ere long it may be decided that it is as much to the advantage of the State as of the individual to retire the employees and officers of the State hospitals honorably and gracefully, after they have completed a long term of useful work.

The prospect for a satisfactory home should be quite definite to those who are able to win advancement in the medical service of the State hospitals. Usually the superintendents are well provided for, and often the first assistant physicians also. I believe, however, that in every position in which good service requires permanence, every interest will be best served if there is opportunity for the establishment of a comfortable home. And every home should be a unit. The unmarried men may be congregated in quarters or staff houses. For the married, separate houses or apartments, each arranged for housekeeping, should be provided. This is the plan which long experience has led the United States Government to adopt, and it works well as far as it has been adopted in the State hospitals I am familiar with. The present custom in the State hospitals is to furnish full maintenance for the medical officers, and in some instances, for their families. There are, however, some, of whom I am one, who believe that this might be modified to the advantage of both the State and the individual by the introduction of a system of partial maintenance and an equivalent increase in money compensation for the balThis would provide for more independence and responsibility in the home life and for less expense and trouble to the hospital. The maintenance received by the officers of public institutions is, I believe, frequently considered of more value to the officers than it really is. The rental value of furnished quarters in imposing administration buildings, or of a house in keeping with the dignity of the institution, and the appurtenances and service which are required by virtue of an official position should not be regarded as entirely in the nature of personal compensation. A man, in private life, with a cash income above his living expenses equal to a medical officer's salary would probably not spend as much for quarters and subsistence as the equivalent of what an institution physician may sometimes seem to be provided with. It might not be at all necessary or to his taste. And whatever he saved in living expenses would be his own, which is not the case with the medical officer of a State hospital, who, when his family

goes away for the hot season, or when his children are sent away to school or college, incurs a large additional expenditure without any corresponding saving at home which he can turn to account, as is possible for the man who receives full compensation for his work in money which he can spend to suit himself.

THE TRAINIng of MedicAL OFFICERS.

In undertaking to build up an efficient medical service in a State system of caring for the insane, some consideration should be given to the present state of medical education in its relation to the study of mental diseases. Scarcely a medical college in the country is provided with adequate facilities for giving practical instruction in this subject, and as a rule the provision made for it is quite meager, or it is entirely lacking. Consequently, physicians in this country take up the work in the State hospitals without having had any special preparation for it. Some systematic training would do much to improve the quality of the service. In the United States Government services the medical officers are given special courses of instruction in the service medical schools in Washington before they are assigned to responsible positions. How much more important is it that systematic instruction should be given those who are about to take up what is considered the most difficult and the most neglected branch of medicine. In New York, under the wise and able leadership of Dr. Adolf Meyer, a large proportion of the physicians of the State hospitals have taken courses of instruction at the institute on Ward's Island. A most striking improvement has occurred in the character of the clinical work in the hospitals. When the institute was removed to Ward's Island from the city, it was hoped that in time a sufficient number of physicians would be employed at the Manhattan State Hospital there, many of them as clinical assistants without salary, to render it a training school from which vacancies throughout the service might be filled. This has not yet been fully realized but may be later. Possibly, when every medical college in the country is equipped with a psychiatric clinic similar to that at Ann Arbor, and to that in course of construction at Johns Hopkins, Harvard, and Toronto, and when the medical service of the State hospitals is more eagerly sought after by medical graduates than at present, those who take up the work may be better prepared. In the mean

time, it would seem as though it would be worth while for the State to make some effort to provide instruction. This can best be done, in part at least, at a central institute. The training which physicians who are entering upon the work receive will also depend to a considerable extent on the way the work at the hospitals is organized and carried out.

METHODS OF Work.

