The subject of the Prognosis in Insanity is a most interesting and important one. The prognosis—prospect of recovery or the reverse in any disease—is the one point around which the hopes and fears of our patients and their friends centre, but perhaps this is more true of insanity than any other ill that flesh is heir to; the interests, as a rule, are great and far-reaching. This is at once apparent when we consider that besides the ordinary domestic relationships at stake such as obtain in all other diseases, the liberty of the subject, administration of the patient's affairs and property by legal inquisition while he is yet alive, and the great question of responsibility, social or criminal, add grave importance to the question at issue.

J. C., a mason's wife, æt. 26. First admitted to the Montrose Asylum 6th March, 1855, labouring under acute mania. No special cause alleged, except a feeble constitution inherited from a mother mentally and physically weak. Had been ill for some days before admission. Imagined that God ordered her to mutilate herself. Attempted to pull out her tongue, and on being restrained, she pushed it out of her mouth, and suddenly clenching her teeth, bit a large portion off.

There is a very general impression among members of the medical profession abroad that it is only by the free use of stupifying drugs that British alienists are able to dispense with the use of mechanical appliances in the management of the insane. It cannot be gainsaid that, by the use of toxic remedies, noisy and violent patients may be as effectually controlled for the time being as by any species of mechanical appliance; nor can it be denied that in many of our asylums narcotics and sedatives are employed in such doses, so continuously, arid for such purposes as to justify the appellation of “chemical restraint.” But there are no facts to bear out the assumption that it is by excessive drugging we are enabled to avoid the use of restraining apparatus in our asylums. On the contrary, there is incontrovertible evidence to show that in foreign asylums where mechanical restraint is extensively practised, chemical restraint is likewise employed to an extent not thought of in this country. Dr. Wilbur∗ has been at pains to collect statistics for purposes of comparing the relative extent to which mechanical and chemical restraint is carried in British and American asylums. The result of his investigation clearly shows that in British asylums and in the few American asylums conducted on non-restraint principles, chemical restraint is not the substitute or alternative for mechanical restraint, but that, on the contrary, the general rule seems to be: the more mechanical restraint, the more chemical restraint.

The following two cases of so-called “Rheumatic Insanity” have recently been under observation in Rainhill Asylum, and I am indebted to Dr. Rogers, under whose care the patients were, for permission to publish an account of them.

G. L. was admitted for the second time on the 1st March, 1880, aged 18 years.

In the autumn of last year an epidemic of enteric fever occurred in this asylum. The cases were all on the female side of the old building, from five contiguous wards, having common drainage. The origin was discovered to be a defect in this system of drainage, which has since been rectified.

The high place assigned by Dr. Ringer to atropine as a sedative and hypnotic has lately suggested to me to try it in the cases which are so much relieved by hyoscyamine. My experience has so far been too limited to pronounce definitely on its value; but it may be sufficient to induce other observers with more ample opportunities to give it a trial, and come to some definite conclusion as to its value. I have given it only in three cases: two of chronic mania with considerable violence and destructiveness, and the third of chronic insanity, characterised by vivid terrifying auditory hallucinations, which caused constant screaming and excitement. All three had been previously treated with hyoscyamine, and with the result of greatly quieting them. Two have now been taking the atropine for three months, and one for two months, in doses I shall presently mention, with occasional intermissions to test the action of the remedy. Comparing its action with hyoscyamine, it seems to me that it is less powerful than that alkaloid. The patients are less completely subdued and helpless: there are occasional outbursts of violence and excitement, though by no means so great as when atropine is not taken. Its effects seem to pass off more quickly, so that it needs to be given two or three times in the twenty-four hours. On the other hand, the patients are decidedly in a more natural and healthy condition; there is less stupor, oppression, and heaviness than under hyoscyamine. The pupils need generally not be dilated, but there is often much dryness of throat before the dose is reached, which quiets the patient. I ordered a solution of atropine in glycerine, of the strength of the liquor atropiæ P.B., on account of the risks from evaporation of the officinal preparation. I began with m. ij of this in each case, and have now pushed it in two cases to m x, and in the third to m vj twice a day. One case I treated for a while with belladonna, giving 3j of the tincture; but the atropine seems more uniform and convenient, especially as it can be administered without the patient's knowledge if necessary. I may remark that hyoscyamine is about fifteen times the price of atropine, which would be a matter of some importance in a large practice, if the action of the two drugs is not very different. I regret that I have had no acute case in which the alkaloid might be suitably tried since its use occurred to me. It might be worth trying whether the persistent use of atropine in full doses might not be useful as a curative agent in chronic mania, as it has sometimes been found to cure that cognate neurosis, exophthalmic goitre.

Mrs. T., admitted May 10th, 1852. Age 34; married. An intelligent woman of kindly and somewhat melancholy disposition, active habits, and nervo-bilious temperament. First attack; duration 14 days; assigned cause, religious excitement; was nursing her fifth child. Fancied that her husband and other relations were going to murder her, and were plotting against her, and expressed many delusions of a religious character. Had attempted suicide by precipitation. There was hereditary predisposition to insanity. Her general health was good.

Although Hyoscyamine in some shape or other has been used now for some time, but little is known of its chemical constitution, and one is, therefore, glad to notice that at the Pharmaceutical Conference, held in London, in August, 1881, a communication was read from E. Merck, of Darmstadt, the now famous producer of this drug, on the “Present State of our Knowledge of the Proximate Constituents of Henbane.”

The persistence of auditory hallucinations is generally admitted to be good evidence of an incurable condition among the insane, and I, therefore, think it may be worth putting on record the following case, in which such symptoms were followed by recovery:—

A married woman, æt. 33, was admitted into the Cambs. Asylum in May, 1874, in a state of acute mania. She was raving, violent, and destructive. She was treated with bromide of potassium, digitalis, chloral, &c., for two months, but got no better. She got better at times, but in December was reported as full of mischief, dirty and untidy, and does a little scrubbing at times.

Mrs. N., æt. 40, married, teacher. Admitted to the Fife and Kinross District Asylum on June 9th, 1880.