Thirty-five states assume the expense of the maintenance of their indigent insane. In nearly all of these the costs of commitment and conveyance to the hospital is a charge upon the county in which the patient has legal residence. The accompanying illustration, Chart No. 2, shows the incidence of the burden of support of the insane in the various states. In six states the county in which the person committed had legal residence at the time of his commitment is chargeable for his maintenance, and in seven the state and county share the expense jointly. In Indiana the state pays all the maintenance expenses with the exception of clothing, which is a charge upon the county. In New Hampshire, if a patient has been maintained by his county in the state hospital for the insane for 20 years, his support is a charge upon the state for the rest of his life.

A progressive measure reflecting humanity and enlightenment is Chapter 589 of the Laws of 1911 of Massachusetts. This act regulates the restraint of patients in institutions for the insane throughout the commonwealth. Apparatus for restraint may be applied in the presence of the superintendent, the physician or assistant physician, or upon his written order, and may be used only in cases of the greatest emergency. In an emergency case restraint may be imposed without such order, but it must be immediately reported to and investigated by the superintendent, physician, or assistant physician. Complete and detailed records must be made of all restraint in a book open for inspection by trustees, state board of insanity, governor, and council, and members of the general court.

Another progressive measure, found in the statutes of Illinois, requires the managing officer of each hospital for the insane to develop occupations that serve the mental, moral and physical improvement, or happiness of the inmates. The benefits from this provision are apparent. Another well-considered law of this same state provides for visits to the home of any paroled patient, or any convalescent patient before discharge, for the purpose of advising the family as to the care and occupation most favorable for the patient's continued improvement.

Next Steps in Reform

It would take one far beyond the limits of one paper or the indulgence of a single audience to point out all the varying features— both good and bad—to be found in the laws of the several states. However, I trust that enough material has here been presented to give an idea of the wide variations in the laws, the inadequacy of many of them, the hopeful note to be found in some, and the need of much constructive work to effect adequate legislation.

What need then should be first emphasized? A uniform commitment law for all the states, providing for commitment with as little publicity and delay as possible, at the same time safeguarding the constitutional rights of the individual, making adequate provision for voluntary admission, temporary and emergency commitments, and commitment for observation. Temporary detention in jail or almshouses should not be countenanced by law, but patients awaiting admission to a hospital for the insane should be admitted to a psychopathic hospital or to a psychopathic ward of a general hospital. There should be a clear and uniform interpretation in the several states as to what constitutes insanity. May I digress at this point, while speaking of the need for uniformity of laws in the several states, to make mention of a movement now under way by the American Medico-Psychological Association, in co-operation with the National Committee for Mental Hygiene, to establish a uniform classification for mental diseases. The advantage of this step is, I believe, apparent to all of you who have ever tried to make use of the statistics of the institutions in this country for comparative or cumulative purposes. It is almost impossible to secure from the reports of the various hospitals, as the reports now stand, any statistical material from which general conclusions can be deduced. There is not adequate data for determining relative per capita costs in the various institutions, the prevalence of the more important types of mental disease, whether syphilitic psychoses are more or less numerous now than formerly, the costs of caring for alcoholic psychoses in this country, the average length of hospital life of the various psychoses, total number of first admissions throughout a hospital year, number of readmissions, etc. Realizing the need for a uniform basis for statistics, the Committee on Statistics of the Association drew up a classification for mental diseases and a set of statistical forms which were submitted to the Association at its 1917 meeting. Letters, together with a copy of the new classification, were recently sent to all of the state hospitals and central boards, which had not already adopted the classification, urging their co-operation. Replies have been most encouraging. Already over one-half of the state hospitals in this country have adopted this classification or have expressed their readiness to do so at the beginning of their next fiscal year. It looks as if uniform statistics for mental diseases would become an actuality and that reliable data may soon be available as an aid to progress in the scientific study of mental disease.

Every state should have provision for the parole of patients, vested in the medical superintendent of the state hospital, who should have adequate experience in caring for mental cases to determine just what patients may be benefited by parole. This provision presents an undebatable argument from the financial side alone, when we consider that the care of mental patients is conservatively estimated at $200 per capita per year. It would also help to relieve congestion in the hospitals and make possible the entrance of more recent cases.

State-wide psychopathic hospital service should be instituted by the several states, as has been done by Michigan and Massachusetts. Psychopathic hospitals and out-patient departments should be established in connection with all existing and future state hospitals. As in the other branches of medical science, emphasis is more and more being laid upon prophylactic measures, so in mental hygiene we must make more adequate provision for preventive work. Free mental clinics should be established along with other clinics, as a branch of the out-patient departments of general hospitals. Psychopathic hospitals should be established in larger cities and psychopathic wards in the larger general hospitals. Here much could be done by directing efforts against early manifestations of mental disease.

The early recognition of mental disorders, however, cannot be generally expected until medical schools give more attention to them. There should be a higher and more uniform standard of psychiatric teaching in the medical schools. Courses should be required in which the medical student himself examines mental patients. Courses in clinical psychiatry, as well as text-book and lecture course on the subject, should be included. The general practitioner should be trained to recognize early symptoms of mental disorders. It is a generally accepted fact that the majority of graduates from medical colleges have insufficient knowledge of the nature of mental diseases because they have had little or no opportunity to study this branch of medical science. This condition could be remedied by requiring the physician to answer questions on mental disease in his state board examination to secure his license to practice medicine. This would necessitate adequate courses in psychiatry on the part of the medical schools. As a result, an increasing number of physicians would enter the field of psychiatry and the young graduate about to engage in general practice would be better able than formerly to recognize mental disease in its incipient stages.

Many of the present laws relating to the insane were enacted at a time when the popular mind regarded the insane as closely allied to the criminal. The continuance of such legislation is bound to cause hardship to the sufferer from mental disease, who occupies a different position in the eyes of the public from any other kind of patient. In spite of the progress than has been made, much still remains to be done. In the development of the treatment of other diseases legal aspects have no weight, whereas in the treatment of the insane legal barriers are ever present. For this reason there is great need for concerted effort, through an everwidening circle of those interested in the welfare of the mental patient to work for adequate legislation, which will make it possible for him to receive the right kind of treatment. To guard against unjustified detention, there must needs be laws—but let us see to it that they are workable and humane, and that they do not bar from treatment the person in the early stages of mental disease who is aware of it and both anxious and willing to receive treatment. Let us do all in our power to assist in removing barriers to the early treatment of mental disease, and in making access to the state hospitals freer. Since it is true that, more than in the case of any other class of sick, the kind of care and treatment which the insane receive depends upon laws ielating to them, it is incumbent upon us to do all that we can to secure adequate legislation for them.

INFORMAL DISCUSSION

The foregoing survey was presented by Miss Furbush informally. The speaker stopped frequently to answer questions. Among others the following named delegates participated in the informal discussion: Dr. A. F. M. Green, Kansas City; Mrs. Carrie Parsons Bryant, Los Angeles; H. W. Moore, Monroe, La.