly physical, can never pur- 
chase what is demanded in justice by the curable, the intelligent 
and appreciative classes of the insane. The remedial and sustain- 
ing stimuli indispensable for these classes should be recognized as 
legitimate matter of expense as much as physical subsistence; 
and it is a faulty principle of management which crowds the rate 
for their care down to simply that which is just and right for the 
more damaged groups. 
The attributes essential to a good remedial and sustaining 
service have a money value. Intelligence, good judgment, quick 
sensibility, self-control, amiable tempers, sympathy and a spirit of 
self-sacritice—these have to be sought in the market, and are not 
to be bought for a song, and should not be, for if anything is 
worth its price, these are. These classes must have this grade of 
service, or fail of the best attainable results. Not to furnish it is 
poor intelligence, bad moral sentiment, and bad financiering. 
So there is a difference in the just wants of the two divisions 
and in the cost of supplying them; and the attempt to organize 
the two grades of service in common is not economy; even if the 
more complete service could be sustained in the promiscuous 
association. 
These considerations seem to me sufficient to sanction the plan 
of provision in separate establishments. A common provision is 
either waste of service on one division, or privation of indispens- 
able agencies in the other; and privation of such character as 
neither the patient nor the public can afford to sanction. It 
would be felt in diminished chances of recovery and restoration to 
home, usefulness and all the blessings of sane life; and to those 
of this class who may not recover, but remain able to appreciate 
the conditions in which they live, the privation is equivalent to 
the loss of the little remnant of rational life left them in this 
world. 
The patient in a fresh attack, brought from the pleasant sur- 
roundings and amenities of home life, with perceptions still acute 
and sensibilities even morbidly alive, when introduced into the 11 
mixed society made up of all shades of character, and many forms 
of morbid manifestation, cannot fail to be most painfully im- 
pressed, and as a matter of fact we have abundant testimony of 
recovered patients that it is so, and that the influence is not easily 
effaced. Change from home life we assume and know possesses a 
a remedial force, but not unqualified; it needs the aid of 
sympathizing circumstances; to make it available, the new 
environment must be remedial and corrective. This determines 
the value of change from home, and that value is vastly lessened 
if not sacrificed by the presence of antagonizing influence. 
In the thronged and miscellaneous ward it is not always easy to 
see the corrective circumstances, but the disturbing ones obtrude 
themselves at once, and often upon the new comer, on whom first 
moral influences are all-important. An individualized moral treat- 
ment of new cases is, I believe, the best assurance of success, and 
yet the obstacles in the way of such treatment in the thronged 
and heterogeneous wards are well nigh insuperable. The best 
personal influences are antagonized at all points. Experience has 
left the settled conviction in my mind that the great mixed ward, 
as a place to commence healing influence in a recently disordered 
mind has, to say the least, very grave disadvantages, and I believe 
stronger terms might be used with truth. 
In the milder cases, not recent, which I have already referred 
to, needing supporting influence, the situation is a constant 
depressant, as illustrative cases would show if time would 
permit. 
If, then, the embarrassments of the mixed, congregate form of 
provision for the care and treatment of the insane in asylums is 
real, and the broad classification inadequate to the best attainable 
curative and sustaining influences, the legitimate remedy is to be 
found in separate provision for the recent and more sensitive 
classes. I do not claim to be advancing a new plan in the face of 
the fact that, in a few instances, special institutions have been 
appropriated to the overflow of the chronic and incurable from 
general State hospitals and asylums; but it is still a fact that 
the classes needing a more individualized care are under the embar- 
rassments claimed, and my contention is that separate provision 
should be carried further—should be applied to the population as 
at present associated in most of the large public hospitals and 
asylums, as fast as it is financially practicable. 
Willard and Worcester are signal and successful examples of 
movement in the right direction. These have opened the way, 12 
and some other States may be acting on the same principle, though 
in modified forms, but all these are only the beginning. 
What remains cannot be done at once, it cannot be a revolution, 
but the principle can be incorporated into future changes. A few 
remarks may be in place on this desirable transition, from the 
promiscuous to the more individualized plan of association; and in 
the first place no general plan can be applied in all places and 
institutions. If all States were now commencing to build insti- 
tutions for the insane it might be practicable, but present 
conditions differ widely in different places. The tendency of the 
time is apparent in the cases already noticed, of States providing 
separately tor the chronic and supposed incurable, and adapting 
less costly construction, and a more simple administration, thus 
recognizing for these classes less necessity for a varied and 
personal service than is demanded for those most hopeful and 
intelligent. This movement has been forced upon the communities 
by the pressure of the chronic insane, rather than chosen as a 
measure to elevate and improve the care and treatment of the other 
classes, which latter is a no less urgent motive. Some States have 
been favorably situated for adopting the separate plan. Rhode 
Island is an example. 
