truth must be impressed upon the thoughtless community by the physician) that, as soon as the teacher or the parent or other relative discovers such disorders and decides that they are more than transient, he should take alarm and seek medical advice for the patient. If, owing to congenital defect, mental development is retarded, the child should have the advice of a psychiatrist. If under the stress and strain of an exacting life an adult begins to "break down," immediate medical relief should be secured. The term "over-work" is relative to the constitutional equipment and to the mental and physical health of the individual. The toxic substances which are produced by activity, and which cause fatigue, are not, in some instances, easily eliminated. We know that rest does less for the recuperation of a fatigued muscle than irrigation with a stream of fresh blood. Given plenty of good blood and an opportunity to rest, but one agency in addition is requisite to restore fatigued muscles, and that is sleep. Insomnia, though a common symptom, is always a grave one in the psychasthenic.

To afford as far as possible opportunities for early relief of the borderland case, New York State, which had for many years authorized licensed private houses to receive voluntary patients, in 1908 amended the insanity law and threw open her 13 civil State hospitals for the reception, without commitment and on their own application, of patients whose minds are not so impaired as to render them incapable of forming a rational judgment or to render them incapable of resisting influence.

Since the change in the statute, comparatively few voluntary patients have taken advantage of the opportunity to enter the State hospitals, the small number being due, apparently, to want of information or apathy of the general practitioner; to the idea persistent among the laity that real insanity is always marked by violence; and to the feeling that possibly recoverable cases of mental disorder should be kept at home, the hospital being regarded by some citizens as merely a receptacle for the desperate or hopeless cases. Too much stress cannot be laid on the importance of instructing the general practitioner and the public to the effect that medical care of the insane should begin before the time when sufficient mental change has occurred to make a commitment possible.

Of the 71 cases received on voluntary application into the New York State hospitals between July 1, 1908, and April 1, 1909, 40 were men and 31 were women. Their ages ranged from 13 to 77, and but 6 were over 60 years of age. The following is the classification of the psychoses:

I

7

Infection-exhaustion psychosis

Unclassified, a syphilitic with confusion episodes and arm weakness..
Not insane

Of these patients, 29 represented readmissions, including 12 cases of manic-depressive insanity, one case allied to manic-depressive, three cases of alcoholic psychosis, two cases each of paresis, paranoid condition, dementia præcox, psychasthenia, and hysterical psychosis, and one case each of acute alcoholic hallucinosis, constitutional inferiority, and depression not sufficiently distinguished.

The fact that 40 per cent of the patients were readmissions is an indication of growing confidence in the friendly offices of the State hospital.

The great desirability, for both individual and family, that cases of manic-depressive insanity should be placed under early

treatment leads us to experience especial satisfaction in the fact that 23 per cent of these voluntary patients were sufferers from this form of psychosis.

The services of the hospitals were of distinct value to the community in the instances of the 14 patients who cannot be cured. Of these, two were paranoic, one of whom was removed by friends in a few days, while the other was committed; four were general paretics, including two concerning whom the diagnosis is still sub judice, and one who was committed two months after admission, his family being thereby saved from disgrace and financial loss; and one who died in six weeks. The case of dementia paranoid left in five days, much improved by rest and catharsis; the case of organic brain disease is a hemiplegic, with incapacity and depression; the epileptic will probably improve so far as to be sent to the epileptic colony when a vacancy occurs; of the two cases of arterio-sclerosis symptom-complex, both over 60 years of age, one was discharged much improved after a trial; one of the three cases of constitutional inferiority is over 62 years old and not hopeful for future self-support, one was committed, and one reacted naturally during a week's observation and was discharged.

Analysis of the six alcoholic cases (less than 8.5 per cent of the total) should reassure the timid souls who loudly prophesied that the voluntary patients would necessarily consist largely of inebriates in search of a refuge in which to recover from a debauch. The victim of acute alcoholic hallucinosis was a readmitted case who suffered from a definite psychosis, and will be discharged in all probability in three months. Of the five cases of alcoholic psychosis, two were committed as insane under the statute, one was discharged in three days, one with a persecutory trend of ideas is improving much, and the remaining one shows a resemblance to Korsakoff's psychosis.

The seven who were found not insane and were promptly discharged comprised the following:

An alcoholic clergyman, who had mentioned suicide; a barber, who was depressed and nervous; a farmer's daughter of 13, who presented disorder in the content of thought, consisting of frequent panics caused by fear of choking and of impending death, and of which she was relieved by direct suggestion and

sensible advice; an alcoholic physician, who while in the hospital dishonorably procured liquor surreptitiously; a weak, excited, talkative farmer; an alcoholic and quarrelsome jeweler; and an emotional pupil nurse. Although, with the exception of the young girl, these were unsuitable for our State hospital treatment, the reception and discharge of these sane patients will be of value in reassuring the community, and in increasing confidence in the hospitals.

There is a very great economic value in the voluntary admission of the incipient case. The average life of the committed patient in a hospital is nine years. It is well known that very early treatment would shorten vastly the duration of the curable psychosis, and would rescue some patients from a nine years' residence. The State is saved from the average expenditure of from $1288 to $1472 for every possible nine years' patient who is discharged at the end of one or two years' treatment. Besides this outlay we must reckon the loss to the Commonwealth of the services of each citizen as producer or worker, roughly stated as $200 a year or $1800 in nine years. If recovery takes place in one or two years, $1400 to $1600 of the value of his life is saved to the patient described who recovers promptly. With early treatment and early recovery, therefore, the State would save on the average $2688 to $3072 on each such patient.

The effect of the presence of voluntary patients on nurses and attendants is excellent, for they must prove corrective in the case of nurses who are disposed to be summary, dictatorial or harsh, and they certainly are more intelligently helpful. The effect upon committed patients is valuable through the example set in activity in occupations, industries and games, and in general encouragement.

The undoubted prophylactic value of voluntary admissions is suggested by the case of one woman who was advised to apply by a sister who had recovered from insanity in a State hospital. Willingness to go to a State hospital certainly includes willingness to receive from the hospital physicians rules and directions for home life which may improve environment and remove precipitating factors of insanity.

The experimental period for New York State has ended, and the trial of voluntary admissions is abundantly successful and full of promise.