As a rule, the number of physicians is too small. In Italy the law requires that in the State institutions for the insane, the number of physicians employed shall not be less than one to every hundred patients, and in Germany the proportion is nearly as great. In this country, the rule is one to a hundred and fifty as a maximum, and usually more nearly one to two hundred, or even much less. The work is much facilitated by good classification of the patients in accordance with special needs, by good nursing and clerical assistance, by adequate equipment, and by transferring from the physicians to others any duties which can be attended to efficiently by those without medical training. The work will also be facilitated if the reception wards, the wards for those suffering from intercurrent acute physical diseases and surgical conditions, and the infirmaries are suitably constructed and arranged for active clinical work. Examination rooms furnished with proper facilities and with instruments of precision and apparatus for minor laboratory procedures should be in close relation with the wards. The physicians should not be obliged to leave their patients to do work that can be just as well attended to near at hand. Attached to the infirmary wards should be a room suitably equipped for the needs of surgical dressings and minor surgical procedures. In these services will be concentrated a large proportion of the active clinical work of the hospital. The proportion of physicians will there be much greater than elsewhere, and may be one to thirty or forty patients in the reception service, or even larger, depending on the number of admissions. Physicians who have just entered upon the work are usually assigned to one of the active services, preferably the reception service, and should be kept there until they have mastered the methods of examination of the cases and have obtained a good insight into the conditions from which they are suffering. This is the only reliable foundation for later efficiency in the work.

One of most important features in the examination and treatment of the patients is the medical history. The number of patients in a State hospital is so large, and the conditions from which they suffer so complex and difficult to understand, that the facts must be ascertained systematically, and accurately and fully recorded. In many instances observations covering a long period and frequently repeated tests are required for a proper understanding of the case. In a large proportion of the patients received, correct conclusions can be arrived at only after the record has reached a considerable length and has then been carefully analyzed and the significant and correlated facts condensed into a brief abstract. This method of work, which is more exacting than most young physicians have been trained to, must be acquired by the new men if they are to meet the requirements of an efficient service. It is an essential of good medical administration. To facilitate the record making, a sufficient clerical force should be provided. The records should be typewritten, and stenographers should be available to take dictation from the physicians, and occasionally to record the verbatim statements and productions of the patients. It is advisable to locate the clerical force and the office for records in rooms adjoining or opening directly from the wards. In order to meet the exacting requirements of the more active services, the proportion of physicians who attend to the medical needs of the more able-bodied chronic cases must, necessarily, be reduced to one to two or three hundred, or even less. Each hospital should be provided with a well equipped surgical operating room, and a laboratory where the more elaborate clinical and post mortem laboratory investigations can be carried on. In New York, the plan is to have on each staff one physician who has been given special training in laboratory work. The aim is to link the laboratory work closely with the work done with the patients, and the post mortem findings are looked upon as the final steps in the investigations and observations which have been made during the patients' lifetime. They round out the study of the case, serve as a check on the clinical findings, and as a guide to the work of the future. Lay assistants are provided for the laboratory physician, and in the larger hospitals, there is a medical assistant also. An effort is made to do all that can be reasonably accomplished to make the investigations at the hospital as complete as possible.

For more elaborate studies, however, which require the highest judgment and skil!, or very elaborate equipment, the material is sent to the Psychiatric Institute, where it is worked up, and eventually it is returned to the hospital with a report.

For the ordinary medical needs of the patients, the resident medical staff of a State hospital is ordinarily self sufficient. In these days of specialism, however, superior ability in certain directions can usually be secured for the patients by means of a number of consultants. In New York, an attending ophthalmologist and a dentist are employed who work systematically and receive a salary or per diem allowance. The active consultants, who serve without pay, should be experts in special lines. A good surgeon and gynæcologist should be one of these, and the surgical conditions from which so many of the patients suffer, should never be neglected. A neurologist and an expert in internal medicine, with special reference to diseases of the digestive tract, can also be of great assistance.

The staff conferences of the hospitals form the center of the organized medical work. In New York, these are now required by law twice a week, and in most of the hospitals they are held more frequently. They furnish means for bringing to a test the work of the individual physician, and for giving the patients the benefit of consultation and study by all the members of the medical staff. It is unfortunate that in the largest hospitals, the superintendents find it impossible to conduct these conferences themselves. Here they are conducted by the first assistant, or by a clinical director or other staff leader. Elsewhere, they are of great value to the superintendents and enable them to keep themselves informed of medical and administrative matters which would otherwise not be brought to their attention. They serve also as a means of instruction for the members of the staff, especially for those who have recently taken up the work, who see the cases presented in such a way as to form clinical demonstrations. The character of the staff conferences forms a fairly safe guide from which to judge of the medical activity of a hospital, and indeed of the medical administration as a whole. In an address at a meeting of superintendents in 1902 Dr. Meyer said: "It is my conviction that what is most needed is to raise the standards of the ordinary work by giving it as much medical meaning as possible and to shape our problems so