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For more elaborate studies, however, which require the highest judgment and skill, 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 that they stimulate the daily interests of the hospital physicians and make the so-called ordinary work valuable for progress. Huxley called science organized common sense. Pathology, to me, means organized practical medicine, and research means the use of the practical and experimental work for the clearing up of open questions." The medical work of the State hospitals should be judged not so much by sporadic research developments which may or may not prove serviceable. The foundation of promising research is good ordinary work, and this can only be secured by starting in with conditions as we find them and steadily improving them along medical lines. Special investigation into the nature and causes of mental disease is, indeed, imperatively demanded. As Dr. Meyer says, however, it should be undertaken to clear up open questions, and the questions which become intelligible enough to be plainly profitable to answer, are the outcome of painstaking effort to apply what is already known.

The PUBLIC AND THE MEDICAL SERVICE. I have in this paper tried to outline some of the essentials of such a medical service as is needed for the ordinary work in the present stage of institutional care of the insane. Much has necessarily been omitted and I have, of course, been obliged to speak from the standpoint of the New York service and of my own experience. In some matters I may seem to have taken a rather advanced position. There is, however, in what I have suggested, nothing impracticable and there is no danger that the medical features will be overdeveloped. I believe that the people wish the work of the State hospitals to be done well, and are willing to provide for it in a reasonably liberal way. No other class of illness reduces the sufferers to such a peculiar and distressing degree of dependence and helplessness as mental diseases. The unhappy situation of most of them is augmented by the fact that from the very nature of their disease they are unable to understand that they are sick, or that there is any reason why they should not be at liberty. Were the inmates of the State hospitals suffering only from conditions in which the mind was not affected, few of them would be in public institutions. They are confined because the peculiar effect of their disorders on their speech and behavior unfits them to be at large or to be cared for at home. Many years ago the New York State Commission in Lunacy showed that few of them could be properly called paupers. Less than five per cent of the cases admitted to the New York State hospitals are received from almshouses, and fully two thirds are reported to have been in comfortable circumstances, that is, they were not in poverty. In a State system of caring for the insane the State practically mo

а nopolizes the treatment of mental diseases. When these diseases invade the home, it is not the pauper alone, it is the self-respecting average citizen, in fact all but the wealthy who must look to the State hospitals for relief. This is an aspect of the situation which concerns everyone, and which should be considered by those who have the responsibility of making financial and other provision for the work. In the care and treatment of the insane the State undertakes to do for the sufferer what in the case of other diseases would ordinarily be attended to by relatives and friends. There is every reason why pains should be taken to see that it is done well. From the business standpoint every precaution is taken to safeguard the expenditures and to see that good business methods prevail in every detail. Every item must be accounted for, and the institutions are inspected with reference to the management of the property and the general comfort of the patients. This is all very proper and is similar to the methods employed in a business enterprise. In a business, however, the results may be reckoned as money profits or losses. The results in a State hospital are, how

a ever, not so easily determined, and as a rule, the methods of ascertaining them are superficial or entirely inadequate. In New York we are trying to improve these methods by means of better statistical studies of the medical aspects of the work, and last year an expert statistician was appointed with this in view. The relations of the Psychiatric Institute to the work of the hospitals have also served as a means of demonstrating the strong and weak features of the medical work in each. Interhospital conferences, at each hospital in turn, which bring together as many members of the different medical staffs as can be spared, also serve to bring into plainer view the character of the medical work which is being done. Medical inspections are also made by the medical commissioner and the medical inspector. Some way should surely be provided by which the intelligent public may obtain a clearer insight into the character of the medical service of the State hos

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pitals and into the value of the results obtained. This would, I believe, assist the work very much. Nothing is doing more to improve the care and treatment of the tuberculous, and to exterminate tuberculosis than the extent to which the public has grasped the known facts regarding the disease and the requirements for its control. It has even been said that in some places the intelligent public is in advance of the local medical profession. A similar awakening of interest and intelligence in regard to mental diseases would revolutionize the work of the State hospitals. The development of institutional care in the past indicates that the progress of the future will be largely, and probably more definitely than even at present, along medical lines. The fundamental purpose of it all is to cure, to care for tenderly and intelligently, and to study how to prevent. It will be successful in proportion to the degree in which this purpose is kept clearly in the foreground and made the controlling motive.

ON THE NIGHTMARE. BY ERNEST JONES, M. D., M. R. C. P. (Lond.), Demonstrator of Medicine and of Psychiatry, University of Toronto; Pathologist to the Hospital for the Insane, Toronto.

Part A. PATHOLOGICAL. No malady that causes mortal distress to the sufferer, not even seasickness, is viewed by medical science with such complacent indifference as is the one which is the subject of this paper. Textbooks, both on bodily and on mental disorders, may in vain be ransacked for any adequate description of the phenomenon, and still less satisfying is the search for anything more than the most superficial consideration of the pathogenesis of it. The clinical aspects of the malady are commonly ignored except for some desultory remarks on the frequency of bad dreams in certain affections, particularly mitral disease, of which condition indeed they are sometimes alleged to be a diagnostic indication. On the rare and embarrassing occasions on which a physician's aid is sought the consolation offered usually takes the form of irrelevant advice on matters of general hygiene, coupled perhaps with the administration of such potent remedies as silica and cinnibar or with a halfjocular remark concerning the assimilable capacity of the evening meal. The relief afforded to the sufferer does not surpass that obtainable in ages when the treatment in vogue consisted in scarifying the throat and shaving the head," in bleeding at the ankle,' or in the administration of wild carrot, Macedonian parsley and the black seeds of the male peony.'

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* Artiques. Essai sur la valeur séméiologique du rêve. Thèse de Paris, 1884, No. 99. Macario. Du Sommeil, des Rêves et du Somnambulisme, 1857, etc.

Marggraf. Die Schlaflosigkeit, Schlafsucht, das Alpdrücken und nervöse Herzklopfen, 1905, S. 12. Caelius. Tard. Pass., I, 3. Rhases. Ad. Mansor., IX, 12. Contin, I. Paulus Aeginata. Syd. Trans., 1844, Vol. I, p. 388. • Andrew Bell. Nocturnal Revels, or a General History of Dreams, 1707. Pt. I, p. 14.

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