recoveries on admissions. At the present time the tendency is rather the other way amongst alienists, and they are cautious in reporting recoveries, so that the actual percentage is being reduced in many tables to a still lower figure than the one first mentioned.

The forms of insanity that may end in recovery, and in which we may even say it is to be expected, under favorable conditions, are the acute, toxic, and exhaustional conditions and the post-febrile insanities. Simple melancholia of the milder type, and mania, are also usually reckoned as hopeful forms of insanity. The fact, however, that simple mania, as Kraepelin has pointed out, is generally a degenerative psychosis, and that relapses or recurrences are almost inevitable, modifies the prognosis somewhat in these cases, and makes it a question whether we should consider them to be generally amongst the recoverable forms. The same is true, also, to some extent, of melancholia when it is not a disease of evolution or connected with the retrogressive changes of life. Many cases of melancholia, however, occur outside of institutions that are never recorded or properly observed, and it is difficult to get statistics as to the recurrence of the disorder in such cases. As regards mania, distinguishing it clearly from confusional and other forms that are sometimes included under this head, the case is somewhat different. In an analysis of 65 cases, Van Erp Tallman Kip found that there were only 4 in which it could be certainly said there had occurred only a single attack of mania, and he concludes that the tendency to recurrence should be considered the most important clinical feature of this special type of insanity. As already stated, however, it is hardly fair to consider insanity as continuing over a perfect intermission that may last for ten or fifteen years, or more, as happens in some of these cases. An attack of mania lasting only a few weeks might be considered as a recover

able form of insanity, when it does not recur within a reasonable period of years.

Recovery usually takes place gradually. There are short remissions or intermissions; the patient gradually quiets down from his excitement, takes more natural and rational views of his surroundings, and finally is apparently restored to his normal self. During this period, however, there may be days in which the recurrence of the old symptoms, to a greater or less extent, is manifested, and it sometimes happens that an apparently complete recovery is followed by a quick relapse for a shorter or longer period. In some cases recovery is rapid; the patient comes almost instantaneously out of his frenzied condition, and is rational and quiet. In some cases, also, the relief of symptoms of insomnia and of constipation produces a very rapid and, as it were, instantaneous cure. The writer has seen a case which for months had been suicidal, depressed, and inactive, requiring artificial alimentation, and close attention in every way, apparently make a rapid recovery after a free injection which relieved an overloaded bowel. From being bed-ridden, almost helpless, acutely depressed and suicidal, and apparently without strength enough to attend to his natural wants, he immediately after the relief got up and dressed himself, made his escape in spite of long search, and the next thing was a perfectly rational letter received from him stating that he was well and asking that his clothes be sent home. The recovery was apparently complete, and, as far as observed, permanent. It is not uncommon in asylums to have cases brought there in a wildly maniacal condition who, after a warm bath and a good night's sleep secured by medication, together with relief of the constipation existing, have made an almost immediate recovery, which certainly persisted for a considerable length of time.

When recovery is sudden, without any special cause,

there is a suspicion, at least, of a degenerative predisposition, and the liability of recurrence must be kept in mind. In cases attended with severe bodily illness, such as in the post-febrile cases, recovery sometimes takes place directly in accordance with the physical improvement. In toxic cases the relief of the system from the toxic product is also sometimes attended with rapid recovery, and this is true, not only in such forms as the delirium from intoxicants like alcohol and other drugs, but also with the slower forms of mental disorder which persist after the system has apparently recovered from the immediate effects of the poison. In other cases, however, and perhaps these are the majority, the improvement is slow, the damage to the nervous system being such as to prevent or render difficult its repair and full restoration of function.

We can say a patient has completely recovered when he shows absolutely no change from his normal self after the subsidence of the attack. Such patients, as a rule, appreciate very fully their condition, and are grateful for the care and control that they have received. This gratitude, however, is not an especially important indication of recovery, as it may occur equally marked in the intermissions of periodic insanity, or in cases where there is a very pronounced mental defect remaining. In fact, the patients in a larger proportion than is generally supposed have more or less consciousness of their condition, even during the acme of the attack of insanity. As was remarked, also, in speaking of delusions, there may remain perverted recollections of events that happened during their disorder, together with a generally complete restoration to mental health.

It must be remembered, also, that in certain forms of insanity, notably in the paranoiac, and in melancholiac sometimes, there may be a wilful suppression of the symptoms, with the idea of creating the impression that recovery has taken place.

Partial Recovery with Defect. It may be a question whether an acute attack of mental disorder does not invariably leave some traces on the organization, but these are sometimes so slight that they may be practically neglected. In a very large proportion of cases, however, recovery is only partial; the patient, while well enough to be discharged from care, is recognized by friends and every one who observes as not being exactly the same individual as before, and this defect may range from a mild general dementia up to merely a slight trace of mental abnormality. The question often arises in hospitals for the insane, whether a patient is to be considered as a case of chronic secondary dementia, and retained, or discharged as fit to take his part, under favorable conditions, in the general population. Hence we have a large list of cases in their published tables that are described "much improved," or "improved." These are patients who are supposed to no longer require hospital attention, but who are not considered as fully recovered. Sometimes the improvement continues after they are discharged until they are very little below their normal condition mentally. More often, however, they continue to show more or less traces of their disorder, and it is very important in such cases that the home conditions and surroundings should be such as not to aggravate their mental irritability, or to claim too much in the way of work or responsibility. They are still, to some extent, weaklings, and should be considered as such.

Passage to the Chronic Condition. The difference between this termination and that of the last described form of acute mental disease is not a very definite one. In fact, many of the cases counted as partially recovered may also be considered as examples of mild chronic general mental impairment. In other cases, however, the disease passes over to the chronic

condition with only a slight abatement of its symptoms. The patients are still wildly disturbed, demented, or deluded. It is a bad sign in a case of acute insanity when marked physical improvement begins to appear without correspondent betterment in the mental condition. A very large proportion of asylum inmates have begun as acute cases, but instead of passing to recovery, they have relapsed or fallen into a chronic condition. As a rule, there is a modification of their symptoms from those of the acute stage. They are less pronounced; the patient is less wild; the bodily functions are more naturally carried on, but over the whole symptom-complex there is a peculiar change that marks its chronicity. The pronounced element of dementia is perhaps the most common type of this. This varies, of course, according to the mental constitution of the individual and the nature of the insanity. Some are agitated and maniacal; others depressed; others decidedly deluded, while others simply seem to show very pronounced mental weakness.

Death.-Death is a frequent termination of acute insanity. Of course, it is the final termination in nearly every case of chronic mental disease. The ratio of mortality in the best regulated asylums is hardly less than 7%, even under favorable conditions, which is about four times as great as should exist in wellregulated municipalities of the ordinary population. If, however, we take out certain forms of insanity, such as paresis and organic dementia, we have the ratio somewhat reduced. In any case, however, it will decidedly exceed that amongst the general population. The death-rate in asylums is less than that of the insane outside of these institutions, excluding the slight cases of melancholia and certain chronic degenerative forms that are largely permitted to be free from restraint. In acute insanity death may occur from various causes. In exhaustive conditions the patient may wear himself