and delivery are concerned, there is much to be learned about their pathogeny. The general disturbance of the sympathetic system during the nine months before delivery is in some women a serious one, and the tax upon the vital powers is very great, so that in women with a predisposition to mental trouble there often occurs a form of aberration of variable degree and continuance. This is due sometimes to uræmia or other forms of blood-poisoning, to variations in the blood-pressure, and to moral causes. Illegitimate pregnancy is, for the last reason, particularly apt to be attended by insanity. The insanities of a puerperal nature, like those incident to prolonged lactation, are due either to septic poisoning, depletion after hemorrhage, or exhaustion. Climacteric insanity is due to the profound process which indicates the commencement of involution. This epoch plays the part, sometimes, of changing existing neuroses, transforming migraine into epilepsy or epilepsy into insanity.

Excessive sexual excitement is likely to enfeeble the central nervous system to an extent which leads to the production of mental impairment, though as a rule nature regulates capacity, and sexual appetite is sated by exhaustion of the spinal centers and fatigue of the normal ideational centers. Of course with unnatural abuses which are suggested by a central condition of existing mental disorder, the individual may goad his wearied sexual apparatus. Those who resort to false means of gratification not unrarely belong to the class of moral perverts, and their vicious appetite is the product of a diseased imagination. In established insanity, especially dementia, the act of masturbation is the direct result of the insanity.

Emotional causes, such as grief, shock, or fright, are alleged to have much to do with the genesis of mental disease. These influences, I think, are often exaggerated, the effect necessary to unbalance the mind depending upon the existence of hereditary influence, or a previously exhausted nervous system which is due to brooding, insomnia, and irregularities. Kirchhoff looks upon psychical influences as important, especially those which are concealed. "Constant gnawing fears, without actual material losses, may lead to the mental break-down. We always find two factors in these causes, viz., the repeated and constant occurrence, and the painful element of feeling. Both together prevent the inhibitory counter-effects of other ideas." Overwork, anxiety without the prospect of affairs getting better, thwarted ambition, and failure, all under certain circumstances act as causes. Disappointment in love and marital discord have, I believe, little to do with insanity, nor has religious concentration, unless there is a degenerative basis.

The feigning of insanity undoubtedly results, in some cases, in the establishment of a real psychosis. I know of two such cases, and there can be no doubt of its easy production in neurotic individuals who are long incarcerated, a laborious effort at deception being made which implies morbid concentration.

The usually curable insanities due to febrile disease are undoubtedly explained by microbic infection or exhaustion. The mental disorder ordinarily follows the febrile condition, and is characterized by a confused train of hallucinations, illusions, and delusions, with moments of apparent lucidity. Suicide is not uncommon.

Injuries to the brain are apt to develop or cause insanities of a more or less constant and progressive nature, though sometimes a blow upon the

head will modify or cure an existing insanity. Affections of the memory from shock are common and of sudden or rapid origin, or an inflammatory condition may be inaugurated which is expressed by the liveliest symptoms, such as illusions, delusions, and violence, which lead to outrageous assaults. A blow may effect, sometimes, a complete transformation in the individual, turning a peaceable, high-minded, honorable man into a lying, brutal thief.

Intracranial disease, the most important etiologically being meningitis, not only effects a blight in development, but gives rise to various psychoses, such as imbecility, epilepsy, katatonic insanity, delusional conditions, and loss of memory, with ultimate dementia. The cutting off of the blood-supply, for example, through an occlusion of one of the middle cerebral arteries, is apt to lead to softening of a considerable cortical area, with dementia as a consequence.

The Course and Termination of Insanity.

