COUNTWAY LIBRARY нс чачто ..... No.. BOSTON MEDICAL LIBRARY ASSOCIATION, 19 BOYLSTON PLACE. THE Alienist and Neurologist A QUARTERLY JOURNAL - --- SCIENTIFIC, CLINICAL AND FORENSIC Psychiatry and Neurology. GION MEDIC Intended especially to subserve the wants of the General Practitioner of Medicine. "Quaptam ego quidem video motus morbosi fere omnes a motibus in systemate nervorum ita pendent, ut morbi fere omnes quodammodo Nervosi dici queant."-Cullen's Nosology: Book II , P. 181-Edinburgh Ed. 1780. VOLUME VIII. . -EDITED BY- C. H. HUGHES, M. D., And an associate corps of collaborators. ST. LOUIS, MO.: EV, E. CARRERAS, STEAM PRINTER, PUBLISHER AND BINDER, 1887. CATALOGUED, E. H. B. ***e ferroflangan PRESS OF Ev. E. Carreras, Steam Printer, Publisher and Binder, ST. LOUIS, MO. ... INDEX TO VOLUME VIII. ORIGINAL CONTRIBUTIONS. 43 09 163 Page. "pueric matter .......... ....... Bi-lateral athetosis, unique case of... 388 Cortical motor centres of the brain... 84 Dipsomania............... .............. 95 Electrotherapy, scientific rationale of 317 Epilepsy, curability of, by galvanism 101 Experimental degenerations in the brain and cord. Female physicians in insane hospitals Forensic medicine............................. 30 Genius not a neurosis.. .................... 341 Hæmophilia............. Hypertrichosis................. ........ Idiocy, notes on the pathology of...... 287 Insane, hospitals and asylums for the 471 Insane, treatment of, by Turkish bath 234 Insanity or mental derangement...... 488 Insanity,true nature and definition of 627 Page Intercommunication of delusions by the insane... ............. 350 Intermittent epileptic aphasia, case of 328 Language, lecture on the origin of... 1 Language, X. lecture on disorders of 210 Language, XI. lecture on origin of. .. 305 Melancholia, treatment of................. 69 Mental and nervous diseases, medical jurisprudence of........................... 619 Nerve centers post-mortem.............. 15 Neuritis plantaris................... ......... 201 Paranoia in a female...... Psychology of a "plot" by the insane 230 Reflex nervous disturbances, obser- vations on....... ........... 352 Secondary Syphilis and the psychoses 197 State medicine........... ............. 366 | Uterine disease as a factor in insanity 532 ........ 360 IV INDEX. 119 116 122 SELECTIONS. Page. Page. CLINICAL NEUROLOGY- NEURO-SYMPTOMATOLOGY- Chorea, cardiac relations of.............. 667 Eye in suspected nervous diseases.... 427 Hemi-rheumatism. ............................ 115 NEUROTHERAPY Hereditary tremors........... .............. 666 Alcohol, influence of, on the gastric Lightning-stroke followed by acute functions... ..................................... 662 Bright's disease..... ............... Alcohol utilized in practice.............. 253 Neuralgic headaches with appari- Ammonia in acute alcoholism............ 259 tions of unusual character............ 667 Persistent patellar reflex.................. 426 Ammonia, picrate of, in malaria....... 418 Antifebrine ......... .................... 412 Apon.............. NEURO-ANATOMY- Cantharides for hydrophobia............ 121 Blood of the ganglionic cells, circu- Chloral and paraldehyde ........ ....... 117 lation of the............. .................... Chloride of sodium................ ........ Elephant's brain............................ Cimicifuga as a neurotic tranquilizer 411 Injury to the atlas. .......................... Cocaine, action of, on animals.......... 409 Skulls of the 17th century................ 423 Cocaine, amyl nitrite an antidote to 121 NEUROLOGY, Cocaine an antidote to strychnine..... 418 Cocaine dosage and cocaine addiction 664 Brain strain............. 250 Cocaine, effect of large doses upon Rheumatic hyperpyrexia .................. the central nervous system ........... 258 Cocaine, fatal poisoning by............... 119 NEUROPATHOLOGY, Cocaine, fatal use of......................... 259 Diabetes and tabes .......... Cocaine, toxic effects from............... 119 Epilepsy, nature of................ ........... Cocaine, toxic effects of.................... Epileptogenic zone.......... ............... Cocaine, truth about..... Fever, immediate cause of death in Diabetes, codeia in......................... 413 malignant cases of. ...................... Drumine, the new Australian local Insane, spinal cord in the................. anæsthetic ..................................... 121 Insanity, pathology of.................. Dyspnea of asthma and the influence Paranoia and human degeneracy..... of nitrites upon it ............ ......... 663 Peripheral Neuritis........... .............. Epilepsy, antifebrine in....... 414 Thyroidectomy and myxædema ....... 420 Epilepsy, Calabar bean formula for... 414 Uræmia and apoplexy................ ... Epilepsy feigned by an epileptic...... 664 Vertebræ, fracture of...... Epilepsy, neuro-therapy of............... 256 Epilepsy, remedy against.. ............. NEURO-PHYSIOLOGY- Hysterical paroxysm, treatment of... 118 Axial nervous current........................ 265 Insanity of criminals........................ 663 Brain, the four heat-centers in the... 668 Kava-kava as a hypnotic.... ........ ..... 419 Heat center.. ....... ............. 423 Kepbir, experimental studies of........ 118 Lymph, influence of nerves on the Malaria, ammonium picrate in the secretion of.. ............ ..........., 422 neurotic sequellæ of........................ 661 Malarial fevers, picrate of ammonia NEURO-SEMIOLOGY, in .......... ... ..... 660 Knee phenomenon, is it a reflex act? 426 Migraine, antipyrin in..................... 413 Radial nerve, temporary paralysis of 425 Neuralgia, ether and chloride of Tobacco asthma........ ............. 266 methyl in....... ....... 412 265 421 ......... 123 121 INDEX. SELECTIONS. Page. Page. Neuralgia, iodoformized collodion in 418 Insane, typhoid fever among............. 408 Neuralgia, methyl chloride in........... 413 Insanity among the Chinese............ 128 Neuralgia, treatment of, by chloro- Insanity, appetite in.......................... form diffusion ............ .... 411 Insanity, classification of.................. Paraldehyde and urethan................ 415 Insanity in California....................... 127 Rheumatism, cure for...................... 418 Insanity, intemperance and bad hy- Rheumatism, potassium bromide in 414 giene, causes of......................... Sciatica, puncture of nerve sheath in 257 Insanity, larvated, and paranoia ..... 403 Splenic tissue as a therapeutic agent 410 Insanity, ovariotomy in................... Sulphate of spartein.................. ..... 414 Melancholia, facial blemishes as a Tabes dorsalis, affections of the heart cause of......................................... 246 in........................... .............. 657 Mind reading................................... 248 Tabes dorsalis, initial symptoms of.. 658 Moral insanity. ............ Urethan vs. strychnia............. Nervous contagion, a case of............ Writers' cramp.... Oxaluria and insanity............. PSYCHIATRY, PSCYHOTHERAPY- Congenital imbeciles, suicide in........ 407 Insane, hygienic treatment of........... 259 · Emotions, influence of, on general Uretban, value of, as a hypnotic...... 261 health............ .............. 402 Female diseases and insanity........... SYMPTOMATOLOGY, Idiot savants.......... 400 Intercranial disease and choked disc 129 ........... .. 121 408 406 ............. PROCEEDINGS. Forty-first Annual Meeting of the As- New England Psychological Society 108 sociation of Medical Superintend- New England Psychological Society 242 ents of American Institutions for the Insane. . 548 445 EDITORIAL. Page. Page ALIENIST AND NEUROLOGIST, commen- Cocaine, fatal results from the toxic dation of............. .............. 277 power of ............... .............. 142 Another year.................................... 131 Contracture diathesis...................... 136, Antipyrine in psychiatry and neurol- Death of Dr. F. E. Roy.................... 674 ogy, memoranda on...................... 441 Death of Dr. John Fulton................. Beri-beri, some cases of.................... Delegates to the Congress in Wash- Canadian medical association.......... ington ............ ...................... 450 Carl Von Schroeder, cause of the Dickens' fat boy a narcoleptic.......... 451 death of................ ................. 279 Dr. Shakespeare's opinion of Ferran 276 Cerebral anæmia and uræmic convul- Epilepsia, consciousness in ............... 439 sions........... .............................................. 451 Feeble-minded, history of the reform Charleston earthquake .................... 148 1 in the care of.. ...... 669 447 vf INDEX. . , EDITORIAL. Page. New York medico-legal society, offi- cers of, for 1887.............................. 149 Ninth international medical congress 150 Ninth international medical congress 446 Non-violent insane..... ........... ........ 430 Paralytic ataxia of the heart......... . 145 Peoria medical monthly.................... 276 Physician as a teacher..... ......... 140 Possible untoward local glandular sequence of hyosciamin and elec- tricity............. ................. ........... 149 Posterior spinal sclerosis, curability ............... 671 Page. Faith-cure folly............. 272 Fifteentb annual meeting of the American Public Health Associa- tion.............. ............. 67 675 G. F. M. Bond, M. D......................... 452 Glaucoma, nervous origin of the col- ored rings in ....... ........................ Hypnolepsy vs. narcolepsy............... 268 Hysteria in its true light.................. Hysteria, more correct views in re- gard to........... ............... 432 Insanity, Dr. Earle on the curabilty of............... .............. International Medical Congress at Washington................................... 271 International Medical Congress........ 437 International Medical Congress, va- cancies filled...... J. B. W. Lansing, M. D................... Knee phenomenon symptom............ Lack of interest in neurology...... .. Late Mr. R. M. Howard.................... Legal inconsistency in regard to in- ebriates and inebriety.................. 269 Lincoln on quarrels.......................... 146 Mania, morbid motor restlessness of 443 Medical standard............ .............. 450 Mentally maimed in court, a word for 673 Miliary aneurism and cerebral hem- orrbage.......... Minute structure of the corpora stri- ata and the thalami optici. ........... 452 Morphiomania.... ........... Murpuromanid.... ............................ 450 Nervous cardiac debility.................. 445 Nervous diseases and their diagnoses 151 Neurological review........................ 278 New forms and symptomatic phases of insanity............. ................ 267 New York medical record................. 452 Pseudo medical experts and amateur alienists........................................ 435 Psychical epileptoid automatism, case......... ................................. 144 Relation of lithæmia, oxalurią and phosphaturia to nervous symptoms 444 Rheumatic hyperpyrexia and bulbar disease............ ......... 148 Sciatica, Malgaigne's ear cautery for 278 Sciatica treated by galvanism........... 138 Sick chamber wit............................., 149 Sixth German medical congress........ 276 Society of medical jurisprudence and state medicine, officers-elect of...... 451 Successor of the late Dr.J. P. Gruy... 151 Succi's fast. ............ ......... 149 To news dealers and book agents...... 149 Treatment of the insane by the Turk- ish bath.. ..................................... 277 Vitiligo, role of the nervous system in the causation of......................... 448 Wanted, the Jan. 1881 of this journal 147 Washington international medical congress...................... ................. 673 Wood's "Nervous Diseases " and Strümpel's “ Practice "..... ........... 278 449 CITY HOSPITAL REPORTS.–St. Louis, Mo. Unilateral internal hydrocephalus from closure of the foramen of Monroe.... ........... 396 INDEX. VII REVIEWS Page. 682 Brain ..... ......... ........... 283 464 ......... 283 ................................ 900 Page. American Journal of Psychology ..... 463 Another valuable contribution to the pathology of the cerebellum......... 468 466 Century for March.............. 282 Common Errors........................... ... 283 Daily edition ........... ... 467 Dawn of a new era in otological sur- gery ............................................ 459 Differential diagnoses...................... 680 Discussion of Paracelsus................... 465 Doctorate address...... ....................... 460 Elementary microscopical technology 468 Field and limitation of the operative surgery of the human brain........... 158 Functional nervous diseases............. 679 Gynecology, lessons in ............... 679 Il Manicomio, May, 1886.......... ...... 155 Index catalogue of the library of the Surgeon-General's office...... ......... 681 Insanity..................... ........... ........... 680 Insanity and the care of the insane... 456 Insanity, curability of, etc............... 681 Insanity, relation of intemperance to 681 La Psichiatria, anno IV., fasc. 1 and 2 280 Lindsay & Blakiston's Physician's Visiting List for 1888....................... Mason's Compend of Electricity ....... 468 Medical Standard.......... Mental epilepsy............ Nervous diseases and their diagnosis 676 New Philadelphia Journal................ 283 New York Medical Journal.............. Noises in the head and ears.... ...... .. 468 Nursing and care of the insane.......... 457 Persistent pain after abdominal sec- tion............ .............. 460 Practice....... ..... .............. Prof. Hunter McGuire ..................... Removal of sebaceous cysts from the scalp by galvano-puncture............ 468 Rules of the neurological society of London, with list of office bearers and members, 1887....................... 466 South-Western Medical Gazette...... 284 Studies from the biological laboratory of Johns Hopkins University......... 462 Text-book of Medicine for students and practitioners.......................... 160 Two unique cases of insanity........... 468 160 . . . . . . . . OBITUARIES. John P. Gray, M. D., LL. D.......... 152 | James Stewart Jewell, M. D............ 453 CONTRIBUTORS TO VOLUME VIII. G. D'ABUNDO, M. D., Naples, Italy. HARRIET C. B. ALEXANDER, A. B., M. D., Chicago, Ills. F. BATEMANN, M. D., Norwich, England. L. BIANCHI, M. D., Naples, Italy. H. A. BUTTOLPH, M. D., LL. D., Short Hill, N. J. S. V. CLEVENGER, A. M., M. D., Chicago, Ills. ALICE MAY FARNHAM, M. D., - Willard, N. Y. WILLIS E. FORD, M. D., Utica, N. Y. HENRY HOWARD, M. R. C. S., L., Montreal, Canada. C. H. HUGHES, M. D., St. Louis, Mo. JUDGE AMOS G. HULL, New York City. JAS. G. KIERNAN, M. D., Chicago, Ills. BRANSFORD LEWIS, M. D., St. Louis, Mo. EDWARD C. MANN, M. D., Brooklyn, N. Y. A. R. MOULTON, M. D., Worcester, Mass. A.H.OHMANN-DUMESNIL, A.M.,M.D. St. Louis, Mo. G. C. PAOLI, M. D., Chicago, Ills. CONRAD RICHTER, M. D., Milwaukee, Wis. CHAS. H. SHEPARD, M. D., Brooklyn, N. Y. E. C. SPITZKA, M. D., New York City. A. W. WILMARTH, M. D., Elwyn, Pa. JOSEPH WORKMAN, M. D., Toronto, Canada. GOST1933 B APR EDICAL , 7 THERIN ALIENIST – NEUROLOGIST. Vol. VIII. | ST. LOUIS, JANUARY, 1887. | No. 1. ORIGINAL CONTRIBUTIONS. Lecture on the Origin of Language.* By Professor Bianchi, Naples, Italy. IN our January (1886) number we noticed, with more I brevity than was befitting, Bianchi's instructive series of lectures, which were given by the author to the students of psychology who attended his clinical course in the Provincial Asylum at Naples. Having since had reason to believe that the extracts then presented were favorably regarded by our readers, and having seen no intimation from any American publishers, of the reproduction of the book in this country, we have, with the kind permission of the author, decided on drawing more largely from its pages. The three lectures, gth, oth and Ith, on the “Disturbances of Language in Hemiplegia,” we venture to hope, will be found so acceptable to the readers of the ALIENIST AND NEUROLOGIST, as fully to justify our decision to present them in series. Professor Bianchi devotes the first of these three to the interesting consideration of the “ origin of language.” As the Italian youths constituting his class, in all probability had never given much consid- eration to this subject, or rather, perhaps, had never been permitted closely to approach it, we can see no impropriety in such a preface to the subsequent clinical instruction given in the 10th and 11th lectures. Nor indeed is it altogether improbable, that a considerable proportion of the • Translated by JOSEPH WORKMAN, M. D., Toronto, Canada, from the La Emiplegia, by Professor Bianchi, Naples, Italy. 11] Professor Bianchi. medical students of our own country, might be much ben- efited by similar introductory instruction. Notwithstanding the fact that we have all witnessed the tedious and tiresome process of the acquirement of language by children, yet the great bulk of mankind, in after-life, seem never to be- stow a thought on the subject, any more than they do on the process of breathing, digestion, or any other capability enjoyed by them. They breathe, they eat, they drink, they sleep, because they were made so to do, and so they must do or die; but though the vast majority can talk, some are dumb. Ask them why some are dumb, and you will not have to wait long for the answer: It is because they were made so. They do not, as Hamlet, think "that some of nature's journeymen had made men, and not made them well," yet what they actually do think, or whether they do any thinking at all, is a puzzle which we may as well leave among the unthinkables. Let us see what Professor Bianchi has to tell us on the ORIGIN OF LANGUAGE. “We cannot have a correct conception of the physi- ology and the pathology of language, so far as the present state of science permits, without having some notion, however general it may be, of its origin and development. If to any of you it may seem that, in treating of this subject, I overstep the limits assigned to the realm of clinical medi- cine, I console myself with the conviction that this science cannot, in the interpretation of morbid phenomena justly pertaining to it, tolerate barriers of any sort, and that in accomplishing its purpose, it must draw from every available source of human knowledge those elements, which may, as rays of light, serve to dispel the lingering shadows of that empiricism, from which in modern times it has been emancipated, let us hope, forever. "I do not here purpose to rehearse, or even to dis- turb in their slumbers, the discussions agitated in past ages, and in different schools, on the origin of language, that is to say, whether it was an intrinsic property of Lecture on the Origin of Language. humanity, and fully developed, even in man of the pre- historic epochs, or whether it advanced by little and little in a progressive development and continuous im- provement, under the same laws that regulate the evolu- tional development of the human mind. "Science has accumulated so great a number of proofs of the law of evolution in languages, and of their genealogy, that although their primordial unity evades clear deinonstration, yet it is certain that by means of philology and linguistics, which have reduced to a small number the roots of modern tongues, we may almost divine the fact. “Instead of entering too far into the naturalistic doc- trines relative to the development of language, some of which are but more or less faint or hazy reproductions of the old opinion of Epicurus and Lucretius, as are those of Renau and Max Muller, I deem it more opportune to adduce a few of the more demonstrative proofs, in order to strengthen in ourselves the conception of the develop- ment of language in correspondence with the evolution of thought, and the result of an organic function. “In like manner as from the cell in the egg, dozens and hundreds, thousands and millions of other cells that compose tissues and organisms; and in like manner, as in the development of animal species and of a single individual in each species, by the different conditions of existence they assume different forms, and differently un- fold their intrinsic force as a functionality, harmoniously with those of other cellular groups, by means of a con- tinuous process of differentiation, distinction, and division of labor, according to the successive development of the ani mal series, and of the individual in each series; so human language in the development of thought, and in continual differentiation, distinction of objects, qualities, states and relations, has gone on, ever enriching itself with new material. Again, as in the embryogenic development of the human organism, some elementary transitional forms disappear, to give place to others more stable, and better Professor Bianchi. adapted to life in its conflict with external agencies, so the dead human languages, and the languages that have to die, are as tissues of transition insufficient for the purpose of their existence in the new conditions of intellectual life in society, and being dead, they will never return into life, having been dissolved in the genesis of those which followed them, and these again, melted down into those which now are. Just as descendants bear the imprint of their antecessors, who disappeared forever from the face of the world, so modern languages bear the imprint of the dead,- of those prim- itive indistinct sounds, with which human beings, who by thousands of ages preceded history, perhaps expressed their primitive, more distinct sensations of pleasure and pain. “Philology and linguistics, as a retrospective embryol- ogy of language, show to us its genealogy and the im- mense development it has attained in the lapse of ages. Analogously the study of the development of language in the child shows the pale reflex of the development of the language of mankind, though in conditions so different (from heredity); and on the other hand the anatomy, physiology and pathology of the nervous system harmon- ize the evolutive law of language with that of the organs, of which it is a functional manifestation. “That language has been derived from a small number of sounds, more or less articulate and distinct, has, I would almost say, been proved by documents now possessed, from a considerably advanced period of human develop- ment. “It is known that the cuneiform inscriptions of Persia contain no more than three hundred and seventy-nine words. “The ancient learned Egyptians, in so far as we com- prehend the hieroglyphic inscriptions, appear not to have had more than six hundred and fifty-eight words (Max Muller). “The radicles, that is to say the material of the lan- Lecture on the Origin of Language. 5 guage, of the Arian peoples, do not exceed four hundred to five hundred words. “In the progress of ages language went on increasing and enriching itself in a marvelous manner. The Old Testament contains five thousand six hundred and forty- two words; the dramas of Shakspeare have not less than fifteen thousand words; the dictionary of Webster and Robertson contained forty-three thousand five hundred and sixty-six words; the new edition of Webster, seventy thousand, and that of Fluegel, ninety-four thous- and four hundred and sixty-four. " It suffices to follow the development of a radicle, in order to form an idea of the marvelous manner in which the grand tree of human language has gone on augment- ing itself with new branches., 1.8., the Arian radicle Spac, which is of a very vague, general and involute significa- tion; has furnished: “ Spas (Sanscrit)—to see, examine. “Spec (Greek), which became Scep, by frequent trans- positions of the letters. “Specto (Latin). “ Spehom (primitive German)—to see. “The Sanscrit Spas has given: “Spas—a guardian. “ Spashta—manifest. “Spasama spy. “From the Greek Scep are derived: “Skeptomai—to observe. “Skepticos—a searcher. “ Skopos—a thing sought for. “ Episkopos-one who examines. "From the Latin Specio, the substantive species (that which is seen). This last word was used first for movable, useful objects; afterwards for aromas (as things useful in life); hence the French espèces and its derivatives, epices, epicier, and the Italian speziale, spezieria, and so forth. "From the Greek episkopos came the Latin episcopus. This word, in passing through the barbarous language of Professor Bianchi. the Franks, and by virtue of syllabic contraction (by se- lection, saving of force, etc.), became in French episc.. The change of p into v is frequent in words that have passed from Latin into French (thus-recipere, recevoir; sapere, savoir, etc.); and thus episc became evisc. This word, by the frequent change of į into e, among the common people at Rome, became evesc, or evesque, in French, in which it suffered yet another contraction, and became eveque (bishop). “Here is another ramification; and in the meantime I notice only the great trunks : “From the Sanscrit Spasa (spy) are derived the primitive German Spöha; “The English Spy; “The French Espie and Espion. “It would be a vain labor to reproduce here the very numerous derivatives of this radicle in modern tongues, and the innumerable compounds (spectrum, suspect, spe- cific, spectroscope, respectable, etc.: who could ever sup- pose, were it not proved, that the words spy, special and bishop (vescovo-Italian), were branches belonging to the same trunk? (A sly hit.) “Nature is essentially what she was and what she will be. It is man who, in recognizing new things and new qualities, new facts, new states and new relations, is under the necessity of expressing the continual increase of his. ideas by new words, which proceed from the old, as new ideas succeed to old ones. “The augmentation of the arts and sciences, the mul- tiplied interrelations of distant peoples, literary genius, brevity and euphony (the cause of selection), syllabic corruption (Max Muller), have sometimes been able to modify words to such an extent as to obliterate the traces of their affiliation, especially in the immense variety of dialects, but yet not to overthrow the general law which governs them. “Let us turn our study to the development of the language of the child; and should we discover some Lecture on the Origin of Language. analogy between the laws which govern it, and those which have governed the development of the language of primitive humanity, we shall have secured a better founda- tion on which to raise more safely our edifice of the pathology of language. “For this study I shall lay under contribution the pa- ticnt and more or less important observations of Darwin, Vierordt, Peyer, Kussmaul, Taine, Schultze and Sikorsky. From all these studies, that of which every person who has the aptitude to observe the varied phenomena of na- ture, might of himself be persuaded, is that the primary elements which serve as the germ of the future language of the child, are indistinct sounds, more or less approxi- mate to the sounds a and e (Italian—not the barbarous modern English), the former expressing a pleasant, the latter an unpleasant sensation, but more or less indis- tinctly.. Vocalization (vowelizing) is the expression of an emotion, an indistinct sensation, not an idea; and here behold why the vocal (vowel) mechanism is the first that is manifested in the child; in the emission of the different sounds that of a (Italian) is more simple than that of e (Italian) with which the first movements of the tongue commence, which are wanting in the emission of the sound a. “The first labial sounds of m and b begin to appear at a later period, in combination with vowels, in forms of syllables, which are altogether devoid of symbolic signifi- cation, or are the expression of imitative activity, in which satisfaction however the child is pleased with the acoustic effect, as in the syllables inain, amin, ni, mi, etc. “Before the first year has passed, the intention of the child to emit articulate sounds is usually evident. The distinction between the Ego and the outside world is traced. But the degree of intellectual and cerebral devel- opment of the child does not comport with poly- syllables, but with monosyllables only, or a syllabic combination less complex than the real word, which the child has the intention to pronounce. The acoustic Professor Bianchi. image of the word indeed exists, but the motor co-ordi- nation for its formation is yet not possible. I know a very intelligent little girl who, in order to say sonno (sleep) when she wishes to go to rest, simply says 00-00 or noo-00; instead of saying acqua (water), children say aa ; or they pronounce only two syllables for a word of three or four; one of my own children pronounced pova for portogallo, and the children mentioned by Taine said cola instead of chocolate (ch hard). “A similar fact to that deduced from the study of the linguistic documents of humanity that preceded us by thousands of years, as for example, from language radicles, is verified also in the language of children, whose partic- ularity is among others, the elementary structure of the syllable, that is to say, the child always employs a less number of sounds: as ban for blanc, omama for grossmama (Shultze). This is not all that is remarkable or particular in the language of children. There is a defect of precision in each particular sound; thus a becomes ai, au, ae, iau, etc., and the consonants are often softened—6 for p, s soft for c, s for 2 (ts), th for v, etc. There is, too, the substitu- tion of some sounds for others; as bloix instead of croix (Sikorsky). • “Though children may be able to pronounce sounds separately, they are yet incapable of co-ordinating them for the formation of a word. Thus they can well enough pronounce ca, mi, na, separately, but not for some time yet can they put these syllables together to make cam- mina ; and so they say nannà or ninà. “All these particularities of the language of children confirm the doctrine of Taine, that is, the sounds by the child are elaborated by means of a constant metamor- phosis of the more simple elementary articulatory move- ments. “The mechanism of speech results from three distinct mechanisms; the vocal, the respiratory, and the artic- ulatory; all these three are exhibited simultaneously during the act of speaking, but in the child, successively Lecture on the Origin of Language. and incompletely. The vocal (vowel) mechanism is the first to appear, and the others are, for a long time in the child, in a condition of continuous development and improvement. In fact, if the syllable is an assemblage of sounds emitted in a single expiratory impulse (Severs),- if these sounds are so numerous and varied for each syl- lable,-if every sound calls for a different expiratory tension, it will be undertstood that this marvelous labor is inaccessible to the child, because it demands an extremely subtle and complicate co-ordination, and the respiratory and articulatory movements. “Sikorsky, who distinguishes the expiratory expiration (?, that of normal breathing) from the vocal expiration, distinguishes by the term articulatory expiration, that frac- tioned and graduated expiration which takes place in the articulation of sounds. “Given this great complication of expiratory and articulatory movements in the pronouncing of a word, it is easy to be understood why the child pronounces only one or two syllables of a polysyllabic word, and why it simplifies the word by substituting, for the complex sounds of each syllable, more simple sounds, resembling each other; it is also understood why vowels predominate in the language of the child-nannà instead of camminare, colat instead of chocolate, ninnade instead of limonade, noo-00 instead of sonno, etc., etc., are not only the expres- sion of the co-ordinative defect of many sounds, and hence the act of syllabic shortening, but they also reveal the tendency of the child to substitute for complex sounds, others more simple and analogous to the former, less by their articulatory than by their phonetic character; hence the child reproduces only the more accentuated sounds of the word, or all its syllabic sounds, but simplifying and vocalizing (vowelizing) them. “Taine and Schultze have given a physiological inter- pretation of the metamorphoses of the different articulatory sounds of children. They have deduced from observations the law, that from the more simple movement, they pass 10 Professor Bianchi. to the more complex, and the articulatory movements are first realized by means of those organs in which the tac- tile sense is most developed. Thus it is that children pronounce first the labials and dentals m, p, t, s, and not until a later period k, or the Italian ch, v and ;. The latter letters require a greater expenditure of muscular force (Schultze); in the second place they require a very complex co-ordination of movements, of which children are yet incapable; finally, because in the pronouncing of the labial and dental letters, the child enjoys the exquisite sensibility of the lips and tongue, as well as the mus- cular sensibility, whilst for the pronouncing of the guttu- rals, as the velum palati has but little tactile sensibility, the different palatal positions of the tongue cannot be guided unless by the muscular sensibility alone. "It is in accordance with an evolutive law, consisting in the increase, the modification, and the varied and com- plex co-ordination of the more simple movements of each of the constituent mechanisms of speech, that the child learns to speak. “Let us now see a little of what has happened in language in general. The language of the child is made up of monosyllables, or of words in which vowels pre- dominate. “It appears to me that the monosyllables of children are the co-respondents of the radicles of a very remote epoch of humanity, and the predominance of vowels in the language of children has its counterpart in the like predominance in many primitive languages. In Hawatano, e. 8., we find kuiaioui—to testify. It is supposed, and many proofs favor the hypothesis, that in the progress of spoken language the more slender articulations have become stronger, and that the fewer are the consonants, the more ancient is the language. As it is in the devel- opment of the language of the child, so happens it among some peoples; in passing from generation to generation some indistinct sounds pass into distinct. In all the Poly- nesian dialects, says Hale, no distinction is found between Lecture on the Origin of Language. II the sounds b and p, d and t, g and k, 1 and r. The Sanscrit word Gharma (heat) became in Greek, thermos; the guttural aspirate of the former became the dental aspirate in the latter, by the very plausible reason ad- vanced by Max Muller, that this phonetic diversity is to be attributed to a previous state of the language, in which the two or three principal points of contact had not yet found themselves definitely separated from each other, as happens in the Polynesian dialects, and in the child. “When the child has learned to pronounce his words properly, his patrimony of them, as that of his ideas, is very slender; the few at his command have very wide signification; for a certain time, e. g., the word papa is applied to every man he sees, he does not yet note the difference between his father and other men. So probably was it with radicles, when they were words in a living language; and thus is it to-day with people whose intel- ligence and culture have still remained very low. “The grand modern verbal patrimony has been acquired by mankind, as it has been acquired by the child, through analogous paths, by a continuous process of differentiation, and, therefore, by the accumulation and harmonious dis- posal of new ideas, and new conceptions derived from the former. But in the child of to-day all the organic condi- tions indispensable to intelligence and to the language of the present, are present, preformed, by atavism; whilst in the prehistoric language of mankind, these conditions had to be realized by means of a slow evolution, determined by the stimuli of the external world, in the widest sense of the word. “This conception finds another confirmation in the analogous development of the senses, by means of which we are put into relation with the external world, and from which fundamentally are derived ideas, and thence words. The eminent philologist Geiger, in his work ‘On the Development of Humanity,' adduces several proofs to demonstrate that in the period of the formation of the Arian tongues, perhaps not more than fifteen or 12 Professor Bianchi. twenty thousand years ago, only one color was known; the blue of the heavens was not distinguished from the green of the meadows or the trees, from the gray of the earth and the rocks, nor the golden aurora from the dawn of twilight. “In the Rig Veda we find noted the difference between red, yellow and black. At a later period white was dis- tinguished, and next green; but both in the Rig Veda and the Zend Avista, in the poems of Homer and in our Bible, blue was not yet mentioned. Nor does it seem that this happened by mere accident, for in the Rig Veda ten thousand lines are devoted to the description of the heavens; in the Bible heaven and the firmament are men- tianed four hundred and thirty times; and the forty-eight books of the Iliad and the Odyssey were written in a country in which the vault of heaven is of the most splendid blue. "Evidently red, yellow, green and black were not to these people the same as they now are to us, but they served to indicate a variety of other colors, the principal dominant tone of which was that which gave the name. We cannot adequately judge of the psychical state of these people, just as we cannot penetrate the psychical conditions of the child, for we hear, perceive and judge very differently from the manner in which the child hears, perceives and judges; and in like manner we hear, per- ceive and judge differently from the artist, of the harmony of a concert or the beauties of a picture. In fact, green, sky-blue and violet were all comprised in black. Ety- mologically blu and the German blau are derived from black; the Chinese hi-uan, which now signifies the blue of heaven, at first signified nero (black); the word nil, which now in Persian signifies blu, was derived from Nilo, or the black river (R. M. Bucke, M. D.)-['The Growth of the Intellect, American Journal of Insanity, July, 1882.] “The fact of the successive increase of words and thoughts, and therefore of language in general, finds proof still more irrefragable in the physical fact spe- cially related to colors. It is known that the rays of Lecture on the Origin of Language. 13 the different colors, differ from each other in the length and amplitude of their waves, and that the energy of each is in the direct ratio of the squares of the amplitudes of the waves. Now if it appears from documents that the first color recognized in the course of human development was red, and next green, and so on to violet, which was the last to be distinguished, the reason is that these rays possessed exciting powers, in the same order as they were successively differentiated; so that red, of which the rays are the longest and most ample, was first recognized, and only at a later period were people able distinctly to note orange, which has shorter and less ample waves than red, and so on to violet, which has the least of all, and was the last to be distinguished. Bucke states that the frequent blindness of colors, in some persons, is a defect pertain- ing to atavism specially, because the faculty of dis- tinguishing colors relatively, is of recent acquisiton. This is in harmony with the other fact, that, in cases of dichro- matopsia the first color that ceases to be perceived is violet, the law of dissolution following, in this respect, the same course as evolution, that is, the first property to disappear is that which had been last acquired. “As with sight, so perhaps it happens with the other senses (Geiger); but we have not documents so numerous and so evident as we have for sight and colors. “From what has preceded, I may here conclude that. language appears to have been developed side by side with the human intellect, from emotive vocal sounds, more or less indistinct; that the articulatory mechanism was more tardily developed, thus furnishing monosyllables as in germ, the primitive elements of future articulate speech;. that languages have been ever more enriched by new words, and by divesting themselves of expressive elements that had becoine unsuited to new conditions of existence, and to improved path of impression; that finally, in the devel- opment of the language of the child we may trace, as reproduced, the process of the development of the lan- guage of mankind. 14 Professor Bianchi. "If this conclusion is a just deduction from the facts relating to language, of which I have noted only a very small part, I purpose to show to you, in my next lecture, that correspondently with the development of language by the increase of its elementary factors, physiological and psychological, the brain also has undergone a pro- gressive evolutive process, in the sense of differentiation, on its cortex, of as many special centres as there are elementary factors of language." How Shall the Student of Psychiatry Examine the Nerve Centers Post- Mortem? INFLUENCE OF ALCOHOL AS A HARDENING RE-AGENT. By E. C. SPITZKA, M. D., New York. TROM its antiseptic properties, and consequent feature T' of preserving tissues which might putrify in other media, alcohol has long enjoyed a high reputation. It hardens nerve-substance rapidly under favorable circum- stances, and requires less frequent changes and less expertness on the part of the student to produce a con- sistency such as will permit the making of thin sections. As far as the nervous system is concerned it presents the following serious—I was about to say fatal-disadvantages: Firstly. The longer nerve-tissue is subjected to its action the more likely is the staining (if carmine and certain anilines be employed) to be diffuse. It is not uncommon to find that the white substance of a cerebral hemisphere, hardened by this method, is stained more deeply than the cortex. The cells are then not distinct; and even where their general outline is plain, the processes cannot be well traced. The basis substance in which the cells are imbedded, is often more deeply stained than the cells themselves. Secondly:-The longer alcohol is allowed to remain in contact with nerve-tissue the more apt are precipitates to form in the natural spaces, such as the adventitial and pericellular gaps. Look at any brain that has been kept in alcohol a length of time, and you will discover shining tablets and round beads scattered over its surface. The former are tabular crystals of cholestearin; the latter are found, under the microscope, to be either concentrically laminated or made up of needles radiating from the center. [15] 16 E. C. Spitzka. Occasionally both the concentric and radial types are im- perfectly developed in the same sphere. Isolating these bodies, and submitting them to certain chemical tests, they are found to be chiefly leucin. On cutting into a brain thus preserved, similar bodies are exposed in vary- ing numbers. It appears that the older the specimen the more they accumulate and the larger the individual spheres of leucin become. They often coalesce in groups. The affinity for crystallization is so great that they press apart the tissues in which they lie, often however incor- porating within them some indications of the stratification of the displaced nerve-fibers. The importance of recogniz- ing them is so great that I will devote some space to the consideration of the appearances they produce. ARTIFICIAL PRECIPITATES. These form, under various, to me, in part enigmatical conditions. Occasionally they will be found in large numbers (and then of small dimensions, from 1-2000 to 1-600 of an inch), in specimens derived from animals dying in warm weather, and whose nervous tissues have been but a short time in alcohol. Thus Hammond, in examining the nerve-centers of McCormack, who died of hydrophobia, had fine sections made of the cerebral cortex and medulla oblongata twenty-four hours after the post-mortem. He resorted to the precaution of hardening the small pieces into which these organs were divided, in tubes filled with absolute alcohol, and surrounded by ice. Yet it is perfectly evident, to any one familiar with the subject (to-day) examining his drawings, that the lesions he describes are the artificial products of the hardening re-agent employed. In other words, he fell into the error of describing artificial precipitates as the lesions of hydrophobia.* It is mere justice to state the following in connec- tion with the above: Some dissatisfaction was expressed in professional circles, at the fact, that newspaper report- • See Agures 91 and 95, in “ Diseases of the Nervous System,'' last edition. Nerve Centers Post-Mortem. ers had published the “discoveries” of Dr. Hammond, and given no little notoriety to the latter. The author has too little interest in the ethical aspect of this dis- satisfaction, believing that abuses growing out of such practices correct themselves, to refer in detail to the numberless instances in which those then foremost in criticism have since aired their opinions on medical subjects, from Garfield's wound down to the etiology of filth diseases in the same media. Suffice it to say, a number of medical men were sworn as a coroner's jury, and the coroner, who in our community is usually a sort of Dogberry, asked this jury to pass on the value of Dr. Hammond's allegations. They were pronounced as of no value, and this condemnation was trumpeted about as loudly as the original assertions of the investi- gator had been, if not more so. A disagreeable contro- versy grew out of this, and a portion of Dr. Hammond's critics finding themselves on the defensive, stated that they had declined to endorse his findings because they were the result of shrinkage in alcohol. The author at once made up his mind that the attitude of the coroner's jury had been dictated by other considerations than those of abstract justice. Countless monographs based on studies made with the same hardening re-agent, had been previously, and have been since cited by these gentlemen, in their various contributions, with confiding approval. Every text-book on histology extant in 1870, endorsed its employment, and the names of Lockhart Clark and Dean, not to mention others who stood high in neuro-anatomy and pathology could be cited among those who employed it frequently. The objection that appearances may be due to shrinkage, can be made against every other hardening fluid, and he is a very crude reasoner, who attributes “fat globules” or “colloid spheres," in other words, substantial elements, to the effects of shrinkage. Although agreeing with the general conclusion of the jury, that the pathological observations made on McCormack were of no value; nay, I will go 18 E. C. Spitzka. further than they, and pronounce them misleading, yet the author would rather have been guilty of the error in this instance, than to have made the criticism in that form. It is not certain but that the surprising amount. of such precipitates, found in hydrophobia, tetanus, death from strychnine poisoning, and acute delirium, as contrasted with other cerebral conditions, may indicate a previous chemical predisposition to dissociation of the nervous. elements. Acute delirium (manie grave) presents us. with at least one instance of demonstrable adventitial and periadventitial exudate, of a proteinaceous nature. The artificial precipitates vary considerably in shape, color, refraction and distinctness, and in size froin ac- cumulations visible to the naked eye, to the microscopi- cal. First variety. – Naked eye appearance. On cutting through the brain-tissue, a transparent irregular mass is seen, indistinctly merging with the surrounding tissue. If a specimen of the cortex in which such a deposit may be expected to form, be examined sufficiently early, nothing beyond a slight waxy or watery luster is seen in its in- tended location. After some weeks, it looks more dis- tinct and as if a transparent gelatine had been cast into a tissue crack. After months and years, its outline be- comes sharply defined, its appearance more opaque, and it is possible-especially when some other hardening re- agent is employed to complete the work of the alcohol- to pick them out and isolate them. This fact was famil- iar to Hun, the former pathologist of the Utica Asylum. I have no question that had he continued at the same kind of work, sufficiently long, he would not have left it to a non-asylum resident to discover the artificial nature of the lesion known as "miliary sclerosis.” Microscopic appearances. In the earliest phase of their formation, the area to be occupied by these bodies is marked by its failure to take up carmine staining. Usually it is colored more deeply by the prolonged action of hæmatoxylin. The cellular elements are faintly stained Nerve Centers Post-Mortem. 19 and of normal number and arrangement. In an inter- mediate phase, the affected area, shows a yellowish tint, the histological elements are still recognizable, but owing to the defective staining, are not identifiable in the nor- mal proportions. It is now seen that the periphery of the mass has an outline, like that of a wreath of smoke, several round, or elliptical projections being visible. Still later, it is seen that this indicates the composition of the mass of several agglutinated, or agglomerated spheres; concentric lamination, or radiatory striațion, is detected in the older forms. In Bucknill and Tuke's “Psychological Medicine" a good colored illustration of such a mass is seen, it being characterized as miliary sclerosis. Schüle also describes such bodies as formed in paretic dementia. Singularly enough, most observers, who unwittingly pro- duced these bodies in the brains of insane patients, seem to have devoted special attention to dementia paralytica. Perhaps this is to be attributed to the greater attention paid to that disease as compared with other forms of in- sanity, and to the encouragement it offers to the investi- gator seeking for a somatic basis of a form of insanity, which above all others is associated with demonstrable brain lesions. No one, up to the year 1876, to the author's knowledge, had called attention to the injurious effect of alcohol on nerve-tissue: indeed as I shall show, there are many excellent observers who are still ignorant of it. Consequently it would be hypercritical to censure those who had been deceived by the spurious morbid appearances, simulated by leucin and other precip- itates. It was not, until the writer found that a modest cedures which smacked of the methods of a secret cau- cus, that he indulged in a certain kind of sarcasm, whose merits and objects are still largely misunderstood by worthy physicians connected with asylums. It is not necessary for me to add anything to the con- troversial aspect of the subject, other than that the views here expressed about the artificial nature of the “grumous 20 E. C. Spitska. granular matter,” “colloid spheres ” et al. of the Utica and Oshkosh Asylum reports, have been finally endorsed by Plaxton* of Ceylon, Savaget of the Bethlehem Royal Asylum, and by a number of German authorities. At no time have the pathologists or physicians of the Utica Asylum acknowledged their error. A few years ago Greiff described what he considered a new lesion in multiple sclerosis, under the name of disseminated vitreous degeneration of the cerebral cortex. I It is the artificial lesion, above described, and like it, con- sists in a precipitation of leucin crystals extracted from the brain-substance by the action of alcohol. His ac- companying figurell represents this artificial lesion very accurately; and Greiff, if he fails to recognize that his vitreous degeneration is a spurious lesion, at least identi- fies it with the miliary sclerosis of Bucknill and Tuke and the spheres of Schüle, which are now generally recog- nized to be the results of post-mortem manipulations, and not actual lesions.Ş • Journal of Mental Science, October, 1882. # Ibidem April, 1883. I Archiv fur Psychiatrie, xiv. p. 286. || Ibid., xiv., Plate ii., Fig. 5. $ Attention was first called to the artifcial nature of these bodies by the writer in the Journal of Nervous and Mental Diseases, October, 1877, and a more accurate description was given in the Chicago Medical Review of 1880, and in a demonstration before the New York Neurological Society, in 1883. In commenting on tbe latter a German critic stated that the facts related had been long known in Germany (Neu- rologisches Centralblatt, 1883, p. 283). On inquiring of the critic what publication contained any reference to this discovery, he frankly stated that he knew of none, but had had in mind what he considered a tradition of the laboratory. It was in the same year that Greift worked at the Heidelberg laboratory under the eminent super- vision of Furstner, and it was a few years previous that Schule, one of the collabora- tors of Ziemmssen's Cyclopædia, had made the same mistake. So it seems that the tradition is in some danger of expiring, and that it would do no harm to accept the cantion, even though it travel across the Atlantic in the reverse of the usual direction. It has been amply confirmed by Savage and Plaxton (Journal of Mental Science, October, 1882, and April, 1883). [To be Continued.] Female Physicians in Insane Hospitals. Their Advantages and Disadvan- tages. * By G. C. Paoli, M. D., Chicago, Ill., Emeritus Professor in the Chicago Women's Medical College; member of the Ameri- can Medical Association; Chicago Medical Society, etc., etc., AND Jas. G. Kiernan, M. D., Late Medical Superintendent Cook County Insane Hospital. THE ADVANTAGES. BY DR. PAOLI. IT is incumbent on physicians whose duty it is to I relieve mental and physical suffering, to investigate and adopt any new ideas which tend to remove suffering. This is peculiarly their duty with regard to anything which tends to benefit “those most pitiable and afflicted children of men” whom we term insane. I desire partic- ularly to call attention to certain reasons why female physicians have a beneficial influence on the female insane; and, as chairman of the Chicago Medical Society's Com- mittee on the Cook County Insane Hospital Abuses, I shall incidentally allude to the confirmation Dr. Kiernan's charges made before this Society, October 19, 1885, have received from the State Board of Charities' Report. In the year 1876 Dr. Hiram Corson, a leading Penn- sylvania physician, observed that the insanity of the female patients of insane hospitals was tinctured by sexual delusions concerning the male assistant-physician. These delusions were more particularly present in cases in which • Read before the Chicago Medical Society, April 18, 1886. [ 21 ] 22 Paoli— Kiernan. gynæcological examinations had been made by the male assistant. Independent observations in the same direction were made by Dr. H. R. Stiles, Superintendent of the Middletown, New York Insane Hospital, and Dr. Spitzka, of New York. These observations led Drs. Corson and Spitzka to strongly advocate the appointment of female assistant- physicians in insane hospitals. Dr. Stiles experimented in the same direction, by the appointment of a two-year female medical student to make gynæcological examina- tions. Of the scientific basis for these observations, there need be no doubt; in insanity, the restraints which the gradual development of our race have thrown around the passions, disappear, and the savage in man appears on the surface. The female insane are, therefore, peculiarly sus- ceptible to any influence which might weaken the checks, already tottering from disease, and true therapeusis requires the removal of such influences. Examinations by male physicians of insane females, in whom sexual ideas are dominant, both from the weakening of checks and the exaltation produced by disease, are therefore unphysiological. How well the female physician in insane hospitals has fulfilled her mission, is shown by the recognition which the labors of Dr. Margaret Cleaves, Dr. Alice Bennett, and Dr. Jane K. Garver have met with, at the hands of the profession. Female physicians are now re- quired by law in many States; in every State where psy- chiatry is really a science and not the creature of politics, the insane hospital inedical staff contains a female. Even in States where competitive examination has accidentally opened the door to the appointment of a female physician, on the score of qualification rather than sex, the results have been such, that honest, but hitherto biased medical superintendents, have borne strong testimony to the value of female assistants. Dr. Richardson, of Athens, Ohio (Report for 1884), after an accidental and somewhat undesired experience, says, “ I believe that the treatment Female Physicians in Insane Hospitals. of the female insane can be more successfully accom- plished by female physicians, than by male, with the same qualification and adaptation for the work.” Dr. Stephen Smith, the New York State Commissioner in Lunacy, who entered upon his duties with a bias against female physicians, has so strongly reported in their favor, that an act was lately introduced into the New York State Legislature requiring every state and county insane hospital to appoint one female assistant physician, where there are more than one hundred insane females. In favor of female physicians in insane hospitals, we have the strong opinion of representative medical men, Drs. Corson, E. C Spitzka, W. A. Hamniond, T. A. McBride, L. C. Gray, E. C. Seguin, U. J. Morton, and the rest of the New York Neurological Society's Committee on Insane Hospitals ; Dr. H. R. Stiles, Dr. Godding, Dr. Richardson, Dr. C. H. Hughes, Dr. D. H. Tuke, Dr. Jewell, Dr. Brower, Dr. Palmer, Dr. Dewey, Dr. Goldsmith, Dr. J. H. McBride, Dr. Stephen Smith and others, the result of experience in Massachusetts, New York, Pennsylvania, Ohio, Indiana, Illinois, Iowa, Wisconsin, California and other insane hos- pitals and a strong physiological reason. Against these facts it is urged: first, that the argument in favor of female physicians is made by females desirous of unsexing themselves; second, that female physicians are apt to gossip and become capricious; third, that they are apt to become insubordinate to the medical superintendent. Had the first of these objections really an existence, it would not deserve consideration, but the movement in favor of female physicians in insane hospitals originated with scientific men; one of them the superintendent of an insane hospital, who had at heart the advancement of science and the welfare of the insane. Sex prejudice finds nothing here to rest upon. That men are equally capricious with women cannot be denied, and if any sex approaches the angels, it is surely the female. This second argument was, however, advanced by two distinguished advocates of “fine work” in politics, Messrs. Van Pelt and J. J. 24 Paoli-Kiernan. McCarthy; their objection seems to be, that female physicians will not tamely submit to maltreatment of those under their charge.* An historical recapitulation is necessary to fully understand their position. In 1882-3, the female death rate in the Cook County Insane Hospital was twenty- four per cent., two per cent. greater than the male. The usual relations between male and female death rates in insane hospitals is here reversed, and, according the law laid down by Dr. Bryce, of Alabama, this would denote greater abuse of the females than males. How great the abuse, is shown in the fact that the New York county insane hospital had a female death rate of nine per cent. and a male death rate of eleven per cent.; the Cook County female insane must, therefore, have been horribly neglected in 1882-3. In 1883-4, the female death rate sank to seventeen per cent., while the male remained the same. Dr. Delia E. Howe had meanwhile been elected assistant-physician, and how effectually she performed her work, is shown by this enormous decrease in the female death rate, when it is remembered that she had to take clothing from her bed to supply patients suffering from cold, and that the patients were so thinly clad in winter as to prevent them taking any exercise in the open air, and to occasion great suffering inside the house, whenever, for any reason, the supply of heat was inadequate; and that in 1884, before the introduction of direct radiation, it was impossible to heat the building properly; and, even after that improvement, the thermometer in some of the wards was at times as low as 55° F., while the heating was unequal, sometimes insufficient, and at other times exces- sive; that there were four rooms in the west wing, into which it was impossible to force hot air; that the supply of quilts and blankets was scanty; that the cooking facil- ities were (and are) insufficient, that it was (and is) impos- • They have since recanted, appointing a l'emale physician, with political influ- ence, destitute of any knowledge of psychiatry. Female Physicians in Insane Hospitals. 25. sible to serve anything but a boiled dinner, which is not properly cooked but parboiled; that the great article of diet was pigs' heads, boiled without being shaved or cleaned; hogs' ears, with the hair on them, were often set before the patients to eat; that bunches of hair, half as large as a little finger, were to be picked out from the patients' food; that dying patients were fed on sour milk ;- that the milk, which is so great a necessity in the treat- ment of the insane, was almost never fit for use; that they had meat never more than once a day, and often not that;. that the meat frequently stank; that incidents like this were frequent: Mr. H. observed it one day, when its appearance led him to ask the butcher, “ What do you do with that?” “That's for the cranks.” “In the name of goodness, you don't cook that for them?” “Oh, that's. good,” he replied, “they don't know the difference.” That patients died from innutrition, owing partly to their own indisposition to take food and the neglect of attend- ants to feed them; that the service was (and is) bad and the table furniture generally uninviting, black and dirty tin cups being used on many of the wards; that the con- duct of the patients at their meals was disorderly. When it is also remembered that sedatives and restraint were (and are) used at the discretion of the attendants, astonishment is naturally created, not at gossip, but that Dr. Howe could do such good work, under such disadvan- tageous circumstances, as was shown in the enormous decrease in the death rate. Dr. Howe has now been nearly two years at the Kankakee Insane Hospital, and nothing but praise has been heard from the authorities of that institu- tion; she neither "gossiped " nor was “capricious” there. That institution is run for the benefit of the patients, and no complaints need be made to its authorities about drunken male and female attendants, brutal housekeepers, drunken, brawling engineers, or a gin-mill drug-store. To the authorities of that institution, such things, as in most American insane hospitals, are an abhorrence. Of Dr. Howe's successor, Dr. H. C. B. Alexander, 26 Paoli-Kiernan. the same thing, in a minor key, could be told. One in- cident will suffice for illustration. A Miss Finerty had been cautioned that a certain patient was not to be left alone in the ward, but taken out when the rest were. She disobeyed, left her in the room, and while there she hung herself. In consequence of this suicide, there was an investigation by the Committee on Charities, when the warden and Commissioner Van Pelt said that she should be discharged, but Commissioner J. J. McCarthy said that she should not be, and she was not. As a result an examination into the food was made, and the cook was asked if the food was always good, and, despite the fact that there were twenty cases of scurvy in the house that day, answered Yes, whereupon Dr. Alexander held up an iron-ringed, unwashed snout of a pig suffering from catarrh, and asked if that was a specimen of the good food ? whereupon Mr. Van Pelt asked for her resignation. Enough has been shown to indicate the desirability of female physicians in insane hospitals with female patients. II. THE DISADVANTAGES. BY DR. KIERNAN. As I was one of the Committee of the New York Neurological Society, which endorsed Dr. Corson and Dr. Spitzka's proposals in regard to female physicians, and as it was in consequence of suggestions from me that Dr. Clevenger set in action the influences which resulted in Dr. Howe's election* as assistant-physician, I cannot be suspected of an animus against the principle enunciated by Dr. Paoli; yet I am ready to confess there are decided disadvantages in the appointment of female physicians, which do not exist in the case of male physicians. Dr. J. P. Grayt has recently expressed very strong and de- • Which was directly due to the labors of Mrs. Helen S. Shedd, who made to, very happy selection of Dr. Howe, to initiate the employment of feniale physicians in Cook County. American Journal of Insanity, April, 1881, p. 395. Female Physicians in Insane Hospitals. 27 cided objections to a mixed staff as he designates it, but, a priori, these objections are such as would lead inevit- ably to a conclusion that there was a danger to morality in associating male physicians and female nurses. The argu- ment, Dr. Gray says, against male physicians in female wards is equally applicable to general hospitals and general practice, and if carried out, would inhibit all practitioners from having anything to do with diseases of women. It would simply amount to the State's forcing upon women patients a kind of medical service which they never before employed, and to which many of them would strenuously object. As has been shown already by Dr. Paoli, insane women, however, differ very markedly from sane women. The in- hibitory centers of the sane woman are in full play, and she is able to control many manifestations which come to the surface in insanity. It should also be remembered that there is strong feeling among Europeans, with whom ideas of feminine ascendancy are by no means received with ac- ceptance, in favor of the employment of midwives rather than physicians. Dr. Ray* has said that it is, in the treatment of insanity, necessary "not to overlook or undervalue, collateral, sub- ordinate conditions. * * * Mental disease may some- times be continued indefinitely by the persistent influence of sexual organic disorder.” It is, therefore, desirable to sometimes make gynæcological examinations; and, as was long ago pointed out by Storer, and fully demonstrated since, these are not unlikely to form the basis of sexual accusations, dangerous to the fair fame of an hospital. The same is true of other physical examinations in insane women. Dr. Gray, therefore, does not advance any argu- ment, which, in my opinion, is not already met in Dr. Paoli's article. The disadvantages I have observed, differ widely from these. As superintendent of an insane hospital I have had experience with two female physicians. The • Quoted by Storer-Insanity in Women. 28 Paoli—Kiernan. first physician, Dr. Delia E. Howe, was emphatically a physician. To her ideas of her duty as a physician, all other theories were subordinate. She was a psychia- trist in the best sense of the word; self-sacrificing, con- scientious, skillful, and devoted to her duty and to the preservation of the authority of the medical head of the institution. My second female assistant, appointed in consequence of the efforts of myself and friends, upon the resignation of Dr. Howe, was equally conscientious and unselfish, but was a woman (using the term in the sense of one of those who desire feminine ascendancy) first and a physician afterwards. To secure the good-will of the minor political magnates, there was no principle of true insane hospital management, which she was not pre- pared to sacrifice. I had strictly forbidden restraint without a physician's orders; she allowed it to be used by attend- ants at discretion, and the same is true of sedatives. She granted politicians privileges which were inconsistent with the welfare of the patients, and which had been strictly forbidden by me, as they are in all well-managed insane hospitals. In all this, she was unselfishly trying to secure a position for female ascendancy in the minds of politicians.* From the same sense of its being her duty to main- tain female ascendancy she neglected to report many instances, in which neglect of duty on the part of female attendants occurred. In one instance, for fear of lowering the general standing of the female attendants, she made no report of a female attendant who took two female patients to a liquor store and treated them there. Now the first necessity in an insane hospital is proper discipline. To secure this, the physician must be supreme in the establishment. A lady of the character just de- scribed, has a bad moral influence on the discipline of an institution, , and the more conscientiously unselfish she is, the more danger to the welfare of the institution, • It is but just to say that this lady was as capable and even more self-sacri. ficing in her way than her predecessors. She was a society woman, who accepted the place purely from ideas of duty, without reference to the piltance paid her. Female Physicians in Insane Hospitals. 29 since she is likely to be associated with some association of determined advocates of feminine ascendancy. The male physician is not so situated. Since I have been an advocate and am a strong be- liever in the principle of female physicians, I have thought it but just to present these disadvantages, so that others may select the good and avoid the evil involved in the appointment of female physicans in insane hospitals. Dr. D. H. Tuke has well summed up the truth of the matter when he says,* "I am, on the whole, disposed to reckon among the advantageous courses pursued by the Americans, the appointment of lady physicans in some of their asy- lums—a practice which is certainly growing. * * * * I would go further, and say that if the lady doctors of the future should be equal in ability and high moral char- acter to those who have hitherto held office, and, if their position is so clearly marked out as to prevent all clashing with other members of the medical staff, they will prove a decided blessing to the female patients in asylums and a real help to medical superintendents.” • The Insane in the United States. Psychological Aspects of Three Cases of Infanticide Considered in their rela- tions to Forensic Medicine. By EDWARD C. Mann, M. D., Brooklyn, N. Y., Member of the Medical Society of the County of New York; New York Medico-Legal Bociety; Associate Editor of the New York Medico-Legal Journal, eto. THESE three very interesting cases, which the writer studied very thoroughly, for the reason that he appeared in each of the trials as the expert for the defence, were conducted on different legal bases and involved three distinct points in Law and Medicine, aside from general considerations on infanticide, which of course came out in these trials. These cases are all of interest, involving, as they do, questions likely to be asked of the medical jurist or expert at any time in similar cases. The first case is that of The People vs. Nelly Van- derhoof, tried before Judge Van Brunt, New York Supreme Court (Oyer and Terminer), April 9th and 10th, 1885. The defence was epilepsy. The second case, that of The Peo- ple vs. Kate Harvey, in the same court. The defence in this case was the insanity of seduced and deserted women. The third case was that of The People (State of Pennsyl- vania) vs. Miss Le Bar, tried before Judge Howard Reeder, at Easton, Pa., October, 1885. This case was ably de- fended by Hon. W. H. Kirkpatrick, of Easton, Pa., on the ground that the child was not born alive, and that it had never breathed as alleged by the prosecution. It was claimed by the defence that, first, there were no evidences of live birth prior to and independent of, respiration; and, second, that there were no evidences of live birth subse- quent to and deduced from respiration. In two of these cases the verdict of the jury was for acquittal and for the defence. In the second case, that of Kate Harvey, unfortunately for the prisoner, I was not [3)] Forensic Medicine. 31 applied to until after the trial was over and the prisoner about to be sentenced. I then examined her and accom- panied her counsel to court and pleaded a modified responsibility for her, with the effect of obtaining for her a very light sentence. The defence might have won their case had they introduced expert testimony on the trial; but as the woman was absolutely friendless and very poor, the case was probably hurried over. arentlye mental por epilepsy.rted to CASE 1.—The psychological aspects of the trial of Nelly Vanderhooff, held in New York, April 9th and 10th, 1885, for the murder of her newly-born babe. Medico- Legal Relations of Epilepsy. During the latter part of the month of November, 1884, the defendant, Nelly Vanderhooff, aged twenty-two years, gave birth to a child. She had suffered from epilepsy from birth; the family were saturated with this disease; she was a young, unmarried woman, suffering from the strong moral shock of seduction and desertion, and the irritable conditions of the nervous system, produced by epilepsy; she also had, when we first saw her, a considerable degree of uterine derangement. When the writer examined her at the Tombs, she had apparently no realizing sense of the enormity of her crime, and the mental powers had become very obviously impaired, as the result of epilepsy. After investigating her mental condition, the writer reported to her counsel, that she was in his opinion irresponsible, and that epilepsy was the phase of mental disturbance that prompted the criminal act. During her past life she had been many times under the dominion of that blind fury so frequently exhibited by epileptics, immediately before or after a fit. Her mind was usually so impaired, that she was seemingly incapable of controlling the feeblest im- pulses of passion. She was laboring under a disease which almost always impairs the mind; she has a sister demented as the result of the same disease, a resident of one of the New York institutions for the insane. Her father is a case of dipsomania; her mother has twice at- tempted suicide. Such was the prisoner's mental condi- tion and her family history. Her trial took place before Judge Van Brunt, in the Supreme Court of the State of New York, New York City, April 9th and oth, 1885. The people were represented by Assistant District fion and suicide. "Slipsomania 132 Edward C. Mann. Attorney Fellows, who, in trying the case, deserves great credit for his enlightened and humane views respecting the exculpatory effect of the disease of epilepsy. In this trial the Hon. District Attorney not only did not by his professional act try to deprive the expert expression of opinion of its proper weight with the jury, but showed every courtesy, and went so far in his efforts to elicit the whole truth, and the matured convictions of the expert, as to suggest to the counsel for the defence that he would not object to Counselor Bailey asking Dr. Mann for his opinion, founded on all the evidence given at the trial, sup- posing it to be true. This was a step in the right direction, and showed a liberal and enlightened spirit on the part of the eloquent and able Assistant District Attorney. Dur- ing the whole trial this gentleman proved himself as humane and progressive in his ideas of the psychical states in epilepsy, as has Sir James Fitzjames Stephens, of England, in his lately published “Criminal Law," 1883, vol. II., p. 141. On the trial there was no attempt on the part of the counsel for the defence to break down the testimony, which proved the killing of the newly-born babe. For the defence the following testimony was elicited from the father and mother: Two aunts and an uncle were epileptics; that a sister Emma, who died at the age of thirty, was an epileptic; that there is a daughter living, and in confinement on Randall's Island, who is imbecile .and epileptic from birth. Both father and mother testified that the prisoner, Nelly, had epileptic fits during her infancy and childhood; wouid cry out and lose con- sciousness, and fall down. Later in life had these attacks with every menstrual period. Had always had impulses to violence, and would threaten people and strike them. Would have attacks of blind irresistible fury, without any adequate external exciting cause. Would threaten her mother; would become violent, incoherent and de- structive at times between the fits; were afraid of her at these times. During her pregnancy, was wild and inco- herent at times, and violent. Adelaide Sullivan, of 2290 First Avenue, was sworn, and testified that she knew Nelly Vanderhooff three years ago. She acted very peculiarly, sometimes acted very nicely, and then would become very angry and violent when no adequate cause existed for such action. “Did not become Forensic Medicine. 33 intimate with her; as I thought her queer.” The witness made up her mind that Nelly was crazy: had heard her talk fast and incoherently; her eye was wild and rolling at such times. She acted without apparent motive; had heard Nelly talk about cutting people's throats and express homicidal ideas. Mrs. L. Kesslar, of 2290 First Avenue, was sworn, and testified that the prisoner, Nelly, lived with her three months in 1882. Never thought she was in her right mind; called her “Crazy Nell.” Without adequate cause she would get into a terrible temper and talk incoherently and make wild gestures; have heard her make homicidal threats repeatedly; would complain of sleeplessness and headache; she would always lose her mental balance upon the slightest occasion. Both of these witnesses testified to having witnessed unusual and irrational conduct at times, and incoherence of speech on the part of the pris- oner. The writer was then sworn as the expert for the defence, and testified substantially to the following facts : Examined N. V. in jail this A. M., and thrice previously. Head hot, eyes suffused, face flushed, pulse full, hard and ninety, skin dry and harsh, tongue has been bitten frequently. Examined for uterine trouble. Found retroversion, with evidences of previous pelvic cellulitis ; complains of pain on top of head, which had lasted for some time; pain and dragging in lower part of the back; pain in the thighs, and leucorrhæa. Think she has had sufficient uterine derange- ment to produce some cerebral irritation. Consider her an epileptic with transitory homicidal impulses in the past and probably in the future. Epilepsy hereditary on father's side; mother a neurotic woman with melancholia associated with suicidal ideas. That epilepsy is a disorder of the nervous centers, the phenomena of which morbid state consist in seizures generally sudden in their invasion; preceded as a rule by well marked paroxysms, charac- terized by loss of consciousness (coming on suddenly), and attended by peculiar involuntary muscular movements, which are highly spasmodic and convulsive in nature; that 34 Edward C. Mann. there may be in this disease, loss of consciousness without evident spasm; that there may be loss of consciousness with local spasm only; that the cause of epilepsy is preeminently hereditary taint; there is generally a family taint present; that epileptiform attacks may be partial in nature and may not reach convulsive activity except as far as the mind is concerned; that there is an epileptiform state which mani- fests itself chiefly by irritability, suspicion, noroseness and peevishness of character, with periodical attacks of maniacal fury; that all kinds of doings after epileptic fits, from slight vagaries to homicidal actions, have one common character- they are automatic, they are done unconsciously, and the pa- tient is irresponsible; there is mental automatism; that elab- orate and highly compound actions may be performed when a patient is unconscious. With respect to epilepsy, it is ab- surd, as Echeverria has truly stated, to suppose that motive and calculation imply necessarily free will or soundness of mind; that great stress should be laid upon nocturnal attacks and vertigo; that the latter is more injurious to the integrity of the brain than any other symptom. That very frequently the presence of epileptic insanity is indicated, not by epilep- tic fits, but by the character of the mental disturbance, the paroxysmal gust of passion, the blind fury without an adequate cause ; thai mere epileptic vertigo or petit mal is quite as dangerous to the integrity of the brain as the grand mal, and even more so; that there is a masked epilepsy marked by eccentric acts or a sudden paroxysm of violence without a distinct epileptic seizure; that there are in epilepsy, from time to time, attacks of mental excitement accompanied by homicidal impulses, which appear to take the place of the ordinary convulsive attacks; that when mental symptoms appear to take the place of a fit, there is, as Hughlings Jackson has au- thoritatively stated, a transitory epileptic paroxysm; that Delasiauve, Trousseau, Falret, Morel, Echeverria, Baillarger, Castlenau, Tardien, Dagonet, Browne, Jackson, Ray and Bucknill and Tuke all agree as to the irresponsibility of epileptics. Forensic Medicine. 35 HYPOTHETICAL QUESTION FOR THE DEFENCE. Take the case of an individual descended from en- feebled parentage-derived from a race in which insanity and epilepsy were hereditary, the victim from birth of diur- nal and frequent nocturnal epileptiform seizures, occurring all through infancy and childhood, and later accompanying each menstrual period, who, after months of intense mental agony, emotional disturbance and sleepless nights, suffering meanwhile with a disease peculiar to women, struggling with alternate hope and fear concerning the probability of a promise of marriage which had been made, being kept; suffering from constant headache; whose judgment and memory have become impaired; who has become, as the result of disease of the brain (epilepsy), irascible, passionate and violent; who was seen to present a wild and staring gaze, and who was seen frequently to mani- fest paroxysmal gusts of passion and blind fury without an adequate cause; who has been heard frequently to ex- press homicidal and suicidal ideas; failing to give ordinary recognition to conversation, when met at various times; acting in an unnatural and irrational manner, incoherent at times; who passes through the throes of pregnancy and parturition; who, after going up and down stairs re- peatedly in an automatic manner, finally sees a knife, and kills her new-born babe; who, immediately after the killing, was calm and absent-minded, made no attempt to escape or to deny the killing; who was careless, unconcerned and unmoved in the midst of intense excitement; and who, during some days prior to the killing, had taken but little nourishment, and was sleepless and who had suffered much previous to the killing from epileptic vertigo; was that individual, at the time of the killling, in your judgment, laboring under such a defect of reason as not to know the nature and quality of the act she was doing, and not to know that the act was wrong? Answer.—She was. The trial judge charged the jury that they had heard 36 Edward C. Mann. all the evidence in the case tending towards the exculpa- tory effect of epilepsy on the mind, and, that if they believed it to be true, it was manifestly their duty to return a verdict of “Not guilty," on the ground of insanity. This the jury did after five minutes' deliberation, without leaving their seats. CASE II.- The People vs. Kate Harvey, for the murder of her newly-born babe. The court acknowledges a modified responsibility as attaching to women distracted by conflicting feelings, guilty of killing their newly-born offspring, when they have been seduced and deserted, and in consideration of this fact mitigates the intended severity of his sentence. hen they sulty of her into women In this case, we have a young girl of nineteen years of age, without the safeguards of home and friends, seduced and deserted by the wretch who had promised to marry her, and who, torn by the distracting feelings incident to her shame and to parturition, undoubtedly drowned, in the bath-tub, her newly-born babe. Such women are hardly responsible for their acts we think, and had we been called upon the case early enough, we should have hoped to have been instrumental in securing an acquittal. As has been stated, however, the counsel made the fatal error of not introducing any expert testimony on the trial, and it was only when the jury had found a verdict of “Guilty," and the girl was to come up for sentence that I was applied to. I then proceeded to the Tombs and examined the prisoner, with the following result: she was nineteen years old, and of neurotic parentage. Her mother had been a life-long sufferer from cranial neuralgia; consumption and rheu- matism were plenty in the family. In my work on Mental and Nervous Diseases I have spoken of the cor- relation of morbific force in diseases, and that we often find phthisis and insanity running in and out in the same family. The prisoner first menstruated at the age of twelve years; always had experienced great pain at the top of the head at this time and much uterine pain. There were always pains in the back and limbs, of consider- able severity; was always sleepless at these times. About a month previous to the trial she acknowl- Forensic Medicine. was seda had night the head during all kne edged killing her baby; said that she did not intend to kill it; that her confinement came unexpectedly, and that she had a great deal of confusion of thought, and " that her brain was in a whirl;” said that she was taken with labor pains in the bath-tub, and could not get out; said that she tried to get out, but that the child was dead before she ſully realized what had hap- pened. Then she was afraid, and hid the child in an ash barrel. She felt sorry about it, and would rather the child had lived than not; said that her statement was taken in the hospital, and that she had so much pain and mental distress that she was not conscious of what passed at that time. It seemed now as if it were all a dream. She lived in New York, and was seduced under promise of marriage. She was sleep- less and had night sweats when we examined her; appetite very poor; the head was hot; said that she suffered very much mentally during all her pregnancy; was educated in the Protestant faith, and knew that mur- der was wrong, but was evidently in such a mental state at the time that, even supposing she had intended to kill her child, which she claimed she did not, she would have not been in a mental state where a calm consideration of right and wrong could have been possible. We accompanied the prisoner's counsel to the court, and although she was about to be sentenced, as the jury had rendered a verdict of guilty, were, by the courtesy of Judge Barrett, a man of habitual fairness, allowed to make a statement in the . prisoner's behalf. We claimed a greatly modified responsibility in these cases, and claimed the existence of the insanity of seduced and deserted women, as in many cases not only existing, but prompt- ing to acts of suicide and infanticide. Judge Barrett then said, that while such a statement should have been made during the trial and not after it, and while, after the ver- dict of guilty, he must do his duty and show the public that infantile human life must be protected and infanti- cide severely dealt with, yet, in view of all the facts of the case, he would pronounce a very different sentence from that he had anticipated, and accordingly did so, giving a very light sentence. The trial Judge in this case evidently felt that there was a degree of irresponsibility here that deserves the protection of the court, and had expert evidence been introduced at the proper time, no jury would ever have convicted the prisoner. ci de infantiles, he numot alter fint should udge Beaute prompt 38 Edward C. Mann. CASE III.- The People (State of Pennsylvania) vs. Miss C. Le Bar. This case was tried in Oct., 1885, at Easton, Northampton Co., Pa., before Judge Howard J. Reeder. The prosecution in this case proved that a child had been born and that its birth had been concealed. These facts were not denied by the defence. The prosecution, moreover, claimed that the prisoner had murdered her newly-born babe. This the defence denied, claiming that the child was not born alive. The questions brought up were, the degree of maturity of the child; the question as to the child being born alive; if alive, how long did it survive its birth? how long it had been dead when found, and the cause of death? The great question with the defence was: Was the child born alive ? and they claimed not. The child was found in a vault behind the house. There were no marks on the body of the child, which could have been inflicted while the blood was still circu- lating, and the prosecution did not claim that death had been produced in any other way than by throwing the child in the vault to die. The prosecution relied as a test of live birth upon the hydrostatic test, or buoyancy of the lungs when placed in water. The prosecution also asserted extra-uterine life from the fact that the umbilical cord was found to be shrunk and mummified. The writer claimed for the defence, that the latter fact was not of the slightest value as a proof of extra-uterine life. That it happens with portions of the cord cut off and exposed; that it was not a vital process. Respecting the allegation of the prosecution of the fact of buoyancy of parts of the lungs as conclusive proof of live birth, we objected for the defence, that the buoyancy of the lungs may be due, not to respiration, but to emphysema, to putrefaction or to inflation. We claimed that many illegit- imate children are born dead from natural causes. That protracted labor, premature birth, congenital want of power to breathe, loss of blood before or after birth and com- pression of the cord may cause death before, at, or soon after birth. That malformation or diseases of important organs lead to the same result, and that no proper exam- ination was made by the prosecution to see if such a thing had happened. That the child might easily have died of neglect during its birth. That no woman is com- petent to attend to her child, alone and unattended, as . Forensic Medicine. 