factor, some of which were not diagnosed as alcoholic insanity, show a steady decrease from 16 per cent in 1911 to 10 per cent in 1915.

If the spread of knowledge in regard to the benefits of temperance in the use of alcohol shows such remarkable results, is it not reasonable to expect an equally good result from the dissemination of views in regard to right living and moral conduct, and from guiding and directing the habits and studies of the young who manifest a tendency toward mental weakness? Mental diseases like all others should be treated in their incipiency if the best results are to be attained. You will, therefore, see what an important place the mental clinic fills. It should be our aim to spread the belief that mental disorders are as curable as any other of the grave diseases, and we should lose no opportunity to impress upon the public mind the necessity of seeking early aid from those in charge of the mental clinics or outdoor departments of the State hospitals.

In 1904 the Massachusetts Board of Insanity instituted an inquiry which showed that 685 physicians of that Commonwealth had treated 2,428 cases of mental diseases during that year and that only 55 per cent were ultimately committed to hospitals for the insane. This was before the "mental clinic" had become an established fact and if it were then possible to care for and cure 45 per cent of mental cases outside of institutions for the insane, is it not reasonable to suppose that a wider knowledge of the preventable causes, accompanied by early dispensary treatment, will result in a far greater number of cures at home?

But when the disease has gone beyond the incipient stage then the best advice the dispensary physician can give is to tell the patient to seek the aid which can only be found in a well-equipped hospital for mental cases. Few private homes can furnish the comforts and safety of a well-equipped hospital and it is only under exceptional circumstances that the home care of a well developed case should be recommended. The majority of cases which can not be cured in

their incipiency will find their way to hospitals designed especially for their care and it is well that it should be so. I would not have you think that I believe that there is any mysterious therapeutical influence" about a hospital for the insane, but I do believe as Sir Clifford Allbut has said that there is more in the medical care of the insane than mere "bottle medicine," and that the established regimen and discipline of a well-managed hospital for the insane "are felt for good by the patient as soon as he comes under their influence. They tend to establish habit and automatism and the annihilation of self. The patient sees everything about him moving with system and regularity, obedient to one will, subservient to established rules. He finds it more comfortable to fall into line and follow, rather than to move in the erratic tracks which fancy dictates, and gradually his delusions and impulses lose control and sane ideas gain the ascendency."

The

Another reason why home care should not be advocated when insanity becomes well-developed, except in exceptional cases, is the fact that occasionally an insane person may so impress his delusions upon another as to produce what is known by the French as folie a deux or folie imposé. When insanity exists in a family it is likely that other members are neurotic and it can be readily seen that it would be unwise to subject such persons to the influence of the insane member. Statistics show that hereditary influences exist in about 30 per cent of first admissions. danger is much greater when the delusions are of a persecutory character and women are much more liable to be affected than men. I would not for a moment have you think that insanity is contagious, for the immunity of doctors and nurses who spend their lives among the insane is sufficient proof that under ordinary circumstances where there is neither hereditary tendency nor neurotic temperament, there is but little danger of being affected by association with the insane. I do know, however, from well marked cases which have come under my observation that there is a certain amount of danger of insanity being

imposed upon others with neurotic tendencies. And in addition the care and worry which the home treatment of a case of insanity entails may be sufficient to break down the physical and mental health of other members of the family.

A large proportion of the cases admitted into hospitals for the insane, in fact not less than 20 per cent are what is known as dementia præcox. These are cases where the mental changes begin in early life, often become chronic and persist until death. In giving early attention to these cases we should also provide for the proper care of the feeble-minded.

As I have told you there are nearly 36,000 cases of insanity under care and treatment in the State, and a conservative estimate of the number of feeble-minded in the State is at least 30,000 and but little more than 5,000 of this number are provided for in institutions. This estimate is probably below the actual facts for where careful investigations have been made, it has always been shown that the number of feeble-minded has been underestimated, and it is just here that dispensary work has a wide field. If the defectives can be recognized in their early years, as they can be by the Binet-Simon tests, and if their future training and education can be directed and regulated so as to bring out the best that is in them, and if they can be segregated when improvement can not be expected, then one of the questions of greatest importance in the prevention of insanity will have been solved. A single generation of effective work in this direction would almost eliminate the problem of caring for the insane.

We all know what has been accomplished in the crusade against the "White Plague" and I believe that the way is now open for the most effective kind of preventive work in connection with the insane.

To point out "the way that madness lies," to show the path that leads to sanity and health, to recognize the backward child and to teach him how to make the most of his limited abilities, to discover latent criminal tendencies in

the young and to suggest a method of treatment which will overcome them before they become fixed, to cheer and encourage the worried and depressed, to correct the habits of those who are burning life's candle at both ends, either by overwork or "the pace that kills," in fact to "minister to the mind diseased" in every possible way is the work that the mental clinic is supposed to do, and it is also the work, that the State is willing and anxious to perform in its "efforts to meet the mentally sick half-way." I, therefore, ask your hearty co-operation in our efforts to perform this work, and I am firm in the belief that as time goes on you will find the clinic a most useful instrument in lessening one of the greatest afflictions that can befall mankind.

SOME CONCEPTIONS OF EPILEPSY

BY DR. C. O. CHENEY,

Assistant Physician, (Pathologist) Manhattan State Hospital.

In any consideration of epilepsy, one is at once met with difficulties regarding the classification and the determination of what should be considered under this term. It does not seem necessary here to go into details regarding the various classifications according to symptomatology or etiology. It appears sufficient to state that instead of speaking of epilepsy in general, the term epilepsies is preferable and that these may be divided into two groups: First, probably the larger group, made up of cases in which there can be detérmined no main etiological factor and termed genuine or unclassified epilepsy rather than idiopathic. Secondly, the group of cases in which there seems to be a main etiological factor may be placed under the heading symptomatic epilepsies with the understanding, however, that probably no one factor is the entire cause in these cases, but that in each case there are certain known causes and other unknown factors which operate together. In this latter group are placed the epilepsies which seem to bear relation to trauma, syphilis, arteriosclerosis, infectious diseases, alcohol, and other conditions. This second group of epilepsies is a large and interesting one but it is our present purpose to consider more especially some conceptions of genuine or unclassified epilepsy.

It is generally conceded that one of the main factors in genuine epilepsy is that of heredity; this has been variously estimated as present in from 8 to 40 per cent of the cases, including not only the direct inheritance of epilepsy, which has been found in a large series of cases to have occurred in 16 per cent but in addition, heredity defects have been considered to be shown in the presence in the ascendants of insanity, alcoholism, syphilis, and even tuberculosis and cancer. It is obviously a very difficult matter to exactly determine the influence of heredity, and there is also an open question as to just what conditions in the ancestors should

FEB.-1917-B