The burden of

been discussed at great length for many years. caring for these cases as if they were sick has more recently been recognized as the better policy; for the cure of any case, or its improvement (without complete cure) to a degree that will relieve the public of its care, is a distinct gain, aside from the humane and prevailing desire to relieve the afflicted.

What has the modern institution gained over the former methods in detention houses? It has (1) organized complete medical staffs, made up of experienced men who have devoted their lives to this work, and whose opinions upon insanity constitute our present authority. (2) It has obtained hygienic conditions in location, construction, and equipment in the fullest degree. (3) It has regulated dietaries and attire to suit the needs of the individual. (4) There are now provided nurses trained in the particular care of mental cases, who recognize insanity as a symptom of disease, instead of a demoniacal possession, to be exorcised by discipline. (5) It has provided objective diversion, in order to make use of psychic influence toward relief. (6) It has brought to bear upon all cases the modern light of science, and has given to all the benefit of the latest therapeutical measures. (7) Finally, the care of the insane is now recognized as a sacred public trust, and humanity has displaced the safety of the community as a motive. Either the insane, who constitute the most helpless and wretched of suffering humanity, must have proper care and receive the benefit of all available relief measures, or the hopeless must pass to lethal euthanasia. No middle course will be tolerated in this progressive epoch, and the demagogue's appeal to the burdened tax-payer will not be heeded.

The State of New York has given an example of providing institutions for all its dependent insane, and maintaining them scientifically and rationally under a system that should insure uniformly good results. Its fundamental principle is the cure and amelioration of the insane, and this rests mainly upon establishing a high grade of physical health in its patients. The best methods of securing it are a constant study, but no absolutely necessary element is eliminated on account of cost. Much may be acquired in simple and economical ways. Thus graded and properly applied, occupation of a useful character has been recognized as a means of controlling and regulating muscular action as well as mentalization, and as a body developer. The principles of physical development by exercise, temperature, and circulatory

regulation, are among the most important therapeutical measures. The recognition of the body forces as a material background for the mind, upon which it depends and with which it oscillates up and down the scale, from its individual standard of excellence to degradation, has done much to modify our treatment of mental disorders. With inherited mind instability much can be done to increase resistance, by physical development and maintaining uniformly an excellent standard of bodily health. Or, even in those cases of mental decay where the tissue changes are destructive and irreparable, great improvement is affected by body development. The arrest of destructive changes and the prevention of dementia - in other words, circumscribing the pathological processes by physical development and maintaining the highest standard of bodily health are among the more important functions of an institution.

A better knowledge of consciousness, its nature and its dependence upon the lower nerve centres, is aiding the treatment of the insane. In connection also with the insane hospitals of New York there is established an institute of research into the nature and causes of insanity. Past experience teaches us that individual effort in this direction has effected but little, and therefore New York has set an example of co-operation which promises good results.

The most encouraging results have accrued from the treatment of the individual, and not by classification. The old medical saw that "there are no two cases alike" is truly adapted to the insane. The teachers of mental medicine now recognize the greater importance of individual symptoms, and emphasize less the necessity of placing every insane person in a fixed classification. Special organs receive the attention of specialists. Our hospitals have ophthalmologists, odontologists, gynecologists, and surgeons on the staff. Bodily irritation of any kind, as a possible cause of the mind trouble, is treated, and frequently, if not usually, with good results.

We are constantly attempting to repair the damage wrought by the over-straining forces of modern civilization. The complex human organism is treated with less regard than a machine; and the insane hospital is the ultimate dumping-ground, when the mainspring is broken. It is true that in these great repair shops we have not yet been able to reach the finer mechanism directly, in a material way; but, indirectly, we endeavor to reach the highest grade of physical health.

BY W. P. SPRATLING, M.D., SUPERINTENDENT OF THE CRAIG COLONY, SONYEA, N.Y.

[Read Wednesday morning.]

I am honored by the invitation of the Chairman of the Department of Health of this Association to take part in discussing the importance of a high grade of physical health in the effort to cure, develop, or reform the dependent and delinquent classes cared for in public institutions.

It is a most timely topic,-timely for the reason that the day of simple, indiscriminate custodial care for such classes is rapidly becoming a forgotten practice, and for the added reason that the greater economy lies in curing or reforming such classes as against giving them custodial care to be perpetuated through the entire lifetime of the dependent individual.