39 this woman did, and that it had been proved that the prisoner was taken in labor, alone and unattended. We asserted that the marks of respiration were wanting; that there was no testimony on the part of the prosecu- tion to prove the appearance of developed air cells on the surface of the lung which is characteristic, and which furnishes undeniable proof either of respiration or inflation. That these groups of developed air cells are bright ver- milion-colored, and that it was the only lung test to which no serious objection can be offered. The witnesses for the prosecution testified that the true skin was more or less extensively discolored, and that the surface of the body was slippery. We testified that we should expect just such a state of things when a child had died in the womb. That these were marks of intra uterine macera- tion. We showed that in imperfect respiration the changes in the size and shape of the chest (becoming after respi- ration larger and rounder) did not occur, and had no independent value as a test of respiration, as also the change in position of the diaphragm (becoming flattened and depressed instead of arched and high). That also altered positions of the lungs and altered consistence of the lungs, although corroborative of other evidence, had no independent value as tests. That respiration might take place before delivery and complete separation, and yet the child die during the delivery at or shortly after birth. That the stomach in still-born children is lined with a glairy mucus, free from air-bubbles, but after respira- tion contains saliva, and air-bubbles swallowed during the establishment of respiration. That later it may contain milk or farinaceous food, proving that the child was born alive and had lived long enough to be fed. The milk may be identified by the microscope and by Trommer's test, as used for detecting sugar in urine. This test gives characteristic results with the whey and curd of milk; that the large intestines in mature still-born children are filled with meconium. Its complete expulsion would af- ford a probability that a child had survived its birth. The question as to how long the child survived its birth was not touched upon. We testified that the changes in the cord of the child were merely the common consequences of putrefaction, and of not the slightest value as a proof of extra-uterine life; that the best test of extra-uterine life, as regards 40 Edward C. Mann. the cord, is the presence of the bright red ring surround- ing the insertion of the umbilical cord, and that no such appearance was testified to by the prosecution in this case. We also testified in conclusion that the cause of death might be due to the infant being immature and feeble, that the infant night encounter obstacles to the continuance of respiration, even if it had been born alive, or that in a similar event congenital disease might shorten life. That the congenital disease in any given case might have its seat in the heart, the lungs or the brain. The prosecution did not claim that death was due to violence, so that there was no occasion to look, as we some- times have to do, for punctured wounds of the fontanelles, orbit, heart or spinal marrow, dislocation of the neck, extensive fractures of the bones of the head, or for suffo- cation or strangulation, the signs of which are apparent to a skilled observer in any given case. On the other hand, the defence did not deny that the woman had been recently delivered; so that this question and the allied one as to whether the period of the woman's delivery cor- responds with the time at which the child is supposed to have been born, were not, in this case, at all for discussion. The question of puerperal insanity was not raised, although really in this case the state of the mother's mind was somewhat problematical. The jury returned a verdict of “Not guilty ” without leaving their seats. The person whose mental unsoundness is suspected should 1. Be examined as to his past history and that of his family. Insanity is generally hereditary, although not necessarily so. 2. The examination of the patient, if not showing hereditary insanity, may show other neuroses or nervous diseases, such as epilepsy, chorea, paralysis, hysteria, ver- tigo, etc.; either in the suspected insane man or woman, or their family. 3. There may have been a change of habits or dispo- sition, the result of injuries to the head, sunstroke, fevers or spyhilis. The existence of disease of the lungs, heart or kidneys is also important. 4. Examine as to the mode or manner of the crime. Forensic Medicine. 41 Many sudden, motiveless, peculiarly atrocious murders are the work of epileptics. Did the criminal attempt to con- ceal the crime or himself? The physiognomy, attitudes and gestures, the words, manner of speaking and writings, the physical condition as to sensaton, 'muscular power and organic functions, should all be carefully examined by the expert who examines a criminal for insanity; and if on a trial, the lawyer for the defence, on cross-examination, elicit the fact that the experts for the prosecution have neglected such inquiries, they should, and properly, claim that evidence based on an examination ignoring such careful procedure, is untrust- worthy and not entitled to weight with the jury. It is preposterous to see, as lately happened in New York, a man who had never personally examined a criminal, testify against him when on trial for his life. Such things should not be allowed. What is wanted is an expert opinion founded on a personal examination of the criminal in whose behalf the plea of insanity is raised, and also on the whole evidence of the trial, provided the expert has heard it all, as he should do. The physician's examination should be very search- ing as to the prisoner's mental condition, and as to amatory ideas, religious ideas, ideas of property, ideas of an ambitious kind, and as to ideas on social subjects. The memory should be very carefully tested. The lawyer who proposes to defend a criminal case, and who alleges insanity as a plea for defence, should learn, as thoroughly as possible, the whole life-history of the criminal. He should ascertain whether there has been a change in the habits or disposition. He should, through a physician, always have the most careful examination of a probable insane patient; peculiarities of residence or dress; the appearances, demeanor and general conduct of a person; the peculiarities of their bodily condition. The peculiarities of gesture and expression of the countenance will generally, to an expert, show clearly either sanity or insanity, if not on one visit, after a few careful examinations. 42 Edward C. Mann. Can see no objection, and can see many advantages, that would result both to society and to the insane, if, in criminal cases where insanity is to be the defence, the disease still existing or being claimed to exist, the court should, by legislative enactment, order the prisoner to be placed in the State Hospital for the Insane, that he might be under medical observation. Sunnyside Home for Nervous Invalids, 204 Leffert's Place, Brooklyn, N. Y. The Physiology and Phenomenon of Atmospheric Matter. By Henry Howard, M. R. C. S., L., England, Medical Superintendent of the Insane Asylum, St. Jean de Dien, Montreal, Canada. PHYSICAL science, or natural moral philosophy, is 1 the physiology of matter and its phenomenon. By the term “ Physiology of matter” is meant the knowledge of the elements that compose the matter. By the term “Phenomenon” is meant the functions, forces, or different conduct of the matter. All matter—the matter of the whole universe--is one, only differing in degree; so does it differ in phenomena, which is always depending on the physiology of the mat- ter. Again: The effects of the phenomena of one degree of matter upon the phenomena of another degree, de- pends very much not only on the difference of degrees, but upon their localities. Again: The phenomena or conduct of matter generally leads to its physiology, but not always. For example: It is very doubtful if the physiology of either the SUN or moon is known to any physical scientist, although many of their phenomena are known to the whole human race; that is, upon our little planet. All know sunlight and moonlight-all know sun heat, and how it varies as our planet is differently located. Astronomers, who are physical scientists, know how that the phenomenon of the sun and moon affects the sea. The sun, by its conduct, causes the wind, which forces the sailing ship to sail across the sea. Again: The sun, by its heat, in the past ages, made the coal, which now, by the heat it creates when burning, causes the phenomena, force, or conduct, which creates the steam which brings a ship across the sea, even against the wind that blows. [43] 44 Henry Howard. As to the moon's force upon the sea, I shall quote from, our poet, John Reade : I've seen the ocean try to kiss the moon Till the wild efforts of his hopeless love Tortured him into madness, and the roar From bis great throat was terrible to bear; And his vast bosom heaved such awful sighs As made earth tremble to ber very bones, And all her children cling to her for fear. I regret to say our very greatest astronomers know but very little of the physiology of the sun, moon, or any of the other planets, although much is known of all their phenomena or force, or conduct. On the other hand, other physical scientists are grad- ually learning the physiology and phenomena of all the matter upon and connected with our own little planet, whether that matter be dynamic, vegetable or animal, or- ganic or inorganic; and the knowledge is chiefly due to the phenomena of matter. For example: As a child advances in age, and gradually develops, we discover from the phenom- ena of its materia cogitans, that is its psychology, whether it is intellectual and moral or imbecile and immoral. If the former, it is a general proof that the matter which composes the whole organization is physiological. If the latter, it is the proof that, at least, the materia congitans is teratological, that is mechanically deformed. If the phenomena be found to be intellectual, it will be proof that the matter is physiological, and as matter changes, phenomena changes, if for the worse, it will be proof, that from some cause, the matter has become pathological, and if the phenomena of teratological matter improves, it will be the best possible proof that develop- ment has taken place in some degree. This phenomena function, or force, is to be found in all animal matter, leading to its physiology. A similar phenomena, function, or force, is to be found in all other grades of matter, leading to their physiology. From experience and study this is most observable by the pharmacologist, in vege- Atmospheric Matter. 45 table matter, consequently no physical scientist will pre- scribe any medicine for the treatment of disease until he first knows the physiology and phenomena, function, or force of the medicine, no matter whether it be mineral, vegetable, or animal. matter. The physicist knows that if he prescribe without this knowlege, he is acting as an empiricist. Same, if he recopimend change of atmosphere, he must know why physiology of atmospheric matter, or of terres- trial matter, or of the matter of some of the other planets, that causes the change of force, function, or phenomena of the atmosphere, to make it suitable for his patient. The medical man, possessing such knowledge, might cure thousands of diseased persons, even insane ones, by or- dering change of air, without administering one dose of medicine. Not only this, but such a perfect physical scientist might discover the cause of all contagious and infectious diseases. As yet no man has gone so near to the mark as the great philosopher, Professor Tyndall. For the future I shall devote my spare time and writ- ings to matter, its physiology, phenomena, function, or force, and its pathology. I have more than once done my best to give physical proof, not only from my own experience, but from the writings of others, that subjective mind was not an entity, but the phenomena of matter, to which matter for some years I have given the name materia cogitans, not because I considered it had no other function but mind, but be- cause that for so many centuries mind was believed to be an entity, only known to the metaphysicist or super- natural philosopher. I now wish to point out that this thinking matter, which in the animal, is the brain, spinal marrow, and the whole nervous system, has other phenom- ena than thought. For example: Vitality belongs to it; there is no animal vitality without it. Sensation belongs to it; consciousness belongs to it; intelligence belongs to it; perception belongs to it; motion belongs to it; seeing, hearing, tasting and smelling belong to it; breathing is 46 Henry Howard. dependent upon it; circulation of blood, as well as molec- ular animal circulation is depending on it; digestion de- pending upon it; even procreation depending upon it, and because of all these forces, functions, or phenomenon that this matter contains, we must conclude that by its phys- iology and phenomena it is, to govern health, life and conduct. All its functions have been well proven by the scientific etiologists, together with the scientific anatomists, the scientific clinicists, the scientific pathologists, the scientific chemists, the scientific microscopists and the scientific morphologist. The great labor of the latter is, to find out the great affinity there is between animal and vegetable organisms, and the affinity there is between higher and lower animals in their organization. The student of nature's laws will observe, from what I have just written, that no man has a claim to the title of physician, who is not, in a great degree, a physical scientist. He will also observe how necessary is the knowledge of the physiology of man, before anything can be known of pathological defect of man, or any at- tempt made to treat it. It is because of our great igno- rance of the physiology and phenomena, not only of animal and vegetable organisms, but of all matter, that we have so much disease and death in the human race. True, that there are hundreds of diseases that are either contagious or infectious, but that fact does not account for the etiology, that is the origin, of contagious or in- fectious diseases, and that is the great knowledge that is required, which knowledge can never be obtained without the previous knowledge of the physiology and phenom- ena of matter. With such knowledge, pathology is com- prehensible. That a peculiar germ is the cause of phthisis, of ty- phoid fever, of cholera, of yellow fever, of pneumonia and of septicæmia, is now pretty well recognized by all physical scientists. Indeed, I believe it to be the cause of thous- ands of cases of mania, because I cannot account for the change that takes place, in any other way. Atmospheric Matter. 47 But after all that has been written by the most scientific men on the germ-theory, we don't know yet where the germs come from, or why they all differ, and all produce different diseases. Perhaps one of the best authorities on the germ-theory is Pasteur, but for the cause of the germ, it appears to me, to discover this, more has been done by Professor Tyndall than any other man in the world, yet I don't think that he has done all that is required. True, he has proven by hundreds of experiments, that the atmos- phere, that surrounds our little planet, is filled with floating matter, that is always undergoing molecular motion. That said matter can be burned by flame, yet that it is the pres- ence of this matter that causes the great planet, the sun, to give our little planet light; in fact, without this atmospheric matter, we would be in perpetual darkness, for it acts on the light of other planets, as it does on the sun. He has also proven by his experiments, that although this atmosphere is composed of oxygen, hydrogen, nitrogen and carbonic acid, yet this floating matter which it contains will, under certain circumstances, cause organic matter, whether animal or vegetable, to undergo change; to be- come putrefied and cause vitality. This evidently accounts for living germs, for the belief in bacteriology. But it does not account for the great variability of germs in their appearance, or in producing different diseases in both animals and vegetables. * In the fall of '54, and the winter of '55 and '56, our whole good city of Montreal was rather surprised by the subjects of cholera and small-pox; cholera, however, did not make its appearance, but certainly there was sufficient of small-pox. All recognized that both diseases were con- tagious, but all were partially ignorant of their etiology. I then read a short paper before the Montreal Medico- Chirurgical Society, which I entitled " Atmospheric Materies Morbis," from which lecture I now quote the following: "We don't know, and perhaps we never will know, what were the characteristics of primordial 'matter; whether if atoms or molecules, or both atoms and molecules. *Should read: “ In the fall of 1884, and the Winter of 1885 and 1886,” etc. 88 Henry Howard. “But this physical science teaches us that matter as it now is, is one, only differing in degree, and that it is indestructible; that mineral matter furnishes the material for the production of vegetable matter, and the vegetable for the production of animal. This evolution of matter shows how it is that all matter is one, differing, however, in degree, both structurally and chemically; and as it dif- fers in degree so must it necessarily differ in its phe- nomenon, forces, functions or conduct. “Mineral matter, in itself, differs in degree, structurally and chemically, and the same can be affirmed of both vegetable and animal matter, and we judge of the physi- ology of each degree by its phenomena or conduct. Therefore, we place the nervous system of man in the highest degree of matter because its phenomenon is higher than the phenomena of any other matter, even the nervous system of other animals. “Under the foregoing circumstances, let us consider what is meant by the term atmospheric materies morbis. Do we mean that there is matter floating in the air, either mineral, vegetable or animal, which is of itself a morbid or destructive matter, when coming in contact with either vegetable or animal organisms, or with both vegetable and animal organisms? “There is no physical proof that such would be the true definition of the atmospheric materies morbis. “Is it the phenomenon, force, function or conduct, of this floating atmospheric matter, to whose morbid effects we can attribute results we consider to be due to an atmospheric materies morbis? It is impossible; for if such were the case, no living organism, be it vegetable or animal, could exist, surrounded with such destructive forces. I cannot conceive, nor do I see any proof, that there is any such thing as an atmospheric materies morbis till one is generated. "The great physical scientist, Professor Tyndall, demon- strated by the most conclusive experiments, that the atmosphere was floating with matter, which under certain Stad Atmospheric Matter. 49 circumstances, when it came in contact with other matter, generated a very low living animal organism. He also proved that another of its phenomenon was to transmit or conduct rays of sunlight to illuminate our planet; and again, that this atmospheric matter could be burned by flame-all these facts Tyndall established by experiments. But he did not demonstrate the physiology of the matter, or say whether it was mineral, vegetable or animal, or a combination of all three.” Now, when I gave my lecture, I was under the im- pression that this atmospheric matter was vegetable. I have since changed my views. More particulars by-and-by. It is in accord with well established physical laws, that latent forces in matter we are ignorant of, till two forces come in contact with each other, and then we have an explosion. It may be dynamite, it may be a fit of epilepsy, it may be an attack of mania, it may be a chick from an egg, or it may be a germ, a materies morbis, that, before its forces were exhausted, would slay its tens of thousands, but fortunately in time, these forces are exhausted, because the physiology of the matter changes. If I am correct in my physical views, I conceive that the atmosphere, of itself, is innocent of generating a materies morbis; but that it contains matter which, when coming in contact with suitable soil—the two forces meeting-result in a low living organism, which may or may not be, a materies morbis, a germ of disease. What this germ will be must depend upon the nidus which is the recipient of the atmospheric matter. It is only thus can we account for the different forms of germs—those of phthisis, of typhoid fever, yellow fever, cholera, pneumonia and septicæmia. Now I do not deny the fact that any germ, once formed, may not be carried from one locality to another, by means of atmospheric air, as well as by any other me- chanical means, such as water, the hands, or clothing ; but I do maintain that there is no physical evidence that atmospheric matter, or any other matter, can, of itself, 50 Henry Howard. generate a living organism, in other words, there is no spontaneous generation. It may be asked: Why, then, use the spray or any other antiseptic treatment in surgical operations? I reply that an open wound, caused by a surgical operation in animal structure, appears to be a most suitable nidus for atmospheric matter to come in contact with, to produce the germ of septicæmia, and the carbolic spray or other antiseptic, which has proven so successful in operative surgery, probably so changes the phenomena or function of the atmospheric matter as to prevent the generation of the septic germ. Moreover, no surgeon can be sure that there may not be septic germs in the locality in which he is operating. Unter any circumstances antisep- tic precautions can do nó harm. In Here it appears to me that the question naturally suggests itself: How so many persons fall victims to these germ diseases, such as typhoid fever, cholera, etc., while so many living in the same surroundings escape from these maladies ? It certainly must be due to the fact that the organs or tissues of the victims, with their functions, must from some cause, be in an abnormal state before being a recipient of the atmospheric matter. Where a nidus is prepared, that causes the evolution of the germ, whereas those that escape do so because they possess normal organs and tissues, consequently normal functions or forces, which will destroy a living germ that comes in contact with them. And under no circumstances will such organs or tissues form a nidus for atmospheric matter, or generate a germ. Germs are not generated in living healthy organs or tissues. The germ-theory has passed into a scientific fact, but I believe that the genesis of germs is as I have explained. dependent as much on the nidus as upon the atmospheric matter. It is the two latent forces coming together that create the germ, and upon the nidus depends the charac- teristics of the germ. Moreover, from the reasons already Atmospheric Matter. 51 given, I consider no germ nidus can exist in normal ani- mal or vegetable matter. Which of us have entered upon this world's stage of existence with normal organs and tissues ? And if any, have we so lived in accord with nature's laws as to main- tain, cultivate and develop those organs? If there be any, then, of such, I consider them proof against all germ diseases. These are they who live in plague-stricken cities without danger of disease. To guard against epidemics by means of quarantine and cleanliness is perfectly in accord with nature's laws, but neither would require to be enforced if all persons were properly educated in these laws. But what use of such precaution, if in our greed for riches we, hour by hour, and day by day, exhaust our nerve-forces by over- work and anxiety, not entering upon the field of labor, as all men should, to be in accordance with nature's laws, and to struggle for existence only, but to struggle for riches, affluence and power, and for the gratification of abnormal, selfish desires. Under such pressure it is no wonder that the nervous system, with all its phenomena, breaks down, and the subjects become victims to the first epidemic, to the first materies morbis that enter their sys- tem, either by means of the digestive or respiratory or- gans. Will quarantine and cleanliness alone save the worn- out and exhausted laborer, servant, tradesman, merchant or professional man, all of whom are slaves to labor, and taking but little rest to recuperate their lost physical forces? Will it save the overworked teacher, and school children, who are starving for air and exercise? What will it do for those whose very pleasures are of most exhausting na- ture, robbing themselves of the proper time to recuperate their lost forces, rushing half mad through the ball room when they should be enjoying “tired nature's sweet restorer, balmy sleep,” these poor slaves of a false social system, who have not the moral courage to live in accordance with nature's laws? And what will it do for the unfortunate 52 Henry Howard. inebriate? Quarantine and cleanliness alone will not save these people. Nature, tired of their unreasonableness, will do in the future as she has done in the past, slay these people with her epidemics: she will not be mocked. The people must choose between nature's laws or sickness and death, or worse still, folly and crime. Within the past year there has been very much writ- ing, and great discussions on the subject of cholera, but like all other medical subjects, with very few exceptions, it appears to me that medical men on these subjects, base all their reasoning upon .false premises. The old empirical school seems to me to have the same sway now that it had half a century ago, when I first entered the profes- sion, and it rather surprises me to see so very few of the young men of the present day that make physical science the basis of their medical reasoning. However, I suppose there are none now, but admit that there is a cholera germ, a toxic germ, that may generate in the manner I have explained, in certain animal organs or tissues, which, when generated, becomes a materies mor- bis, that may be taken into the system either by the respiratory or digestive organs. But what has never been proven, at least to my satisfaction, is as to the locality of the tissues that form the nidus for the atmospheric matter, which, with the nidus, produces the germ, or the germ already existing, where becomes its nidus, after it has been received into the system. There is no secret about the nidus of the germ of typhoid fever; not so with the nidus of the cholera germ. It has been assumed that it is in the alimentary canal, because of the fluid discharge from the intestines. But other symptoms don't justify such a conclusion. The general symptoms presented by the person dying of cholera, resemble the symptoms of a person dying from the loss of blood; there is the greatest analogy in both cases, and why, but that in reality the person dying from cholera does die from loss of blood-that is to say, the whole serum of the blood is poured out through the coats Atmospheric Matter. 53 of the arteries and ejected by means of the viscera, leav- ing only in the blood-vessels the red globules, which, being deprived of the serum, soon coagulates, arresting the heart's action, and resulting in death. Now what must take place before the serum of the blood is separated from red globules? Evidently it must be preceded by paralysis of the vasomotor nerves, causing paralysis of the vascular muscular fibers, particularly of the constricting fibers; then the vessels becoming relaxed, the serum of the blood being the most fluid, is poured out, while the red globules coagulate. So it appears to me that the action of the toxic germ of cholera is to cause paralysis of the vasomotor nerves, and all the other symptoms of cholera are the result of that cause. All this does not prove that the nidus of the cholera germ may not be in some part of the alimentary canal; and the vasomotor nerves be paralyzed from the poison from that source; but I think it more probable, although I have no positive proof to offer, that the nidus be in some part of the great vasomotor center, the great sympathetic nerve, or its ganglions. My object is to try and establish, as a fact, that the action of the toxic germ of cholera is to produce paral- ysis of the vasomotor nerves, and, consequently, that the treatment must tend towards restoring those nerves to their normal state. It seems to me that dropsy, from heart disease, bears some analogy to cholera, as in cholera, it is caused by serum being poured out from the blood-vessels, and in its last stage death is generally preceded by serous diarrhea. Is it not probable that here also we have pa- ralysis of the vasomotor nerves, and as digitalis has proved such a potent remedy in dropsy, might it not prove equally efficacious in cholera ? Dr. Stewart, in his very scientific lecture "On Digitalis," points out its valuable therapeutical effects upon dropsical effusion and in arresting serous diarrhea, and I presume it is by giving tone to the vasomotor nerves. He says: 54 Henry Howard. “the action of the digitalis on the circulation in full med- icinal doses may be summarized as follows: “1. It makes the ventricles beat more powerfully. “2. It makes them beat slower. “3. It contracts the arterioles. “4. It raises the blood pressure." Here we have physical phenomena produced by digi- talis, the very opposite or antagonistic to the phenomena produced by the toxic germ of cholera; therefore, it should be a remedy for that disease. But the question arises : Would the digitalis produce these therapeutical effects where the case was cholera poisoning ? I don't know. Unfortunately for the sake of medical science, that is a question to be answered with regard to the therapeutical effects of all medicine. From the well known action of ergot upon the vaso- motor centers and their peripheræ, we would naturally look to it as a remedial agent in cholera, and an electro- therapeutic treatment in the hands of an experienced electrician, appears to me worthy of consideration. In fact, any treatment that would be likely to restore the para- lyzed vasomotor nerves to their pristine state of constrict- ing vasomuscular fibers, should prove the best remedy for the treatment of cholera. My object in bringing this short paper before the Society, was an effort to stimulate dis- cussions on medical subjects from a physical standpoint. Medical empiricism has had a long reign, and it pays so well, it will be pretty hard to wipe it out, but in time it must give way to medical philosophy, the basis of which is physical science or natural philosophy. It is quite evident that having discovered some of the phenomena of atmospheric matter, we may proceed and learn more, which may finally lead us to its physiology and phenomena. This matter, which I presume unites all the planets, making all matter one, only differing in degree, so that the phenomena of all matter has some influence, for good or evil, upon each portion of other matter, for there is no proof that our little Atmospheric Matter. . 55 planet, or any other planet, is independent of other forces. The great physicist Tyndall has shown that one of the phenomena of this matter is to transmit to this planet the light of the sun. Therefore, I presume there can be no doubt but that it also transmits to it all the other lights received by it from all the other planets. It is a physical fact that without matter sound cannot be conveyed. There- fore I consider that another phenomenon of this matter is to convey sound. So we are indebted to it, that we hear one another when we talk, hear music, and even hear the thunder storm. There are some localities where we hear and even see, better than in others. Perhaps the cause for effect may be due to the difference in quantity of this at- mospheric matter's consistency, which will change the phe, nomena. It is possible that electricity in the atmosphere may be a phenomenon of this matter, which is atomic, and traveling with molecular motion. Again: Because of its rapid and perpetual motion this matter, which Tyndall, by experiments proved, with other matter became vital; may contain what is conceived to be objective mind; which may, in many instances, control subjective mind, without either minds having consciousness of the phenomenon, yet in some instances there may be consciousness in the sub- jective mind, but of the objective we know nothing. If objective mind be a phenomenon of any matter, it certainly must be of atmospheric matter, for we have sufficient proven phenomena to conclude that if atmospheric is not primordial matter it is certainly the allotropic modification of primordial matter from which this little planet of ours was, to a great degree, formed. From whence it came we have not as yet any scientific proof; but I presume it is matter detached from some of the greater planets—some say the sun—which keeps up supply with the growth of the matter we have, so that there is constant equilibrium in the planetary system. Whether I am correct or not in my views, one thing is certain, that the life, health and happiness of the human 56 Henry Howard. race on this planet, and of the whole animal and vegeta- ble matter upon it, is to a very great degree depending upon the atmospheric matter that surrounds this planet. Therefore the necessity of the physical scientist, to do all he can, to learn its physiology and phenomena, at least until it is as well known as the oxygen, nitrogen, hydrogen and carbon that is in our atmosphere. The physical scientist must recognize, that for effect there must be cause; therefore, that for the natural there must be the supernatural. But, whether this planet was formed from primordial matter, or from allotropic modifi- cations of primordial matter, we are perfectly ignorant. However, the more honestly we examine it and humanity, the more miserable we find all to be, and we are bound to recognize the great truthfulness of the metaphysicist and physical scientist Job, when he said: “Man that is born of woman hath but a short time to live, and is full of misery.” It is a natural law, which mankind, without any par- ticular education, recognizes the supernatural, and worships it, and always has, like ourselves, without comprehending it. But all the pagan philosophers worshipped him or it as the unknown God. They pretended to be metaphysical as well as physical scientists, and it was as such they rec- ognized the supernatural. While they used all their power as astronomers to discover the phenomena of the other planets, and see if their forces had much or any control over the phenomena or forces of this small planet, true that as physical, scientists, they did not know the physi- ology of other planets no more than they did of this, but they knew as we do, that all matter was one and of the natural order, governed by nature's laws, and although they gave great names to the different planets and what they believed to be their phenomena, and spoke upon the effects these forces had upon all the matter of this planet, particularly upon its animal and vegetable organisms, they did not believe that these forces were supernatural, but natural. I don't mean to say that those pagan philoso- Atmospheric Matter, 57 phers were true physical scientists or natural philosophers, but I am convinced that their great object was to under- stand matter and its phenomena, nature and her laws, yet they believed in the supernatural, that is, they believed in cause for effect. Now from my reasoning powers which I possess, I consider that we have lost much knowledge of physical science and of nature's laws, from the conduct of the pseudo-metaphysicists, who by their confounding the nat- ural with the supernatural, have led the human race astray. The sun shines, the winds blow, there is lightning and thunder, it rains, it hails, it snows, all in accordance with nature's laws, but the pseudo-metaphysicist calls it super- natural. There are, in both the animal and vegetable kingdoms, conceptions, births, developments, progress, decay, and what is termed death; all natural laws, but, unfortunately, declared by the pseudo-metaphysicist to be supernatural laws. Consequently, great injustice is done to the super- natural, when mankind dies in his youth, by thousands from various epidemics, for the cause is attributed to the anger of the supernatural. Again : Injustice is done to nature and her laws, when in truth, disease, sickness and death are due to the fact, that because of our ignorance, the human race is living in the breach of nature's laws. Were we living in obedience to her laws, there would be no sickness or suffering, and the change in man called death, would be looked upon as the greatest blessing, for it would be passing from old age to rest, passing from the natural to the supernatural. This we know from the fact, that matter, although it is always changing, is indestructible. Of course, no matter how strong our faith may be in the supernatural, it is to us incomprehensible, ontological and metaphysical speculation or thinking, is an attempt to deduce the true nature of things from our concept of them. Now, the moment we try to conceive or form a concept of the supernatural or of entity, some- thing without genesis, without beginning, we first conceive Henry Howard. a person, then by metaphysical reasoning, we try to deduce the true nature of the supernatural. This we find it impossible to do, because we cannot conceive as ob- jective anything else, only that which is of the ma- terial order. And no doubt but that, therefore, it was that Christ, when speaking of the supernatural, always spoke of matter; his language was purely material- istic. It was the same with the pagan physicists, and with the physicists of to-day, and as I have already said, no matter how strong may be our faith in the super- natural, we can only conceive and reason upon the materialistic, although we have no doubt of the super- natural. To return to the consideration of atmospheric matter: That trasmits planetary light to this planet; that transmits atmospheric sounds to this planet; that, by finding a nidus, is the cause of living germs, and disease and death, in the animal and vegetable organisms on this planet; that may have been thc primordial matter of this planet, or allotropic modifications of primordial matter; that probably is the only motive matter which contains objective mind, and perhaps with it intelligence; and therefore, that this matter, by depositing itself upon this earth, after it (the earth) was formed, caused the evolution of both vegetable and animal life, which, it appears have been always under its control. What is it, and where does it come from? It has been discovered that it can only be seen by sunlight, and that it is atomic matter with molecular motion; and chemistry has proven, that the air in which it is, is composed of oxygen, hydrogen, nitrogen and carbon. This atmospheric movable matter, seems to me to be the most extraordinary matter in nature, for by its motion it comes in contact with all nature. Its phenomena not only govern the hu- man race, but the whole planet and all that therein is. No doubt that this matter is combustible, but indestruc- tible, even by the forces of the other planets which this planet comes in contact with. The following proves this statement : Atmospheric Matter. 59 TAE AUGUST METEORS. A Brilliant Display Expected To-Morrow. - The best-bebaved of all the meteoric streams holds its anniversary on the 10th of August, and the few days preceding and following. “ The Tears of St. Lawrence," it is called, because it makes its appearance on the day sacred to the memory of that august saint. We call this zone the best- behaved of the family, because the fiery rain never fails to fall, and no one is disappointed wbo looks sky-ward when tbe shower is due and the clouds are kind. The tiny atoms of which it is composed are sure to im- pinge against the earth's atmosphere, burst into yellow stars, and descend with trains of silvery light. The August meteors consist of a swarm of particles following Comet II., 1862, in its orbit. The disintegrating process has been carried on so long that the debris of the comet are nearly evenly scattered throughout the gigantic eclipse in which they wander. One ex- tremity of the zone crosses the earth's orbit, and the other extends far beyond Neptune. The earth encounters the meteor zone on the 10th of August, and countless meteors falling from the skies attest the fact that the earth is then plunging full tilt through the swarming atoms. Last year there was an unusually fine show of the Persids, as they are called. It is well to be on the watch for the coming occasion, for such is the uncer. tainty of operations in the cometic family that a grand outburst is not impossible at any time. Therefore, observers should diligently watch the northeastern sky and the constellation Parseus, the radiant point about which tbe meteors congregate. The earth will plunge into the meteor zone as surely as sbe turns upon her axis, and if the fiery shower is un- usually brilliant, observers will be on hand to see the exbibition and count the meteors as they fall. Only those that start from Parseus are Persids. The sky is aglow with other meteor streams, radiating from other constel- lations, for more than a million meteors, large enough to be visible to the naked eye on a dark, clear night, fall from the sky every twenty-four hours.- Providence Journal. This beautiful statement would lead us to believe that the beautiful light meteors that traverse our atmosphere and strike our planet, were fire-were combustible matter; but most surely they are not, for they never cause com- bustion in the atmospheric matter that Tyndall proved was combustible. Moreover it has also been proven by acci- dental circumstances, if not combustible it would be impossible from natural laws, to give any reason for the manner in which fire sometimes spreads throughout a country. Such is no uncommon thing : on the contrary, it spreads so much that some religious fanatics call such fires miracles and a proof of the anger of God. Other fires besides meteors pass through this atmospheric matter without injuring it-electricity, for exampie. 60 Henry Howard. This atomic matter rapidly traveling by molecular mo- tion, like all other forces of matter, is indestructible. And it certainly appears to be the highest grade of matter that we, on this planet, know of--the highest matter in nature, even higher than the animal nervous system at least, if I have properly (with others) discovered its phe- nomena, which phenomena I believe will lead me, in some degree, to its physiology. If it is not the same as pri- mordial matter, it certainly is the allotropic modification of primordial matter. There appears to be positive proof that one of its phenomena is vitality, for where there is a proper nidus vitality is the result. It is possible then that from it came primordial vitality, not only to this planet, but to the whole planetary systems which it unites, mak- ing all matter one, although differing in degree. There is no sky but this atmospheric matter. From whence comes the great natural materialistic liv- ing force that is indestructible? The only answer I can give is, from the supernatural. But what that supernatural is, as a physical scientist, I cannot tell. I can only take cognizance of matter, and, generally, by its phenomena, learn its physiology. It ap- pears to me that the early pagan philosophers, although they believed in a special revelation, and that they were endowed as a priori philosophers, even those that existed long before the Greeks and Romans, had some physical ideas very like what I have just said, and it was there- fore that they recognized the great physical union there was between all the planets, and led them to speak so much of the physical effects of those planets upon each other, and upon man and all other animals, as they were conceived and born into the world; as they spoke of ani- mal organism so they spoke of vegetable also. These were the a priori philosophers who pretended to be met- aphysicists as well as physicists, studying nature and her laws. Has all this physical science disappeared ? Not at all. The most ignorant knows the effects of the sun upon the animal and vegetable organisms; that sometimes its Atmospheric Matter. 61 phenomena, or conduct, towards man, is to render him insane, or kill him. Again: How many are there that believe that, under certain circumstances, the phenomena, or conduct, of that great planet, the moon, is to render some persons insane? therefore the term lunatic. Some have laughed at this supposed phenomena of the moon. But, from twenty-six years of experience, I am satisfied that there are cases of mania where excitement is increased as the moon becomes developed. Let us go to the shepherd who has charge of sheep, and the cowherd who has charge of cat- tle, and listen to their physical science. They will tell of the moon's effects when sheep are going to yean, and the cows to calve. Aye, and how many men and women are there who have good reason to believe in the physical effects of the moon when a child is about to be born into the world. Let us next go to the educated cultivator of the land and see into his knowledge of physical science, although he may never have heard the term. We find how much he believes in the physical effects of the moon upon the grain he sows, and all the crops he grows; and how the moon affects the climate that so strongly controls his crops. Again: All men recognize the influence of the moon upon the tides as well as did our Irish poet. From all of these facts we must come to the conclu- sion that amongst the early pagans there were good phys- ical scientists, who were not spoken badly of by Christ, who respected them because they had natural religion, which was more moral, less hypocritical and less criminal than is the religion taught by the pseudo-metaphysicists of the present day. To return to the atmospheric matter, which I believe to be the living bond between the whole planetary system : I believe this to be its physiology, because of its phenom- enon or conduct, which is not only for this, but for all the other planets; therefore that all are material and homoge- neous. This I conceive to be an axiomatical truth which 62 Henry Howard. is of the greatest possible importance to the whole human race, because it will hasten the time when the human race will try to know and live in obedience to, nature's laws, as the only means of rendering the human race moral, happy, and consequently contented, while they remain upon this planet. There can be no manner of doubt but that one of the true methods for the physical scientist to discover the physiology of matter, whether the material mass be man or any other matter, animal or vegetable, organic or inorganic, is by scientists closely observing the phenomena, function, force or conduct of the matter. If physiological, or per- fect matter, in man or any animal, the phenomena or force, or conduct is good. If the matter is non-physiological, speaking mechanically, it is teratological; consequently conduct or phenomena is bad, no matter what the animal may be, it is a teratological fool. The same can be said of vegetable organisms. There is no doubt, but to know the physiology of man or any other animal, or of any plant, we must first know him or them anatomically, as far as it is possible, by comparison with the anatomy of the dead, not only the physiology of the materia cogitans in man, but of every particle of the matter we wish to know the physiology of. When we know the physiology that governs man's conduct, we know how far he is a responsible being. If his conduct is bad, he is not responsible, yet he is not fit to associate with those that are good, the good man being a physiological man, the bad, teratological or pathological. The pseudo- metaphysicist says man can form his conduct by his will. We know he can if he is a physiological man, but then the will is good; but the will is in some way bad, if the materia cogitans is teratological or patholog- ical. The anatomy, physiology and pathology of man prove that his will is of the natural order; if it were of the supernatural, it would rule the natural. The man who treats disease is the man of all others Atmospheric Matter. 63 who should know physiology of matter, or he cannot know pathology, which is disease. Here I repeat what I have so often said: that the more perfect the physical scientist, the more perfect the medical man, for he is the man of all others to compre- hend pathology of matter, when he has understood the the phenomena and physiology of it; and if this be true when speaking of the ordinary medical man, it is more so still, when speaking of the alienist and neurologist, the man who is called upon to say who is sane and who is insane, who is physiologically wise or teratologically fool. Judging the whole human race by its phenomena or con- duct, I must confess that to me, mankind appears to be greatly debilitated animals, not worth the notice of the supernatural, unless he has some object in view, incom- prehensible to the physical scientist, which the great metaphysicist, Christ, said he had, and I believe him. But as man is a changeable, developing and progress- ive animal, we have a right to expect that he will continue to develop and progress, till he becomes so far superior to what man is now, that it will be difficult for the scientist that will come, to prove that there was ever any physical connection between the man of to-day and the man that will be in another million of years. Let the natural philosophers, however, of the present day, do all they possibly can to have the human race instructed in, and governed by nature's laws, always, however, admitting the supernatural to be the author of the natural. Now it must be borne in mind, that all the phenomenon of nature is nothing more or less than the phenomenon or conduct of matter, and that the phenomenon depends upon the physiology of the matter from whence the con- duct comes, whether it be lightning and thunder in the atmosphere, which frequently kills man, or the phenomenon or force of the maniac or teratological fool, which acts similar. As I have already said, all phenomenon, whether good or bad, is depending on the physiology of the matter from 64 Henry Howard. whence conduct comes. Therefore every man is what he is, because of the physiology of the matter of which he is com- posed. A is a murderer because of his bad physiology, B is a robber because of his bad physiology, C is both immoral and criminal because of his bad physiology, D is an upright, honorable man, because of the good physiology of the matter of which he is composed. What I have said of man, is equally applicable to woman. This is true physical science, the physiology and phenomena, or con- duct of matter; therefore, in general terms, a man's physiology must be judged by his phenomena or conduct. It must, however, be borne in mind, that the physi- ology between youth, maturity and decay in man, and in all other animals is always undergoing change, from the moment he is conceived to the moment of his death ; if it were one hundred years, therefore, phenomena or conduct is always undergoing change. But in accordance with nature's laws, the physiological change is not from good to bad, but by the law of development, the change is good, better, best. Development, however, depends in the greatest degree upon living in obedience to nature's laws; this, man cannot do if he is ignorant of them. Therefore that mankind should advance physiologically and phenomenally, he must be educated to a greater or lesser degree in nature's laws, without opposition to the supernatural. But then comes the important question : How does it occur, so frequently, that the good physiological, well conducted man, undergoes such a change as to become a badly conducted man ? The only answer that can be given is, that the matter that composed him, has from some cause become patho- logical. Here come in the duties of a well organized and well educated physician, who can be only such because he is a good physical scientist. Every day's experience convinces me more and more, that a man to be capable of treating disease of, or the pathology of man, he must be a man that knows the physiology of man, which is Atmospheric Matter. 65 impossible without first knowing his anatomy, that is the anatomy of man generally. The basis of all education is physical science, even theological education; more particularly is it the basis of the education of the medical man. The more a man knows of the physiology and phenomena of matter, which is physical science, the better is he educated and the more suitable for a high social and moral standing. It is men of such education who are fit to lead and help society out of the miserable, immoral and criminal state it is in at present. Therefore I would say to all parents, however you may wish to worship and adore the supernatural, in which I don't interfere, let the basis of their general education be physical science, which is the physiology of matter and its phenomena. In conclu- sion, I would say to all physical scientists, Don't be interfering with metaphysics. All, as naturalists, you can know as such, is that there is supernatural, but its physi- ology and phenomena you cannot know, because it is not matter. I don't pretend to be a metaphysicist; yet as a phys- icist I believe in the supernatural, and worship him (God), although he is, to me, incomprehensible. I don't deny but that the human race may be, and is, responsible to him, but I don't understand it; I cannot comprehend it. One thing I do conceive, however, is, that the thousands of assumed metaphysicists that the world has, and does now contain, have been the cause of rendering thousands upon thousands atheists. The great question I, as a physicist, am considering is, where comes in the solution of the question, “Is man responsible for his conduct to his fellow-man, seeing that it is a scientific fact, that conduct is the phenomena of the matter of which man is made ?” Well, I maintain he is responsible, in a degree, just so far as he is respon- sible for his own physiological state, because upon such physiology depends the phenomena or conduct, whether it be good or bad. As a rule, a man who willfully, or 66 Henry Howard. in ignorance, lives in a breach of nature's laws, changes, for the worse, his physiology, consequently his conduct. Now the first law of nature is self-preservation, and there are but few individuals who do not do their utmost to fulfill that law, and generally with some success. Those who can do so, we may presume are well organized, and capable of fulfilling the second law of nature, which is, “Do unto others as you would have others do to you." If such be the case, and it's a physical fact, that it is, so far man is responsible to his fellow-man, and I believe such mnen do fulfill the second as well as they do the first law of nature. I see no reason to suppose but that the phenomena or conduct of a well organized, that is a good physiological man, is to fulfill these two laws of nature, and if so, there would be no immorality or crime, consequently, for such, no demand for punishment, nor would obedience to God be wanting. But physical science proves, by phenomena, or conduct, that the majority of the human race are not so physio- logically constituted; therefore that this majority breaks both these laws. What then is the duty of the physio- logical portion of society towards them? The first duty of the non-criminals is to protect themselves against the criminal portion of society. The second duty is, as far as it is possible, to avoid punishment, but otherwise to do all that is possible to improve their organization, that their physiology may produce a good phenomena, that is good conduct, under all circumstances. Every man is under obligation to his fellow-man, to perform nature's two first laws, as I have already said, “self-preservation," and “do to others as you would have others do to you.” When a man does his best to fulfill these two laws, and he finds it impossible to do so, he gives the best possible proof that he is an imperfectly organized man, due to either teratological or pathological cause, and certainly not responsible for his conduct to his fellow-man. But his fellow-man has the right to protect himself against his conduct. From all these physical facts it is necessary Atmospheric Matter. 67 that the criminal law, in every part of the world, should undergo the greatest possible change, to bring it in accord with physical science, or natural philosophy. I will conclude this article by quoting from a work of that great physical scientist whom I have been following these forty years (I speak of the great Cardinal Newman). The book I quote from is the “Grammar of Assent,” page 333: We are in a world of facts, and we use them; for there is nothing else to use. We do not quarrel with them as they are, and avail our- selves of what they can do for us. It would be out of place to demand of fire, water, earth and air, their credentials, so to say, for acting upon us or ministering to us. We call them elements and turn them to account, and make the most of them. We speculate on them at our leisure. But what we are still less able to doubt about or annul at our leisure or not, is that which is at once their counterpart and their witness: I mean ourselves. We are conscious of the objects of exter- nal nature, and we reflect and act upon them, and this consciousness, reflection and action, we call our own rational nature; and as we use the (so-called) elements without first criticising what we have no command over, so is it much more unmeaning in us to criticise or find fault with our own nature, which is nothing else than we ourselves, instead of using it according to the use of which it ordinarily admits. Our being, with its faculties, mind and body, is a fact not admitting of question, all things being of necessity referred to it, not it to other things. If I may not assume that I exist, and in particular way, that is, with a particular mental constitution, I have nothing to speculate about, and had better let speculation alone. Such as I am, it is my all. This is my essential stand-point, and must be taken for granted; otherwise thought is but an idle amusement, not worth the trouble. There is no medium between using my faculties, as I have them, and flinging myself upon the external world according to the random impulse of the moment, as spray upon the surface of the waves, and simply forgetting that I am. I am what I am, or I am nothing. * * Truths, such as these, which are too obvious to be called irresist- ible, are illustrated by what we see in universal nature. * But man begins with nothing realized, and he has to make capital for himself by the exercise of those faculties which are his natural inheri- tance. * * * * * * * * * * * * * Knowledge is power, for it enables us to use eternal principles, which we cannot alter; 80 also is it'in that microcosm, the human mind. Let us follow Bacon more closely than to distort its faculties according to the demands of an ideal optimism, instead of looking out for modes of thought proper to our nature, and faithfully observing them in our intellectual exercises. I hope the above quotation will convince some of our 68 Henry Howard. assumed metaphysicists that the bases of all education, even of theology and religion, should be physical science or natural philosophy, as for my part I confess I am not capable of defining metaphysics, and I do not claim to be much of a physical scientist. Considering, as I do, that physical science is the physiology and phenom- ena of matter, I devote my time chiefly to the physi- ology and phenomena of the materia cogitans. In a few words I wish to say that I know from nature that there are no two persons exactly similar in their physical organization, therefore not in their phenomenon or con- duct. But I believe the physiological man to be in society an altruistic egoist, who fulfills nature's three great laws—first, self-preservation; secondly, does to others as he would have others do to him; thirdly, all his life- struggles/ for existence, such a man does right because it is right, and loves truth for truth's sake. But the teratological man is an egoist—a lazy 'man who hates work, and prefers to live in idleness; selfish- ness is his phenomenon or conduct. Would that the human race was composed of physio- logical persons, when there would be no more immorality nor crime upon our little planet; no more envy, hatred and malice; evil speaking, lying and slandering, which is now the flourishing phenomenon to be found in society, and the very opposite of nature's laws and what was taught by the great metaphysicist and physical scientist, consequently moral natural philosopher, Christ. The Treatment of Melancholia. * By A. R. MOULTON, M. D., Assistant Physician of the Worcester Lunatic Hospital. IN bringing my subject before this society I have a somewhat selfish motive, inasmuch as I expect to gain information from the ripe experiences of its members, who I hope will discuss this paper fully; and I am too wise to imagine even that I shall impart any knowledge to this audience. All I expect to do is to restate a few well established facts, as they have appeared to me, for the time allowed for the preparation of the paper, coming as it did at a very busy season, was too short to admit of any extended reading or study. Without going at length into the etiology, symptomat- ology or pathology of melancholia, let me draw attention to the manner of patient, whom we may be called upon to treat. The person may or may not have an hereditary taint, the individual is suffering from depression, and is per- haps stupid and silent, or confused and delirious; or the patient may be in a state of great apprehension and agitation, and is probably in reduced physical health, with weak pulse and lowered temperature. There are all degrees of mental disturbance, from that resembling and reminding us of acute dementia to that of extreme rest- lessness and noise. In the first case the person will rarely reply to questions, and then only by the greatest per- suasion; the facial muscles are relaxed, the natural expression lost, there is an apparent disregard of surround- ing events, the hands hang listless or remain where placed, the sphincters are relaxed, or there may be an accumu- lation of urine and fæces, and there is seldom any voluntary motion; while in the latter case the patient is not only willing but anxious to converse, and if permitted • Read before the N. E. Peychological Society, October 12th, 1856. [69] 70 A. R. Moulton. will relate various apprehensions, forebodings and delu- sions; he is seldom or never quiet, his face expresses the greatest. fear and despondency, he walks up and down the room, wrings his hands, bemoans his condition, condemns himself, asserts that he is the cause of all the world's affliction, and in fact everything seems to go wrong with him, for in his imagination others usually appear fortunate and well-circumstanced, while he is the most wretched of mortals; and between these extremes of hebetude and great agitation there are many degrees of disturbance, none of which will I mention. In most cases of melancholia there is emaciation and loss of appetite, and in many utter refusal to take food; the circulation is sluggish, and the extremities cold. Clouston found only thirty-six per cent. as being in "fair general bodily condition "; fifty-seven per cent. were “weak and in bad condition"; and seven per cent. were “very weak and exhausted.” Wakefulness is a prominent and distressing state; many complain of pain, weariness, or the indefinite term “disagreeableness” in the head; consti- pation is usually present, and there is a furred tongue, offensive breath, and the skin may be rough and dry or greasy and fetid; there is lack of self-control and the will is lost. While I have no figures of my own to which I can refer to substantiate my statements, I have been strongly impressed by the large number of melancholics who suffer from the long list of dyspeptic symptoms; and the usual story is that the person, who finally has broken down, has been for many years of constipated habit, has often suffered from nausea, has experienced pain in the stomach after eating, has long had headache, lassitude and mild depression; and has dropped off many necessary articles of food from his dietary list until he has reduced himself to a dangerously small variety, which trouble him as the predecessors have done. Clouston, in three hundred and sixty-five cases of melancholia, taken at random, found constipation in fifty per cent., sleepless- ness and want of appetite in sixty per cent. The Treatment of Melancholia. 71 Thus we have a person to treat who is suffering from a long train of physical ailments, who is depressed, over- anxious, very apprehensive, perhaps delusional, and who has lost his self-control and independence; hence, the ob- vious needs are, rest, nourishment and diversion; and in the treatment of the case these requirements will go along side by side—they depend upon one another, and we would not think of resorting to one, if we could, with- out the others. Some of the books speak of the treat- ment as moral and medical, and in that case each is necessary, although, perhaps not equally; we can do with- out drugs merely, we cannot prevent a mental effect. The cause should be removed, and at an early period the physician is called upon to advise or decide where the patient should be treated, whether at home, by travel, or in a hospital, and I believe with Dr. Folsom, that in in- sanity we should consider the various matters operating in each individual case as we would in a case of purely physical ailment. Of course among the destitute there is but one thing to advise, but the milder forms of melan- cholia can often be best treated at home, and may do well by change of scene, although in many there is too much physical exhaustion and weakness to warrant ex- tended travel. The kind of home association will have much to do in settling the question; nervous, injudicious and annoying relatives would not properly be allowed to care for a fever patient, nor should they nurse a melan- choly friend; yet, if the members of the household can control their sympathies, can devote the necessary time to the patient, and are not repulsive to him, it is, I con- sider, eminently proper that an attempt should be made to care for the inild cases at home, always under the di- rection of an experienced physician; but I should hesi- tate about advising treatment at home of patients with suicidal tendency, or cases of melancholia agitata, among which most of the suicides occur. The cause may be inoperative, when we have remain- ing the effects alone, as when occasioned by heredity or 72 A. R. Moulton. parturition; but when occasioned or excited by overwork, confinement, unsanitary surroundings or physical disease, we have a tangible cause with which to work, and treatment upon such basis is efficacious if begun promptly, before the disease has continued to a marked degree; I refer to the uncomplicated cases, not hereditary. The causes assigned are not always reliable and often are merely symptomatic or incidental, referring usually to some recent occurrence; thus, the insanity of a patient recently in the Worcester Lunatic Hospital was said to have been occasioned by overwork. It was learned upon inquiry that the mother died insane, and that several of the maternal relatives had suffered from insanity, epilepsy and neuralgia, while the father was intemperate. She had always been eccentric and emotional. Another patient, who strongly inherited nervous tend- ency, broke down under slightly increased responsibility, and the cause given was anxiety and care. In a third case the patient's grandfather and sister were insane, and she was said to have become melancholy through illness; she had slight menorrhagia. In these cases the assigned causes are removable, yet the predisposition to insanity exists in each person, and I fear neither will recover; so that in many instances when the cause given is removed the effects remain, or the foundation of the trouble is permanent. As I write a young man is brought to the hospital in a state of great excitement, whose friends are at first unable to give any sufficient reason for his condition or satisfactory history of the case, yet by continuous interrogatories the fact is established that his father is insane, his mother nervous, that he has a brother in another hospital, and that he, who has always been moody and odd, has recently been on drunk after drunk. Fortunately in such cases, as in others, much can be done for the benefit of the patient. If the perturbation is occasioned or increased by mental or physical strain, rest should be enjoined; the patient should be put to bed, The Treatment of Melancholia. 73 all annoyances and vexations, so far as possible, removed, nourishment given and sleep induced. I do not mean that all melancholics should be put to bed, for thereby we might be fostering the desire for seclusion and with- drawal from society, which we should steadily strive to correct, and we must not lose sight of the fact as stated by Mitchell, quoting Seguin that “when we put patients in bed and forbid them to rise or to make use of their muscles we at once lessen appetite, weaken digestion in many cases, constipate the bowels, and enfeeble circula- tion ”; but those cases in which there is a constant feel- ing of physical exhaustion should be kept as quiet as possible until recuperation begins, or the urgency of the symptoms demand other treatment. If placed in bed we should prescribe massage, general rubbing, or electricity to counteract the dangers above spoken of, and the patient should have the attention of a competent and agreeable nurse. As many of the associations which were active in inducing the depression, as possible, should be removed, and upon this principle a change is often best. Many melancholy people are engrossed in them- selves, and seem to think of no one else's comfort ; these patients will exercise a more healthy fellow-feeling among strangers, and should be sent from home. When they have become familiar with their surroundings, and take advantage as it were of their companions, another change should be made, thus inducing an exercise of the will. Old hospital cases of a troublesome nature sometimes become more comfortable by transfer to another institu- tion, and those who improve for a time, but have come to a standstill can profitably be placed among new surroundings. Keep the mind off the disturbing elements, and supply new scenes, new associations and new thoughts to occupy it-a kind of rest which does not mean idleness. Here it is that the moral treatment comes in, by which I mean all healthy mental diversions and impressions. The patient should be induced to converse upon 74 A. R. Moulton. . general subjects, about books, people, places, and reference should seldom be made to the delusions. After the first examination, which should be searching, it is better to let the personal matter which is taking the attention of the patient, wholly alone, and lead him to abandon it, upon the theory that two substances cannot occupy the same space at the same time. There are ways enough of de- termining the existence of melancholy delusions without questioning the patient in relation to them. While it is not well to converse upon the subject, it is decidedly bad to combat delusion; anything appearing to oppose the delusions of the individual will fix them more firmly, and render their removal less probable; and acquiescence in delusion is equally improper. Upon this matter Griesinger says: “All direct, especially passionate discussion, gener- ally augments the delusion by instigating the patient to justify his views, to seek reasons for them, and irritates and exasperates him according to the force and acuteness of his opponent's argument. The morbid ideas are not to be subdued by any kind of proof or evidence. If possi- ble, still more reprehensible than direct opposition is the so-called method of assent, sympathy with the delusion of the patient, whether it be with the view of temporary soothing, or possibly to employ what is conceded by the patient as a new means of removing delusions. "Such assent will only confirm the patient in his de- lusions; he may afterwards appeal to it; and from such a system of treatment pursued with the best of intention, we often see the saddest results, especially in the deep melancholic conditions, since the insane ideas which the patient till then, at least inwardly, opposed, become rap- idly confirmed.” Idleness is a boon companion of mental weakness; and healthy, agreeable, and, if possible, profitable occupa- tion should be insisted upon, but above everything else, the work should be suited to the tastes of the individual, and it must be of a kind to interest and divert the mind, thus allowing it to rest, and augmenting improvement. The Treatment of Melancholia. 75 There are many things to which a woman can be induced to turn her hand, while it is more difficult to provide employment for men, especially indoor-work; but for- tunately, that employment which is the most health-giving is that which we in hospitals can most easily supply, and work upon a farm or in a garden can be rendered agree- able, and even a man who is wholly unused to anything laborious will oftentimes take to gardening or the care of a lawn eagerly. It is of the utmost importance that a melancholy patient should spend a good deal of time in the sun- shine, and best of all open air and sunshine ; but where for any reason it is impracticable to remain long out of doors, the room selected for the person should be flooded with light, and he should be induced to sit in the sun's . rays. The time spent out-of-doors, as well as that passed inside, should be made as agreeable as it well can be ; pleasant walks, rides, croquet, tennis, base-ball, light gymnastics are all useful, and part or all should be pre- scribed, care being taken that the patient does not overdo, yet in severe cases of restless melancholia exhaustion pro- duced from prolonged out-of-door exercise is sometimes followed by calmness and natural sleep. In all cases there should be regularity in this morale—a time for work, reading, walking, riding, games, etc.; and many points are gained when the patient's obstinacy or in- difference is overcome, and he enters into the life with something more than passiveness. We know this is a disease of malnutrition and exhaust- ion of vital force; there is a distaste for food and often absolute refusal to eat, or if any is taken the quantity is so small that the patient is in fact suffering from starv- ation ; hence, the food should be of the most nourishing kind, easy of digestion, and of proper quantity and variety. In the majority of cases it is necessary to persuade the patient to eat, and when he will do so it is much better that he should take solid food, or rather a mixed 76 A. R. Moulton. diet. When the patient has no delusions which prevent the taking of food voluntarily there will be little trouble of his getting sufficient variety; and easily-digested animal food, vegetables, farinaceous food, fish, eggs, milk, etc., will be recommended by the careful physican, heed being taken that it is well cooked and appetizing; in too many cases, however, the patient not only will not eat, but makes violent opposition when food is offered. The first signs of exhaustion should be met, and forcible alimentation not long delayed. When it becomes neces- sary to give food through an esophageal or nasal tube there is greater difficulty in nourishing the patient; for the same reasons which compel fasting retard proper digestion and assimilation, besides, foods taken in the manner indicated do not do the good that they perform when taken in the natural way. Under these circum- stances liquids alone can be given, and we are forced to rely upon beef-tea, milk, eggs and milk beaten together and well-sweetened, gruels, soups, broths, etc. Patients are sometimes fed in this way for many months, and are well nourished ; more, however, grow thin. A female was admitted to the Worcester Lunatic Hospital in August, 1878, and was fed by means of the stomach tube until January, 1881, being well nourished all that time. An excellent plan, where insomnia accompanies the reſu- sal for food, is to give a hypnotic, and just as the patient is dropping off to sleep, or is awakening, to offer a glass of milk or beef-tea, which oftentimes will be drank with avidity. Some physicians feed only once a day, or at long intervals; but it seems to me much more in accord- ance with reason to feed, at least, twice, and usually three times. A patient may possibly be starved into eating, but starvation is what we are trying to avoid, and when we remember that a pint of milk disappears from the stomach in an hour, and that a medium-sized person requires three quarts of milk to sustain him, the admin- istration of nutriment three times in the twenty-four hours does not seem too often. The moral effect of The Treatment of Melancholia. 77 feeding with the stomach-pump is often remarkable, especially upon the first visit to the patient, and by it we can give medicines to aid digestion, tonics, laxatives, sedatives, etc. The physical disturbances, whether they stand in the relation of cause or effect, demand prompt attention; if causative, improvement awaits their removal; if they are a result of reflected nervous derangement, still the body needs to be put into such condition that it can best sustain the ravages which it is called upon to bear. As I have already stated there is a long list of dyspeptic symptoms, which are persistent if let alone, and at best are very troublesome. I have seen constipation more con- stant than any other single state, and having long ante- dated the depression, it has become increased. The food should have reference to this condition, and beef-tea, while being a nutritive tonic, is a good laxative. Purga- tives should seldom be administered, for after acting they close the door more tightly than they found it, those remedies which give tone to the alimentary canal and increase peristaltic action, being indicated; nux vomica, stillingia, belladonna, physostigma, and cascara sagrada are representatives. Unless urged to drink melancholy patients take little or no water, and this alone will some- times relieve the constipation; they should be induced to drink a glass before breakfast, and it is well to add a few grains of common salt or a mild bitter. In the October number of the American Journal of Insanity, Dr. Hutchinson, superintendent of the Hospital at Dixmont, Pa., reports a case of melancholia in a woman, caused by impacted fæces. She “was very weak, extremely emaciated, skin bronzed, dry, harsh, hair dry and falling out, and all the secretions of the body were perverted.” She was suicidal, destructive and incoherent. The mass was with difficulty removed, and improvement rapidly followed. In less than a month she was well. Tonics and stimulants are indicated. Iron, in those cases where it does not produce headache, so combined that 78 A. R. Moulton. it will not disarrange the stomach, should be given for the attendant anæmia ; quinine, cinchona, gentian, nux vomica and other bitters increase the appetite and assist digestion. Phosphorus and the mineral acids are useful. I hope to hear an expression from the members about the use of the hypophosphites, for I have not seen the benefit result from their use which the literature has led me to expect. In cod-liver oil and malt we have nerve tonics and fat-producing agents, and those remedies can- not be replaced. In the main there is an incompatibility between adiposity and melancholia. Clouston lays great stress upon this fact, and advises that “every therapeutic agent whose effect is hunger-producing, digestive, vaso- motor and nerve-stimulating, we should give.” For wakefulness it is better to prescribe through the general system than directly. This troublesome symptom will usually disappear as the general health improves; the occupation, diversion and change will tend to counter- act the insomnia. Perhaps, at first, active remedies will be necessary, when we should give a glass of lager at bed-time, a bowl of egg-nog, beef-tea or a generous punch. Should they not prove effectual, we have a few drugs that are sure in their operation. Hydrate of chloral, in doses of from ten to twenty grains, either alone or combined with one of the bromides, hyoscyamus, cannabis indica, conium, lupulin or gelseminum, will produce tranquil sleep; and I have seen patients awake from such induced slum- ber refreshed, and have known improvement to evidently then begin; but chloral or any allied drug, unless it is opium, cannot be said to have any real curative effect; patients sleep from their administration, but, usually, a wake and go on with their fancies where they left them. I have had many patients complain of an uncomfortable cu- taneous irritation after taking a few doses of chloral; some, too, suffer from conjunctivitis and complain of ordinary sunlight after continuing a few weeks under its use. I have known two patients, women, to contract the chloral habit. Hyoscyamine is a paralyzing agent which The Treatment of Melancholia. 79 leaves unpleasant after effects, and I seldom use it in mel- ancholia. By drying up the secretions, reducing the flesh, producing general lassitude and weakness, it seems to be contra-indicated in this disease. The bromides give good results in those few cases where there is cerebral hyperæmia, as does ergot, and arsenic is recommended by Ham- mond for the same purpose. When the bromides are given for any length of time, cod-liver oil should be administered to counteract the waste which they produce. It should not be forgotten that the activity of hypnotics is increased by combination. In the use of opium there is great difference of opin- ion. The indications for which opiates are prescribed are for securing rest to the overtaxed mind and to increase the arterial blood supply to the brain. Blandford advises giving opium in sub-acute melancholia, and he has found the patients to improve promptly. He gives several small doses during the day, and a full dose at night. Dr. Hammond “has derived great benefit from doses rarely exceeding half a grain, repeated three or four times a day, and continued systematically for several weeks,” and he states that Courtney “regards opium in small doses as the most valuable of all medicines in the treat- ment of the condition in question.” Dickson thinks that any temporary benefit resulting from its use is followed by increased depression, and that it is always harmful. Griesinger concludes “that the cases for its use occur more frequently in private practice, during a short existence of the malady, than in asylums." Clouston “utterly disbelieves ” in opium. Dr. Henry M. Lyman says that “opiates calm, but do not nourish-they hinder the process of nutrition; hence, the sufferer wakes unrefreshed by the sleep which they produce, and is soon in a condition worse than ever." I have seen no benefit arise from the use of opium ; indeed, every case in which I have used it has done badly as regards disarranged stomach, constipation or diarrhea .80 A. R. Moulton. and general malaise; in several instances there has been an increase of delusion and depression. Paraldehyde is a newer remedy, and its hypnotic effects are much like those of chloral, but it has no effect upon some patients, given in safe doses. I have not seen lach- rymation caused by it, nor some of the other effects which chloral will produce. In two cases, the beginning dose of half a drachm, which occasioned sleep, had to be increased to two drachms in order to afford any relief; and in one of these patients, to whom I gave one drachm from a fresh supply, sleep was produced, too profound to witness with satisfaction. Its odor is penetrating and its taste exceedingly unpleasant, so much so that many insane patients utterly refuse to take it; this may not be an objection, for where only a few doses are required the patient would be less likely to continue its use un- necessarily, or perhaps form an appetite for the drug. I have administered urethane to eight patients, of whom four are suffering from melancholia, two from mania, and one each from the effects of the opium and alcohol habits, and am much pleased with the remedy. It is not disagreeable to the taste. I have seen no unpleasant, effects from its use, although one woman who is subject to asthma thought it induced an attack, but in subsequent trials she was not so affected. The sleep from it is calm, and patients wake refreshed. The dose varies from ten to thirty or forty grains, and in each individual it is nec- essary to determine the required quantity, beginning with the minimum dose and working up, for a dose too small has no apparent effect. Given in divided doses the effect is not so satisfactory as when the whole is administered at once. It does not relieve pain, nor has it any effect upon the pupil. . I believe that most, if not all, extreme melancholics contemplate suicide at some period of their disease, usually in the earlier stages, and the propensity may con- tinue indefinitely. Patients of this nature usually talk about ending their lives, although some are perfectly calm The Treatment of Melancholia. 81 and noncommittal, only showing the desire when the first opportunity presents. I know a woman who is quiet, orderly and industrious, who is not sad, who reads the daily papers, is interested in all kinds of fancy work, eats and sleeps well, yet she never allows an opportunity for sus- pension to escape. In this form of hereditary insanity the various members of a family sometimes employ simi- lar means of self-destruction, and at about the same age or under like circumstances, so that by keeping this fact in mind one can look for premonitory signs, and possibly save the patient. They do not, however, always wait for certain means for suicide, and deny themselves of others; nor do they invariably consider their own comfort, but accept any methods that occur. A gentleman living in central Massachusetts belongs to an insane family, several members of whom have committed suicide by cutting their throats; he is subject to periodical melancholia, and when he finds he is becoming depressed or wakeful he takes a long drive, and invariably returns well. The matter of selection of an individual means of suicide is well illustrated in the case of a man who was in the Worcester Hospital several years ago. When admitted he had a slight wound upon the forehead, caused by a pistol- shot, fired by himself the night before. A few weeks pre- vious to this he had flattened fourteen (No. 22) bullets against his skull at two sittings. He made a good re- covery, and after being at home a few weeks he had another attack of melancholia, following a prolonged debauch, and at that time he discharged five chambers of a Smith & Wesson revolver at his head. His skull was not fractured by these attempts, although the last shot in the first, second and fourth, and the single shot in the third attempt, stunned him. He was again committed, and made a drawing of a method of suicide, which he said he should test when he went home. It consisted of a gun, block, pail of water, a weight and a cord line; after confining his neck to the block, he proposed to draw the spigot from the pail, and when the water 82 A. R. Moulton. became lowered to a certain point the weight would fall, pulling the trigger by means of the cord, and discharging the gun, which was to be pointed at his head, and only a few inches removed. Fortunately he had no oppor- tunity to try this device, for he died, not by suicide, a few weeks later. · The methods already indicated of treating our patients, by improving the general health, placing them amid good sanitary surroundings, occupying and divert- ing them, will tend to prevent suicide, but all methods of treatment are defective that do not comprise watch- fulness. These people are never safe to themselves and should never be left alone. The suicidal impulse often comes up without any warning, or by some suggestion which is out of our control. If treated at home all knives, scissors, razors, etc., should be kept under lock and key; should it be necessary to restrict or oppose his movements, the house is turned into a hospital, and not being equipped for that purpose, is a poor one of its kind. The best place for such patients is a hospital for the insane. There should be attendants enough to keep the patient under constant observation without appearing to follow him, or the ward should be so constructed that all parts of it can be seen from any given point. The milder cases can be placed in the general ward, and the receiving ward is a good place for such persons, as they meet more recent cases and may gain courage as they witness the recoveries and discharges; they should sleep in a room opening out of that occupied by the attend- ant, or in the watched dormitory. There is a class of desperate melancholics who have attempted or will attempt suicide, and sentiment should be set aside and their own safety insured; they should never be left alone a moment, and if it is impossible to give each a constant companion, they should be placed in a ward designed for such cases as already indicated. The day room should not be a place of detention merely, but should be made attractive, and supplied with books, papers, magazines, games and The Treatment of Melancholia. 83 means of occupation for the use of the family' when in- doors, or when off duty, as it were; and there should be relays of attendants or companions, so that there should be no lack of constant enthusiasm and attempts to divert by every healthy means. It is reported that more suicides occur in the early morning than at any other time during the day, due, as Blandford thinks, to the length of time that has elapsed since the evening meal. I have certainly known patients to rise more than usually cheerful after taking a warm drink or a milk punch in bed, and additional sleep will some- times be secured by the same means. Melancholia is peculiar inasmuch as recoveries now and then occur after many years of illness, which teach us that we should never give up hope, but should, on the other hand, persist in the various lines of treatment indi- cated; should try to improve the general health, give the patient rest and occupation, and endeavor by every pos- sible means to induce the individual to act, think and talk like a well person; and we shall sometime be re- warded by seeing a seemingly hopeless melancholic shake off his despondency, and return to an active and useful life. Something More on the Doctrine of the Cortical Motor Centres of the Brain. AN EXPERIMENTAL CONTRIBUTION. By PROF. BIANCHI, Naples, Italy. IN order to confirm the doctrine of the localization of I the motor functions on the cortex of the brain, in definite areas, two methods have been presented to the observer, of which one is the experimental and the other is the anatomo-pathological and the clinical combined. The latter is the safer, but the longer. It has, without uncertainty, conducted to unassailable conclusions, and all who have eyes and minds not preoccupied by older doc- trines, or more recent errors, have seen the facts. The other method, less secure, more accidental, and involved in all sorts of difficulties, presents, rambling and numerous directions, and diverts the mind into mazy wanderings, and hasty and diverse interpretations of facts. Some travel on rapidly and confidently, and seem to be masters of the field; but some discover insurmountable obstacles, and retrace their footsteps. Thus it happens that whilst the victorious banner of the doctrine of localization has been for some time floating on the impregnable rock of clini- cal medicine and pathological anatomy, thc war over the doctrine of experimental physiology is yet hotly waged, with different and changing fortune. The contending forces seem at length exhausted, and a truce has been sounded. Two illustrations of experimental physiology have re- vived the vanquished or sleeping doubt as to the exist- ence of a cortical motor zone in the brain of animals, and especially in that of the dog Vulpian has stated before the Academy of Medicine, in Paris, that the sub-cortical white substance of the brain of dogs is more excitable than the gray substance, [84] Cortical Motor Centres of the Brain. 