depends. If their knowledge of the hospital and extent of their powers as trustees are not appreciated to the degree that is expected of them by the people under the law upon which they serve, grievous results may fall on the institution with which they are connected. With a hospital moving smoothly, accomplishing its object yearly without friction, the position of a trustee is not difficult, for he need not contend against the anxiety and annoyance which are inseparably connected with a poorly managed hospital; but the condition should never lull him into a spirit of restfulness, nor give him reason to believe that the responsibility connected with his position is in any degree diminished.

What the patients expect.-Proper care is what their condition requires and should receive, when the State assumes the responsibility of the treatment of her insane. It should be a guarantee that such care will be given. But the State proposes and man disposes. There are many citizens who unfortunately possess a predisposition to insanity, coupled with a degree of self-knowledge that enables them to foretell the approach of an attack, and who desire the right of having medical treatment before all self-control is lost and they commit some overt act. At present this is not possible in the State of New York, owing to the inelasticity of the existing interpretation of the statutes. The unreasonableness of this state of affairs may well be compared to a fond father refusing his children permission to enter a house to escape an approaching storm until their garments are drenched. Serious results are likely to follow in both instances. The insane want protection; it may be from themselves, or to save others. The distress arising in one who craves help, who has silently struggled against worry, sleepless nights, failing appetite and morbid fears, in which the words, acts and motives of his friends have been misconstrued, can never be comprehended by an experienced interpreter of our laws. "Protection" is a word that holds more meaning to the insane than any other word in the English language. The importance of it is recognized when the insane are referred to as the "wards of the State." Politics is an enemy to efficient hospital service, whether it be shown in changing superintendents or in the appointing of his subordinates. An illustration may be given by citing the act of the Governor of a powerful state, a state strong in its resources and which has been the central object of the curious gaze of the entire civilized world, who has asked

the superintendent of a well-known state hospital-a hospital noted for the general excellency of its management during the fourteen years he has been at its head-to resign for political reasons. As if a professional man, successfully performing a delicate and trying task to the benefit of the entire state, could not hold such political beliefs as his conscience directs. This hospital had been conducted on what is known as the "Merit System "-the highest and best practical method that is known to hospital men—a civil service that has but one object in view; namely, the right man in the right place. This is for the good of the patients, of the hospital and of all concerned. It is by the merest chance that any appointment to a state hospital, in which any position whatever, is a good one when made through the channels of political preferment.

When a patient enters a state hospital for the first time he has little idea of what is before him. The possibility of seeking medical treatment in such a place may never have occurred to him, and the very existence of a state hospital may never have aroused enough curiosity to cause him to visit one. If then, on admission, he has fed a morbid vein on the tales furnished the press by those unfortunate insane who have not recovered their equipoise, but who are actuated by suspicions that have never subsided, the mental unrest that results is a hindrance to his recovery. In time, however, depending of course upon the extent to which his mind is affected, he recognizes the aids to recovery that properly belong to a state hospital. The effort that has been made to render his surroundings pleasant sooner or later attracts his attention and suggests the home rather than a custodial institution. The air of neatness and order may be a novel but not unpleasant feature, even when he finds that he is no longer entrusted with the whole care of himself. Baths will be given him, clothes changed, the hair, face, hands and nails receive attention, and he will find that his needs are anticipated by the nurse. He will enjoy good ventilation, afforded by many open windows and high ceilings, and on recovery will wonder how he ever lived, sleeping in a close room with no ventilation, and perhaps his head covered with bedclothes. He will notice that when he is annoyed from any cause it is removed if possible; and that his contentment of mind is an object of interest to the nurse as a help to recovery, and is a part of the general treatment for him and his fellow patients. The

regularity of method and the uniform kindness and high degree of care bestowed, he recognizes as his right, as one accidentally helpless in the grasp of disease intelligently and humanely cared for by kind and willing hands. He may have discovered these things in the hospital department, where rest in bed has been one of the means employed to tempt self-control and reason back to their old camping-ground; where also diet has been the proper one for the sick man, and where any desire for a change, a craving for something that memory calls up with a pleasant association, has been granted. His entrance into a general ward may strike him as an innovation not wholly to be desired, for it is a fact that many who have recovered a healthy condition of mind in a certain department of a hospital dislike to leave it. This is usually a recommendation of that department. In the general ward he associates with those congenial in disposition and tastes, where there is more of an active mental life going on that is in touch with the outside world, where in the exchange of experiences he is constantly learning something, and the ward becomes to him what a hotel corridor does to many men, in furnishing mental attrition. This is no optimistic statement, but is the actual result of having congenial wards in a hospital for the insane. As the patient approaches complete recovery, he may, in assisting the nurses, visit every ward in the entire department. He learns that in a true hospital no filthy ward exists; that no weak, tremulous paretic, liable to a sudden apoplectiform attack, is ever sent to work in the hot sun or allowed to subject himself to any muscular strain. He sees that the homicidal, suicidal, feeble, sick and excited are in bed, and that they are not allowed to be out of sight of trained nurses during any part of the day or night. This is recognized as right, and in the spirit of the "Hospital Idea."

In addition to the benefits directly derived by those patients just mentioned, are the good results that come to those on the wards outside of the hospital department proper. It allows all the wards to be kept quiet and in order day and night. It permits sleep for both patients and nurses. If nurses complain that they are not able at night to sleep in a ward, it casts a strong suspicion that a proper classification has not been made. When the healthy sane cannot sleep, can it be that a broken-down, nervous, insane patient is getting that degree of consideration he should receive from his physi

cian? It is scarcely wise to subject an invalid to a strain under which a well person may break down. The crowding of a hospital may make this a necessity, yet this is an insufficient excuse; for there should be no crowding. The treatment of five hundred patients is enough for one physician to direct, in justice to himself and to them.

All these considerations and more, the patient asks of the hospital. If they assist in his recovery he has a right to ask for them. It is his health, happiness, home, everything on the one side; and on the other side, whether or not a State, whose name is synonymous with generosity and wealth, and that has stepped forward with the avowed purpose of caring for the insane, will do it. Individual care, with all that this implies, for every case, whether rich or poor, is all that is asked in the humane, and modern treatment of the insane in the latter part of this nineteenth century.

BY JOHN E. JAMES, M.D., CHAIRMAN, PHILADELPHIA, PA.

Gentlemen: I propose presenting a very brief review of surgery for the year. The last year has not been marked by any number of new and brilliant operative procedures, but rather by the confirmation of certain hitherto well-known modes and by a larger record of cases operated; thus enhancing the value of the statistics. In bacteriological studies much the same may be said.

* These papers have not reached the General Secretary.