The course of insanity is nearly always downward and the proportion of real cures comparatively small. Statistics are apt to give false impressions, as they usually do, and the temptation to make good records has occasionally led the chronicler to amplify the list of recoveries. Earle (Curability of the Insane) cites the instance of one woman who was reported as cured twenty-two times in twelve successive months, although the fact probably was that she had twenty-two paroxysms of mania during this time. This careful observer collated the statistics of twenty American asylums and found the percentage of recoveries for five years to be 29.9, which is a much smaller number than it was during either of two periods of five years that preceded; showing that there was a better system of reporting, or that the means of cure and treatment are more imperfect than in the past, which is improbable, or, what is more likely, that a mistake had been made. He appends another table, which includes the statistics for one year relative to the insane in 58 American asylums of 14,372, 27.88 percent. recovered, and 20.74 percent. died. The prognosis of insanity as a rule, therefore, is not good, and the outlook becomes more unfavorable as the time of improvement is prolonged.

Blandford (Insanity and its Treatment, 3d ed., 1886, p. 249) presents a table showing the history of 244 insane persons who died at or after discharge from the York Retreat from 1796 to 1840, with the number who died during or after recovery from the first or subsequent attacks of mental disease:

These cases were well watched and recorded, and the deductions to be drawn are like those of Earle-neither favorable nor encouraging.

The insane die most often from exhaustion. Sometimes the acute

stage is fatal in a week or two after complete insomnia and refusal of food, although in most cases hypnotics and artificial feeding will keep many of these cases alive. Heart failure is, however, sometimes induced, especially in cases whose real condition has not been appreciated, and who have been kept at home and permitted to exhaust themselves. Sometimes malpractice upon the part of an ignorant physician or nurse will result in the death of a patient from careless feeding. I was called to see a case where the liquid nourishment had been forced through a soft catheter into the trachea, the patient being unconscious at the time. A resulting mechanically produced pneumonia proved fatal in a few days. Death from exhaustion in acute cases may be prolonged after a gradual and unpreventable waste of energy, and such an ending sometimes occurs in acute mania, the brain after death presenting great hyperæmia or sometimes no gross change whatever. Rapid exhaustion, with the development of unsystematized delusions and hallucinations, is a grave indication.

Chronic cases show great vitality, occasionally physical improvement, and a great accumulation of fat occurring after a time without any mental improvement. In fact this condition of affairs is always unfavorable.

Acts of extravagance, so-called impulses of an immoral character, and sexual abuses in a patient with an insane family history are bad signs.

Insanities expressed by periodical attacks have a bad prognosis. Even though the interval of lucidity may be marked it is unsafe after two attacks of mental aberration to make favorable predictions. Other exacerbations are probable, and a termination at some later time in dementia is to be looked for, the intervals usually growing shorter in such cases. If the recovery from an attack of mental derangement be very rapid the indications are that there will be a recurrence. Curable cases of any kind as a rule present a gradual disappearance of symptoms; the patient showing his favorable progress by anticipating the future, making plans, and analyzing his old delusions after explaining them satisfactorily. The general physical condition of the patient improves; his skin becomes moist; sleep returns; and should the patient be a woman, sometimes the menstrual flow is reëstablished. One writer calls attention to the return of former ailments as a coincident indication of commencing recovery. However, a cunning lunatic, seeing in what manner his false ideas impress others whose favor he seeks to obtain, will conceal and disguise his real delusions as far as he can. This often occurs in connection with the desire for liberty. Sometimes he cannot thus dissemble, disclosing another delusion at the same time that he strives to control the one that has gotten him into trouble. He may deny his delusions to one person, but express them to others, or he may verbally disclaim any mental infirmity or false belief while he still shows it in his manner and dress, or in his unconscious actions. A fixed delusion may lead to exhaustion and starvation through refusal of food. The case of a patient occurs to the writer whose delusions were of a religious character. He would not ride on Sunday even to church, and displayed a morbid conscientiousness of an extreme kind. As his symptoms grew worse and insomnia could not be overcome by ordinary means he was sent to an asylum, where his condition did not mend. He still manifested a fear that he might do something to shock the Almighty, and

absolutely refused to sit down. He stood so constantly that his feet and ankles became cedematous and he grew more and more weak, as coupled with this was a refusal to take food. It was finally found necessary to strap him in bed, but despite artificial feeding and enforced rest he failed and died in collapse.