85 and that all that has been said about the electric excit- ability of the cortex of the brain, applies much rather to the excitability of the nervous fibres of the sub-cortical stratum, by means of the simple transmission of electricity. The method adopted by this famous physiologist for demonstration of his assumption is as follows: Having laid bare the brain of the dog (?) and excised the cortex at the proper part, he passes an acuform electrode into the organ beneath the excitable area of the hind leg; the other electrode he applies on any point of the head, but preferentially on the nostrils, and he brings the two into communication by a well graduated slit of the Faradic apparatus. Under these circumstances, the current required for provoking muscular contractions in the hind leg was found to be much less intense than that necessary for provoking such contractions by applying the current on cortex. If, therefore, the white substance is more excit- able than the gray, contrary to what has been believed, by directly exciting the white substance after removing the cortex, it is more than probable that what has been attributed to the cortex, in relation to its electric excita- bility, should on the contrary be attributed to the under- lying white substance. So thinks Vulpian. If, however, we analyze the conditions of Vulpian's experiment, we may arrive at the conclusion that the inferences drawn by him do not withstand criticism. Electricity, applied on the cerebral cortex, in order to reach its excitable elements, has to overcome the resistances presented by the tissues which cover these elements (the cerebral arachnoid, the pia mater, and the first cortical stratum, which contains no nervous cells), a condition all the more important, as Vulpian applies the other pole at a great distance from the first. When, on the contrary, an acuform electrode is in- serted below the cortex (rather where the cortex was) and is thus put into direct and inninediate contact with the 86 Professor Bianchi. excitable sub-cortical elements, it is very natural that an equally intense current should produce much greater effects, just because it does not here encounter the same resistance, and it is known that the intensity of a cur- rent is in the inverse ratio of the resistance to it. But there is yet another consideration to be kept in view; a current applied on a conducting surface, especially when the two poles are placed at some distance, şpreads its waves over this surface, and consequently diminishes much the intensity of the other waves which go down to, and stimulate, the excitable parts, and these are actually situate in the deepest stratum of the brain cortex. The conductor in our case is a curved surface, in which a greater extent of the cortex becomes excited, and a certain number of units of electro-motor force, are transformed into other specific energies, which are not manifested to us, but remain latent in the field of the sensory functions of the animal under experiment. On the other hand, a greater number of electric threads, if I may be allowed the expression, come together in the point of sub-cortical excitation, and at the same time the cortical cellular elements are not (?) spared from this excitation; hence the factors of the result are increased in number. Here too we ought to add that the excitability of a denuded cortex is soon exhausted. If matters stand thus, because of the physical laws governing conductors of electricity, what marvel can there be that the current necessary for exciting the sub-cortica elements has been found by Vulpian less intense thanl that required for exciting the cortex? We cannot, there- fore, participate in the doubt which the experiments of Vulpian might awaken, as to the significance of the electric excitability of the motor zone of the cerebral cortex. When I have examined dogs deprived of the cortical motor zone, by suspending them by the trunk, with the feet hanging down, I have observed, as I have before stated in another work, that the limbs opposite to the Cortical Motor Centres of the Brain. 87 inutilated hemisphere, remained, in this circumstance motionless, even under the influence of tactile and painful stimuli, whilst the will had full control over the other limbs. Now Prof. Schiff, in repeating in the same man- ner these experiments, has observed, in contradiction of what I have stated, that the limbs which I have regarded as totally paralyzed, sometimes move, do not always con- tinue in the same position, and in extension, and the movements which the dogs make with them are voluntary. If then some movements are sometimes accomplished even with the limbs opposite to the cerebral lesion, which have been considered by me as unfit for voluntary move- ments, it is, according to Prof. Schiff, because by the excision of the accredited motor zone, the tactile sense alone, and not voluntary movement, has been abolished in these limbs. This is an old theory which this brilliant physiologist continues to uphold with considerabe vigor, always regarding the cortical motor zone as a tactile centre. It was not with a view of resuming the question of the cortical motor centres, but for thę purpose of another order of researches on descending degenerations of the brain and the spinal cord, in which I am associated with Dr. Abundo, that I procured several dogs, on which I extirpated, some time ago, more or less of the cortical motor zone, or of some other cortical area, and hence I have been enabled to make on these animals a series of researches, in order to assure myself as to the exactitude, or the contrary, of my first observations. Whenever one of these dogs was suspended, he as- sumed, especially on applying to the forelegs tactile stimuli, the same position in extension, with the fore and hind legs opposite to the mutilated hemisphere. On stim- ulating the limb in relation with the sound hemisphere, he voluntarily withdrew and flexed it, but the other remained extended, and indeed under a more intense stimulation, it sometimes becomes more tense. But in truth movements were sometimes observed, and in this fact the observation 88 Professor Bianchi. of Schiff is accurate, but in certain conditions which I be- lieve I can fully determine. The cerebral decortication may have been too limited, and a part of the motor zone, absolute or relative, may have been spared, and then the immobility of the limb would not be so absolute as in the dogs on which the decortication was more extensive. It is only thus that we can interpret the possibility in Schiff's dogs, of volun- tarily reaching forth their paws. The spared portion of the zone assumed the function lost in consequence of the traumatism, and compensated for that of the small area excised. Some movement may be realized, even when the motor zone has been completely excised, if we apply more intense stimuli to the foot. The compensative ac- tion of the other hemisphere may here intervene; but we set this question aside; in every case these move- ments are limited, rapid, occasional and very different from those accomplished by the other side. Analogous movements are observed, but in association with those of the sqund limb. In the preceding case the movements had möre of the character of reflex; in this second case, I cannot but regard them as associate movements; in no way can they be held as voluntary, so great is the difference between the movements on the two sides! In order to prove this it was merely necessary to neutralize completely the motor activity of the limbs of the sound side, and to study the motor behavior of the opposite limbs. Here is what I was enabled to observe: By laying any of the dogs with the sound side on the edge of a table, with the legs under the trunk, and so fixed that he could not make the least movement of them, whilst the legs opposite to the cortical lesion pro jected over the edge and hung down. By means of this arrangement, these dogs were unable to accomplish any movement whatever with the pendant legs. This being a very annoying position the dogs were next so placed as Cortical Motor Centres of the Brain. 89 to have the sound legs hanging down. They then used every effort to escape from this disagreeable and unbal- anced position, by seeking with their feet for some point of support on which to poise; but whilst the paralyzed limbs hung down they were totally motionless (when the excision of the cortex included the entire motor area). Schiff explains the immobility in these cases by assuming the diminution or abolition of the tactile sense in the limbs believed to be paralyzed, because these limbs do not respond to any tactile stimulus whatever; yes, and I say to any dolorific stimulus also, as when we pull out hairs from the back of the foot. But admitting that there is a defect of tactile sensibility, why should the result of this defect be abolished movement, whilst the dog under experiment remains with his eyes open ? If we ought to judge from analogy, we should be induced stoutly to reject this explanation, because in no case does anæsthesia in man induce abolition of move- ment. I have observed hysterical persons with profound hemianæsthesia, who by the aid of sight were able to accomplish the most delicate movements with the anæs- thetic member, as those necessary for playing the piano; and I do not know of a single case in which an altera- tion of sensibility, of any nature whatever, or from what- ever pathological process arising, having had, whilst sight remained perfect, complete abolition of movement as the consequence. At the most, movement might become incoördinate, but by no means abolished, for sight must, at least in part, compensate for the want of tactile sense, in direction of the movements. It would be very strange that we should interpret the facts observed in animals at a valuation so different from that applied to man. That the dog when stimulated does not react by mov- ing the foot, most probably depends on the abolition of voluntary movement, by which alone we can judge whether the animal has felt a stimulus from which he tries to free himself. In fact, in man with a common 90 Professor Bianchi. hemiplegia, without disturbances of sensation, or also when these are not profound, we may stimulate, in any manner whatever, a paralyzed member, without the individual being able to withdraw it from the stimulus that is tor- menting him. He may, to be sure, express his sensations by grimaces or by words; but if he has lost these two modes of reacting, and has been reduced to the same conditions as the dog, we might, in man also, confound a motor disturbance with a sensory one. We may at the most hold that the extirpation of the so-called motor zone, implies the abolition of the source of mnemonic reproduction of movements that had been learned. In such a case the motor zone would not cease to be a sensomotor centre; and we can perfectly con- ceive it to be so. But in repeatedly examining the dogs, from which I had, many weeks or even months before, extirpated the motor zone, I was able to discover a fact which could not but influence the decision to which we should come respecting the cortical motor zone. The limbs of animals, placed as I have before de- scribed, on the edge of a table or a bench, not only appear altogether motionless, but also contractured; they become rigid in extension ; tactile stimuli then applied aug- ment the rigidity; it is only with some force that the members can be passively flexed, and when again left to themselves they immediately return to their prior posi- tion. Under palpation all the muscles, but especially those of the antero-external region of the foreleg, are found hard and prominent, from contraction. Surely a similar attitude of the paretic limbs is very like that of post-hemiplegic contracture in man; excepting that the degree of it is different, proportionately to the degree of development of the cortical motor centres of the dog, in comparison with those of man. It may be affirmed that the post-hemiplegic contrac- ture of the dog stops at the state of latent contracture in man. There are in truth cases in which human subjects, with limited cortical or subcortical lesions, present slight Cortical Motor Centres of the Brain. 91 paretic forms in a given member, which can be employed in every act required by life, and in which nothing is wanting excepting the agility and elasticity of the limbs in their normal condition; but in the moment of a great effort, the limb, and especially the hand and fingers, show a tendency to rigidity. A patient observed by me showed contracture in his arm only when he was requested to grasp strongly an object in the hand; for example, the dynamometer. In other persons with paresis, or better, with hemipar- esis, from cerebral lesions, contracture may be induced by asking them to make some efforts with the sound limbs of the other side, or by causing a diapason to vibrate in front of the muscles of the anterior region of the forearm, or in front of their tendons. In dogs the phenomenon is similar. The limbs opposite to the lesion remain weak for a long time after extirpation of a large part of the cortical motor zone, and sometimes they con- tinue so permanently—a fact which may be exhibited in vari- ous ways; they do not, however, differ from the opposite limbs in any of the ordinary movements of the dog, such as walking, leaping, etc.; 'the animals thus operated on, when suspended by the trunk, appear rigid only in the limbs op- . posite to the cerebral lesion, for, in that inconvenient and strange position the psychical tension is augmented by the incitements to get from it, precisely as takes place in man; but if they sometimes conquer the rigidity and ac- complish some movement, it is always associated with that of the limbs of the other side. In these conditions no isolate, extensive and intensioned movement is ever accomplished unless when the cerebral lesion has been very limited, and in this instance, as is well known, the first paralytic symptoms are as intense as perhaps those arising from more extensive lesions. From the moment in which all movement in the sound limbs is rendered impossible, these paralytics fall into a most absolute state of immobility with rigidity. Every effort made by the animal to liberate himself, 92 Professor Bianchi. by means of the sound limbs or the trunk, increases cor- respondingly the intensity of the contracture in the con- tracted limbs left free and hanging down. All tactile stimuli act in the very same manner, and this leads me to suppose that though tactile sensibility may be diminished, it is not really abolished, for in man also, intense tactile stimuli and the dolorific, when noticed, augment post- hemiplegic contracture. The animal, in such conditions, does not respond to tactile stimuli, and this is natural; man never reacts by movement, to tactile stimuli applied on the hemiplegicº side, except when the paralysis has been so slight as to permit movement. If the dog has no other way of ex- pressing his sensations than co-respective movements, it cannot be inferred that sensibility is extinguished when movement is abolished. On the contrary, all that may be asserted with certainty, apart from the more or less sub- jective interpretation of the phenomena, is what falls properly under objective observation, and is therefore quite unquestionable; and this is the state of absolute immo- bility with rigidity of the paretic limbs, in the conditions before indicated by me. Here I may appropriately relate one out of many facts, which I have had occasion to observe in dogs mutilated in a part of the brain. The fact above intimated by the eminent Professor, is very quaintly detailed by him in a couple of paragraphs, As an accurate rendering of these passages into our bald idiom might be unacceptable to American linguistic deli- cacy, and to depart too far from literal exactitude would be unjust to the author, the translator deems it best, for the protection of his own gracious repute, as well as for the avoidance of offence to the tender susceptibilities of readers habituated to blushing, on seeing or hearing cer- tain displeasing old English monosyllables, to condense the narrative into more euphonistic terms, as follows: A female canine, or in more delicate American phrase, a lady dog, on which the author had performed an impor- tant cerebral experiment, completely recovered from the Cortical Motor Centres of the Brain. 93 injury, and in obedience to an imperative physiological law, she presently became the victim of the tender pas- sion. In the Professor's happy family of cortex-shaven quadrupeds, there was a gentleman canine who was una- ble to withstand the charms of his lady associate, and was accordingly very earnest in his endeavors to please the object of his affections. Unfortunately the right side had remained paralyzed, or rather, perhaps paretic, for under amatory excitement, he was able to rise on his hinder props, but just as the Professor has told us about other hemiplegics, the effort, combined with the psychologic enthusiasm that prompted it, aroused in the dilapidated cortical workshop, the wrath, or the envy, of the lightning maker, and he sent a flash into the flaccid right-side limbs, which, wonderful to say, stiffened the muscles and threw them into "forced adduction," altogether beyond the con- trol of the owner. Suffice it, with due brevity, to say that “la posizione del maschio è insostenibile, l'atto è frustrato.” Nevertheless, we are assured the attempt was several times in succession repeated, with the like calami- tous issue. The author closes his amatory novella with the follow- ing complacent reflection: “I think it is useless to institute comparisons between these facts and the crossed reflexes met with by Schiff.” He then proceeds: “A contracture such as this, has its analogue in the latent contracture of man, which it resembles both in the form and the behavior which it maintains under the action of in- ternal and external stimuli. Whether then, this must be found in relation with a lesion, which is universally rec- ognized as a cause of contracture in man, that is, irrita- tion of the nervoso-motor apparatus, be it in the centre or along the paths of transmission, is a question which Dr. Abundo and I will discuss very soon, in another work. For the present it may be of interest to state a fact of great physiological importance. It is this, similar con- tracture was never met with in dogs on which I had ex- tirpated a large extent of the cortex of the occipital lobe. 94 Professor Bianchi. “With all due homage to a physiologist so illustrious as Schiff, I think the fact of post-hemiplegic rigidity, observed by me in the dog, also serves once more to show the analogy between the significance of the motor zone in man and in the dog, the difference of which is reduced to that of degree and not of intimate nature, as the results of the experiments of Schiff, and the interpre- tation of them which he offers, might lead some persons to believe." DIPSOMANIA. By EDWARD C. MANN, M. D., Brooklyn, N. Y. Superintendent Sunnyside Home for Nervous Invalids, Dipsomania and the Opium Habit; Member of the Medical Society of the County of New York; American Association for the Cure of Inebriates; New York Medico-Legal Society, etc. IT is now more than eight years since the writer I established a Home for the Treatment of Nervous and Mental Diseases, with especial reference to the treat- ment of dipsomania or uncontrollable intemperance in the middle and upper classes. The desirability of such a home was attested by all those leading physicians to whom we applied for information and advice on the subject. The home, or private institution we established, has re- ceived the countenance and aid of our professional brethren, and especially of leading members of the pro- fession, who have given us their support. From our personal experience in this field we take a very sanguine view of the good that can be achieved by the control and treatment of such cases. Ordinary intemperance is quite distinct from dipsomania, which latter means an irresistible craving, which overcomes the patient's will, for intoxicating drinks. This disease exists to an alarm- ing extent to-day among all classes of society, females being quite as prone to it as males, especially young married ladies. As we have had several years' experience in the care and treatment of nervous diseases and dipso- mania among the upper classes, some general facts which we have gathered relative to the disease of inebriety or dipsomania may not be altogether uninteresting. In our intercourse with those classes who exhibit nerv- ous and mental diseases, we have found insanity resulting from alcohol in a good many cases that have been under our observation and treatment. In the upper classes, the [95] 96 Edward C. Mann. insanity which can be traced to habits of intemper- ance is not so great as in the lower classes of society. It is very difficult to deal with intemperance as a vice, but when it passes the boundary line and ceases to be a vicious propensity, whatever form it may assume, then the depraved morbid craving for stimulants is clearly traceable to the mental condition, and of course, under these circumstances we can deal with the disease. A physician, who has had ample opportunity of observing these cases and studying them, is able to diagnose pretty accurately the difference between normal drunkenness and abnormal drunkenness, or the disease of inebriety. In many cases we could mention, the exaltation of the instincts becomes a disease or mania. For a certain time a man may show a morbid and a diseased craving for drink without any other symptom of disordered brain, but if it goes on unchecked and untreated, it must pass into actual insanity. When we can treat these cases in the early stages, in which we find morbid, irresistible and uncontrollable desire for drink, we can check and cure the disease in that stage by placing the patient under strict control, and by treating him as we would treat any other form of disease in its incipient stage, and we can thus arrest the development of incurable forms of disordered brain. These latter terminate either in chronic aberration of the mind or in chronic brain disease. There seems to be a prevalent mistake in supposing that injury arises from stopping the drink in cases of inebriety. It is poison that the man or the woman is drinking, and we must stop the poison, and we may do so with perfect impunity. I have seen the most frightful loss of life, poverty brought on families, grievous, dreadful and dire domestic distress and sorrow, and families wrecked and ruined, by the family not controlling and dealing with these cases. The man or woman, who is an inebriate, requires firm and judicious control, just as surely as do other suicides. We estab- lished our institution on a broad basis and the patients are allowed every possible rational enjoyment, and sub- Dipsomania. 97 jected to the minimum amount of restraint, and that not an offensive restraint. They have ladies and gentlemen for nurses; they are not allowed to go out alone, until the lost will-power is perfectly restored; and they are not allowed to visit any place where alcohol is sold. There are certain symptoms that clearly indicate dipsomania, in which the morbid craving for drink springs from a disor- der of the brain, and there is a craving for drink which is to be considered as a vice. An experienced physician ought rarely to make a mistake in his diagnosis as to whether the boundary line has been overstepped. Many patients have come to us and voluntarily placed them- selves under control, thoroughly conscious of their sad and lamentable condition. They feel the necessity for restraint. They know that they by their habits of intoxication are ruining themselves and beggaring their families. Another class are sent by the family physician. There is a pecu- liarity about even grave cases of dipsomania. The patient is put under proper treatment, and in the course of a few weeks he is apparently well. The poison, in the shape of stimulants, has been kept away from him or her, as the case may be, and the patient loses the craving for it and is apparently in possession of his senses. The craving for drink perhaps returns; perhaps it has been in existence during the whole time the patient has been under restraint, but has been kept in subjection. The patient now says that he feels quite well and wants to go home. Long experience has taught us that no cure can be made in a fortnight or even in a few weeks. It takes not less than from sixteen to twenty-six weeks, to cure the morbid desire for stimulants by building up the cen- tral nervous system which is diseased. If time is not given to remove the disordered state of the brain and nervous system and build it up, the patient will inevitably relapse, and I think that there is no class of diseases, which, viewing them as mental diseases, are so liable to relapse as inebriety, and the reason for this is, as I have said, that the patient and his friends and relatives insist 98 Edward C. Mann. on thinking that a cure has been accomplished in a very few weeks, merely on the strength of the patient's assev- eration that he feels quite well and wants to go home. Upon the physician rests the responsibility of the cure, and he should be the one to decide the difficult problem as to whether the morbid desire for stimulants has been cured and the lost will-power restored. By legislation we should prohibit as far as we can the improper sale of al- cohol. There ought to be as many restrictions upon the sale of various kinds of alcohol as upon the sale of or- dinary poison. Alcohol eventually will have to be dealt with as a source of terrible moral and physical deteri- oration. The whole human race is deteriorated by the poison, morally, mentally and socially. The disease of inebriety is transmitted hereditarily, causing insanity, epi- lepsy and idiocy, or a proclivity to crime. Dipsomania should be dealt with promptly and firmly. It is no kind- ness to allow a man or woman to squander their property and reduce the whole family to the utmost extremity of ruin and despair. THE TREATMENT OF DIPSOMANIA.—Dipsomania is more troublesome to manage than simple insanity, and requires more perfect discipline, both moral and physical, than the latter. In the treatment of inebriates we have primarily to build up and restore shattered constitutions and broken- down nervous systems. We have a class of patients to deal with, whose digestive powers are weakened, whose appetite is impaired, whose muscular system is enfeebled, and whose generative function is often decayed. The blood is impoverished and the general nutrition disordered. They are indirectly predisposed to the acquisition of nearly all diseases, as they have, by long indulgence in alcohol, lessened the power of resisting their causes. We have to deal with the result of a toxic poison, which has resulted in more or less pathological changes in the brain and nervous centers. We have also to deal at times with various complications proceeding from the abuse of alco- hol, such as cirrhosis of the liver, gastritis, epilepsy, vari- Dipsomania. 99 ous forms of dyspepsia and, in some cases, with Bright's disease. We must place our patient under the most fa- vorable hygienic influence, and provide for him cheerful, tranquil and pleasant surroundings, repress cerebral ex- citement, procure sleep for him, and we must also give him plenty of good nourishing food, and an abundance of fresh air and exercise. I believe that to this disease, as to insanity under other forms, the remarks of Sir James Coxe are equally applicable, that “purgatives, hypnotics, anodynes and tonics are useful auxiliaries; but a com- fortable meal is the best of sedatives, and abundance of exercise the best of hypnotics." All remedial measures are, I think, inferior to wholesome exercise of body and mind in this disease. We must provide amusements of every kind and encourage patients to work. We must stimulate inertia, resist every kind of perverted feeling and check morbid impulses; and at last we may, if we exercise a wise care and discrimination, restore our patients to their homes, and to society, permanently cured. In building up the system after the wonted stimulus has been withdrawn, which is invariably from the first, and in combating the nerve-exhausting tendencies which, are invariably present in a marked degree in such cases, in addition to nerve sedatives and tonics, we have had surprising results from the use of electricity to the brain and spinal cord, and by its use we avoid the terrible nervous prostration which would sometimes follow the withdrawal of liquor from an inebriate. Our patients, who have applied in fear and trembling, dreading the ordeal they must pass through in the beginning of treatment by reason of such withdrawal, have been as much surprised as pleased to find the use of electricity supplied to the nervous system an agreeable and invigorating substitute for the stimulus which they were debarred from using, in such a marked degree that little or no suffering was experienced. There is no other such combined sedative, restorative and refreshant to the central nervous system as electricity in the hands of an experienced physician. It 100 Edward C. Mann. is a remedial agent which furnishes us with the means of modifying the nutritive condition of parts deeply situ- ated and of modifying the circulation to a greater extent, I think, than by any known agent. By the judicious employment of the constant and induced currents, we have it in our power to hasten the processes of nerve- growth, and nerve-repair, and thereby indirectly hasten the acquisition of nerve-power. The action of electricity is always followed, in my practice, by an increase of strength and nerve force, and the results gained are gradual and permanent. 204 LEFFERT'S PLACE. The Curability of Epilepsy and Epilep- toid Affections by Galvanism and the Phosphated and Arseniated Bro- mides. By C. H. HUGHES, M. D., St. Louis, Mo. THE experience of more than a quarter of a century 1 with this once intractable trouble of the cerebral. centers, has confirmed the growing conviction that epilepsia, in its graver, as well as in its multiform milder varieties, is not the approbrium medicorum our fathers regarded it. The unfavorable prognostications respecting this disease, universally made, up to the time of and by Elliotson, so late as 1844, and reaffirmed later by Watson and his co- temporaries, up to the time of the introduction of the bromides in its treatment, a little over thirty years ago, that “it is a disease, which, in a large majority of cases, cannot be cured,” will not be borne out in the experience of the diligent physician who keeps his cases well in hand, and under uninterrupted therapeutic control for a sufficient length of time to enable the irritable psycho-motor area and disordered vaso-motor centers to regain, by prolonged rest and steady reconstruction, their normal tone. The physician who undertakes the treatment of a case of epilepsia, either petit or grand mal, with the expectation of being able to safely suspend treatment before the ex- piration of eighteen months, or two years, will, in most cases, have a record of failure for his pains; but the phy- sician who, in the beginning of every case, has the courage to accept his cases only upon condition that they are to be constantly under his observation and treatment for a year and a half, or two years, and who will treat them in accordance with the plan which here follows, will, we [101] 102 C. H. Hughes. confidently believe, have for his reward more successes than failures. At least, such has been the writer's experi- ence, and he confidently commends it to the profession. This is not a novice's enthusiastic "great expectations,” based upon a few fortuitous results, but the testimony of the steady experience of a professional life, lasting over a quarter of a century, and nearly four-fifths of it spent in the constant study and treatment of epilepsia and its allied neuroses. Epilepsia is curable only through absolute medical con- trol of the patient for a long time, the removal of all organically depressing influences, and all central nerve excitation and over-tax. In some cases the time of treat- ment above indicated-eighteen months or two years, is too brief. A much longer period or central nerve tran- quilization and reconstruction must be persistently main- tained, in order to overcome the conditions upon which the characteristic, explosive paroxysms of nerve force depend. The expression of a paroxysm of an ordinary epilepsia is, in a certain sense, that of a discharging lesion, like the force represented in the tightened spring of a wound-up clock after the pendulum weight has been removed; the normal inhibitions over irregular discharge are inactive, and the regular volitional display of normal, cerebral life, passes suddenly into irregular psycho-motor activity or convulsions, and stertorous coma. But the ever-present and persistently abiding condition, in every case of epileptic or epileptoid convulsion, is a vaso- motor failure and vascular disturbance, whether the remoter cause be a cerebral tumor or a traumatism, a heart failure, or an embolus, a toxic or thermal blood influence; and this vasomotor disturbance has its locus morbi more often in the cortex than elsewhere, as shown by the early suspended or impaired consciousness, and the incipient, sensory, motor or illusory aura; the quivering eyelid, perverted sense of smell, visual and aural hallucinations; though, by the same interpretation, the initial irritation not unfrequently begins The Curability of Epilepsy by Galvanism. 103 about the bulb, as shown in the early moving lips and acts of automatic deglutition. The purpose of this paper is not, however, to discuss the pathology of epilepsia, though the writer, for want of better time and opportunity, would here briefly record his conviction that all true epilepsia and epileptoid is cortical in its origin, and essentially a brain disease, though the initial irritation may be, in many cases, of peripheral source. The following formula will indicate the writer's outline theraphy in this affection, a combination which he generally employs, varying the dosage according to circumstance of age, idosyncrasy, etc. : R Potass. brom. 3 iss. Syr. hypophos. co. 3 iv. (Sine strychnia).* Liq. pot. ars. gtt. lx. Aq. menth. pip. q.s.ft. 3 vj. M. S. Two teaspoonfuls three times a day, till bromism is induced; then t:vo doses daily, for a few days; after that two doses for two days, and three for two days, and so on. In this combination a bitter tonic (as employed by Brown-Sequard) may displace some of the pepper.nint water, if desirable, and a half-ounce of the bromide of sodium or ammonium may take the place of half an ounce of the potassic bromide; and if syphilis or malaria be complicating influences, ioide of potassium or quinine are given, in addition, in full and adequate doses. The bro- mide of calcium or syrup of lactophosphate of calcium, the bromide of lithium or manganese, may also be sometimes added to this mixture with advantage to the patient. Chloral, digitalis, iron, rhubarb, glycerine and creosote, or carbolic acid and gastric and pancreatic digestive com- pounds, are, in my practice, often indispensable for certain obvious indications of head, heart and gastro-intestinal tract. • Contrary to the views of McLane Hamilton anıl others, I consider strychnia contra-indicated in epilepsia. 104 C. H. Hughes. The bad breath which follows excess of bromides is always corrected by glycerine, listerine and carbolic acid, or cre- osote and the reduction of the quantity of bromide for a while. In regard to the employmennt of galvanism, a mild, constant current, plainly percepitible, but not painful when applied to the cheeks with wet sponge electrodes, should be passed from the forehead (each side, over the eyes) to the back of neck, and from the motor areas of the head to the hands of opposite sides. I use this designation of the current, instead of the more scientific Milleampere, be- cause most physicians who hear me are unaccustomed to the use of the Milleampere meter, and because I consider this a good practical method of dosage measurement for cephalic galvanization. The current through the head should always be gentle, and never painful beyond a very slight and tolerable pricking over the superciliary arches at the superficial distributions of the supra orbital nerves, and a little more at the nucha. This is my management, in outline, of these cases. I need not give you a tedious array of successful cases, They will be made a matter of history in a subsequent and more elaborate communication, designed to be read at leisure, and not to be listened to at the expense of precious time which belongs partly to others as well as myself. Many of you, however, have seen my cases return to your communities after a lengthened treatment, and quite a number of them effectually recovered, and all of them greatly benefited by this method. These results I atribute chiefly to the persistency of the combined medical and galvanic treatment, and the changed habits and surroundings of the patients. No epileptic can be cured who persists in the use of tobacco, alcohol or other depressing narcotic, or vicious habit, or who does not give up coffee and tea and learn to use milk and a minimum of animal food, or to use tea and coffee only very sparingly, in the forepart of the day only. He must have acquired the habit of sleeping abundantly The Curability of Epilepsy by Galvanism. 105 and quietly, and should avoid all sources of passionate outbursts and mental worry. His bowels should be kept uniformly regular on a laxative pill, containing aloin, ergot, colocynth and rhubarb extract, or blue mass, with belladonna (as indicated), at night, with an eighth of a grain of extract of belladonna and a fourth of a grain of extract of conium. An elegant liquid laxa- tive, where capsules cannot be swallowed, is half a drachm, or more, each of A. ext. ergot and cascara cordial. The indications for the successful management of epi- lepsia are to put the general and whole glandular system in physiological working order, remove all sources of eccen- tric nerve irritation, and daily tranquilize and reconstruct the irritable cerebral centers, keeping up the treatment till all tendency to psychical or motor explosion in the cere- bral centers disappears, if it takes a lifetime to do it. The cephalic galvanization should be employed from three to five minutes at least three times a week, with a descending and labile current, until improvement in the cerebral nerve tone is accomplished and confirmed. Ordi- narily a four to six-cell current from a simple McIntosh battery will suffice. I consider skillfully employed cephalic galvanization a most essential remedy for the permanent cure of epilepsia, notwithstanding it has been disparaged by those who ought better to understand its use and powers before condemn- ing it. The same is true in my experience with its use in chorea,* and all central neuropathic states in which morbid irritability and a tendency to "explosive" cell action- motor or psychical, as in active mania, the paroxysms of hysteria, tetanus and hydrophobia, exists. To sum up the matter : When the cure of epilepsy is. possible by medical means, and it is very often possible to cure this disease if we treat it properly, it is necessary, in every case, to adopt a plan which consists of: ist. A judicious combination of cerebral reconstruc- • To ihis point this paper (barring soine important typographical corrections, especially in the formula of hypophosphites, bron ides, etc.) was read before the Missouri etale Medical Association, May 3d, 1886. 106 C. H. Hughes. S. tives, conservators and tranquilizers of nerve force and regulators of explosive action, epilepsy being a discharging lesion—the brain of an epileptic expending its accumulated psychical and motor force during a paroxysm, much as a spring and pendulum clock expends its power by suddenly running down all at once, whenever the pendulum or reg- ulating (“inhibitory force ") is removed. 2d. The control of the cerebral vasomotor system through persistent galvanizations (never Faradizations). The galvanizations of epilepsy are with us, in some cases, an every-day affair (so to speak) for several months—short seances, but long-continued treatments. 3d. The regulation of all the patient's habits, moral, social, psychical and physical; as much so as if he were a patient in an insane asylum, or a pupil in a school for the feeble-minded. To do this the patient must be studied and treated daily for a while, and must be as well understood by the physician and cared for, as a case of pneumonia, typhoid, or phthisis. We cure epilepsy in this way—not always, but quite often-often enough to satisfy us well for our pains. Surgical cures of epilepsia are infrequent and excep- tional. The records have many more reports of recoveries than the completed sequences of operations, if recorded after a year or two, instead of after a few weeks or months, would confirm. Our experience with trephining has never been satisfactory. We often found meningeal lacerations, and loose or imbedded spiculæ, which, when removed, left the patient worse off than before so far as the recurrence of the epileptic paroxysms were concerned, and necessitating a return to medical treatment. Ligation and arterial compression of the carotids is but little better in the long run, than trephining, without conjoint medical treatment. Neither the mechanical or surgical shutting off or dim- inution of the blood supply of the brain nor the removal of a localized mechanical compression will, as a rule, cure a chronic epileptic habit, which is due, whatever may be · The Curability of Epilepsy by Galvanism. 107 its initial source, to a final implication and consequent control-failure in the vasomotor center, permitting sudden arteriole spasm and unequal and alternating blood-tension in the cerebral capillaries. But whether or not we attempt surgical relief of this formidable and distressful malady, the preliminary and after-treatment, if we would finally succeed in curing it in any particular case, must be accomplished in accord- ance with the principles of corrective and restorative neurotherapy above indicated, until our ability to manage epilepsia shall have been enlarged by a wider pathological knowledge, and even more extended observation than the extensive acquaintance Medicine has thus far made, of this most ancient of diseases. I conclude this note with the scarcely necessary ad- dendum, considering the high professional character of my auditors, that, in addition to this outline management, no therapeutic resource is at times unworthy of employment; nitrite of amyl, chloroform, ether, ammonia or other pun- gent and vasomotor influencing inhalations; borax, valerian, ferrosocyanuret of iron, serpentaria, aurum bichloride, calabar bean, etc., and occasionally still argenti nitras. Lass. PROCEEDINGS OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY. The Society met at the Hotel Brunswick, October 12th, 1886, Vice-President Dr. J. P. Bancroft in the chair. Present, Drs. J. P. and C. T. Bancroft, Dr. Ira Russell, Drs. Draper, Sanborn, Moulton, Quimby, Baker, Cary, Sledman, Hall, Cowles and Fisher. The question of having two meetings .yearly, one in April and one in October, came up under the rules. Dr. Draper would be glad to attend three meetings, but thought the attendance would be larger with two. In Vermont, and some other States perhaps, courts were in session during April and October. Except for that reason would approve of those months. Dr. Fisher thought the first meeting of the year should be in October, as many members, like himself, went to the woods or elsewhere in September, and it was difficult to prepare papers during the hot season. He was in favor of three meetings, October, January and April. Dr. Quimby said Massachusetts superintendents were busy in getting out annual reports in September. Fa- vored three meetings, the first to be in October. Dr. J. P. Bancroft favored three meetings as more likely to keep up a sustained interest in the objects of the Society than two. Dr. Russell thought more papers would be offered than could be read at the meetings. Dr. Sanborn could not attend three meetings annually. He believed there should be three. Voted, on amendment of Dr. Russell, to hold meet- ings in October, January and April - January to be the time of annual meeting. [108] Proceedings. 109 Resolutions were read on the death of Dr. Shew, as follows: RESOLUTIONS ON THE DEATH OF DR. Shew. At the regular meeting of the New England Psychological Society, beld at boston, April 13th, 1836, the following resolutions, in reference to the death of Dr. A. M. Shew, were unanimously adopted, and a vote passed that a copy of the same be sent to the family of the deceased member. Whereas: An all-wise Providence has removed from this Society and a large sphere of usefulness, one of its most valued members, DR. ABRAHAM MARVIN SHEw, Superintendent of the Connecticut Hospital for the Insane, therefore, Resolved: Tbat in the death of Dr. Shew, the State, in whose service he labored so earnestly and successfully during twenty years, loses not only an officer whose executive ability was of the highest order, but also one who was most keenly alive to the interests and requirements of its insane, and most anxious that all efficient measures should be adopted to advance them. Resolved: That this Society, the largest number of whose members have long and well known Dr. Shew, sincerely mourns his death, wbich occurred at that period of life when it would seem that he was most fully qualified to be of the bigbest service to that specialty in medicine to which he had devoted very nearly his entire professional life. Resolved : That tbis Society tender to the bereaied widow and children of the deceased, its profound sympathy and heartfelt sorrow in view of their severe affliction. Drs. Cary and Channing were appointed to read at the next meeting. Dr. Moulton read a paper on “The Treatment of Melancholia." Dr. Russell read a paper on “The Morphia Habit.” Dr. J. P. Bancroft read a paper by Dr. Benner: “ Clinical Items, in a case in which a patient passed from the ordinary into a new consciousness of two weeks' du- ration." DISCUSSION. Dr. Draper said Dr. Moulton's paper was a good illus- tration of a fresh treatment of an old subject; the great duration of melancholia as compared with other forms had struck him forcibly. Reported two recoveries after more than five years' duration. This shows the impor- tance of continued efforts at treatment. Dr. Draper said it was necessary to discriminate between melancholia and IIO Proceedings. suicidal monomania. Had seen cases where there was no apparent depression, but a dominant impulse towards self- destruction. Dr. Draper agreed with Dr. Russell in the propriety of the gradual disuse of morphia in cases of the morphia habit. Dr. Benner's case reminded him of one at the Worcester Hospital twenty years ago. A gen- tlemen disappeared froin home, and stated that he just came to a realizing sense of what he was doing when on board ship in mid-ocean. Dr. Russell said that his experience was, that all melancholy patients at some time contemplated suicide. Referred to the case of Rev. James Beecher, who was at one time in his charge. He left his parish and a salary of three thousand dollars, and made his home in the woods; represented himself as having been in a state of religious ecstacy. His communion with God and nature made him supremely happy at first; he then became de- pressed and thought he was a castaway; was sent to the Homeopathic Hospital at Middleboro, N. Y.; ran away, got better, and tried missionary work; became suspicious that he had done wrong, charged himself with improper conduct and thought he was to be prosecuted; consulted thirty-five different physicians of all kinds, mostly irregu- lar ones; at Winchendon, could only exclaim “Misery, misery;" hoped he would not wake up alive. Remained a year, and for last three months improved; became very brilliant and talkative with the other patients, was still depressed however, and wished the end would come. Wife took him home against advice; was warned of his suicidal tendencies. After two months at home, was sent to a water-cure establishment, where there was a shooting gallery. He was allowed to take his rifle to his room, where he shot himself. Dr. Cary said she had a large number of melancholy patients under her care at Danvers. Had used the hypo- phosphites, but did not get as satisfactory results now as formerly from their use. In regard to tube feeding, Proceedings. I11 thought some patients could not bear three feedings daily. Some dreaded feeding exceedingly, could not digest so much food, and delusions seemed to be created. Reported the case of a lady who seemed quite cheerful, read, sewed and formed a companionship with another patient. She never gave up the idea of suicide however, and was always on the watch for an opportunity. Tried to per- suade her friend to join her in her attempt, but she suc- ceeded in hanging herself, while her friend failed to keep her promise. In answer to Dr. Fisher's inquiry, said she had tried washing out the stomach in feeding cases with good results; said she always diluted the food with a tumbler of water. Dr. Sanborn said they had received a larger propor- tion of melancholy cases at Augusta of late years than formerly, and more with suicidal tendencies than formerly. The first indication in the treatment of melancholia is to feed the patient; they should be fed twice a day at least, in cases where tube feeding is required. Don't believe in starving the patient to see if he will eat. Reported the case of a patient whose attempt at suicide was the means of her recovery. Had been four or five months under treat- ment, when he was called up at midnight to see her; it was said she had disemboweled herself. He found that she had literally ripped herself up with the back of a metal comb. Was utterly insensible to pain, and had pecked away at the umbilicus, where there may have been a slight hernia, until she had made a large opening; the tumor was reduced and the wound sewed up. There was no peritonitis, and she began to recover mentally from that date. In two months went home, and has remained well twenty years. Dr. Moulton said they always have one or more cases of the morphia habit at Worcester. Have found the last grain of morphia the hardest to discontinue; in two cases have omitted the morphia at once, and felt well pleased with the result in those cases. One was a woman who had taken twenty grains of morphia with a large quantity of chloral II2 Proceedings. and bronide; she was very weak and confined to her bed. She had a hypodermic of one grain of cocoaine three times daily. In a month she was in good condition, had no diarrhea, and was eating well; made a good recovery. The other case had suffered much in the attempt to re- duce the morphia gradually at home; in hospital had the same treatment as above, and says she had a more com- fortable time than previously. In another case, a patient had been accustomed to a pint of laudanum daily; was put on above treatment with good results. Dr. Benner's case reminded him of a man who went West with a view to lo- cate there. Took letter to the mayor of the town; on the way lost ordinary consciousness, and remembered nothing until he found himself in the Worcester Hospital. It was proved that he went to lowa, presented his letters, re- mained a few days, and returned. His conduct excited no comment, and he made a good impression on strangers whom he met. On his return to Worcester, he reported to the police that his pocket had been picked; he then was vague in his statements and somewhat incoherent. At the hospital consciousness returned in two or three days; in a week or two went home recovered. Dr. Russell stated that he found cocoaine agreeable and useful in the morphia habit, but he did not dare to use it for fear of setting up a worse habit than the opium one. Dr. Moulton said he never let the patient know what he was taking; had given hypodermics of water with good results in some cases. In answer to Dr. Cowles, said he gave the cocaine only for a week or ten days; the effect of one grain was soothing and agreeable. One patient said “that isn't morphine, but it feels much better.” Patient will find out, if possible, what is given. Dr. Cowles gave some account of his use of morphia in melancholia. He had never used the very large doses, fifteen grains, recommended by English and French writ- ers. Had never exceeded one and a half-grain doses three Procecdings. 113 times daily. Began with one-fourth-grain doses, but did not meet with much success until he increased the dose. Detailed a case of melancholia with delusions and halluci- nations. He got worse steadily for a year under one- fourth-grain doses of morphine, lost appetite, grew pale and was more depressed. Then gave three-fourths-grain doses, which produced constipation and nausea, and seemed to be all he would bear without producing a dangerous con- dition. He soon began to worry about the future, saying he never would be well; thought this was better than bewailing the past. Showed great homesickness, and promised, if he could go home on a visit, to come back. After four or five visits went home to stay; morphine was gradually stopped; was no longer suicidal, and in a year was well. He found benefit from this treatment in eight cases of acute agitated melancholia. Same change noticed in another case of anxiety about the future instead of the past. Has used codeia to advantage in cases of senile mania. It takes the edge off the excitement but produces irritability, which he counteracts by combining morphia with it. Believes that to a certain extent it is true that morphia feeds the brain and the bromides starve it. Dr. Fisher said that twenty years ago the morphia treatment of melancholia was the routine practice at the Boston Lunatic Hospital. He had seen some striking re- sults from its use, but felt doubtful in what cases to use it, as in many cases results were so disappointing. In some cases which recovered under its use it was doubtful whether time or the drug was more efficient. He feared also some patients may have been led to continue the use of morphia after recovery. He believed the cases of mor- phia habit were fewer than is popularly supposed. He would recommend the Legislature to include opium habitués under the new law applying to inebriates. The case of Dr. Benner's reminded him of a remarkable case which he reported some years ago, of modified conscious- ness following heatstroke. A gentleman had been collect- ing bills on a hot day in Portland. He then dined with 412 - -21s ... bis and bromide; - She had a hy times daily. I no diarrhea, a The other cas, duce the mor same treatme: fortable time had been acci on above tre reminded hin cate there. way lost ord until he four proved that mained a fe no comment whom he n to the polic was vague At the ho days; in a Dr. Ru: and useful use it for one. Dr. M what he with goo Cowles, si ten days; agreeable. feels muc what is Dr. C in my nie En:.-.. vis TASI ace. sered -.: is in of the recenzir ar vi de- sich und be ... ... es . SELECTIONS. CLINICAL NEUROLOGY. HEMI-RHEUMATISM, OR THE ONE-SIDED PREDOMINANCE OF MANIFESTATIONS OF CHRONIC RHEUMATISM.—Dr. Cazalis draws attention to a feature of chronic rheumatism which he and others, as well as Dr. Denieaux, have frequently observed. His conclusions are as follows (Bulletin de l' Académie de Médecine): In more than two-thirds of chronic rheumatics there exists, in some cases during a long period, a tendency to arthritic manifestations, external or internal, predominating on one side of the body; and sometimes this predominance is such that these cases might be called hemi-rheumatics. In these hemi-rheumatics the right side appears the most frequently affected. When pulmonary congestion, or bronchitis of an arthritic nature, shows itself in these patients, these conditions oftener appear on the side in which the rheumatism preponderates. It is on that side is observed that pleuritic friction which M. Collin (de Saint Honoré) has considered to be an indication of arthritism, and which, with M. Cazalis, cor- responds to the friction or crepitation of the joints in dry arthritis. As hemi-rheumatism is oftener observed on the right side, one understands why M. Collin at once local- ized his pleuritic friction on the right side. On the side on which rheumatism predominates, is also more frequently observed that other and more constant sign of chronic rheumatism—some time ago recognized and described by M. Verneuil and M. Potain—the deformity and projection of the great toe. If, in simple chronic rheumatism, hemi- rheumatism appears oftener to affect the right side, hemi- chorea and hysteria, on the contrary, which to many practitioners of the present day seem to be transform- ations of arthritism from one generation to another, more frequently affect the left side. Now, if hemi-crania is added to these arthritic attributes, a singular tendency to hemi-laterality will be recognized in all these ar- thritic modifications. These facts seem to support the still uncertain theory, but which is becoming more and more in favor, that the central nervous system greatly influences the localization of these chronic rheumatic manifestations.-N. Y. Med. Review. [115] 114 Proceedings. a friend and took a ride. He went to the steamboat office and telegraphed his wife that he would come home by the boat, and then, instead of going on board he started across the country on a tramp which lasted many days. His non-arrival excited great anxiety, and detect- ives were sent in search of him in vain. After a week's absence his wife received a letter from him, dated from the former residence of his uncle in New Hampshire, one hundred and fifty miles from Portland. In this he stated that the spirit of a dead burg!ar (he was a manufacturer of safes) had appeared to him and promised to show him where great treasure was buried on his uncle's farm. In accordance with the instructions of the spirit, he had tramped across the country, sleeping in barns or in the field; had turned his coat wrong side out, and hidden his diamond pin; had eaten sparingly, and prayed often, to make himself worthy to receive the great wealth that was in store for him. On Dr. Fisher's arrival he was found to have just recovered reason and consciousness. He had not revealed his delusions to the farmer with whom he had been boarding, and no idea that he was insane had been excited in anyone's mind. There was a heat of the head and congestion of the scalp and face. After a few days he went to the mountains, soon recovered his usual health, and has been well for fifteen years. Dr. J. P. Bancroft thought that it was the duty of the physician to deny the reality of delusions in melancholia. Tell such patients the truth simply, it may be incidentally. When they bring into question the truth of their own de- lusions they will recur to what has been said, and be helped by it. THEO. W. FISHER, M. D., Secretary. SELECTIONS. CLINICAL NEUROLOGY. HEMI-RHEUMATISM, OR THE ONE-SIDED PREDOMINANCE OF MANIFESTATIONS OF CHRONIC RHEUMATISM.—Dr. Cazalis draws attention to a feature of chronic rheumatism which he and others, as well as Dr. Denieaux, have frequently observed. His conclusions are as follows (Bulletin de l Académie de Médecine): In more than two-thirds of chronic rheumatics there exists, in some cases during a long period, a tendency to arthritic manifestations, external or internal, predominating on one side of the body; and sometimes this predominance is such that these cases might be called hemi-rheumatics. In these hemi-rheumatics the right side appears the most frequently affected. When pulmonary congestion, or bronchitis of an arthritic nature, shows itself in these patients, these conditions oftener appear on the side in which the rheumatism preponderates. It is on that side is observed that pleuritic friction which M. Collin (de Saint Honoré) has considered to be an indication of arthritism, and which, with M. Cazalis, cor- responds to the friction or crepitation of the joints in dry arthritis. As hemi-rheumatism is oftener observed on the right side, one understands why M. Collin at once local- ized his pleuritic friction on the right side. On the side on which rheumatism predominates, is also more frequently observed that other and more constant sign of chronic rheumatism—some time ago recognized and described by M. Verneuil and M. Potain--the deformity and projection of the great toe. If, in simple chronic rheumatism, hemi- rheumatism appears oftener to affect the right side, hemi- chorea and hysteria, on the contrary, which to many practitioners of the present day seem to be transform- ations of arthritism from one generation to another, more frequently affect the left side. Now, if hemi-crania is added to these arthritic attributes, a singular tendency to hemi-laterality will be recognized in all these ar- thritic modifications. These facts seem to support the still uncertain theory, but which is becoming more and more in favor, that the central nervous system greatly influences the localization of these chronic rheumatic manifestations.—N. Y. Med. Review. [115] 116 Selections. NEUROTHERAPY. CONTRIBUTION TO THE HISTORY OF CHLORIDE OF So- DIUM.- The American Practitioner contains the following apropos translation from the Jour, de Med., Paris: “We yet understand only incompletely the physiological office which chloride of sodium fills in the animal economy. We know that it does not enter into the constitution of any tissue, but all the physiological fluids contain it in notable proportions. “The flesh of sea-fish, which live in salt water, is taste- less. It has been observed that animals, which by their mode of living are able to obtain chloride of -odium with great difficulty, hold on to that which is contained in their physiological liquids with great persistence, although they renew these continuously. In man, who adds chloride of sodium as a condiment to his food, nearly always in greater amounts than his needs require, and sometimes in great ex- cess, all that is not utilized is easily eliminated, in some instances by provoking thirst. “ Liebig believed that the greater part of phosphate of soda met with in the economy of animals comes from the phosphate of potash in plants, which the chloride of sodium causes to pass into the state of a soda salt by double de- composition. “ Plants contain only salts of potassa, among them phos- phates, and the animals which make them their exclusive food find only phosphate of potash in them, when at the same time they need phosphate of soda in equal propor- tion. It is obvious, then, that if the chloride of sodium has the property of favoring the formation of this phosphate it is a pysiological fact of extreme interest, and one which gives to chloride of sodium a very important role in the “To test these points a solution of these salts was left to evaporate spontaneously in the cold under a cover containing also a quantity of concentrated sulphuric acid. At the end of 'some day's crystals of phosphate of soda were found, abundant and easily recognized.” THE TRUTH ABOUT COCAINE.—Dr. C. H. Hughes, in Il'eekly Medical Revieti', says: The truth about cocaine is that it is a tonic and stimulating exhilarant of some power in melancholia, mental depression and nerve weari- ness. That it acts rapidly but more evanescently than morphia. That, excessively used, it intoxicates and con- Selections. 117 verts melancholia into mania. That, given largely in the upright position, it is capable of inducing vertigo, whether, as Dujardin-Beaumetz thinks, by inducing anæmia, is not proven. That, as an antidote to alcoholism and its effects, it is not equal to morphia. That it is not equal to morphia as a tonic in melancholia or as a narcotic in certain states of nervous debility. That in equal doses it nause- ates more certainly than morphia. That it is not an anti- dote to meconophagism, though beneficial if judiciously used and timely abandoned. That it may be used with advantage, if carefully given, in the withdrawal of opium and the cure of the opium habit, as one of the many substitutes, but cannot be alone relied upon. That it intoxi- cates some persons and poisons them. . That its continu- ous use is difficult to break off. That it is probably capable of developing permanent madness, like similar intoxicants, as a few doses occasion temporary insanity. That it is a dangerous therapeutic toy, not to be used as a sensational plaything. That it will probably help to fill rather than deplete the asylums, inebriate and insane, if it should unfortunately come into as general use as the other intoxicants of its class. As an intoxicant it is more dangerous, if continuously given, than alcohol or opium, and more difficult to abandon. CHLORAL AND PARALDEHYDE.— The December American Practitioner translates the following from Deutsche Nied. Zeitung : “Proſs. Arpad Bockai, and Barcsi, of Klausen- burg, in order to determine the question whether chloral hydrate or paraldehyde is to be preferred for long-con- tinued use, gave to a number of dogs poisonous but not fatal doses of these drugs for a long period. The organ- ism did not become tolerant of either drug, but its power of resistance rather became less, the latter condition being more marked with paraldehyde than chloral hydrate. From these experiments the conclusion was drawn, that during long.continued use, the dose of these drugs need not be increased. The animals perished from the chloral hydrate in about half the time as from paraldehyde. "In every case where catarrhal pneumonia appeared as the cause of death, this was due to fatty degeneration of the heart. Chloral hydrate affected nutrition much more strongly than did paraldehyde; a five-per cent. solution of the former producing erosion of the mucous membrane of the stomach, while this did not occur with paraldehyde even in the concentrated form. 118 Selections. “From all of which it results, that paraldehyde adminis- tered for a long time, effects incomparably less injury than the long-continued use of chloral hydrate.' EXPERIMENTAL STUDIES OF KEPHIR.—We abstract the following résumé regarding kephir, from the Verhandlungen der Med. Gesellschaft zu Würzburg, 1886, 4, xix. The ob- servations were all made on patients reduced by exhausting diseases, such as diarrhea, anæmia and tuberculosis. 1. Kephir increases the urinary secretion appreciably. only when used in large quantities. 2 The specific gravity of the urine and the total weight of the solids in the urine sink under the influence of kephir. 3. The nitrogenous tissue-changes are checked. 4. Digestive energy and nu- trition in general are invariably raised even in the most exhausted individual. 5. The bodily weight increased ma- terially. 6. The number of red blood corpuscles increases. 7. The pains of lung and stomach affections subside in a few days. 8. The sleep becomes more quiet and more re- freshing. 9. The body becomes rounder and fuller. 10. The pallor of the face yields to a fresh and red color. II. Hence we must regard kephir as one of the most effective of all means to recover the physical powers after a long or exhausting affection. THE TREATMENT OF THE HYSTERICAL PAROXYSM.— Ruault, of Paris, in the Abeille Médicale, No. 42, 1885, has found a successful method of treating hysterical paroxysm by forcible compression of some superficial nerve, especially at its point of emergence, particularly the supra-orbital. The head of the patient is fixed with both hands, the thumbs being applied over the supra-orbital notches, where they are made to exercise steadily increasing pressure. The effect is as follows: The patient begins to twitch the facial muscles, she shrieks, two to four short inspirations occur, the thorax remains a few seconds in the condition of inspiration, simultaneously the muscles of the back con- tract, extending or hyper-extending the spinal column; then follows a deep expiration, the muscles relax, and the fit is over. In many cases the compression must be re- peated, as the fit recurs. The method is more efficacious the earlier it is applied after the commencement of the fit. Ruault succeeded by this method in arresting an attack of hysterical dyspnea with threatening asphyxia, and in the same patient an attack of delirium with hallucinations. Selectioris. 119 On Apon.-A new antipyretic and hypnotic, Apon is smply the name given by Dr. Poulet to a tincture prepared by himself, according to the Bull. de Thérapeu- tique, as follows: B Tr. capsici, 200.0; ammon. liquidi, 100.0; essentiæ thymi.; hydrati chloralis, äā, 10.0; alcoholis (sixty per cent.) 1000.. The pepper is digested with the alcohol and ammo- nia for a month, then the essence and the hydrate of chloral are added to the expressed liquid, and finally the whole is preserved in a hermetically-closed bottle. Apon applied locally has been found of great value in hysterical pains, general muscular cold, angina, influenza, muscular rheumatism. dysentery, enteritis, hemorrhoids, sea-sickness, and suppressed sweats. It is applied on a flannel rag, either pure or mixed with a fatty oil. Inter- nally, ten to twenty drops may be given in a little water; shortly after that half a glass of water or tea is drank. TOXIC EFFECTS FROM COCAINE.-G. Bockl (Deutsche Monatsschr. fr. Zahnheilkunde, February, 1886) observed once out of some one hundred and forty cases of tooth extraction under cocaine alarming symptoms follow its use. He had injected six drops of a twenty-per-cent. solution into the gums and removed the tooth without pain. Ten minutes later the patient's gaze became fixed, and there was temporary visual defect, with slight delirium. Inhala- tion of nitrate of amyl quickly put an end to these symp- toms, nor were there any bad after-effects. In a similar case reported by Schilling, of Nüremberg, in which the nervous symptoms were more marked, the effect of amyl nitrate was equally decisive.—American Journal of Medical Sciences. FATAL POISONING BY COCAINE.—At a meeting of the Medico-Legal Society, held November 18, 1885. Prof. R. Ogden Doremus reported the case of fatal poisoning of the woman in Kansas City, who was found unconscious and in a dying condition, by Dr. F. M. Thomas, a graduate of Bellevue Hospital Medical College. It was ascertained that this was the result of medicine she had used for an aching tooth, and this he concluded to be hydrochlorate of cocaine. All that was left of it in the bottle was sent to Dr. Doremus, and an examination had proved that such was the case. 120 Selections. Toxic EFFECTS OF COCAINE.-During the past year Dr. Boldt, in presence of Drs. Spitzka, Waldstein and Brill, injected eleven minims of a thirty-three and a third per cent. solution of cocaine into a cat weighing seven and a half pounds. Death took place twelve minutes after the injection was administered. The first effect noticed, was a sort of leaping gait, with dragging of the hind extremities, and soon convulsions took place, probably . forty in number. After each convulsion there was a period of quiescence, during which the legs of the animal straightened, the head turned up, the neck curved back- ward, and immediately afterward a severe convulsion took place. The respiration simulated the Cheyne-Stokes. After death the temperature in the rectum was 104° F. An autopsy was made half an hour after the animal ceased to breathe. A small quantity of dark-colored blood oozed from the dura mater, and the vessels of the pia mater of both brain and cord were intensely congested. There was an extravasation of blood in the fourth ventri- cle, and also a small extravasation in the anterior part of the medulla. There were minute extravasations all through the brain. The lungs were entirely collapsed, empty of blood, and the right ventricle of the heart was overdistended; the left empty. Death seemed to have taken place through paralysis of the respiratory center The gray substance of the cord was overfilled with blood, and resembled, as Dr. Spitzka remarked, a bloody sponge. Dr. Putnam-Jacobi remarked that the phenomena de- scribed by Dr. Boldt implied rather contraction of blood- vessels from vasomotor irritation, analogous to the contraction observed after a local application of cocaine, and that death was due, not so much to direct effect upon the respiratory center, as to contraction of the blood-vessels in the lungs and secondary obstruction to the circulation in the right side of the heart. The President remarked that all the capillaries throughout the body being affected, the heart was para- lyzed, and first the right ventricle, because it was the weaker. Dr. Boldt said that might be the case, but clinical experience had shown that the most important trouble after the use of cocaine was primarily encountered in the respiration.—New York Neurological Society. Selections. I 21 CANTHARIDES FOR HYDROPHOBIA.—A Russian doctor says that he has successfully treated with cantharides some patients who were bitten by a rabid wolf. Three men were badly bitten by the animal in various parts of the body, and cantharides plasters were applied to the wounds. At the same time, powdered cantharides was administered to each in doses of one grain each day, until certain well-known symptoms were exhibited. These patients have now been in perfect health for eight months since the bites were given.--Chambers' Journal. URETHAN versus STRYCHNIA.—Professor Coze counter- acted the tetanus produced by seven-hundredths of a grain of strychnine in a frog weighing an ounce, by five grains of urethan. In a dog weighing twenty-five pounds one- fifth grain of strychnine was completely counteracted by seventy-five grains of urethan. The effect of the urethan upon the blood appears to be due to an increase of oxygen.- Medical Abstract. AvYL NITRITE AN ANTIDOTE TO COCAINE.—Dr. Shilling reports in the Medical Chronicle that a female patient, to whom a solution of cocaine had been administered hypo- dermically, became suddenly unconscious. Suspecting that this was due to a contraction of the blood vessels in the brain, he caused her to inhale the vapor of three drops of amyl nitrite, which restored her in a very short time.- Texas Courier Record. . DRUMINE, THE NEW AUSTRALIAN LOCAL ANÆSTHETIC.- This was discovered and described by Dr. John Reid (Aus- tralian Med. Gaz., October, 1886), and is the alkaloid from Euphorbia Drummondii, an almost tasteless substance, sol- uble in chloroform and water. It produces local anæs- thesia of mucous membranes similar to the anæsthesia of cocaine. A REMEDY AGAINST EPILEPSY.— The Pharın. Zeitschrif. Russland, of June 1, 1886, gives the following: B Ext. fab. Calabar., gr. viiss; spir. æth., f3iss; aq. amygd. amar; (sive aq. mentha pip.), 13vss. M. S.-Five to eight drops, t. d. for children; Eight to fifteen drops, t. d. for adults. 122 Selections. NEUROLOGY. RHEUMATIC HYPERPYREXIA.—Dr. Maclagan believes, (1), “that there is a special thermic center, seated probably high up in the cord controlling and regulating the temper- ature of the body ; (2) that this center is endowed with heat-producing and heat-inhibiting powers; (3), that it has intimate physiological and anatomical relations with other important centers; (4), that it has connected with it a special set of thermalnerves distinct from the ordinary nerves of sensation ; (5), that these nerves are fully distrib- uted to the skin.” The probable existence of such a thermic center is shown both by physiological experiment and by physio- logical processes. The section of the pons at its junction with the medulla will cause the temperature to rise. Injur- ies and diseases of the nervous system, especially in the cervical region, are often accompanied by remarkable rises of temperature. In some cases the temperature falls below normal after arrest of the nervous supply, or destruction of the center. In acute rheumatism there is excessive action of the skin, as is evidenced by the severe perspiration which some- times occurs in connection with it. Lactic acid existing in the blood is the cause of this increased action. Excessive and prolonged irritation of the whole cutaneous surface, and its contained thermal peripheræ may cause such a disturbance of the thermic center as to overthrow the proper balance, and thus allow the body temperature to rise to such abnormal heights. In other words, the inhib- itory power of the thermic center is destroyed by the constant irritation, the result of influences conducted from the periphery to the center. Dr. Maclagan is further of opinion that the severe nerv- ous symptom is not the result of the hyperpyrexia so much as of the direct irritation of the brain. Therapeutically the editor of the Practitioner adds: “ This theory is of great importance. Cold, when applied to the skin, has a sedative action on the thermic center and aids it in restoring the normal balance. In such severe cases of rheumatic hyper- pyrexia the best course then to pursue would be the application of cold to the surface, thus bringing down the temperature. In general practice we occasionally meet with these cases of excessive hyperpyrexia when it is very diffi- cult to ascertain the cause. * * * There is no Selections. 123 doubt but that the application of ice to the surface of the body is one of the best remedies for the hyperpyrexia after sunstroke.” NEUROPATHOLOGY. PATHOLOGY OF INSANITY.—Dr. H. C. Wood says (Therapeutic Gazette, July, 1886): "The pathology of insanity is so utterly recondite and so little understood, that symptom-groups are almost the only thing we can at present recognize. Scarcely two writers upon insanity can be found to acknowledge the existence of the same so-called diseases, much less to define them similarly, or to group them in like manner. The classification of the forms of insanity, seems to be utterly hopeless, probably because we know nothing whatsoever of the diseases which afflict the mental functions, and substitute for such diseases the symptom-groups already spoken of. If mel- ancholia, mania, etc., are diseases, we must consider that distinct diseases are based upon the same brain-lesion, for it is well known that in general paralysis of the insane the sufferer may be profoundly melancholic, may be wildly maniacal, or may in contented quiet nurse his delusions of grandeur." It is obvious from this, that Dr. H. C. Wood is neither an alienist nor a pathologist. His arguments are about as valid as would be those of a nosologist who argued that because cardiac, hepatic and gastric crises occurred in locomotor ataxia, there could be no hepatic, nephritic nor cardiac disease distinct from locomotor ataxia. It is the best plan for a dilettante alienist without asylum experience, without logical training, to become a Philistine of the school of Blandford and decry the scientific study of insanity because it is complex and not simple, more especially when such a one has to pose as a teacher with- out ever having been a student of insanity. J. FRACTURE OF FOURTH AND DISLOCATION OF THIRD CERVICAL VERTEBRÆ.-On Oct. 19th, 1886, W. F- , aged nineteen, fell from the top of an old willow-tree to the ground, a distance of thirty feet. Dr. W. J. Best was summoned, and found him completely paralyzed from his shoulders down-both motion and sensation being lost; the left femur was fractured at the lower third of the shaft. He was perfectly conscious from the moment of his fall to his death-which occurred on the 3d inst. By 124 Sclections. a gentle pressure of the finger at the third cervical verte- bra, his eyes would roll upward and backward into the sockets-breathing became stertorous, and he would lapse into unconsciousness if the pressure was kept up for a mo- ment. All available means failed to excite the lost motion and sensation. His bladder had to be emptied with a catheter, and the intestines evacuated by enemata. Rapid emaciation went on from the onset. Death occurred on the fifteenth day from the time of injury. The post mortem revealed the third cervical vertebra dislocated forward and downward-closely compressing the spinal cord at the lower portion of the bone. The spinous process of the fourth cervical vertebra was fractured.-[Extract from pa- per in New York Medical Record.] PARANOIA AND HUMAN DEGENERACY.—Dr. Kiernan (Neurological Review, Vol. I., No. 1.) concludes: First, that the character of the government and institutions of the United States is such as to attract thither paranoiacs, “since they are great project makers,” and see in this country a wide field for their projects. Second, that in consequence of the unsettled condition of civilization in many parts of the United States, they readily pass mus- ter and even become leaders in the community, and rear families without their mental defect being discovered. Third, that probably at least one-seventh of the insane entering the United States belong to this ciass, whose insanity is sufficiently concealed to enable them to escape detection until long after their arrival, pending which they marry and transmit the same tendency to their descend- ants. Fourth, that until the ancestry and history of immigrants to the United States is rigidly traced and the insane excluded, insanity will continue to increase among the foreign-born population and their immediate de- scendants in the same disproportionate ratio as now obtains. PSYCHIATRY. OXALURIA AND INSANITY.—Dr. G. D. Stahley Medical News, June 5, 1886) says that of 172 patients—72 mani- acs, 38 melancholiacs, 41 dements, 18 paretic dements and 3 imbeciles, 18.6 per cent. had oxaluria; 18 per cent. of the maniacs, 7 per cent. of the melancholiacs, 25 per Sclections. 125 cent. of the dements, il per cent. of the paretic dements and none of the imbeciles were oxaluric. The classifica- tion is of the most indefinite character. Dr. Stahley says that if oxaluria is to be considered symptomatic of any form of mental derangement, it is of dementia, not melancholia. Melancholia, with its 18.4 per cent., falls somewhat short of the average 18.6 per cent. The quantity of the oxalate present in each case was as follows: Two cases of mania and one of paretic dementia had an abun- dance, and all the remainder showed but one, two, or three crystals at most in each microscopic field. Of these two cases one was subacute with suspicional delusions and due to alcoholic excesses; the other was acute, characterized by mental confusion, restlessness, and homicidal impulses ; the case of paretic dementia was typical. It is obvious that neither of these two cases were mania; one was clearly alcoholic insanity and the other confusional insanity. Fifteen of the oxaluric cases recovered, but no determina- tion had been made as to the disappearance of oxaluria. The 17 cases which still remain are as follows: Mania, 7; melancholia, 3; dementia, 6 and paretic dementia, I. Of the 7 cases of mania, in 3 calcium oxalate has disap- peared from the urine; the mental condition has not improved since admission, nor is recovery expected. The remaining 4 cases still exhibit some oxaluria, but in only one, a case of acute religious mania, is recovery expected. Of the 3 cases of melancholia, the oxalates have disap- peared in all; I is convalescent, and the other 2 present a very unfavorable prognosis. Of the 6 cases of dementia, oxaluria is absent in 5. and in none is there the remotest chance for recovery. The urine in the sixth case, compli- cated with epilepsy, still contains some crystals, and presents no favorable symptoms. In the case of paretic dementia, some calcium oxalate still remains; the prog- nosis is the customary one. Thus, of a total of 11 cases in which oxaluria was present on admission, but subse- quently disappeared, only I case is convalescent.. Of a total of 6 cases in which oxaluria existed on admission, and still continues, only I case has any reasonable pros- pect of recovery. Dr. Stahley very sensibly says, when melancholia is found associated with oxaluria the physician should not be guilty of an irrational division of the disease into two varieties, based on the fact that in one case nitromuriatic acid dissipates both diathesis and disease, and in the other does neither. Such a division is irrelevant 126 Selections. and unscientific. As well divide all headaches into two varieties—the first, those relieved by inhalations from the family camphor bottle; the second, those not influenced by this procedure. As has been recently shown by Dr. C. L. Dana, many of these oxaluric conditions, etc., are the expression of trophic changes secondary to nervous strain. That in a few cases these should second- arily cause psychical disturbances there can be no doubt. At the same time it seems clear from the researches of Dr. Dana and others elsewhere recorded (Neurological Review, Vol. I., No. I) that nervous strain produces at once the oxaluria and the psychosis accompanying it in many cases. The gastro-intestinal anæsthesia resulting from melancholia plays its part in producing oxaluria in some cases, arily causetrain. Thation of trophese o MORAL INSANITY.—Dr. P. Bryce (Alabama Insane Hos- pital Report, 1886) says: “ This is a form of deficient cerebration in which there is an absence of moral principle without notable, and in many cases, without any percep- tible lesion of the intellect. I object to the popular term “Moral Insanity,' because there is in it an implication of disease, whereas, the condition of brain which induces it is the result of hereditary transmission, and not of disease. There may be cases of moral insanity supervening upon disease of the brain, as reported by others, but I have never met with such a case, that is to say, where the moral obliquity has not been conjoined with defective reasoning powers. Moral imbecility is the best name for this condition, since it conveys the correct idea of its eti- ology." He has had twenty-eight such cases under observation. He has known such persons (and has such at present under care), blessed with fortune, brought up in cultivated Christian families with all the advantages that education and polite society could give them, who would talk well, even eloquently, of the charms of chas- tity and probity, and were ready on all proper occasions to express a contempt and even scorn for licentiousness and dishonesty, but would not hesitate, when opportunity offered, to appropriate the unguarded property of others, or to give themselves away to the first libertine who solicited their favors. The unfortunate subjects are re- garded by the mass of mankind as simply vile or wicked instead of morally imbecile. Nor is this surprising in view of the fact that the intellect, so far as can be ascer- and wered even scate, when ople of Selections. 127 tained is perfectly normal-no delusion of any kind seem- ing to affect it. But the actuality of such cases is well calculated to embarrass our courts of justice in discrimi- nating between them and those in whom the intellectual and moral faculties are better balanced, and whose criminal conduct would seem to be the result of bad training or vicious surroundings and associations in early youth. It is, therefore, not unreasonable to suppose, what we call vice and lawlessness are, in the main, inevitable outcrops of a vicious organization-a lack of co-ordination in the various mental powers, or lack of proper moral impulse in particular directions. The remark has often been made, and I do not question its truth, that many of the most outrageous criminals of which history gives ac- count, were probably insane persons, or, as I would prefer to term them, moral imbeciles. But if, as is often the case, our most skillful experts cannot always discern be- tween moral deficiencies and moral depravities, how can judges and jurors escape the perpetually recurring danger of condemning to severe punishment those who are morally incapable of walking in those straight and narrow paths which the law has marked out for the welfare of society? INSANITY IN CALIFORNIA.--Dr. Mays (Report of the Stockton, Cal. Insane Hospital, 1886) holds that there are no grounds for the impression that there is an abnormal inciease of insanity in California, since the aggregate num- ber of the insane must ever be on the increase in any prosperous community. So plainly is this so, that the demand for additional asylum accommodation may gen- erally be taken as an index of the advancement of a State, and a proof of its material and social development. But the repetition of these demands, with the frequent attrac- tion of public attention to the subject, conveys to some the belief that insanity is inordinately active here. Cali- fornia, absorbing a large immigration yearly, yet with capabilities for great future numerical expansion, must expect to be called on to erect a new asylum every nine or ten years for perhaps the next half century. The pro- portion of insane is not in excess of that of many other States. There are 2,922 inmates in our two asylums, which gives us one to every 360 inhabitants. The ratio in New York is one in 365; in Massachusetts, 1 in 350; in Australia, 1 in 375; in Great Britain, I in 345 ; in France, i in 405; in United States, I in 545, excluding idiots; I 128 Selections. in 300, including idiots. A study of the statistics of in- sanity shows that foreign-born inhabitants of this country are more liable to insanity than native-born. No State in the Union has so large a proportion of foreign-born, except Nevada. Over a third of the population of California in 1880 were born outside of the United States. The number returned as insane in that year was 2,503, of whom 1,618, or two-thirds, were of foreign nativity. That is to say, one-third of our population (the foreign-born) produced two-thirds of the insane. It will be seen that a low rate of insanity would, under present circumstances, be akin to a miracle. INTEMPERANCE AND BAD HYGIENE CAUSES OF INSANITY. — Dr. Mays (Report, Stockton, Cal. Insane Hospital, 1886) re-echoes the words of Morel (“Les Degeneres del Espèce Humaine ") when he says that the prime causes of insanity are intemperance and neglect of the laws of health. It is in the second generation that the evil works its most harm. One-half the insane-perhaps more-owe their derange- ment to hereditary influence, in inheriting an ancestral taint or predisposition. The families of intemperate par- ents furnish the recruiting ground for insane asylums. These unfortunate children, if not idiots or epileptics, are liable to grow up with querulous, explosive tempers, with feeble powers of self-guidance, weak in temptation, un- stable, self-indulgent, vicious, hysterical. They form the bulk of what are known as the defective classes. It should however be remembered that intemperance is often only a result of bad hygienic surroundings and neurotic degen- eracy. Intemperance, bad hygiene and neuro-degen- eracy are frequent alternates in the role of cause and effect. INSANITY AMONG THE CHINESE.—Dr. Mays (Pacific Rec- ord of Medicine and Pharmacy, December, 1886) finds that insanity is frequent among the Chinese in California, and is chiefly of the degenerative and toxic types. Dr. Spitzka found (Journal of Nervous and Mental Disease, 1880) that the only Chinese insane among 2,297 in New York were paretic dements. Insanity does not appear to be very fre- quent among the Chinese east of the Pacific Coast, probably because of the organized despotism of the Four Companies over them there enforces a routine which ren- ders insanity less demonstrable. Selections. 129 NEURO-ANATOMY. ELEPHANT'S BRAIN.