The changes in the outlook for the care of the insane largely as- a result of all this scien tific work have been very great. Interest no longer centres in the autopsy room in attempts to correlate pathological findings and mental symptoms. The interest now is in the living patient and the scientific institutions have elabo rated their -departments • of -clinical pathology fbr the purpose of studying the processes that are going on in the living patient, while psy chological investigations, are becoming much more in vogue with the development of definite interests in psychotherapeutics.
The large housing problem which confronts the several States is still dealt with by the State hospitals, none of which are longer considered, however, as institutions for the chronic insane. All of the hospitals are equipped for taking care of all varieties of illness, mental and physical, acute and chronic. It is recognized, however, that in large centres of population there should be easy access to wards where mental illness could be intelligently handled. The result has been the creation of psychopathic wards or in stitutions in a number of cities: Albany, N. Y., Boston, Ann Arbor, Mich., Baltimore. These institutions care for the great stream of men tal cases which come from large urban popula tions and which ordinarily would be distributed in other wards of the city hospital. For exam ple, the alcoholic wards of Bellevue hospital are under the immediate charge of the psychia trist in charge of the psychopathic pavilion. Thus are the problems of general medicine and psychiatry coming to be considered together and their respective specialists are coming to be of mutual assistance.
As mental disease has come to be considered more and more a matter of defective psycholog ical adjustment and methods of psychotherapy have been more and more applied, the hospitals have reached out into the communities which they serve and through the intermediation of dispensaries and social workers have endeav ored to extend aid to these communities and also endeavored to assist the discharged patients in rehabilitating themselves in the community. The State hospital, therefore, has come in the past hundred years from a condition in which it was merely a place to confine °ma& persons, to be a centre for education in matters pertain ing to mental illness and for the rehabilitation of failures and defects in adjustment for the community in which it is located.
As outlined, the problem of the care of the insane has been gradually evolving as it became progressively larger, first a matter for villages and townships, and for counties, and finally a matter for individual State hospitals, receiving patients from a certain number of counties, then a matter for the State as a whole, govern ing its several State hospitals by a central board.
Beyond that there has never been any recog nized statutory central control. The superin tendents of all of the institutions for the care of the insane have been organized into a medi cal society which has now been in existence since 1844, originally known as the Assocation of Medical Superintendents of American Insti tutions for the Insane. Since 1893 it has been known as the American Medico-Psychological Association. This association has through the years been the clearing-house to which annually was brought all institutional problems and has served most eminently in helping along the work of the care of the insane in several States of the Union. This until recently has been the only agency which in any way correlated the work of the several institutions throughout the country. In 1909, however, there was organized the National Committee for Mental Hygiene under the stitisdut and as a result of' the un ceasing efforts of Mr. Clifford W. Beers. Mr. Beers had himself had a serious attack of men tal illness in the course of which he had been a patient in more than one institution. As a result of his experience he felt convinced of the need of an organization which was independent either of political influence or financial or other personal consideration which would help various hospitals to deal with their problems to better advantage. As always happens in large prob lems the individual elements of which are dis persed over a wide territory, many of the insti tutions and some of the States remained very backward in their care of the insane. There were no members in their hospitals of the cen tral organization, The American Medico-Psy chological Association. As some of the. State institutions were as badly off as had been the county asylums, it became the function of the National Committee to endeavor to improve these bad spots throughout the country and in doing so it took an attitude of helpfulness rather than one of criticism and as a result almost always found that, defects in methods were due to ignorance, many primitively conducted insti tutions really believing that they were giving the best possible service that 'medical science could suggest. Such institutions were quick to avail themselves of the help of the National Committee and a great deal of improvement throughout the country has resulted from its activities. This has been the work of the Na tional Committee until the beginning of the European War, when it turned its attention practically entirely to war work. The great importance, however, which the conduct of this war of necessity attached to mental problems will result in great benefit to this particular department of medicine.
Wri..mam A. Wurre, Superintendent Saint Elizabeth's Hospital, Washington, D. C.