The Butler Hospital, an institution fully equipped for remedial 
treatment, receives those requiring it, whether self-supporting or 
supported at public charge, as private patients. The State has 
provided an institution of cheaper grade, not equipped for curative 
treatment, but with all comforts essential to the well being of the 
chronic classes. 
The Butler also provides for persons of slender means, but not 
dependent on the public, assisting them from its charities. On 
this plan this hospital is devoted very largely to remedial work. 
Separation is gradually working itself out in the State of Vermont. 
Hitherto the chronic and pauper insane have been provided for 
at the Brattleboro Asylum, a private corporate institution, as 
boarders, at public expense, the institution receiving and treating 
at the same time self-supporting boarders. 
Within the past year the State legislature has made appropria- 
tions for a State asylum, which, when completed, will absorb 
mostly the State patients, largely the chronic classes. When this 
is done the resources of the Brattleboro Asylum will be devoted 
more exclusively to remedial work. 
The same tendency to separation is seen in the State of New 
Hampshire. Until a comparatively recent date the dependent 
insane were supported mainly at the State asylum, and these were 13 
largely of the chronic classes. As these classes have accumulated 
the several counties have erected small asylums near their alms- 
houses, where now all the pauper insane whom the county authori- 
ties consider as not requiring remedial treatment are supported. 
By a recent legislative act these asylums are placed under State 
supervision, and it is anticipated that great improvement in 
methods of care will soon be realized. This movement relieves 
the State asylum of a large chronic and generally hopeless popula- 
tion. So that in the future, as in the other States referred to, its 
resources will be devoted much more largely to remedial work. 
And the privileges of these classes will be proportionally enhanced. 
As in the Butler, the charities of the institution are appropriated 
to the assistance of the indigent of the private class. Some of 
the same class of persons are able to avail themselves of the 
superior benefits of the McLean Asylum by securing the aid 
afforded from the charitable funds of that institution. 
Thus, in the cases named, a gradual solution of the question of sep- 
aration seems to be in progress, as far as it goes, originating more in 
the force of external circumstances than in any definite theoretical 
plan for enhancing the efficiency of remedial agencies; but if that 
end is reached the method of reaching it is of minor concern. 
In States where the less aggravated cases are provided for 
promiscuously with all other grades of disease, there would seem 
to be open one practicable way to effect separation without very 
great delay. 
Almost everywhere through the country asylums are full, or 
sure soon to become so, and the necessity for further construction 
in the near future is certain. Such new construction might, and, 
as it seems to me, in justice to all the interests involved should 
be planned and organized to meet the necessities of the smaller, 
but more hopeful division of the insane. In this way room for 
the chronic would be increased in the existing buildings, and more 
fitting accommodations for those needing a more discriminating 
service would be afforded in the new and smaller structures. 
The present pressure for asylum room, urgent in many parts of 
the country, should be seized upon as the fit opportunity to 
advance the standard of remedial care and treatment, by providing 
in the new construction better and more varied facilities for indi- 
vidualized methods, and at the same stroke excluding the many 
obstructing and demoralizing influences unavoidably attaching to 
the association of all grades of mental disorder together. 
I cannot overstate my conviction that where asylums are over- 
crowded with mixed populations, and where new construction is 14 
demanded, it would be wise to build in the shape of smaller 
hospitals, designed and equipped for a more diversified practice, 
with more flexible adjustments. And, more than that, I believe it 
due to our Christian civilization so to build. 
The old institutions, even the most liberal of them, are planned 
and equipped on a large scale, and fitted for a generalized service, 
a service well adapted to the large class of the more damaged 
patients, but not for the smaller sensitive classes. The proposed 
smaller hospital must be planned to support a more diversified ser- 
vice, so subdivided as to render possible more classes, and each class 
smaller in numbers. Its resources should be many sided, to adapt 
it to many phases of mental disease, and many diversities of 
individual character and habit of life, for this has everything to 
do in determining the efficiency of remedial measures. It is, 
therefore, manifest that plans of construction must depart in many 
respects from those hitherto mostly followed. Apartments must 
be so far subdivided and diversified as to adapt them to the 
greatly varying tastes and preferences of individual patients. 
Facilities for substantially private care even should not be omitted 
in plans, and from this up to groups sufficiently large to secure all 
the advantages of a felicitous social adjustment. 
There is little danger of too much variety in plan in these 
hospitals, for all along the line are found shades of difference in 
individual wants, which will make the architectural variety most 
convenient and remedial. And this is one of the strongest reasons 
for devoting new construction to these classes instead of multi- 
plying buildings on existing plans, and perpetuating existing 
deficiencies. Plans for remedial work should not omit more or less 
small detached houses, and these would not long lack occupants, 
to the great satisfaction of both patient and physician. 
