Our daily average number has been 853.5, which is about our present normal capacity.

The percentage of recoveries, calculated upon the number of discharges and deaths, was 15.85, the same as last year; calculated upon the number of admissions, it was 15.68.

The death rate was 9.72, calculated upon the average number of patients; and 5.91, calculated upon the total number under treatment.

There has been no unusual amount of sickness in the house during the year. We have, however, had two cases of diphtheria, one at the farm-house and one at the hospital, both in employees. Happily each of them recovered, and no other cases followed. There have been in all 83 deaths, 24 less than during the previous year. In 36 of these cases we have been enabled, with the permission of the friends, to verify or determine the diagnosis by an autopsy. It is to be wished that still more of the friends of patients could be induced to overcome their prejudices in this direction, as we feel assured they would do, did they realize how important, even from a purely humanitarian stand-point, an autopsy is. It is certainly from no mere curiosity, whether scientific or otherwise, that we urge an examination in all instances, but solely on account of the great assistance which an accurate knowledge of the condition of the brain and the other organs of the body gives us in carrying on that exhaustive study of our cases which we have undertaken, in order that we may determine, if possible, the exact nature of the processes underlying the disease. It is through autopsies alone that certain problems in regard to the brain and its diseases can be solved, - problems which may have an important bearing upon the treatment and cure of insanity.

By a reference to our statistical tables, it will be seen that we have changed somewhat the older classification of insanity and replaced it by one closely following the principles of Kraepelin's psychiatry, as set forth in a review of Kraepelin's work, in the "American Journal of Insanity," Vol. LIII., pages 298-302. Here the acute forms of insanity are classified according to whether they are processes of deterioration with or without remission (katatonia with occasional remissions, or dementia precox practically without any remissions), or whether

they belong to the group of periodic insanity (mania, with its various types, circular stupor, melancholia, etc.). The melancholia of the pre-senile and climacteric periods have been classified apart. The various forms of alcoholic insanity (delirium tremens, subacute and chronic alcoholic hallucinations, etc.) are not specified. The group of constitutional inferiority includes a variety of defects, such as moral imbecility, constitutional neurasthenia, etc., which may be subdivided into several types. This, however, will be the task of a special comparative study of cases, which necessarily oversteps the limitation of mere statistics.

The plans for the reorganization of the medical work of the hospital, as detailed in my last report, have now been in operation a full year. As was perhaps inevitable in such an important and wide-reaching an undertaking, we find that we have not accomplished quite all that we had hoped, and that our plans. have still to be perfected in many of their details; but the results already attained have been eminently encouraging, and fully warrant all the outlay in the way of time, energy or expense which has been found necessary in carrying them out. Although our work is greatly increased, no one would now for a moment think of returning to the old methods. Besides making an exhaustive study and full record in all recent cases, we have, so far as possible, compiled the histories of the older patients after the new plan, making them as full and accurate as the lapse of time since the inception of the disease would allow. We have also taken advantage of the relief given us from overcrowding (through the transfer of some two hundred chronic cases to the Medfield Asylum) to reclassify our patients, grouping together all of the recent cases, and those in which the disease is still in a transition state, on the first two floors of the hospital, where they can more easily be observed.

The staff of the hospital now consists of the superintendent, who is in charge of all the medical and administrative work of the hospital; he is assisted by the assistant superintendent, who is at the same time in direct charge of the acute cases of the female department; the second assistant is in charge of the acute cases of the male department; and the third and fourth. assistants have the wards for the chronic patients. Each assist

ant physician has a junior assistant to help him. The supervision over the purely medical work of the hospital is put in the hands of a physician who is as far as possible free from routine and administrative duties, and who is director of the clinical and pathological work.

The division of labor is carried out as follows: the first floors are reserved, as has been stated, for the observation cases; the second floors, for observation cases and some private patients; the third and fourth floors are occupied by patients who do not need continual clinical observation in the strict sense of the word, i.e., chronic cases and patients in stationary phases of their disease. Each physician has two floors of the male or female side under his charge.

ence.

