in the recoveries from melancholia; that more recoveries occur in the springtime than at other seasons of the year. So far as this is true, it is probably due to the more cheerful and brighter climatic conditions existing at this period, and the greater amount of open air and exercise allowable at this season, when also the oppressive heat of summer has not yet had any deleterious influence. Treatment. The treatment of melancholia varies with the character of the attack, its stages, and the opportunities and facilities of the patient's circumstances. There is probably no form of insanity that is more often the subject of home treatment than this, especially in the milder or slighter forms. A large proportion of these cases, in fact, get well without any treatment whatever except such as the patient can give himself. Some, feeling the need of change of scene, travel, and the effect is good; others deliberately work off their depression in their ordinary daily occupations, or with such diversions as they can devise for themselves. When, however, the disorder has become well established, the patient is comparatively helpless, and generally outside aid is required. An excellent thing for many of these cases would be a sojourn in a sanitarium or similar institution, where, without the name of being inmates of an asylum, they could have the regulated living, the oversight and attendance, and the medical treatment they require. Unfortunately, the expense of such a change of scene and surroundings is to many an insuperable bar to the treatment, and, if it cannot be met, isolation and removal from the ordinary conditions of living are advisable, and this can best be managed at home by the "rest in bed" treatment. It may be difficult to enforce this in the milder cases; but when the patient's melancholia is well developed, there will be good reason for it as a sort of needful restraint; and if the patient is sent to a hospital for the insane, it will be in many cases the best treatment to be adopted there. At the patient's home it has the drawback of requiring close day and night attendance by those who can be fully trusted to be watchful and carry out orders, and these cannot always be obtained. Trained asylum attendants are better for these cases than ordinary trained nurses, in view of the constant watchfulness. required; the latter do not always fully appreciate the necessity of this, and accidents may occur. The first things to attend to in the care of melancholiacs are that they obtain proper nourishment and sleep, and have the constipated condition relieved, and the routine method of the rest in bed treatment attends to all these matters. The patient receives a thorough enema, is given a warm bath, and food is administered; the prone position and the above antecedents favor the giving of food, and it is sometimes possible to make the patients eat or accept their food as given them without resistance. In extreme cases, however, artificial feeding is generally required, and it can be done to the best advantage under these conditions. As the stomach is often or even generally disordered to some extent, it will be well to investigate its condition, if possible, and in many cases warm water lavage, with perhaps some safe disinfectant added, may be advisable. As these patients generally refuse medicine as well as food, both can be given together by the feedingtube when necessary. Food should be given at least. twice a day, and oftener if not contraindicated, if the feeding-tube has to be used, and should consist largely of milk and eggs. The bowels should be carefully attended to, and with the laxatives and enemata some intestinal antiseptic is often useful. Insomnia is combated by warm baths; in some cases also by mild alcoholic stimulation and opium, or other hypnotics. The only specific drug treatment of melancholia that has much testimony in its favor is that with opium in gradually increasing doses, as the patient gains a toleration of the drug. As much as forty or fifty minims of laudanum or other liquid preparation of like strength, three times a day, have been reached in this way as the regular dose. This, in cases suited for it, does not appear to increase constipation, but to have rather the contrary effect, and there is not usually a danger of producing a habit, or difficulty in stopping the drug when required. It is not by any means a specific, however, and in some cases it has a directly opposite effect from that desired. The administration of any drug in melancholia should be kept closely under the charge of the physician, and carefully watched as to its effects. As the case progresses toward recovery, tonics-quinin, iron, and strychnin-are often advis able. CHAPTER XII. THE TOXIC INSANITIES. THE toxic insanities are included here in the general group of the acquired mental disorders, though, like the other members of that group, they may be, and often are, complicated more or less with heredity and degenerative taint. The fact, however, that they may occur de novo in normal individuals is a sufficient reason for their position in the classification. It is said, indeed, by some that alcoholic insanity is a degenerative type, that only degenerates become inebriates; but this opinion has not the support of the general experience and common sense of mankind. It is a common cause and origin of degeneracy, it is true, but it is not necessarily an indication of prior mental weakness any more than is insanity from lead or carbonic acid poisoning, or traumatic insanity. An inherited taint may be a factor in causing a man to become a drunkard, but he can also become one without it. The same is still more true of morphinic mental derangement, and of the toxin insanities, like paresis. The toxic insanities fall readily into two clinical groups: the drug insanities and intoxications, and the toxin forms. The first of these is more distinct in its generally obvious causation; the second is less clear in its origin, and has not been so universally recognized as pertaining to this general class. The whole group is very illustrative of the difficulties of making a perfect etiologic classification of mental diseases, though clinically quite well marked and distinct. The drug insanities are of special interest to the alienist, since here we have a direct visible connection between cause and effect, and one that cannot be as easily established in any other of the morbid psychoses, except, it may be, in the insanities of organic brain disease. While we may admit that in many cases there was a defective original organization, a weakness that succumbed in time of trial and under circumstances in which a normal individual would have resisted, yet we can see and know that the insanity was the direct and immediate result of the intoxication. These insanities, moreover, have their distinct clinical characteristics that appear only with these agents acting as the cause. ALCOHOLIC INSANITY. The effects of alcohol on the brain and central nervous system generally are matters of too common observation. We all know the symptoms of ordinary intoxication, but we are not always awake to the fact that even small amounts, well within the limits of that which it is claimed can be economically consumed in the body, have a decided, though not directly apparent, deleterious effect upon the function of the nervous system. Aschaffenberg's experiments upon the working capacity of type-setters with and without the ingestion of small amounts of alcohol demonstrate this fact. The action of alcohol being thus primarily on the nerve elements, it is the more easy to perceive the injurious effects of its long-continued or excessive use. Any marked cerebral intoxication produced by alcoholic excess is really a temporary insanity, but its brief duration puts it out of the category here considered. It is only when the alcoholic indulgence, either by its excess or individual idiosyncrasy, produces still more marked symptoms of mental aberration that we speak of acute alcoholic insanity, and only when its prolonged usage has given rise to permanent changes |