I have little doubt that moderate sized hospitals, so constituted 
and operated, either independent or as annexes, would return 
increased ratios of recovery, while adding vastly to the comfort 
and happiness of patients during hospital residence. 
An objection to such a plan may be anticipated on the score of 
increased running expense, and I do not overlook the item; for it 
is not to be denied that a hospital constructed and equipped for 
such a diversified and flexible service will call for a somewhat 
modified administration; a wholesale method is less expensive 
than an individualized one. 
This applies in a measure to outfit, but more largely to personal 
services, but on this point it should never be forgotten that no 
aegncy bears so close a relation to recovery from insanity as that 15 
of direct personal influence, which often stands in importance 
before even medical prescription. 
Any reasonable expense invested in intelligent and judicious 
individualized attention is pretty sure to be returned in earlier 
and better curative results, and what results are good to the 
patient are good to the public. 
May I be allowed to digress briefly from my main subject 
to make a remark on the prevailing popular idea of what is a 
proper cost of the treatment of insanity in public asylums. In a 
majority of the large State hospitals in the east the rate is three 
and one-fourth dollars per week, and in a few it is four, this rate 
including board, nursing and medical treatment. This rate applies 
to receut and acute cases in common with the chronic cases passed 
hope. The average rate of cost in hospitals for general diseases in 
the same region of country is about ten dollars per week. 
This is certainly no discrimination in favor of the insane 
requiring curative treatment, but an immense discrimination 
against them; for to set aside purely medical prescription, there 
is no sickness justly requiring a more judicious, intelligent, faithful 
and constant nursing service than mental diseases. The demand, 
too, for strictly medical care is certainly not less than in general 
diseases, to say the least, and yet the public, to me unaccountably, 
expects and demands that curative treatment for the acute, recent 
and curable insane, shall be secured for the same rate allowed for 
the chronic and hopeless pauper. 
Money is profusely poured out by wealthy persons, by church 
denominations and general contributions to build and operate 
hospitals for general diseases, but the number so built and run for 
mental diseases is soon counted; and yet it is impossible to find 
victims of disease in more urgent need of Christian sympathy and 
material help than that portion of the insane in need of treatment 
who are in narrow pecuniary circumstances, and who shudder at 
the thought of becoming paupers. The number of these is large 
everywhere. 
This disposition to cheapen care and nursing is seen in no other 
than mental diseases, and it is so absurd as to be almost a 
curiosity. It should be seen that no human skill or ingenuity can 
throw around the appreciative insane all the neeeded supporting 
and remedial agencies, for the sums fixed in most large mixed 
asylums. In view of this situation, there is no finer way for 
persons in affluence to exhibit philanthropy and make their names 
beloved and honored in the present or the future, than by gifts 
devoted to the care and nursing of the indigent insane in hospitals 16 
or asylums. There is golden opportunity to lighten the load of this 
bitterest of human sorrows within the easy leach of every wealthy 
person, and many shall rise up and call him blessed who shall avail 
himself of the opportunity. He who endows a small remedial 
hospital, or an annex to a large one, for improving the situation 
of the hopeful insane may make for himself a name which will long 
outlive his days, preserved in grateful hearts and loving memories. 
The space proper for this paper will not allow me to go into 
more detailed illustration of the position taken, that the class 
I have indicated, namely, those requiring remedial treatment and 
those requiring sustaining associations, should be provided for 
under separate organizations, and apart from the great chronic class. 
I have attempted to give the general reasons for such a separation 
of classes. 
The sum of what I wished to say in this paper is this: The 
affluent classes need give us no concern, since wealth will open 
places of their own choosing. The second group considered, 
embracing an immense preponderance in numbers, and generally 
in the extreme stages of mental failure, and substantially without 
hope of restoration,—these depend on public provision, and the 
circle of their needs is somewhat narrowed as compared with the 
third group. 
The third group, much smaller in number's, but mentally much 
less damaged and more hopeful, embracing nearly all the curable, 
and a large number, who though mentally diseased and incapac- 
itated for home life, are still sensitive and appreciative of their 
surroundings, many of them in straitened circumstances,—these 
too, require public provision, though not necessarily public support. 
With comparatively few exceptions these two groups are now 
provided for, and associate together in large congregate hospitals or 
asylums, organized in large divisions, with generalized systems of 
classification. 
The contention is that these two groups are incompatible 
as associates ; that the influence of this contact is detrimental and 
obstructive to the success of the curative and sustaining measures 
which are the main hope of comfort and relief to those less 
advanced in disease ; and that bare justice to these demands sepa- 
ration of the two groups. 
It is further contended that separation alone will admit of 
an individualized system of care and treatment; and that no other 
treatment and service can ever insure the best attainable fruits of 
hospital work, whether measured in relation to the interest of the 
sufferers or the public.