predisposition in the causation of mental disease, it may be readily inferred that the prognosis of insanity is not commonly altogether favorable. This is especially true if we consider the possibilities of relapses as well as the outcome of the actually existing attack. The number of forms of mental disorder that may occur as episodes in the life of a perfectly normally constituted individual is small, and modern studies are reducing rather than increasing the number. As the simplest form of mental affection, we may count febrile delirium, which occurs many times in the lives of a large proportion of the population. This is a simple exhaustive or toxic disturbance of cortical function, and is, as we all know, transient and slight in its aftereffects. When especially severe, however, it may leave its traces, but then it is hardly to be considered as full-fledged insanity. The patient may have delirious recollections which are as real to him in afterlife as actual recollections, but these are not to be considered as insane delusions. The prognosis, therefore, of simple ordinary delirium, alone, is always good.

When, however, the delirium follows a condition of profound toxemia or exhaustion, such as may occur in puerperal conditions and various febrile disorders, we have a genuine insanity, which, if not accompanied by, or due to, a marked predisposition, may be said to occur in normal individuals. The prognosis of these cases depends largely upon the restoration of their normal physical condition, and if the prospect of this is favorable, the prognosis of the mental disease is also reasonably so. In some cases, however, there is sufficient mental damage produced to make the case a tedious one in its recovery, and recovery sometimes only partial or even impossible.

Sometimes this form of disease may occur after intense overstrain or exhaustion in an otherwise healthy individual, but even then it is so connected

with the physical conditions, to a certain extent, as to depend upon them largely with regard to the prognosis. Certain forms of toxic insanity, also, are usually quickly recovered from, and, provided predisposition is absent, may be considered as recoverable. During the special developmental periods, also, mild forms of neurasthenic aberration may occur and yield readily to treatment, but care should be taken in estimating the future of these cases to consider all degenerative possibilities. The developmental insanities are not by any means those of which a favorable prognosis can be given.

Simple mania and melancholia have long been reckoned as the most curable forms of mental disorder. Of late years, however, there has been a tendency to adopt a slightly different view. According to Professor Kraepelin, mania and melancholia, excepting the latter in the aged, are generally, if not universally, based upon a degenerative taint, and their recurrence is almost inevitable. Their prognosis, therefore, as regards the future life of the individual, accepting these views as correct, can hardly be called a good one. As regards mania in its truest type, separating it from cases of confusional insanity, etc., with which it has been often confounded, there seems to be considerable reason in Professor Kraepelin's views. Melancholia, however, including all the milder forms which exist and hardly come under the observation of alienists, probably includes a certain number of cases that will not correctly fall under this category of degenerative insanities. The point is a new one, comparatively, and further and wider observation will be required before it is universally accepted.

Mania is certainly hopeful as regards the immediate attack; and the more acute the attack, as a rule, the better the prognosis. When periodic or circular insanity of a short period can be excluded, one may

generally give a hopeful opinion as regards the outcome of the attack. Melancholia, in the forms under which it comes in the care of asylum physicians, is also hopeful as regards recovery from the attack, and there is less reason to be discouraged, even after it has existed for a long period, than is the case with most other forms of insanity. Predisposition, of itself, does not necessarily affect the prospects of recovery from the immediate attack, and where there is no predisposition, it must be also borne in mind that the damage done the brain by the attack may conduce to a state of weakness that will favor future attacks. Insanity is least of all a self-protective disease.

When serious organic changes have occurred, and insanity depends upon them, as in the various forms of organic mental disease, the prognosis is necessarily bad. In toxic insanities, where brain damage has ensued, the prognosis naturally depends upon the degree of the latter, and may be favorable or otherwise. In alcoholism and alcoholic insanity, also that due to morphin, cocain, etc., the possibility of predisposition is always to be kept in mind. Certain forms of apparently acute insanity occurring in old age also sometimes undergo a though, as a rule, their outcome is not favorable. In secondary dementia the prognosis is almost universally bad, but there are occasionally surprising recoveries— striking exceptions to the rule. In no case is it absolutely safe to say that recovery is impossible, unless we know that irreparable damage has been done to the mentally functioning portions of the brain.

cure,

CHAPTER VIII.

GENERAL THERAPEUTICS.

THE first question that arises when a case of insanity is diagnosed is where it shall be treated, at home or in a public or private institution for the insane. In cases of acute maniacal excitement this question is usually readily answered, as there are few families that are in condition, financial or otherwise, to care for and have treated amongst them an acute maniac. For the great majority of the people the public institutions for the insane are an inestimable blessing, as they afford the means of caring for those who cannot be cared for by their relatives or treated to advantage by physicians at their homes. Cases of agitated melancholia, also, and generally in cases where there is decided mental or motor excitement the asylum is almost the only resource. To those who have unlimited means and when, through prejudice, family pride, or otherwise, the use of a public or private institution is objected to, home treatment is possible, but under disadvantages. The question of expense is, of course, the first one to be settled, but no amount of expenditure will make it possible to give the patient some of the advantages which can be had in a well-managed hospital for the insane. The mere fact that he is kept amongst his accustomed surroundings is a drawback by itself. The complete change from home life to hospital life, the discipline and routine of the latter, and the moral effect of judicious and kindly control which can be there obtained, are impossible to be provided in the patient's home, where distraction of various kinds, the old habits of authority and responsibility, and

the lack of judgment often shown by relatives and friends, all contribute to hinder and embarrass the treatment. It is also to be considered that when insanity exists in a family it means, to some extent at least, a family taint, and the disadvantages of the detention of an insane person amongst others of various ages and conditions of health, who may themselves be susceptible to mental disorders, cannot, in any case, be considered as altogether advisable. This same family predisposition often displays itself in a sort of unreasonableness that embarrasses the doctor, and prevents him from using the means that are most advantageous to his patient. With the best intentions for their afflicted relative, the family and friends of the patient are often capable of doing him infinite damage by their misdirected interference and sympathy.

In a very large class of cases, however, the question of asylum treatment as opposed to home treatment is a still more difficult one to settle. Among these we may include the milder cases of melancholia, a large proportion of which never go into any public or private institution, but are simply office cases of the family or specialist physician. In the majority of instances of this kind recovery probably occurs, and they are not included in any statistics of insanity. The disorder may be purely emotional, there may be no intellectual aberration whatever, the patient may continue his ordinary occupation without any serious interruption, and, while his depression is noticeable, no one thinks it serious enough to demand his sequestration. It is just these cases, however, that furnish the tragedies that we read of from time to time in the daily press; they are the suicides, or combined suicides and homicides, and it must be remembered that the successful cases probably form only a small proportion of the number of attempts. It is exceedingly difficult in some of these cases to say exactly what is to be done;