—The brain of the elephant which was removed by Drs. Spitzka and Brill, on the occasion of the slaughter of that animal at Central Park, weighed thirteen pounds and two ounces. Each cerebral hemis- phere weighed singly four pounds and twelve ounces. The weight of the mesencephalon with attached optic nerve origin was three pounds and ten ounces. Dr. Spitzka was enabled to confirm the absence of the true pyramids in the elephant, and says the representation of the ele- phant's brain in the text-book is a mere caricature. The olivary bodies are extraordinarily prominent; the deep trench between the pons and olives is not filled out, and that therefore the only animals in which the trapezium is completely hidden by the redundant development of the pons are: Man, anthropoid apes, and the elephant. The brain weights given above do not include the membranes, and it is intimated that the deep structure of the elephant's cerebral hemispheres indicate a remarkable approximation to the type of the porpoise.—[Dr. Primm's abstract from Journal Comp. Anat. and Surgi, in Weekly Med. Review.] SYMPTOMATOLOGY. INTRA-CRANIAL DISEASE AND CHOKED Disc FROM AN OPHTHALMOLOGICAL STAND-POINT.-Dr. Edward G. Loring contributes to the June number of the New York Medical Journal and Obstetrical Review for 1882, an article on the nervous connection between intra-cranial disease and choked disc, which is worthy of record as the view of the ophthal- moscope. The following are Loring's conclusions: 1. That the vasomotor theory, as advanced by Benedikt, is not sufficient to explain either the mode of transmisson of the morbid irritation within the head, or the resulting neuritis optica. 2. That the irritation is conveyed, not by the isolated fibers of the sympathetic system, as stated by Benedikt, but through the agency of the trigeminus. 3. That choked disc or papillitis, in connection with brain disease, is the expression of an irritation or compression of certain intra-cranial fibers of the fifth pair which pre- side over the blood supply of the disc and neighboring parts, and also maintain the healthy processes of waste and repair of the tissues themselves. This being so, he 130 Selections. adds, the same analogies and distinctions between “irrita- tion” and “inflammation" can be made here as with sympathetic ophthalmia, so that here, as well as there, the irritation may exist as such for an indefinite time, or may so reduce the vitality and resisting power of the tissue of the disc and surrounding parts, as to develop gradually, or explode suddenly, into an actual inflammation—that is, into a neuritis. The immediate and exciting cause of this neuritis may then be either an external one, such as expos- ure to cold or heat, over-exertion, either mental or phys- ical, or, indeed, too much exposure to light, the effects of which, under the 'weakened condition of the organ, may be looked upon as a "traumatism;" or the exciting cause may be an internal one, such as some irritation from the condition of the blood and circulating fluids, either chem- ical or mechanical, either local or general, which, insufficient in itself to produce any bad effect upon a normal disc, may yet be just sufficient to produce a condition of inflammation in a part that is weakened and irritable. EDITORIAL. [All Unsigned Editorials are written by the Editor.] Another Year in the career of the ALIENIST AND NEUROLOGIST has gone into the history of the past. It has been to us a satisfactory and profitable year. We hope it has been so to you, dear reader. We have not been so well satisfied with our own part of the work essential to its welfare as with the work you have performed as subscribers and contributors. We are conscious of many omissions, and have had many burdens outside the work done on the ALIENIST AND NEUROLOGIST, but our editorial work has been easy and our burden light compared with other demands upon us dur- ing the year; but our outside work has been of especial service to us in fitting us for the conduct of the journal ; and it is through this outside work that we have been constantly impressed with the practical wants of a physi- cian engaged in neurological practice, and have endeavored, as faithfully as our opportunities and powers would allow, though not so fully as our judgment has indicated, to sup- ply these practical and essential demands. We enter another year hopefully encouraged and with cheerful heart and charity of purpose. In the coming year and in the further on-coming future, (if we should conduct it long), this journal's pages will be free to all true students of psycho-neurological sci- ence and clinical and forensic neurology who choose, with tion with their confrères in psychiatry and neurology. The broadest latitude will be allowed in the discussion icine. And why should it be otherwise? The Autocrat of the breakfast table, himself an autocrat in our own ranks, shall express our creed: Why should we look one common faith to tind When one in every score is color blind ? And while thus in all things we shall accord charity and grant the greatest liberty in non-essentials, we shall seek to bring about unity in the essentials of true prog- ress and good practical work. In omnia caritas, in [131] 132 Editorial. non-necessariis libertas, in necessariis unitas shall be, in brief our aim. The older we grow the more forcibly does retrospection reveal the imperfection of our work. But there would be no need of us here if we and our work were perfect, and there would be no need, we opine, of a future state if we were all complete in this. So, with the words of one whose good deeds (with all his human infirmities) were not few, we may ask and con- clude and go on to our unknown but hopeful destiny: Who, looking backward from his manhood's prime, Sees not the specter of misspent time? And through the shade Of funereal cypress, planted thick behind, Hears no reproachful wbisper on the wind From his loved dead ? Who bears no trace of passion's evil force ? Who shuns thy sting, O terrible remorse? Who does not cast On the thronged pages of bis memory's book, At times, a sad and half-reluctant look, Regretful of the past? Alas! the evil which we fain would shun We do, and leave the wished-for good undone : Our strength to-day Is but to-morrow's weakness, prone to fall: Poor, blind, unprofitable servants all Are we always. Yet who thus looking backward o'er his years, Feels not bis eyelids wet with grateful tears, If he hath been Permitted, weak and sinful as he was, To cbeer and aid in some ennobling cause His tellow-mau ? If he bath bidden the outcast or let in A ray of sunshine to the cell of sin- If he hath lent Strength to the weak, and, in an hour of need Over tbe suffering, mindless of his creed Or bome, liath bent- He bath not lived in vain. And wbile he gives The praise to Him, in whom he moves and live 8, With thankful heart He gazes backward, and with bope before, knowing that from his works he nevermore Can henceforth part. Editorial. 133 How like is this to the life of the battle-tried physician! If he have been only true to the demands of his noble calling, either at the bedside or in his study, he has done as much as any mortal to lift up the fallen—to heal the wounded, in body and spirit-and bind up the many wounds of weak humanity, of body and soul; and whatever may have been in life his own shortcomings, though he may have slipped backwards with each step forward in the line of moral progress, truly he hath not lived in vain. Dr. Earle on the Curability of Insanity.- Dr. Pliny Earle's book on the “ Curability of Insanity," the advance sheets of which are just from the press of J. B. Lippincott & Co., Philadelphia, is before us. It treats the subject much more at length than in the articles which have appeared in these pages and in the reports of Northampton, but the same characteristic views and array of asylum records upon the subject of the cura- bility of insanity, appear in the book as were put forth in Dr. Earle's papers. The book ought to be in the hands of every asylum medical officer, especially of the young superintendents. It draws the line sharply between the temporary cure of cases and the final recovery of individuals, and makes a clear exhibit from extensive hospital records, of the lia- bility of insanity to recur. It must have a good effect in repressing over-sanguine superintendents ambitious for a good present showing of their cures, and by leading to more cautious injunctions on the part of alienists, and more careful following of the laws of mental hygiene on the part of the once victims of mental disease. Dr. Earle's picture of the permanent curability of in- sanity, reducing the average of final cures to between twenty and twenty-five per cent., is not so discouraging in our estimation as it seems to our author, when we con- sider the grave and subtile forms of the disease which are now recognized and the profound character and forms of cerebral dissolution attendant upon the conditions of mod- ern life, mental and physical. It is certainly true, as stated by the author, that many reported asylum recoveries were imperfect and incomplete, and that new cases are only old cases renewed; but all second attacks are not necessarily the sequences and con- tinuation of the previous attacks, and in many, in fact in 134 Editorial. most instances, might be averted under judicious hygienic conditions, such as, if conformed to in the antecedent life of the individual, would have made the first attack impossible. But it must be borne in mind that insanity is the product usually of more than one generation of brain degenerative influences, and is more often than otherwise either a direct hereditary transmission or the result of a congenitally entailed propensity to those intellectual and moral excesses of character and conduct which tend to the development of cerebro-psychical instability and the final culmination of marked mental aberration. There is far more insanity in the world than even the profession recognizes. There is much more congenitally-entailed cerebro-psychical in- stability, which is but an earlier stage of insanity, under environment more favorable to sanity than surrounds the more positive and recognized forms, than is generally be- lieved in by lay or professional students of psychiatry and psychology. There is likewise an inside and an outside experience with the insane with reference to hospitals for the insane and the curability of insanity. Usually when an insane man finally reaches the asylum it is because he has either become so dangerous or disagreeable to his friends or relatives that they have no interest in keeping him out of an asylum, or the case has become of comparative long standing, and reached a more or less hopeless period. The filthy, the obscene, the noisy, destructive and violent, and those who from the start commit the greatest improprieties, that make their friends and relatives blush for shame or fear for the safety of, are the fortunate lunatics in securing timely treatment. To become insane in its milder and less aggravated forms is to become, in most instances, hopelessly deranged. The patient is fortunate in such a state of mental derangement, if he fall into the hands of a physician who can appreciate his true condition and properly treat or dispose of the case for proper treatment. The stage of most hopeful treatment in many cases has passed before all concerned in the unfortunate one finally acquiesce in his removal from his adverse surroundings to a suitable place of treatment, especially if he have the misfortune to be a good-natured and mild- mannered insane person and can be categoried as harmless. Even some States, looking only to the possible criminal side of insanity, and over-looking the feature most essen- tial to the unfortunate victim, its curability-consider that Editorial. 135 the insane person should be dangerous before the State will undertake to save him to himself and the State, by allowing him to be deprived of his liberty. He must be physically dangerous to the community or himself, as if the mental danger to himself of permanently losing the right use of his reason, and to the commonwealth, of losing for the poor man's life-time, a possible useful member of the body politic, were not worthy the consideration of the State. A human mind should be as valuable to its possessor, in the eye of the law, as a human life, and as valuable to the State, but they are not practically so regarded by the manner in which the state often acts on the question of insanity and towards the insane. And as a conse- quence they are not lawfully helped everywhere to that prompt treatment of their malady which is their due from their proper guardian, the law. On the contrary, the law, in its over-anxious regard for personal liberty, places the mentally sick upon the same basis as the mentally well, in some States, and make access to prompt and early asylum treatment of insane persons as difficult as possi- ble, by requiring not only the “dangerous” condition, but the jury trial, which seldom discovers and concedes insanity except in the most flagrant forms. Being ourself in a position to see the many early stages of mental disease before they have reached the aggravated period at which the concession of insanity is either popular or general even in the profession, and to see these cases often averted by timely treatment from culminating in marked and unmistakable outbreak, we are convinced that insanity is, in the vast majority of cases, curable, if early and judiciously treated. The subject of the curability and the successful treat- ment of insanity in its early stages, in and out of asy- lums, at home and by change of environment, is one demanding the more earnest and thorough study of the profession at large, with a view not only to its prompt treatment by the family physician, aided by the judicious counsel of Alienists, who have had special opportunities of observation and study of this malady, but with a view to the judicious and timely disposal of each case, as it presents itself, so that, in time, a change may be made apparent even in the asylum records of recoveries, much more favorable than that shown in Dr. Earle's excellent and pains-taking studies. 136 Editorial. Our own personal experience is more favorable in re- coveries of those cases which we have diagnosed as cases of prodromal and early active mental aberration, and undertaken to treat at home or away from an asylum, than the results in the list of cases sent by us promptly to asylums. Some of these were acute cases, and most of them recovered and returned; others where chronic and hopeless, and had lost their best chances of recovery be- fore we saw them. Our experience for the past twenty years inclines us to the individualized over the aggregate treatment, but not to the exclusion of the latter, and to the conviction, that insanity timely managed in and out of hospital, as the exigencies, form and stage of cases required, by prop- erly experienced Alienists, is far more curable than fatal to healthy mentality. Its pathology, so far as we have learned it, in its earliest stages, is far oftener a disturbed vascular condition than an irreparable organic change in the brain. It is because in asylum cases real remedial treatment has been too long denied the patient, and be- cause also in many asylums new political appointees have to glean all their clinical and therapeutic knowledge of mental aberration after they take charge of an asylum, and are often too far advanced in life to learn all that they might have learned of this profound disease and its management and cure, that patients are discharged pre- maturely and average results are no better. The reluctance of friends to let insane persons go promptly to asylums, unskillful treatment and dangerous delay through advice of the family physician sometimes, and the importunate efforts of friends to get their afflicted relatives home again from the asylum, often too soon yielded to by superintendents, also contributes no small share to the making of Dr. Earle's unfavorable records. Many of these causes are more or less remediable, and despite the pessimistic showing of the book before us, we look upon the present and future curability of insanity with more faith and brighter hopes than the author. “The Contracture Diathesis.”_Under the name of diathèse de contracture, M. Charcot attempts to make a distinctive pathological entity of this nervous condi- tion. The New York Medical Journal of November 20th, thus refers to the views of Charcot and others on this subject: Editorial. 137 Charcot tried to explain tbe pathology of the conditiou by a local ischæmia induced by a more or less complete obstruction of the blood- vessels supplying the part. In order to test his theory, be applied an Es- march's bandage to the arms and legs of several colleagues and students wizout, however, being able to evoke the phenomenon. But it was quite different when the same thing was done to the limbs of hysterical subjects; contractions of the muscles set in almost immediately on tightenning the bandage. The bandage was applied at the wrist, the elbow, and the point of insertion of the deltoid muscle, always with the same result, contrac- tion extending from the distal end of the limb to the point of constriction. Both upper and lower extremities acted in the same way. On the removal of the compression, the contractions nearly always ceased. Berez, who has studied seventy cases (forty-tbree in females and twenty-geven in males) in reference to this phenomenon in hysteria, observed it in as many as fifty-two cases. In two instances the contractions extended to the wbole body, and in one case affected the right side after the bandage was removed. Of the fifty-two subjects, nineteen were men and thirty-three were women. The same observer states that massage or percussion of the muscles prior to the application of the bandage will evoke contractions wben constriction alone will fail. In most of his cases the existence of the condition was evident only on examination ; but a few of the patients said that, on giving a sharp blow, the hand remained closed in a "state of tixation.” The contractions may be called forth, indepen- dently of constriction, by massage of the muscles, percussion of the tendons, rough handling of the limb, Faradization of the muscles or nerves, or simply rubbing the skin. These observations seem to clash with those of Troussean, Kussmaul, and our recent distinguished English visitor, Dr. Julius Althaus. In his paper on " Tetany," read before the Medical Society of the County of New York, Dr. Althaus stated that the effect of compression was an important feature in the differential diagnosis of hysteria and tetany, and tended to show that they were two widely different conditions. In doubtful cases of hysterical contracture, he says, compression of the limbs bas enabled him to decide the question, for it appeared that, while in tetany pressure increased the rigidity still further, in bysterical contracture, on the con- trary, the rigidity was lessened and ceased after the bandage had been applied for some time, to return, however, almost immediately when the pressure was withdrawn. This rather striking contradiction in the observations of renowned clinicians forcibly illustrates how much we are still in the dark in reference to (we will not say with the Journal, to this class of neuroses), but to this variety and form of neuropathic manifestation. It will probably be long after M. Charcot and Foster shall have gone where disputations on ultimate neural pathology are at an end, before anything more than is now known shall be brought to light on this subject. The neurosis spasmodica or the diathesis spasmodica is 138 Editorial. at the bottom of the insane temperament, and alienists and neurologists have long recognized it, in a tendency to explosive rather than regulated emission of force in motor or psychical centers, and the true pathology, what- ever may eventually be found out as to its now hidden nature, is in the inherent or early acquired character of the nerve center displaying the morbid activity The pathological (immediate) cause of the display of the mor- bid function is known to a certain extent, and may be further known long before the cause of the pathological condition in the aberrantly inclined center-psychical or motor. We know from abundant clinical experience and chemical testimony as to blood states, how malnutrition affects unfavorably some motor and psychical centers, so that spasmodic, sepplants normally regulated functional activity; and we know why this is so, whether the illy nourished center be in the brain, the ganglionic system or in the cord, and we explain it in the aforetime-evoked diathesis spasmodica, but there is a hidden wherefore un- derneath this why, which neither M. Charcot nor any other savant in neurology has solved. Sciatica Treated by Galvanism.-In the Lancet, July, 1886, Dr. W. E. Steavenson gives a short account of sixty cases of sciatica treated by means of galvanism. In the Lancet, July 19, 1884, the author published a paper upon the subject in which he described the mode of applying the current. Out of the sixty cases, thirty-seven were cured; eleven improved only ; nine did not remain under treatment long enough for a certain result to be noted; two were still under treatment, and one had a return of sciatica, which was cured a second time. The number of applications needed to produce a cure was about six to eight; some few patients came twelve or fifteen times. The author concludes by stating that the favorable results obtained by him bear out the opinion given by Dr. Stone in his Lumleian lectures.- Medical and Surgical Reporter. This record comes to us from across the Atlantic. If the reader will turn to the October, 1885 number of this journal he will find a record of a most obstinate case of sciatica. The whole of the great sciatica with its branches having been implicated (the most excruciating pain being at the point of emergence of the nerve from the cavity of the pelvis), the relief of which was finally accomplished, after four weeks, by twice or thrice daily repeated and Editorial. 139 prolonged galvanizations, with a strong twenty-four-cell de- scending galvanic current and sponge electrodes. He will also there find incidental mention of another and equally intractable form of neuralgia, a case in which all branches of the seventh pair were implicated, the con- vulsive paroxysms of pain recurring incessantly, which yielded to galvanism after having been treated by other means for nine years. The cases were reported for another purpose, namely, to record some cases of temporary mental aberration fol- lowing the cure of prolonged neuralgia ; but they serve to show the value of a therapeutic practice older than Meyer, Benedict or Anstie, and so common in successful neurotherapy as to no longer require special testimony in confirmation. To treat a persistent, grave neuralgia, without galvan- ism, is to neglect the most valuable and certain of all permanent resources, not even excepting the knife, for a cut nerve may reunite or collateral branches show the often remaining central pain. In all neuralgias of nerves which can be traversed from center to periphery by the galvanic current skill- fully regulated galvanism is the best and most certain and permanent of all therapeutic resources. Its therapeutic value needs no further confirmation. Nervous Origin of the Colored Rings in Glau- coma.-Neurologists are quite familiar with the various subjective color impressions due to cerebral hyperæmic impressions; each or all the prismatic colors being observable in certain cases (and the clinica! fact tells plainly enough of the existence of a color center within the cerebrum, whether we are agreed to its precise locality or not), and ophthalmology now adds another confirmation in its concession of the intercerebral origin of the colored rings around a light seen by the glaucomatous eye, as the most plausible and probable explanation of this ophthal- mic phenomenon. We quote in confirmation from Prof. Adolph Ault's report on ophthalmology in the Weekly Medical Review of December 4th, the following discussion of an article by Dobrowolsky in Archives of Ophthalmology of September: According to Donders and his followers these colored rings were con- sidered to be due to a cloudiness in the refractive media, as it is most fre- quently observed in glaucoma. Mauthner had, however, come to the 140 Editorial. conclusion that these rings were due to nervous irritation only, at least in one case « xamined by him. This idea of Mauthner receives a very strong support by the experience of Dobrowolsky made on his own eyes whilele was in the Russian bath. While in the bath he at once noticed colored rings, and at first he thought them due to the steam in the air, but subse- quently he proved to his own satisfaction, that they were caused by, and disappeared with the hyperæmia of the head and face which the heat of the bath produced. After having related some furtber experimenis, he comes to the conclusion: “That rainbow rings may be seen by eyes which are free from any cloudiness of the refracting media, and that the only way to explain this phenomenon is to assume, that it depends upon irritation of the retina and the optic nerve by hyperæmia.”' The Physician as a Teacher.- In addition to treat- ing those who are sick, there is much that a physician can do by way of teaching people how to maintain health. Every physician has in his patients an audience that re- gards his opinion on medical matters as final; if, therefore, he is informed in mental and physical hygiene, a mission- ary of health, cleanliness and cheerfulness, he can be a constant teacher in the circle in which he moves. As medical knowledge is esteemed, the prevention of disease becomes more and more prominent in the work of medical science because we have learned the value of health, and that very simple rules of right living are alone necessary to promote both health and longevity. There is doubtless no class of diseases more largely preventable than diseases of the nervous system, and though the causes of these disorders are sometimes remote, yet they are usually traceable to violations of the laws either of mental or bodily hygiene. Over-study in early life, without causing an immediate break-down, may dwarf the development and lay the foundation for future inval- idism, and we believe that a considerable proportion of nervous disorder is attributable to such influences that, in early life when the nervous system is sensitive and impres- sible, check its normal growth and leave it ever after irritable and unstable. The same considerations apply to over-work in adults. There is much brain-failure now-a- days from what is called over-work, and yet much of it is probably due more to the manner of work than to the amount of work. Hard and prolonged mental labor is not injurious if carried on under proper conditions; the brain is strengthened by exercise, and the work of a man of an intellectual pursuit, if properly diversified, is recreation. The harm of mental labor is in waking at wrong hours, Editorial. 141 or without system, or with both, and tension that wear upon the brain more than work. In this age men rush, and rush means high tension, and tension means rapid wear and waste of vitality. Emerson says "all haste is vulgar,” and he might have said it is injurious to health, and those who work with that high pressure which haste invites, are certain to suffer for it. It should be consid- ered one of the beatitudes of mental physiology, that sys- tematic, deliberate mental labor is normal; it develops the brain and prolongs the period of its activity in old age, and the converse of this is also true, that mental labor performed with anxiety, haste and high pressure is exhaust- ing and is certain, sooner or later, to produce injurious results. Those who deal much with nervous disorders know how large a share of these troubles is due to the habit of worrying. People fall into the habit of worrying about those little mishaps that of necessity come up in the life of every one, and the habit once formed is a difficult one to overcome; worry, above all things, consumes vitality, and disarranges the harmonious working of the functions ; it leads to loss of appetite, to sleepless nights, to irritable nerves, to impaired nutrition; it robs the disposition of attracitve qualities, it lessens the mental vigor and it not infrequently is a father in the production of nervous dis- order. Sensitive people, those who are easily wounded and discouraged, are most apt to worry when affairs go wrong, and yet they are just those whom worry will harın the most and who will lose the most in life by indulging in it. Trials and reverses may destroy the over-sensitive or the weak, unless such persons prepare for them by the cul- tivation of patience and courage. Those, however, who are not fretted and depressed by the small mishaps and adversi- ties of life are the better for encountering them, for they are a part of the necessary and kindly discipline of experience that helps to build up character, and strengthens it, as the storm that bends the vigorous tree strengthens and consolidates its healthy fiber. In this world only the idiot makes no mistakes; the intelligent and progressive men must blunder and meet with disappointments occasionally. The proper mental attitude to cultivate is that which accepts such experi- ences with cheerful serenity; for he who would climb the steps of Progress, even a little way, must expect to slip and fall as he toils along. 142 Editorial. The physician who deals professionally with these vic- tims of worry (and who of us does not?) is the one person alone, of all others to teach people how ruinously demoral- izing worry is, and how much better it is to cultivate patience and cheerfulness. That mental attitude which ex- hibits patience and cheerfulness conserves the mental health and helps to success in life. By seeming gay, we grow to what we seem, has a bit of good philosophy in it. These remarks are of necessity fragmentary, and are intended to be suggestive only; but we simply wish, with- out elaboration, to call attention to the function of the physician as a teacher. Bacon says “all men are debtors to their profession," and physicians have been ever ready to concede the truth of this saying of the great philosopher. But this may prop- erly be extended, for surely they are also debtors of society, by whose protection and favor they do the work of life. The physician, aside from the routine of medicine, has special and superior opportunities of usefulness, and he should utilize them for the benefit of those among whom he lives. J. H. McB. - - -- - Fatal Results from the Toxic Power of Co- caine.-The recent tragic death of a patient in a Russian hospital from twenty-four grains injected into the rectum preparatory to a surgical operation in this region, the op- erating surgeon, Prof. Kolomum, having committed suicide from remorse, proves the toxic power of this drug so com- pletely that no one familiar with this sad case and its sequel will care to repeat the experiment recorded by Dr. Hammond. Within an hour after the fourth six-grain injection into the bowel, this patient was dying, with cyanosis, gasping respiration and flickering pulse, which the most vigorous measures-electricity, tracheotomy, art- ficial respiration and stimulating hypodermics and enemata- could not change for the better. This fatal case, now a matter of authentic record before a St. Petersburg Medical Society, is another warn- ing of the direct danger of cocaine. It is by no means a harmless remedy in either its immediate or remote effects. It is regretful that any reputable physicians whose Editorial. 143 opinions are weighty with the public should, after so inad- equate a personal experience, proclain the incapacity of this “third scourge of humanity,” as Erlenmeyer has not inaptly termed cocaine, to enslave with the chains of a drug habit. Not long ago the most laudatory public proclamation of the benign therapeutic potency of cocaine came from one whose fulsome and groundless laudations of it suggested cocaine intoxication in the writer. It were far better that such men had never been born than that they should live to enter a great profession, become in it shi- ning lights, and then mislead a confiding public to ruin by inspiring security where there is no safety. Cocaine is too new in therapeutics to have, as yet, made many exclusive victims, but it has shown its power to enchain the nervous system and substitute, to a great extent, its own for the slavery of alcohol or opium, and this is a power so formidable as to be dangerous if lightly re- garded. It is doubtful if cocaine can ever be abandoned after its long continued use, unless opium or acohol, or possibly hash-heesh and chloral aie substituted for it. All cocaine- takers whom we know who have dropped the use of cocaine, or who assert that they have, are now using opium instead. From all that we have seen of the capacity of cocaine to enslave, its power to enthrall its victims, is only equaled by that insidious but less violent intoxicant, opium. Truly has it been called the third scourge of humanity, for it is the third link in the devil's triple chain-alcohol, opium, cocaine—that binds man in the vicious slavery of neuro- pathic and psychopathic habit from which only the most skillful medical treatment and long persistent restraint, or the miraculous grace of God, can free its pitiable victims alive. It means nothing in favor of cocaine that its victims have mostly been the previous slaves of alcohol or opium, and that they can exchange its misery for the vicious slavery of these other drugs. Since Dr. Hammond's record, another physician, Dr. John T. Booth, has recorded a different personal experi- ence with this drug, with reference to the facility of its discontinuance, also in a daily paper, but he had taken it for a longer time. (See Cincinnati Enquirer.) We are a little surprised that Dr. Hammond, from 144 Editorial. what he and all physicians know of the comparative tar- diness with which drug habits are formed, should have expected anything like a long slavery from so short an experience with cocaine. It is not the single spree for the first time that makes a drunkard, nor the brief employment of opium that makes the opium slave; it is the long-continued use of the drug, especially when there is no pressing therapeutic necessity, that makes the opium slave. We should almost as soon expect to become a slave to chloral from a few consecutive nightly doses for insomnia, or to ether, after a capital operaton, as to see one become per- manently enslaved by cocaine from an experience like that which Dr. Hammond records. The experience, however, is of some value to the profession, though the experi- menter's conclusions be erroneous. A Case of Psychical Epileptoid Automatism. - The following record comes to us from an intelligent physician in Illinois : It is probably a case of psychical epilepsy, the psy- chical change of character and conduct being either sup- plementary to or a sequence of a nocturnal epilepsia. There may have been remote specific trouble, probably unknown to the patient. At all events, a treatment having the bromides and iodides with arsenic and mild cephalic galvanizations, from forehead to nucha, would give best promise of recovery, coupled with a change of environ- ment and cessation of accustomed occupation. We must here say that we have not time, though dis- posed to oblige, to answer all the communications of this character which come to us; much less can we be expected to answer inquiries requiring diagnosis and treatment of obscure cases in extenso. We will do the best we can for professional brethren in distress, but there is a limit in this direction. We must care for our own as well as others, and are forced to look upon, and work upon, the business as well as the charity side of our profession. A physician, forty-four his next birth-day, with good family history on both sides. He has always been a great student, having graduated at Yale, for twenty years past, and has been engaged in active pursuit of his chosen profession since that time. He has made himself a self-imposed eunuch, and so far as I can learn, he has never had sexual intercourse with any woman in his life. For years he has been entirely devoid of beard, and his pubic hair has long since disappeared. His complexion in former years was ruddy and healthy, but for a year or more it has been between a white Editorial. 145 and jaundice-a sort of cadaveric as it were. His appetite is good most of the time, and his bowels are fairly well opened every day. He always was a good sleeper, and is now. For about a year it has been noticed that he was forgetful or absent- miuded, and if he started to go to a given place, he might forget where he was going or what he was going for. He will sometimes think he is going in an opposite direction, even in a part of country where he is well acquainted. Not long since he wakened bis nephew in the night and asked him where he was. He sometimes forgets the daily happenings, and they seem a perfect blank to bim when told of them. On one occasion he bad a long talk with a party on important business, and the next day be bad forgotten all about it. These strange actions have occurred but a few times, some of tbem but a single time. He seems ordinarily well most all of the time, these strangc aciions recurring with no regularity. He is always ready and anxious to do business, but his people think he is in need of prolonged mental rest. He realizes that he is “off” sometimes, and says 80. He is never melancholy, and maintains a weight of one hundred and seventy pounds all the time. Paralytic Ataxia of the Heart.-The New York Medical Record, of November 20th, makes the following editorial comments on Professor Semmola's late contribution to this subject: For the third time in the last ten years Professor Semmola has called to the attention of the profession a peculiar disorder of the heart, of purely nervous origin, which he calls “paralytic ataxia of the heart, of bulbar origin." In a recent communication to the Paris Académie des Sciences he brings, as he believes, new evidence of the existence of tbis disease. Paralytic ataxia of the heart is a disease which usually affects men be- tween the ages of forty-five and sixty. It is caused, as a rule, by powerful emotions and venereal excesses. The disease begins with gastric disturb- ances—an obstinate dsypepsia, followed by gastric catarrh. Then the cardiac symptoms appear, and consist at first simply of systolic weakness and increase of the heart-beat. This constitutes the prodromal stage of the malady, and it may last for one, two or three years. The patient wbile in this stage may recover; but if the causes continue, the disease pro- gresses and new symptoms appear. These consist of attacks of palpitation, irregular heart-beat, and respiratory troubles. The patient, during an attack, develops a marbled discoloration of the hands, forearms and legs, especially at the finger-joints and about the knees. This symptom is characteristic and differential, and it is due, says Semmola, not to any me- chanical disturbance of the circulation, but to a vasomotor paralysis, and it shows that the vasomotor center as well as the cardiac center in the medul- la is affected. The heart shows no enlargement and no evidence of a valvular lesion. The patient suffers from shortness of breath on slight exertion, and auscultation of the lungs reveals crepitant râles at the base. These Semmola believes are also due to vasomotor paralysis, and not to mechanical obstruc- tion. Against this view, however, it may be said that it is doubtful whether the pulmonary blood-vessels are influenced by vasoconstrictor nerves. 146 Editorial. The paijo nt also suffers from attacks of suffocation, which arouse him from sleep and force him to sit up in bed, when the symptoms soon disap- pear. After a time cedema of the feet begins to develop, and this marke the terminal period of the malady. At this tiroe a slight cardiac bruit is heard; but Semmola believes that this does not indicate a valvular lesion, since it disappears with the improvement of otber symptons. It is stated that post-mortem examination of these cases shows a distinct degeneration of the cardiac ganglia, and also of tbose parts of the medulla in connection with the vagus nuclei. The disease is a progressive degen- eration, therefore, of the cardiac nervous apparatus. Our readers will see that the paralytic ataxia of Semmola may easily be confounded with simply irritable heart, or angina pectoris, or with a fatty heart. We regret that we have been unable to find Sein mola's reports of illustrated cases or records of autopsies. A good many of these are reqnired to give to tbe disease the distinct clinical and anatomical entity which is claimed for it. • A careful examination of Milner Fothergill's “Neurosal and Reflex Disorders of the Heart” might tend still further to shake Prof. S.'s rather too stringent conclu- sions from the clinical side of the pathological picture. Nevertheless Semmola is on the right track, and what are now regarded as only and exclusively functional disorders of the ganglionic system must sooner or later take their proper place among the truly structural diseases. The • ganglionic system can no longer remain a comparative terra incognito to pathologists. Semmola has our thanks for the enlightenment he has given us in this direction, and Fothergill may read what Semmola has written, with profit equal to that which he has bestowed on the pro- fession. nglins al rep for a hably Lincoln on Quarrels.-After telling of the Shields. duel in the January Century, Nicolay and Hay give the following: “This was Mr. Lincoln's last personal quarrel. Although the rest of his life was passed in hot and earnest debate, he never again descended to the level of his adversaries, who would gladly enough have resorted to unseemly wrangling. In later years it became his duty to give an official reprimand to a young officer who had been court-martialed for a quarrel with one of his associates. The reprimand is probably the gentlest re- corded in the annals of penal discourses, and it shows, in few words, the principles which ruled the conduct of this great and peaceable man. It has never before been published, and it deserves to be written in letters of gold on the walls of every gymnasium and college : Editorial. 147 " The advice of a father to his son, · Beware of entrance to a quarrel but being in, bear it that the opposed may beware of thee!' is good, but not the best. Quarrel not at all. No man resolved to make the most of bim- self can spare time for personal contention. Still less can be afford to take all the consequences, including the vitiating of bis temper and the lo:8 of self-control. Yield larger things to which you can show no more, than equal right; and yield lesser ones though clearly your own. Better give you: path to a dog than be bitten by him in contesting for the right. Even killing the dog would not cure the bite." Medical men might profit by the example of the martyred president. The loss 'to science and to humanity from personal controversies, and the unseemiy and unnecessary differ- ences over the forthcoming congress and over the code question, it would be difficult to compute. There are certainly ways by which the good and true men of medicine might be kept together in all true professional essentials if all of its good members were right-minded on the subject of personal quarrels, and felt, as we do, that life is too short and our art too long and intricate, demanding too much of our time to profitable study, for profitless personal controversy. Medical men would generally act about right towards each other if they were kept longer in the family during their apprenticeship to become practically fainiliar with its principles of etiquette, but a great many doctors were not kept long enough in the fold before graduating to learn good professional manners. Train the boys four years in college before giving them their diplomas, and when they become doctors they will quarrel less and study more. Quarrels will be distasteful, if for no other reason, because of the too valuable time they consume and take from medical study and advancement. Wanted, the January (1881) Number of this journal. Subscription price will be paid for it. j | Also for any number of 1880. International Medical Congress; Vacancies Filled.- Dr. J. J. Chisolm, of Baltimore, Maryland, has been appointed President of the Section of Ophthalmol- ogy, in place of Dr. E. Williams, who was compelled to resign on account of ill-health. Judson B. Andrews, M. D., Superintendent of the Hospital for the Insane at Buf- falo, New York, has been appointed to the place made vacant by the death of Dr. John P. Gray, as President 148 Editorial. of the Section of Psychological Medicine and Nervous Diseases. No vacancies now remain in the list of the chief officers of the preliminary organization of the Con- gress or its Sections, and our information from all de- partments is of the most encouraging character.- Journal of the American Medical Association. Effect of the Charleston Earthquake on the Health of the Inhabitants.-A very interesting com- munication to the Medical News has been made by Dr. F. Peyre Porcher, of Charleston, on the influence of the recent earthquake shocks in that city upon the health of the inhabitants. In addition to the natural alarm and fright which were quite universal, some persons were attacked with nausea and vomiting, which recurred or persisted in several cases for days. Two gentlemen on the islands eighty miles from Charleston had their eyes filled with tears not to be repressed, but not caused by alarm, or fears for their personal safety, for the danger there was not imminent. Many persons experienced decidedly electrical disturbances, which were repeated upon the successive recurrence of the shocks. These were generally tingling, pricking sensations, like “needles and pins,” affecting the lower extremities. One gentleman was completely relieved of his rheumatism ; another, who for months was nervous, depressed, and entirely unable to attend to business, regained his former activity and energy. Several cases of mental disturbance, owing to anxiety and prolonged loss of rest, some of them persistent, occurred among Dr. Porcher's patients. Rheumatic Hyperpyrexia and Bulbar Disease. -Our enterprising contemporary, the Canadian Practitioner, has examined the new work of Maclagan, who it will be remembered is the reputed author of the salycilic acid treatment (though salicin was on the supply table of the U. S. army, and used freely during the war, as early as 1862, by the editor of this journal, and other army surgeons, for malarial rheumatism and all other malarial diseases, with success), and presents the distinguished author's very plaus- ible views on the subject of rheumatic hyperpyrexia and bulbar disease. The Practitioner very pertinently refers to the cases of rheumatic fever reported by Sidney Ringer in 1867, which, after beginning in the usual manner and pur- Editorial. 149 suing the ordinary course, suddenly developed marked nervous symptoms, higher tenperature, and died of coma, with a temperature just before death of 109.2° F. in one case, and 110.8° F. in another, and 112.8° F. in the third. No post-mortem evidences explained the symptoms. Officers of New York Medico-Legal Society for 1887.-President, Clark Bell; First Vice-President; Dr. J. M. Carnochan; Second Vice-President, Dr. A. H. Smith; Treasurer, Dr. S. N. Leo; Secretary, Albert Bach, Esq.; Corresponding Secretary, Mr. Moritz Ellinger; As- sistant Secretary, Mr. Clark B. Augustin; Curator and Pathologist, Dr. Th. H. Kellogg; Chemist, Dr. Chas. A. Doremus; Librarian, Dr. Chas. F. Stillman; Trustees, Long Term, Wm. Davies, Esq. and Dr. R. O. Bronson; Trus- tees to fill Vacancies, Simon Sterne, Esq. and Ferd. C. Valentine, M. D.; For Permanent Commission, Long Term, Clark Bell and Prof. R. O. Doremus-To fill Vacancies, D. C. Calvin, Esq. and R. L. Parsons, M. D. To News Dealers and Bonk Agents.—This jour- nal pays no commission on renewal of its own regular sub- scribers. if you want your orders honored send checks for full subscription and save us the trouble of returning your checks. Sick Chamber Wit.-Some of our exchanges come to us laden with levity and abounding in sick room wit. The “phunny phellow" is abroad, and when you see him his mouth seems puckered up as it were for a ghastly pun. Succi's Fast. It is said that the reason Succi succeeded in his fast was because of the lacteal suck from a young mother who attended him, she sharing the lac- teal secretion of two bounteous breasts with Succi and her son. Possible Untoward Local Glandular Sequence of Hyosciamin and Electricity.-In an old lady of eighty-nine years, suffering from acute insomnia and delu- ions of dread and violence, in the editor's practice lately, the use of a mild current of electricity from head to nucha, and from nucha to buccæ (the mouth having been previously quite dry) was shortly followed by the swelling of the submaxillary glands of either side to the size of an En- glish walnut. 150 Editorial. The galvanism was used from neck to cheeks, not only to counteract the natural dryness (which it did), but to counteract the arrest of secretion in mouth and throat which frequently takes place after hyosciamin. Before using the galvanism the patient would con- stantly put her fingers to her tongue, and the tongue was very dry. She would not permit an examination, as she resented every attempt to look into her mouth; conse- quently, it could not be minutely inspected by palpation; but a light reflected into it (when her mouth was inci- dentally opened) revealed nothing. The parotids did not swell. Mental tranquilization to a considerable extent has followed the nightly hyoscyamin hypodermics-one-twelfth grain Merck's amorphous, in seventy-five per cent. alcohol and twenty-five per cent. water solution, but under iodide of potassium and iodine (locally) no subsidence has taken place in the swollen submaxillaries. This is the first ex- perience of this kind we have had in a very extensive use of these two therapeutic agencies, and as we are unable to judge of its significance we submit the facts to the con- sideration of others. There was no appearance of glandular induration when this treatment was begun, and nothing suggested the possibility of glandular obstruction except the previous existence of a not very extensive bed sore and the his- tory of a former ranular or salivary calculus. din Washingtoill be openen M. Sectioide The Ninth International Medical Congress will be held in Washington, D. C., U. S. A. The General Session will be opened on Monday, Sep- tember 5th, 1887, at twelve o'clock M. Section in Psychological Medicine and Nervous Diseases. President, Judson B. Andrews, A. M., M. D., Buffalo, N. Y.; Sec- retary, E. D. Ferguson, M. D., Troy, N. Y. EXTRACTS FROM THE RULES.—“ Brief abstracts of papers to be read in the Sections shall be forwarded to the Secretaries of the proper Section on or before April 30, 1887. These abstracts shall be considered as confiden- tial communications, and shall not be published before the meeting of the Congress. * * * No communication shall be received which has been already published or read before a Society.” We have received the following circular from the Secretary : Troy, N. Y., December 23d, 1886. DEAR DOCTOR: If it is your intention to attend the meeting of the Editorial. - 151 Ninth International Congress, or to contribute to the scientific work of the Section in Psychological Medicine and Nervous Diseases, will you be kind enough to notify me? As the time is now limited, please forward at once the title of any contribution you may intend to make. Attention is called to the above Extracts from the Rules relating to abstracts of papers. It is iinpossible for us to ascertain the names and addresses of all physicians interested in the specialties. Will you kindly interest yourself in the work of this Section so far as to send to me the names and addresses of those who might attend, and also ascertain who of your professional friends propose to attend. A circular will be sent to any name and address you may furnish. Hoping to meet you at Washington in September next, and request- ing an early reply, I remain Your obedient servant, E. D. FERGUSON, Secretary, etc. llings, is theirsystem, wijeno Nervous Diseases and Their Diagnoses, by H. C. Wood.-A treatise on the phenomena produced by diseases of the nervous system, with especial reference to the recognition of their causes, dedicated to Surgeon John S. Billings, U. S. A., facile princeps of medical bib- lingraphers, as the author terms him, is on our review table for future notice. Likewise a valuable “Text-Book ON PRACTICE," by Strümpel, and a pre-eminently practical treatise on " OPERA- TIVE SURGERY," by Bryant. The latter is the best book for ready-reference and plain, practical instruction on the subjects on which it treats, we have lately seen in the English language. The Successor of the late Dr. John P. Gray.- The Board of Managers of the Utica Asylum have appointed Dr. G. Adler Blumer superintendent, to succeed the late Dr. Gray. Dr. Blumer graduated in medicine seven years ago at the University of Pennsylvania, was Dr. Gray's assistant, and is well qualified for his new position. The late Mr. R. M. Howard.-With regret we announce the recent death of Mr. Rice Meredith Howard, son of Dr. Henry Howard, Medical Superintendent Longue Pointe Asylum. IN MEMORIAM. THE DEATH OF John P. Gray, M. D., LL. D., Superintendent of the New York State Lunatic Asylum at Utica, New York, died at the Asylum on Monday, November 29, 1886, of Bright's disease. Dr. Gray was born in Centre County, Pennsylvania, August 6, 1825. He was educated in the common schools at Bellefonte and at Dickinson College, receiving the de- gree of A. M. in 1816. His medical degree was received at the University of Pennsylvania in 1848. After serving for a time at Blockley, he went to Utica in 1851 as an assistant-physician. In 1853 he was appointed Acting Superintendent, and in 1851 succeeded Dr. Brigham as Superintendent. As Superintendent of the Asylum, Dr. Gray made himself felt in a way that had a more tban local influence. He insisted upon a bigh stand- ard of general and professional care, and carried his views into every de- partment of asylum administration. He early established the rule of receiving for assistant medical officers young men of thorough medical training, making general hospital service a prerequisite to appointment. As a result of this high standard and the training received under Dr. Gray, no less than six State asylums have called their superintendents froio Utica since bis appointment as its chief medical officer. He took an active interest in hospital architecture, and was the author of the plans for the asylums at Kalamazoo, Michigan, and Buffalo, New York. As the editor of the American Journal of Insanity, and in addresses be- fore medical societies and other scientific bodies, Dr. Gray contributed largely to the literature of Insanity and Medical Jurisprudence. He was an earnest advocate of the physical basis of insanity, and early omitted from his reports any enumeration of the so-called moral causes. He took a strong interest in pathological investigations in insanity, and nearly thirty years ago contemplated and suggested the institution of systematic pathological study in the Asylum. It was not, however, until several years later tbat he was able to put his views into practical operation, when he was the first superintendent to appoint a medical officer in an insane asylum for special pathological work. The high standard of care of the insane attained by the State of New York, is largely due to the influence of Dr. Gray, and the example of Ulica has been widely felt, and for good. He was a man of positive ideas, and seldom permitted opposition to intimidate or influence him. In any body of men he made himself felt, and, while in many matters of a conserv- ative tendency, his influence was always in the direction of advance. As a medical witness in cases of public interest he was widely known. His most exhaustive services in the Guiteau trial are probably the best re- membered. During the war, he several times gave the government the benefit of his advice, and his services were employed in the trial of the Lincoln assassins. [152] In Memoriam. 153 In 1874 he was appointed Professor of Psychological Medicine in Bellevue Hospital Medical College, and in 1876 he received a similar ap- pointment from the Albany Medical College. Both of these positions be filled with ability. He was a member of the American Medical Associa- tion; at one time President of the New York State Medical Society, and recently President of the New York State Medical Association. In 1876 he was chairman of the Psychological Section of the International Med- ical Congress, and he held the same appointment for the Congress of 1887. He was a member of the Association of Superintendents of Asylums for the Insane, and once its President. The British, French, and Italian Medico-Psychological Associations elected him to honorary membership. In 1882, Dr. Gray was shot by an insane man, resident in tbe city of Utica. The ball from a large navy revolver entered over tbe left malar prominence and came out at the center of the right cheek. From the shock of this, although the wound was not serious, he never fully recov- ered, and the impediment to free respiration produced by the cicatrization in the course of the bullet, wbich traversed the floor of each nostril, was a continual source of annoyance. In the winter of 1885–86 his health became seriously impaired, and the managers of the Asylum gave bim leave of absence. He spent some weeks in the South, and returned much improved. In July he sailed for Europe, returning early in October. He felt that the trip bad been of benefit, but shortly after his return he was exposed to cold, bad a chill- some bronchitis, considerable dyspnea, and disturbance of circulation, His kidneys had been diseased for some time, but a more active process was lighted up, which terminated in death from uræmic coma. In his death the profession of medicine has lost an active and earnest practitioner, one who in his special department has added honor and rep- utation to American medicine, and whose work as an alienist will long continue to influence for good the public care of the insane. E. N. B. The preceding record of the life and career of the deceased Alienist of Utica, from the pen of one who sustained to him the relationship of assistant-physician, is an impartial and not over-drawn account of one who has made an ineffaceable mark upon the records of American forensic psychiatry. Dr. Gray was a practical superintend- ent of rare executive ability and great capacity for literary as well as executive work. No American superintendent, of his day, with the same amount of personal executive hospital work to perform ever did more. He filled his place well everywhere, whether at the head of a hospital, as superintendent and physician; at the head of a medical society, as its president; leading a corps of experts in psychiatry, in a forensic contestof opinion; teaching a class in the amphitheater; addressing a popular audience, or pleading for an appropriation with an obstinate Legis- lative committee. He was everywhere a power. He was 154 In Memoriam. ognize them alienists and didiscerned a worthy successor, as a practical alienist, to his distin- guished predecessor. Dr. Amariah Brigham, and the interests of the Utica Asylum and its inmates did not suffer in his hands. His ways and views were somewhat different from those of his predecessor, but they were nc less forcible or influential with the public. Dr. Gray was uncompromising, unyielding and, in a certain sense, coercive in his views of psychiatry and psychiatric problems. He studied the phases of mental disease well as he saw them at Utica and in the asylum, and his deduc- tions had to him all the force of truth and he expected others to see as he did. He did not recognize certain forms of mental disease discerned by other American and foreign alienists and did not think they should rec- ognize them either. With him moral insanity, dipsomani- acal and kleptomaniacal insanity were psychiatric myths and misnomers invented to shield depravity and crime; and he thought there could be no other correct view of these real morbid mental conditions. They might be concomitants and symptoms, but they were never true, and only expressions of real insanity. The affective aberrations of Ray, Brigham and Tyler, Maudesley, Prich- ard and Pinel, had no place in his nomenclature of mental disease, and he contested their acceptance by American alienism as though they had no right to recog- nition in psychiatry. He fought out his convictions on this line throughout a vigorous and never idle life, and carried his convictions, often triumphantly, to the forum, winning there popular acquiescence, as in the trial of Guiteau and his execution, though at variance with the views of the majority, or at least a very large number, of his American confrères in psycho-pathological science, a view which so gained ground after the insane death of President Garfield's assassin, as to become an almost universal professional and popular belief. Such was the force of his testimony and expressed convictions on the witness stand, and the captivating power of his analysis of psychological problems. On the witness stand or in the hospital and amphi- theater, and in private life, he was earnest, forcible, imperturbable, and unyielding in his convictions. In his loss the profession loses a most valuable member, psychi- atry a most worthy confrère, and his nearest friends and his family more than words can express. REVIEWS, BOOK NOTICES, &C. IL MANICOMIO. May, 1886.- We have again much pleasure in acknowledging receipt of the above valuable serial, which is issued three times yearly from the Interprovincial Asylum for the Insane, at Nocera Inferiore, Italy. The present is the first number of the second year. The contents cover 214 pages octavo, and are certainly very creditable, not only to the publish- ing directorate, but also to the alienistic literature of Italy. We bave perused, with much interest, the various articles of the present number, several of wbich would doubtless prove very acceptable to the readers of the AL'ENIST, did our space permit their reproduction. The first article is a report of two cases of “Communicated Insanity," by Prof. Tebaldi, a foriu of mental aberration by no means of recent birth, but only of late years attracting the attention of psychiatric observers. The second article, by Prof. Venturi, is in reality identical in its subject with the first. It is entitled “ L'Allucinazione a due, e la Follia a due." It is based, like that of Tebaldi on the cases of two lunatics who were sisters, the one apparently infecting the other. Tebaldi had not only a brace of insane sisters, but also a husband and wife, in whom the mental malady in each pair seemed to have been communicated contagiously. It is, however, rather improbable that any asylum physician of prolonged experience will be disposed to admit into his already over-populated nosology, as a perfectly distinct form, this new-fangled type. The almost simultaneous occurrence of insanity in two sisters, is by no means a fact so rare as to be ranked in the catalogue of modern wonders. It is not very long since the writer bad intimate knowledge of four cases occurring counectedly in three sisters and their mother; but in these there was no need for invoking the agency of infection. The mother's father died in an asylum for the insane, and a brother of the father also died insane. Very few persons have been killed by the discharge of unloaded guns. Was it Seneca who 8:1id that his mother was a midwife, but she had never delivered a non-pregnant womin of a child? It is a serious, though a very common mistake, to regard coincidences as con- sequences, just as it also is to confound the post hoc with the propter hoc. Heredity of insanity is quite as common in Italy as it is in other coun- tries, and our acquaintance with Italian psychiatric literature enables us to recognize in the cases of Tebaldi and Venturi, two very patent determining factors in the induction of insanity, the morbific efficiency of which would seem to us quite sufficient to warrant the ruling out of court of the charge of mental infection. These two factors were pellagra and extreme poverty- quasi-starvation. The two pairs of sisters and the man and wife, whose cases prompted the articles in qriestion, were but the equivalents of three double-barrel d guns, and that each pair of barrels went off almost simultaneously, was not very wonderful considering the enticing game. 155 ] 156 Reviews, Book Notices, &c. So long then as all possibility of hereditary taint with the co-efficiency of physical misery or distressing psychical affliction, is not eliminated from the history of such twin cases of insanity, it may be as well to abstain from encumbering our nosological catalogue with additional new terme. Dr. Rosciolli contributes an interesting report of a case of “ cerebral hemiatrophy, with consecutive imbecility and hemiplegia.” The reader. of this article can have no reason to complain of oversight of minutiæ, in the details; a charge, indeed, from which Italian phychiatrists must be very generally exempted, though it is possible that English and American readers would sometimes feel much inclined to condone the offence. The next article, by Dr. Conger, on “The Age of Parents, in Relation to the Forms of Mental Alienation," is one of which we can safely say that its greatest fault is its brevity, and the limited extent of the field of observance on which the author's conclusions have been based. It must, however, be admitted, that he makes a modest and discreet use of those at his command. We give a few extracts from the closing part of his article, which may not be found unprofitable. “Man," says Conger, “affected with furious mania, and woman affected with simple and furious mania, bave for the most part, bad fatbers of the same age as the melancholics, but the prevailing age of the mothers of maniacs bas been from twenty-one to thirty years, that is to say, they have been too young ; but on the other hand, the melancholics have never had parents of similar age.” The idea of Marro being thus confirmed by the result of our statistics, the question naturally arises, Can we, in the present state of our knowl. edge, discover the reasons for the fact above stated ? Why do melan- cholics, for the most part, come from parents of advanced age, and maniacs from young parents ? We believe that by ascertaining the different age of the man and the different nature of the two principal forms of alienation, that is, mavia and melancholia, we may arrive at some sort of conclusion. The difference in the nature of these two forms may guide us in our interpretation of the fact observed. But we are not to lose sight of the fact, that hereditary predisposition constitutes the basis of our investigation. Whatever may be the number of cases in wbich bereditary predisposi- tion may be doubted, we believe that the faculty of transmitting insanity to the progeny, is to be held as one of the most common factors of the psy- chopathice. In this relation we are gratified in quoting the words of Maudesley: “In the midst of the doubts wbich abound in the statistics collected, as to the frequency of hereditary infection, one truth eprings- fortb, wbich is, that the number of the insane in wbom this fatal action is discovered, increases with the increase of our opportunities for obtaining exact information." Comparing the states of excitement with those of depression, and com- paring the different ages of parents who, by predisposing their offspring to insanity, bave produced children who have become melancholics or maniacs, we may find the reason for what we have stated. What is the fundamental character of mania, and what is that of Reviews, Book Notices, &c. : 157 melancholia? In the former, it is activity, which sooner or later passes into respondent exhaustion; in the latter, it is a state of apparent depres- sion or passivity, which has for its basis an augmented power of resistance. The maniac manifests rapidity in tbe consumption of psychical force, by his remarkable speed in the reproduction, association and combination of ideas; the melancholic shows arrest of the mental fulictions, with slowness of ideas, and arrested association, to which tixed ideas are favorable. In the maniac there is greater organic disintegration; in tbe melancholic, sensibility is diminished; hence, in mania there is greater unconsciousne:s and amnesia, but in melancholy there is greater consciousness, and am- nesia is more rare. * * * * * * * * * * * We see the relations that may exist between the ages of the parents and the foring of neurotic insanities arising in their children, warranting us in holding what has been said, that is, that maniacs in general come from parents too young, and melancholics from parents of mature age. Youth undoubtedly represents the period of activity in our organic de- velopment. The brain, like every other organ of the body, loses activity with the advance of age; it reacts with decreased vigor to impressions. The age from twenty-one to thirty represents an ascending period of organic evo- lution. In this period, the person assimilates and grows, and all the faculties are developed ; life is all activity. From thirty-one to forty is the stationary period, in which the person- ality is fully developed in its whole form; the physical evolution is complete, and the active work of development has ceased, to give place at a later period, say tifty, to a retrogade metamorphosis of the organism. Etiological investigation of mental disease shows the necessity of considering, more amply than has hitherto been done, the origin of it. The temperament which nature gives to the individual, bas, beyond doubt, a great influence in determining the species of mental disorder; and though education, the social surroundings in which he lives, and the special con- ditions of life, have great influence in forming the character, yet this can- not escape the fatal laws of hereditary transmission; the age of the parents is mirrored, more or less faithfully, in the character of the offspring. The son of young parents will show, in his lively character, his deg. cent, just as the epileptic, the moral fool, and the imbecile show those degenerative characters wbich they have inherited from their progenitors. During the energetic period of the vital functions, in youthful age, mania is the form in the psycho-neuroses, which most frequently appears, and is most readily transmitted to descendants; but as the age advances, and energy declines, melancholy is the more common, and the more readily transmitted form. The results obtained by us, as to the age of the parents of those affected with degenerative forms, present considerations of no less impor- tance. The percentual calculation shows that in monomania, as well as in the neurotic forms and the phrenasthenias, there has been a difference in the ages of the parents, and that one of the two has constantly beer very young. Let us search for the cause of this fact. 158 Reviews, Book Notices, &c. In all the degenerative forms we must take into account those factors, on the part of the parent, which constitute the basis of the development of the psycbopatby of the child. Among the bereditary degenerative agencies in the parents, statistics ascribe a special importance to epilepsy, to cere- bral diseases, and signally to the psychoses, to marriages in consanguinity, drunkenness, etc., etc. The hereditary factor may be transmitted to descendants as a simple neuropathic constitution, as a neurosis, or also as a defect of development reaching even to idiocy, which is the most grave of the bereditary degen- eracies. Since then, it results from our statistics that the prevailing age of one of the parents of individuals affected with degenerative forms, and especially tbe age of the mothers, is between twenty and thirty years, there undoubtedly exists a relation between this age and the greater facility of transmission of degenerate cbaracters to the offspring. And in fact, the man between twenty and tbirty is in the most favorable conditions for procreating degenerates (?), just as is the very aged. Because of his yet incomplete organic development, he has been unable to free himself from the hereditary stain, which he unfortunately trans- mits to his descendants, but wbich in maturer age, through the influence of adaptation, evolution, or education, he might perhaps more or less notably modify. The organism, between twenty and thirty is yet incomplete; educa- tion has not been able to exert much influence in determining those possible cbanges which are adapted to modify congenital tendencies, In a word, the individual between twenty and thirty feels too much the influence of atavic characters, and too readily transmits to his pos. terity the brands of degeneracy. Although our statistics do not show figures related to the far-ad- vanced ages of the parents of phrenasthenics, yet experience has made it well known, that the children of the aged readily show degenerate types. I know of too many children of old fathers, who have undoubt- edly inherited all the characters of the weakness of the age in wbich they were begotten. Old age represents the period of retrogression or involution, and hence it the most readily transmits the marks of degeneracy. The children of either too young or too old parents, failing to escape hereditary predisposition, may from birth inberit those characters which are proper to incomplete organic development, or to the period of involution. THE FIELD AND LIMITATION OF THE OPERATIVE SURGERY OF THE HU- MAN BRAIN. By John B. R. beris, A. M., M. D., Prolessor of Anatomy and Surgery in the Philadelphia Polyclinic, Surgeon to St. Mary's Hospital. This book is apparently the result of the author's personal experience, and is an interesting and instructive volume. He first announces what he calls bis creed of cerebral surgery, wbich is as follows: 1. The complexus of symptoms called “compression of the brain," is Reviews, Book Notices, &c. 159 due not so much to displacing pressure exerted on the brain-substance as it is to some form or degree of intracanial inflammation. 2. The conversion of a closed (simple) fracture of the cranium into an open (compound) fracture by incision of the scalp, is, with the improved metbods of treating wounds, attended with very little increased risk to life. 3 The removal of portions of the cranium by tbe trepbinic or other cutting instruments is, if properly done, attended with but little more risk to life tban amputation of a finger through the metacarpal bone. 4. In tbe majority of cranial fractures the inner table is more exten- sively shattered and splintered than the outer table. 5. Perforation of the cranium is to be adopted as an exploratory measure almost as often as it is demanded for therapeutic reasons. 6 Drainage is more essential in wounds of the brain than in wounds of other structures. 7. Many regions of the cerebral hemispheres of man may be incised and excised with comparative impunity. 8. Accidental or operative injuries to the cerebral membranes, menin- geal arteries or venous sinuses should be treated as are similar lesions of similar structures in other localities. 9. The results of the study of cerebral localization are more necessary to the conscientious surgeon than to the neurologist. He then discusses at length the propositions here formulated, but space will not allow of an abstract of bis statements. One statement that he makes is of great practical importance in deter- mining surgical procedure in cranial fractures. He holds that in the majority of cranial fractures the inner table is more extensively sbattered and splintered ihan the outer table. This splintering of the inner table is the great element of danger in cerebral fractures, and because of the dan- ger from this source he recommends trephining. On page 18 he says, “It is to prevent inflammatory sequences due to splinters forced into the mem- branes and brain, and to avert the consecutive occurrence of epilepsy and insanity that the operation should be performed; not because of the fear that symptoms of compression of the brain may arise, nor because necro- sis of detached portions of bone may occur." We believe tbis to be eminently sound doctrine. In cases of traumatic epilepsy there is no doubt that in many cases the epilepsy could bave been prevented by early trephining and thereby relieving the brain of the irri- tation of a depressed fracture. The same remark is, we hold, true of trau- matic insanity, though in a less deyree. The second chapter is devoted to a statement of the relation between the cerebral convolutions and the skull, with a view to localization for surgical purposes. He gives instructions for an accurate survey of the skull, so that the exact localization of the various centers can be made, The chapter is completed with a series of tables, which indicate the local. ization of every possible morbid condition due to cerebral traumatism. either sensory or motor in origin. It is also indicated where operative interference is or is not demanded, Chapter three is devoted to the subject of the operative treatment of 160 Reviews, Book Notices, &c. cerebral lesions. He gives a table stating the conditions which justify surgical interference. In speaking of intracranial suppuration, he says that operative evac- uation should be undertaken in all cases of localized intracranial sup- puration. The chief difficulty, in the author's opinion, is in establishing the diagnosis and to give a detailed description of the signs and symptoms that are to be expected in this condition. The author's methods, and his bold way of proceeding, may be inferred from the follow- ing, on pages 68—69: “Incision of the membranes and exploratory puncture of the brain-substance with aspirating tubes, to the depth of three or more inches, in various directions, is justifiable if the symptoms of abscess are undoubted. The abscess cavity or cavities, wben found, should be drained by free openings and counter openings and drainage- tubes; and should even be washed out by bydrostatic irrigation if it is probable that there are pockets in which pus may remain and decompose. Scarcely any limitation should be dogmatically given regarding the opera- tive search for pus in undoubted abscess of the cerebral tissue, so long as the aspirating tube is not thrust deeply toward the vital centers located in the medulla and base of the brain. It is never too late to seek for pus, for Naurede gave a patient several days of life after he was thought by several competent observers to be dead, by promptly opening by incision a cere- bral abscess. The earlier the operation is performed the better, but it is never too late to make the attempt at evacuating an intracranial abscess." The author advocates trepbining in cases of cerebral tumor when the the growth can be located, and holds that in certain cases of traumatic insanity trephining is also justifiable. J. H. M. A TEXT-BOOK OF MEDICINE FOR STUDENTS AND PRACTITIONERS. By Dr. Adolph Strumpell, formerly Professor and Director of the Medical Polyclinic at the University at Leipsic. Translated by perinission from the second and third German editions, by Herman F. Vickery, A. B., M. D., and Philip Coombs Knapp, A. M., M. D)., with editorial notes by Frederick C. Shattuck, A. M., M. D., Visiting Physician to the Massachusetts General Hospital and to the House of the Good Samaritan; Instructor in the The- ory and Practice of Physic, Harvard Medical School, etc , Boston, Mass. With one hundred and eleven illustrations. Published by D. Appleton & Co., 1, 3 and 5 Bond Street, New York, 1897. Price not known. “PRACTICE," the new Richmond medical journal, comes to us looking well and creditably filled with practical matter for the practicing physi- cian. “Medical Methods and Opinions" is a distinguishing feature of this new candidate for professional support. The two numbers which we have seen give evidence of capacity on the part of its management to Win(n) its way to popular medical favor. Arrest and Aberrant Development of Fissures and Gyres in the Brains of Paranoiacs, Criminals, Idiots and Negroes. Preliminary Study of a Chinese Brain. By Charles K. Mills, M. D., President of the American Neurological Association, Vice-President of the Philadelphia Neurological Society, Professor of Diseases of the Mind and Nervous System in the Puiladelphia Polyclinic and College for Graduates in Medicine, etc. Pres- Reviews, Book Notices, &c. .161 . idential address delivered at the meeting of the American Neurological Association, held at Long Branch, June 21, 22 and 23, 1886. A Report on Diseases of Children. By J. P. Matthews, M. D., Car-' linville, Ill., a member of the Society of Macoupin County for Medical Improvement; a member of the Ilinois State Medical Society; a member of the American Medical Association; and formerly Assistant-Surgeon of tbe 1220 Regiment of Illinois Infantry Volunteers. A Successful Case of Gastrotomy, with Critical Remarks: Illustrated. By Augustus C. Bernays, A. M., M. D., Heidelberg; M. R. C. S., England; F. R. M. S., London; Member German Society of Surgeons, of Berlin; Professor of Anatomy of St. Louis College of Physicians and Surgeons. Clinical Lecture on Idiocy and Imbecility. Delivered to Students of Owe16 College, Manchester (Dr. Asbby's Class for Diseases of Children). By G. E. Shuttleworth, B. A., M. D., Medical Superintendent of the Royal Albert Asylum, Lancaster. Address in State Medicine. Delivered at the Thirty-Seventh Annual Session of the American Medical Association, in St. Louis, on May 6, 1886. By John H. Rauch, M. D., of Illinois, Chairman of the Section of State Medicine. Sequels of Naso-Pharyngeal and Aural Catarrb Illustrated by Cases from Private Practice. Read before the American Rhinological Associa. tion at St. Louis, October, 1883, by J. G. Carpenter, M. D., of Stanford, Ky. The Value of the Knee Phenomenon in the Diagnosis of Diseases of the Nervous System. By Pbilip Zenner, A. M , M. D., Lecturer on Dis- eases of the Nervous System in the Medical College of Ohio, Cincinnati. . Report of the Chairman of the Section on Medical Jurisprudence. By J. D. Roberts, M. D., Goldsborough, N. C. The Relationship of Marriages of Consanguinity to Mental Unsound- ness. By G. E. Shuttleworth, B. A., M. D., etc., Medical Superintendent Royal Alnert Asylum, Larcaster. President's Address: Tenth Annual Meeting of the Detroit Medical and Library Association. By C. J. Lundy, A. M., M. D., October 4th, 1886. Nerve Stretching for Traumatic Tetanus and Sciatica, with remarks by J. G. Carpenter, M. D., Stanford, Ky. On the Classification of Insanity in Asylums or Hospitals for the Insane. By H. M. Bannister, M. D. · A Case of Lithotomy, with Artificial Opening for Drainage. By J. G. Carpenter, M. D., Stanford, Ky. A Brief Résumé of the Original Contributions in The American Journal of the Medical Sciences, January, 1887. Treatment of Neoplasms of the Naso-Pharyngeal Cavity. By J. G. Carpenter, M. D., of Stanford, Ky. A Contribution to the Study of Tumors of the Spinal Cord. By B. Sachs, M. D. Insanity in the Colored Race. By J. D. Roberts, M. D., Goldsboro, N.C. Naso-Pharyngeal Catarrh. By J. G. Carpenter, M. D., Stanford, Ky. THE ALIENIST = NEUROLOGIST. No. 2. Vol. VIII. | ST. LOUIS, APRIL, 1887. ORIGINAL CONTRIBUTIONS. Experimental Degenerations in the Brain and the Spinal Cord.* A CONTRIBUTION TO THE DOCTRINE OF CEREBRAL LOCAL- IZATIONS. By L. BIANCHI, M. D., Naples, Italy, Professor of Neuropathology, AND G. D'ABUNDO, M. D., Naples, Italy, Assistant in the Psychiatric Clinique of Naples. I THE problem of functional localizations on the cortex 1 of the brain, so earnestly studied and so thoroughly examined and discussed, and testingly constructed by the genius of many of the most renowned physiological ex- perimenters, required the concurrence of numerous factors before reaching a certain degree of scientific evidence and being placed on the path to a more reliable experi- mental solution. From simple electric excitation of the .cortex of the brain, a part so obscure in its mechanism, .so illimitable in its action, and therefore so little adapted • In order that each of us may have that part of the responsibility, and the merit (if there is any) which pertains to his own contribution, we now state that the microscopic preparations are the exclusive work of D’Abundo, the experi- mental part, and the whole article, as it has been edited, are the exclusive work of Bianchi; the microscopic research has been made by both. (NOTE BY THE TRANSLATOR.-In view of the above, the words uno di noi-one of us wherever the real personality is clearly that of the author-Bianchi, will be rendered by the editorial pronoun we or I.] [163] 164 Bianchi-D'Abundo. to bring to the observer a complete conviction of the localization of its action, onwards to the decortication of more or less extensive cerebral areas, practiced in accord- ance with all the instructions of the Listerian surgery, in order to preserve the animals in life, so as to have the advantage of examining, for a long time, the various phases of the phenomena of decortications, such as those of arrest, the collateral, those of deficiency, etc., assuredly the pace has been gigantic, and we might say, rapid. But it would be an error to say that the subject has been exhausted, and the problem solved. It is however true that the doc- trine of localizations has now been placed on a foundation sufficiently broad and solid; but the evidence is not yet complete, nor is the doctrine perfectly assuring. We find in it but the general terms; the details remain confused. When it is regarded with an eye not severely critical, and with the knowledge of only that part of the clinical facts. relating to it, which influences our mode of interpreting the experimental facts, we become favorable to the doc- trine; the mind assents and takes rest; numerous facts find a ready interpretation, and every difficulty is leveled down. But yet the numerous and obscure problems relat- ing to cerebral localizations, which are obstinately presented to the consideration of the physiologist, together with the disaccord between Schiff, Munk, Vulpian, Betcherow, Goltz, Luciani and others, as to the true significance of the phe- . nomena observed in the mammifera operated on by cerebral decortication, as well as with regard to the extent. of the individual areas, to which specific functions have been assigned, constitute a most eloquent proof of the intrinsic difficulties of the problem. It is very true, that we are engaged in the interpreta- tion of the phenomena of the psychical life of the lower mammifera, from the human point of view, and the physiologist explains them after his own fashion with all the appearance of experimental positivism; he is in the wide domain of speculation, in which phantasy and abstract. thought sometimes have full play. Experimental Degenerations in Brain and Cord. 165 Let us enter into some details. We set to work to learn whether a dog, from whose brain the motor-zone has been removed, has lost motion or sensation. If we touch one of his feet, taking him by surprise in his various posi- tions; or if we pull out some hairs of it, or put him into an unpleasant position, and he does not withdraw the foot, nor react or move in any way; or if some parasites crowd on this foot and over the entire side opposite to the muti- lated cerebral hemisphere, we are promptly led to believe, and to assert, that on this part of the body sensibility is diminished or abolished—that the dog does not feel the stimuli, and that the parasites, as we think, not torment- ing him, accumulate on that side; or we say that the mnemonic images of analogous stimuli are not awakened, because the centre of the reproduction of the mnemonic images of tactile stimuli has been destroyed. But in all this what is there of truth? It is not per- missible to reply pointedly in one way or the other; unless we should say that here the experiment closes, and the mind of the experimenter enters on the stage, and on he goes with a presumption that is not the true reflection of the real mechanism of the phenomenon observed by him. The dog does not react; and no sensation can be awakened in him, yet both sensation and the mnemonic image may be present in him, or in other words, sensation up to the point of perception, but the latter is not trans- muted into a motor impulse, which remains only potential because the path of extrinsication is interrupted, where the motor impulse is concreted into its mnemonic image and the centrifugal discharge. Reaction implies voluntary movements, that is to say, the very facts which are pre- sumed to be wanting. The dog has no other way of exhibiting his sensations and emotions; he does not possess our faculty of imita- tion, our facial emotionality, our grand prerogative of language, and if under the influence of stimuli he does not move, we have just as much right to assert that the central organs of motion are wanting, as others have to 166 Bianchi-D'Abundo. hold that the tactile sense is absent, or that both the motor and the tactile centres are located in the same part, which would then be a sensori motor centre. What does all this prove but inability to demonstrate what the fact is? But the dog walks, runs, leaps and swims; consequently the true centres of motion are not actionless (Lusanna, Lemoigne, Munk), for this would be quite inconceivable, and as the movements are accomplished with some irregu- larity, this serves to show that the tactile and analogous sensations, which preside over the regularity and coördi- nation of movements are in defect, and the result is ataxic movement, altogether similar to the movements of those dogs on which the posterior cords of the spinal medulla has been cut through (Schiff). The cerebral motor zone of some writers seems to be supplanted by the posterior cords of the medulla, according to the views of others. In fact, we are in a domain in which everybody moves as he may, unless we draw from this point some other lines, and look at facts more closely. In the meantime we ask, Why does man also walk, when the motor zone has been destroyed, and at the same time his arm is quite powerless ? How much is there of volition in walking, and how much of automatism ? or in other words : what part is contributed by the cortex of the brain, and what by the other organs within and without the hemispheres ? And as we are drawing a parallel between man and the dog, how comes it that the dog shows his ataxia all the less the more com- plex the movements performed by him, as in leap- ing, running and swimming, in comparison with those of man? The eye contributes too much to this contrast, for in man, when the ordinary movements do not appear ataxic, the incipient process of degeneration of the posterior cords is clearly shown when the subject is incited to jump, or is asked to run; sight, which so efficaciously corrects the ataxia of man, goes for nothing in the ataxia of the dog ; and closure of the eyes, which so much increases the Experimental Degenerations in Brain and Cord. 167 átaxia of man, even when existing in but a very slight degree, does not increase that of the dog. Some have desired to define the limits of the sensory areas, and this is quite right; but where do they properly begin, and where do they end—where does the visive sphere end and the auditive begin ? Every boundary define- ment is super-artificial. Here Goltz would be right, who, wherever he destroys the cortex, obtains disorders of sight and of the other senses; and we would be right in admitting prolongation of the visive sphere to the anterior extremity of the second external convolution in dogs. Hitzig might be right, who provoked visive disorders by destroying the extremity of the frontal lobe, and Luciani might be right, who, by his acute genius, divined the complexity of a phenomenon, to the solution of which he has said an entire generation of physiologists would be inadequate. Munk would be right, who distinguishes psychical from true blind- ness, and would not we be right, who believe that vision results from different factors, diversely located ? Here we stand in a tilting arena, in which genius sports itself freely, but with little profit to the reality of facts. II. I do not intend to give a methodical account of the works published up to this time, and to pass under review the phases through which this conspicuous chapter of the physiology of the brain has passed. From 1878, when for the first time I published, in a simply critical work, the different sides of the question, down to the present time the number of works published has been so great, that a faithful and impartial review of them might be regarded as an impossibility. Besides, in a former exper- imental work, in which I endeavored to show, under the guidance of physical and physiological data, the true significance of the electric excitation of the cerebral cortex, I succeeded, in spite of myself, in detailing facts excessively critical. Every one who delights in this study, will find abundant gratification in the masterly part 168 Bianchi-D'Abunde. of Luciani, in the book recently published in conjunction with Seppilli, on the question of localizations : Naples, 1885. [N. B.