to follow. The management of these cases should be with a firm yet gentle hand.

One thing should be remembered in the treatment of every form and case of insanity; that is, to look out sharply and constantly for any symptoms of change. The insane are characteristically unreliable, and even the most harmless cases may sometimes develop dangerous or unfortunate tendencies. On the other hand, even in the most hopeless appearing cases, a change for the better may sometimes occur, and if promptly taken advantage of may end in at least a partial recovery. Cases are constantly reported in the journals of recoveries from chronic insanity of five, ten, or even twenty years' duration. While these are rare, they should not be forgotten, and no case, where there is not irreparable and demonstrable organic disease, fatally affecting the mental functions of the brain, should be considered as absolutely hopeless. Even paresis, which is considered as perhaps the most hopeless form of mental disorder, and the most inevitably fatal within a few years, may undergo long remissions, some of which can hardly be separated from actual recoveries.

CHAPTER IX.

CLASSIFICATION.

SOME Sort of classification of the different forms of insanity is a necessary prelude to their description. It has been customary of late years to disparage classifications of mental diseases, and to say that the simplest and briefest is the best. This fact is due largely to the difficulty of making any uniform systematic arrangement that is accepted by or acceptable to all who have written on the subject. Almost every author of a work on insanity has promulgated his own classification, differing more or less widely from that of all others. The result has been to discredit, in a measure, all such attempts. It is nevertheless the fact that some sort of systematic classification is absolutely necessary, and it cannot be up to the needs of our knowledge of disorders of the mind and merely include the simple symptomatic forms that were alone represented in the earlier classifications.

A classification of insanity falls usually and naturally into one of three groups: the symptomatic, the pathologic, and the etiologic. We might add, also, the psychologic, of which a few examples have been given in times past. The most natural and readily made classification is the symptomatic, and the earlier ones were nearly all of this type. It is easier to see the obvious distinction based on symptoms than to attempt to divide all the forms of mental disorders according to any supposed pathologic condition. We say supposed, for our knowledge of the pathology of insanity is yet too little advanced to enable us to carry even the simplest classification entirely on this one standard.

The pathologic classifications which have been attempted are therefore unsatisfactory, because they are based on imperfect knowledge, and their inconsistencies are too obvious to render them acceptable. An etiologic classification is simple enough, but that is about all that can be said in its favor, and it necessarily fails where the history of the case is lacking. There is a certain relation often between the cause and the form of the disease, but this is not constant, and the exceptions are too numerous to permit any positive general rules. One has, also, in following this plan, to include under the same head the most widely differing symptomatic forms, a course which is too unnatural to be desirable, in spite of the convenience of referring each case to a species based upon its alleged or presumed causation.

Most classifications of insanity which have been made are therefore composite productions, based on no one simple plan. They are partly etiologic, largely symptomatic, and, where possible, pathologic, in their general idea or conception. Occasionally we have one that follows the psychologic plan, like the following of Ziehen. It will be seen that here we have a rather consistent system, based upon the mental states alone:

CLASSIFICATION OF TH. ZIEHEN.

1. Psychoses without intelligence defect.

A. Simple psychoses: only one chief phase.

1. Affective psychoses: chief symptoms in the emotional sphere.

(a) Mania.

(b) Melancholia.

(c) Neurasthenia.

2. Intellectual psychoses: chief symptoms in the region of the intellect.

(a) Stupidity.

(b) Paranoia.

(a) Paranoia simplex.

(b) Paranoia hallucinatoria.

(c) Delirious (Ideenfluechtige) form.

(d) Stuporous form.

(e) Incoherent form.

(c) Insanity of fixed ideas.

B. Combined psychoses, with several phases.

2. Defect psychoses.

A. Congenital mental weakness.

(a) Idiocy.

(b) Imbecility.

(c) Debility.

B. Acquired mental weakness or dementia.

(a) Dementia paralytica.

(b) Senile dementia.

(c) Secondary dementia after functional psychoses.

(d) Secondary dementia with local brain disease (syphilis cerebri, etc.). (e) Epileptic dementia.

(f) Alcoholic dementia.

This is the most recent classification proposed on a purely psychologic basis. It has the advantage of being symptomatic as well, and is probably as good a type of a special systematic arrangement based mainly or entirely on mental symptoms as has been proposed. It also is consistent throughout, and not mixed, partly pathologic, partly symptomatic.

Another German classification of very recent date, and one that has some special features of interest,for example, the inclusion of the usually considered primary insanities, mania and melancholia, in the degenerative periodic forms,-is that of Kraepelin. It has, as will be seen, a sort of pathologico-etiologic basis, one which seems likely to come into favor as probably the best available basis with our present knowledge of the actual underlying conditions of mental disease.

CLASSIFICATION OF KRAEPELIN (1897).

A. Acquired insanities.

I. Exhaustive conditions.

a. Collapse delirium.

b. Acute confusional insanity (Verwirrheit).

c. Acute dementia.

d. Acute nervous exhaustion.

II. The intoxications (toxic insanities).

1. Acute intoxications.

a. Febrile delirium.

b. Intoxication delirium.

2. Chronic intoxications.

a. Alcoholism.

b. Morphinism.

c. Cocainism.

III. Metabolic insanities (autotoxic).

a. Myxedematous insanity.
b. Cretinism.

c. The dementia-producing types.

1. Dementia præcox.

2. Catatonia.

3. Dementia paranoides.

4. Dementia paralytica.

IV. Insanities from organic cerebral disease.

V. Insanities of old age.

a. Melancholia.

b. Senile dementia.

B. Insanities from morbid predisposition (degenerative).
I. Constitutional insanities.

a. Periodic insanity.

1. Maniacal form.

2. Circular form.
3. Depressive form.

b. Paranoia.

1. Combined forms.

2. Hallucinatory forms.

II. The general neuroses.

a. Epileptic insanity.

b. Hysteric insanity.

c. Shock neuroses.

III. The psychopathic conditions.

a. Constitutional" Verstimmung " (insane diathesis, psychic neurasthenia).

b. "Zwangsirrsein" (phobias, obsessions, etc.).

c. Impulsive insanity (morbid impulses, etc.).

d. Contrary sexual feeling.

IV. The defects of development.

a. Imbecility.

b. Idiocy.

NOTE.-In Kraepelin's later edition (1899) there have been some slight changes in this classification.

The more recent French classifications, those of Regis (1892) and Dagonet (1894), are quite different from the above, and are based on a different principle. That of Regis, which is, in its way, the more philosophic and consistent of the two, divides mental