Auditory hallucinations are indications of a more grave form of insanity than visual, and the same is true of sensory and olfactive. In verbigeration or confused speech, the compounding of words attests an involved dissolution. Many forms of chronic insanity are characterized by periods of remission. Recurrent insanity, or folie circulaire, is one of such. In the intervals the patients are apparently so much themselves that they are treated as sane persons. Paretic dementia, or general paralysis, is another affection in which such an apparent return to sanity is found.

Changes in the organic structures of course point to an unfavorable course and ending. This is true of the destruction of the cortex which belongs to paretic dementia, a disease of remarkably rapid progress. With extreme exhaustion due to a continued light grade of excitement we are apt to have an oedema of the brain, with collapse. This is particularly true of anæmic cases. The prognosis of insanities due to epilepsy, meningitis, sunstroke, injury, and syphilis is bad; and when lesions exist and produce progressive paralysis, convulsions, obstinate disorders of motility or ocular disease, we can never take a favorable view of the patient's condition.

The progressive appearance of symptoms in childhood or advanced age is bad. In the latter case an early fatal termination is to be feared, as the powers of resistance are feeble. The insanities of childhood are usually due to hereditary influences; and though the psychoses of puberty when acquired are favorable, the reverse is true where the insane diathesis exists. It is held that "there is a difference, as regards prognosis, between hereditary psychoses whose outbreak is due to late accidental causes, and those in which heredity has produced a morbid development of character in early childhood. If the patient with hereditary taint has been mentally normal until his attack of insanity, the prognosis of the single attack is more favorable than in non-hereditary cases, but there is a greater predisposition to relapses." (Kirchhoff.)

The following table is presented, which is based upon the observations of Krafft-Ebing, Schüle, Spitzka, Kirchhoff, Clouston, Blandford, Savage, Stearns, and my own experience, which indicates the gravity of symptoms alone or associated:

Unfavorable Indications.

Htates characterized by slowly developing
loss of consciousness, indifference, or
hebetude, with staring.
Lass of facial expression; organic flatten-
ng or change in shape of features.
Moral indifference; degeneration shown
by impulsive criminal or destructive
moda, including filthy practices, self-
deftioment protracted indifference, with
twysduntary discharges of contents of
Idolder and rectum.

Pudiendunt apual excitement; manifest

Favorable or not absolutely Bad Indications.
Rapidly developing unconsciousness, ex-
cept in repeated attacks like epilepsy.
Return of harmonious play of facial mus-

cles; quick reflexes of emotional states. Self-defilement in puerperal condition or acute mania not necessarily bad; incontinence in acute conditions compatible with recovery.

rical contraction of pupils.

Verbigeration.

Chronic alcoholism or coarse cerebral dis- Temporary causes, such as the influences

Excitable forms of disease are more hopeful than those in which depression predominates, and while an attack of acute mania may recover in two or three months, one of decided melancholia is at best apt to drag on for a much longer time, or actually end in dementia.

Alcoholic and toxic insanities are recoverable unless the organic changes are profound or there is a transmitted inherent weakness.

The Morbid Anatomy of Insanity.

In all cases the configuration of the brain, its size, and the depth of the gray cortical substance, as well as the signs of recent disease, must be considered. If a small brain has an increased specific gravity which is disproportionate with its size, we shall probably detect the existence of sclerosis and atrophy. It has been found that the weight of this organ undergoes decided modifications in connection with insanity, and Clapham (West Riding Reports, vol. vi., p. 11) presents a table which includes twelve nundred cases of insanity. It would appear, according to this, that the brain-weight is greater in the insane, between the ages of forty and fifty in women and between fifty and sixty in men, than at any other