The patients are given a complete mental and physical examination as soon as possible after admission. The examination is made by the physician in charge, with the help of the junior assistant. The physician on the third and fourth floors also takes his share of examinations, since his medical duties are considerably less than those of the physician in charge of the observation cases. The history is taken by the junior assistant, from the patient, from the friends and by correspondAs soon as the necessary data are at hand, the physician who examined the case reports to the staff meeting, makes a summary of the available facts and a diagnosis, which is submitted for discussion. A provisional prognosis is made, and where necessary the treatment is discussed. The further duty of the physician is to continue the record of the patient, with the help of the junior assistant. Notes are taken in the ward, at the medical round, and handed to the stenographer to be typewritten. The clinical microscopy and analysis of urine, etc., are done by the junior assistant.

In order to keep up a uniform arrangement and completeness of the records, the director of the clinical and pathological work outlines the scope and order of the history and the case record. He sees the patient with the physician in charge every second morning, and is responsible for the accuracy and usefulness of the record.

The

The staff meetings take place from 11.30 to 12.30. time is devoted to the report of the cases recently admitted,

to those ready for discharge, and to matters of importance occurring in other patients. The report of deaths and autopsies is also considered. Frequently the patients themselves are brought before the staff for clinical demonstration.

The autopsies are made by the physicians and junior assistants. The brain is usually examined by the director of the pathological work, and the plans for the future microscopical examination and the necessary preparatory steps are outlined by him. The work is to some extent distributed among the junior assistants, according to their interest and ability.

This general plan has given much satisfaction, and the attempt made to group the result of the year's observations has revealed a steady improvement of the material, and much evidence of a faithful elaboration of the plan adopted.

Apart from the work directly referring to the patients, the medical spirit of the staff is further cultivated by regular weekly journal meetings. The liberal supply of books and periodicals allowed by the Board of Trustees makes a division of labor necessary. Each physician takes a number of journals and reports the contents briefly, frequently in connection with a short review of the whole field to which a given article belongs.

During the winter months a course on neurology, embracing especially the anatomy of the nervous system, was given by Dr. Meyer; also occasional instruction on methods, clinical and pathological. Apart from the current work in the laboratory, the minute study of special specimens and the preparation of material to illustrate the normal histology of the nervous system were carried on. Among these studies we mention: (1) a case of middle ear disease with acute facial and auditory paralysis and typical secondary lesions in the medulla oblongata (to appear in the Journal of Experimental Medicine "); (2) a histological study of the nervous system of one of Dr. Sanger Brown's cases of heredo-ataxia (to appear in Brain"); (3) the nervous system of an anencephalus, and of normal fetal brains (cut in complete series); (4) the secondary degenerations in a case of infantile hemiplegia with sclerosis of the temporal and parieto-occipital lobe of one hemisphere (also cut in complete series); (5) normal series of the human brain stem,

etc.; (6) studies of brain cells in various forms of insanity, partly communicated by Dr. Meyer at the meeting of the Medico-Psychological Association in Baltimore.

During the second term (January to March, 1897) a series of lectures and clinics to the students in psychology of Clark University was given, in which the medical staff of the hospital took part. During the summer school a course of ten lectures at Clark University and two clinical demonstrations at the hospital were arranged.

This plan may safely be said to have grown, on a natural basis, out of the conditions present in the hospital, and to be the outcome of the medical needs of the institution. Its aim is to do the best that medical science can do for the patients, and to gather from the experience, systematically and conscientiously, all that may benefit the work. Thus it becomes incidently a plan for research work, in the same way as every physician will try to use his experience for the future, — only with the advantage that the co-operation of ten physicians, with the same methods and the same aim in view, will be likely to be more fortunate in the results of research than one physician alone can expect to be. "Efficiency of the work on ground of well-sifted experience" is its purpose; it is not put on the basis of experimental stations, of which the financial spirit of the administration might urge results in the shape of startling discoveries or a discontinuance of the financial support. Although we may confidently expect that, in time, results of great scientific value will of necessity come from such a plan, its true raison d'etre rests upon the added interest and efficacy which it gives to the every-day work of the hospital, to say nothing of its direct and immediate effect upon the patient, in that it assures him that he is being treated individually, rather than en masse.

The principal point is that all the physicians are kept in contact with the best work that literature gives evidence of, with the best methods that we can agree upon, and with a spirit which considers guess-work the most dangerous enemy of medical practice. With this attitude, every physician is likely to do his best work in all his relations to the patient and to the administration of the hospital.