–Our American medical publishers would seem to regard this book with less favor than Prof. Bianchi, for not one of them would touch it, even when a translation was tendered gratis. . Our Italian confrères must not marvel at this. Publishers must best understand their own business, and if able, scientific works attract but few pur- chasers, it is quite natural that they should shun them. We have heard that the American publishers of Ferrier's grand work on brain localizations, suffered so great a loss from defect of sales, that nothing will induce them to make a similar venture. If the knowledge of brain functions, and the treatment of brain diseases were as productive of dollars as are the maladies, real or fictitious, of the female reproductive organs, books of such ability as that of Luciani and Seppilli would be rushed upon with impetuosity by publishers, and pored over with miserly earnestness by thousands, in whose brains there is but one centre, and it covers the entire cortex.] The vastness and the difficulty of the theme do not permit even the most acute experimenters to consider it in its entirety, and all who have embarked in the study with the true spirit of research, have felt called upon to test over and over again, many times, the evidence obtained by them. The new path has, by bringing into light new points of view, enlarged the horizon; the physiologist, in considering the subject and feeling himself too weak for the undertaking, has left the solution to time, and, con- fronting the invariability of the phenomena, he has changed himself. Thus has it proceeded, and now we meet with an enormous pile of works, in which the question has been treated up and down in terms identical, and loaded with old and new material. Critical work, in this state of mat- ters, besides being of little benefit, as it would necessarily involve repetition in at least the greater part, would to us have been an ungratifying labor. Under these consider- Experimental Degenerations in Brain and Cord. 169 ations we have abandoned the writing of an expository part in relation to the present state of the question. On the other hand, the notable material which we bring in contribution to the increment of this important chapter of cerebral physiology, relieves us from any re- trospective consideration of the question, and all the more so, as in our exposition of facts we shall be obliged to touch on the most salient points of the divergences, as well as on the advancements, made in the doctrine, by the researches of Munk, Goltz, Schiff, Luciani, Tamburini, etc., we now, without further remarks, enter upon our subject. III. Human pathology, which has furnished so large a support to the doctrine of cerebral localizations, has pre- sented a side (though not altogether new) from which to treat the question experimentally, still however but too little explored; yet it is exactly that which might furnish the greatest number of absolutely objective and much less questionable facts. It is well known that some parts, or I might better say some organs, of which the nervous central system is com- posed, are in such close relation to each other that a lesion in one induces, in a secondary line, not only a func- tional but also a nutrient alteration, which is observable even by ordinary means, in the other parts with which it really has such relations. Clinical observance and pathological anatomy have already brought into light some facts, on which some writers express their doubts; for instance, whether a lesion, somewhat diffused over the cortical motor area of the brain of man, besides producing a more or less complete and permanent hemiplegia on the opposite side, produces de- generation of the pyramidal fasciculi along its whole tract into the internal capsule, the peduncle, the pons and the spinal medulla. According to some writers (Charcot and his scholars) this relation would be constant, but this is 170 Bianchi, D'Abundo. denied by Binswanger, who says that lesions, which are exclusively cortical, are incapable of producing descending degenerations of the pyramidal fasciculi. On the other hand, a lesion situate outside the motor area does not induce degenerations in the pyramidal fas- ciculi; but at the most only disturbances of the special senses. Confirmation of this is found in the fact that abolition of movement in a limb or in the whole of one side, in childhood or infancy, is associated with defective development in the medulla spinalis and the brain, exactly corresponding to the medullary area of the pyramidal fas- ciculi and the cortical zone of the paralyzed limb. Again, the extirpation of the ocular globe, in man, as well as in animals, especially in early age (Panizza, Gudden, Mona- cow), causes defective development of other parts of the brain, and of other paths of transmission, exactly those whose destruction, whether experimentally produced, or resulting from disease, is wont to induce disturbances of sight more or less serious. If then, setting out from the data furnished by human pathology, we can experimentally provoke a constant, iso- late, definite alteration of nutrition, by destroying a given cortical area, we may be authorized to assert that between this peripheral area, which possesses a known and indisput- able functionality, and the area extirpated, there exist very close relations, not only functional but also anatomical; that the one is complementary to the other in the constitu- tion of a unique functional system, which is distinct from the others, inasmuch as cortical lesions at other points in- duce nutrient alterations in other paths, that is to say, the latter constitute systems altogether different from the for- mer. This is the point to which we have carried forward our investigations, and brought our experimental researches to converge; they were commenced over two years ago, and we now venture to submit them to public judgment. Being on the other hand convinced, from a series of comparative experiments, that lesions of the zones be- tween the volute cortical motor area and the occipital Experimental Degenerations in Brain and Cord. 171 lobe are not, because of the nature of the symptoms to which they give place, the most suitable for throwing light on the question we had proposed to solve, we have omitted further investigations in this direction; and we do not detail those made by us. In order to render the task more easy, and the results more demonstrative, we have limited our remarks to the exposition of the results of our researches on the brain and the spinal cord, conse- quent on decortication of the motor zone and the occipital lobe separately. We put the question briefly thus: Given a decortication of the so-called motor zone, and of the occipital lobe, in dogs and cats, what is the group of symptoms to which it gives origin in the two cases; what secondary alterations are met with in the brain, the spinal cord, or the organs of sense ? The subjects taken for our researches were dogs and cats: we preferred adults and the very young. We pre- served several of them in life for weeks, some for months, and some for about two years. We examined compara- tively in each class the phenomena presented in life, as well in relation to the organs of sense as to those of motion. We minutely dissected the brain—not with the precon- ceived intention of discovering this or that other alteration in this or that other part of it, but rather to find that which was best adapted to give us light in studying and following the diverse systems of fibres and organs of the brain, the mesencephalon and the spinal cord, with their reciprocal relations, and to mark that point, wherever it might be, at which a lesion had occurred. We thus succeeded in laying up certain materials, which we now submit to those who have been engaged on this question of cerebral physio-pathology. In this first part we shall treat of the motor cortical zone only. IV. The research is not new, but the material collected by us, and especially the method followed, of making hori- zontal and vertical sections of the whole brain, by means 172 Bianchi-D'Abundo. of which we were enabled to study comparatively the con- dition of the various cerebral organs, their reciprocal relations, in the two hemispheres, the mutilated one and the sound, and to follow into all their important locations the most important bands of cerebral fibres, through the mesencephalon and down to the spinal cord, secured to us the strongest evidence of the facts, and a certain .contribution to the solution of the problem we had cho- sen as the subject of our studies. The experiments of Phillipeaux and Vulpian, instituted for the research of descending degenerations in dogs, had a negative result, because of the single fact that a consid- erable part of the cortical motor area had been spared. Vulpian, however, in the year following, in renewing his examination of transverse sections of the spinal cord and the bulb of the same (? class of) animals, had doubts as to the complete absence of secondary descending degeneration. Some years afterwards he ascertained the fact of a degen- eration of one pyramid, from extirpation of the anterior lobe of one hemisphere. A similar observance by Franck and Pitres served to confirm the researches of Vulpian. On the other hand, although of some value, regard being had to the extent of the lesion found in the brain of the dog of Carville and Duret, and in another of Dejarine, yet their observations were in no way demonstrative. Gudden certainly has the merit of having first undertaken these researches and he showed, as far back as 1872, that, having extirpated the anterior lobes of small mammifera, the foot of the cerebral peduncle was, after some time, found atrophied. These 'researches were from that time prosecuted by him; and he last year presented an ample .communication on the subject, at the annual meeting of the German Association of Alienists at Baden, on the 16th and 17th September. In the meantime Binswanger, in a remarkable work, pointedly denies that the pyramidal fibres terminate in the cells of the so-called motor zone, .and he concludes, in a second work, that when a cortical lesion, whether produced experimentally in the mammifera Experimental Degenerations in Brain and Cord. 173 or pathologically occurring in man, does not reach the underlying white substance, descending degeneration does not follow. I am pleased here to reproduce his own words: “Diese Versuche hatten ergeben dass Zerstörungen der motorischen Rindenzone (beim Hunde) Keine secon- däre Degeneration der Pyramidensbahnen nachfolgt.”* * Pitres and Franck almost cotemporarily described a bilateral degeneration of the crossed pyramidal fasciculus, met with in the medulla of a dog, on which the cortex of the brain had been extirpated on one side only. Moeli found, after unilateral lesions of the middle brain, not only degeneration of the crossed pyramidal fasciculus of the opposite side, but also degenerate fibres in the pyramidal tract of the same side; and Schäfer, almost at the same time, degeneration in both pyramidal fasciculi of the cervical medulla of a monkey, on which a cortical lesion had been produced six weeks before. Ferrier and Yeo, in their interesting work on the physiological effects of extirpation of the cerebral cortex in monkeys, incident- ally touch the question of degenerations following lesions of the cortical motor zone. A remarkable thesis on exper- imental degenerations has been published in the last year by Lowenthal, but it has not been put into the conditions desirable for a clear demonstration of the disputed facts. One fact, howeyer, is not a little interesting: it has for the first time been amply demonstrated experimentally, that bilateral degeneration has followed unilateral ablation of the motor zone. Another contribution has been fur- nished by Langley and Sherrington, who examined the pons and the medulla oblongata of some dogs presented by Goltz, at the congress in London. Lastly, a short prefatory communication has been presented by Marchi and Algeri, of the Institute of Reggio Emilia, which, how- ever, because of its brevity, cannot be taken into that full consideration which the work would have merited, had it been published entire. After all these researches, the doubt has not, however, been removed whether experi- mental lesions of the cortex have involved the subcortical 174 Bianchi-D'Abundo. white fasciculi, and the question remains open for further discussion, as it was put by Binswanger. [The author here commences the details of his cases of experiment, which, though only four in number, per- haps samples, cover a couple of dozen pages. As it is doubtful whether many readers would sufficiently appreci- ate the minute exactitude of these notes, or have so strong a desire for instruction in the technics of canine or feline cerebral vivisection, as to render the perusal compensa- tively gratifying, we pass over this part, believing that the author's allusions to the resulting phenomena in the sub- sequent sections of the work, will be sufficiently instructive.] V. Two culminant clinical facts merit special record, be- cause constantly observed, and in such a degree that no doubt could legitiinately be raised in regard to them, in the cases of the dogs mutilated in the motor zone some- what extensively : these facts were disturbances of motion and disturbances of vision; the former permanent, the lat- ter lasting for some weeks, or even for months. The former consist in a real weakening of several muscular groups of the feet which rest on the ground spread over a wide surface, the cause of which is, that in consequence of the diminished resistance (tone) of the muscles, the paw is flexed at a more acute angle, and the toes are separated from each other. This paretic condition of the limbs opposite to the mutilated hemisphere reaches, in some cases, such a degree that when the animal is standing still on his four feet, the two paretic limbs at every lateral movement of the tail, as when he stands facing his master throwing bits of food to him, are carried from their ver- tical axis, following the movements of the tail. The ataxic movement proceeds from the fact, that in conse- quence of the rigidity which arises in the paretic limbs in the act of moving, the foot is raised higher and stretched farther by the more active extensors, and it comes down again in a certain rigid manner, as if all of a piece. Experimental Degenerations in Brain and Cord. 175 Movements truly voluntary are wanting, and those re- garded as such have most probably been but reflex or associate movements. Proof of this is furnished by the facts partly related in our cases. When one of these dogs is suspended by the trunk, he every time, but especially on applying tactile stimuli to the forepaws, assumes the same position in extension with the fore and the hind-leg opposite to the mutilated hemisphere. Under the influence of dolorific stimuli, the limb related to the sound hemisphere is volun- tarily withdrawn and flexed, whilst the other remains extended, or indeed it sometimes, under more intense stimulation, becomes more stiffened. On a few occa- sions movements were observed, and in this the state- ment of Schiff was correct, but they occurred under certain conditions which we think we are able to deter- mine. The cerebral decortication may have been too limited, and a part of the motor zone may have been spared; the immobility of the limb is then not so absolute as it is in dogs on which the decortication has been more exten- sive. It is only in this way that we can explain the possibility, in the dogs of Schiff, of voluntarily reaching out the paw. The spared zone assumes the function of the part destroyed, and compensates in part for that of the area removed. A certain movement may be discov- ered after repeated and intense stimulations of the foot, even when the motor zone has been completely cut away. The compensating influence of the other hemisphere here intervenes; but leaving aside this question, to take it up hereafter, in every instance these movements are more rapid and occasional, and very different from those accom- plished by the sound limbs. They are true reflex move- ments. Analogous movements have been observed in associa- tion with movements on the sound side. In this case we cannot regard them as any other than associate move- ments; in no manner can they be held as voluntary, so 176 Bianchi–D’Abundo. . great is the difference between the movements on the two sides! In order to prove this, it was only necessary to neu- tralize completely the motor activity of the limbs of the sound side, and to study the motor behavior of the oppo- site limbs. Here is what was presented to us : By placing any one of the dogs, with the sound side on the edge of a table, and fastening the legs under the trunk so that he could make with them no movement whatever, whilst the limbs opposite to the lesion projected and hung down, not the slightest movements were accomplished by them. As this was a very unpleasant position we changed it, and when the sound limbs were placed hanging down, the dogs made every effort, by seeking with the feet for some point of support against which to press, in order to move so as to free themselves from the disagreeable and unbalanced position, so contrary to what was observed when the par- alyzed limbs hung down (i. e., if the cortical excision included the whole motor area). The limbs of these ani- mals, placed as above described, are seen to be not only altogether motionless, but they are also contractured; they become rigid in extension; tactile stimuli, and still more the dolorific, being applied on them, augment the rigidity; it is only with some force that they can be passively flexed; and when left again to themselves they immedi- ately fall back into their previous position. Under palpation all the muscles, but especially those of the antero-external region of the fore limb, are found hard and prominent from contraction. This condition of the paretic limbs seerns to be very similar to that of post-hemiplegic contracture in man, only that the degree of it is different, in proportion to the degree of develop- ment of the cortical motor centres in the dog, as compared with those in man. The post-hemiplegic contracture of the dog stops at the state of latent contracture in man. There are indeed cases in which human individuals, with limited cortical or subcortical lesions, present slight forms of paresis in a given limb, which may be used in all the Experimental Degenerations in Brain and Cord. 177 acts required in life, the agility and elasticity of the members in thei: normal state being alone wanting; but, at the moment of any effort greater than usual, the limb, and especially the hand or the fingers, present the ten- dency to rigidity. A patient observed by me shows contracture in the arm only when he is requested to grasp an object firmly with the hand-for instance, the dyna-- mometer. In other persons with paresis, or better, hemiparesis, contracture may be brought on by asking them to make efforts with the sound limbs of the opposite side, or even by the vibrations of a diapason in front of the muscles of the region of the forearm, or of their tendons. Any effort whatever made by the animal to release himself with the sound limbs, or with the trunk, increases the intensity of the contracture in the contracted limbs which are left free and pendant. All tactile stimulants act in the same manner; and this leads us to suppose that tactile sensibility is, at the most, but diminished, not abolished. In man also intense stimuli, as well as the dolorific, when perceived, increase post-hemiplegic con- tracture. In such conditions the animal does not respond to tactile stimuli, and this is natural; man never responds to tactile stimuli applied on the hemiplegic side, unless when the paralysis has been so slight as to permit movement. Since the dog has no other manner of showing his seny sations than by corresponding movements, it is not to be concluded that sensibility is spent when movement is abol- ished. A more brilliant proof of this assertion was fur- nished by the manner in which the dog, which was the subject of our second experiment, attempted to copulate with the female of the first experiment. In all the agi- tation of the dog to effect coition, not only did he give no sign of voluntary movement with the stiffened limb, however trivial it might be; not only was he unable to use it for grasping the trunk of the female, but he could never prevent the rigid limb, which was absolutely 178 Bianchi-D’Abundo. withdrawn from the domain of the will, from taking the fatal direction of the contracture, and so preventing the act in view. Disturbances of vision were evident in all the animals that were mutilated both in the sigmoid gyrus and in a surrounding zone behind and below it; they were al- together wanting in those animals on which the decorti- cation was limited to the excitable area alone, as in the kitten on which I destroyed the cortex superficially by the submeningeal method (Case fourth). Comparative examination of the animals before and after observance, by the same methods and by means of the same visive stimuli, gave assurance of the faithful- ness of the assertion, that the visive area extends forward to the extremity of the second external convolution, with the sole difference that visive disturbances consequent on extirpation of the anterior part of this extensive zone, are less intense, and relatively of shorter continuance than those which follow extirpation of the occipital lobe not too circumscribed. On this head we have nothing to add to what we advanced in a work published by us three years ago “On Functional Compensations, etc.” The form of homonymous lateral henrianopsia was always pretty exactly demonstrable by delicate, but reliable methods; 1.8., by directing a beam of light, not too bright, in a dark chamber to one side from behind, while the animal stood still or was in repose. In this instance the dog, when the light fell on the hemiopic side, did not show that he perceived it until it reached a certain angle of incidence; but when it fell on the other side, he immedi- .ately turned the eye, or the head also, to the light. Again, when a piece of flesh was suspended by a thread, availing of an hour in which the dog was hungry, and making the bait descend laterally to the head on one side or the other, the reaction was quick and lively when it came into the normal visive field. This mode of testing became less demonstrative when pieces of food of different sorts were let fall on the floor at one side or Experimental Degenerations in Brain and Cord. 179 the other, with both eyes open, or with one bandaged, as it was then almost impossible to exclude the influence of smelling in the search. We have seen the statement in several clinical reports, that hearing was never observed to be affected. We shall add but a very few words with regard to the psychical condition of the animals mutilated in the motor zone. The adults, in general, showed no disturbance in the in- tellective and affective faculties. They were depressed for some days after the operation, according to the amount of hemorrhage or the duration of the act, or the occur- rence of reactive processes, such as suppuration, etc., but in other respects they acted just as they had done before. They were lively, active and cheerful; they lived well among their comrades in the same kennel; in the conflict pro victu, they were not inferior to their sound associates; they were docile and affectionate towards the persons who had charge of them; they could not easily be induced to fight; on the contrary, they were cowardly and humble. Whenever I assumed a hostile attitude, they crouched, and urinated between their legs; in this only, and their soon becoming tired, a certain degree of psychical weak- ness was shown. Yielding to the enticements of love, they propagated and nursed offspring; but their young ones usually died epileptic (two, which seemed well de- veloped, died epileptic in a few months after birth). Such was not the case with the young or the new- born. These, after decortication of the motor zone, usually fell behind in bodily development; they fed less than the others of the same litter; they were torpid, flaccid, awkward in walking, had no elasticity, were hardly ever cheerful or sportive, were unsocial and mean, and extremely different from their companions; they were the canine representatives of human idiots. Nothing of all this is observed when the cerebral decortication is very limited; the eat of the fourth experiment was distin- guished from his companions by his cunning, temerity and ferocity, and was an extraordinary thief. 180 Bianchi-D’Abundo. VI. Having in hand the clinical facts and anatomo-patho- logical findings related by us, it is not difficult to come to some conclusions which overstep the limits of supposition and mere hypothesis, and assume a more demonstrative character. As even diffused lesions of the occipital lobe, and not alone those limited to the cortex, but deep in the white substance, do not produce any alteration of the inotor paths in the brain and the spinal cord, as do those which we hitherto have described, this fact alone should overthrow the doctrine of Prof. Goltz. This distinguished pysiologist recognizes scarcely any functional difference between the anterior and the posterior lobe of the brain. According to his views the cerebral cortex is always the organ of the highest psychical faculties; sensation and motion are there represented, not as elementary processes, but as elaborated by psychical functions, the domains of which are not individual and distinct cortical areas, but on the contrary, the whole of the cortex, taken promiscu- ously. The visive disturbances of sense and motion which follow cerebral decortications, are but phenomena of ar- rest, and according to Goltz, dogs, from progressive decortications lose only the capacity for the psychical elaboration of sensory impressions. This doctrine is in open contradicticn of the results of our researches. In my work before cited, “On Func- tional Compensations, etc.," I showed that the believed phenomena of arrest are permanent phenomena of defi- ciency. The difference in the clinical forms presented by dogs mutilated in the anterior lobe, and in the occipital, is most remarkable; and the anatamo-pathological facts so clearly shown by us, constitute one of the most irre- futable proofs, that in mutilations of the anterior lobe, the cortical motor apparatus is represented, and in those of the occipital lobe, the cortical visive apparatus. There is an intermediate promiscuous zone. There is more: That the cortical motor apparatus is specially repre- sented by the convolutions of the sigmoid gyrus in dogs. Experimental Degenerations in Brain and Cord. 181 and cats, was demonstrated by the fact that the degen- erate fasciculi can be followed from that part; this fact stands in connection with the greater efficiency of electric excitation in that area. We must, however, hold, that the motor area extends farther all around, when we take into account the triviality, and the short duration of the phenomena, when only the post-crucial convolution is destroyed, in contrast with the intensity and the duration of the same, after more extensive destruc- tions of that zone. I have adopted for this area the denomination of the functional centre of greater intensity, and I demonstrate an area of minor functional intensity, much wider surrounding the former. The doctrine of Goltz is in part true, but only in the sense that destruction of the anterior part of the cortex of the brain in dogs and cats, is constantly followed, not only by disturbances of motion, but also by those of sight. But this fact cannot satisfy the requirements of his doctrine ; for motor disturbances are not obtained by occipital decortications, but only visive, with this difference, that the visive disturbances following decortications dif- fused below and behind the sigmoid gyrus, are less dur- able than those following extensive decortications of the occipital lobes. In the latter case we have not only found that the visive disturbances were permanent, but after many months ophthalmoscopic proofs of the fact were obtained (thanks for the service of the able oculist, Dr. Sgrossi). The doctrine of Professor Schiff does not withstand the negative evidence brought to light by the study of descending degenerations. If the posterior cords contain fibres of sense, they are never found altered in dogs mu- tilated in the motor zone; and, if in some cases we have met with degeneration of the cords of Goll, in the whole length of the medulla, and also at some points in it de- generative alterations in the cords of Bourdach, this was due to a myelitic diffuse process, which took as its point of departure the degenerate pyramidal cords in the dorso- lumbar tract of the medulla. 182 Bianchi—D'Abundo. If degeneration of the pyramidal fasciculus is a con- stant, never-failing alteration, and if this fasciculus is no other than a motor one, the cortical area whose destruc- tion provokes this degeneration cannot be otherwise regarded than as an organ making a constituent intrinsic part of the same system, that is, the motor apparatus. Further, one of the most valid arguments of Schiff, that the behavior of dogs mutilated in the motor zone, is just the same as that of others on which the posterior cord of the medulla has been cut, has been refuted by Victor Horsley, in terms most strongly favoring the doctrine opposed to Schiff's, as he succeeded in showing that the cutting of the posterior cords of the medulla spinalis, either because of the impossibility of limiting the cut to these cords only, or because of the diffusion of the reactive process, terminates by involving the pyramidal fasciculus. This signifies that in the absence of an ana- tomical analysis, so directed us to show clearly the true conditions of the experiment, that is to say, the parts of the medulla primarily or secondarily interested, there has been ascribed to lesion of the posterior cords, a complex of symptoms, which were wholly or partly the effect of anatomo-pathological conditions, created in the pyramidal cords. The doubt that the degeneration of the pyramidal fas- ciculus may originate in lesion of the white substance underlying the so-called cortical motor area, and in a pure and simple cortical lesion (a fact that would give to the zone in question the real value of a centre), has been decisively eliminated by our researches, which were specially directed to this object. • The negative results of the researches of Binswanger lose very much of their value, when confronted by the evidence furnished in the degenerate fibres proceeding from the gray substance of the motor zone that was spared in the act of decortication. In what manner exactly the degenerate fibres penetrate into the residual gray substance, and what relation they Experimental Degenerations in Brain and Cord. 183 enter into with the spared cellular elements of the deep strata of the gray cortical substance, we are not now able to say, because the method of hardening and coloring we were obliged to adopt, in order to enable us to make sections of the entire brain, did not permit a more par- ticular histological examination. A certainty is that they are dispersed in the deep stratum of gray substance, which, with the rest, has undergone a sclerotising process, from the reactive encephalitis following the decortication. Another fact seems evident: the subcortical area, where the greater number of degenerate fibres come together, finally to assume the appearance of a degenerate fascic- ulus, is exactly that which underlies the post-crucial con- volution, which we have considered as the area of greater functional intensity for motion; this is the area which is excitable under the action of electricity. The degenerate fasciculus represents the peduncle of this area. It trans- mits the excitements which are sent from this cortical area, it degenerates when this area has been destroyed. Here are two facts which in concert demonstrate the same thing. In a former work (“On the Significance of Electric Excitation of the Motor Zone,” 1880), I showed that by circumscribing the excitable area, and separating it all around from the remaining parts of the cortex, by means of a fine platinum blade, made hot by a galvanic current, the electric excitability of the isolated cortical area was not lost, and that the transmission of the cortical excite- ment down to the opposite limbs is possible, so long as the continuity of that peduncle has not become inter- rupted, either by cutting the internal capsule, as was done by us, or by cutting the said fasciculus higher up, as was done by Paneth, availing himself of a method very similar to that adopted by us, and afterwards by Marique. We say a centre of greater functional intensity, because the motor zone is to be considered as much more extensive, especially backwards. On this matter the results of our experiments, executed 184 Bianchi-D'Abundo. in the method of successive extirpations, were con- firmed in another way by those of Loeb, and by our own latest, by the presence of degenerate fibres proceeding from the posterior segment of the decorticated zone, cor- responding posteriorly to the sigmoid gyrus. With these facts brought to light, the idea of a motor centre, limited to the excitable area, vanishes; we have, instead, but a centre of greater functional intensity for motion, and all around there is intergranging and promiscuity. This con- ception, which is also sustained by Prof. Luciani in his cited last work, is applicable to all the other sensory and motor functions located on the cerebral cortex. VII. After the preceding brief physiological considerations, relative to the motor zone (the only part taken under examination in this study), we must halt a little over the anatomical facts clearly shown in our researches. The pyramidal fasciculus derives its origin from the cells of the cortical motor area by a central part, in which its fibres are more closely grouped, and by a peripheral zone, in which they are more sparse and further apart from the centre to the periphery. These fibres, commingled with others of the corona radiata (system of projection), and interposing into those of association, run, less recog- nizable, through the centrum ovale, and unite in a single fasciculus where the internal capsule is formed, in whose anterior segment it is found outside the head of the cau- date nucleus, from which it is separated by a zone not degenerated, and going farther backwards and downward, it is lodged between the lenticular nucleus and the thalamus opticus. The degenerate fasciculus does not enter -into relation with the nuclei through which it passes; we have been unable to trace any evident, associative, direct path be- tween them; it is separated from the caudate nucleus by a capsular layer of normal aspect; the degenerate fasciculus is found very near the lenticular nucleus; but Experimental Degenerations in Brain and Cord. 185 whilst it runs in close vicinity to the middle and the in- ternal segments of this nucleus, which do not show any remarkable pathological modification, the external seg- ment is seen to be much atrophied, and the degenerate fasciculus, in most of the sections, is more distant from this segment. In the meantime, in both the anterior seg- ment and the posterior, the pyramidal fasciculus occupies chiefly the centre of the capsule. An atrophic process which happens to the caudate nucleus and the external segment of the lenticular nucleus, cannot be taken into account, in considering the relations with the cortex, es- tablished by means of the pyramidal fibres. With respect to this the clinical facts are in accord with our experi- mental results. The observations of Nothnagel, and some others found in the literature of destructive foci of the caudate nucleus and the lenticular, which were not fol- lowed by permanent hemiplegia, have been confirmed by the experimental and anatomo-pathological facts with which we have been occupied, and these induce us to rank with those who hold that the voluntary impulses do not tra- verse the caudate or the lenticular nucleus. The atrophy of these nuclei would lead us into a series of considerations which would carry us away too far from our undertaking, and we confess that we have not mastered materials sufficient to warrant our offering hypotheses and doctrines respecting these basal gray masses, which have up to the present fruitlessly tormented the inge- nuity and talents of such a multitude of physiologists. We merely desire to indicate a few of the questions to which it seems to us some contributions might be tendered. It is known that Meynert regarded, and yet regards, the gangliar masses of the caudate and lenticular nuclei, as masses of interruption in the system of projection, con- sisting of fibres that run from the cortex to the cerebral peduncle. The fibres of the corona radiata, as he thinks, enter at one of the poles of the caudate nucleus, and are brought into relation with the cells of this nucleus, and 186 Bianchi-D'Abundo. pass out by the other peripheral pole, and then in part tra- versing the internal capsule, they enter the peduncle. In this manner fibres from the corona radiata would pass into the external segment of the lenticular nucleus, and after assuming relations with this gray mass, they would issue from it. Wernicke does not concur in the views of Meynert. He believes that the scheme of Meynert is merely one imaginated by him over longitudinal sections. The fibres of the corona radiata, according to Wernicke, appear to penetrate into the external member of the lenticular nu- cleus, but in reality, after having touched (kissed) it they leave it and converge towards the cerebral peduncle. As to the caudate nucleus, a central pole of it, in the sense of Meynert does not exist, for the corona radiata does not enter into relation with this nucleus, from which it is separated by a cord of white substance. The caudate nu- cleus and the external segment of the lenticular nucleus, would be cortical equivalents, considered with regard to their structure. Kowalewsky rebuts the statements of Wernicke, as he had opportunity, in making sections in another direction, on the brains of dolphins, cats, monkeys and man also, to follow fasciculi of fibres which, running from the corona radiata, the internal and the external capsule, entered into the external member of the lenticular nucleus, and in part terminated there. A fasciculus was also followed from the corona radiata into the caudate nucleus. These two nuclei therefore really seem to stand in direct relation with the cortex, by means of a fasciculus from the corona radiata, Our own researches would lead to this conclusion. From the white substance of the olfactory lobe a fas- ciculus undoubtedly passes into the head of the caudate nucleus; and in the sections succeeding those represented by figure it, plate 2, the head of the caudate nucleus, extremely lessened and atrophied, seems to be suspended from this fasciculus, which had also degenerated, because of its vicinity to the encephalitic process. In horizonta Experimental Degenerations in Brain and Cord. 187 and vertical sections also of the brain in dogs, but especially on the vertical ones, fasciculi were observed passing from the corona radiata and the anterior segment of the internal capsule into the caudate nucleus. Furthermore the atrophy of these two basal gray masses, which was all the more evident the more the cortical lesion had extended, and proportionate to the length of time since the operation, showed in another way the existence of direct relations between the cortex and the lenticular and caudate nuclei. And if these relations are not maintained by the pyramidal fasciculus, which we are obliged to regard as distinct in its whole course, it is a matter of necessity to admit that anatomical and functional relations are established between them, by means of other fibres from the corona radiata, the nature of which has as yet evaded our research. Here another corollary emerges, in relation to the character and nature of the so-called cortical motor zone. We characterise this zone by its chief attribute—the most conspicuous phenomenon emanating from it; but who can seriously deny to this very conspicuous cerebral area another activity, besides that signified by the motor phe- nomena which are evolved by it? What is represented by the paths which are associated with the basal ganglia ? What activity in the latter is induced by the cortex whereby its abolition should be followed by atrophy of these ganglia ? Here are problems presented to phy- siology, to the solution of which we think the studies. prosecuted on degenerations following cerebral lesions, will not a little contribute. And now another of the abstruse questions on cerebral physiology is presented to us : we mean that of functional compensations. It fell to me, in another work, to sustain the doctrine, that functional compensation, naturally apart from the collateral phenomena, which were very distinct from those of deficiency, was effected by the activity of the brain cortex, chiefly by the parts around the excitable zone, and to a small extent by a homonymous cortical area 188 Bianchi—D'Abundo. of the other hemisphere. Although the supposition of compensation of the nuclei of the base rested on the authority of the eminent experimenters, Profs. Luciani and Tamburini, and on the equivalence of the basal nuclei and the cortex, it was however only because of the similarity of structure and of the constituent elements presented in these parts; but the fact that these nuclei become atrophic a long time after the anterior lobes of the brain have been largely decorticated, gives very great value to the hypothesis of cortical compensation. Successive de- cortications, after apparent recovery from the paralyses consequent on extirpation of a motor zone, reproduce or aggravate the paralyses, which become persistent; that is to say, the areas or zones lastly destroyed had been com- pensating for the functionality of those first destroyed. Finally, we can accord but a trivial value to the atro- phy of the nuclei in excluding them absolutely from the possibility of compensating for the functions of the cortex, and the more so as the paralytic phenomena in the dogs and cats which were largely mutilated by us, on the cer- ebral cortex were permanent from the first and only corti- cal demolition, and not fleeting, and hence we were not properly obliged to have recourse to any doctrine of compensations. As regards the paralytic phenomena arising from decortications of small extent, and therefore disappearing in the course of a few days, the compensa- tive influence of the surrounding spared cortical area seemed almost indisputable. Resuming now our remarks on the pyramidal fascicu- lus, we must, for a short time, direct our attention to the .anatomical finding in the corpus callosum; there was thinning away of all the right half of it, homonymous with the mutilated hemisphere, degeneration of a certain number of the fibres composing it. We can, however, merely note the fact, as the method of coloring which we were obliged to adopt, did not permit us to follow the .course of these degenerate nervous fibres, from the point at which they became few, because of the number detached Ea 189 Experimental Degenerations in Brain and Cord. from them; and being lost in the convolution of the corpus callosum, they were confounded with others. We were not persuaded of their existence in the internal capsule of the second hemisphere; but the degenerate fibres which we recognized once more in the foot of the other cerebral peduncle, and which we followed from this point into the half of the pons, and into the corresponding pyramid, appeared to us to have no other possible course than through the corpus callosum, where, up to a certain point, they proceeded from the decorticated zone. When the degenerate fibres cannot be followed with clearness throughout their course, their reappearance in the foot of the peduncle almost constrains us to follow their course ideally across the internal capsule, and induces us to re- ceive the assertions of Beevor, in relation to the corpus callosum, with many reservations. Ageno and Beisso, Wernicke and Hamilton have de- scribed, with varying details, fasciculi of fibres of the corpus callosum, which take the path of the external capsule (Ageno and Beisso), or constitute a cord which runs in the internal capsule, flanking the central pole of the caudate nucleus (Wernicke), or is brought into relation with the basal nuclei, representing a commissural system between the cortex and these ganglia (Hamilton). Beevor denies all this, and by means of delicate preparations of the brains of monkeys, he believed he demonstrated that the corpus callosum is no other than a commissure be- tween the two hemispheres, and that the fibres of the internal and external capsules do not pass, by crossing through the corpus callosum, into the cortex of the other hemisphere. In the midst of so many disagreements, the insuffi- ciency of the ordinary means used, whatever may be the method of coloring preferred, for following with certainty the course of individual systems of fibres in the brain, is quite manifest. Only by separating the different systems of fibres by means of provoked degenerative processes, can this obscure chapter of the anatomy of the brain be 190 Bianchi—D'Abundo. augmented, as by this method the fibres show differences in structure and color. As to ourselves, we feel author- ized, exactly by this method, to assert that a fasciculus is detached from the motor zone, which, in passing through the corpus callosum, is in part lost in this convo- lution, and the other part passing on by a recognizable tract, and then by an unknown path, which, however, is very probably the internal capsule, reaches the foot of the peduncle of the opposite side. The topography of these degenerate fibres in the foot of the peduncle, permits us to believe that in all likeli- hood we have here the pyramidal fibres decussated in the corpus callosum. It is difficult at this point to speak of the ulterior course of these fibres; they can be followed both on sec- tions of the pons and the pyramid, on the side opposite to the mutilated hemisphere; but whether they decussate once more at the level of the bulbar crossing or run on without undergoing an ulterior crossing in the correspond- ing half of the spinal medulla, is what we cannot absolutely assert. However, on the plans of bulbar cross- ing, as one is represented by figure 14, plate I, a com- plete crossing is shown at p. p., and the reappearance of the degenerate fasciculi in pl. pl. If such be the fact, the fibres of the mutilated right hemisphere would return into the crossed pyramidal fascicle of the right half of the spinal medulla, undergoing a second crossing; and the more likely as the fascicle of Türck, which is so little developed in the dog, cannot be taken into much consideration. All the facts noted by us in the first ex- periment, incline us to hold that the things do go in this way, and here we may find the reason of some experi- mental facts which are yet sufficiently obscure. In dogs, in which the fascicle of Türck is comparatively seldom found degenerated, bilateral contraction from uni- lateral excitation of the motor zone, is frequent. This fact, before observed by Hitzig, has been the object of our special consideration, as well as of that of Franck Experimental Degenerations in Brain and Cord. 191 and Pitres, and Prof. Luciani. Now we believe the path of the corpus callosum to be that most probably taken by, those artificial stimuli of the cortex. We do not overlook the value of the experiments of Franck and Pitres. These gentlemen, from having found that movements on the same side as the excited hemisphere are weaker, and are produced after a longer time, than those in the opposite limbs, argue that bilateral reactions cannot be produced by the direct nervous fibres of the same side, as we main- tain, but rather by transmission, by means of the gray substance of the spinal medulla, as happens in reflex movements. Confronting the argument as to the longer time expended for movements on the side homonymous with the excited cerebral hemisphere, as always happens when a stimulus traverses the gray substance, stands the fact, that the fibres which run in the corpus callosum, are relatively few, as compared with those which follow the usual path, and their transit is much longer. We should not therefore wonder that the reaction is weaker, and also slower, seeing that the weakness of the stimulus cannot be excluded (proportionally to the small number of the excited fibres), in the time of reaction, even should we leave out of account the longer course taken by it. But the closest-fitting proof in favor of the doctrine advocated by us, in opposition to that of Franck and Pitres, consists in the fact observed by us, that if the paresis of one side, consequent on extirpation of the motor zone of the opposite hemisphere, passes off in a certain time, or seems to have passed off, it reappears, or is aggravated, on the extirpation of the motor zone of the other hemisphere, that is, the one homonymous with the side primarily paralyzed. On the other hand, the new weakening lasts too long to be regarded as a simple phenomenon of arrest. This weakening and the reaction on the same side as the mutilated hemisphere, find their natural explanation in the presence of the degenerate fibres in the corpus callosum, the foot of the peduncle and the pyramids, opposite to the mutilated hemisphere. 192 Bianchi-D'Abundo. In this the physiological facts are in unison with the anatomical, which are the best guarantee for all we have been stating. The anatomical finding, the particulars of which we have above related, renders easy the solution of the question respecting the progression of the degenerate fibres often met with in the postero-lateral cord of the same side as the unilateral mutilation. Our first experiment gave a notable example of the bilateral degeneration of the pyramidal fasciculus, from unilateral cerebral lesion. Had ours even been the first observance of the sort, it would not have been difficult to discover the reason of it, in the degenerate fibres in both the peduncular feet and both the pyramids; but it has been observed several times, and in no instance has a word been said about degen- erate fibres, as in our case, in the other foot of the peduncle. Let us then analyze the facts: Charcot states the pos- sibility of a bilateral degeneration, and he explains it by assuming that a part of the crossed pyramidal fasciculus decussates, in passing to the other half of the medulla, passing across the anterior commissure of the spinal me- dulla, specially in the upper part of the dorsal tract. Pitres, in forty cases, met with pyramidal degeneration ten times after unilateral lesion of the brain; he noted that there was no relation between this bilateral degeneration and the presence or absence of the direct fasciculus of Türck, and he explained it by assuming that the degen- eration, which is met with in the posterior part of the medullary half which is homonymous with the cerebral lesion, falls on the fibres which proceed from the homon- ymous pyramid of the medulla oblongata. The presence of the long anterior commissural fibres, admitted by Bouchard in 1866, and located by him on the outside of the true pyramidal fasciculus, between this and the direct cerebellum fasciculus, found confirmation in the observations of Pitres, and more lately Lowenthal, from having met with the degenerate area smaller in dogs Experimental Degenerations in Brain and Cord. 193 after cortical lesions, and more extensive after unilateral section of the spinal medulla, and also having found the fibres of the bandelet exterior to the pyramidal fasciculus thicker than those of the true pyramidal fasciculus, ad- mitted the presence of long commissural fibres, or at least of commissural fibres, between the pyramid of the medulla oblongata and the different segments of the spinal medulla of the same side, which very probably are invaded by a hardening process, after lesion of the motor zone, a process limited in the outset to the pyramidal fas- ciculus alone, but becoming diffused simply because of vicinity. It is to these fibres proceeding from the pyramid of the same side, that Pitres attributes the presence of bilateral degeneration in the spinal medulla. If this were so, the degeneration ought to occupy the proper area of these fibres, that is, a small zone exterior to the pyramidal fas- ciculus, and this fasciculus should not present marks of degeneration, or at the most much less than the external area. Instead of this (as is shown by our figures of the spinal medulla with bilateral degeneration of the pyramidal tracts, which figures represent sections of the medulla of the bitch of first experiment), the degeneration is more intense in the centre of the area of the true pyramidal fasciculus, and thins off equally in both sides, as it pro- ceeds towards the periphery. On the sections of the spinal medulla of the dog and the cat of the second and third experiments (though not shown in the figures, be- cause appreciable only by microscopic examination with very great enlargement), evident marks of degeneration were met with, both in the centre of the area of the py- ramidal fasciculus and in the crossed pyramidal fasciculus, and this degenerative process thinned off towards the periphery. These facts, therefore, render but little proba- ble the explanation given by Pitres, of bilateral degener- ation in the spinal medulla. But now we ask, Where do the degenerate fibres of the other pyramid, that is the one opposite to the lesion, take origin? 194 Bianchi—D'Abundo. We do not by this intend to prejudge the question as to whether these run, in each side of the spinal me- dulla, in addition to the crossed lateral pyramidal fascicu- lus and the direct fasciculus of Türck known to all; also another lateral pyramidal tract on the same side, and a direct pyramidal tract on the opposite side. Sherrington, who has met with direct pyramidal degeneration much oftener than Lowenthal, in dogs on which he had extir- pated the motor zone, and who has certainly studied the subject more profoundly, gives a different explanation of the fact. He and Langley argue that degeneration of the pyramidal fibres produces a degenerative process also in the cells of the anterior gray substance of the spinal medulla, with which they are in relation. The fibres which depart from these cells degenerate, and this would explain the anatomical finding, that in the pyramidal fasciculus some fibres degenerate first, and some afterwards; and the fibres that establish relations between the homonymous parts of the two halves of the medulla would in like man- ner degenerate, hence the appearance of degenerate fibres in the other half of the medulla. This constitutes the “ tertiary degeneration” of authors, corresponding to the "recrossed” degeneration. This doctrine, besides having a certain basis in the anatomical fact above mentioned, as to the successive and not simultaneous degeneration of the fibres that enter the pyramidal fasciculus, to take a part in it, would ap- pear to find confirmation in another fact, which is, that although the tertiary or recrossed degeneration dimin- ishes from above downwards, yet it is usually more intense at the level of the cervical segment, and the dorso-lumbar, of the medulla, than in the median dorsal tract; and this doctrine would be corroborated by some observances of a pathological process in some cells of the anterior corona, from a primitive or a secondary degen- eration of the pyramidal fasciculus of one side. We, however, have been among the first to maintain, on the basis of rigorous observation, that not all the cellular Experimental Degenerations in Brain and Cord. 195 groups of the anterior cornu have this significance; that some of them may disappear after the complete degeneration of the pyramidal fasciculus, without either the nutrition of the muscles suffering thereby, or electric reaction undergoing any qualitative modification. Yet all this demonstrates nothing in support of the assump- tion of Sherrington and Langley. It has not been demonstrated that cellulo-pyramidal degeneration, on one side, produces tertiary degeneration in the pyramidal fasciculus of the other side. That the recrossed degeneration (we accept this desig- nation in the sense of which we shall presently speak) commences later than that of the opposite side of the medulla, may be explained by the fact, that the fibres which undergo degeneration are very few, in com- parison with those on the other side; they are scattered among those of the lateral pyramidal fasciculus, which does not degenerate, and therefore they escape even the most close examination. It is only at a later period, when the process of sclerosis begins around the fibres which disappear, and when it lays hold of and degen- erates the others of the lateral pyramidal tract, that degeneration is shown, and only at a much later period the degenerate area reaches almost the same degree, and the same extent, as on the other side. That the degenerate area is more diffuse in the cer- vical and dorso-lumbar segments than in the other parts of the medulla, may be explained by the greater activity of these segments, from which the innervation of the muscles of the limbs starts, and hence the degenerating process is more rapid, because of the greater functional stimulus. But, setting aside all these merely simple con- siderations, we note the fact, that though in some sections of the medulla of the bitch, the subject of our first case, we were able to note some slight degenerative process in the gray substance, this part was absolutely normal in the medulla of the other dogs, on which we were enabled, by a more accurate analysis, to discover incipient "recrossed” 196 Bianchi-D'Abundo, or “tertiary” degeneration of the lateral pyramidal fascic. ulus. In defect of any anatomical evidence in the direction of the hypothesis of Sherrington, we venture our hypothesis. that the fibres proceeding from the motor zone, which de- cussate in the corpus callosum, and reappear in the peduncular foot and the pyramid opposite to the mutilated hemisphere, again cross at the level of the pyramids, and pass into the postero-lateral fasciculus of the medulla, on the same side as the cortical lesion, mingled with the fibres of the crossed lateral pyramidal cord. In this sense we admit a “recrossed” degeneration, by means of a double decussation of the fascicle that is affected by it, and we regard as but little probable a tertiary degenera- tion in the sense of Langley and Sherrington. We are, however, very far from considering so interesting a question as exhausted, and one to which we have brought our little contribution. Secondary Syphilis as a complication of the Psychoses. By Jas. G. KIERNAN, M. D., Chicago, Late Medical Superintendent Cook County Hospital for the Insane; formerly of the New York City Asylum for the Insane; Member of the New York Society of Medical Jurisprudence and of the Chicago Medical Society. 7 HILE the ætiological influence of secondary lues W has been much discussed, the subject of its psychical influence as a complication of the pyschosis has not received the attention it deserves. While investigating the ætiological influence of lues my attention was attracted to a case in which secondary lues had produced peculiar effects in the psychosis complicated by it. This case bore such a marked resemblance to two previously reported by myself * that the three seemed to deserve collation and comparison. My first two cases are as follows: Case I.-I. B., age forty-two, American, printer, periodic drinker. Patient has two brothers insane, and his grand- father and brother's son died insane; presents marked asymmetry of face and skull. On admission is very incoherent and extremely terrified at something; rushes wildly across the room; at times remains quiet, then starts up suddenly, exclaiming: “Murder! look! they are playing the battery on me!" He frequently brushes himself and then stamps on the floor. Asked why he does this, says: "Scorpions, spiders, biting me, biting me !” Always has an expression of terror on his face. He is much run down and has a temperature of 40.5°C. The lungs, heart and other organs were normal; the remains of a recent chancre were noticeable on his penis. Ordered mercurial inunction and eggnog; no other treat- ment. Two days after admission, the patient has quieted down; is less terrified, still very incoherent; his temper- ature has fallen to 37.5°C. He was arrested in a dance • Journal of Nervous and Mental Disease, July, 1880. [ 197] 198 Jas. G. Kiernan. house, where he had been for two weeks previous, and it has been ascertained that he belongs to Massachusetts. Four days after admission, a roseola has made its appearance on his forehead. Just previous to this his temperature rose to 39.3°C., but has fallen to 37.8°C. He was very much agitated during the rise of tempera- ture, brushing his clothing repeatedly. He has been recognized by a friend visiting a patient in the same ward, who gives the family history above mentioned, and says that the patient has been insane for a number of years, but is now worse than he ever saw him. One week after admission, the patient was sent with two other more intelligent patients (just admitted) from a Massa- chusetts asylum, to be dropped in New York; each of them being given a small sum of money. Ten days after admission; patient is markedly quiet; no evidence of hallucinations; is still very incoherent; roseola is fad- ing. Twenty days after; no hallucinations; is evidently an old case of chronic insanity, passing into dementia; was three years an inmate of the asylum in Massachusetts, and always noted for his good humor. Treatment sus- pended, patient having no fever. A year after was still quietly incoherent; has been recognized by a workhouse woman as an old crazy man who went into the dance house where she was employed, and had intercourse with one of the inmates under treatment for venereal disease. Case II.- Jas. McG., age seventy-five, periodic drinker, Irish, was admitted to the New York City Insane Asylum, with a history of having been a year previous very rest- less, getting up during the night and searching for people long dead-for instance, his father and mother; wandering off during the day to look for his mother and sisters, most of whom died in his infancy. Has a good memory of far-off events, but is markedly oblivious of the fact that he has been married, and has children, some of whom are fifty years old. He went out into the street dressed in his daughter's drawers, with her frock on as a shawl. This and similar performances caused such a Syphilis and the Psychoses. 199 scandal that home treatment was abandoned and he was brought to the asylum. On admission he was a typical case of the insanity of senescence and was sent to one of the quiet wards. At the time of his admission, workhouse women were employed in the wards by order of the com- missioners, as assistants to the attendants. About a week after admission, three ulcers were noticed on the patient's penis, one of which was clearly the initial lesion of syphilis, while the others were simple venereal ulcers. On admission the patient was perfectly healthy; it was therefore obvious that the ulcers had been contracted in the asylum. The workhouse women of the ward being examined, one of them was found diseased in a similar way. Nothing unusual was noticed about the patient till three weeks after, he having been meanwhile under the usual treatment for his venereal disease. Three weeks after the patient became very violent, tore his clothing to get at the mice gnawing his bones, and said that the "hearts of steel” were after him, and he heard them cry, “Shoot, shoot him!” and saw their guns pointed at him. His temperature at this time was 41.1°C. In the course of the next week a roseola appeared on his forehead, the mental symptoms just mentioned persisted, and the patient was put under chloral, hyoscyamus and conium in two-gramme doses, with quinine to reduce the fever; none of these had any effect. On the appearance of the roseola it was determined to place the patient under mercurials. A sheet well smeared in mercurial ointment was wrapped round him, and he was placed in a camisole. In six days the fever fell to 36.9°C, the hallucinations dis- appeared, but his old restlessness returned, and in an attempt to get out of bed he bruised his penis, causing an ulcer which became phagedenic. It was cauterized while the patient was under ether, but he did not rally markedly after the operation, dying in the course of the next two days. Case III—which came under my observation at the Cook County Hospital for the Insane, is as follows: B. E., ætat seventy-three, Irish, hotel man, married. The patient, 200 Jas. G. Kiernan. May, 1884, about six months before admission, suddenly began to display wandering tendencies and dissipated habits. . He had a congestive chill, from which he passed into a condition of stupor, from which he recovered, com- plaining of cold (his temperature is subnormal). He con- tracted the initial lesion of syphilis about this time, and in the course of a month complained of being dead, had hallucinations of hearing and delusions of persecution by a priest. On admission he had these delusions and hal- lucinations well marked. He had secondary luetic ulcers on his limbs. Under the modified McDade anti-syphilitic treatment (mercury bichloride gr. 1-32, being added to the original formula) the ulcers improved, and with them the patient's delusions of persecution and hallucinations grew fainter, until he was not certain that they were aught but imagination. He presented, on admission, slight physical evidences of paretic dementia ; these are now well marked, and he displays a silly optimism and con- tentment with his surroundings. His temperature is 94.5 F. right, g6°F. left side. The tendon reflex was normal. These three cases present one thing in common: in all three distressing hallucinations and delusions were present; in all three much agitation was exhibited, and the acute psychical symptoms belonged evidently to Wille's class of the irritative psychoses due to syphilis. It may be asked: Were the hypochondriacal and de- pressing symptoms exhibited by B. E. due to syphilis or paretic dementia simply? If they were due to paretic dementia only, it is difficult to explain their gradual fading under anti-luetic treatment. They approximated so closely to the psychical symptoms produced in the other cases cited, that it seems more than probable that they arose from the same cause. The cases cited illustrate two pos- sible elements of error in the determination of the ætiol- ogy of insanity. It is obvious from the character of these cases and of others due to the specific fevers, that ex- haustion, rather than any germ or poison, is the essential exciting ætiological factor. NEURITIS PLANTARIS. * A CLINICAL RECORD. By C. H. HUGHES, M. D., St. Louis, Former Surgeon, U. S. d.; Superintendent and Physician-in-Chieť, Missouri State Lunatic Asylum; Lecturer on Neurology, St. Louis Medical College, etc. THIS rare, painful and formidable malady of the terminal distributions of the two popliteal nerves in the foot is worthy of the physician's especial study. It comes on as the sequel, usually, of a low form of blood-deprav- ing fever, like typhoid or protracted malarial, with typhoid- like depression, or in the latter stages of phthisis; but it may be the sequel of an exhausting, long-continued rheumatism, or possibly of a badly-managed or neglected and chronic gonorrhea, as Ross asserts, though I have never seen this as a result of that disease. It appeared as a conjoint symptom in some of the cases of cais- son disease at the time of the building of the St. Louis Bridge, and I have seen it follow upon a resi- dence in the high altitudes of Colorado and an attack of the so-called mountain fever of that region. It comes upon a nervous organism, shattered and tremulous and choreic, and the painful paroxysms are agonizing. The pa- tient cries out with pain, and often cannot rest at night, even after prolonged wakefulness, without powerful anodynes. The slightest touch, such as the application of local ano- dynes with the hair pencil, to the painful parts, often can- not comfortably be borne. A peculiar burning sensation, without thermoinetric evidence, accompanies the pain. The pain is usually localized in the balls and the tips of the three toes supplied by the internal plantar nerve and in the heel and plantar arch of the foot, but sometimes implicates also the two smaller toes, which are supplied from the external branch of the plantar nerve, the fifth toe being supplied exclusively by the external plantar, • Read belure the St. Louis Medical Society, Saturday, March 5, 1887. [ 201 ] 202 C. H. Hughes. while a filament from the internal joins with the exter- nal, in giving the fourth its æsthesiodic supply. Misleading vasomotor disturbances, suggesting erysip- elas, or incubating abscess, are sometimes sssociated with this form of neuralgia, but in those intensely severe cases which have fallen under my observation, the feet have been pale and dry. A sour sweat has been mentioned as associated with some quite similar cases described by Ross. I have never observed this. Poulticing does not help these cases, and the meta- tarsal and tarsal swelling, and fluctuation which usually follows this procedure, sometimes excites the fear of form- ing abscesses, but this soon subsides if the poultices are not renewed. Intense dry heat or a draft of cold air are alike painful to the patient, and the weight of the bed- clothes cannot be tolerated by the toes, or even a feather pillow, sometimes, by the soles of the feet; but hot water, beginning with a temperature of 100° and gradually raised from 130° to 150° is often a source of comfort to the patient. Ether and Goulard's extract give a little temporary relief, but are often too painfully cold: chloro- form does better but is sometimes too burning. A paint of equal parts of chloral and camphor with morphia or belladonna is pretty well borne in some cases, and gives considerable, and sometimes complete local relief for a time. Cocaine, likewise, but is usually too painful when first applied. Iodine is not worth much, nor is oil of winter-green, and the latter, after a poultice, is excruciat- ingly painful to the patient. In fact, to precede these applications when they can be borne with poultices is apt to make them unbearable. Weir Mitchell was the first to describe an affection similar to this but not the same, under the name of ery- themomegalalgia. He regarded it as a rare vasomotor neurosis of the extremities, and Ross, the only neurolog- ical writer, who, to my knowledge, refers to this subject, regards it as plantar neuralgia, “inasmuch as the vaso- motor disorders are preceded and accompanied by some Neuritis Plantaris. · 203; paroxysms of pain.” My cases may possibly have been more exclusively neuralgic or neuritis, for there was no redness in any of them. The present case is the third or fourth well defined case of this kind coming iunder my observation. They are very rare, as Mitchell says in the description of his cases; Anstie makes no note of them, and the cases described by Elliotson, which Ross thinks were plantar neuritis from gonorrhæa, were prob- ably cases of gonorrhical rheumatism, involving the ten- donous portions of the muscles of the sole of the foot and plantar fascia. The history of the following case is somewhat unique, and while it might be described as a newly discovered disease, I think it well to group it as only a variety of the already noted cases of plantar neuritis and tarsal hyperalgesia. About the first of August, 1886, G. B., a young man of nineteen years, was taken sick in the mountains of Colorado, thirty-six miles west of Gunnison, at or near Dry Fork, of Gunnison River, with a chill. A low form of fever followed, called, in that section, mountain fever. He was brought to his home in Illinois. After, or about the end of the fifth week of his illness he had sharp, lan- cinating pains in the toes and under the plantar fascia. The tips of the three inner toes, supplied by branches from the internal plantar nerve, could bear not the soft- est wet sponge of an electrode to touch them without a little flinching, and only a very mild, constant current passed from these to the internal malleolus could be borne. The surface temperature of the foot was not above normal, but the subcutaneous ædema increased the cir- cumference of the foot and toes fully one-fourth more than their natural size. The patellar tendon reflex and tendo- Achillis reflex were exaggerated in both extremities, but much more so in the left than in the right leg. No effort at eliciting the reflex phenomena was attempted till after the hyperalgesia and hyperæsthesia had disappeared from the feet, but when accidentally touched they showed exag- gerated reflex. 204 C. H. Hughes. Without fever and without evident organic lesion, the heart-beats continued throughout two months of his illness at a hundred and twenty per minute, except when modified by treatment. A tenderness, on pressure, at the emergence of the left great sciatic from the sacrum persisted after the pain had left his foot. The patient was much emaciated and very feeble when he came under our observation on the 23d of Sep- tember. He had lost much of his hair and his nails were changed to a dirty brown color. The movements of the upper and lower extremities were tremulous and choreic on attempting exertion, but the toes were not paralyzed. The paroxysms of pain in the feet recurred every few minutes without exciting cause, but a touch or a draft of air or putting the feet pendant, would start the pain immediately. The pain was often in the two feet at the same time, but most frequently alternated. The most comfortable attitude the patient could assume was to flex the thigh on the abdomen and to grasp the leg below the knee with locked hands, while lying recumbent or holding his knees up in that way. Under a treatment which consisted mainly of rest, a liberal diet, judicious galvanism, quinine, belladonna, gelsemium, aconite, arsenic and the bromide and muriate of ammonia, with occasional doses of morphia and chloral, the patient became practically convalescent of the neuritis by the 7th of October, the pain paroxysms having ceased to recur, no tarsal or plantar pain to touch, and but a little ten- derness to firm pressure remains, October 12th, over the sciatic notch. The patient has increased a good deal in flesh, rests well at night without hypnotic aid, and takes a nap or two during every day, while active treatment , for the neuralgia is almost entirely withdrawn. But there remains the irritable heart, a lame step in walking, to accommodate the left side, and some incomplete rheumatic and malarial symptoms have appeared. October 24th the patient was sent home for a few days, free from pain, Neuritis Plantaris. 205 but still walking somewhat lame and with a pulse of a hundred and twenty per minute. On October 29th the patient returned for treatment, without pain but still with a lame step and an abnormal heart-beat, and remained under treatment till the 4th of November, when he was discharged convalescent, with a slightly lame step, no pain, and a heart-beat when sitting, of eighty-four per minute. There was no history of vene- real disease in this case. A case came under my care last June not preceded by any pronounced form of fever, but by a general malaise, irritable heart and a masked intermittent, in which there was only restless sleep and night sweats, in the person of an old lady of sixty-five years, who has had a chronic station- ary left ovarian tumor for over thirty years, which Dr. Jesse Judkins, of Cincinnati, thought it not advisable to operate upon. This trouble was followed, on the first of July, with a dysentery which lasted till about the middle of Sep- tember. Dr. Elsworth Smith, of this city, succeeded me in charge of the case on the 24th of July (when I took my vacation), and the patient, by our joint advice, went East, to the sea shore. After her return, in September, the foot trouble reappeared and was much like one of Wier Mitchell's typical cases of erythemomegalalgia. The skin in this case was red over a certain area of the sole of the foot and the great toe and the two adjoining lesser toes, and peeled off. The nails were not discolored, but the ball and tips of the great and adjoining toes were intensely painful. An ointment of acetate of lead and belladonna was however well borne, and this and quinine and belladonna internally, gave relief. The patient is now (November 25th) quite well for one of her age and other local infirmities, and has gained in flesh, appetite, sleep and strength. There was no persisting accelerated heart action in this case. While I regard these cases as all belonging to the same category of peripheral nerve irritability from 206 C. H. Hughes. inflammatory states of the nerves or their sheaths, or conditions approximating inflammation and due to blood states, as other forms of neural pain and nerve-sheath inflammation after fevers, they may also precede, as well as follow poison or depravity of blood, and the effect is not always, nor do I believe ever altogether spent on the peripheral nerves, though it is there usually most apparent. In the case first above described, there was pain in the sciatic on pressure near its point of emergence from the pelvis under the pyriformis muscle, and lower down between the trochantor major and the ischium. There was also some sense of constriction complained of about the waist, even after the pain had left the foot, so that what Ross says of this disease, viz., that it is sometimes progressive and in its later stages may be associated with evidences of spinal disease, such as girdle pains and partial paralysis, muscular atrophy is not a future impossibility with our patient, though we shall endeavor by judicious manage- ment of the case, if permitted, to avoid so dire a result. The efforts of pathologists have, of late, been in the direction of establishing them as febrile sequelæ, as they most usually, but not invariably are, as MM. Pitres and Vaillard (Review de Medicine, December roth, 1866) have lately shown in regard to post-typhoid neuritis and in regard to post-neuritis (tuberculosa. They belong to the same category as those extremely sensitive states of teeth and nails and hair roots which sometimes are seen to precede, but more often to follow certain states of depravity-or poison of blood; the clinical cachæmias and toxhæmias. Neuritis plantaris, as I have observed it, is seldom dis- played in the constitutionally neuralgic, like sciatica and tic-douloureux, and singularly does not suddenly migrate from one branch to another of its great nerve root, the posterior tibial, or of the popliteal bifurcations of the great sciatic, in imitation of neuralgia trifacialis and other forms of transitional neuralgia. It does not even alternately pass to and from the external and internal Neuritis Plantaris. 207 plantar, which bifurcate from the posterior tibial, but is exclusively confined in all the cases I have seen to the digital branches of the internal plantar, extending no further outward than the distribution of the nerve to the inner aspect of the ball of the fourth toe, and the toes all seem to be more or less conjointly rather than alter- nately painful, as is usually the case in true neuralgia of central origin of the common terminal branches of a certain nerve-trunk. This gives it the character of peripheral neuritis rather than of simple neuralgia. But why neuritis plantaris should select the internal plantar nerve about the point of its bifurcation, and at its distribution in the toes is only conjectural. It may be due to the fact that it is larger than the external, has more to do in the movements of foot and toes and is more pressed upon in standing and walking than its out- side neural neighbor. Ross, we think, has justly criticised the name erythe- momegalalgia, given by Mitchell to these cases, "inasmuch as the vasomotor disorders are preceded and accompanied by severe paroxysms of pain,” though the name given by Mitchell is certainly very descriptive of his own cases, as they all had erythema as well as intense pain and the flushing over the painful area is quite characteristic in many cases, though by no means in all. Fig. I shows the painful area in the first case above, the intensest pain being at the darkest spots. There was no erythema in this case, but pallor of the foot and toes. The shaded parts in, - Fig. 2 shows area of flushing in second case above described, and region of pain, the chief pain being at darkest points. Fig. 3 is a diagram of the digital nerve distributions and their trunk connections with the plantars and beyond, showing how the internal aspect of the fourth toe is sup- plied by a branch from the plantaris internus. We must either accept the term “neuritis or neuralgia plantaris” for these cases, or apply to some of them a 208 C. H. Hughes. new designation, as they are often, as in the cases here described, instances of evident constitutional neuropathia with local neuritis, for both patients above were hyper- æsthetic to sound as well as touch, both were mentally very irritable, and one had marked cordio-gangliopathic irritability. (Fig. 1.) (Fig. 2.) 1st Toe First Digital Second Digital 2nd Toe INTERNAL PLANTAR Third Digital fourtb Digital EXTERNAL PLANTAR 30 Toe Fiftb Digital 4th Toe External Digital Erhal Digital 5th Toe Deep Branch (Fig. 3.) . Veuritis Plantaris. 209 ADDENDUM.—In the discussion which followed theread- ing of this paper the question was asked if there was any atrophy? There was not appreciable in the affected toes or portions of the foot involved. We did not look elsewhere. Nor was there the not uncommon reaction of degeneration and paralysis which we see coupled with absence of the cutaneous and tendonous reflexes in the secondary neuritis. of wounds and organic inflammation, or in primary multiple neuritis. The cure was perfect, and these frequent untoward sequelæ were not apparent at the time treatment of the pa- tient was discontinued. The best and most marked results followed the aconite and gelsemium, and the galvanismn. A drachm of quinine and four grains of belladonna were given during the two first days, but not so heroically employed after. The other remedies, except the gelsemium and galvanism, were employed pro re rata, the aconite being discontinued after the first week, but the galvanism and electricity were kept up to the end of treatment. No anæsthesia has ever appeared. For brevity's sake the subject of multiple neuritis and the post febrile neuritides in general are not considered. The alcoholic, plumbic, arsenic, meconic, and sometimes hydrargyric neuritides, had likewise to be omitted, unless we had been prepared to write a volume. Though it may be conceded, as Strümpel has lately said of simple and multiple degenerative neuritides,“ little that is definite is known as to the precise cause" of them, yet there would seem, the more we study them, to appear in all a common causative kinship in neurilemma nutritional disturbance, and in the atrophic molecular changes in the nerve itself, whether these states be in- duced by blood-perversions, blood-pressure or blood- derivation from the affected part. This patient was innocent of alcoholism, of mecono- phagism, saturnism, or any other toxic influence save the precedent malarial febrile damage, which will be inferred, we hope, from the fact that these states are not referred to in the text. Lecture on the Disorders of Language.* By Professor BIANCHI, Naples, Italy. IMARY. LECTURE X.—Summary. The different elementary factors of language. The neuro- psychic factors. Their extrinsication by as many cortical centres.—Progressive perfectioning of these centres.—Suc- cession in the development of language. Of the diverse neuropsychic elements.--Signification of specialised cen- tres. -Sensory aphasias.—Verbal deafness.—Its semiology. -Its influence on the other neuropsychic factors of speech. Its localization.— Clinical case and necroscopy.—Amnesic aphasia.—Its analogies with verbal deafness.-Its symp- toms.- Clinical case and necroscopy.- Question as to the localization of amnesic aphasia. Verbal blindness. Its difference from ataxia.-Its symptoms.- Localization.—Relations to hemiopia and aptitude for writing:- Clinical case.--Influence of verbal blindness on the intellect. IF it has been demonstrated that language, starting in I simple, inarticulate sounds, has reached the degree of development in which it is found to-day, it should not be very difficult to prove that an analogous perfectioning has been progressively going on, on the part of the brain, of which language is one of the most delicate functional expressions, and that this progressive development has had as its basis a successive differentiation of different organs, which are the organic substratum of the different elementary acts, of which language is composed. Let us turn our attention for a little to the neuropsychic ele- mentary factors of language, which are those most frequently found altered in hemiplegia. * Translated by JOSEPH WORKMAN, M. D., Toronto, Canada, srom the La Emiplegia, by Professor Bianchi, Naples, Italy. [ 210 ] Lecture on the Disorders of Language. 211 Language, physiologically considered, consists of many elementary acts, some of which are simply mechanical (phonic, respiratory, articular); others are purely psychical (perceptions, ideas); others again, are of a promiscuous nature, and may be denominated neuropsychical. The number of these acts is four-two sensory and two motor: first, the hearing of words; second, the coör- dination of the movements for the formation of articulate speech, and the articular motor memory; third, the sight of words written (reading); fourth, the motor coördination of written words and the graphic motor memory. To these we might add the touch of words (in cases in which language is apprehended only by gathering in, by means of this sense, the images of words). The apperception of words, which furnishes the intellective content of Jan- guage, is a factor eminently psychical. The different ele- mentary acts, of which language consists, are functional extrinsications of diverse parts of the brain, which are closely affiliated in reciprocal functional, and therefore, anatomical relation. If we consider severally the neuropsychic elementary functions of language, we cannot disagree as to their pro- gressive perfectionment and their successive individualiza- tion, distinguishing them from the more general function, of which each of them has become a more particular manifestation. In truth the hearing of words has not only advanced in perfectioning by the complexity of verbal sounds, and the very great number of them, as compared with that of the words of primitive tongues, but it has also proceeded in distinguishing itself from the general function of hearing to which it appertains by characters more intrinsic and fundamental. The motor coördination of the movements for speech, which is essentially intrinsic to the motor memory, is at this day far more complex than it was in early times, when the number of words was small, and they were mostly monosyllables, or vocalization (vowels) predominated; and in correspondence with this fact, the motor coördination of speech has assumed 212 Professor Bianchi. functional characters of its own, which, up to a certain point are independent of the analogous motor functions of the organs to which, as a function, it belongs (the movements of the tongue, the lips, and the lower jaw for mastication). The like may be said as to the seeing of written words, which may now be regarded as something distinct from the general visive function, to which it fundamentally pertains; and the movements of coördination for writing are also special to this work, being differentiated and dis- tinct from all the other complex motions of the arm, to the functional explication of which writing is intrinsic. If we carefully consider all these facts, it will be easy to argue from them, that the functional destruction of the diverse elementary factors of language has been produced but recently, as respects the historic progress of mankind. This applies specially to writing and reading. To the progressive differentiation of the elementary factors of language, there corresponds an analogous pro- gressive differentiation of the cortical zones within the confines of these areas, which are regarded as cortical centres of the general functions, of which the elementary factor of language is no other than a specialization. Of the four elementary factors, two sensory (the hearing and the seeing of words), and two motor (the spoken and the written words), the former two representing the im- pressive or centripetal momenta, the latter two, the expressive or centrifugal, it is evident that the sight of the written word and the writing of it are two factors of much later incidence than the two others—the hearing of the word and the spoken form of it. The written sign of the idea came into the evolutive history of man much later, just as we observe in childhood. The boy always, in all times and all places, when his development is phy- siological, speaks and understands, within certain limits, spoken language before he is able to learn to read and write; for indeed the hearing of words and the articulate expression of them aloud, are biological factors necessary to the ulterior phases of language-reading and writing. Lecture on the Disorders of Language. 