sanity in 2 cases, toxic insanity in 7 cases, and chronic mania in 4 cases. The approximate ages of the recovered were as follows: Ten were under 20 years, 19 between 20 and 30 years, 19 between 30 and 40 years, 11 between 40 and 50 years, 14 between 50 and 60 years, 7 were over 60 years.

There were discharged improved during the period of 25 men, 45 women; total 70; unimproved, 3 men and 3 women; total 6.

One alien admitted during the period was, after a sojourn of twenty-four days in the Hospital, deported by the Bureau of Immigration at the expense of the steamship company which brought the patient to the United States. This action was based upon the information gathered and submitted to the Bureau that the subject had previously been insane and an inmate of a foreign institution, was insane on landing and had become dependent on the State within one year after arrival in this country. At the instance of the Federal Government, the responsible steamship company reimbursed the Hospital for the cost of the patient's brief stay in it.

Mortality Record. The number of deaths for the first year was 47—25 men and 22 women, or 5.4 per cent. of the whole number under treatment. During the second year there were 35 deaths

22 men and 13 women, or 4.2 per cent. of the whole number under treatment. Of the 82 deaths during the period 28, or 34 per cent., were cases of general paresis, and 13, or 15 per cent., were due to tuberculosis.

Two patients suicided during the period, one by strangulation with a piece of wearing apparel and the other after escaping from her attendants in the darkness while returning from the evening meal, and managing to elude her pursuers, threw herself in front of a moving railway train. Both were known to have suicidal tendencies and were subjects of very careful supervision, but in spite of it, they finally succeeded.

The death rate during the past year was the lowest in the history of the Hospital.

The appended medical tables set forth in detail the record of the movement of patients.

Infectious Diseases. The period has been exceptionally free from epidemics of infectious diseases of every kind. Tuberculosis is always present, not by the spread of the infection within the Institution, but infected cases in varying stages of development

2-Eastern Insane.

+

are constantly coming in. At the end of the period there were eleven demonstrated cases present against seven at the beginning of the period, and the number of deaths due to this cause were 13, or one more than during the previous period. This is a slight increase due solely to the number of infected cases admitted. Two cases on admission were in advanced stages of the disease and died within a short time thereafter. The new cases are the source of the greatest menace to the general population, as usually they are actively maniacal and their isolation is much more difficult. In the management of this disease the observance of sanitary rules. is strictly enforced and the history of the past four years proves that it has been kept under control.

There have been no cases of typhoid fever excepting only one in a member of the medical staff, who contracted the disease while absent on a short vacation and which developed two weeks after his return. No cases of smallpox have occurred, although one patient was admitted directly from the house and the very room occupied by a relative seriously ill of it. This fact was not discovered until twenty-four hours after the patient's admission, when she was temporarily removed from the premises, and every precaution taken to protect all who had come in contact with her. The rule of vaccination as a requirement of admission is still rigidly enforced in all cases.

General. The medical work of the period has had a serious. handicap in the disordered classification, which has grown steadily less defined as the overcrowding has increased. At the beginning of the period the groups of cases were so nicely balanced as to be almost ideal and with a few vacancies in each for a working margin, a transfer could be effected as promptly as the condition of any case indicated its advisability. Moreover, it was then possible to receive the acute cases without delay and place them under immediate treatment. During the period, however, the conditions, especially in the Department for Men, have been much altered. Every cottage has become crowded, and some much beyond their rated capacity. The question of the assigning of the new patient to his proper group where the chances of improvement and recovery are the best, has yielded to the more pressing one of possible accommodations of any kind. This in the very nature of things is a hindrance to the best medical work and necessarily

influences its results. It is hoped, however, this situation is only temporary and that some relief may be found in the suggestions elsewhere submitted.

The results of the medical work during the period are nevertheless gratifying. The death rate was exceptionally low, and particularly so during the past year, and the proportion of recovered and improved cases was high. The medical supervision has steadily improved year after year, and the usual standard of nursing has been maintained.

