Many establishments possess the advantage of a good position, the opportunities they afford for excursions, for enjoying the pleasures of nature and indulging in sports and harmless games. Work-cures, to which I have already called attention, are best carried out in institutes. But one point on which special weight must be laid, and to which attention has already been drawn, is that a doctor is better able to bring his personal influence into play inside an institute than out. The discipline that so many patients require can be best exerted by a conscientious and energetic hospital doctor. Every one, even the rich and pampered, should submit to it. It is just this compulsory subjection that proves beneficial in so many cases.

It is certainly easy to understand that every institute is not suitable for the purposes mentioned above, especially when we come to consider that the personal influence of the doctor is greater the smaller the establishment. All large institutions conducted on the lines of an hotel must therefore be rigidly excluded when it is intended that such personal influence of the medical director is to play the chief part in the treatment. In the same way, when rest is essential for the patient we must be careful not to select one of those badly-planned establishments in which the position of the rooms is calculated to endanger the patient's peace and quiet. Unfortunately, in many establishments the thoughtlessness of the servants and the constant din of music frequently disturb the patient's rest at night It should be the duty of every doctor to avoid recommending any establishment in which a patient is likely to be annoyed and disturbed. This does not imply that large establishments are not without their advantages, especially for patients who are more in need of the stimulus of social intercourse than of the personal influence of the doctor. But even in such cases an establishment should be selected that is built and conducted in a way calculated to save the patient from any kind of annoyance.

As Edinger has rightly pointed out, many a one is more benefited by a trip to the hills than by the treatment he was advised to undergo in an establishment. In the latter form of treatment special care must be taken to give prominence to the psycho-therapeutic moment. Patients who enter an institute in the hope of obtaining rest, only to find that the whole day is occupied in exhausting hydropathic treatment, massage, etc., may easily be seriously injured by such processes. In any case, even where somatic treatment is concerned, the importance of mental influence should never be overlooked.

The psycho-therapeutic effect of treatment in an institute may often be considerably increased by strictly isolating the patient. That can hardly ever be done outside. Attempts to isolate a patient in his own home scarcely ever succeed. Even when the patient's relatives promise to do so, the doctor may assume with a degree of probability bordering on certainty that there will be no really strict isolation, and that either the curiosity or anxiety of the relatives, or else their desire to prevent the patient becoming ennuyem will soon lead to his instructions being evaded. The good effect of solitary treatment, especially in cases of hysteria, has long been known. Charcot was a particularly warm advocate of the method, and he was quite right in considering isolation the working principle in the Weir-Mitchell treatment. When discussing that system Charcot called attention to the interesting historical fact that Weir had already recommended isolation for the treatment of demoniacal obsession. From the psycho-therapeutic standpoint isolation may be just as necessary for preventing unfavourable influences being brought to bear on a patient as it sometimes is from the standpoint of somato-therapeutics for safeguarding a patient from the acquisition of noxious drugs - morphia, for instance.

Of course, strict isolation is only possible in relatively speaking few cases. It also presents certain dangers: the possibility of a patient devoting too much attention to his morbid fancies calls for special consideration in cases of hysteria. But then there are contra-indications in every form of therapeusis, and they have also to be thought of in the case of treatment in an institute. It is rarely possible for a doctor entirely to prevent patients discussing their maladies, no matter how firmly he forbids it, and we can understand how injurious such conversation is to very impressionable people. How great these dangers really are is proved by the fact that when I was in Paris I often heard the Salpetriere referred to as a Fabrique d'hysterie, notwithstanding the authority exercised there by Charcot. We must therefore be most cautious before placing an impressionable girl in an institution where she is likely to get into conversation with hystericals, victims of fear, etc. Morphinomaniacs may also be dangerous companions, and I know of patients who, having stayed in an institute on account of some neurasthenic trouble, have there become perverted to the morphia habit.

The essential thing in every institute is the spirit that pervades it, and that depends more especially on the doctor who has the post of medical director. But even where the conditions are most favourable we must not expect miracles to be worked. There are many cases in which the disappointment is all the greater because the symptoms that disappeared while the patient was being treated break out afresh when he leaves the place. A balance must be struck between the advantages and disadvantages of treatment in an institute, and it is for the doctor to find out which is the right establishment in each particular case.

Just now I made mention of the danger of mental infection occurring in institutions. It may also happen outside such establishments, especially in the consultant's waiting-room. I will take traumatic neurosis as an example. It only requires one such patient to describe his sufferings and their cause for a number of others at once to imagine they are suffering in the same way, because they have met with an accident at some time, or at least think they have. In the same way we often observe that many a waiting-room in the out-patients' department of a busy hospital, for instance, is a very hot-bed of "traumatic neuroses." Of course there are many other opportunities for morbid symptoms to be created in a similar way; we can never entirely exclude this possibility; but we are bound, as doctors, to bear it in mind and do our best to avoid the risk of any such danger arising. We are sometimes able to do this by requesting patients who, for instance, are likely to prove dangerous to others, only to visit us at times when they will find nobody in the waiting-room. Of course, we should not go so far as to attempt to prevent every possible kind of injurious influence; we are not able to do this, and it would be opposed to a wise system of psycho-hygienics.