213 Corresponding to these functional facts, the centre for the seeing of words, and that of the movements for writing, must be established much later than the other two, alike in the species and the individual; since it is not con- ceivable that special centres existed on the brain cortex, for a function not yei existing, and which did not exist in prehistoric man; just as it does not exist in the child up to a certain age, and likewise in the adult man who has not learned to read or write. [Is not this rather assumptive? What once existed not, but now exists, must be a new creation. Does function create organism, or is not function the action of organism ? The function of reproduction does not come into action before puberty ; surely the reproductive apparatus does not then first come into existence. The function of a railway locomotive does not create the engine, but the engine was designed for the function; otherwise better not fire up.- Translator ] Let us now determine more minutely the cortical areas in which the above indicated elementary functions of language are evolved. The hearing of words has its centre within the limits of the cortical zone of general hearing, that is, on the first temporal convolution and a portion of the second; the centre for the seeing of words is located within the limits or the visive cortical zone, and specially in the area of its greater functional intensity- the inferior parietal lobule. The two motor areas, whether we should regard them as centres of coördination of the specialised movements for the formation of articulate words and graphic signs, or as centres of memory of the above movements, appertain to the motor zone. The centre for articulate language represents a specialised area of the motor zone of the lower jaw, the tongue and the facial muscles, and it is located on the foot of the inferior frontal convolution of the left hemisphere (Broca's -or the third frontal); the centre for writing is within the motor zone of the arm, on the foot of the second frontal convolution of the left. By specialised centres we 214 Professor Bianchi. understand those which stand solely for the respective special movements of speaking and writing, and in which are deposited the mnemonic images of such move- ments; these have nothing in common with the gen- eral function of the organs to whose central area they belong; in other words, a lesion limited to these differ- entiated areas abolishes the special function, but not the other movements of the tongue and the jaw, or, respec- tively, those of the arm, for any other activity besides that of writing. Now that we have learned to recognize the different neuropsychical elementary factors of language-the two sensory and two motor—as well as the respect've frac- tional centres of the cortex of the brain, it will be more easy to us to approach the study of the disorders of speech. Above all things it is well to bear in mind, that the different cortical centres stand in so close a relation with each other, that a lesion of one of them can hardly occur without causing some perturbation in the function of some other; it may stand on the path of currents proceeding from other centres, or of currents directed to them by the organic cerebral apparatus of speech. The disorders of speech are in general much more complex than might appear from the examination we have hitherto made of the four elementary factors of language. Medical literature, however, possesses some cases of alterations of speech, which are referable to a single one of its neuro- psychic elementary factors, from a lesion limited to a related cortical centre, or to one of its paths of trans- mission. The great disaccord between authors, as to the true signification to be given to the aphasias, depends, in part, on the rarity of simple cases, and in part on the defects of observation, resulting from the multiplicity of symptoms, which has confused the description of the form of the aphasia, to which the most dominant symptom of the disorder of speech was referred. We cannot, how- Lecture on the Disorders of Language. 215 ever, assert that the four elementary factors can be abolished isolately by a circumscribed lesion of the respective centres, and that all the other more complex forms of aphasia are caused by more extensive lesions, or by cotemporaneous interruption of the various paths necessary for the normal explication of spoken and written language, or by individual conditions. Let us first see what disturbances proceed from abo- lition of the sensory factors, by lesion of the respective cortical centres. I have said that the cortical centre for the hearing of words is the depository of their acoustic images. When another person speaks to us, the acoustic image of each word heard is presented to our consciousness, which is evoked by the words; and the acoustic images, by awaking in the ideative field the correlated ideas, render the words spoken by another intelligible. On the other hand, when we ourselves speak, not only is the acoustic image of our words awakened by the idea, and presented to consciousness (a process named internal diction), but it is this which determines the complex coördinate move- ments for the expression of our words; the acoustic centre further exercises a continuous control over the articulation of speech, warning consciousness of possible errors in the mechanism of the coördination of the move- ments for the words, and thus protecting us, so that the words articulated perfectly respond to the acoustic image of the idea. When the acoustic centre for speech is destroyed, the mnemonic deposit of the acoustic im- ages of speech has also gone to ruin, so that all the words pronounced by others, failing to awaken the corre- lated acoustic image, and hence also the idea, remain a dead letter-they are not understood. Not indeed that hearing has been abolished; the individual hears, but he does not comprehend the meaning of the words addressed to him ; speaking to him is the same as speaking to a child that has not yet learned the meaning of words, or the same as speaking to an adult in a strange tongue, of 216 Professor Bianchi. which he is altogether ignorant. This is the so-called sensory aphasia of Wernicke, which has of late been better designated by Kussmaul and others, verbal deafness. The person affected with it can speak, read and write (not always, see after this), but he does not understand what is spoken to him. And as he has lost the acoustic con- trol of the words which he pronounces, he frequently ruins them, altering some syllables, or introducing others which deform the word, and give place to another motor dis- turbance, known as paraphasia. The opinions of various writers, especially those of Kussmaul, Charcot, Bastian and Lichtheim are not in complete accord, as to the influence of verbal deafness over the other neuropsychic factors of speech. According to Kussmaul and Charcot, verbal deafness may exist alone, and in these cases articulate speech may be perfect, ex- cepting that paraphasia will be present, as admitted by all; according to Lichtheim, on the contrary, the acoustic centre of speech, and through it the acoustic image of the word, should be an indispensable condition for the determination of articulate speech, inasmuch as the acoustic image of the word is, in the physiologic process of spoken language, represented to consciousness (internal diction) by the instant excitation of the coördinating and mnemonic centre for the movements necessary for the pronouncing of words. The assertion of Lichtheim is therefore far too exclusive, for there are cases in which spoken language has been possible despite the presence of complete verbal deafness. Here is another profound disagreement: Charcot and Kussmaul hold it possible, indeed as the rule, that simple abolition of the hearing of words, from lesion of the acoustic centre, may exist, and yet speaking, reading and writing may be possible; Lichtheim, on the contrary, holds that these simple cases of verbal deafness are due to lesion of the centripetal auditive paths before their entrance into the centre, the latter being in a sound state. In cases of verbal deafness with conservation of spoken Lecture on the Disorders of Language. 217 and written language, as Charcot justly observes, the acoustic image of the word may be substituted by its visual image; and the latter may be so lively as to call into activity the articulatory motor centre. The question cannot yet be decided: one fact is almost constant in verbal deafness; it is paraphasia. Those who are affected with verbal deafness sometimes appear demented or foolish; they speak without connection with the words addressed to them; they seem stupefied, and yet the process of ideation in them may be relatively normal, they have conserved hearing. If, when they have turned about, any small thing is let fall on a table, they turn around towards the slight sound; if any one speaks to them behind their backs in a low voice, they turn, though ihey have understood nothing that has been said to them; they seem to be demented, because one of the most important paths for the relations of the individual with the external world is obstructed. The case however, of Laura Bridgman, who, though born deaf and blind, was able to acquire, by means of touch, a high degree of cul- ture, clearly shows that not alone the visive centre may substitute the acoustic in determining the articulation of speech, but also the tactile centre. Recently I have observed in the Provincial Asylum for Insane, a very interesting case of verbal deafness. Case VI.-On the 7th of August, 1885, I admitted into the asylum of Sales, one Cerbone G., aged sixty-one years. His mother had been for a time insane, and was confined in an asylum, 'from which she was discharged recovered; a sister was a lypemaniac, and committed suicide. He was a working man, an excessive drinker and smoker, and much addicted to sexual indulgences. His intelligence was low, and the history of his life bears the imprint of predominance of the baser instincts; and gen- erally when he raised the elbow too often, he became violent and quarrelsome. One morning, about a month before, his wife observed 218 Professor Bianchi. that "he began to show signs of insanity :" he could not understand anything. He spoke disconnectedly, and it was impossible to understand him, as he so mixed up his words and the syllables of words. Only a few days be- fore being brought to the asylum, asymmetry of the face and paresis of the right arm appeared. From the day of his admission into the asylum, and throughout all the time he remained in it, he had con- stantly a stupid aspect; his gaze was interrogative. He did not understand a single question, and it was necessary to ask him in a loud tone three or four times in succes- sion, in order to get him to pronounce his own name. In these instances he fixed his eyes earnestly' on the movements of my lips. If I stealthily approached his bed, so that he might not see me, he would, on the slightest sound, even of my breathing or of my feet, turn him- self in the exact direction of the sound, and with an air of suspicion he would mumble some words, which were sometimes intelligible and at other times not. He spoke seldom, preferring to mutter some words to himself. His words were well articulated, but stumped and intermixed with strange syllables; in a few instances they were complete, but they never had any connection with the question put to him, though from time to time there was some logical relation between them. He could neither read nor write, being uneducated. His state did not permit me to form any just decision as to the state of common or special sensibility. His sight seemed to be good enough. There was paresis of the face on the right side, but no deviation of the tongue. He had paresis of the right arm, which was flaccid ; there was no trace of rigidity. The right leg was weaker than the left, but this did not appear in his walking. The tendon reflexes were exaggerated on the right. Indica- tions of atheroma were diffused over the aorta and the arteries. On the 26th of August he had an apoplectiform attack: there was a lowering of temperature at first, and after- Lecture on the Disorders of Language. 219 wards a slight augmentation of it; he remained in a state of semicoma for five days. He died on the 31st of August. Necroscopy. I report only so much as relates to the brain. Besides the marks of atheroma diffused over the cere- bral arteries, there was presented an area of softening, elliptical, in the direction of the temporal convolutions, occupying a little more than the posterior half of the first temporal and a part of the median. The pia mater hav- ing been detached the softened area appeared as a pulp. The softening dipped down into the oval centre of the temporal lobe and pervaded the whole of the island, and it advanced to the white bundles of the foot of the ascend- ing parietal, the cortex of which was unaffected. The ascending frontal and the inferior (3rd) frontal were sound, The inferior parietal lobe and a great part of its oval centre were sound. The convex part of the cortex of the lenticular nucleus was softened. We therefore had here one of the few cases which show that verbal deafness is produced by a lesion of the first two temporal convolutions. A very important question, in close relation with that of verbal deafness is that of verbal amnesia (amnesic aphasia). This consists in the forgetting of words or phrases, especially of proper names, substantives, then ad- jectives, and at length verbs and adverbs, in the order in which I have named them. In such cases conversation becomes very difficult, and sometimes impossible, as the verbal form which should clothe the respective ideas, does not present itself to consciousness. The idea is present in consciousness in more or less clearness (as the highest degree of clearness in idea is reached only when it is in- vested in spoken or written plastic form, or in other words, when it is associated with the respective acoustic, or visive image), but the remembrance of the form which ought to invest the idea is lost; the acoustic image can- not be evoked, and therefore the idea cannot be extrin- sicated either in spoken words or in writing, which alone 220 Professor Bianchi. are capable of exactly calling up the idea in other persons. If in these cases the idea is present in consciousness, and it is only its acoustic image that is wanting, it would seem natural that the lesion should be located in the mnemonic centre of the acoustic images of words, and therefore it should be found in the closest relation with the verbal deafness before spoken of. According to some writers, verbal deafness and verbal amnesia have the same seat, and the two forms are often associated. It is, however, necessary neatly to distinguish verbal deafness from verbal amnesia, although the two forms may be found associated. There are not a few cases in which it is observed that the patient hears and understands all the words addressed to him, but he is unable to express in words all his own ideas; he is aware of his state, it pains him greatly to be unable to express his ideas, he anxiously seeks for the acoustic or graphic image which should invest his idea, but despite all his efforts these images remain buried in the thick darkness of the de- parted. If in this circumstance some one present sug- gests to him the missing words, he is satisfied and is relieved from the pain caused to him by the impossibility of expressing himself; he now invests his idea in the form suggested to him, and he would continue his dis- course, but that he forgets his idea a little after, and runs aground in other analogous shallow waters. The great difference between verbal deafness and verbal am- nesia consists exactly in this, that the patient with verbal deafness does not at all understand the meaning of what is said to him, or at least of a great part of it, and yet he can speak, if the idea has such intensity as to excite the activity of the mnemonic centre of the muscular movements for the articulation of speech. If the patient can read and write, there will then be the visive image of the word, which, on the awakening of the respective idea, will call into action the motor centre of language. On the contrary, the subject of verbal amnesia under- stands all that is said to him, but he cannot by his own Lecture on the Disorders of Language. 221 will, evoke from the centre for acoustic images of words those suited to invest his own idea. Charcot holds that the lesions in the two cases have the same seat, that is, the specialised mnemonic centre for the acoustic images of words (the first and second temporo-spheroidal convolutions), with this difference, that in the case of verbal deafness, this centre is destroyed or paralyzed, whilst in the case of verbal amnesia it is more superficially injured, or simply paretic; so that the acoustic verbal image, which cannot be called up by the simple idea, may be aroused by the more intense stimulus of the verbal sound, which comes from the word spoken by another person. It seems to me that verbal amnesia cannot always be ascribed to the centre which has been recognized for verbal deafness; I think that verbal amnesia may be produced by an interruption of the paths of communication between the idea and the centre of acoustic images, or of the paths through which the idea calls up the articular motor mem- ory (Lichtheim, Grainger, Stewart); furthermore, it may be the result of enfeeblement of the ideative process, either from the facile evanescence of the ideas which are pre- sented to consciousness, but in a fleeting manner, so as to be incapable of adequately exciting the acoustic centre of verbal images; or it may be that the idea has lost a part of its content of associate relations, and in conse- quence the elements of re-enforcement necess iry for send- ing the centrifugal currents on to the centre of acoustic images of words, are defective. This view is corroborated by the fact that verbal am- nesia is almost always associated with more profound psychical disturbances than verbal deafness, and corre- spondently the lesions met with in cases of verbal amnesia, are frequently of a more diffuse form than those discov- ered to have been the cause of verbal deafness. Apropos to this question, I am able to present to you one of the most typical cases of verbal amnesia which we shall study : 222 Professor Bianchi. CASE VII.—Piquatore N-, was admitted into the asy- lum in a state of psychical weakness, which followed an attack of chorea that after a certain time had disappeared on the right side, and for about a month was observable on the left side only. A month after he was received into the asylum, I began to examine him more closely, and I observed a certain difficulty in expressing himself, which gave him so much pain that he preferred to re- main coiled up in his bed, without speaking a single word. He was unable to read or write; he perfectly understood the meaning of all words, and he replied properly to all qnestions put to him, even when we band- aged his eyes, or when we spoke to him in the dark- ness of night. In expressing himself he often ran aground, at a loss for substantives, which he only sometimes suc- ceeded in pronouncing with great effort, but with much complacency. This condition became progressively so much worse that his discourse became very imperfect and almost impossible, as at length he failed in all substantives, and verbs also commenced to fall short. When he was examined in school, his psychical faculties had become enfeebled, but no sign of localized paralysis of sense or motion was discovered. When we presented to him a hat, and asked him for its name, he fixed his attention on it, he blushed, and made every effort to remember the word hat, without succeeding. He then made signs to me to reach him the hat, which I was holding in my hands in front of him ; having taken it he turned it round in his hands, repeatedly felt it with feverish anxiety, as if he had decided to recall the acoustic image of the word hat by his sensations. of touch; finally, taking it laterally in his two hands, and putting it on his head with some force, just as when we might give a cordial salutation to a friend whom we have not seen for a long time, he pronounced the word hat. He acted similarly when I presented to him a key, that I'might hear him name it, but he did not recall it from the mere sight of the object; he was obliged to hold it Lecture on the Disorders of Language. 223 in his hands, and after turning it over and over again between his fingers, he succeeded in pronouncing the word key, just as he was in the act of accomplishing with the right hand movements similar to those made in entering a key into the key-hole of a lock, in order to open a door. Every time he thus succeeded in recalling a name he showed himself extremely well pleased. In this case it was evident that the acoustic image failed to appear because of the enfeeblement of the idea, which had lost all those associate relations that ordinarily serve to reinforce it; and it was therefore necessary to awaken these relations by a dissolving mental process, by means of new and recent sensations of sight and touch, and especially of the muscular sense, which was excited by those movements which stand in closest relation with the use of the object whose name was forgotten. Speech is the result of associative processes; putting the hat on his head and simulating the act of opening a door with the right hand, whilst holding the key appropriately in his hands, recalled those mnemonic images which almost necessarily stand bound up in the ideative process with the idea or the concept of a hat, a key, and so forth. That in these cases we probably have not a paralysis or paresis of the acoustic centre for words, was in the preceding instance strengthened by the post mortem find- ing, since on the most minute examination (non-micro- scopic) of all the convolutions, and more particularly of the temporal and of the Sylvian fissure, no special alteration was discovered, beyond a slow process of lepto-meningitis, diffused over the whole surface of the brain, which did not present any destructive focus of greater intensity. This is the typical form of amnestic aphasia, dissociate from all other disturbances of speech; it is one of the forms of the sensory aphasia of Wernicke, which is, on the contrary, regarded by Grainger Stewart as a motor form. But amnestic aphasia and verbal deafness are found not rarely associated with other disturbances of speech, 224 Professor Bianchi. by means of which the general symptomatic cortege of each has appeared more complex than it really is. This fact has induced some writers to include, in the symp- tomatic depicture of these forms, certain other disturb- ances, which are mere complications. We shall hereafter state the opinions of different authors in this relation. For the present let us continue the study of the more genuine forms, that proceed from alterations of the most elementary factors of lan- guage. Language, as we find it to-day, appears to have an- other elementary factor more recent in its historical development; this is the property of gathering in and understanding the visive images of words, as they result from the grouping of letters and syllables, as written symbols of ideas. This property is the result of a process of education by means of reading, by which there is formed a specialised centre on the cortex of the brain, that, analogously to the acoustic centre of verbal images, is the mnemonic depository of the visive images of graphic signs. In the physiologic process of speech, not only the acoustic image, which is more vivacious and active, is evoked, but also the visive image, which is less so; it however reaches its highest degree of vivacity in the explication of thought, by means of written lan- guage. In like manner as, before pronouncing a word, we perceive it as a word heard within ourselves, so also be- fore writing a word, we hear and see it within ourselves. It is a sort of physiological hallucination. Any pathological process that impedes the reproducing of the visive images garnered up in the related centre, will induce a morbid condition consisting in the inability to understand the signification of the written signs, and to group the written letters and syllables, so as to con- stitute the word as it is presented, and thus to awaken the correlative idea; hence, reading becomes altogether Lecture on the Disorders of Language. 22 225 impossible (verbal blindness or according to others alexia*,) or the words are transformed and spoiled (incomplete capacity to read the words regularly: paralexia). The incapacity to read, of which we are speaking, goes by the name of verbal blindness. One who is affected with it may have perfect sight; he sees, as all do, the other things that come under his eyes, also the written signs, the lines, the curves, and so on; but he knows not how to group these signs so as to constitute syllables and words; it happens to him with a language with which he was before familiar, as it does to an untaught person, or a child before learning to read—both see the written symbols of the words, but these symbols have to them no signification; they are barren signs in their ideative field. In reading it is necessary to distinguish two elements; the capacity to group letters and syllables according to their due positions, and to educe from them their co- respective verbal sounds, and the capacity to understand the ideal signification of the written word. In verbal blindness both these elements are disordered; if we should say that one who is affected with verbal blindness and does not understand the written word, is like a person who has before him a page written in a language of which he is totally ignorant, we should fall into a gross error. If I get under my eyes a German word for the first time, of which the meaning is absolutely unknown to me, I have not verbal blindness to this word, for I comprehend the relative disposition of the letters and syllables, and construct the visive image of that word, and I reproduce its acoustic complex as a spoken word; I fail simply as to its meaning, and this fact, applied in a pathological sense to all the words of a language pre- viously known, does not constitute verbal blindness. A dement may read and not understand a jot of what he * Alexia is not equivalent to verbal blindness, because the inabillty to read may depend also on dementia, or on disartbric disturbances, from lesion of the more peripheral apparatus entrusted with the mechanism of the articulation of speech. 226 Professor Bianchi. reads; this is not verbal blindness. In verbal blindness not only is the written word not understood, but the visive image of it is not formed, and neither are the visive images of the individual letters, formed; there is an incapacity to co-ordinate together the various elementary visive images so as to constitute the entire word; it is as if the letters and syllables were presented in a new form, just as when, for the first time, there should be presented to a cultivated man, words written in Hebrew, Chinese, etc. A person affected with verbal blindness may articulate words perfectly well; he may also hear and under- stand one who speaks to him; he may sometimes also write, inasmuch as the mnemonic images of the muscular niovements for writing may supplement the visive images of the words; but in the meantime he is unable to read. either internally or aloud any word whatever. Persons affected with verbal blindness may read and even write currently and correctly, yet cannot read a word of what they have themselves written. Some of them can read only at the instant when, in writing, they form the letters one by one, or when they imitate, with the hand in the air, the figures of the letters which they see, but they do not otherwise interpret them than by awaking the mnemonic image of the word by means of the muscular sense, admitted, as already understood, that the individual knows how to write. Verbal blindness may be met with as a symptom of hemiplegia, but this affection may have altogether disap- peared, and then we shall find the verbal blindness alone, as the unique residue of an apoplectic attack. It is some- times associated with homonymous lateral hemiopia, at other times the visive field is normal. I may here appropriately mention an hypothesis of De Watteville. He thinks that just as in the course of development the child learns to read only after having learned to speak, and learns to read by confronting the acoustic verbal image already appro- priated, with the visive image (written or printed sign) of the word; so likewise after learning to speak, reading is Lecture on the · Disorders of Language. 227 possible only with the true mnemonic reproduction of the acoustic image of the word-in other terms, with the integ- rity of the acoustic verbal centre and the commissural paths between this centre and the visive centre of words. If this is the fact, there may be verbal blindness from lesion of the visive centre of words, and in this case there will be associated homonymous lateral hemiopia; and likewise verbal blind- ness from interruption of the commissural paths between the acoustic centre and the visve, and in this case lateral hemiopia will be absent. The following is one of the purest cases of verbal blind- ness that have occurred in my practice: CASE VIII.-C. P., a gentleman from Pisticci, in Basili- cata, was presented to me for consultation by Dr. Leone. A year before he had an attack of apoplexy of short dura- tion, from which there ensued right hemiplegia and great difficulty of expressing himself. In the course of a month or two the paralysis totally disappeared, and his speech improved so much that he could speak without any diffi- culty, excepting perhaps that he had lost some substantives, in consequence of which he had recourse to certain para- phrases, the proper word not presenting to him. He presented notable proofs of atheroma of the arteries, and the heart was weak from incipient wasting. He suffered frequent vertigoes, which was the chief reason for his com- ing to consult me: and as he had, by the advice of his physicians, after his last illness, retired from the manage- ment of all his affairs, and had never again tried to read or write, he had not discovered the disorder which I detected. I presented to him a book, and to his great surprise he could not read a single word, nor a syllable, nor even the letters. He barely recognized the large letters of the title page by passing his index finger over them. This proved that he saw the letters, but they had lost for him the significance of graphic signs; he could not associate two letters in order to make of them a syllable, otherwise than by recognizing them by the 228 Professor Bianchi. movements of his hand. But the most interesting fact was, that on being requested to write a letter to his fainily, he wrote, without any hesitation, and just as any sound per- son, the following letter: “ Respected Doctor: I am very grateful to you, if you will restore me to health, which I hope, having heard the name you have. I am from Pisticci, Provincia (Diacaincia)* of Basilicata. “P. C. “ I was struck with a cerebral malady, of which i wisko When he had finished, and wished to read the letter, before sending it off, to his great surprise he was unable to read a single syllable of what he had written. Perimetric examination in this case showed the pres- ence of left homonymous lateral hemiopia (blindness of the visual field in the right half of both eyes). His in- tellect was sufficiently well conserved; none of the other elementary factors of language had suffered any disturb- ance; verbal blindness was the exclusive and isolate symptom. This fact confirms us in the interpretation before given, of the nature of the disturbance, and hence in our con- ception of the visive centre of speech. If an idiot who had been capable of receiving a certain amount of instruction should read a sentence without understanding, in any man- ner its meaning, as indeed often happens with children, we would not, in such a case, have anything to do with verbal blindness; the psychic field is here too limited for the ideas which, at a late period, the child will, multi- plying them, put into relation with the graphic signs- this the idiot will never do. If a person, for some reason, cannot read aloud, but understands, by inward reading, written words, or even when not comprehending them, is able ro reproduce The word (Diacaincia, in parenthesis, is exactly thus in the letter, and is a sample of paragraphia, Lecture on the Disorders of Language. 229 written words placed before him, we have not here a case of verbal blindness. The visive centre of speech is no other than the depository of mnemonic graphic (I would almost say brute) images, which may become as many forms of ideas, but may be devoid of any truly psychical element of them whātever. And as the necessary informative vesture of an idea is the acoustic verbal image, to which the visive image ought always to correspond, so is it that verbal blindness may exist without any disturbance of the intellect, whilst there are not a few cases of verbal deafness, in which the ideative process appears in no manner altered. Psychology of a “Plot” by the Insane. By Jas. G. KIERNAN, M. D., Chicago, Late Medical Superintendent Cook County Hospital for the Insane; formerly of the New York City Asylum for the Insape; Member ot the New York Society of Medical Jurisprudence and of the Chicago Medical society. Late si or your se do Sul NONCERTED plots by the insane are so exceptional that the following almost unique case merits record. The dramatis persone first deserve description. The instigator of the attempt was L. L., whose history is as follows: L. L., age twenty-nine; nativity, Chicago, Ill.; occupation, stone paver; Roman Catholic; education, common school; mental condition on admission, excitable, destructive, gives irrelevant answers; physical condition on admission, emaciated; has a slight contused wcund on forehead and under left eye. September 26th.—Under restraint; noisy, destructive, belligerent; engaged in a fight with Mr. M., resulting in the wounding of both. Patient is intemperate; he became ugly and was quite destructive. He was quite incoherent. Some fifteen years ago had an attack of brain fever, seemingly the result of insolation. He was then incoherent but not violent. September 29th.—Threw jacket out of window after tear. ing it. Had to be strapped to seat; in restraint all night of September 29th. October ist.-Had to be carried to seat and strapped, to keep him still. October 2nd. - Was very noisy during night; had to be strapped to seat for fighting; he broke strap; had to be put in restraint and seclusion. Ordered conium, ergot and hyocyamus, in ten-minim doses, under which he became quieter and his head clearer. Has recurrent attacks of insanity resulting from traumatism and excited by alcoholism. Is not con- scious of what then occurs. The attacks seem to be of an epileptic nature and are kleptomaniacal at their onset. The history of the other “conspirators" is as follows: [ 230] Psychology of a “Plot” by the Insane. 231 J. D. V., age twenty-seven; American; farmer; Protestant; divorced; mental condition, on admission, was religious at first; delusions of grandeur; wealthy; has erotic dreams; physical condition on admission, luetic eczema; urine albu- minous; luetic phthisis; mother living, aged sixty; father died of hydrophobia twenty-two years ago, he has delu- sions that he has intercourse sexually with angels ; imagines he is made to take medicine to cure others vicariously; began with irritability; memory not impaired, and sensitive. February 14th, 1884.-Appeared paretic, but is quiet. He was formerly treated with potassium bromide, now on mercury and kali iod. Patient has delusions of suspicion, and has very decided insanity of manner; he is somewhat incoherent. His exaggerated delusions are systematised. G. M., age twenty-two, American, laborer. During in- sanity, which is post-epileptic, he is very violent. He some- times has epileptic fits, and no outbreak follows, but he is very destructive when it does occur; sometimes has full warning. Post-epileptic insanity severe. He has remis- sions of a month, but excitement causes an attack. He was demonstrably epileptic when nineteen years old, and insanity followed in a year. Typhoid fever preceded the epilepsy and fits came at monthly intervals, almost reg- ularly. He ran away several times when engaged to a farmer, who did not discover the cause of his actions until he had a fit. In the asylum he was very treach- erous; broke down door once. August ist, 1883.-He worked occasionally. September 11th, 1884.-Was ordered : I kali brom. 3j; liq. kali arsenitis, 3 i.; A. ex. ergot, 3 iv.; ext. Al. conii. 3 iv.; aquæ z ii. mist. laxativæ, q. s. ad. 3 viii. Tablespoonful every three or four hours. September 14th.—He had a severe epileptic attack during the night. September 17th.—Bromic eczema. September 2gth. Had five epileptic attacks yesterday. September 30th.—One fit this morning; refused to have enema injected as ordered. October ist.—Is in room; had to be locked up. October 3rd.—Attempted to escape, but was captured and returned 232 Jas. G. Kiernan. to ward; resisted restraint and fought the attendants. He has delusions after his recovery from his post-epileptic furor, of ill treatment; is very suspicious; he does not retain remembrance of what occurs during his attacks. J. McC., age twenty-one, American Celt, laborer, of common school education; single ; up to the age of fif- teen had epileptic attacks. These then disappeared to give place to periods, during which he lost himself. He then became irritable, suspicious and excitable. He was hurt in the head by a machine. He was admitted to the institution in a condition of violent mania. He had, prior to adınission, spoken foolishly to people and stood laugh- ing on street corners. He carried a knife in “self-de- fence," and was “irritable, suspicious and believed he could do anything. He could walk through the sea and could cut the earth in half.” He had hallucinations of sight and hearing. On the day of the escape these patients had been taken out for their usual airing, and the four were seated together. M. and McC. were in a post-epileptic condition of mental disturbance. L. suggested that they all go home, more as he confessed, from a mischievous spirit than anything else; M. rushed on the attendant and threw him down, and the other three made a rush for the woods. M. does not seem to have had a clear consciousness of what he was doing, as he contented himself with the attack on the attendant. He had no recollection of his violence nor of the suggestion of L., although his conduct was seemingly prompted by it. McC. had the idea of flight suggested to him, as was indicated by his conduct in addressing L. and people with whom he came into contact in the city after his escape. V. looked upon the whole occurrence as a providential means of setting him free from his persecutors; L., M. and McC. he looked upon as lunatics, but as they were, in his opinion, instruments of providence, he accepted their aid. Strictly speaking, there- fore, there was in this case no real concerted action on the part of the insane. There were several coincidences which Psychology of a “Plot" by the Insane. 233 led to the appearance of such a concert. The post-epilep- tic conditions rendering the patients peculiarly likely to re- spond to suggestions from without in an indefinite manner, the peculiar delusional condition of V. rendering him, with his logical perversion, likely to look upon occurrences as providential interpositions, and the mischievous disposition of the instigator, all united to give an appearance of plot to what was, in reality, the result of practically inde- pendent actions. The medico-legal bearings of the present subject are so obvious as to need no discussion. Treatment of the Insane by the Turkish Bath.* By Chas. H. SHEPARD, M. D., Brooklyn, N. Y. L AVING given over twenty-five years to the study 11 of a specialty, my mind naturally has turned to see to what new fields that specialty would be applicable, and none appear more fruitful than that of the right care and treatment of the insane in this country. The question' whether they are to be treated in large asylums or in private families has been discussed by many, and yet it is more than probable that for a long time to come the asylum treatment will prevail. It would there- fore seem the part of wisdom to make such institutions and their proper management our objective point. While many abuses are bequeathed to them from the past, the future is full of promise. Of all things it is certainly most desirable that asylums for the insane should have taken from them the character of prisons, and restraint should be only apparent in exceptional and extreme cases, thus giving them the more desirable character of hospitals. While there are some disadvantages in having large numbers of varied conditions congregated together, there are also many advantages. Appliances and facilities can be furnished to the many that would be unattainable for the few. After pleasant surroundings and a wholesome dietary are first secured, then, paramount above all other reme- dial measures for the welfare of the inmates would be a well furnished Turkish bath. I would say that no asylum or hospital whatever should be considered complete, hardly habitable, without such an establishment. To one not posted in this matter it may sound strange : • Read before the Society for Promoting the Welfare of the Insale, 33 East Twenty-Second Street, New York City, February 8th, 1887. [ 234 ] Treatment of the. Insane. 235; he would say that a well-stocked drug store would be more appropriate—not that the drugs themselves are so desir-- able, but the effects they are supposed to produce are.. Now if we can secure these resuits without the wear and tear of the drugs, by all means let us do so. Thirty-one years ago there lived in England an enthu- siast; in these days he might be called a crank; Mr. David Urquhart, who had been a member of parliament, and an extensive traveler in the East, including Turkey. He was also the author of several books, one of them entitled “The Pillars of Hercules,” and in it he describes. some of the customs of the Turks. One chapter of the book was particularly devoted to the bath. About this: time he met Dr. Richard Barter, the proprietor of a water-cure establishment, near Blarney Castle, in Ireland.. A friendship was formed, and afterward Mr. Urquhart: sent this book to Dr. Barter, upon the reading of which the doctor was so impressed with the force of the state- ments in that chapter that he sent at once to London, requesting Mr. Urquhart to come down, and together with men and material, they went to work to build the first Turkish bath of modern times in Western Europe, and thus was commenced a work destined to confer inestima- ble blessings upon mankind. Already has it won its way by sheer force of merit to a prominent position in Great Britain and on the continent, as well as in this country, and proved itself one of the most remarkable agents known, and one that must eventually be placed at the head of all remedies. It is curious that the hot-air bath was used neither by the Romans nor by the Turks as an agency in the treat- ment of disease. It was simply a luxury, but so univers- ally resorted to that sickness was comparatively unknown among them. But, alas, the modern Turk is degenerating ! He is copying the Frank, who does not go to the bath. In the summer of 1865, when the cholera was raging in Constantinople, the authorities there issued a circular ad- vising all the people, among other things, to abstain from 236 Chas. H. Shepard. the bath!—the very thing and the very time when it was most needed. The modern Turkish bath is simply the scientific ap- plication of heat to the body through the skin, as a remedial agent, and by it we have complete command over organic disease. Its processes are simple, and consist of several stages, whereby the patient is gradually brought to a condition of profuse sweating, and while in that stage well manipulated, and then the entire exterior thoroughly washed-cleanliness can go no farther. After- ward, by gradual stages, he is brought back to his ordinary condition, but with every sense quickened and the tone and vigor of the body much superior to what it was when he commenced the process. No violence has been offered to any sense whatever, as is sometimes supposed. It is more like a development. In the first place the Turkish bath purifies the external body in a more perfect manner than is possible by any other process, while at the same time it is an exceedingly enjoyable luxury. In the next place it regenerates the blood by bringing it more completely to the surface, and there unloading its impurities; then again, by this very process, it equalizes the circulation, and by quickening its action in every organ of the body, it renders more perfect each and every function, whether it be of the secretions or the excretions. A medical man knows very well that when he has a fever to deal with, the crisis is passed when the sweating stage is reached. With heat applied to the surface of the body we can bring on that stage at once. If the system is 'loaded with poison of any kind, whether it be of rheuma- tism, malaria or what not, the first thing in order is to eliminate that poison from the body, and no way has yet been found at all comparable to the heat-cure as found in the Turkish bath. If the skin itself is not in order, is there not danger of poisoning one's self by the non-removal of the disintegrated tissues that are being generated every moment? Treatment of the Insane. 237 Have we a congestion in any part of the body? Is it in the arm, the foot, the liver, the lungs or the bowels ? The action of heat is to relax the tissues of that special part, and thus permit the circulation to pass on in its natural course, and when once we have established a per- fect circulation in the part, the congestion is gone. What is true of a part, is true of the whole. Let it also be borne in mind that the action of heat upon the blood itself is more than salutary—the unin- formed might imagine that the temperature of the body would be much increased thereby—such, however, is not the fact. The uniform standard of health or blood-heat, is 98°, maintained in all seasons. Necessarily in a low temperature the external vital changes are slowly carried on. But when, under the influence of a high temperature, the action of waste and repair is more active, exhalation and evaporation secure the equal temperature of the blood, and it is upon this adaptability of the body to sustain high artificial temperatures that the bath relies for its marvelous sanitary and sanative virtues. When under its influence the pores of the skin are thoroughly opened and the circulation perfected, then we have an unloading of all useless material that would otherwise remain to clog some organ or function. You have all heard of the child that was gilded to represent the golden age, and who quickly died. Thus by the action of the bath we produce the results sought to be brought about by drugs themselves; that is to say, it removes the symptoms for which they are ad- ministered; whether it be a cathartic, a diuretic, a tonic, a detersive or a narcotic, without any of the un- pleasant sequela that too often follow their administration. The bath will bring sleep to one suffering from insomnia, but will not, like opium, make the healthy man drowsy. Again, we find this fact very prominent; that when a patient comes to the bath for any special disease, he is not only relieved of that trouble, but his whole system is placed in an improved condition. 238 Chas. H. Shepard. As in other countries, so in this, the growth and prog- ress of the bath have been remarkable, though its way has been through mountains of ignorance and prejudice. Even the medical profession, either from conservatism or apathy have been slow to receive the truth as it is in the Turkish bath. Was not the Christian religion first preached to and received by the common people? So with the bath. By making it popular with the masses, the pro- ſession have been obliged to look into it, and the evidence of facts has been so overwhelming, that now many of the highest and ablest in this and other lands give it their unqualified approval. One object I have kept steadily in view during these many years of inspiring labor, and that is to show the world what. the bath, in and of itself, and without any help from drugs, could accomplish; and the result has more than justified the endeavor. Each day has been a new revelation. This much in applying the bath to man in his normal condition of mind. Still more so will it apply to man in an abnormal condition. Without stopping to define insanity, we would say that it is characterized by abnormal mental action and condition; there must necessarily be more or less con- gestion of the brain substance. To change this condition would seem to be the first requisite. It the blood is loaded with impurities, must it not necessarily affect the brain that is nourished thereby? If we could only call the blood in greater force to the extremities and surface of the body, is it not reasonable to suppose that we would thereby relieve an overcrowded brain? How much more so when we can at the same time purify this circu- lating Auid! There are two peculiarities of insanity, an inertness of the skin, and a peculiar odor, which the bath quickly remedies. It is generally acknowledged that there is no specific for the cure of insanity, as it is a disease depend- ing on and associated with various functional disorders, Treatment of the Insane. 239 especially with the perverted nutrition of the organ of the mind. Experience has shown that if we bring har- mony to the various functions of the body, the mind quickly regains its lost balance. The soothing, quieting effect of the bath needs to be personally tested to be fully appreciated. Little has been done in this country to test this in asylums: conservatism and self-sufficiency have acted like walls of adamant heretofore. It is to be hoped that this society may not only act the part of the Good Samaritan, but also have the power to enter this wedge of reform. Some years ago, Dr. McDonald, then superintendent of Blackwell's Island Asylum, attempted to introduce the bath there, but ignorance, politics and boodle had more influence with the New York aldermen than science or the claims of humanity, and the attempt was ultimately abandoned. Much, however, has been done in Great Britain and Ireland that we may well study. Dr. Power, superintendent of the lunatic asylum at Cork, Ireland, reports that by the use of the Turkish bath he has cured seventy-six per cent. of the patients. After a few applications they like the treatment and ask for it. The number of cures is double the proportion of cures to the old system, the deaths have been diminished one-half ; thirty idiots have been so improved as to enjoy their lives and be made useful, and many persons pronounced in- curable before, have recovered and been restored to their friends. Dr. Robertson, superintendent of an asylum at Hay- ward's Heath, England, says: “The noxious secretion so frequent with the insane, and which in the asylums of twenty years ago, one could recognize as distinctly as the smell of a dog kennel, and which sometimes refuses to yield to ordinary ablution, the bath entirely removes. The bath is a remedial agent, grateful to the feelings of the insane, and which they do not, like other means of wash- ing, associate with the idea of punishment." 240 Chas. H. Shepard. He also gives several cases of cure by the bath treatment, but it would take up too much of your time for me to narrate them now. Some years ago I visited a large asylum at Colney Hatch, England, where there were acommodations for some two thousand patients. Here they had erected a small, separate building, expressly for a Turkish bath, and the attending physician spoke to me in very high terms of the success they were having with the bath treatment of their violent patients. In a report of the Newcastle Infirmary the saving of drugs is particularly insisted on as one of the benefits obtained by the introduction of the Turkish bath, and add: “The bath became a species of elysium, where ache and pain vanished as if by magic.” Listen to what one of the patients said, when taking a bath at one of these institutions I have been telling you about: “I say,” said he, “this bath is good for everybody!” When asked, Why? he replied, “When I was working in the fields my sweat rolled down from me like water; it had no nasty smell nor disagreeable taste. Now, sir, my perspiration is thick and nasty, like oil. It has a bad smell and a worse taste. When the cook puts a pot on the fire with a piece of meat or vegetables to boil, doesn't the fire throw the impurities to the top? and doesn't she take a spoon and skim them off?”. He was asked how long he had been at the institu- tion?“ Nine years! was the reply, and he was what was called a taciturn lunatic. For six years previously he had not exchanged a single word with his fellow-men, and he was considered incurable, but after the fourth bath he was discharged cured, and he has remained out of the asylum since, a comfort to society and to his fellow-men. Dr. Barter, who is my authority for the above incident, and who was very active in extending the benefits of the bath to the asylums and institutions of his own land, on a public occasion said: “The bath is a luxury free from Treatment of the Insane. 241 vice, and may be taken daily with increasing pleasure and benefit in health and disease. Its mission is to suf- fering humanity, its objects are, the prolongation of life, the increase of human happiness, and the mitigation of human misery.” It was well said by Walter Savage Landor: “This is the grandest matter of modern times, because even the cleansing of the mind from error is inferior to the puri- fication of the body itself, for unless the body is well- conditioned, the mind never can be so.” PROCEEDINGS OF THE NEW ENGLAND PSYCHOLOGICAL SOCIETY. The New England Psychological Society met at Hotel Brunswick, Tuesday, January 11th, 1887, at 3.30 P. M. Dr. Quimby, in the absence of the president, occupied the chair. Present: Drs. Stearns, Russell, Twitchell, Brown, of Barre; Goldsmith, Cowles, Channing, Tuttle, Quimby, Cary, Benner, Lawton, Stedman and Fisher. Voted: To exclude reporters, but secretary was allowed to furnish the papers a general account of the proceed- ings. The secretary's report was read and accepted. Dr. Julia K. Cary then read a paper entitled “Notes .and Answers to Queries,” of which she declined to fur- nish an abstract. Dr. Channing read a paper on “ An International Classification of Insanity.” As a member of the committee appointed by this society to attend the meeting to consider an international classification of mental diseases, Dr. Channing, on behalf .of himself, presented the following report: REPORT on the Conference of Alienists to consider an International Clas- sification of Mental Diseases, held at Saratoga, September 8, 1886. ABSTRACT. Mr. Clark Bell, of New York, editor of the new Medico-Legal Journal, ·called this meeting. He was present at the International meeting at Ant- werp, and was appointed the American member of the committee to which was left the further consideration of the subject. .[-242] Proceedings. 243 The members of the medical profession present, and taking an active part, were Drs. Pliny Earle, J. P. Bancroft, H. P. Stearns, W. B. Fletcher and myself. Dr. Earle represented the Medico-Legal Society, of New York, Dr. Stearns the Association of Medical Superintendents, and Dr. Bancroft and niyself the N. E. P-ychological Society. In accordance with previous arrangement, Dr. Earle presided. Dr. Stearns was elected vice-chairmail, and Dr. Channing, secretary. Mr. Bell continued to perform the practical duties of secretary. Mr. Bell bad invited a large number of persons, and though only a few were present, we still felt called on to do the best possible under the circunıstances. Mr. Bell stated the object of the conference, and wbat other countries had already done. He spoke particularly of the intention of the Inter- national Committee, to establish a classification for the purpose of unifying hospital statistics, rather than for the purpose of meeting the highest scientific requirements. He also presented the principal classifications of foreign alienists. Several systems were presented by those present. After several bours' discussion it was decided that none of them were applicable for use in this country, and there would be no possibility of their adoption for years, however admirable they might be in conception. The English system, as presented in the Journal of Mental Science, for July, 1886, was next considered, and this seemed, for ordinary purposes, to present more desirable features than any other. Haviny arrived at this conclusion we proceeded to remodel it, in a manner mure 11-eful for this country. The congenital forms we put last, the English system putting them first. The word Infantile,” which is found in the tirst order of the English plan, “ Cougenital or Infantile Mental Deficiency," we oniitted. The tirst form adopted by us was “ Mania, Acute, Chronic, Recurrent, Puerperal.” The second forin was “Melarcholia,' with the same subdi- vision. Form three we called “ Primary Delusional Insanity," a substitute for 46 Monomania." This term was suggested by Dr. Stearns. Form four includes the various forms of dementia, or primary, secon- dary, senile, organic (tumor hemorrbages, etc.) This is an exact copy of the English form six. Form five is "General Paralysis of the losane," and corresponds to form tbree of the English plan. Form six is “ Epilepsy." The English put it second. Form seven is · Toxic Insanity," of which alcoholism is an example. The English put this in form four as “ Mania-a-potu." Our eighth form is “Congenital Mental Deticiency," with the subdi- visions --" Idiocy, Imbecility, Cretinism." This form we bave already seen in form one of the English. Dr. Channing stated the reasons wbich led to the adoption of the above forms, at some length, and closed his paper with a brief consideration of the systems of classification of some of the recent writers. 244 Proceedings. DISCUSSION. Dr. Goldsmith was sorry not to hear Dr. Cary speak more definitely as to the value of gynæcological work among the insane. The difficulties of such work are not always appreciated, especially in respect of the application of apparatus to rectify displacements. In general practice the difficulty is great, and it is still greater among the insane. He has yet to see a single case of insanity whose recovery had anything to do with the local treat- ment of interim disease. In reference to Dr. Channing's report of the classifi- cation adopted at the Saratoga conference, he said it seemed as good a classification as could have been made. He would change it to suit his individual views, and so would every other alienist; but it must be simple and general, to stand any chance of being adopted and used. Thought it should agree essentially with the English classification as far as possible. Had no faith that uni- formity of practice would result. Thought primary delu- sional insanity was an incorrect synonym for paranoia or ferimare verrucktheit. The latter was characterized by great egotism, mental instability and bad heredity, and delusions were obscure or absent. In chronic delusional insanity the delusion is well marked and is the basis of the insanity. In paranoia the delusions grow out of the exalted state of feeling. Dr. Stearns would like to hear the classification criti- cized, as he was on the committee. Declined to discuss the paper until later. Had not heard Dr. Cary's paper. Dr. Twitchell had considered the subject discussed in Dr. Cary's paper well, and had modified his views on the matter. He believes there is very little connection be- tween insanity in women and diseases of the sexual apparatus. Has seen much of uterine and ovarian diseases in general practice, and thinks that even hysteria is sel- dom due to such disorders. Many forms of displacement of the uterus are physiological. The uterus is not a fixed organ. Flexions are pathological. Pessaries are of Proceedings. 245 doubtful usefulness, and local treatments of little avail. Thinks patients' circumstances and surroundings have most to do with inducing insanity. Related the case of a lady who was insane and very erratic. A careful ex- amination revealed no disease or displacement of the uterus. Ovaries were removed by a specialist and found to be perfectly healthy. He had not heard the result as to her mental condition. Dr. H. B. Storer used to assert that most of the cases of insanity in women were due to uterine diseases, and that there should be a gynæcologist in every insane hospital. The mere fact that insanity is not much more frequent in women than in men shows that this cause can have but little influence in determining insanity. Such diseases should be treated where they exist, but calling attention to them often has an unfavorable effect. SELECTIONS. PSYCHIATRY. FACIAL BLEMISHES AS A CAUSE OF MELANCHOLIA.—Dr. Savage (Journal of Mental Science, July, 1886) says that about the age of forty single women have come to the conclusion that they are not attractive, and magnify some deſect; and married women, fearing the loss of their hus- band's love with the change in their own feelings, may become morbidly self-conscious or jealous. If at this period any bodily peculiarity appear, the morbid mental growth may rapidly develop. Skin eruptions, or the growth of hair on the face, are the most common sources of trouble. These hair-growths are common among insane women, and do not usually affect the mental state; but sometimes a mind, already unstable, is completely upset by the constant worry about the unnatural disfiguring growth. A thirty-eight-year-old woman, who had an insane paternal aunt and a phthisical brother, was admitted to Bethlehem; she had always been nervous and easily de- pressed; she was sober, well educated and in comfortable circumstances. She had four living children and two mis- carriages, and suffered from uterine trouble; the cause assigned to her insanity was a recent growth of hair on the chin. The earliest symptoms noticed three weeks before admission were sleeplessness, depression, restlessness and a wish to die; she was no longer any good to her family, had committed all sorts of crimes, and was accused of sins ; had no affection for her children, attempted to kill herself by strangulation or precipitation; thought she was damned. On admission in 1884, she was thin and spare, with the aspect of profound melancholia ; she had to be fed with a spoon. Within a week she slept better and took her food voluntarily; in February, 1885, she was at needlework, but was still dull. There was no sign of lung disease. Early in March the report was still more favorable, but toward the end of March she suddenly broke down; all her quiet and calm had been assumed, as she cried vehemently, and accused herself of producing all the ill- ness and madness in the Hospital. In June she was sent to the Convalescent Hospital and July 4th she escaped, but was discovered July 6th. She said she had slept one night in the woods, and one in the churchyard, and she [ 2461 Selections. 247 had taken only one glass of milk during her absence. She says her escape was the result of a sudden impulse, but a letter in her pocket showed it had been premed- itated to commit suicide, since she says: "And all this caused by the vile hairs on my chin—they have cursed my whole life, made a happy life miserable, taken away the power to enjoy it, until I see too late the folly of it. They, and they alone, made me think of such a dreadful thing as killing myself. Oh, if only I had never thought about them at all! It seems such a trifle to cause the ruin of body and soul, and others tou—more awful still.” During July and August she remained very miserable, when talked to, admitted that she might have been insane, and went so far as to acknowledge that she might not have done so much harm as she imag- ined, but these confessions were wrung from her, and she was no better. Dr. Radcliffe Crocker decided on removing the hairs from the chin and destroying the bulbs by galvano-puncture. She was pleased at the idea, and was sent twice weekly for several months to the doctor, who removed the hairs, one by one. At each sitting from ten to forty hairs were removed, the patient submitting most stoically. But little change appeared at first, but as the hairs were reduced in number and did not reappear, she steadily improved; after nine hun- dred hairs had been removed and the chin had only a a slight, smooth scar-like aspect, she was sent home on trial December 23rd for a week, and in February for a month. In March she was discharged recovered, thinking life was worth living, and that home was happy and de- sirable. She had lost all morbid self-consciousness and self-accusing thoughts. The case illustrates the desirabil- ity of removing the sources of any delusions, whether ætiologically related to the psychosis or not. At the same time it is obvious the hair-growth only tinctured and ex- aggerated her depression. CLASSIFICATION OF INSANITY.—Dr. Selwyn A. Russell (Medical Annals, July, 1886) advises the following classifi- cation as combining the ætiology with the symptomatology, and is perhaps as perfect as any that has been proposed. It is that of Dr. Batty Tuke, based on the previous clas- sifications of Schroeder van der Kolk (1852) and Morel (1860): (1) Idiopathic insanity, inciuding idiopathic mania, melancholia, dementia and paretic dementia ; (2) traumatic 248 Selections. insanity; (3) insanity associated with other neuroses (as epilepsy, hysteria, hypochondria); (4) insanity resulting from the presence of adventitious products; (5) insanity resulting from morbid conditions of the general system (as phthisis, rheumatism, syphilis, sunstroke); (6) insanity occurring at evolutional periods (as of climacteric, senile, puerperal); (7) toxic insanity. In its essence this classifi- cation is almost identical with that of Spitzka, who, like most modern scientific alienists, belongs to the school of Morel. Spitzka has expanded the principles laid down by Morel and Schroeder van der Kölk, and in the opin- ion of Tamburini, his classification is superior to that of Krafft-Ebing and Kahlbaum, the most prominent disciples of Morel on the European continent. Dr. Russell does not seem to be acquainted with the more recent literature, but shows the spirit of a true clinician in using the clas- sification he does. Its principles, which underlie all con- tinental European classifications, require more brains to master, than the average society dilettante alienist has to spare, and the latter seeks refuge in the works of Philis- tines like Blandford, who look upon the emotional depres- sion in melancholia as a “delusion” and not an actual emotional state. These society alienists, unable to distin- guish between an emotional state and an intellectual product, naturally regard Blandford's book as (Therapeutic Gazette, June, 1886) the product of one “who possesses good common sense, has not been driven mad by an excess of German speculative medicine, and has seen much of insanity.” The large sale of works of the Blandford type is as great a reflection on the profession of medicine as the large circulation of the “Medical Brief,” whose editor, however, keeps a little advance of his readers, and thus educates them. Mind-Reading.-Science, for January 7th, analyzes Mr. Cumberland's article on mind-reading, in the December Nineteenth Century, and says: “Mr. Stuart C. Cumberland, of mind-reading fame, gives a very frank and rational ac- count of his doings, in the December issue of the Nine- teenth Century. As a child, his perceptions were unusually keen, but his career as a mind-reader began only six years ago; his first attempt was entirely impromptu, but was as successful as any afterward. The gift was present, and future practice made it only quicker and more delicate, but not more certain. At first, Mr. Cumberland frankly Selections. 249 confesses, he was apt to imagine himself supernaturally endowed, but soon convinced himself that the whole thing is simply an ingenious and skilled interpretation of the unconscious movements of the subject. Willing is either dragging or pushing,' is the mind-reader's formula. 'Dis- tinct and intense apperception, fixed attention is incipient motion,' is the psychologist's conclusion. “Mr. Cumberland, from his experience, concludes that the best subjects are among active brain-workers, states- men, scientists, etc., where concentration is easy and usual. Military men make excellent subjects; lawyers are dodgy and unsatisfactory; musicians cannot fix their attention on anything but music; artists are better subjects; clergy- men are perfect in the drawing-room, but not in public; physicians are good subjects when they have no theory about thought-reading. Von Moltke was the best and M. Dumas the worst subject. Englishmen and Germans are perhaps the best races for subjects; while uncivilized races, such as Chinamen and Indians are bad. In regard to thought-reading without contact, Mr. Cumberland has never yet seen experiments of this kind successfully per- formed, unless there had been opportunities for observing some phase of physical indication expressed by the sub- ject, or unless the operator was enabled to gather infor- mation from suggestions unconsciously let fall by somebody around. He has on several occasions managed to accom- plish tests without actual contact, but has always been sufficiently near to his 'subject' to receive from him, and to act upon accordingly—any impressions that he physi- cally might convey." APPETỊTE IN INSANITY.—Dr. J. A. Campbell ( Journal of Mental Science, July, 1886) concludes: 1. The voracity of paretic dements is well known; patients bolt their food without regard to the size or heat of the viands, yet, as a rule, they confine themselves to articles of real food, and rarely eat clothing or dirt. At a very early stage he puts these patients on special diet; mincemeat with potatoes two days in the week, broth and milk diet on the remain- der, and restricts the food to a given allowance. Paretic dements should not be allowed to get very fat, as they have a tendency to bedsores in the latter stages; the power of assimilating a vast quantity of food and of rap- idly increasing in general bulk is most extraordinary in this disease. 2. In epileptic insanity the appetite tends 250 Selections. th. Two may ina fatness to voracity. Reasonable restriction in diet is necessary in this disease; a great increase in fatness renders life more uncertain, and a surfeit may induce a succession of fits, and cause death. Two patients, after partaking too well of plum-pudding, succumbed to a succession of fits; post mortem examination showed the stomach overloaded with plum-pudding. 3. Chronic insanity. In some cases the appetite is truly extraordinary; a private patient eating two rations to a meal without either gain in bulk or making himself ill. 4. In melancholiacs want of appetite is a most marked feature in many cases; both it and mel- ancholia probably result from visceral causes. A good purge, a course of blue pill and saline treatment frequently proves efficacious. A pretty sensible melancholiac once told Dr. Campbell that (which proved to be true), if he were allowed to fast for two days, his tongue would be- come clean. 5. In mania, patients refuse food from delusions; these are fed on the third day. 6. Masturba- tory patients are voracious and emaciated; farinaceous food is here indicated. 7. Restless excitement often does away with the feeling of hunger. 8. Failure of absorb- ents. In acute and persistent excitement and melancholia the absorbents often fail to act; the nerve supply takes a wrong direction. This is why noxious substances eaten, are often without effect. 9. Perverted appetite. Patients eat fæces, drink urine and filth from the spittoons. NEUROLOGY. RELATION OF TEETH AND HAIR FAILURE TO BRAIN STRAIN-EARLY AGE, GENERAL PARESIS.—The relation of the failure of hair and teeth nutrition to brain strain is. becoming justly recognized. It has been recently observed that the teeth of the pupils of the Paris public schools deteriorate in a few weeks after entry. The second den- tition is often premature. Dr. J. L. Williams has shown that any mental strain shows itself upon the teeth in a short time, both in increased decay as well as in increased sensibility of dentine. Dr. D. M. Parker has reported that these same changes are always apparent in men who are in training for athletic trials. And the late discussion of the relationship of baldness to intellectuality and intellec- tual occupations has resulted in a decision of the question in the affirmative. Selections. 2511 Great brain strain, either by worry or work of mind, but especially worry, is undoubtedly a great factor in these results. A large demand for nerve energy, and consequent waste of nerve force, draws upon the general reservoir, and in good cerebral organizations the least essential parts break first. It is thus that strong brains may pass through great trials with only the rapid blanching or falling out of the hair, while weaker ones go to destruction in some of the many forms of neuropathic degeneration and mental aberration. In great mental stress, such as results in insanity, we often see the nutrition of hair and teeth and skin fail, as well as the failure of the physiological function of other organs, before the final catastrophe to the brain. But the conjoined depressing ifluences of vices and vicious indulgences, like excessive tobacco, venery, alcoholic stimulation, depressing drug poisoning, especially chloral and bromide of potassium injudiciously and untimely used, prolonged night-work and violence done to the organism by irregular and inadequate meals and sleep, have more to do with failure of hair and teeth nutrition and brain break-down, than brain strain alone. The over brain strain is the determining factor, but it alone, without other causes, would far less often show in hair and teeth decay, if the vicious weaknesses and weakening influences of modern civilized life in the study, the office or the labo- ratory, not necessarily connected with mental work, did: not combine with the brain tax to cause nutritional failure in hair and teeth, and elsewhere. The causes that break the brain are not all in books and study. The hair and teeth fail, like the stomach fails; in intellectual dyspeptics. The brain strain of excessive study is but one of the causes. The direct brain strain of improper hours of study and indirectly of wrong times of eating and sleep, of electric lights, and the blood- depraving and brain-exhausting influences of steam-coil heated bed-rooms, of tobacco-saturated blood and tobacco smoke-charged sleeping apartments, the overtax and exhausting irritation of telephonic untimely interruptions of rest, the needless noises of city life and railroad travel, the ceaseless whirl, anxiety and unrest of so many solicit- ous lives, especially such as are spent on Change, in bucket- shops and pool-rooms, combined with the physical depres- sing vices referred to, blanch more locks, decay more teeth and denåde more heads of hair than severe study alone. 252 Selections. The average professional or business man of to-day makes heavy drafts on the vital energy bequeathed him by a more rugged and less restless ancestry, and adds nothing to the hereditarily-acquired store of nerve capital bequeathed by organizations which thought they required and accepted the nights, at least, for sleep. The fagot- lights and tallow-dips, and one-candle power lights of the obliterated past, saved our fathers, or grandfathers, from over-mental strain during a third part of the twenty-four hours of each day at least, and modern diseases of over brain strain, like general paresis, were comparatively un- known to them, and premature bald heads and white hairs and decayed teeth were the exception and not the rule as they are now It is modern civilization and its fast ways which have made all the places that are filled to-day by the neurolo- gists, the dentists and wig-makers, and developed those most important branches of medicine, psychiatry and neurology, though mental aberration has been, in lesser degree than now, common to every age, and so have pre- maturely gray hairs and decayed teeth. But insanity, like the early decay of the teeth, was never in past ages so .comnion among the young as now. The announcement, so late as half a century ago, of diseases like general paresis and the affective insanities, was received with incredulity; and when they finally became accepted facts in clinical psychiatry, it was only here and there in hospitals for the insane that they were .conceded to exist; but now the world outside finds these cases everywhere as common as the antero-lateral, poste- rior spinal, and disseminated cerebral sclerosis, of which our ancestors knew nothing. The age at which insanity is possible has moved forward, like the average age when it is possible for the hair and teeth to fail, which has been advanced by psychiatric clinicians several decades uver the mental failure possibilities in this direction, of the remoter past. Accordingly we find records by Wiggles- worth of paresis occurring at fifteen, by Claoston at six- teen, Morrison at nineteen, Mickle at twenty, Turnbull at twelve, Köhler at six, and other early-age cases by Krafft- Ebing, all recorded by Mickle, who also saw this dis- ease in several soldiers before the age of twenty-five. I have myself known it to occur at twenty-two. The nerve and brain strain of the present age is different .and more incessantly continuous in the life of individuals the horward, likene, age at whisis, sychiatric ilities in this direc by Wiggles- Selections. 253 sar than the overtax of the past. The "night” no longer “cometh when no man work,” but brain strain in the ordinary channels of business is possible at all times. Men work unremittingly and “pray without ceasing," for gain. Under such circumstances of continuous overpressure, with but a limited amount of reconstructive force in the organism, something somewhere must give way. It is fortunate, if the nutrition of the hair and teeth fail, that the normal vitality of the brain may endure. Better an early bald pate and “sans teeth, sans eyes, sans everything" than that the brain should give out before its time. All honor to the bald heads, whose brains beneath continue bright as their glistening pates above. All honor to the hairless crown and prematurely gray and toothless, if study and the pursuit of knowledge alone have made them so, and not the precocious, vicious indulgences of this rapid age; but more honor to the man who, wisely grown in wisdom's honored ways, still retains a covered crown, and hair and teeth unchanged, until they must in nature part at the “sere and yellow leaf” time of ripe old · age.—Dr. C. H. Hughes, in Medical Register. [In transferring the above some slight verbal alterations have been made by the writer, but not changing the sense.—Ed.] he" and ping pathose gut be no pursuitsematurely above.meneath ime. All NEUROTHERAPY. D. W. Hurson Ford's RESEARCHES ON Alcohol Uti. LIZED IN PRACTICE.-Austin Flint, of New York, in a recent article on the therapeutic uses of alcohol, in which views advocated many years ago by Todd, Linton, White and others, are reiterated in regard to the therapeutic value of alcohol in phthisis and the fevers, and its utility in diabetes and other diseases, is set forth, pays the following high and deserved compliment to the well-known re- searches of our fellow-townsman, Dr. W. Hutson Ford. “In 1872 a remarkable paper on the 'Normal Presence of Alcohol in the Blood' was published by Dr. William Hutson Ford, then of New Orleans * Since the discovery of the sugar-producing function of the liver, by Claude Bernard, the final destination of sugar in the economy has been an important question of discussion. That the sugar produced in the body, introduced with the food and • Dr Ford's article appeared in the New York Medical Journal for July, 1872. 254 Selections. resulting from the digestion of starch, disappears as sugar and is not discharged, there can be no doubt. The the- oretical modes of its destruction are by the lactic acid and the alcoholic fermentation, either singly or both combined. “There is no positive experimental basis for the theory that the hydrocarbons undergo lactic acid fermentation in the body. Dr. Ford demonstrated the presence of a small quantity of alcohol in the normal blood, using for his analysis large quantities of the fresh blood of the ox. Reasoning from this as the main fact, Dr. Ford came to the conclusion that the hydrocarbons are gradually and constantly undergoing alcoholic fermentation, that the al- cohol thus formed is oxidized as fast as it is produced, and that in this way the hydrocarbons act as important factors in the production of animal heat. My reflections and observations have led me to adopt this view, ad- mitting, however, the possible formation of a certain quantity of lactic acid, although this lacks experimental proof. My confidence in this opinion is strengthened by facts and observations relating to disease." Dr. Flint then makes the following applications and reflections: “In fever there is an excessive production of animal heat at the expense of the solid tissues, as is shown by the pyrexia, the loss of body-weight and the parenchy- matous degenerations. "In the constant elevation of the body temperature, which is observed in progressive pulmonary tuberculosis, there is destruction of tissue and consequent loss of body-weight. “In diabetes mellitus, in which sugar is not destroyed in nutrition, but is discharged as a foreign substance in the urine, there is usually a reduction of the general temperature of the body. “In fevers, alcohol, judiciously administered, is useful in supplying matter for consumption in the excessive pro- duction of heat, thereby saving the tissues from destruction and degenerations. Thus administered, it does not increase the pyrexia; it sustains the strength of the patient, and produces no degree of alcoholic intoxication. “In certain cases of pulmonary tuberculosis alcohol is remarkably tolerated, and probably acts in the same way as in fevers. “In pathological conditions, chiefly in acute diseases, Selections. 255 in which alcohol is useful, it acts as a representative of the hydrocarbons, in a form in which it is readily ab- sorbed and oxidized, requiring no preparation by digestion. In this way the hydrocarbons may be introduced when the digestive function is impaired, in a form which may be compared to the condition of peptonized nitrogenized elements of food. A small quantity of alcohol produces a certain degree of nervous excitement; and a consider- able quantity induces, in a more or less marked degree, the well-known phenomena of alcoholic intoxication. These effects are due to the circulation in the blood of actual alcohol; and they continue until the alcohol is either destroyed or eliminated. This is one of the effects of alcohol, which it is seldom, if ever, necessary or de- sirable to produce in the administration of this agent in disease; and it is questionable whether alcohol be ever useful as a beverage, under conditions of perfect health and proper nutrition. “In certain pathological conditions, a moderate and some- times a large quantity of alcohol may be administered without producing any appreciable excitement, much less evidences of alcoholic intoxication. Notwithstanding this, the alcohol has a certain effect, although this effect is quite different from that produced when it excites or intoxicates, and when it exists as alcohol in the circulat- ing fluid. “It is with regard to this second effect of alcohol, unat- tended with what may be called its toxic manifestations, that I propose to present certain physiological and clini- cal reflections, “With regard to the effects first mentioned-alcoholic excitement or intoxication—these are easily recognized and are a sure guide to the administration of alcohol in disease. When these effects are apparent in the slightest degree, alcohol is either contraindicated, or the quantity administered has been too large. “In two cases of diabetes of long standing, now under his care, in which a cure cannot be effected, the object of treatment being to produce a tolerance of the disease, he gave in small doses, a quantity of whisky exactly equal to the weight of sugar discharged daily. In one of the cases, in which he had been able to follow the changes in temperature, the temperature under the tongue was 971° on December 15th, 1886. After taking four ounces of whisky daily, for eight days, the temperature on 256 Selections. December 23d, was 98°. He proposes to employ this treat- ment in other cases in which the glycosuria cannot be arrested, in the hope that the supply of alcohol to com- pensate the discharge of sugar may bring the temperature of the body to the normal standard, and contribute to the tolerance of the disease. “As the alcohol is oxidized in the body, the loss of sugar might be compensated by the introduction of the amount of alcohol which the sugar lost would produce if converted into alcohol in the body. One grain of sugar used in forming carbonic acid and alcohol would produce about one-half grain of alcohol and about one-half grain of carbonic acid (180 weight of sugar=92 alcohol and 88 carbonic acid). For every grain of sugar discharged, give one-half grain of alcohol, or one grain of brancy or whisky containing about fifty per cent. of alcohol. The weight of one fluid ounce of brandy, specific gravity 0.93=446.4 grains, counting one fluid ounce of water as equal to 480 grains." THE NEUROTHERAPY OF EPILEPSY.—Dr. C. L. Dana, in the Quarterly Review, gives the following plans of treat- ment of epilepsy, of different authorities. The zinc treatment of Herpin was as follows: Give gr. ij 1-5 of zinc oxide ter. in die. Increase the dose by gr. three-fourths every week until gr. xj are taken t. i. d. Keep this up at least three months. It appears that Herpin subsequently used to add or alternate with am- monia-sulphate of copper or selinum. . The belladonna treatment of Trousseau : Ext. belladon. fol. 1 Pulv, belladon. fol. . aa gr. 1-6. M. Sig.-One A. M. and P. M. for one month. Then increase the dose by one pill daily each month until twenty pills are taken night and inorning. The treatment must be continued for a year. Grover's method consists in giving the bromides in single doses at intervals of from two to five days, these single doses being gradually increased. Thus the patient takes one drachm on the first day, one and a half drachms on the third day, two drachms on the sixth day, three drachms on the ninth day, four drachms on the fourteenth day, and so on until the maximum dose of about one ounce is reached, when the drug is decreased in the same way. Selections. 257 I have found this a very good method if, during the intervals, tonics and adjuvant measures are employed. The method of Meynert, in many cases, is to give fifteen grains of bromide of potassium three times daily, and increase the dose by fifteen grains every time a fit occurs, until they are suppressed. A mixture treatinent like the following is recommended by Ball and Hanfield Jones : 1. Ammon. bromid. Sodii bromid. . . . aa 3 ijss. Infus. valerianæ . . . 3 x. M. Sig.-3 ij daily, increasing until 3 ijss of the bromides are taken daily. 2. At the same time take a pill: Ext. belladonnæ. . . gr. $. Linci OXiai . . . . grs. 11). M. Sig:-One, morning and night. 3. A drastic purge weekly. An acid mixture for epileptics, which he found efficient in two cases which resisted other forms of medicine, was: Acid. hydrobromic. dil., 10 per cent. 3 j. Atropinæ hydrobrom. . . grs. 1-200. Zinci citrat. . . . .. grs. iv. M. Sig.–Take this t. i. d., and gradually double the dose. A mixture alleged to be very efficient is: Potass. bromid. . . . grs. xv. Sodii arsenit. . . . grs. 1-120. Picrotoxin . . . grs. I-180. M. Gradually increase. PUNCTURE OF THE NERVE SHEATH IN SCIATICA.—Sir Joseph Frayer, M. D., in Practitioner: Some years ago I was asked by a medical man in Calcutta to see a case of aggravated sciatica of long standing in a man of middle age. The pain was very severe, continuous, and liable to in- crease, of a paroxysmal character. The posterior muscles of the thigh were somewhat atrophied; the patient him- self was wasted and worn by continued suffering and deprivation of rest and sleep. There was no history of syphilis, gout, rheumatism, or other specific cause. A malarial origin of course was possible, but as far as I can remember, there was no satisfactory explanation of the origin of the disease. All the usual methods of treatment had been resorted to, but without relief. On examining the 258 Selections. limb more carefully, I detected some feeling of fluctuation ; a fulness and tenderness in the course of the sciatic nerve inear its origin, in the upper part of the limb; I thereon introduced a long narrow knife in to the swelling, until it entered the sheath of the sciatic nerve; this gave exit to a certain quantity—a couple of drachms or so—of clear serous fluid, which was followed by immediate relief, and rapidly resulted in a complete recovery. I have seen other cases, none so well marked as this one, however, and with much less effusion of fluid, where incision, or rather I should say puncture, has given relief; but I am not aware if others have had similar experience, and would call attention to it as of practical interest. It has long been known that acupuncture with needles not in- frequently gives great and permanent relief in some forms of deep-seated pain; indeed it is practiced by some Oriental races for this purpose. I think it possible that its success may sometimes be due to the relief of tension, caused by evacuation of the fluid which has accumulated as a result of inflammation, in large or small nerve-trunks. - New England Medical Monthly. The EFFECT OF LARGE DOSES OF COCAINE UPON THE CENTRAL Nervous System.—Dr. Bey, of Cairo, has had the following experience in the use of cocaine as a means of checking the opium habit. He began with doses of five centigrammes, three or four times daily, but the pa- tient's sensations of relief and stimulation were so pleasurable that he soon established a cocaine habit. He sought relief for each slight ailment in an injection of cocaine, the dose increasing until half a gramme, and even eighttenths of a gramme was taken secretly daily. This produced loss of appetite, great irritability, ringing in the ears, and, from time to time, dyspnea and halluci- nations of sight and hearing. These unpleasant syınptoms the patient had learned to relieve by injections of morphine until he became skilled in the antagonistic use of the drugs. An attack of herpes and its neuralgic pains drove him to double his doses of cocaine until for two or three days he took a gramme, and at times one and a half grammes daily. Then followed a condition very like de- lirium tremens--tremors, lack of tonicity, incontinence of urine, alterations in the nails of the fingers and toes, the greatest agitation, severe hallucinations of sight, hearing and smell, injected conjunctivæ, a staring expression. He Selections. 259 fired a pistol at imaginary objects, attacked his servant, and was finally placed under hospital restraint. Here he soon recovered under morphine injections of five centi- grammes, three times daily. FATAL USE OF COCAINE.