The sanitary conditions of the buildings and the grounds are good. The new tile floors and extensive repairs and alterations in the plumbing are the most important improvements lately made in the sanitary conveniences. The sewage purification plant has completed its third year of service and continues entirely satisfactory in every way. The cost of its maintenance is almost nothing, as it operates automatically. The contact beds occasionally are plowed and raked to remove the rank vegetation, which thrives luxuriantly upon them, but otherwise the plant calls for very little attention. The effluent continues clear, odorless and practically free from organic substances, the oxidation being so complete that it has never been necessary to remove any sludge from either the septic tank or the beds. The water supply continues abundant and of good quality. The late improvements in this system have removed a danger of possible pollution of the water in storage, which was ever a source of anxiety to the management. The overcrowding of some of the cottages it is feared will lower the standard of sanitation, but it seems unavoidable in view of the large number of acute cases being constantly urged for admission. In some of the dormitories the established allowance of fifty square feet of floor space for each patient has already been reduced to thirty, and if this encroachment continues, serious impairment of health conditions will be the penalty. Some compensation for this evil of overcrowding has resulted from the effort made to increase the outdoor life as much as possible and to find employment for as many patients as can be interested, the state of health permitting, in work of any kind. Likewise, the number of patients receiving meals in their respective wards has been reduced, and now seventy-two per cent. of the total number of patients are going out regularly to the dining-halls for meals, a proportion

which, although now unusually high, might be slightly increased if the accommodations of the dining-halls would permit. The value of this practice is more considerable than is at first apparent. It insures to all able-bodied patients, however sluggish, indifferent, and even antagonistic they may be to exercise per se, and the class is not a small one, a modicum of fresh air three times daily regardless of the conditions of weather. The exposure is nothing, but the breath of fresh air, the little exercise, the new scenes and strange faces are much, and aid both appetite and digestion, to say nothing of the refreshing advantages accruing from methodically and completely vacating and opening the cottages to the air, even though for a short period of time only. The contrast between the system of congregate dining-halls and that of our former cottage dining-rooms and kitchens is so vast and the advantages and conveniences of the former are so numerous and superior, that it seems, in view of an experience of eighteen years, incomprehensible that the individual dining-rooms and kitchens should find favor in any institution for the insane.

Faith in the value of occupation of the more vigorous patients grows with the years, and the effort to engage as many as can be induced to take employment has not been abated. The regret is that we have not a greater variety of industries to tempt and interest them, although much has been accomplished. It is apparent that this feature of the work can not reach its highest and best development without the broader opportunities of a colony. A more definite segregation of the working group must be secured than is possible in the parent institution before the best results are obtainable. Within the institution proper, which provides for all classes of cases, the main body of patients are so incapacitated by reason of either infirmity, mental or physical, or life-long anenergy, that the example of well directed activity and industry is wanting, and the patient naturally inclined to industrious habits, easily falls into the life of ease and indolence of the majority unless prudently directed and influenced by those charged with his care. This is in a sense a therapeutic problem which is always before us and not easy of solution. The amusements and entertainments have received the usual attention during the period, and much credit is due the numerous members of the organization for the large number of pleasing and clever exercises they have

with much labor worked out.

These have consisted of theatricals, weekly dances, socials and celebrations of the important holidays by fitting and more or less elaborate programs.

CAPACITY.

The Hospital has a rated capacity of 712 beds, of which 341 are for men and 371 for women, with reservations of fifteen beds in each of the two hospital cottages for the sick. The daily average number present during the past year was 731, showing 19 patients present in excess of the accommodations and an encroachment of that number upon the reservation in the hospital cottages.

The pressure for admission has never been so great in the history of the Hospital as during the past two years. This was particularly true in the Department for Men, which was overcrowded even at the beginning of the period and the conditions have steadily grown worse to this time. The demand for room exceeded by far the vacancies created by deaths and discharges, and yielding from time to time to the pressure for the admission of very urgent cases, the reserved beds for the very sick have even been filled, and the classification throughout the department so seriously disordered as to affect to some extent the results of treatment. In the Department for Women nearly all acute cases were admitted without long delay, but during the past year incurable cases could not be received. In the selection of cases for admission from the long waiting list, preference, according to the statute, has been given to the presumably curable. During the first year of the period the applications for admission aggregated 240, of which 121 were for men and 119 for women. Of these 145 were admitted, 16 were accepted for admission and afterwards withdrawn, 5 were rejected as inadmissible and 74 were denied admission for want of room. During the second year the total number of applications was 228-124 for men and 104 for women. Of these 112 were admitted, 13 were accepted and afterwards withdrawn, 1 was rejected as inadmissible, and 102 were denied admission for want of room. The total number of suspended applications during the period was therefore 176. If these are considered in connection with the list of 100 suspended cases at the end of the previous biennial period and make a fair esti