Statistics recently came under my observation of a French family of dependents, where the initial fault lay in the mother four generations back, and whose progeny was so numerous and defective through the four succeeding generations that their care imposed upon the French government an outlay of one and a quarter million of dollars.

But the money value of such care cannot be compared to the distress and suffering that followed this family and its immediate connections through four generations. The public charities of this country, and particularly of the great Commonwealth of New York, have grown to fairly astounding proportions; and some of the millions of dollars that are being spent annually do not go into the channel the current of which flows to cure, development, and reform, but leads into the stagnant waters of simple custodial care, pregnant with the inaction of routine practices and fruitless of beneficent results.

In this State and elsewhere there are notable exceptions to this, but they only serve to accentuate the too widely prevalent policies that varying circumstances compel in caring for the dependent

and delinquent classes. Sometimes it is politics; at other times, a lack of money; or, again, it may be laid at the door of a cause just as disastrous as either of the above, namely, inaction.

My province in this discussion has to do with the epileptic; and whatever may be said hereafter in this paper on the subject of sound health, how to attain it, and its value to the dependent classes, will be in its application to the epileptic. And my remarks will be under two heads: the one theoretical, or what it is possible to do; the other practical, or what has been done.

These will be prefaced by a brief description of the disease from which the epileptic suffers. "A sound mind in a sound body" is an adage so old and so commonly used that we do not stop to consider the wealth of its meaning. Yet the sum total of the entire complex problem we are called on to consider lies wholly within its meaning. If the entire human organism is sound in all its parts; if that soundness extends to and includes the nucleus of every cell and protoplasmic mass and to the outermost ramifications of every nerve fibre,- there can be but one condition of the body as a whole; and that will be one of perfect physiologic health and soundness. But such a condition would be an anomaly, it would be so rare.

Epilepsy was described by Hippocrates thirty centuries ago, and from that day to this its treatment has been as persistent as ambition could make it, and as varied as the resources of the Materia Medica, combined with the art and skill of the physician and surgeon, could devise.

Epilepsy is generally described as being a paroxysmal affection, characterized by convulsive movements and followed by loss of consciousness. The latter may or may not be true, since we know that certain types of seizures do occur without loss of consciousness. The attacks may be foreshadowed by a warning or they may come without warning. The convulsive movements vary in degree from the most delicate twitching of the finer muscles about the mouth to convulsive shocks so universal and violent as to throw the patient forcibly to the ground. They may occur as often as every three minutes or less apart, or they may be separated by intervals of months or even years.

The mental and physical deterioration that epileptics are so prone to suffer from differ widely in degree, and depend originally upon the physical and mental stamina of the individual, and later on the frequency and severity of the seizures.

It is largely a disease of childhood and early life, since 70 per cent. of all cases begin under the age of twenty years; and this is an important fact to remember when we come to study its

treatment.

The causes that produce it are legion, but the etiological factor of greatest importance is heredity, 35 and 37 per cent. of all cases in males and females, respectively, being ascribed to that cause.

After heredity comes a long list of causes as numerous as are the varieties of the disease itself, but which may be stated in the concrete to include the specific and non-specific diseases of a general nature and their sequelæ, the various forms of auto-intoxicants, the numerous excesses, shock, fright, and causes removable through surgical procedures.

Referring again to the factors in heredity, the so-called stigmata of degeneration must be mentioned. They include asymmetry of the face and cranium, protruding teeth, malformed ears, and various deformities of the hard palate.

To what extent these influences are responsible for the production of epilepsy, I do not know; but it is my belief that, if they mean anything at all, it must be that they stand as part evidence of the fact that the structural organization of the individual, as compared with the normal standard, is incomplete. And, since it is incomplete, in this respect we have some warrant for assuming that some omission has been made from the integral structure of the central nervous system of the individual at fault.

Out of one hundred and forty-five cases studied at the Craig Colony, including both sexes and all ages from eight to seventy years, and among whom, individually, the disease had existed for from one to forty years, one hundred and thirty-one of them presented evidences of the stigmata of degeneration. And in the treatment of the epileptic, in trying to give him a higher grade of physical health as a preface to curing his disease, we must constantly recognize the presence of congenital deficiencies, and not vainly strive to supply what nature originally omitted. Among those, then, of the public dependents who demand a high grade of physical health as a prerequisite to the cure of their disease, the epileptic stands in the foremost rank.

Not only does it too often happen that congenital deficiencies handicap the possibility of his recovery, but the very nature of his malady is such as to rob him of whatever mental and physical stamina he may possess. And this will seem all the more strange