—Dr. Knabe, of Berlin, records the case of a girl, aged eleven, who, after a severe attack of scarlatina, suffered from fatty degeneration of the heart. In her case the hypodermic injection of cocaine was rec- ommended, as a tonic, to remedy the frequent fainting fits to which she was subject. Certainly the physician advising such a procedure could have had no idea of the morbid condition underlying these attacks of syncope, nor must he have possessed any knowledge of the physiologi- cal action of cocaine. Four or twelve drops—they were never able to tell the exact dose-of a four per cent. solution of cocaine were injected under the skin over the deltoid muscle of the left arm. Scarcely forty seconds later the girl took a deep breath, became deadly pale in the face, and dropped down unconscious. She never re- covered consciousness, death ensuing a minute later.- [Abstracted from “Something More About Cocaine,” in Medical and Surgical Reporter.] AMMONIA IN ACUTE Alcoholism.—Dr. A. G. Glinsky (Russ. Med.) injects a mixture of liquor ammon. with from two to six parts of water hypodermically into the epi- gastric or dorsal region. He gives a case where the patient was in a seemingly hopeless comatose state, but recovered full consciousness in three minutes after the injection.-Med. Abst. PSYCHOTHERAPY. HYGIENIC TREATMENT OF THE INSANE.—Dr. J. B. Andrews, superintendent and physician for the Buffalo, N. Y. Asylum for the Insane for 1886, makes the following remarks on this subject: “It is impossible to separate occupation from the hygienic treatment of patients, nor would we make the attempt, as this, in fact, constitutes a large share of it. Most of the occupation provided is simply exercise and not labor. When a party of men is sent out to rake the lawn, or hoe in the garden, or to assist in other kinds of farm work, they are deriving more 260 Selections. benefit, if the degree and period of occupation is propor- tioned to the physical strength of the individual, than if they walked out or sat under the trees, idly contemplating their state and position, for in doing this, they render themselves discontented and unhappy. In fact, few, even of the sane, can occupy their whole time in self-contem- plation and be either satisfied or contented. “The divine command, ‘In the sweat of thy face shalt thou eat bread,' is without exception as true to-day as when first uttered. This must be modified according to the health and power of the individual, and this distinction is in part recognized in the substitution of 'occupation' for 'labor.' “Let the amount and kind of occupation be properly and judiciously regulated, and the highest good is attained in the application of the principle. “This fact is coming to be more fully recognized, and greater efforts are being made in asylums to increase the scope and variety of both mental and physical occupations and employments for the insane. This is progress in the right direction. “Hygienic treatment further consists in enforcing cor- rect rules of living. These relate to regularity in rising and retiring, taking meals, bathing, cleanliness of rooms and persons, the provision for a proper dietary, for a full supply of light, heat, air and water, and for the removal of sewage without contaminating the air of the living apartments. In the asylums of the present, all these par- ticulars demand and receive the closest attention. It is evident that in the proportion that these conditions for health are met, in exact ratio will be the value of the hygienic treatment of patients. “In this asylum, both in its erection and subsequent changes and improvements, as well as in the administra- tion, the effort is made to give all these factors due con- sideration and attention. “The supply of water is ample, the heating is uniform and of the proper temperature, the wards and rooms are flooded with light, and the ventilation is such that all of the air capacity of the ward buildings can be changed every twenty minutes, while the air space allowed each patient is about 4,000 cubic feet. “ The drainage and sewerage of the buildings are good, the dietary is arranged with reference to affording the proper variety and amount of nutritive material, while cleanliness and regularity of life are enforced. Selections. 261 “All things conduce to healthfulness and comfort to a degree to which life in an ordinary household bears no comparison. “In attention to these details, this asylum is not an exception. The general freedom from acute forms of dis- ease, which have their origin in neglect of hygienic law, and the small death rate annually of the insane in public institutions, point to the success attained in establishing conditions favorable to health. “The same fact is also shown in the prolonged life of the insane, an appreciable factor in the present large number of this dependent class.”—Assem. Doc. No. 10. it hada king, theny grains was made VALUE OF URETHAN AS A HYPNOTIC.-We make the following extracts from Dr. J. B. Andrews' report: “The first experiment was made on the 8th of May, when I took thirty grains of urethan at three P. M. Be- fore taking, the pulse stood at eighty, in fifteen minutes it had fallen to seventy; and at forty minutes was sub- stantially the same. I fell asleep while sitting in my chair about half an hour after taking the medicine. The sleep was natural without any unpleasant sensations, without disturbance of respiration or the pupils of the eye. It was not prolonged, but was interrupted by the taking of a sphygmographic trace. After this interruption no further opportunity was given for sleep as I got up and walked about. “On May 14th a second experiment was made. I took fifty grains of urethan at 8:25 P. M. The pulse be- fore taking stood at eighty-eight. In fifteen minutes the pulse was reduced to eighty-two, and in an hour after taking, to eighty. At nine o'clock, thirty-five minutes after taking the drug, I fell asleep. At 9:20 tracing was taken; at 9:35 I was awakened by a report from the night watch regarding patients which demanded my at- tention. This aroused me so fully that I did not sleep again. The character of the sleep and the effects of the drug were the same as before reported. “On May 27th the third experiment was made. I took sixty grains of urethan at ten minutes past nine P. M. Pulse before taking stood at eighty-six, in ten minutes it had fallen to eighty-four, in forty minutes to seventy-two, and in fifty minutes to seventy. A tracing was taken ten minutes after taking the medicine, another forty minutes 262 Selections. after, and another fifty minutes after. At 9:35, twenty minutes after taking the medicine, I fell asleep. At 9:45 sleep was profound, respiration seventeen. At ten P. M. I still slept, respiration sixteen. After this I was awakened, and though feeling profoundly sleepy, I did not yield further to the sensation. Retired at eleven o'clock and slept soundly all night, as usual. "In all these experiments the sleep seemed to be of a strictly physiological character. Its approach was normal, and on awakening there was no headache nor any other feeling than that of having been aroused from pleasant sleep. There was no subsequent disturbance of the stomach of any kind, and, in fact, nothing to distinguish it from a pleasant period of repose. “The drug was taken simply dissolved in water and no attempt was made to cover it. The taste is not unpleasant, resembling in a mild degree that of spirits of nitre. “For administration it can readily be covered by any of the ordinary excipients. In regard to the tracings taken, I was unable to make out any marked effect upon the character of the pulse, except a reduction in the number of the beats, hence these are not presented. “On analyzing the cases of which notes were taken we find that there were nine of women and nine of men. Di- vided as to forms of insanity, acute mania, six; paresis, four; melancholia, four; chronic mania, two; dementia, two. “The dose most commonly given was thirty grains. In two instances, however, it was carried to the extent of sixty grains. This was ventured upon after my personal experience with the same dose. “So far the results have been quite favorable, and show that urethan has marked hypnotic power. There were in no case any unpleasant results of any kind. There is nothing to indicate any further action than upon the cere- brum. The effects of the drug were felt, so far as we are able to judge, within an hour after its administration, and the sleep lasted in most cases from the time of observation, commencing at ten o'clock, until five o'clock in the morning. "We do not consider these experiments sufficient to enable us to speak positively of the effects of the drug, or to give it its true position as a sleep-producing agent. This can be done only after it has been used a long time and in large quantities. They are, however, such as Selections. 263 to lead us to recommend its trial in cases where other drugs are contraindicated, either from the pathological state present, the unpleasantness of the dose, or the peculiar idiosyncracy of the patient. "It may do well in private practice, where there is a demand for a variety of hypnotic drugs, and I would commend it for careful consideration and further use. “We have used in all something over five ounces of urethan. This, upon an average of thirty grains to a dose, which is probably very nearly correct, would give eighty doses as having been administered. “Equally good results followed in cases which have not been reported as in those which are referred to in this paper.”—Report of Buffalo Insane Asylum for 1886. NEUROPATHOLOGY. PERIPHERAL NEURITIS.—A very interesting contribution to our knowledge of peripheral neuritis in tabetic patients is found in the Revue de Medecine, No. 7, July roth, 1886, by Pitres and Vaillard. The conclusions of their memoir may be summed up as follows: 1. The peripheral nerves of tabetic patients are often the seat of neuritis. 2. The neuritis of tabetic patients does not differ in any essential respect from other forms of the non-traumatic affection. 3. Their topographical distribution in the body is variable, for the neuritis may attack the sensitive and mixed nerves and the visceral. 4. In the majority of cases, but not always, the disease begins at the outer extremity of the nerve. 5. Their extent and gravity have no constant relation in respect to age, or the extension or depth of the medul- lary regions of the locomotor ataxia. 6. It is probable they do not play any part in the pro- duction of the specific symptoms of tabes; such as the lightning pain, incoördination of movements, abolition of patellar reflex, disorders of the muscular sense, etc. These latter symptoms depend rather upon the condition of the posterior columns of the cord. 7. Certain inconstant symptoms, however, which are added to or complicate the symptomatology of tabes, appear to depend upon the peripheral neuritis; such, for 264 Selections. example, as anæsthetic spots in the skin, localized trophic disease of the skin and its dependencies, certain localized motor paralyses, accompanied or not by muscular atrophy, isolated joint affections, visceral crises, etc.— The Neurolog- ical Review. ble with ent he rehemiplegia her att URÆMIA AND APOPLEXY.-C. W. Suckling, M. D. (Brit. Med. Jour., Dec. 4), gives the case of a man of forty, with right hemiplegia and without convulsions. Pulse was of high tension, heart considerably hypertrophied, and there was a trace of albumen in the urine. “All these symp- toms were compatible with the diagnosis of cerebral hem- orrhage. To my astonishment he recovered consciousness immediately after being bled, the hemiplegia passing off in a few hours." The patient had five other attacks, which were always preceded by delirium, restlessness, violent convulsion of right side of face, right leg and arm, and conjugate deviation of eyes to right, giving place to hemiplegia, the eyes then being turned to the left. Each attack was cured by a small bleeding. The urine was free for days from albumen, although it was frequently tested. Another case is given in which tem- perature was sub-normal, and he records another case with sub-normal temperature, and concludes “when in doubt whether the case is one of uræmia or apoplexy— bleed!" THE EPILEPTOGENIC ZONE.-In connection with an ar- ticle on “Epileptic Brains" which occurred in the Review two weeks ago, page 205, which pointed out some ana- tomical peculiarities noted by Dr. Dercum, we may men- tion a very interesting pathological study made by M. Zohrab, of a number of epileptic brains : In all the brains examined there were necrosed, softened spots beneath or around the posterior horn of the lateral ventricle. From this fact he concludes that there is a certain number of cases of epilepsy, either essential or secondary, accom- panied by softening of the region beneath that point, and that in these cases the clonic convulsions were in proportion to the extent of the lesion, and are more marked on the side opposite the hemisphere affected. He concludes also that in this region of the brain we may be allowed to assume the presence of an epileptogenic zone. - [Dr. B. J. Primm. Report on “Progress " Weekly Medical Review.] Selections. 265 DIABETES AND TABES.—MM. Pierre Marie and Georges Guinon (Rev. de Méd.) have found the knee-jerk absent in three cases of diabetes; and some cases of dia- betes approach so near some forms of tabes as to be distinguished only by the excretion of sugar. A case might be one of tabes or diabetes, with complete loss of knee-jerk, lightning pains, unsteadiness with the eyes shut, etc. The presence of sugar in the urine would, however, determine the diagnosis, as the writers have not found sugar in the urine of any case of tabes at the Salpêtrière. M. Jendràssik says the knee-jerk can be revived in cases of neurasthenia and diabetes, where it has sunk to almost nothing, by making the patient attempt a muscular effort with his body and arms while the knee-reflex is under examination.- New York Medical Abstract. NEUROPHYSIOLOGY. RESEARCHES RESPECTING THE AXIAL NERVOUS CURRENT. -At a recent meeting of the Académie des Sciences, M. Marey read a physiological communication from M. Men- delssohn, who had proved that the electro-motor power of the axial current of a nerve-fragment increases with the length of that fragment, though not proportionally with it. If the trunk of the nerve be gradually shortened, it is seen that the direction of the axial current ceases after a certain limit to conform to the rule which the author had already mentioned, viz., that the direction of the axial nervous current is always in opposition to the direction or course of the physiological function of the nerve. The electro-motor power of the axial current in- creases with the area of the transverse section of the nerve. This correlation disappears when two different nerves are compared in the same animal or analogous nerves belonging to animals of different species. The electro-motor force of the axial current decreases with the exhaustion of the nerve which is induced by prolonged tetanization. This exhaustion may even completely de- stroy the axial current. Desiccation of the nerve, and especially of its sectional surface, rapidly lowers the electro-motor force of the axial current. All these facts show that this current possesses essentially the same physical and physiological properties that M. Dubois- Reymond has described as existing in other nervous cur- rents.— Philadelphia Medical Times. 266 Selections. NEUROSEMIOLOGY. TOBACCO ASTHMA.—Russo Gilberti reported to the Società d'Igiene numerous cases of functional disorders. caused by tobacco, among which is the following: A young man twenty-four years of age, well developed and nourished, but of an erethistic temperament and a here- ditary tendency to convulsions, was seized with severe attacks of asthma which he attributed to smoking. His physician advised him to discontinue the use of tobacco and avoid rooms where there was tobacco smoke, and for more than a year he has not had the slightest attack of asthma. This case confirms the opinion of Peter, who considers. tobacco a true poison to the pneumogastric, and may, even in small doses, injure those who are especially susceptible to its influence (Le Sperimentale).—Buffalo Medical and Surgical Journal. NEURO-ANATOMY. THE CIRCULATION OF THE BLOOD OF THE GANGLIONIC CELLS.—Prof. Albert Adamkiewicz has made a searching examination of the blood supply of the ganglia, his ex- periments being confined more particularly to the inter- vertebral ganglia connected with the cords forming the brachial plexus. The vessels supplying these ganglia were injected with carmine through the spinal arteries, with the result of showing that each cell is supplied with blood by means of a separate arterial loop, so disposed as to invest the ganglionic cell, which is thus bathed in the arterial blood, much as the placental tufts are bathed by the blood in the maternal sinuses. The cell itself, niore- over, is said to contain very minute ramifications or pas- sages from the circumference to the center, through which serum alone can penetrate.--[Dr. B. J. Primm. Weekly Medical Review.] EDITORIAL. [All Unsigned Editorials are written by the Editor.] New Forms and Symptomatic Phases of In- sanity.-Within the domain of psychological research there appear, sometimes, morbid and rational psychical phenomena so aggregated in an individual as not to con- form to our preconceptions of any typical form of mental disease, yet presenting such blended features of rational and irrational conduct as to impress the mind of the discerning and unbiased alienist as incompatible with a perfectly sane state of mind. Cases like that of the Pocassett letter-carrier, Freeman, the “Second Adventist" fanatic who, though a kind and temperate father, discharging his daily duty and exciting no suspicion of insanity, in a moment of religious fervor and folly, deliberately drives a dagger into his little child's heart, under the mistaken belief that his hand, as was Abraham's of old, would be stayed, because of his faith, and who still believed that God would restore the life of his child long after its little heart had ceased to beat. Though the insanity of Freeman was neither discernible nor suspected in the community in which he lived and daily labored up to the time of the commission of the awful crime, he was found, on his trial, to have been insane, and sent to an asylum in New Jersey. Cases similar in character but not precisely like that of Bernard Cangley and Michael Trimbur, reported by Dr. Ray, those sudden outbreaks of latent mental disease described by Jarvis, or the aberrations of the moral faculties first described by Prichard, and the obscure displays of epilep-- sia and the unclassified monomanias, now and then appear to excite anew our wonder at the deep mysteri- ous ways of mind unhinged, and stimulate our curiosity to psychically fathom its singular workings. Thus mania without delirium before Pinel, and paretic insanity before Arnold and Bayle, were non-existent as insanity in the professional mind, and primaire verrückt- heit went unrecognized till demonstrated by that scien- tific interest which prompts the student of anatomy and. [ 267 ] 268 Editorial. pathology to make unwearied search when apparent or- ganic anomalies are within possible reach of his knife, and throws about a new phase of mental derangement a fas- cination that charms to indefatigable study, even though the unfortunate victim be destined for the gallows. For it is from their study as from new phases of physical dis- order that, if we investigate them aright, may be gained the most knowledge. “Their existence, however infre- quent, must necessarily modify the conclusions that might be drawn from the more common forms of mental disease,” said the great Ray. Psychiatry is not a completed science, and the wise man therein will hear and will increase learning. The laws of aberrant mental display are not yet all definitely established. Irrevocable rules of action, for minds diseased have not been unalterably determined. As many exceptional phases yet undescribed of insanity probably still remain to be described and named by the observant student of psychiatry as were unnamed a few years ago, before the profession became familiar with inanie sans délire, manie raisonante, moral and emotional insanity, manie transitoria, general paralysis, folie circulaire and certain of the partial insanities. Predicating the statement upon what thus far has been revealed to us of the varied displays of deranged mind, it would be as unreasonable to limit our compre- hension of diseases in which mind is involved, to forms embraced within our present nomenclature, as to ignore the existence of new diseases revealed in derangement of other functions of other organs than the brain, because we cannot precisely name them. New diseases and new forms of old disease appear before they are categoried. We cannot have a nomenclature ready made, in which to include every new form of mental disease. Hypnolepsy vs. Narcolepsy.-Dr. Arthur Wynn Foot, in a recent article in the Dublin Journal of Medical Science, describes a case and suggests the term “hyp- nolepsy” for the narcolepsy of M. Gélineau, which, by the way, was described by Graves, as Wynn makes note, under the familiar term “lethargy." He thinks “hypnolepsy” would be a more expressive term. In narcolepsy the word vapkn means a becoming stiff-numbness, deadness, such as would be caused by palsy, frost, fright-and can only indirectly have the secondary meaning of quiescence from sleep, whereas Editorial. 269 the word invos conveys only the idea of ordinary sleep. Wynn regards hypnolepsy as quite a different affection from the sleeping sickness (maladie du sommeil) of the tropics, and which is almost endemic on the western coast of Africa; for this latter is almost invariably fatal, exclu- sively attacks the black population, and is usually asso- ciated with glandular swellings in the neck; "and from epilepsy, to which at first sight it may seem to be related, This remarkable points of differen's it has remarkable points of difference, in there being neither tonic spasms nor clonic movements, in the preser- vation of common sensation, and in the consciousness, to a certain degree, of what is going on around. It is also noteworthy, in reference to this point, that neither picro- toxin nor the inhalation of nitrite of amyl has proved of any more service in this affection than has caffein." But a malarial epileptoid neurosis might possess all these features. Graves' case of hypnolepsy is introduced in the same article by Dr. Wynn in the following words: Under the heading“ Lethargy,” Dr. Graves describes a case of this affec- tion which is not included in the fourteen cager M. Gélineau bas been able to collect. Dr. Graves writes : "I know a gentleman advanced in life and of plethoric habit, who has been for several years affected with letbar- gic symptoms, but without any headache, tendency to paralysis, or impair- ment of his general mental energies. He is frequently attacked, however, even at his meals, with unconquerable sleepiness, and it is surprising bow suddenly it comes on. Thus he will be sitting, talking quite cheerfully, and unexpectedly he drops into a sleep, which lasts for about half a minute or a minute, and then be rouses himself and continues awake for a few min- utes longer. This happens 80 often that he cannot venture to go into company. At one meal he has broken three or four glasses by becoming unconscious wbile raising them to his mouth. He was consequently obliged to bave an attendant to watch bim going to bed, lest he might fall asleep and endanger the house by allowing the candle to fall." Narcolepsy, or hypnolepsy, therefore, is another “Graves' disease.' Legal Inconsistency in Regard to Inebriates and Inebriety.-The Journal of Inebriety contains the following suggestive record of the law's inconsistency on the subject of inebriety, and injustice to the inebriate: In a Western city an inebriate was on trial for manslaughter; the de- fence was insanity from alcohol. After a long trial, and deliberation of two days, the jury brought in a verdict of guilty. A new trial was granted, on the grounds that two of the jury were so much intoxicited as not to be 270 Editorial. able to decide on the verdict. It was alleged that all the jury drank, and bad several free tights in the jury-room. At the close of the second trial, one of the jury bad an attack of delirium tremens, and rushed for the judge to whip him. In the third trial, the jury brought in a verdict of guilty, but not responsible. This was not accepted : then they disagreed. The ca-e was then taken into another court, where the plea of guilty was made, and the judge sentenced him for life, with a heavy fine. The law here grants a mistrial for inebriety among the jurors, but sees no extenuating circumstance in the alcoholic insanity of the accused. The drunken jurors were probably given the stereotyped instruction that “ drunkenness is no excuse for crime,” as it was probably no excuse for the judge who gave it, who, the record says, was so intoxicated when he sentenced the prisoner, that a new trial was asked for on that ground. The law cannot make men responsible, who are physically and mentally incapable of responsibility. It may assume a degree of previous responsibility for drunk- enness and self-induced insanity, but law must be wiser far than science, when it can discern full responsibility in the acts of the liquor-maddened inebriate. The man who, on crime intent, gets drunk, and perpe- trates a premeditated crime while under the influence of liquor imbibed for the purpose, is a very different sort of criminal from the helpless periodical dipsomaniac who, automatically (unconsciously often), and without previous preparation or premeditation, violates the law he always respected when sober. The question of inebriety and crime before the courts is a study for experts. It is a ques- tion of scientific fact, hard enough sometimes for the most experienced expert to consider and judge justly, and should never be one of sentiment or of simple public safety. There are inore ways of saving the people from the crimes of inebriates than by hanging them, and instructing juries that drunkenness without exception is no excuse for crime. That all men who commit crime under the influence of liquor are not irresponsibly drunk is most true, nor are the majority of them perhaps, but there are a large num- ber whose execution is as much judicial murder as the hanging of the veriest maniac, and psychological science has reached a point where the courts would be justified in inquiring of its experts, as to the real mental states as to responsibility of inebriates arraigned for crime against the State. The commissio de ebrietatis inquirendo should become a lawful procedure as much so as Editorial. 271 de lunatico inquirendo, and we hope this century, which has been characterized by so much legal progress in the direction of science and true charity, will not close before this is a fact accomplished in the jurisprudence of crime, else municipal law need no longer be defined to be a "rule of action commanding what is right and prohibit- ing what is wrong." The Coming International Medical Congress at Washington.-In September, will assemble at Wash- ington, through invitations extended from this country, representative medical men from all parts of the world, whom Americans, in common with all other medical scien- tists the world over, delight to honor. This most worthy cosmopolitan assembly will be our guests. They have been invited to come by members of our professional household, to share our hospitality. It does not now matter how they came to be invited, or whether we like the men who invited them, or the man- ner in which they were invited; we only know now they have been invited, and we shall like our guests and make them cordially welcome. They shall be received with open hearts and homes and hospitable hands. They have been bidden to come, and they will be entertained. The latch-string of our American homes hangs out as it has done since the days of the pioneers; Americans do not know how to be inhospitable to their friends. We may, after they are gone, fight out the little unpleas- antness (if it be not forgotten in the united effort we shall make to make our guests feel at home with us), but we are not fighting now; so far as providing for our guests is con- cerned, and wishing them to come, “this cruel war is over.” Come, medical men of the old world—the new world bids you come! Never mind the little “racket” in the kitchen; you will find all serene in the parlor, and not much of a row down stairs either. Americans have a happy faculty of settling little unpleasantnesses; witness the late war. They can wrangle violently, but they can join hands heartily, and we'll all be in Washington to re- ceive you. There will be no family quarrel when you get here. The vintage is ripe and the wine-press is ready, and when you come, brethren over the water, “we'll crush the grape and clink the glass,” to days of happy memory, and to your health and the future glory of our common profession the world over. 272 Editorial. Faith-Cure Folly.-From an article in The Century for March, on faith-cure, by the Rev. Dr. Buckley, we quote as follows: Families have been broken up by the doctrine taught in some of the leading faith-homes, that friends who do not believe this truth are to be separated from because of the weakening effect of their disbelief upon faith, and a most heartrending letter bas reached me from a gentleman whose mother and sister are now residing in a faith institution not far from this city, refusing all intercourse with their friends, and neglecting the most obvious duties of life. Certain advocates of faith-healing and faith-homes have influenced women to leave their husbands and parents and reside in the homes, and bave persuaded them to give thousands of dollars for their purposes, on the ground that “the Lord had need of the money." This system is connected with every other superstition. The Bible is used as a book of magic. Many open it at random, expecting to be guided by the first passage that they see, as Peter was told to open the mouth of the first fish that came up and he would find in it a piece of money. A missionary of high standing with whom I am acquainted was cured of this form of superstition by consulting the Bible on an important matter of Christian duty, and the passage that met his gaze was, “ Hell from beneath is moved to meet thee at thy coming." Paganism can pro- duce nothing more superstitious than this, though many other Christians, instead of "searching the Scriptures,” still try to use the Bible as a divin- ing rod. It feeds upon impressions, makes great use of dreams and signs and statements foreign to truth and perpicious in their intluence. A young lady, long ill, was visited by a minister who prayed with her, and in great joy arose from his knees and said, “Jennie, you are sure to recover. Dis- miss all fear. The Lord has revealed it to me.” Soon after, physicians in consultation decided that she had cancer of the stomach, of which she subsequently died. The person who had received the impression that she would recover, when met by the pastor of the family, said, “ Jennie will certainly get well. The Lord will raise her up. He has revealed it to me." "Well," said the minister, “sbe has not the nervous disease she had some years ago. The physicians have decided that she has cancer in the stomach.” “Oh, well,” was the reply, “if that is the case, she is sure to die." A family living in the city of St. Louis had a daughter who was very ill. The members of this family were well acquainted with one of the leading advocates of faith-healing in the East, who made her case a sub- ject of prayer, and wrote her a letter declaring that she would certainly be cured, and the Lord had revealed it to him. The letter arrived in St. Louis one day after her death. These are cases taken, not from the operations of recognized fanatics, but from those of leading lights in this ignis fatuus movement. It is a means of obtaining money under false pretences. Some who promulgate these views are honest, but underneath their proceedings runs Editorial. 273 a subtle sophistry. They establish institutions which they call faith- homes, declaring that they are supported entirely by faith, and that they use no means to make their work known or to persuade persons to con- tribute. Meanwhile they advertise their work and institutions in every possible way, publishing reports in which, though in many instances wanting in business accuracy, they exbibit the most cunning wisdom of the children of this world. * * * The horrible mixture of superstition and blasphemy to which these views frequently lead is not known to all persons. I quote from a paper published in Newark, N. J., in the interest of faith-healing: “ DEATH.-Three of the richest men in Ocean Park, N. J., have died. Faith-bealing has been taught in the place, but was rejected by them, so death came. “ CHARLESTON, S. C.-A few years ago the Holy Ghost sent me to preach in that city, but tbey rejected the gospel and me. A wicked man shot ar me and tried to kill me, but God saved me so that I was not barmed. * * * But I had to leave Charleston and do as the great Head of the Church said, * * * when ye depart out of that house or city, shake off the dust from your feet.' Earthquake, Sep- tember 1, 1886, one-half the city in ruins. It bas a population of about fifty thousand people. Ye wicked cities in the world, take warning! God lives!" Lack of Interest in Neurology by the General Profession.-The Neurological Review thus expresses its convictions on this subject, which in great measure we endorse, though professional apathy on this subject is disappearing, as the increasing circulation of THE ALIENIST AND NEUROLOGIST among general practitioners convinces us: We are willing to run the risk of being misunderstood in calling attention to tbe astonishing apathy that exists as a whole, in regard to the importance of a knowledge of the nervous system in the daily work of every member of the profession, from the practitioner in the remotest backwoods to the specialists, and even the highest grades of practitioners in our larger cities. We are not mistaken when we declare that, by forty- nine out of fifty members of the profession, take them as we find them, the nervous system is to a greater or less extent looked upon as a part of the human body with which they have in their professional studies or duties but little to do. It is confessed to be, of course, an intricate part of the body, a better knowledge of which, it is not for a moment disputed, would be beneficial to practitioners in medicine and surgery, but, upon the whole, as chiefly falling, in its practical relations, within the working limits of a rather small band of specialists in the profession; or it is mis- takenly regarded as so intricate and difficult as to render its fruitful study a practical impossibility to the “busy practitioner.” It seems to be not regarded as a fact, as it is, that the nervous system is the most elevated of all the systems of organs composing the animal 274 Editorial. .body: that in man, in particular, it penetrates to every part of the living body, unless we except a few comparatively unimportant structures; that there are but few blood-vessels, * * * tbat there is not a mus- cle; not an active portion of any of the membranes, either outside or inside of the body; that there is not a secreting gland, however small or large; that there is not an organ of sense; not a single viscus, whether pelvic, abdominal or thoracic,—which is not interpenetrated by and more or less completely under the control of, the nervous system, whether in health or in disease; that, as a rule, without the intervention of the nervous system, no marked changes can occur in the rate or force of the heart's action, or in the tonicity of the muscular arteries, and hence, no pulse changes, as a rule; no rise or fall of temperatures; no changes in rate of action of glands, or of muscles, or of the varied forms of sensibility, from the most general to the most special, not to speak of that most exalted of all classes of animal functions, comprised under the head of mind and mental operations, and of which the brain is the cbief organic seat, not to extend the list farther, nor to analyze and carry out into their all but innumerable ramifications, the func- tions of the nervous system. We say it seeins, either never to have occurred to the mass of the profession how important and wide-spreading, from both anatomical and physiological stand-points, the nervous system is, particularly in man when in abnormal states, or, how curious it is, that with singular inanimity they have permitted their earlier impressions to fade away. We have taken the pains to collect and look through nearly all of the prominent text-books on practical medicine, published as written by home authors in this country, or that have been republished from foreign sources; and we feel obliged, in candur, to declare that few of them show anything like an adequate knowledge of the anatomy, physi- ology and pathology of the nervous system, on the part of their authors, as it really existed at the times when the books where written, not to speak of the glaring errors in respect to those topics, that to no inconsid- erable extent prevail in the meager sections in them devoted to diseases of the nervous system. (Strümpel's new book being the most and only signal exception-ED). These feelings are by no means recent in origin. Neither the writers of text-books, as a rule, nor the teachers in our col- leges, nor the mass of physicians themselves, after graduating, and after reading the latest text-books, and, finally, after reading one or more of those pamphlet or vest-pocket condensations of medical science, prepared especially for the “busy practitioner," seem to be aware of the importance of a better knowledge of the nervous system itself.- Neurological Review. Hysteria in its True Light.--In his report on Medicine in the Weekly Medical Review, Dr. R. M. King, of St. Louis, thus refers to this subject : HYSTERIA IN A New Light.— According to the Lancet, September 4, 1886 (Med. Record), the views of Mr. de Berdt Hoveli on the subject of hys- teria are to be carefully received as those of a shrewd practitioner of long practice and large experience. He strongly protests against the whole by. pothesis of hysteria. He thinks the theory that localizes the disease in the Editorial. 275 uterus is the mere survival of medical demonology, which located ill- humor in the spleen, blue devils in the liver, and the soul in the pineal gland. He claims for bysterical patients more fairness of treatment and more discrimination. He attributes many of the cases to shocks, physical or moral, leading to deficient or depressed nerve-power, with all that tbis implies in the way of pain, irritability, inability for locomotion, etc. Mr. Hovell admits that the cases are difficult to cure; but be maintains that it we are to deal with them effectually we must" set aside all considerations of the organs of reproduction, which probably are not concerned, and transfer our attention to the moral nature." Mr. Hovell gives several cases in wbich there was a distinct history of shock or exhaustive work, to ex- plain the break-down in the nervous system. We live in days when the nervous system is getting its full share of attention from pathologists and physicians, and when even gynæcologists are finding out that the uterus, and even its appendages, which are now blamed by some for everything, are not such culprits as bas been supposed. Mr. Hovell will admit that the cases of so-called hysteria do occur chiefly, though by no means exclusively, in women. In their organization there is something specially favoring the occurrence of this state or diseasc. It may not be in the spe- cial organs of the female as much as in the special organization of the nervous system. Mr. Hovell deserves credit for insisting on this point, and he may well be satisfied to know that the drift of opinion among phy- sicians is toward the acceptance of his views. Women are more finely struny than men. They are more liable to pain or pains of all sorts from mere functional ciuses. Such a constitution is perplexing to the physician, but it bas to be considered, and not treated as a sort of crime, as has too often been the case. These views are correct, and show signs of progress outside the domain of neurology, though they have long been familiar to and accepted by neurologists. This is only a new-light view to the profession at large, which has been too long dominated by the narrow doctrines concerning women, of the hysterologists, who call them- selves gynæcologists, and who monopolize the whole do- main of disease affecting women. An enlightened and broader-visioned gynæcology, embracing physicians and not mere hysterologists, sees disease affecting women in a broader and clearer light, and it is not a new light to the more enlightened and skillful in the nature and man- agement of disease as it affects women. The Peoria Medical Monthly says: “If our gen- eral physicians would make neurology a more important branch of their study, our insane asylums would not be so overcrowded as they are," and we add, read the ALIEN- IST AND NEUROLOGIST regularly. They might then send some cases to the asylums that they now keep too long 276 Editorial. at home, fruitlessly treating them in the face of adverse environments, that make, in many cases, home cure im- possible. They might also be less confident of the existence of sanity, when skillful experts find plenty of mental aberration in certain obscure but grave states of mind, when the whole character and conduct is changed by morbid states of feeling, antipathy and suspicion with- out marked delusion. In psychiatry "a little learning is a dangerous thing” to the true welfare of the insane sometimes, and medical conceit without practical knowledge, freely expressed on the witness stand with reference to the sanity or insanity of prisoners on trial, by physicians who draw upon their inner consciousness, in lieu of the experienced observation which they lack, for types of mental aberration, is some- times fatal to the best interests of science and humanity. Dr. Shakespeare's Opinion of Ferran,-This JOURNAL did not join in the fraternal cry, “Cruciſy: him!” made against the Spanish Pasteur, and takes pleasure in recording the testimony of a most competent and credible American witness in Ferran's behalf. Dr. Shakespeare testifies that he found Ferran to be a cul- tured gentlemen and a skillful bacteriologist. In his labor- atory, he found as handsomely mounted and stained specimens, and as pure cultures of the comma bacillus as could be found anywhere in Europe, and Shakespeare exhibited some of them at his recent lecture before the Philadelphia College of Physicians and Surgeons, which was so meagerly attended by the profession. With regard to the result of Ferran's inoculations, Dr. Shakespeare demonstrated by the official returns made by the government officers, who are not friendly to Fer- ran, that there was a sudden and marked reduction in the number of cases and in the mortality in several villages after the inoculations were begun,-this measure apparently having about six times the value of ordinary hygienic precautions in checking the epidemic. The Sixth German Medical Congress (Congress für innere Medicin), will be held in Wiesbaden, on the 13th, 14th, 15th, and 16th of April, under the presidency of Dr. Leyden, of Berlin. Dr. Dettweiler, of Falkenstein, and Dr. Penzoldt, of Erlangen, will report on “The Treat- ment of Phthisis”; Dr. Nothnagel, of Vienna, and Dr. Editorial. 277 Naunyn, of Königsberg, on “The Localization of Brain Diseases"; and Dr. A. Vogel, of Munich, and Dr. Ha- genbach, of Basel, on “The Pathology and Treatment of Whooping cough.” In addition, the following papers are announced: “Pernicious Anæmia,” by Dr. Lichtheim, of Berne; “ The Pathological Anatomy of Tabes Dorsalis," by Dr. Rindfleisch, of Würzburg; “Experimental Epi- lepsy," by Dr. Unverricht, of Jena; and “The Physiolog- ical Significance of Wandering Leucocytes proceeding from the Tonsils and the Sebaceous Glands of the Tongue," "Chyluria,” and “A Respiratory Chair for Emphysema- tous and Asthmatic Subjects,” by Dr. Rossbach, of Jena. The secretary of the Congress is Dr. Emil Pfeiffer, of Wiesbaden. of theo this arthrope that_not to a lot 66 Treatment of the Insane by the Turkish Bath."-We give place to this article to call renewed attention to the subject and with the hope that it may call forth other communications on the subject—not to en- dorse, in their entirety, Dr. Shepard's view of the value of the bath, or his limited view of the pathology of in- sanity. The author talks too much like the proprietor of a Turkish bath and too little like a broad-minded and widely-experienced alienist or even a great pathologist, when he says that through the Turkish bath we have complete command over organic disease. There is much more in insanity than can be found in states of blood or localized blood congestion to be relieved by free sweating; nevertheless, the Turkish bath is a valuable auxiliary when judiciously used in the treat- ment of many conditions of body associated with insanity, and has been used and still is used to this end in some American asylums. Commendation of the Alienist and Neurolo- gist.“ The ALIENIST AND NEUROLOGIST, conducted by Dr. Hughes, gives no Bign of relaxing in its efforts to stimulate a more lively interest in the neurological department of medicine, and in collecting and diffusing sound knowledge. * * * * * * * * * * * * Special credit is due Dr. Hughes for the manly and courageous stand he has maintained in his endeavors to support his journal. Anything that we can properly say or do, will not be omiited, to aid unselfishly all efforts, that must be largely self-sacrificing, to elevate and broaden the spirit of the profession, and to place before it more correct and fruitful 278 Editorial. views, that have as their end the alleviation of human sufferings.- Neuro- logical Review. It gives us pleasure to receive commendation of our work and mission from so worthy and discriminating a source, and we heartily reciprocate this good opinion, and apply it to Dr. Jewell's new journal, the Neurological Review, whose untimely suspenson will be felt as a great loss to the neurological world. Wood's “Nervous Diseases ” and Strumpel's “Practice.”—A Canadian contemporary, the Medical and Surgical Journal of that province, makes the following com- plimentary mention of the above-named new books, which we place with pleasure before our readers: Of recent books, Professor Strümpel's “Practice,” edited by Dr. George Shattuck, of Bosto:, will give to English readers one of the best of German text-books by one of the rising clinicians of Europe. Dr. Strümpel was assistant to Wunderlich and to Wagner in Leipsic, and now holds the cbair of medicine at Erlangen. On diseases of the nervous sys- tem the work is exceptionally good. D. H. C. Wood's “ Nervous Diseases and their Diagnosis" is a very successful attempt to deal systematically with “the pbenomena produced by diseases of the nervous system, with especial reference to the recogni. tion of their causes." Malgaigne's Ear Cautery for Sciatica.–One of our contemporaries makes the statement which has never hitherto come under our observation, that in the treat- ment of sciatica, Malgaigne applied the actual cautery “to the external ear at the anterior part of the helix at its entrance into the concha," and quotes Erb as having said of this procedure: “Our ignorance of its mode of action is no reason why it should be held up to ridicule ;" and he might have added, " or be neglected.” We should be pleased to learn from the readers of the ALIENIST if they have any experience with or explanation of this singu- lar surgical remedy for sciatica. The Neurological Review.-The vigorous and valuable triple number of the Neurological Revietu before us, filled with such choice original and selected matter, and such terse and timely editorials, on topics in psychi- atry and neurology, has afforded us no small degree of real pleasure, but that pleasure has been greatly marred by the intelligence that Dr. Jewell's ill health will pre- vent its reappearing, at least for a year. Editorial. 279 We sincerely hope Dr. Jewell may soon regain his health and resume the work he loves so well and for which he is so peculiarly well adapted. our and P The Cause of Death of the distinguished Carl Von Schroeder, the eminent and well known gynæ- cologist of Berlin, was an old encapsuled abscess, the size of a walnut, situated in the right fornix, bursting into the ventricle and setting up a fibrinous suppurative inflamma- tion. His death was sudden. REVIEWS, Book NOTICES, &C. LA PSICHIATRIA. Anno IV., Fasc. 1 and 2. The above is a quarterly journal of neuropathology and the kindred sciences, directed by Professor Buonomo (a first-class Goodman), and edited by the distinguished Dr. L. Bianchi, an alienistic physician and a physiological experimenter of whose merits the readers of our journal have had the opportunity of judging, and we venture to indulge the belief that their estimate of this Italian worker is of no low order. The two fasciculi now before us are really a rich treat, for which we beg to tender to the publishers our most hearty thanks. The following is the list of contents: 1st.-Lesions of the bladder and the prostate in general progressive paral- ysis (general paresis); a clinical and anatamo-pathological study; by Dr. G. D'Abundo. 2nd.-A case of insanity of doubting; by Dr. G. Seppilli. 3rd.—The electric current in a case of paralysis agitans; by V. E. Ingia. 4th.–The cranium of man; considered under the anthropological aspect; by M. Centonze. 5th.-New researches on hypnotism; by G. D'Abundo. 6th.-Experimental degenerations in the brain and spinal cord, in contribu- tion to the doctrine of cerebral localizations; by L. Bianchi and G. D'Abundo. 7th.-Projects of laws relating to public, private and criminal asylums; by Buonomo. We have read, with great interest, all the preceding articles, but especially that by Bianchi on “Experimental Degenerations in the Brain and the Spinal Cord.” In a future number of the ALIENIST we hope to be able to present this production, or at least its most valuable portions, to our readers, who, not generally being very ardent vivisectional devotees, will be grateful alike for the valuable instruction given them, and for their exemption from the unpleasant labor vicariously performed by the author. The article by Dr. D’Abundo, on diseases of the bladder and the prostate in general paresis, is of so great practical value to asylum phy- sicians, and more especially to tho.e whose daily experience painfully confirms the fact of the increasing incidence of this specific form of insanity, that we must not defer our notice of it to a future occasion. It is a fact well known to the writer of these lines, thai forty, nay, indeed, thirty years ago, general paralysis of the insane, as the affection was then termed, was unknown, or rather, perhaps, was unrecognized in American asylums. The eminent Dr. Ray declared his disbelief in its existence as a special form of mental alienation, and asserted that the so-called general paralysis of the insane was simply ordinary paralysis, occurring as a somatic complication of the primary mental disorder. Not one represen- tative of United States asylums expressed dissent. As a close and saga- [ 280] Reviews, Book Notices, &c. 281 cious clinical observer and an erudite alienist, Dr. Ray bad few superiors. What an amazing change as regards this form, has the lapse of a quarter of a century brought about in American asylums for the insane! The last annual report of the Danvers Asylum, in Massacbusetts, shows that in the total mortality of eigbty-four deaths, no less tban twenty-two occurred in general paralytics. Perhaps these figures should be toned down, for when the reports of other Massachusetts asylums are explored, a spontaneous suspicion arises that Danvers is largely utilized as a dumping ground for the waste material of other asylums in tbe State. Indeed, the “ Residence" Table would fully justify this suspicion, for out of the total admissions for the year, amounting to tive hundred and five, no less than four hundred and forty-three were residents of “ cities or large towns," whilst only sixty-three were from“ country districts.". But other States of New England present figures which might con- vince even the most conservative survivor of the illustrious thirteen, that general pare Bis is no longer rarissima avis in that region. The Connecticut Asylum at Middleton, according to the last annual report, bas had, in the twenty years since its opening, sixty-seven deaibs of males, and six of females, from general paresis, in a total of seven hundred and six deaths. Even the Maine Asylum adiits tive deaths from general paresis, in 1855, and its inmates are chiefly drawn from the rural population. It might not be either an uninteresting nor an uninstructive research to trace the march of this malady from its first appearance,or, perh:1p8, better to say, its first rec- ognition, in this country, down to the present time. Though it no doubt was very rare thirty years ago, it is beyond all question that it is now alarmingly usual in asylums, and that its annual incidence is progressively auginenting. For these reasons we regard Dr. D’Abundo's article on vesical and prostatic diseases, in general paretics, as a very timous contri- bution to psychiatry; not indeed tbat it is likely to enrich our curative armamentarium, for these organic disorders are but little amenable to treatnient, but because an assured diagnosis of their presence cannot fail largely to mitigate the discomforts of patients, and to a corresponding extent to enhance that of their medical attendants. Dr. D'Abundo's researches in this relation were carried out in the cases of forty general paretics, whose bodies, after death, were submitted to minute examination. In twenty-one of these, no organic lesion of the bladder or prostate was found, but microscopic and chemical examination of the urine revealed vesical and renal abnormality. In the remaining nineteen cases, a marked diseased condition in one or both these organs .was shown. The most accentuated forms were contraction and thickening of the bladder walls, and enlargement of the prostate gland, which in a few cases might be designated as enormous. The author states the well- known, though not universally confessed fact, that unhealable bed-sores supervened in almost all his cases, in the last stage of the disease. Now, the extent to which these lesions may be attributed to the diseased state of the urinary organs, is a question of the very bighest importance to all concerved in the treatment of the insane. It is well known that paretice (and other insane persons also) are continually “ wetting their beds," nor is this evil monopolized by the urinary excretion. From whatever cause 282 Reviews, Book Notices, &c. originating, a bed-sore, subjected to the persistent irritation produced by immersion in wine and fæces, both often morbid products, cannot be expected to heal, so long as this state of matters continues, and in truth healing, under any circumstances, is a very problematic event; neverthe- less, any remedial means, even though only palliative, by which the dis- tress to the patients and their attendants may be lessened, must command the serious consideration of asyluin physicians. One means very gener- ally adopted, is that of instructing night attendants to raise witting patients and cause them to urinate. Now, it is a fact, the denial of which should be accepted only with an ample margin of discount, that despite this precaution (or the morning reports recording its observance) many of the beds of these night-roused wetters are found by the day attendants in a very undry state. A truthful night attendant, when called up to explain the anomaly, will say that he (or she) did obey the instruction, but bad utterly failed to induce the patient to pass water. It inight be unjust or uncharitable to supplement this explanation, by hiuting that the patient did not yield to the persuasion of a sound shaking; yet, human nature is but weak, eren in daylight, and it is very exhaustive of the patience of wearied nurses to go the rounds of these nocturnal excursions, and enconnter the unyielding obstinacy of those under their charge. What does an untaught-perhaps an unteachable-asylum attendant know about enlarged prostates, thickened bladders, capricious kidneys, or benumbed neries? It is an old proverb that “one man may lead a horse to the water but ten men cannot make him drink, if he does not require or desire to do 80." But these asylum urinary recusants both require and desire to pass their water, and they would very gladly do so, if they coulil. They return to their beds with unemptied bladders; they again fall asleep, and when the bladder reaches a certain grade of distention the urine escapes un- known to them, and their beds are soaked. In cases of advanced paresis the urine diibbles out unperceived, and the same wetness is recorded. It must be utterly supererogatory to indicate to duly qualitied medi- cal officers the proper means of managing such cases. Regular, cautious introduction of ihe catheter is the only rational course, and no person should be put into the position of a night attendant of the insane before having been well instructed in the art of catheterization. It cannot be expected of the overworked and wearied medical officers, that they shall make the indispensable ward rounds. Let them relieve themselves of the toil by teaching intelligent and docile subordinates 1o do the work. THE CENTURY.- Among the other features which contribute to the individuality of the March Century are, a complete short story by Mr. Cable, entitled * Grande Pointe," being the second of his stories of the Acadian country of Louisiana. Two other features are an article on “Composite Photography, by Professor John T. Stoddard, of Smith College, accompanied by eight ex- amples of this weirdly fascinating art; and “The Coinage of the Greeks," by J. Stillman, the art critic and connoisseur in coins. Reviews, Book Notices, &c. 283 On the art side, also, the number contains the third of Mr. Brownell's notes on “ French Sculptors,” accompanied by four full-page reproduc- tions, giving one example each of the work of Barrias, Delaplanche, Le Feuvre and Frémiet, the aim of this series being to represent the best achievements of contemporary French Sculpture. There is also an introductory paper to a series on “The Cathedral Churches of England," by Mrs. M. G. van Rensselaer, which is to be one of the most important art enterprises which The Century has undertaken. Common ERRORS: Theoretical and Practical, relating to Insanity. By Orpheus Everts, M. D., Medical Superintendent of the Cincinnati Sani. tarium. From the American Journal of Insanity for October, 1886. Revised by the author. OUR NEW EXCHANGES. THE NEW PAILADELPHIA JOURXAL.- The early issues of the Medical Register," a new weekly journal published in Philadelphia, bave reached us. It is edited by Dr. John V.Shoemaker, the editor of the Medical Bulletin, of Philadelphia; and Dr. William C. Wile, the editor of the New England Medical Monthly. The first number contains reports of clinical lectures by Dr. W. H. Pancoast and Dr. P. D. Keyser, of Philadelpbia ; original articles by Dr. J. W. S. Gouley, of New York, Dr. H.O. Marcy, of Boston, Dr. Frank Woodbury and Dr. Benjamin Lee, of Pbiladelphiu, and Dr. William Murrell, of London; and an attractive array of editorials, book notices, abstracts, etc. The Register Is a handsome journal of twenty-four pages. The acquirements and enterprise of the editors may be expected to make the new journa) a creditable addition to the list of Philadelphia medical journals, of which there are now tbree published weekly. New York MEDICAL JOURNAL.- We welcome the new journal to our exchange list, and wish for it the prosperous career the three first nun- bers, and the ability of its managing editors, promise. W(h)ile Shoemaker lasts we feel assured the Register will live in the family of journals. THE MEDICAL STANDARD is the name of another new and meritorious claimant for professional favor. The following table of contents of the initial number shows how well- deserving of medical support it is. Though printed for the present, anony- mously we can detect by its make tbe impress of a master editorial band, and cheerfully commend it to the favorable consideration of all live medical practitioners who are desirous of not missing anylbing good and valuable in medical literature: Original Contributions.-Glycosuria ; Its forms and causes, by Dr. O. C. De Wolf, Chicago. Diuretic action of mercurials, by Dr. S. V. Clev- enger, Chicago. Medicating by electricity, by Dr. C. H. Hughes, St. Louis. Nature and treatment of epilepsy, by Dr. E.C. Spitzka, New York. Capsicum in opium-poisoning, by Dr. Jas. G. Kiernan, Chicago. Wiring and drainage of compound fractures, by Dr. W. P. Verity, Chicayo. 284 Reviews, Book Notices, &c. Editorial –The medical standard; “Christian science" and state boards of health; Cerebral rheumatism; Pneumotomy; Hepatic surgery; Living skeletors; Identity; Infantile death rates; Brain weight; Pust mortem temperature. Therapeutics and Pharmacology.-Stigmata maidis in gonorrhea; Ar- senic in arthritis deformans; Cold air in fevers; Gelseniium in prostatitis; Alcohol in scarlatina; Pasteur and dumb rabies; Euca- ly ptol in malaria ; Ice water enemata in diarrhea ; Bryonia in literine hemorrhage; Sparteine sulphate; Drumine; Crotalus in feveis; Local anæsthesia; Heart tonics and albumen; Campbor-charcoal in ulcers; Pilocarpin in nigbt sweats. Obstetrics, Diseases of Women and Children.- Measles, communication by healthy people ; Intra-mural uterine tumors; Tympanites in hysterical women; Pregnancy and cholera ; Curette in obstetrics ; Pertussis; Pregnancy at sixty-five. Eye, Ear and Throat Diseases.-Zonular cataract and rachitic treth ; Electric light and the eye; Tobacco amblyopia ; Cataract operations without iridectomy. Surgery and Operotive Gynæcology.--Widely-gaping wounds; Morbus cox and hip-joint amputation; Vertebral artery ligation; Rivil wity injuries; Gunshot spinal wounds. Skin and Venereal Diseases.-Progress of syphilis ; Speciticity of chan- croid. General Medicine.- Variation in albumen excretion; Insanity among the Chinese. Societies and Colleges.-Chicago Medical Society ; Society notes. Reviews and Book Notices.— Pepper's System of Medicine; Tuke's Body and Mind; Cutler's Differential Diagnosis. Notes and News.- G. P. Engelbard and Company, 69 and 71 Dearborn Street, Chicago, are the publishers. THE SouthWESTERN MEDICAL GAZETTE, a Montbly Journal of Med- icine and Surgery, edited by M. F. Coomes, A. M., M. D., and J. B. Marvin, B.S., M. D., is likewise a new, worthy and promising, bandsomely-priuted, double column, octavo journal, with an attractive table of contents. The editors are M. F. Coomes, A, M., M. D., Professor of Physiology and Clinical Lecturer on Diseases of the Eye, Ear, Nose and Throat, in the Kentucky School of Medicine, and J. B. Marvin, B. S., M. D., Professor of Theory and Practice of Medicine and Clinical Medicine in the Kentucky School of Medicine. For subscription, specimen copies, advertising space and rates, address the publishers, The Bradley and Gilbert Company, corner Third and Green Streets, Louisville, Kentucky. It starts on its career with the following bill of lading for the first monthly voyage: Reviews, Book Notices, &c. 285 Original Articles.- Inquiry into the causes of the great mortality of in- fants in Western Norseland, by Frederick Eklund, M. D. Produc- tion of heat in muscular tissue; A septic dressing of penetrating and punctured wounds, by 0. Grothan, M. D. Clinical Notes.--Strabis- mus operation, by E. Landolt, M. D., and W. B. Meany, M. D. Trau- matic tetanus, by Prof. E. Fletcher Ingalls, M. D., and R. H. Lull, M.D. Amyl nitrite in tobacco amblyopia ; A iarge serous cyst of the brain, by W. C. Dugan, M. D. The cause of rigor mortis ; Sterility, by Prof. Wm. H. Wathen, M. D. Hardin County Medical Society; Intestinal obstruction, by L. S. McMurtry, M. D. A survival of the unfittest. Editorial.-Salutatory; Abuse of medical charities; An outbreak of small- pox; States rights carried to an extreme; The Alabama Surgical and Gynæcological Association; The Scotia, Nebraska, Medical Society; Female graduates in pharmacy; The Louisville Clinical Society ; News items. Review 8.-Minor surgical gynæcology, by Paul F. Munde, M. D.; Woods' Library for 1885; The physicians' visitiug list (Lindsay and Blakes- ton); The niedical news visiting list; Books and Pamphlets Received: Reading Notices. Noises in the Head and Ears. By Robert Barclay, A. M., M. D. Read at the Annual Meeting of the Mississippi Valley Medical Society, at Quincy, 111., July 13, 1886. Reprinted from the Weekly Medical Review, St. Louis, August 28, 1886. Du Délire Chez Les Dégénérés. Observations Prises a L'Asile Sainte- Anne, 1885-1886 (Service de M. Magnan). Par Le Dr. M. Legrain, Ancien interne des asiles d'aliénés de la Seine, Ancien externe des bôpitaux. Recoveries from Insanity in Cases Accompanied by Hæmatoma Auris. By Carlos F. MacDonald, M. D., Medical Superintendent, New York State Asylum for Insane Criminals. Benjamin Rush and American Psychiatry. By Charles K. Mills, M. D., President of the American Neurological Association. Paraldebyde and Urethan. By H. B. Williams, M. D)., Assistant Phy- sician Arkansae State Lunatic Asylum. Leçons sur les Maladies du Système Nerveux. Par T. M. Charcot, Proféssées à la Salpêtrière. Neurasthenie und Pathophobie. Von Prof. P. J. Kowalewsky, in Charkow. THE ALIENIST – NEUROLOGIST. | No. 3. Vol. VIII. 1 ST. LOUIS, JULY, 1887. ORIGINAL CONTRIBUTIONS. Notes on the Pathology of Idiocy.* SECOND PAPER. By A. W. WILMARTH, M: D., Elwyn, Pa. IN the paper read before this Association in 1884, I I endeavored to describe such peculiarities of surface- markings, structural deficiencies, and other instances of faulty development or destructive lesion, as had come to our observation in the rather limited number of brains which were then in our possession. In this paper, I pur- pose to follow the same general plan with the consider- ably increased number of brains now in our hands, adding the result of a microscopical study of these cases. The total number of brains examined is thirty. In a few of these cases, our descriptive notes are incomplete, but in most of them our observations have been thorough, and a careful record kept. ANOMALIES OF THE SKULL. Hypertrophy of the skull was found in two cases. In one of these the bone in some places was fully half an inch thick. In the other it measured about seven-six- teenths of an inch at the thickest part, which was in the temporal fossa, where the bone is usually the thinnest. • Read before the Association of Superintendents of Institutions for Feeble- Minded Children, 8 ptember, 1886. [ 287 ] 288 A. W. Wilmarth. In two cases the skull was unusually thin. Deformity of the base, especially about those portions of the ethmoid and sphenoid bones that go to make up the base of the cranial cavity, exists in nearly all congenital cases. Adhesion of the membranes to the cortex, with or without apparent thickening, and varying in extent from a very small area to a complete adhesion, is very com- mon, being found in forty per cent. of our cases. Where the original inflammation is confined to the dura mater and outer fold of the arachnoid, it is not to be considered of the same etiological importance as where the pia mater is implicated. The cortical substance of the hemisphere depends so largely on the vessels of the pia for its blood-supply that any interference in the circulation of this membrane is liable to affect the nutrition, and con- sequently the functional activity of the ganglionic cells in the underlying brain-substance. The location of such changes in the membraneous envelopes of the brain ought always to be noted, especially in the milder cases of men- tal infirmity, as a record and comparison of a considerable number of cases may at some future time be of great value in the study of the localization of the mental faculties. BRAIN WEIGHT IN TWENTY-Sıx CASES. In twenty-six cases the brain was carefully dissected, drained for an hour, and then weighed. The average weight was 37.5 ounces. The average weight of the cerebrum was 32 ounces; of the cerebellum, 4.65 ounces. Of the pons and medulla, from a section just front of the tubercula quad- rigemina to a point immediately below the olivary bodies, was gi ounce. Counting only those cases known to be congenital, the weight of the entire brain averages only 33 ounces. The weight of the cerebellum is to that of the cerebrum as 1 : 61%; or, if we count only congenital and exclude one case of non-development of the cerebel- lum, we find the ratio to be 1:6 instead of 1 : 81 to 1:84, which Sharpey assumes to be the normal propor- Notes on the Pathology of Idiocy. 289 tion. As some of the children were quite young, and the cerebrum attains nearly its full weight much earlier than the cerebellum, it is readily seen that the growth of the latter organ suffers less than that of the cerebrum in imbecile brains. Indeed, the mental status of the individ- ual furnishes no guide to the size of the cerebellum. Wherever muscular power is deficient in any marked degree, and particularly in cases of congenital or infantile paralysis, it shows a marked diminution in size. In one case, where there was complete paralysis of the lower extremities and very limited use of the hands and arms, the cerebellum weighed less than 2 ounces.. Measuring along the superior border of the great lon- gitudinal fissure, the frontal arc is found to bear the proportion of 51 : 10 instead of 6 or 6 : 10, which Clev- enger assumed to be the normal proportion. The frontal lobe very generally exhibits a lack of width and height as well as length. Counting only congenital cases, the proportionate length of this lobe reached even below 51: 10; in one case, where there was no destructive lesion visible, being only 41 : 10. Perhaps in no part of the nervous system is defective formation more marked than in the cerebral commissures. In three cases, or ten per cent., there was seen defective corpus callosum. Two of these were described at length in my first paper. In the third case the commissure ter- minated posteriorly just front of the pineal gland, leaving this body and the tuberated quadragemina exposed. It is also observed, that wherever extensive lack of develop- ment or destruction of brain-tissue in early life occurs, the corpus callosum is thinner in its corresponding region. The middle commissure was absent in four cases; the pos- terior in one. The island of Reil was exposed (by defec- tive development of the inferior frontal gyrus in nearly every instance) in four cases on one side, in four others on 'both sides. It is in this region that the small size of the convolu- tions is most readily noticed, as any defection is sure to 290 A. W. Wilmarth. uncover the insular. It is seen that this exposure occurs on one or both sides in about twenty-seven per cent. of the cases examined. I have already referred to one case of non-develop- ment of the cerebellum. In this case the boy had neither walked nor spoken. Total paralysis of the legs, limited motion of the arms, and perfect muscular movements of the face describes the condition of the muscular sys. tem. In this case the cerebellum weighed less than two ounces. In one case, associated with defective corpus callosum and absence of the middle and posterior commissures, was a total lack of connection between the two optic nerves. There was a slight protuberance on the inner side of each nerve in the usual situation of the commissure, but they did not touch at any point. An alternating external squint existed in this child, and temporal heminanopsia was assumed to be present from the fact that when one eye was covered, the finger could be snapped in front of the other eye on the outer side, and there was no winking to escape the threatened blow until the finger was near the median line. The case was reported by Dr. William Lit- tle, of Philadelphia, before the American Ophthalmologi- cal Society, and was said to have created considerable interest from its rarity. The fact of the existence of tem- poral heminanopsia is of interest in connection with the absence of the commissure, as having a bearing on the distribution of the nerve-fibers in the retina. Certain observations, concerning peculiarities in the arrangement of the fissures and convolutions, described at length in my first paper, were confirmed by examination of cases since, and deserve some detailed description here. Ever since the publication of Benedikt's little work on the “ Brains of Criminals,” with its admirable descriptions of the physical characters of these brains, and exceedingly brief and unsatisfactory description of the mental and inoral char- acteristics of the possessors of these brains, much interest has been felt by neurologists on the subject. They have Notes on the Pathology of Idiocy. 291 never, I think, among our own race, found the confluence of fissures, which he observed so constantly among the criminal brains which he examined, to recur with the frequency which he describes. Among our children, how- ever, especially among cases of the congenitally feeble- minded, this peculiarity is often a marked feature. The parieto-occipital fissure in ten cases on one side, in five on both sides, or in fifty per cent., cuts through the superior occipital convolution into the parietal fissure. Internal annectant gyri in the upper portion of this fissure are of frequent occurrence. In five cases on one side, in four brains on both sides, or thirty per cent. of cases, the calcarine fissure passes across the gyrus fornicatus into the fissura hippocampi. The interparietal fissure ran an uninterrupted course in eight cases on one hemisphere, in seven others on both sides. Prof. Wilder, of Ithaca, has recently written an inter- esting monograph on this fissure, which he describes as consisting in reality of two fissures whose extremities fre- quently join. The short deep fissure, commonly known as the transverse occipital, he describes as a branch, or rather two terminal branches, of the posterior portion, which he terms the par-occipital fissure. The fissure of Rolando was found confluent with the fissure of Sylvius in three cases on one side, in four cases on both sides, or over twenty-three per cent. of the brains examined. The extreme rarity with which this occurs in the normal brain makes these instances of more than ordi- nary interest. That confluence of these two principal fissures does occur in the normal brain is shown in this pho- tograph, which is from one hemisphere of a lady said to have been of more than ordinary intelligence, of no criminal propensities. As there was no other unusual feature about the organ, I think we may regard it as accidental, and of no particular significance. With the secondary fissures, conflu- ence occurs with still greater frequency than with the primary. The significance of this peculiar fissure-conformation is not 292 A. W. Wilmarih. easy to demonstrate. That it is peculiarly a criminal type, as assumed by Benedikt, seems difficult to credit. It seems more plausible to assume that it is merely an expression of a low type of development, resulting from a failure of the usual connecting gyri to attain their full growth. A defec- tive or unbalanced mind would seem entirely consistent with this defective growth of its organ of reception and expres. sion. Of late years the public mind has been awakened more and more to the fact, that there exists a moral imbe- cility as certainly as a mental; that there is a connection between the two is easy to perceive in actual cases, but difficult to define. You will remember how many of Ben- edikt's cases were mentioned as “of weak intellect," “excessively ignorant,” etc. Is it not probable that in his cases, and in ours, these signs of low development in the course of physical growth are indicative of, and coincident with defective development of the higher men- tal qualities of judgment and self-control ? Gentlemen, I would earnestly ask your assistance in this matter, that the brains of the feeble-minded which may come under your examination should be carefully studied, and a record, and if possible, photographs made, that by a large number of cases we may be able to com- pile valuable statistics bearing on this subject, that all available light may be thrown on the relations existing between the development of the mental and moral natures and the developmental phenomena of the brain itself. In about ten per cent. of our thirty cases a strong tendency is shown for the fissures to assume a vertical direction, those fissures which are usually vertical becoming very strongly marked. The Sylvian or supe- rior temporal may, perhaps, be prolonged nearly to the superior border of the hemisphere, while the præcentral and paracentral, as well as other vertical secondary fis- sures, become prominently developed. This peculiarity probably owes its origin to the same cause as the conflu- ence of fissures just described, and is the expression of a low order of brain development. Notes on the Pathology of Idiocy. 293 The following cases of lesion and defective development were met: Case I. (8-540). Male; age, twenty ; mute ; profound idiot; defective vision ; defective development of the cortical substance in the posterior portion of both hemispheres. There was no motor or sensory disturbance that we could detect in this case except defective vision. This was very evident to every one, but the exact nature and extent of his defect we were never able to ascertain, owing to his low grade of intellect. He could certainly see well enough to find his way about without assistance; could recognize people and see his food. After death, exami- nation revealed the following lesions: The posterior horns of both lateral ventricles were found dilated, and the por- tion of the brain-substance covering them was very thin, measuring only from one-eighth to one-fourth of an inch in thickness, and was soft and wrinkled, exhibiting but little attempt to form convolutions. These tracts of unde- veloped brain-substance embraced the following con- volutions: On the left side, the posterior portion of the supra marginal, angular, posterior extremity of the parietal, and a considerable portion of the second and third temporal gyri. On the right side, the second and third occipital, angular, and posterior portion of the supra- marginal, and of the first, second and third temporal gyri. The first occipital was well developed on both sides, while the cuneus was very small. The possession of the faculty of sight to a considerable extent, in connection with the non- development of angular gyrus, would tend to support the view advanced by some of the latest observers, that the area of vision in the cortex extends beyond this region, and embraces a part of the whole of the occipital lobe. A microscopical examination of this region shows abundance of small granule-cells plentifully scattered throughout the cortex, even in the outer layer. Tracts of considerable size were found where hardly any cells of any description were visible. Again, in other places the 294 A. W. Wilmarth. cortex presented quite a normal appearance, but these last-mentioned areas were small in extent and few in number. In the regions where small granules predominated no attempt at stratification existed. The absence of all signs of disease in cells, neuroglia, or vessels, excludes the opinion that the appearance of the cortex was, in any way, due to disease. It was a simple case of arrested development, where for some rea- son this portion of the brain never advanced beyond the fæetal condition. CASE II. (28-869). Age, fifteen. Defective in sight, hearing, general sensation and taste. Partial paralysis of the left side. Speaks but little, but the few words she does say are articulated distinctly. The leſt leg is par- tially paralyzed. The left arm is not so strong as the right, though not distinctly paralyzed. Oblique external strabis- mus of left eye. There is a history of convulsion just after birth, but none recently. She is very slow of comprehension. Sight poor. She was unable to distinguish colors when she came, and after much patient teaching, only learned to distin- guish two of the primary colors. Ideas of form and size also exceedingly defective. She always appeared eager to learn. “She tries hard to learn, but cannot," is the verdict of all her teachers. Death occurred from phthisis, and at the post mortein examination the following conditions were found: The head alone was examined, owing to a lack of time. The skull was found hypertrophied, especially in the temporal region, where it measured a full half-inch, while the average thickness in this place of the section was over three-eighths of an inch. The skull cavity was very shallow anteriorly. The dura was thickened, and contained between its folds two plates of bone about the size of a silver quarter. Smooth on the outer side, rough on the inner. One of these was situated over the middle portion of the second frontal gyrus of the right side, the other over the posterior portion of the first frontal on the left side, encroaching on the ascending frontal gyrus. The Notes on the Pathology of Idiocy. 295 basal ganglia were much larger on the left side than on the right. The optic thalami were whiter and harder in consistence than in the normal brain, while the middle or gray commissure was light in color and much hardened. The cerebrum weighed only 20ounces; the cerebellum, 43. Total weight of the brain, 26 ounces. On examin- ing the surface of the hemisphere, on the right side, the middle third of the first and second frontal convolu- tions are decidedly atrophied. The remaining gyri of this lobe are small, except the extreme posterior fold of the first frontal. The first occipital is well developed; the other convolutions of this lobe, including the cuneus, are very small. On the left side the anterior two-thirds of the first frontal and the middle third of the second are small, while the third frontal is ill developed. The convo- lutions of the occipital lobe exhibit the same appearance, while the fusiform and lingual lobules are flat and shriveled. Those portions of the hemisphere described above were subjected to microscopic examination. The functional activity of the left frontal convolution may have been in- terfered with by the pressure of the bony plate above, but except the thinness of the cortex nothing abnormal was found. The right frontal convolution exhibits not only a thinness of the gray matter, but scarcity of gan- glionic cells and some slight degenerative changes. The flat, shriveled portions in the posterior lobes, ex- hibit the same appearance as those described in the first case, the cell elements consisting principally of small round granules with an almost entire absence of true ganglionic nerve-cells. Sections of the optic thalami through the middle commissure and elsewhere show a de- cided increase in the neurolgia with paucity of nerve-ele- ments. The corpora striata exhibit increase in the quantity of the neuroglia, the perivascular canals filled with granular effused material; also the presence of large round cells formed of a finely granular protoplasm, and a faintly defined nucleus and nucleolus. The cortex, ex- cept as described above, appeared normal. 296 A. W. Wilmarth. Two entirely different symptoms characterized this case, associated with two distinct lesions : First, the paralysis associated with atrophy of the corpus striatum of the op- posite side and pressure on the upper portion of the so- called motor region, where motor impulses to the lower extremities are supposed to originate. Second, imperfect sensation, employing the word in its widest sense, associ- ated with sclerosis of the optic thalami and defective development of portions of the posterior lobes. Notwith- standing the extent of this latter condition, there was no other function of life that was seriously interfered with; for with the child's long residence with us it would have hardly escaped notice. Being shut off in a measure from the reception or rather the appreciation of all sensory impressions by the interference with the ingoing fibers to the higher centers, it is not surprising that her intellectual centers never developed to any great extent. From the absence of other symptoms, except the sensory one already described, it seems safe to assume the probability that all the undeveloped tracts described above belong to the sen- sory region. Case III. (32-879). Age, fourteen ; mute ; idio-imbecile. Extensive lesion of the frontal lobes, with defective develop- ment of certain convolutions. Abscess of cerebellum. But little is known of his early history, except that he had convulsions twenty-four hours after birth. Special senses appear normal. Knows simple colors. Has some idea of, and memory for, locality and time. Memory at least fairly good. Notices and points out promptly the absence of any child from its accustomed seat, or of furniture from its usual place. Power of muscular movement always defective. Walks with an ataxic gait. Tendon reflexes weak. Nutrition poor and circulation sluggish. Hands always blue and cold. No organic heart-disease detected. In school his usual occupation was watching other children at their work, but could be induced to do but little himself. Notes on the Pathology of Idiocy. 297 After being free from convulsions for many years, he had two, with an interval of several days. During the second one he died. They were probably caused by the irritation of a forming abscess in the cerebellum, which was found after death, and will be spoken of at length farther on. Post mortem examination eleven hours after death. Nothing peculiar was found about the skull, except that it was shallow in the frontal region, rather tapering in form, and demi-microcephalic in size. Both frontal lobes presented interesting lesions. On the right side a cyst with thickened walls, occupied the place of the mid- dle third of the first and second frontal convolutions; the third frontal is only rudimentary. The middle portion of the gyrus fornicatus was absent. The island of Reil con- sisted of a smooth surface, with a slight attempt at the for- mation of convolutions anteriorly. The gray matter covering it was exceedingly thin. The corpus callosum was very thin opposite the locality of the lesion, but normal elsewhere. The posterior portion of the first temporal was ill de- veloped. On the left side, the middle portion of the frontal was almost entirely destroyed. The posterior third of the third frontal was very small. The middle portion of the gyrus fornicatus was almost entirely absent, while the insula showed the same deficiency as that of the other hemisphere. The cerebrum weighed 26 ounces; the entire brain 33 ounces. No microscopic study yet made. The interior of the right lobe of the cerebellum was almost entirely destroyed by abscess. The middle and left lobes were not implicated. The symptoms associated with this lesion were progressive muscular weakness, appearing first in the lower extremities, but soon becoming evident in the upper. Loss of the knee-jerk early in the course of the disease. No other symptoms except a slight rise of temperature (100.8°) the day before his death. This brain is the only one in which we have found defect in the island of Reil. Unfortunately, so many other parts of the cerebrum were abnormal that it is difficult to 298 A. W. Wilmarth. associate symptom and lesion, and it will be valuable only to compare with other cases which may come to our hands. CASE IV. H. M. Age, twenty-six. Progressive muscu- lar degeneration. This case, who is one of three brothers similarly afflicted, was described at length in a paper published by Dr. Kerlin in conjunction with Dr. Mills, of Philadel- phia, in the “Transactions of the American Medical Association, 1880,” where a full description of the case is to be found, and from which I have made the follow- ing abstract: “Was twenty-two years old at the time this paper was written (in 1880). Had never had convulsions, but suf- fered during infancy from digestive trouble, and early gave evidence of muscular weakness. Muscles of body and limbs exhibited decided wasting, except the calves of the legs, which were enlarged. Knee reflexes absent, but skin reflexes present. The extensor muscles of the legs were particularly weak. 'Muscular weakness without defi- nite palsy,' seemed to describe his condition. Sensation appeared normal. His disease steadily progressed, phthisis developed, and he died in 1884, of acute con- gestion of the lungs." During the last few months of his life he was troubled with regurgitation of thick, transparent mucus coming into his mouth without apparent effort on his part. At the post mortem examination, a large portion of the mucous coating of the stomach was found deeply congested and thickly coated with this mucus. From our school record and descriptive blanks I have gleaned these notes. He was said to have had a sickly childhood, and a few months after birth “showed a want of smartness." The mother was said to be nervous and trifling, not capa- ble of exercising proper judgment. She died paralyzed, at the age of thirty-three; was for several years epileptic. No history of muscular atrophy in ancestry, though this. Notes on the Pathology of Idiocy. 299 could not be followed farther back than the grand- parents. In school he learned to read simple reading. Could tell time, but never learned to count above twenty. Power of imitation fair, and could do considerable indus- trial work fairly well. He was never able to select colors accurately. Speech was always imperfect, more so at some times than at others. In 1880 (July) he is reported as insisting on using his left hand instead of his right, weaving mats and doing other similar work backwards. This the teacher ascribes to a notion, as he could use the other hand if it was insisted that he should, and after- wards he again began to use his right. Nothing of interest was found on removing the brain. The head was well formed. The brain was also of good form and size, weighing 411 ounces. The pons and me- dulla were large, weighing a little over 15 ounces. Through- out the cerebrum evidences of miliary sclerosis existed. In most parts it was confined to the medullary substance. the gray matter being only slightly or not at all implicated. In the central gyri and posterior parts of the frontal con- volutions the masses of sclerosis are more plentiful, the gray matter is invaded in many places, the nerve-cells are included in the diseased masses, and are seen in all degrees of atrophic change. In the frontal lobes the gray matter is more implicated than in other portions of the brain except those just referred to. The optic thalami in some portions exhibited considerable change, but here it was found mainly in the vicinity of the vessels, and the ganglionic cells were but little disturbed. In the corpora striata a number of round, faintly nucleated cells, a few corpora amylacea, thickened walls of the arterioles, and increased density of the neuroglia, indicated atrophic change, a few vessels exhibiting lardaceous degeneration ; also some small deposits of small cell growth in the vicin- ity of vessels, suspiciously like commencing tubercular growth, were found, both apparently recent, and due to the low tone of the general system and tubercular disease 300 A. W. Wilmarth. under which he was suffering. Bundles of degener- ated nerve-fiber were plentiful. In the pons and medulla descending degeneration of the pyramidal tracts could be seen, but very little change otherwise. It is in the spinal cord, however, that the most marked degenerative lesions were seen. Both in the direct and crossed pyramidal tracts the fibers had undergone extensive atrophy. In the dorsal cord and upper portion of the lumbar enlargement the anterior gray cornua were extensively implicated, and many of the large ganglionic cells destroyed, and in some places the anterior and posterior “root zones" and white com- missure exhibited scattered tracts of atrophied nerve-fibers. The muscles were found in all stages of atrophy, and small pieces were taken from ten different muscles in various parts of the body. The fibers seemed to be undergoing a process of absorption. In a few cases mus- cle-fibers would appear swollen and occasionally under- going a process of longitudinal fissure, but for the most part they were simply disappearing from the ends towards the middle, exhibiting in some places one or two small frag- ments of muscle-fiber, in perfect condition, in a fine net-work of the muscle-sheaths left by the disappearance of the fiber. In other fibers they simply lost in diameter, and fibers were seen of exceeding small size. But all fibers, whether in a process of fission or of longitudinal or transverse absorption, if I may so describe it, retained their striæ until the last. In some places there was a proliferation of the connective tissue, but for the most part fat formed between the sheaths of the fibers, rarely appearing until the muscle had nearly disappeared, and then often forming beautiful rows of single fat-cells between the connective tissue elements. In no instance, among the many specimens exam- ined, did I find any true fatty degeneration of the muscle. CASE V. (17-765). L. T.; age, eighteen; deaf-mute ; choreic; weakness of left arm. This girl was a high-grade imbecile, observant, quick to learn, and very neat in the execution of any work. Notes on the Pathology of Idiocy. 