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The first State asylums in this country were comparatively small, designed for not more than 300 persons. In the third quarter of the nineteenth century, the agitation for the removal of the insane from county to State care resulted in the building of mammoth institutions, capable of accommodating as many as 2000 patients. In some cases the expenditure for buildings and plant amounted to $1000 to $3000 per capita, a cost exceeding that of the most expensive hotels.

These great caravansaries filled up, and still the counties had a large number of the insane. At the opening of Willard Asylum, in 1869, there were 1500 insane persons in New York State in county care. Six years later it was reported by the State Board that Willard Asylum was full, and that there were still 1300 remaining in county institutions. Mr. F. B. Sanborn points out that in most States which are attempting to provide for all the insane, the large central hospitals continue to be full to overflowing, and concludes:

"The effort to provide for all the insane (of any but very small States) in large asylums seems to me as futile as the schoolboy's hope to make the hind wheels of his wagon overtake the front wheels. Local asylums, good or bad, -- too often bad, -- always have existed and always will, if we speak of the United States as a whole." (145)

It was soon found that the very large institutions were not answering their purposes, because their size made the individualization of cases difficult or impossible, and there was a sort of contagion of insanity resulting from the presence of such large numbers of lunatics on a small area. Later there came a tendency to build cottages grouped about a central administrative and hospital building, where families of the insane in the care of proper housekeepers and attendants can live in relative seclusion. Kankakee, Illinois, was an early illustration of this system of construction. To save expense, however, the legislature insisted on making the "cottages" much larger than was desired by those having an interest in this new development.

The tendency at the present time is to transform the large institutions as they grow into something approaching: the colony by placing detached small buildings for special classes upon the estate; and some of the best new institutions are built wholly upon the colony plan. With this modification in the methods of building, the tendency toward State care has been greatly strengthened. New York has finally transferred all the insane from county to State care, and the same system has been adopted by most of the Western States.

Wisconsin has had the distinction for many years of being able to provide for all her insane either in State or county institutions. Whenever cure or improvement is considered possible, the patients are sent to a State hospital under the charge of specialists. Chronic cases not needing special restraint or care are sent back to the county after hospital treatment can benefit them no further; but no county is allowed to care for its own insane unless the plans of its almshouse buildings and the management of that institution are approved by the State Board of Control. If so approved, there is a small weekly per capita allowance from the State treasury to the county that cares for its own insane. If not approved, at any time the State Board has the power to transfer all the insane belonging to the county to State institutions or the almshouse asylums of other counties, and collect the bill for their maintenance from the county to which they belong. Thus it is to the interest of the county to care for its own insane and to care for them properly. (146)

About 70 per cent of the total insane are cared for in county asylums for chronic patients, and the remaining 30 per cent in large State hospitals for acute cases. It is claimed for the system that it is both economical and humane and that it makes it possible for the State to keep up with the increasing number of the insane. Although highly praised by some experts, it has been criticised for certain practical defects. Dr. C. B. Burr summed up the objections to the county asylum system as follows: absence of the hospital idea, lack of medical oversight, lack of sufficient attendants, lack of standards of care prescribed and enforced by central authority, and lack of both State and local supervision. (147)

The idea of segregation and of special provision for the harmless chronic insane has been carried in Massachusetts to the point of boarding selected cases of the insane in families. The amount paid for the board, together with the cost of the necessary visiting, makes it not much more economical than asylum care, although it is much more satisfactory for selected cases. There are those who hope that, as with children, the placing-out system is supplanting the institution system, so with the insane it may be possible to board larger numbers of them, and incorporate them thus in the ordinary population. In Scotland this system has been developed much further than in this country, and not less than one-fourth of the insane are living in families. (148) In Massachu-setts 350 patients were so placed in 1906, and although indiscriminate boarding in families is not advocated, yet this method certainly provides at minimum cost for a certain class of patients who could not be discharged upon their own resources, but who appear fit for greater liberty than an insane hospital provides. (149)

(149) Fish, N. C. C., 1907, pp. 438 ft.; Sanborn, pp. 448 ff