These laws and the founding of these hospi tals as above noted show the origin sporadically of those activities which were addressed toward the more humane and intelligent care of the in sane. From the beginning of the 19th century on these activities became more numerous and the demands for better care gradually increased. For the most part, however, throughout the first half of the century and daring a 'consider able period of the latter half, the insane were eared for in a desultory and unintelligent way, largely by local communities, more especially in the various county houses throughout the States. This county house care of the insane placed them on a social par with the paupers, and it not infrequently became a matter of pride to see how cheaply the county could care for these unfortunates. Not only was this true, but the mentally sick patients in the almshouses re ceived practically no medical attention what ever. except as they might be visited occasion ally by the physician who was employed to look after the almshouse patients and who almost always was a practitioner in a nearby town and only spent a brief period at intervals at the almshouse or came out on emergencies when requested. He practically never had any ex perience or any special knowledge of mental illnesses and did little more than look after the physical condition of his patients, generally in a very crude way. The quarters where the mental cases were kept were usually presided over by persons who had no idea of the nature of their problems, were ignorant, often cruel and unsympathetic, so that the lot of these poor people was indeed miserable. They were prac tically prisoners shut out from all intercourse with their fellows, confined in quarters that were often filthy, dark, unsanitary and • un hygienic in every particular, dominated by ignorant and not infrequently cruel caretakers, cheaply fed and clothed, with no medical saner vision worthy of the name, and without any effort being made in any direction to bring about an improvement or to effect a cure. The most important move toward the latter part of the century which was made for the better and more humane, more intelligent and scientific care of the mentally i11, was the movement in augurated in many of the States for State care, namely, provision by the State of public hospitals for the insane, with the consequent removal from the almshouses of this class of patients and transferring them to the State hospitals.
This was the only solution of the neglect and inefficiency of the county care system. The most fundamental defect of the county care system was that the county was too small a political unit to undertake the problem. It had not enough money to properly equip an insti tution nor did it have a sufficiently broad vision to secure the services of persons competent to handle the problem. All these matters were changed in the State hospitals. .The State hos pital was well built, well equipped and for the most part well officered, and the improvement in the care of the insane as a result was very great.
In the first period of State hospital care the main effort was to get away from the abuses of the county system and was directed toward humane and philanthropic efforts. The dealing with the mentally deranged patients as though they were sick and trying to effect a cure was as a matter of fact in the minds of the early hospital superintendents, but did not prevent them in many instances from malting the mis take of creating enormous asylums for the so called chronic insane and setting apart single institutions for the care and treatment of the acute cases, thus making out of the asylums places where all hope was lost- for those who entered, and overcrowding and overworking the 'acute reception hospitals beyond their capacity.
For many years, for example, the Utica State Hospital at Utica, N. Y, was reserved for the .acute cases of the State, while other insti tutions, as they were built, were reserved for nhe 'chronic, incurable class. The next move ment was to make out of all of the State insti tutions hospitals in the real sense of that word, places where the patients would be dealt with as actually ill and an effort made to cure them. The first efforts in this direction were crude, consisting largely in endeavors to treat the patients as patients were treated in general hospitals by keeping them in bed, making ob servations upon their general physical condition, .taking their pulse, temperature, respirations, examining urine, the internal organs, etc., and treating. the• physical disease which might be found as a result of such examination. This movement did much toward getting better sur ' roundings for the patients, it was contempo raneous with the establishment of training schools for nurses in the State institutions. and its general result was a vast improvement in the quality of care.
Throughout this latter period the hospitals had more or less actively been engaged in a study of the problems of mental disease with a view to discovering their scientific bearings. These researches led to the definite establish ment in connection with well-organized State institutions of scientific departments, usually consisting of a laboratory for clinical pathology, and generally also a laboratory for research in pathology. In these laboratories the autopsy material was studied with a view to discovering the correlation between the mental symptoms of the patient and the changes that were found to have occurred in the brain.
Beginning with the latter portion of the 19th century the several States began to appreciate the great extent of the economic problem that was involved in the care and treatment of the insane in their large public hospitals, and there began to be a more or less consistently directed attitude of study of these problems together with a study of methods of administration and control which would look toward higher etfi .
ciency and greater economy. The result has been that in most of the States where there are several institutions for the care of the •insane that these institutions are controlled by a ten, tral body, a- lunacy commission -or a board of control, usually appointed by the governor. Sometimes these boards of control have still larger powers and include all of the charitable institutions. The details differ in the different States, but central control is the thing aimed at. Along • with this central control the scientific departments of the institutions increase in im portance and in some as in New York, Massachusetts, Illinois, there are central re search departments for all of the hospitals.