tirely to some avoidable cause, recurrency can be absolutely prevented. This is a large group of cases consisting of the alcoholic psychoses, morphinism, cocainism, etc.

For the practical and efficient after-care of the insane with a view to the prevention of recurrencies elaborate facilities are required which could be established either as a very liberally endowed private charitable organization or, and perhaps better, by the state, as an After-care Bureau.

Such an organization or Bureau should, for reasons that are sufficiently obvious, be preferably under the directorship of a physician of experience in the care of the insane. For his guidance he should have on file a transcript of the hospital records of every patient that is discharged. Connected with the Bureau should be an employment agency, a visiting agency for the purpose of visiting discharged patients at their homes and facilities for the temporary housing and boarding of recovered patients who are homeless and whom it may be particularly important to keep from returning to their old environment; for reasons of economy, if for no others, it is not prudent for the state to discharge from its care "into his own custody" a homeless bartender, after several months of treatment for alcoholic hallucinosis: his only friends are in the saloon where he was employed, or in some other saloon, and there is hardly anything else left for him to do than to go back to them, and straight to perdition, to have recurrencies and ultimately to become a permanent charge upon the state.

CHAPTER VIII.

THE PRACTICE OF PSYCHIATRY (Concluded).

PROGNOSIS. - PREVALENCE OF MENTAL DISORDERS: IS INSANITY ON THE INCREASE? - PREVENTION. — MEDICO-LEGAL QUESTIONS.

Prognosis. In the early part of the nineteenth century, when the care of the insane had passed from the hands of the clergy, penal authorities, and poor-law officials to those of physicians, the hope was widely entertained that the medical treatment which thus became available for the insane would result in high percentages of cures. Thus, in one of the most important documents in the history of psychiatry in this country, a report under date of March 29, 1834, made to the New York state legislature by a special committee, we read: "It is now satisfactorily established that diseases of the mind yield even more readily to medical treatment than those of the body, and that in at least nine-tenths of the cases of insanity the patient may be restored to the full enjoyment of his mental faculties by the early application of judicious medical treatment." To-day not the most sanguine in the psychiatric branch of the medical profession would make such an assertion. The prognosis of insanity is more correctly indicated by the following analysis of the recovery statistics of the Kings Park State Hospital, at Kings Park, New York, for the year ending September 30, 1915.

214 cases were discharged during the year as "recovered," making the recovery rate, based on direct admissions, 20.78%. Many of these reported recoveries, however, can be regarded as such only from a non-medical point of view; for of these cases 31 were suffering at the time of their discharge from epilepsy, imbecility, constitutional inferiority, or paralysis agitans, having recovered merely from their “insanity," i.e., from acute psychotic manifestations which had led to their commitment; 49 had had one or more previous admissions to institutions for the insane and were evidently recurrent cases without any likelihood of continued mental health in the future; 13 had recovered from alcoholic psychoses but probably not from the habit of intemperance; and 24 had been classed as constitutionally of inferior or defective make-up and had recovered not, of course, from their inferiority or defectiveness but, like the first mentioned group, merely from acute psychotic manifestations which had led to their commitment.

This leaves but 97 cases which can be said to have recovered in the sense of having shown at the time of their discharge a real freedom from demonstrated psychic abnormality. But if the universal past experience is a trustworthy guide, then it is unfortunately but too sure that a certain proportion even of this remnant will prove sooner or later to be of a recurrent nature; so that it is extremely doubtful if complete and permanent recoveries have occurred in more than 5% of all cases admitted.

It should be added here that the experience of the

Kings Park State Hospital is, in this respect, by no means unique; on the contrary, it is but the general experience of psychiatric practice all over the world, as may be judged from the following passage quoted from Kraepelin: "Only a comparatively small percentage of cases are permanently and completely cured in the strictest sense of the word." This statement, we believe, voices the concensus of competent psychiatric opinion.

It would seem from this that radical dealing with the problems of mental disease must be by way of prevention and not treatment.

Prevalence of Mental Disorders: Is Insanity on the Increase? 2 During the past several decades the number of insane in institutions has been increasing at a faster rate than the general population. Thus, according to the United States census statistics there were, in 1880, 81.6 patients in institutions for the insane per hundred thousand of the general population; in 1910 the number had risen to 204.2. To what extent, if any, does this fact indicate an actual increase in the prevalence of insanity in the American population?

There can be no doubt that, at least to some extent, the increase of patients in institutions is due merely to the general improvement in the kind and adequacy of facilities for their care; and if the statistics of various states for any one year are com

1 Kraepelin. Lectures on Clinical Psychiatry. Second edition in English, New York, 1906. P. 2.

2 A. J. Rosanoff. Is Insanity on the Increase? Journ. Amer. Med. Ass'n., July 24, 1915.

pared with one another, marked differences are found, corresponding to stages of progress in social organization, and altogether analogous to those shown by the entire country in years separated by decades.

Thus, for instance, in 1910 there were in the state of Oklahoma 67 patients in institutions per hundred thousand of the general population, while in the state of Massachusetts there were 344.6; and between these extremes all degrees of transition were presented by the statistics of other states.

It is obvious, therefore, that the number of patients in institutions, either in the entire country at different times or in different parts of it at any one time, cannot be taken as a correct measure of the prevalence of insanity among the people.

For this reason, attempts have been repeatedly made to enumerate the total number of insane persons both in and out of institutions in the various states.1 The resulting data were, however, so manifestly untrustworthy that eventually it became apparent that the difficulties inherent in such an undertaking were greater than, for the present, we can cope with successfully, and such attempts have, accordingly, been given up.

Of these difficulties the greatest and, perhaps, the sole insurmountable one is that of formulating such a definition of insanity as to enable enumerators readily and uniformly to distinguish between sane and insane persons, under all conditions.

Furthermore, whoever is familiar with psychiatric

1 U. S. Census from 1850 to 1890.