melancholia associated with fears and indecision that may be almost considered as a variety of the genuine form, so far as its more obvious manifestations are concerned. These patients, however, are less self-accusatory, less positive in their self-condemnation; they may worry over the unpardonable sins they fear they have committed, but are not so convinced of the fact as is the case with the genuine melancholiac, and they do not have the continuous distress of the latter; they strive against their feelings, their ideas do not have the character of actual delusions, and the symptoms of refusal of food and wilful suicidal intention and desire to die are not characteristic. There are undoubtedly many cases, however, that have been classed as melancholiacs, and if there is any type of true insanity that their condition may most readily pass into, it is likely to be this. Certain cases of incipient paresis may also cause confusion for a time, especially the depressed and hypochondriacal cases and those in whom a kleptomania is one of the earliest symptoms. Sooner or later, if not at once, however, the characteristic physical and mental symptoms of paresis will remove all doubts as to the true nature of the case.

When marked degenerative stigmata exist, they will aid in the diagnosis to some extent, but they are also equally liable to be present in many other conditions, such as hysteria, imbecility, original paranoia, etc., which may possibly in some cases be complicated with obsessions. Hysteria itself is a sort of borderland, but it has its special stigmata and characteristics. The so-called traumatic neuroses are often mentioned in this connection, but are best treated of in special works on neurasthenia. There is an occasionally litigious psychosis connected with railroad traumatism that is a genuine mental aberration in degenerative individuals. In kleptomania and sexual perversions it may also be difficult to exclude criminality, and in

many other cases the diagnosis of neurasthenic obsessional conditions may have a forensic importance, as crimes may be committed in them and the question of criminal responsibility arise. In non-degenerative cases or those where the physical stigmata are few it may be difficult to establish irresponsibility, but it is well to keep in mind the fact that it may exist. The whole history and all the facts of the case require to be learned and studied in such cases with especial care.

The prognosis of neurasthenic obsessions and of all the borderland states we have been considering depends in each case on the amount of original defect. No one would say that the slight obsessions experienced by nearly every individual have any dangerous significance, and yet in conditions of ill health or with other nerveexhausting factors they may be greatly intensified even in the normally constituted. There are many individuals who cannot trust themselves to look down from a height and yet who are in other respects perfectly sound and sane. Among such individuals may be reckoned, on their own testimony, Verga, the distinguished Italian alienist, and Beard, the first to fully describe the symptoms of neurasthenia. We have seen very striking instances of obsessions of indecision and of aboulias where the symptoms disappeared completely and, so far as observed, permanently. In probably the majority of cases, however, there is an original nervous weakness, and on the amount of this defect the prognosis depends. With a very marked degenerative taint it is bad as to recovery, and the condition may even pass finally into some form of insanity-true melancholia or some phase of paranoic delusion.

The treatment of these conditions is that of neurasthenia, and sometimes will simply tax the skill and tact of the physician. Change of scene or occupation in some cases will be sufficient, but travel is not often

advisable. Rest, eliminants, tonics, such as iron, strychnin, etc., and in some cases sedatives, like the bromids, cautiously used, are all of service in appropriate cases. Some patients react well to cold morning sponge tub-baths, others are better for warm baths at night. General faradization, and static electricity in some of the forms of its application, have been highly recommended by some and may sometimes be serviceable. Hypnotism, though it has its advocates, is not to be generally advised; it is of dubious advantage and may do harm. One or two German authors have made much of it, often in an objectionable way, in the treatment of sexual perversion, but we cannot indorse their methods. In very degenerate cases a cure is not to be looked for; all that can be expected is temporary relief or palliation. a certain class of neurasthenic cases isolation, with special feeding, massage, etc., the Weir Mitchell rest cure, may be advisable. One thing must be especially remembered in these cases: that every fact bearing on the condition, every variation in general health, every possible collateral or direct cause, should be searched for and studied for therapeutic indications.

In

CHAPTER XXII.

TERMINAL DEMENTIA.

THE great mass of the inmates of our asylums are cases of terminal stages of mental disease. We have already noticed in connection with the different forms of insanity the general symptoms of the secondary conditions that follow them. While it is often the case that the original condition implants its type to a greater or less extent upon the terminal condition, this is not by any means the universal rule. All forms of insanity of many years' duration, with the exception possibly of certain types of delusional derangement, fall under the general head of terminal dementia. The impaired mental action or dementia is characteristic of them all in varying degrees. In the very large proportion of cases it is the one prominent feature, and varies in its degree from a mild general defect to a completely vegetative condition, where the patient can only follow a certain simple routine requiring the least possible degree of intellection. In the milder form the mental action, though limited, is sufficient to make the patient a useful member of the society in which he finds himself if he is only subjected to the proper control and to judicious general management. These patients do well in asylums, and can do much to make themselves useful; outside of such institutions they are, as a rule, incapable of taking care of themselves. Their condition is, in fact, a more advanced degree of what we have already described as recovery with defect. Sometimes they have a certain tendency to excitement, and are usually classed as

chronic maniacs. In other cases depression is the ruling feature, and they are usually called chronic melancholiacs. Delusions may be present and very marked, likewise hallucinations and illusions, and some of these cases fall under what is called secondary paranoia; and in still other cases mental confusion is marked. In fact, the symptoms are infinitely varied, so that all of these types and some others may be counted in the permanent population of any large institution. The bodily health in these cases may be reasonably good; they are able to work and often are extremely willing and useful; others, again, are absolutely helpless, and their general condition requires the constant attention of the physician, not so much to treat actual illness as to oversee and prevent a general, more rapid decay that would follow from their lack of attention to all the ordinary rules of healthful living. As a rule, the chances of life of these patients are far less than those of the average normal individual. They break down readily in disease and are especially subject to accidental ailments, lung trouble, etc. The average

mortality of an asylum which is made up of this class is therefore higher than that of communities in any condition except the most unsanitary. In a wellregulated institution the death-rate can not well be kept under 6 or 7%, and while this higher rate is largely due to deaths in acute insanity, these chronic insane furnish far more than their share as estimated by the usual ratio of deaths in the general community. Outside of asylums and poorhouses these chronic cases are sometimes found, and with kindly and judicious friends they manage to live a comparatively comfortable existence. These cases, however, are exceptional, but the facts of family care of the insane as shown in Belgian and Scotch communities demonstrate how practicable this method of controlling them may be found. It has, however, its disadvantages, and re