301 In school her progress was not so marked, although it compared very favorably with the majority of children in her room. Her choreic movements seemed apparently to affect every muscle in her body. She died of typhoid fever. Nothing unusual was found on post mortem examina- tion about the head or brain. The brain was large and well formed, weighing 43 ounces. A very careful examination was made of the cord and brain. The cord was placed in a microtome, and sections cut every one-tenth inch throughout its entire length. No lesion whatever of the cord was found. The medulla and pons were also healthy. On examining the cortex, sclerotic changes were found in the right motor region. They con- sisted of small foci situated, for the most part, in the white substance, but appearing in some parts of the cortex. The new growth in the brain-tissue seemed to consist of a fine granular material, with a number of large round cells, either homogeneous or faintly granular, with, in some cases, a hardly visible nucleus. The cortical cells appear unchanged. The spots which you can readily see in the specimen slide I pass you, are most plentiful in the ascending frontal and the bases of the other frontal convolutions. The ascending parietal, the anterior portion of the frontal lobe, and the gyrus fornicatus are but little affected, and the disease does not spread beyond this limit. The corpus striatum on this side of the brain shows some signs of degeneration; some of the ganglionic cells stain imperfectly. Small white masses like those in the convolutions above are present. The left lobe of the cer- ebellum also has small masses of effused material in its medullary substance. The cell elements do not appear to have suffered. The spinal central canal is crowded and distended with epithelial cells, and all the vessels throughout the cord and brain are distended with blood, but no general change in the vessels is present, and this appearance is probably due to the acute disease from which she died. 302 A. W. Wilmarth. It is difficult to understand how lesions of one hemi- sphere should create general chorea, unless we assume that the impulse for motion alone comes from above, and the com- pletion of this impulse with the coördinating force is effected in centers lower down. That the severance of connecting fibers between these higher and lower centers may cause either a loss of inhibiting control over these lower centers and their consequent erratic action, or possibly that the active cells of the cortex, shut off from their usual channel of communication, may seek another course to transmit their energy to their subordinate cell-groups, and so disturb other centers into action. This is, of course, purely theo- retical, but seems to explain the symptoms in this case. CASE VI. T. A. (7-1180). This case, that of a mute idiotic child, paralyzed in its lower extremities, was de- scribed in my first paper. The corpus callosum was very defective, the septum lucidum absent. The pillars of the fornix not connected, the genital organs malformed. A description of the case can be found on page 325 of our “Proceedings.” She was supposed to have had scarlet fever when a few days old. About that time she began having spasms, and continued to have them at irregular intervals until her death. She evidently possessed sight and hearing and cutaneous sensibility only to a very slight extent. The other special senses we were unable to determine. She did nothing but sit and rub her teeth together, moving her jaw from left to right until it protruded towards that side in a striking manner when it was at rest. This brain is a marked example of that curious condi- tion known of miliary sclerosis, where we find, scattered throughout the entire substance of the encephalon, micro- scopic grayish spots, in some places occupying, with their combined area, at least one third of the area of the sec- tion; in other places scattered rather sparingly in the brain- substance. They are much more frequent in the white sub- stance, though not by any means confined to it. In the Notes on the Pathology of Idiocy.. 303 center of these minute masses may be seen a faint nucleus in many instances. Some are nearly transparent or very faintly granular, others have assumed a fibrillar condition. They are very abundant in the pons and basal ganglia. The effect of their presence in brain-substance is best seen where a bundle of nerve-fibers follows the plane of the section for a considerable distance, and the fibers are seen crowded to each side by the pressure of the effused material in its meshes. The connective tissue elements are increased, and the nerve-cells are comparatively few. Small bundles of degenerated nerve-fibers could be found scattered at intervals through the brain. It is difficult to understand how the brain could have retained even the feeble activity it did under the pressure and irritation of so large an aggregate amount of effused material in its substance. Case VII. (15-1119) was also described with the other cases as having no corpus callosum and the atypical arrangement of its convolutions. At the time of his death he was nine years old, par- alyzed in both legs and left arm. He was always weak and sickly during infancy, not being able to sit up alone until a year and a half old. Could speak plainly when eighteen months old; at that time was taken ill, and has never spoken since. He began having convulsions when two and a half years old. Had none for two years pre- ceding admission. Two epileptic seizures occurred dur- ing is stay with us, and he died in the second. He apparently knew nothing when admitted, but was taught by the nurse, by much patient effort, to touch his finger to his mouth, nose or eye when requested. Appeared to have some idea of height, and afraid of falling from his high chair. Aside from these little ideas, his mind seemed a blank. The brain was found in an advanced state of degen- erative change. Throughout the cerebrum the superabun- dance of nuclei, density of connective tissue, and thickened 304 A. W. Wilmarth. vascular walls, showed the progress of the sclerotic change. This change was found in all degrees. The motor regions had suffered the most, especially those of the right hemi- sphere, with the occipital lobe of the same side, where both the white and gray matter were in an advanced state of degeneration. The upper portion of the left motor region and the posterior third of the third frontal were affected in a nearly equal degree. The left ascending parietal and extreme frontal and occipital lobes, while presenting isolated patches of sclerosis, with an occa- sional diseased vessel, were much less affected, while the middle portions of the brain, embracing the infe- rior and superior parietal lobules and the temporal lobes, had suffered least of all. The changes seem to have affected the vessels first, then the neuroglia, and last of all, the ganglionic cells of the cortex, these in some cases retaining nearly their usual appearance when the character of the medullary substance had become com- pletely changed. The pons and medulla appeared but little affected, and exhibited no lesion except descending degeneration of nerve-fibers. A curious arrangement was found in the pons, where the bundles of nerve-fibers from the various parts of the brain cross in different directions with numer- ous collections of ganglionic tissue between them. In this case these cell groups occupied their usual position, but were so thin as to be barely visible, and in places were invisible to the naked eye, consisting of a single layer of cells, and forming a beautifully delicate net-work. The cells, though so few in number, appeared perfectly healthy. Lecture on the Origin of Language. By Professor Bianchi, Naples, Italy. LECTURE XI.-SUMMARY. IMARY. Motor or ataxic aphasia.—Retrospective glance on the development of articulate speech.-Motor aphasia of idiots : its characters, its analogy with the motor aphasia of the normally developed adult.-Characters of motor aphasia.-Its difference from amnestic aphasia.--Res- idues of articulate language in motor aphasia.—Possi- bility of writing in it. Agraphia.- Its characters, localisation.-Complex forms of aphasia.- Associative paths between the various centres.- Influence of education on the development of these paths.—Difference between the two liemispheres as respects the neuropsychic factors of language.-Dysarthric dis- turbances in hemiplegia.—Dyslogical disturbances in the same. W E have hitherto been studying the sensory disturb- V ances of speech : we shall now occupy ourselves with its motor disturbances. Here also we shall find two elementary forms, one related to articulate speech, the other to written speech: in the former we have motor aphasia, in the latter agraphia. Motor, or ataxic aphasia, as it has been called by Kuss- maul, consists in the abolition of the coördination of the movements necessary for the articulation of words, or better to say, the abolition of the motor memory of words. When the child learns to speak, and also when an adult learns a strange tongue, the movements necessary for the phonic and articulate reproduction of the words and syllables heard, leave, in a centre which is specialised in the motor field of the tongue, the face and the lower jaw, the mne- monic image of the associate and coördinate movements [ 305 ) 306 Professor Bianchi. for the several articulate sounds, which, on the one part are in strict relation with the acoustic verbal images, and on the other part, with the correlative ideas—with the ideo- genetic centre. The specialisation of this centre takes place slowly, by long exercise in childhood. Volitional vocalization (vowel utterance) displaces, by little and little, the emotional; many phonic combinations, not yet artic- ulate in the child, are the expression of ideas which are faintly sketched, and are emitted under the action of volitive impulses. The patient who was presented to you in one of my former lectures, must have proved to you that vocalization becomes volitional. With the development of the brain, and exercise, coördination of the articulate movements, at first in mono- syllables, becomes possible; children pass through an educative period, in which language is variously incom- plete, but always on the way to perfectiorment, according to the evolutive laws which I have stated in the preceding lecture. For the movements of language, the same muscles are used as serve for mastication; and it is in the area of the cortical centre of these muscles, that the part for the movements of language is specialised (the foot of the infe- rior frontal)—third, or Broca's. Whenever this centre is destroyed, there is abolition of the coördinate movements for speech, motor aphasia, and there may not be present paralysis of the corresponding muscles. When, through defect of cerebral development, this centre does not attain the due degree of adult devel- opment, we observe the language of idiots, which has been arrested in one of the phases which we have seen succes- sively developed during the growth and education of the child. In asylums for the insane, and still better in estab- lishments for idiots, the whole evolutive history of language might be reconstructed. There are idiots who express their few ideas and emo- tions only by vowel sounds; some others are able to reach as far as monosyllabes. An idiot in the establishment of Lecture on the Origin of Language. 307 Sales furnishes an example. His name is Antonio. Despite all my efforts to teach him to pronounce Antonio, or tonio, I have failed; he is unable to give his own name, unless the last syllable nto; for pane (bread) he says pa. Idiots sometimes vocalize the articulate sounds of each word; at other times they simplify them by shortening; instead of Benevento, an idiot says Beven, thus omittting the dental sounds, as more difficult than the labial. These disturb- ances, in my opinion, ought to be ranked among the aphasias. The aphasia of the idiot stands in relation to that resulting from disease in an adult, who had previ- ously been sound, as the lowest degree of imbecility does to dementia. Just as in the demented we may always dis- cover some residue of the pristine mental edifice, now gone to ruin, so may the aphasic pronounce some words, or some combinations of sounds, more or less insignificant, but always sufficient to bear evidence of a language once developed. A person affected with motor aphasia perfectly under- stands the words addressed to him by another, but he cannot express in words his own thoughts; the ideas are present in consciousness, and in their logical order; the vestment of the idea, as the acoustic verbal image, or also as the visive image, is perfectly conserved, but he is not able to reproduce it as an articulate phonic combination. He cannot repeat what is said to him: sometimes how- ever, he can express his own thoughts, in writing. The essential difference between amnesic aphasia and motor aphasia, consists precisely in this, that in the former the acoustic image of the word is absolutely wanting, and the patient is unable to express himself either in spoken words or in writing, but in the latter the acoustic image is pres- ent as it is in a sound person, and the patient who cannot express himself in spoken words can sometimes express himself by writing his thoughts; in the former it suffices to suggest to the patient the word which fails him, that he may immediately reproduce it; in the latter the repetition of the word suggested is absolutely impossible to him ; in the 308 Professor Bianchi. former he may read aloud (if he has learned to read); in the latter only internal reading is possible (if he has been habituated to it). The majority of those who are affected with motor aphasia, emit some articulate sounds, some monosyllables, such as yes or no, or some more complex articulate sounds, which occasionally are entire words, but at other times have nothing like them in the vocabulary, and sometimes are mutilated and distorted phrases, as cusi, cusisi, very well, etc.; too often they are real oaths, and rather long at that. The afflicted persons, as long as their malady lasts, which is generally throughout life, do not otherwise express their thoughts and emotions, than with that more or less monstrous and always insignificant remnant of the language, which has been abstracted from the dominion of volition, and is ever the same, just as if it were stereotyped. The patient we have studied can emit certain articulate sounds, such as chichi, nonnó, mamma, but if we call his attention to it, he is unable to repeat at will and by selection, any of these articulate sounds; he cannot associate the same syllables in a different order, so as to form, for example, the words manno, nocchi. Further yet, vocalization is often itself withdrawn from the control of the will, so that doing his very best, he would utter one sound instead of another. These per- sons express themselves pretty well by mimicry, and some- times they are able to reduce their thoughts into writing. From the fact that some aphasics can write and others not, we are obliged to admit two forms of ataxic aphasia; in one the aphasic writes, in the other he does not. in the latter case two explanations of the phenomenon may be given: either the lesion causing the aphasia is dif- fused so far as to destroy the graphic centre, or the hypothesis of Lichtheim is true. He believes that the functionality of the cortical graphic centre is subordinate to the functions of the articular motor centre just as in the development of the man and the child, the spoken lan- guage long precedes the written, and the former is a Lecture on the Origin of Language. 309 condition necessary to the latter. Whether then, the doctrine of Kussmaul is true, that agraphia is independent of ataxic aphasia, or the doctrine of Lichtheiin, which teaches that in those cases in which writing is possible, the path between the will and the articular motor centre is interrupted, and this centre is not destroyed, is a ques- tion which cannot be considered as at all exhausted, rather, indeed, is it hardly yet faintly outlined. Agraphia consists in the incapacity to express in writ- ing one's own ideas, in other words, to clothe the idea in its graphic form. We naturally speak of agraphia only when the patient has learned to write, when he has con- served his ideas; and when he is not prevented writing by paralysis of the arm and hand; (the agraphia so fre- quent in advanced dementia is not included in the form of which we are now treating.) Like motor-aphasia, agraphia may be complete or in- complete; in the former instance, the ability to write even single letters is lost, while in the latter letters, and even syllables, or fragments of syllables, may be written; but the patients are unable to associate the different letters as they are required for the regular formation of syllables and words. With all this they are able to hold and direct the pen. They understand one who speaks to them, and they speak more or less perfectly themselves; they possess, therefore, the acoustic verbal images, and sometimes the graphic visive, but in the meantime they cannot reproduce them by adequately coördinate move- ments, such as those necessary for writing; the special coördination of the movements for writing, or in other words, the motor memory of these movements, has been lost. The movements for writing, like those for articulate speech, proceed in specialisation in an area of the motor field of the arm, and exactly in the foot of the second or middle frontal convolution. This is generally now held by all, for genuine agraphia, as I have described it, with integrity of the other elementary factors of language: I 310 Professor Bianchi. should, however, here observe that cases of agraphia are extremely rare in comparison with those of motor aphasia,-a fact that is not difficult of explanation, when we consider the great number of the uneducated, in whom we cannot speak of specialised, visive and graphic verbal centres. Hitherto I have spoken of genuine ataxic, isolate dis- turbances, but certainly the cases are very rare in which we meet with this form. Language, as it now exists, is an organism; its different constituent parts are closely connected and associated. As in all organisms there are essential, vital parts, and others non-essential or accessory, so also is it with the organic factors of language. The accessory parts are represented by reading and writing. The abolition of either, or of both of these, does not damage either the hearing of words, their articulation, or the intelligence and the form of discourse. But far otherwise is the want when verbal deafness or ataxic aphasia is present, since not only the hearing of words, and their articulation, are closely associated, but these two factors govern the whole ulterior development of language, in reading and writing. On the other hand the aptitude, and the course of education of each individual, operate so that the reciprocal influence of the different factors is exercised, now of one and again of the other; that is to say, there are established diverse associative or more numerous paths between some centres, and less numerous between others, by means of which the abolition of one does not always produce a constant phenomenal com- bination. Hence has arisen the great discrepancy of authors, in determining the type of the various forms of sensory and motor aphasia. Nor has the other fact less value; that is, we do not find in every case a lesion constant in its extent and depth ; and from numer- ous associate paths or parts of areas of different phys- iological attributes being included in the focus of lesion, there must of necessity arise a great variety of phenomenal combinations in the diverse forms of aphasia. Lecture on the Origin of Language. 310 Verbal hearing is a condition necessary to the normal explication of articulate language. The idea may some- times be sent forth from the ideo-genetic field, and traverse the motor centre of articulate speech, even perhaps in defect of the acoustic verbal image, which may be substi- tuted by the articular motor memory; but in this case the words are devastated and distorted in various ways; some syllables are omitted, others are added or interca- lated in the word: this disturbance is designated para- phasia. We find it not only after a lesion of the acoustic verbal centre, but also after lesion of the commissural paths between this centre and the articular motor centre. These paths pass through the island, which is included. Parapha- sia has indeed been called insular aphasia (Wernicke). Verbal deafness does not produce paraphasia alone; it is frequently associated with verbal blindness and agraphia. This association does not authorize us to es- tablish a constant genetic relation. Verbal blindness in fact was observed in the cases of Broadbent, Wernicke, Heilly and Chautemesse, but the patients of Skwortzoff, Bernhardt, Grainger and Magnan read correctly. We cannot therefore regard as altogether true the hypothesis of De Watteville, who admits a stabile rela- tion between the acoustic verbal centre and the visive cen- tre of words, by means of a definite commissural fascicle. Writing, which is preserved in some cases, as in those of Burkhardt, Magnan, Girondeau, Bernhardt and Skwortz- off, does not behave differently. Bernhardt's patient replied to questions by writing, and he affirmed by writing; he said, “I hear everything, but the thought corresponding always fails me.” Patients of this class may write before a mirror (Weiss). · Writing was abolished in the case of Heilly and Chautemesse, but in this patient there was. verbal blindness. Agraphia therefore seems to have its certain counterpart, when verbal deafness and blindness are cotemporary, but with verbal blindness alone writing is most generally preserved. Does motor or ataxic aphasia always bring with it 312 Professor Bianchi. agraphia ? So thinks Lichtheim, and in many cases it seems true. In many others aphasics express their thoughts in writing, and Kussmaul makes this an essential character of it. These are two extremes, and both border on the false. The truth is that there are persons in whom the visive image of words, and the graphic memory, are so lively that writing is possible; although motor aphasia is present. Lichtheim holds that when there is agraphia with motor aphasia, the lesion is not cortical, but sub- cortical, near the periphery; and when the lesion of Broca's convolution is properly cortical, there is always agraphia. In the meantime, a case related by Magnan proves that writing may be conserved, notwithstanding the co-existence of verbal deafness and motor aphasia. This signifies that the path conceived for writing, by Lichtheim, which I have mentioned before, may be substi- tuted by one shorter, leading from the ideo-genetic centre directly to the graphic centre, under the government of the visive memory, or the graphic memory of words. Sometimes there is only paragraphia, that is, the words are written mutilated or distorted in every way. I repeat: education and exercise, given certain special individual conditions, increase and develop some paths and some centres rather than others. Besides, as I have already said, the seat of lesion must here exercise no insignificant, perhaps even a capital influence. Let us imagine that a destructive focus interrupts the paths of communication between the intellective field and the centre for the hearing of words. There will ensue, as from the destructon of the latter, verbal deafness and paraphasia ; but the faculty of writing (with paragraphia), of repeating words, of reading aloud, of writing under the interruption is located between the periphery and the acoustic centre, it is not possible, apart from verbal deaf- ness, to repeat words and to write under dictation, but instead, the will may be freely carried out in written and spoken language. Lecture on the Origin of Language. 313 There are no direct necessary commissures between the visive centre of words and the graphic centre, as is believed by some. There may be verbal blindness and not at all agraphia, nor even paragraphia. Here I deem it well to halt a little. I merely desire to remind you, that the great discrepancy of authors, in furnishing to the disturbances of speech a fundamental character, has arisen from their desire 10 create types, as has been that of Broca. Away with types: there are but four fundamental disturbances, and these correspond to the four neuro-psychic factors of language; and the symptom- atic combinations vary according to inherent circumstances, and to the seat of the focus and the individual conditions. I cannot, however, close this chapter on the dysphasic disturbances, with which we have until now been occupied, without calling attention to the much-debated question, as to the very different behaviour of the two cerebral hemispheres in relation to speech. Language is, in the great majority, a function of the left hemisphere. All the parts, to which we have assigned the location of the dif- ferent elementary factors of language, pertain to the left hemisphere only, not at all to the right. As the right side of the body is, through atavism and individual edu- cation, the one that is generally most used, and over which the volitive impulses exercise most control, the left hemi- sphere thus acquires a significant preponderance over the right, in all the motor functions, and perhaps in the psy- chic also. Language is the highest expression of this preponderance of the left hemisphere. When the child accompanies its first articulate sounds with a gesture of the right hand, he graves on the left hemisphere the first association between speech and the movements of the right arm. The right hemisphere does not remain altogether a stranger to language; it partici- pates actively in the emission of the first articulate sounds of the child, when language is most emotional. In pro- portion to the better differentiation of ideas and their connection with words, the activity of the left hemisphere 314 Professor Bianchi. increases, and the right hemisphere remains afterwards as it was in the child. Thus it is that aphasics are able to utter those mutilated, strange words, monosyllables, etc. The right hemisphere coöperates in these organic sounds, such as oaths and the most common words, as Yes (si) and No. This is the opinion of Hughlings Jackson, and it is the most largely accepted. In fact, some cases are registered in literature, which show that aphasia is more grave or absolute when the lesions are bilateral. Thus the patient of Vernet, who had, on the left, only a hem- orrhagic focus on the island, was completely aphasic, a fact which could be explained only by another focus that existed on the right, and which involved the root of the third frontal convolution. The following are positive facts: the child speaks with both hemispheres; left-handed per- sons do not become aphasic from destructive foci in the left hemisphere, but from foci in the right one; between the centre for articulate speech and the homonymous part of the right hemisphere, there exist commissural fibres. The assertion of Biot, who concedes as much importance to the right hemisphere as to the left, in the manifesta- tion of language, is as insubsistent and strange as it is devoid of any fact in proof of it. It occurs to us, sometimes, to observe hemiplegics with disturbances simply in the articulation of words: dysar- thric disturbances, as they are now called. These are very rare in simple destructive foci of the brain, excepting when the focus is located in the pons, or in the medulla oblongata, or when a focus exercises, from its proximity, a paralyzing action on these organs. There are, besides, hemiplegics who, from grave paralysis of the face, and deviation of the tongue, do not succeed in regularly form- ing sounds, especially the labial and also the dental. From lesion of the pons and the medulla oblongata, articula- tion is often quite impossible; vowel sounds are emitted with indistinct articulation, sometimes with a nasal tone (from paralysis of the lips, the tongue, the velum palati, etc.); at other times that special coördination, the relation between Lecture on the Origin of Language. 315 vocalization and respiration, is altered, and hence we observe some things that resemble stammering or scanning speech. With exception of these, all the other dysarthric dis- turbances of speech in hemiplegics, belong almost exclu- sively to degenerative processes diffused over the whole cortex, or also within the central mass of the hemispheres and the mesocephalon. The like may be said as to dislogical and syntactical disturbances, or agrammatism. These are observed when profound disorder of the intellect has already been ob- served (intellectual decadence in dementia, in protracted forms of paranoia, general paralysis, etc.), or when hemi- plegia has struck one already insane, or the destructive focus (ordinarily in these cases of great extent) had pro- foundly shaken the intellective edifice. The more important bibliography relating to the neuropsychic disturbances of speech. Bouillaud (Archiv de Medic., 1825). Dax (Cong. de Montp., 1836). Broca (Bullet de la Societe Academique, 1861). Trousseau (Clinique de l'Hotel Dieu). Jaccoud (Leçons de clinique Med., 1874). Wernicke (Der aphasiche symptomencomplex, Breslau, 1871). Bastian (Paralysis from brain disease, London, 1875). Tamburini (Rivista speri- mentale di Freniat. e Med., Leg., 1876). Kussmaul Enci- clopedia delle Ziemsen, 1877). Broadbent (Med. Chir. Transactions, 1872). Bristowe (Brit. Med. Journ., 1879). Bateman (on Aphasia, 1870). Ogle (St. George's Hospital Reports, 1867). Bastian (Le cerveau organ de la pense, 1882). H. Jackson (Brain, 1880). Raggi Rivista clinica di Bologna, 1871). Schmidt (Allgemeine Zeitschr. f. Psych., 1871). Broadbent (The Lancet, 1871). Kahler and Pick (Viertel-jahreschrift. f. d. prakt. Heilkunde, 1879). Weiss (Wiener Med. Wochens, 1882). Burckhardt (Corresp. f. Schweizer Aertze, 1882). Girondeau (Revue Mensuelle, 1882). Heilley et Chautemesse (Progres. Med., 1883). Wer- nicke (Lehrbuch der Gehirnkrankheiten, 1881-83). Char- cot (Differenti formi di Afasia-Lesione raccolte e publicate 316 Professor Bianchi. del Prof. Rummo, Milano, 1881). Lichtheim (Brain, part 18). McBride (American Journal of Neurology and Psychiatry, 1883). Schwortztoff (De la cecité et de la sordite des mots dans l'aphasie, 1883). Brugia (Archivio Italiano di malattie nervose, 1880). Seppilli (Rivista sper. di Fren, e Med. Leg). Ball (L'Encephale, 1883). De Rause (Gazette Med. de Paris, 1883). Grainger Stewart (Edinb. Clin. and Pathol. Journal, 1884). Bitot (Archives de Neurologie, 1884). De Watteville Progr. Med., 1885). See besides, the rich collection of cases by Prof. Luciani. Sigismond Berthold (Kind und Welt-Braunschweig, 1856). Darwin (Biographische skizze eines Kindes. Ediz tedesca, 1877). Preyer (Die Zeele des Kindes, Leipsig, 1881). Vierordt (Anat und Physiologie des Kindesalters, Tubingen, 1881). Taisal (Revue Phylosophique, 1876). Loebisch Entwickelungsgeschichte der Seele des Kindes, Wien, 1851). Preyer (Psychogenesis, Deutsche Rundschau, 1880). Schultze (Die Sprache des Kindes). Sikorsky (Archiv de Neurologie, 1883). The foregoing references certainly indicate no meagre acquaintance, on the part of Italian physicians, with the medical literature of other countries. Let us reverse the shield, and behold the emblematics of John Bull and his Jonathan cousins. What a beggarly showing do we not make? It must be least uncomforting to those who have forgot, or never have learned how to blush. The reprint of any Italian scientific work, either in England or America, might take rank as an eighth world's wonder, “Wisdom is justified of her children.” English and American pub- lishers have a magnificent monopoly of the commodity. Is it the fact, that the uncouth barbarism of our own tongue inspires us with a horror of all those of other nations, and coils us up into that fat, contented ignorance, which promises to become our inalienable inheritance ? The Scientific Rationale of Electro- therapy.* A REVISED PAPER ON THE THERAPEUTIC APPLICATIONS OF ELECTRICITY. By C. H. Hughes, M. D., St. Louis, Lecturer on Neurology and Electrotherapy, St. Louis Medical College, etc. L VER since Thales of Miletus, six hundred years be- fore the Christian era, discovered the power of electron (amber) after friction to attract light bodies, electricity has been a subject of general wonder, whether displayed in the electric eel, in instruments of man's construction, or in the batteries of the great Omnipotent, when the electric currents of the clouds are seen or heard in light- nings and thunder. And since Swammerdam, toward the close of the sev- enteenth century, saw a frog's leg contract through its influence, and Galvani, a century later proved it, this wonderful force has presented a peculiar and increasing attraction to scientists; and ever since our own Franklin, who, with lightning hand, grasped God's hand in nature and brought the convulsive force of the clouds to earth, it has been a subject of therapeutic study in this country. For in 1758 he applied it to disease, and caused a * Read before the St. Louis Medical Society, January, 1887. NOTE.-For many years we have endeavored to study electricity with that rational and scrutinizing credulity and reasonable confidence in the powers of pature which should ever characterize the true physician. We have sought for the facts upon which the power of this agent to modify organic conditions and processes are based. Such as they have appeared to us, we here record them, in justification of the therapeutic faith that is in us. It is hardly necessary to add that this paper does not claim to be an exhaustive showing of the therapeutic capabilities of electricity, but only a cursory exhibit of its principal therapeutic powers as a working basis for the practical physician. It will serve to show why we employ it in the treatment of disease though it does not give every valid reason for its employment, and it is in- Tended rather for the general practitioner of medicine to read in his office, than for the expert electrician in his laboratory. [317] 318 C. H. Hughes. paralytic hand to regain, in great measure, its cunning; and before him, in Geneva and the metropolitan centers of all Europe and Great Britain, its powers over disease had begun to be a subject of investigation. Its promiscuous, purely empirical employment by the unprofessional, among thein the renowned and Reverend John Wesley, and the exalted claims put forth for it by its hopeful votaries, raised public, expectation so high that a reactionary in- credulity concerning its powers took the place of pre- vious faith, when its many failures became as well known as its published miraculous cures. For though Watson by it cured a child of chronic congenital muscu- lar spasm (something akin to the later discovered Thom- sen's disease) and Brydone, Nilson and DeHaen, cases of long standing deafness, and it had been successfully used by a surgeon of Leeds in amaurosis, and others had re- lieved neuralgia, headache, rheumatism and chorea, the disappointments and accidents which followed its incau- tious and unskillful employment counteracted the good impression made by these physicians. Quacks and mountebanks seized upon it because of its astonishing power, and being reckless and indifferent to its dangers, as they are to this day, employed it without .caution, and promised cures it could not, in their hands at least, perform. Out of this ill usage of a truly good remedial agent, the false hopes raised, and unfulfilled promises made, grew distrust in the professional mind, which, to some extent, still abides, but which is destined, under the more certain and definite light now being thrown upon this subject, to give way to its confident and satis- factory employment in therapeutics. Neurotherapy has taken the lead, but general therapy must and will invoke its certain aid in all those morbid conditions in which its therapeutical utility can be dem- onstrated. It is one of the greatest forces of nature and destined, in my judgment, to play as important a part in influencing, and controlling morbid conditions in the human organism, The Scientific Rationale of Electrotherapy. 319 as it exerts upon inanimate nature, as displayed in its employment in physics, the arts and the natural sciences. To employ it aright in therapeutics we should study well its precise powers over the physiological and chem- ical actions of the organism, and to an inquiry into these powers we first address ourselves. These are its physical effects on the system, and to understand them thoroughly is to find out a rational basis for its successful thera- peutic employment. With this enlightenment the stone which the earlier therapeutic builders rejected, is destined to become the head of the corner in the new remedial foundations in the temple of therapy. CHEMICAL AND PHYSICAL CHANGES IN THE SYSTEM, INDUCED BY DYNAMIC ELECTRICITY. ABSORPTION AND ENDOSMOSIS.—While strong galvanic currents can arrest endosmosis, mild induction currents have a contrary effect. Remak promoted this physiolog- ical phenomenon by placing the positive pole on edema- tous parts, and the negative pole between the swelling and the cerobro-spinal axis. If two small blisters are made upon the skin, and the positive pole be placed on one and the negative pole on the other, and a strong current be passed between them, the blister under the positive pole will become dry within a quarter of an hour after the electricity has passed, and under the negative pole a new blister will be found. This law of electrical promotion of endosmosis can be proven out of the body: If two platinum electrodes should be connected with a constant galvanic current from ten or twelve cells, and then be immersed in pure water, the negative or zinc terminal within a porous vessel, and the positive or car- bon terminal outside of this porous medium, the water in the inner vessel will accumulate in two hours to a level about one-sixth higher than that in the outside (Amory, 320 C. H. Hughes. p. 291). There is a flow of the fluid through a porous septum from the positive towards the negative pole. Likewise in pure electro-cautery the eschar under positive pole is paler, dryer and harder than that under the negative pole which is soft and moist. Remak was the first to observe this, and Legros and Onimus first explained the phenomenon upon the hypothe- sis of vascular contractions, a physiological fact, since abundantly confirmed, but the power of electricity over endosmosis was known to Detrouchet. EFFECTS ON NERVES AND FLUIDS.—The nerves and fluids of the body are good conductors, and it is through nerves and channels of moisture that with galvanism or Faradism we can get into the interior of the body in certain direct lines from pole to pole, in certain parts. Schiff asserted that the passage of an induction current through a nerve produced appreciable elevation of tem- perature, and very strong currents must, undoubtedly, heat and destroy nerves, as the galvano-causty current heats the wire, but heat is mostly developed in a part by increase of vascular supply through muscular contraction and reaction- ary influx of blood after brief vasomotor stimulation and arteriole contraction. The opposite state of heat-depression through electrically-induced anæmia, would likewise occur if applications were not too prolonged. Nerves may be damaged by crossed currents, but they cannot be excited to physiological action by electricity applied in this way. Galvanic, Faradic and static currents may be made to penetrate the cavities of the body, the two former only through connecting the body with both poles, the latter in this way and also by electrical discharge. Faradic electricity is, however, more a surface current than galvanic. The Faradic and static forms of electricity exert greater power over the voluntary muscular contractions than the galvanic. The galvanic exerts its most beneficial influence on the non- striated muscular fibers through the vasomotor mechanism. The Scientific Rationale of Electrotherapy. 321 It may be sent to remote interior parts with more cer- tainty and accuracy and less harm than other currents. It can be passed through the brain, and is the only current which, as a rule, in the present state of our knowledge, can be safely employed, to any considerable extent, upon the interior of the head. A Faradic current, from center to periphery, causes stronger muscular contractions than from periphery to center. CHEMICAL EFFECTS-ELECTROLYSIS.—Electrolytic de- composition is the chief chemical effect of electricity, acids being formed and liberated at the positive electrode, and alkalies at the negative. When muscles, severed from the living organism, are subjected long enough to electric cur- rents, the mineral acids, sulphuric, nitric, muriatic and phosphoric, are formed at the positive pole, and potassa, soda and ammonia at the negative electrode. This decomposition at the poles is due to the acids and alkalies formed at the respective poles; for if alkalies be placed at the positive pole to neutralize the acids, and acids at the negative pole to neutralize the liberated alka- lies, no blister results. It can be shown that any internal decompositions take place in electrolysis when the ordinary currents are used. The decomposed elements of the organism appear only at the electrodes. . This is an important point with reference to constitu- tional electrization, and also shows the probable fallacious- ness of the claims of certain quacks that they have been able to extract the mercury and other poisonous min- erals put into the system by the regular profession. Its POWER TO COAGULATE THE Blood.—Electrical cur- rents passed through the blood in sufficient strength cause it to coagulate at both poles, but chiefly at the positive pole. Heidenriech found the coagula at the positive pole to 322 C. H. Hughes. be composed mainly of albumin, fibrin, fat and acids ; chlorine also appeared at this pole. The coagula at the negative pole were made up mainly of iron and the alkaline and earthy bases. The watery and alcoholic extracts and coloring matter also appeared at the negative pole. The contractile power of electricity over surrounding muscles and its influence over the ganglionic system added to the coagulating power, contribute to the cure of aneurism, by toning and contracting arterial walls, es- pecially of the small arterioles in miliary aneurisms, and strengthening the vessels by artificial, walls of fibrin, etc., when electrodes can be inserted. In 1869, Cliniselli reported out of twenty-one aneurisms treated by voltaic electricity, fourteen successes and seven failures. Inflammation and gangrene set in in five of the failures, probably because too strong a current was used. He used a current of sixty to eighty piles of large surface elements. The current emitted bright sparks and its ten- sion was greater than necessary for mere coagulation of blood. Out of nineteen aneurisms treated by the batteries of Wollaston, Daniel, Bunsen and Senée, there were eight cures and eleven failures. Of the eleven failures four failed because the operation failed, five died and two were made worse. Grave accidents followed in all the eleven. This was in the earlier days of galvano-puncture for aneurism. Since then numerous successes have been reported by different surgeons, and likewise many failures. I do not think the coagulation should be so much aimed at, especially in the aorta, as tonicity to the weakened arterial walls; and I believe it would be better to apply the current along the arterial walls and to affect the vasomotor ganglion supplying the affected artery, where practicable, by a number of preliminary mild treatments, say fifteen or twenty daily séances, if that much delay were admissible before resorting to the puncture. Hamilton has reported one hundred and twenty-six cases, out of which there were forty-six recoveries. He might have had more recoveries had he treated his The Scientific Rationale of Electrotherapy. 323 cases earlier and endeavored to affect the tonicity and im- prove the strength of the arterial walls by electrization, preliminary to galvano-puncture. In all such cases I would insulate the patient daily and give him a quiet charge of positive static electricity. Some put the positive pole in the sac. This pole makes the firm clot, the negative makes the soft one. Althaus and Pepper employ both. I believe it is best to put in only the positive pole. It is said that clots formed by electro- lysis have not been known to dislodge and cause embolic closure of distant vessels. This statement is not proven. This coagulable power of electricity suggests its value in purpura hemorrhagia, varicose veins and hemophilia. I have employed it to some extent in these states, but not alone because of its power of coagulating the blood, and not without the aid of static electricity. Static currents of a certain strength not only produce decomposition of blood, but they exert a physiological action over the vessels, as already intimated, which will claim our attention later. We are now considering the locally disintegrating power of electricity. The blood is here disorganized, and its component elements are separated by chemical action. In it the scientific therapeutist has the control of a great power for good or ill, just as the machinist and the engineer have in steam a great power evolved from the disintegration of inanimate matter, and either, according as they are used, may benefit or destroy. The judicious physician will not ignore this power because of its strength for evil any more than he rejects a potent drug because in improper hands it may do harm. GALVANO-CAUTERY.—Next to the electrolytic power of this agent is the galvano-cautery which is direct disinte- gration by heat destruction. The heat is developed by the quantity of electricity and the degree of resistance in the conductor. It is the most perfect form of actual cau- tery because it is a fire without blaze or smoke, which 324 C. H. Hughes. may be lit and extinguished at pleasure, and definitely circumscribed. It stops hemorrhages as the ancients did (with boiling oil) but in a more refined, less formidable and less painful manner. Ends of nerves may be instanta- neously destroyed by it in a part, and after that there need be no pain. It may be made to cut with the pre- cision of the knife in certain otherwise inaccessible parts, and it leaves an eschar that protects against hemorrhage and infection. (There are obstacles in the way of suc- cessful galvano-cautery in certain regions and tissues, which it is not germane to our present purpose to dis- cuss.) It requires a skilled hand in its use, just as the surgeon's knife does, and may kill or cure; but the surgeon does not hesitate to resort to a daring amputa- tion, because, perchance, the only knife at hand may be an assassin's dirk. ACTION ON THE NERVOUS SYSTEM.-Electricity has the power to contract muscular fiber, both striated and non- striated, and in non-striated muscles the temperature rises very sensibly, often as high sometimes as four or five degrees Fahrenheit. The temperature change is due mainly to the muscular contractions and circulatory changes. In the beginning of electro-muscular contrac- tions there is, according to Ziemssen and others, a slight lowering of temperature, but Ziemssen found, after Faradic contraction had been continued for a few minutes, the temperature began to rise, and continued rising till it reached an increase above normal of one to two degrees centigrade. The maximum temperature was reached after cessation of contractions. Here are two other therapeutic powers-muscle-contraction and heat-production in a part. Faradic or induced currents contract the voluntary muscles more powerfully than galvanic or voltaic. The real cause of this difference is not certainly known. of the two currents, but this is not known. The contractile effect of galvanic currents, even when The Scientific Rationale of Electrotherapy. 325 interrupted, is markedly less on voluntary muscle than those of Faradic electricity. When nerves or muscles undergo alteration, their im- pressibility to electric stimuli generally diminishes, and a longer and stronger current is necessary to promote con- traction, but there is an exception to this law in certain states of muscular degeneration. When from any cause striated muscles undergo a cer- tain kind of generation through central nerve conditions, and they lose their striated character, they contract more readily to the constant current—this is the reaction of degeneration. Electrical currents have the following effects on the muscular system in disease : 1. There are cases of peripheral paralysis, when the muscles do not contract either under influence of the will or of voltaic or Faradic currents, and I have found some cases will not respond to static shock. 2. In some cases motility is in part preserved, but neither the affected muscles nor their motor nerves are excitable by induced or voltaic currents. Eulenberg found this the case in rheumatic and facial paralysis. 3. Motility may be entirely extinct, while muscular excit- ability for both kinds of currents is equal and weakened. 4. The muscles and their motor nerves have lost all contractility under influence of the will and of in- duced currents, while it is increased for voltaic currents. Observations give the following phenomena in such cases : · A-during absence of motility.-1. The contractility of voltaic currents is increased; a very feeble current, which would cause no sign of contraction in healthy muscles, produces energetic contractions in the paralyzed muscles. 2. Voltaic excitability increases during the course of treatment, rapidly reaches its maximum, and then diminishes. 3. Voltaic excitability is not always increased at the same time in all the branches of the paralyzed nerve. In the least excitable muscles and nerve branches it increases and diminishes more slowly than in those which are more so. 326 C. H. Hughes. . ") 4. The contractility produced by voltaic current is less rapid for the paralyzed muscles than for the healthy ones. 5. The contraction often occurs only by direct irrita- tion of the muscles, and not by irritation of the corre- sponding motor nerve. 6. The voltaic excitability is gradually lost with the return of voluntary movements, whilst the Faradic excit- ability gradually returns (Schulz and Ziemssen). 7. The voltaic excitability is gradually lost with the return of motility, but Faradic excitability remains extinct despite restoration of motility. The excitability for all kinds of currents becomes normal slowly, and in like proportion, after several months or years. 8. Faradic excitability, although reappearing, remains more feeble than for corresponding muscles of healthy side. 9. Voltaic excitability remains the same, and Faradic excitability never returns. These conclusions are true for rheumatic and trau- matic paralysis, and also for diphtheritic and cerebro-spinal fever and some other post-febrile paralytic states. The same differences between voltaic and Faradic currents has been observed by innumerable observers since Ziemssen, Eulenberg, Legros and Onimus first noted them in cases of muscular degeneration, and in lead palsy, where the voltaic current (fifteen elements) caused no con- traction of the healthy muscles, but only of the common extensors of the fingers, extensor proprius of index finger and the extensors of the throat, that is to say, those muscles in which Faradic currents caused no contraction. After even this incomplete review of what we know to be the power of electric currents ought not pessimism to stand aside and skepticism to be abashed. For one, we confess ourselves to belong to that class of “happy thera- peutists” at which Möbius sneers and other German phy- sicians smile. Despite all incredulity and the opposition of the faithless this great and wondrous force is destined to become as indispensable and powerful in the cure of The Scientific Rationale of Electrotherapy. 327 disease as it is indispensable and powerful in the arts and in the economy of nature. But this is only a part of what we positively know of its powers. In the next number this review of its powers will be extended into a domain still more interesting to the neurotherapeutist. NOTE –The reader will perceive how rational the basis for the employment of electricity on the foregoing facts and those to follow in the next paper as compared with such reasoning as appears in the following, which may be found in two works by irregular practitioners, whose authors it is needless here to mention. These writers substitute an unproved and improbable theory for proven fact, and like the blind leading the blind, they go into the ditch together. The theory fixes the nature of the supposed disease and the diseare corfirms the theory, and thus the vicious circle of their reasoning is complete. The electricity of these fellows is generally of a most positive and shocking kind, and their ignorance and assurance are as positive as their electricity. Muller's idea of weak currents, with which he bas done so much, finds no place in such positive and sensational minds. Indeed they have evidently not carefully studied any scientific treatise on the real powers and uses of the electric currente: " The reader will bear in mind that all acutely inflammatory or hypersthenic affections are electrically positive in excese-having too much vital action-being overcharged with the electro-vital thuid; and that all paralytic diseases, or those of sluggish, azoodynamic character, or electrically negative, having too little electro-vital puid, too little vital action. It is a universal law of electricity that pos- itives repel each other, and that negatives repel each other, but that positives and negatives attract each other. This is a principle of electric action everywhere known where anytning is known on tbe subject. We appropriate it practically to thera. peutic purposes. Therefore, when I wish to repress or repel inflammation, which is electrically positive in excess, I put the positive pole to it; or, at least, I bring it under that half of the circuit with which the positive pole is connected, and as near to the pole or electrode as possible. And because two positives repel each other, and also because the direction of the current is always from the positive to the nega- tive pole, carrying the electro-vital fluid with it, either I must withdraw my positive electrude, or that excess of electro-vitality in the diseased part which makes it mor- bidly positive, and thus produces inflammation, must give way. I will not withdraw my positive pole, and therefore the positive inflammation must retreat and be dis- persed. In treating this case, I will place my negative electrode either on some healthy part, or, if there be perceptible anywhere in the system a morbidly negative part, as is often the case, I will place my negative pole there. For example, if I am treating for nephritis-inflammation of the kidneys,when I do not perceive any part to be abnormally negative, I manipulate with my positive electrode over the in- ative electrode placed at the coccyx, the lowest part of the spine. My positive pole repels the positive inflammation from the kidney; or, rather, repels from it that excess of electro-vital fluid which makes it morbidly positive and induces the inflammation, while the negative pole attracts the same towards the coccyx. On its way it becomes more or less diverted to adjacent nerves; or, if gathered in the healthy part, under the negative pole, it is immediately dis- persed by the normal circulation as soon as the electrode is removed. But if I find a spinal irritation, say in one or more of the cervical cr dorsal vertebræ, and, at the same time, a stomach affected with chronic dyspepsia, accompanied with constipation of the bowels, I will work over the inflamed or irritated spine with my positive pole, because I know from the irritation that there is an excess of electro-vital fluid in the part, making it improperly positive; and, with my negative electrode, I will at the same time, treat over the stomach, bowels and liver; because I know, from the in- action of these organs, that there is a lack of vital torce, a deficiency of the electro- vital fluid, there, and that, cunsequently, they are too negative." A Case of Intermittent Epileptic . Aphasia. * By F. BATEMAN, M. D., Physician to Norwich Hospital. PRESUME the title which I have chosen for this article may excite surprise. Having myself been a pupil of the celebrated pathologist Piony, who was the first to propose a systematic nomenclature, which should express correct ideas of pathology, I would not like to use expressions less explicit concerning the anatomical and pathological condition of the patient. However, in cases where the pathogenesis is doubtful, it is bad policy to use terms that would convey an idea of a well estab- lished diagnosis. Both of the cases here reported are of this nature, and still they present so many complicated symptoms that I publish them, hoping that the combined experience of my readers will furnish us with an expla- nation of the morbid condition which I have expressed by the term “Intermittent Epileptic Aphasia." . Case I.--M. D- , a miller, aged twenty-seven, a teetotaler, was admitted to the Norwich Hospital, on the third of May, 1884. His previous history in regard to any neuropathic hereditary tendency was as follows: One of his sisters was a subject of hysteria; but, except this, the information obtained about his family was of a nega- tive character. He had always enjoyed good health up to the month of December, 1884 (twenty months after his marriage), when he became the victim of pains in the posterior aspect of the head down to the nape of the neck. These pains were so severe that when an attack came on he would leave the house and run aimlessly about out-doors, and his appearance was such that people in the neighborhood thought him to be insane. Shortly • Translated from "L'Encephale" for January and February, 1887, by Conrad Richter, M, D., Assistant Physician, Milwankee Sanitarium for Nervous Diseases. ( 328 ) A Case of Intermittent Epileptic Aphasia. 329 afterwards when his physician, M. Long de Wells, saw him, he was more quiet and tried to explain by signs that he had peculiar pains in his head. Now it was observed that he had completely lost speech. As he had no sign of any kind of paralysis, M. Long was puzzled by these symp- toms, and told me that if the patient had been a woman, he would have believed her to suffer from a violent attack of hysteria. M. Long added that at the same time the ability of recognizing the actual condition of things was at fault in his patient, or as he expresses it, his patient was suffering from “unreality.” Bromide of potassium was prescribed, which seemed to quieten him. The aphasia, however, persisted for four days, after which time speech suddenly returned, and the patient was then enabled to take up his regular occupation. Four years passed, during which time he always en- joyed perfect health, when about five weeks before he entered the hospital, he left his work, saying that he felt as if there had to come a crisis. He was again the subject of pains in the posterior aspect of the head, and became so violent that it took two men to bring him home. Arrived home, he seemed to be out of his senses; he even threatened his own children, and they had to be taken away. Upon the arrival of M. Long, he had be- come calm, but suddenly speechless, and pointing with his fingers to his head, seemed to be reasonable. As he had not regained the power of speech after the elapse of five weeks, he was admitted to the hospital. Condition of the patient at the time of admission.AC- tual Condition : The patient seems to be quite well and does not present any abnormal symptom except the com- plete loss of articulate language for the period of five weeks, with the exception of two hours, a week ago. Although the faculty of articulate speech is completely lost, the general faculty of language is not extinguished, for the patient is capable of expressing himself by writing as well as by sign-language, and it so happened that one of the internes understood the deaf-mute sign-language. 330 F. Bateman. In this way they conversed with each other. The patient could produce phonic sounds, and neither his lips nor the muscles of the palate or tongue were paralyzed. All these organs were perfectly at the will of the patient, with the one exception-speech. His mind is clear, normally active; he finds the right words, but the difficulty is in articulation. That his hearing is intact and that he clearly comprehends spoken lan- guage is proven by the fact that he can write down what is said to him. Five grammes of bromide of potass. are daily prescribed for him. The 13th of May: On visiting him this morning, nine days after his entrance into the hospital, I note that he speaks without difficulty, as his speech has returned at twenty minutes to eight o'clock in the morning, after a speechless period of six weeks and two days. He gives the following interesting facts of the invasion and disap- pearance of the aphasia, both of which, as he says, are preceded by what he calls “attacks;” and between those attacks he makes a distinction of "silent attacks and at- tacks without loss of speech.” Asked to describe them, he says that the silent attack is preceded by an intense heat at the nape of the neck, followed by a very strong pain at the same place, and this makes the impression upon him, as if several bullets starting from his back in an upward direction produced the sensation of an ex- plosion on arriving at the neck, and then speech is lost. The attack, in which he does not lose speech, is not accompanied by any pain. It starts from the spinous processes of the lumbar vertebræ and ascends to the nape, and speech returns immediately, preceded by a sort of trembling and shaking. The 14th of May: The faculty of speech returned yesterday has only lasted fourteen hours, for at noon to- day, those pains in the neck, or as he calls them, silent attacks, return and he is speechless again. The inter- rupted current is used from tongue to neck, in the hope of re-establishing speech, but this is without avail. A Case of Intermittent Epileptic . Aphasia. 331 The 15th of May: The speech has not, at any time, been perfect, and phonation has also gradually disappeared. He is incapable of producing any sound from his throat; trying either to sing or otherwise, nothing is heard but a sort of growling, which is hardly perceptible. His muscu- lar force examined with the dynamometer shows 37 to the right, and 27 to the left. The 16th of May: To-day he is able to speak; speech returned at seven o'clock in the morning, after three days of silence. I am told the following facts: Yesterday, at eight o'clock in the evening, feeling a pain in the neck (his usual attack) he got up and wished to have adminis- tered a cold douche upon the spine; this was without any effect. At ten o'clock he went to bed without pain; between midnight and one o'clock in the morning, he had an ordinary "attack," and without informing the nurse, took as hot a bath as he could endure, and slept after this till a quarter to four o'clock in the morning. The pain had disappeared from his neck, but it could be seen that one of his “attacks accompanied with speech” was starting again in his back, and grew to such an intensity, that, ignoring the nurse, he took a second hot bath. At half-past five o'clock he began to speak, at first indistinctly, gradually better and better up to seven o'clock, when he spoke perfectly clear. His voice is, to-day, more hoarse than it was at the last return of speech, and the patient remarks that his voice becomes more and more hoarse each time it returns; the warm baths seem to have relieved his pains. The 19th of May: Eleven o'clock in the forenoon, patient has been well and without pain since the return of speech on the 17th. He complains, however, of slight pains in the lumbar region, at half-past one o'clock. The 22nd of May: Speech has disappeared, all of a sudden, at half-past three o'clock in the morning, after half an hour's pain in the neck. The 26th of May: Electricity has been employed at 9.30 in the evening, to counteract an “ordinary” attack of 332 F. Bateman. pain. The pain has been relieved, and has entirely dis- appeared at eleven o'clock in the evening. The 28th of May: Again an "attack accompanied with speech,” beginning at 6.30 in the morning; speech, which had been lost for ten days, returned gradually. The 30th of May: Pain at the nape of the neck at 9.30, loss of speech, immediate use of the Faradic current. The 31st of May: Speech has returned to-day at two o'clock in the afternoon, having been preceded by pains in the back. The 3rd of June: The pain in the neck returned at nine o'clock in the morning; Faradization has been used, and after the lapse of an hour and a half, the pains have stopped without speech having been lost. An interne, M. Kempster, has observed that if electricity is used at the time of these crises, the aphasia is prevented and speech is preserved. The patient himself has the greatest confi- dence in Faradization : “It soothes my pains and saves my speech,” he says. The 4th of June: His urine is charged with oxalates, and the following prescription is therefore given: R. Acidi nitro-muriatii . . . 3 ij. Tinct. Colombo . . . 3 iv. Infus. Gentianæ . . q. s. ad 3 viij. M. S. One ounce, three times a day. At 4.30 in the evening, while in the chapel, he was taken with pains in the nape of the neck, and lost speech. The 8th of June: Speech has returned; its return has been preceded by pains in the back. Shower douches have been administered. The nith of June : Pain in the neck at a quarter to eight o'clock in the evening, followed after application of the douche, by loss of speech at 8.30. The 16th of June: The douche has been administered every day at 4.30 in the evening, and after each douche the pain in the back is felt and is followed by the return of speech at 8.30, after an interval of five days. The 19th of June: Pain in the back at four o'clock A Case of Intermittent Epileptic Aphasia. 333 S that the pa: Carance in the morning; speech is lost gradually, the pain ceases at 5.15 in the morning. The 21st of June. Speech returned at ten o'clock in the evening, after the usual pains in the back, when the patient was asked to give his ideas on the disappearance of speech. He answers, that in his opinion the pain in the neck is responsible for it; he adds that he never had those pains in the back without the return of speech fol- lowing them. Patient says that the pains of both varieties are much diminished in intensity. The 26th of June: A quarter-past eight o'clock in the morning, pain in the back till a quarter-past nine o'clock, but without loss of speech; the pain was less sharp in character than usual. The 28th of June: Speech was lost at twenty minutes to five o'clock in the morning, after the occurrence of pains in the neck, and it returns at half-past three o'clock, having been preceded by slight pains in the back. The 3rd of July: He has preserved speech. The patient has not urinated for forty-five hours. He says that he has had difficulty in urinating for several months, and that sometimes he has had retention of urine for twenty- four hours. When speech disappears he says, “these urinary disorders are lessened.” Oxalates are always present in the urine in large quantities. This morning I have been witness of an “ attack in the back.” It was wholly of an epileptiform character. I observed contractions of the muscles of the posterior part of the neck-genuine clonic contractions- followed after each convulsion by a sort of tonic con- traction of the muscles. He seemed to suffer a good deal, and put his hand upon the nape of the neck, as if in so doing he soothed the pain. The attack lasted a little less than an hour, and he said that he felt weak on the right side of the body. After this he rapidly recovered his health. He was markedly benefited by Faradization and he was dismissed recovered, after a residency in the hospital of eleven weeks. -334 F. Bateman. Case II.—I have also observed, another similar case. The subject was a laborer, twenty-eight years old, who presented himself at the dispensary of the Norwich Hos- pital. His previous history is as follows: He had pre- viously enjoyed good health until the past nine months, during which time he busied himself with his usual work. He was subject to vertigo, the room apparently turning around. He had to give up his work and returned home very much troubled, staggering from one side of the walk to the other, so that he was taken for a drunken man. This symptom of vertigo was for about a month the only one, so that he took up his occupation again and did not cease to feel well up to the day he was taken sick again while at work; his symptom then being a thick- ness of the tongue. This sensation returned several times each day, having each time the duration of about half an hour. This thickness of the tongue was the only morbid phenomenon during a new period of one month; but one day, while taking a meal, two or three minutes after the begin- ning of the sensation of this thickness of the tongue, he lost speech, and to use his own language, he had “become mute." He was telling his wife that this sensation had begun, and she, asking him if it grew better, saw him shake his head, as he was utterly unable to answer, and could not pronounce a single word. This incapacity of speech and this thickness of the tongue persisted for three-quarters of an hour, when both disappeared simultaneously and he was able to speak as usual. He told me that he was so very uncertain of being able to speak when he had to, that whenever his employer sent him to make purchases, he would write down in advance what was necessary for him to say, for fear the loss of speech might come upon him and leave him incapable of expressing himself. Fur- thermore, he stated that he had never had any venereal disease, but that he was an habitual smoker. While we were talking together, he notified me that this sensation of thick tongue began to be felt by him, but that speech still remained. I pricked his tongue with a pin, which he A Case of Intermittent Epileptic Aphasia... 335 did not feel. Answering to another question, he told me that his tongue is not immovable when he loses speech; he can move it in all directions, but to protrude it is diffi- cult, and he can only retract it half its length. I did not follow up this case. It is sufficient to say that the patient has remained subject to these periodic attacks involving the tongue, temporarily suspending the faculty of articulate :speech. As the patient has failed to come to the dis- pensary I have lost sight of him, but from the information which I have received I believe that the patient has died from bulbar paralysis. Such are the facts. It remains only to interpret them. We will not try to make them conform to the doctrines of cerebral localization; the elements to attain this are wanting. We will only try to study the pathogenesis, keeping ourselves exclusively in the domain of general facts. Pathogenesis. Was there any persistent pathological change in the nerve centers of the patient who was the first subject in the two cases observed? The symptoma- tology of this case was studied correctly; but it is not easy, from a pathogenical point of view, to attribute these symptoms to changes in the organic mechanism; and, as I myself was in doubt about it, I acquainted one of the greatest authorities in neurological matters in London, with the facts, and he frankly admitted that the case was obscure, A superficial observer would have concluded, without hesitancy, that we had to do here with an exaggerated case of hysteria. Well then, to begin: Hysteria is extremely rare in the male. Of three hundred and twenty-two cases cited by Hammond, only three were males. Furthermore, M. D— is entirely free from an “hysterical diathesis.” He is not subject to emotions; his will-power is not disturbed; he has neither hallucinations nor illusions. The recognized cases of hysterical aphasia do not have any resemblance to this one. 336 F. Bateman. Kussmaul gives the following observation, which is the type of these cases: A cook was a subject of these spells of muteness, which sometimes took place several times a day, and lasted for several hours. During such a spell she was unable to speak a single word. Every kind of treatment was employed without success. Finally, she was advised to whisper the follow- ing formula at the beginning of the spell: “God the Father, the Son, and the Holy Ghost;" then to turn around and spit, and at the same time to say, without it being heard, these words: “ This is for you," thinking of Satan. By this means the attack was invariably arrested. It is unnecessary for me to say that any treatment of this kind-simply influencing the imagination, by its emotional character-would not have made the slightest impression upon a man like D- In studying carefully the symptoms observed in this patient, I am inclined to range them among the mumer- ous varieties of epileptiform attacks. The convulsions. were not of a character which characterize the epilepsia gravior; and, on the other hand, there was no loss of consciousness which is observed in such a case. The symptoms were rather of a character which the French call "petit mal." It is necessary to mention that there was a distinct aura, characterized by an abnormal sensation in the cer- vical region. Gowers, in his “Monograph,” says that all the patients who came under his personal observation and had a spinal aura, were epileptics. It is admissible that the excitement, the violence and the strange conduct in the beginning of the disease may, in the first years, have an automatic character-be of the nature of hysteria- but even here there is an inability for self-control, as there also is, in epileptic vertigo. Trousseau, in his admirable chapter on “Apoplectiform Cerebral Congestion," cites similar facts, which he regards as irregular epileptic crises, and, among others, one of the A Case of intermittent Epileptic Aphasia. 337 most striking, the one of a French judge, the president of a court, who was subject to these spells of epileptic vertigo. One day, while in court, he suddenly rose, went into the ante-room, where the doorkeeper saw him urinate in a corner. A few moments afterwards he returned to his chair, and listened with attention and intelligence to the momentarily interrupted plea of a lawyer. It is evident that there remained nothing to remind him of the im- proper action which he had committed. Kussmaul speaks of similar cases to the one of D- under the title, “ Apthongy, or Reflex Aphasia," a term used to express cramps taking place in the region of dis- tribution of the hypoglossal nerve, occurring when patient tried to speak, and which rendered articulated expressions impossible. He says that they have a resemblance to the writer's cramp. In one case the patient, a young farmer, was much impressed with the death of his father. At the burial he fainted and remained unconscious for a quarter of an hour; upon recovering from the syncope, he was entirely well in mind and body, but during three days he could not speak, although he was able to move the tongue and lips without difficulty, and could swallow. When he undertook to speak, his mouth, jaws and tongue remained immovable, but the large muscles innervated by the hypo- glossal (sterno-thyreoideus, thyreo-hyoideus and sterno-hyoi- deus) began to move with visible contractions; when he ceased to make the efforts, these contractions ceased. If pressure was made upon the muscles, the spasm was modified and the patient was able to speak; this effect lasted as long as the pressure was continued. Fifteen days afterwards a relapse took place, caused by fear, which lasted two days. A second relapse, which, how- ever, lasted several hours only, was the consequence of a strong emotion some weeks afterwards. In another case, a child, suffering from an inflamma- tory affection of the throat, became suddenly frightened, and trying to speak, was taken with spasms of the 338 F. Bateman. muscles of the tongue, which prevented it from speak- ing. In a third case, the patient had undergone an excision of the tonsils. The operation was followed by disturb- ances of sensation, loss of taste, aphonia, cerebral congestions and epileptiform spells. Each time when he made an effort to speak, the tongue would cleave to the palate and become immovable. His reason was intact, and the patient could read and calculate. It will be noticed that the case of D- differs from all these. It seems to have been one of a special kind; and once more looking over all the symptoms, I feel in- clined to believe that they were due to a disturbance of the vasomotors, due to a derangement of the sympathetic system. It is necessary to say that there was always an epileptic aura present, the epileptogenic zone always being in the neighborhood of the great cervical sympathetic ganglion. The most learned author of whom I know, Professor Eulenberg, in using an expression of Du Bois-Reymond, mentions "a hemicrania sympathetico-tonica,” which is an affection of the vasomotor system, due to a tonic spasm of the arteries supplying the head, caused by a morbid condi- tion of the great sympathetic in the region of the neck. The transitory and capricious character of the symptoms; the constant presence of an epileptic aura; the permanent close relation of the epileptic zone to the great sympa- thetic of the neck; the beneficial influence of electricity; all these point to the sympathetic system as the seat of the evil in this exceptionally remarkable case. Whatever may be the exact pathological state which produced these abnormal symptoms, I am not ready to admit that there existed an organic change. I for my part believe that the disorder was a nervous one. I do not believe that patients presenting these abnormal symp- toms in the same degree as we have observed in this case are often met with. In this case everybody who had occasion to study the case, either by a combination of the A Case of Intermittent Epileptic Aphasia. 339 unusual symptoms or by the questions of diagnosis, etiol- ogy and treatment, has been impressed with the great interest the case offers. Since I have written the above I have read the highly interesting article by Professor Ball (L'Encéphale, Mars, 1881), “On Functional Cerebral Anæmia,” in which I find several cases which have a certain analogy with the one I have related. I would be glad to learn the highly valued opinion of the learned Professor Ball. REMARKS BY PROFESSOR Ball.-It is absolutely impos- sible in the absence of any anatomical facts to inform us, to give an exact judgment concerning the peculiar features which have been reported; on the field of hypotheses, epi- lepsy should evidently hold the first place; but what do we understand by epilepsy ? The most generally accepted doctrine to explain the associated and so perfectly characterized “attack” is the one of partial cerebral anæmia. This mechanism is uniformly the one which would most rationally explain the facts given by M. Bateman. It is difficult to otherwise explain the cases of inter- mittent aphasia that are manifested in certain subjects, with or without accompanying migraine. It is difficult to conceive of the most severe and most general cases of disturbances of reason and sensibility which are observed in certain patients; and it would be likewise difficult to understand the more or less prolonged cases of loss of speech following a violent emotion (as passion or fright). An organic lesion of a permanent nature (tumor, softening, a limited hemorrhagic spot, etc.), may without doubt pro- duce in certain subjects more or less varying disturbances more or less suddenly arising, but the development of the disease keeps step with the anatomical development of the lesion which has produced the disease. It is diffi- cult to admit a lesion of this character in a patient like D- , whose pathological history ends in a complete 340 F. Bateman. recovery. On the other hand the violent pains which he perceived from time to time at the nape of the neck, seem to approach those cases of aphasia connected with migraine, of which there exists a certain number of well observed cases. We, therefore, feel inclined to ac- cept the theory of an intermittency in the cerebral cir- culation; we are obliged to hold ourselves to this rather vague expression, for evidently we do not possess the necessary elements to solve the problem. GENIUS NOT A NEUROSIS. By Jas. G. KIERNAN, M. D., Chicago, Ills., Late Medical Superintendent Cook County Hospital for the Insane; formerly of the New York City Asylum for the Insane; member of the New York Society of Medical Jurisprudence, and of the Chicago Medical Society. TERTAIN alienists, notably Moreau de Tours," have claimed that genius, especially poetic genius, is a neurosis, and that the man of genius is but a- Poor lunatic wbo makes bis moan, And for a while beguiles his lookers-on. He reasons well. His eyes their wildness lose; But if you hit tbe cause that hurts his brain, His eyeballs roll, and he is mad again. Nathaniel Lee, the periodical lunatic who wrote these lines, had very good reason for accepting this theory. Nor is Nathaniel Lee the only mad poet. Sappho, Lucretius, Marlowe, Ben Jonson, Bunyan, Wycherley, Torquato Tasso, Molière, Swift, Pope, Defoe, Rousseau, Goldsmith, Johnson, Savage, Cowper, Byron, Walter Scott, Coleridge, De- Quincey, Rogers, Southey, Shelley, Emerson, Saxe, Poe and Victor Hugo, all suffered from insanity. 17 Poetry is an emotional outburst of a perception of sim- ilarities in unlike things. Hence the “fine poetic frenzy" of the poet is not unlike the emotional exaltation of the insane. Many a matter-of-fact young man or woman, in the emotional stages of insanity, has composed respectable poetry, and lost this faculty on recovery. In periodical insanity, the appearance of poetry is often an indication for medical treatment. Rushhad under care an insane woman, over whose songs "he hung with delight.” Pinel 3 has cited the case of a young girl who, during paroxysms of insanity, expressed herself in very harmonious verse, and lost this faculty on recovery. Van Swieten' has had under observation a very similar case. Hammonds reports the case of a rhyming clergyman. [341] 342 Jas. G. Kiernan. The analogy is, however, of the most superficial kind; none of these lunatics were capable of a sustained poetic flight; nor do the cases cited bear out the theory. Sappho was a victim of sexual perversion, whose love for Phaon was a healthy conception which dominated her insanity and gave birth to her poetry. Lucretius' acute attack of insanity marred his poem, as will be obvious on comparing portions of Book III. of De Rerum Natura with the rest. Marlowe's wild outbursts against society and religion, his delusions and persecutional visions, were of insane origin; but the insanity marred his genius. His “ Jew of Malta ” is a mass of turgid bombast compared with the “Merchant of Venice." Ben Jonson's insanity arose from his gout, and marred much of his work. When most free from gout, his work is the best. His hallucinations of vision were those of gouty insanity. Bunyan was a paranoiac, in whom emotional perver- sion and hallucinatory disturbance therefrom resulting, were in the foreground. He, as Spitzka6 has pointed out, made a nearly complete recovery, and not till then did his “Pilgrim's Progress" appear. When Wycherly's mind gave way under debauchery, his work, when it did not consist of unconscious assimila- tions, was sheer drivel. During Torquato Tasso's periodical attacks of insanity, nothing poetic was produced. Swift's middle-ear nerve disease caused insane suspi- cions and irritability. In his youth he was wild and erratic, and was rejected at first for his “B. A.” degrees as “conspicuously deficient.” His servitude to Sir William Temple held his insane tendencies in check by its rigid discipline. He marred his writings by the introduction of physically disgusting irrelevant topics. From his irritabil- ity resulted his cruelty to Stella. His insanity once fully developed, his creative powers vanished. Molière's epileptic insanity tinged his genial humor Genius not a Neurosis. 343 with sarcastic suspicion. His savage diatribes against phy- sicians increased or waned as the number of fits decreased or increased. Pope's malignancy, coarse language to women, egotism, suspicional delusions, mean conspiracies for notoriety, tricks on his dearest friends, were the outcome of an insanity which checked his intellect at the boyish stage. Pope was intellectually a hebephreniac all his life. His poetry was a "mere methodic art," and hence was the result of forces antagonistic to insanity. Defoe manifested insanity only as a result of age. No trace of mental disease appears in “Robinson Crusoe." Rousseau, like Pope, was the victim of the unequal development of mind and body after boyhood, a hebe- phreniac. He manifested much the same suspicional delu- sions as Pope ; on one occasion accusing David Hume ? of an attempt to murder him. He believed that enemies were leagued against him, and delighted in cheap notoriety 8 while affecting to despise it, and manifested this very ob- trusively. He was, in all his philosophy, the outcome of Locke. Had Locke never existed, there would never have been a Rousseau. Goldsmith had a slight imbecility of judgment which led to his inventively stupid deceptions of his mother and his “uncle Contarine," and his incongruities with his sur- roundings. The “ Deserted Village,” “Vicar of Wake- field,” “She Stoops to Conquer,” were not the offspring of mental disease: but his “ Animated Nature " displays his imbecility of judgment to a great degree, albeit it is concealed by a pellucid style. His mental defects were but a slight twist in the judgment, and a blunted moral sense. That the sanity of Johnson, the great“ Cham” of liter- ature, should ever be doubted, will seem strange to the students of English literary history who remember the “club,” with its brilliant conversaziones. As Macaulay has said, Boswell, and not his own works, made Johnson immortal. Johnson's father suffered from a mental 344 Jas. G. Kiernan. twist which tinged all his ideas with gloom, and made him the prey of imaginary disease. He fell under the sway of the established church, and the simple creed, “fear God and honor the king,” repressed all religious emo- tionalism and the mental disturbances which result therefrom. This creed strengthened the checks on his emotions. As Spitzkał has pointed out, Johnson him- self was the born victim of nervous and other diseases. He suffered from hallucinations of hearing; he heard his mother, then many miles away, call him “Sam! Sam!” When he entered a doorway he would suddenly whirl and twist about in strange gesticulations. He would often stop in the middle of the streets to go through this ceremonial. At a dinner party he once twisted off the shoe of a lady who sat next him in one of these performances. He was subject to lengthened periods of mental torpor, when he hardly knew what was going on around him. His “Rasselas" indicates that he, at times, suspected his own mental con- dition. Much of this “insanity of manner" served as a safety-valve to work off the morbid force. The comfortable routine faith of the English church acted like spiritual laudanum on such a mind. That the keenness of his mind was blunted by the torpidity of disease, is evident in his works. As Leslie Stephensº remarks, had he "gone through the excitement of a religious conversion, he would probably have ended his days in a madhouse." His men- tal disease marred his genius, as cracks distort the reflect- ing powers of a mirror. Savage had all the characteristics of the lunatic who is a reversion to the barbarian type of man, born in the midst of civilization with which he is unable to reconcile himself. His works, kept alive by Johnson, are not intel- lectually above the level of the "sweet singer of Podunk,” or some similar locality, and their equals are often thrown into the waste-paper basket by the insane-hospital physi- cian after his return from his daily visits to the scribbling insane. The genius in Savage was swamped by the insanity. Genius not a Neurosis. 345 Cowper was subject to a periodical melancholy. His poetry, composed under this influence, was beneath medi- ocrity. Fortunately for Cowper, he fell under the influ- ence of the religious quietists, and the soothing influence of their mild creed favorably affected him, so that the “ Task” was the outcome of a period of sanity between the periodical attacks. Byron came from a family in which insanity was rife. His desire of cheap notoriety, his obtrusiveness of his own affairs, his mendacity, his affectation of vices which he did not possess, show that he was, as Swinburneo says, a “brilliant boy" whose intellectual development into manhood was checked. The insane tendency checked the full development of genius. In him the hebephreniac tinged with paranoia appears. No clearer intellect ever made its appearance in the world of letters than that of Walter Scott. Not until his brain broke down under the mental strain of the failure of the book-publishing speculation and the struggle to pay his debts, did the dead Byron appear at his window. There is no mental weakness in the “ Lady of the Lake,” nor in “Rob Roy;” but it appears in every page of “Count Robert of Paris," written when paretic dementia had seized him. Southey and Rogers both fell victims to coarse-brain- disease-dementia, the distant outcome of apoplexy. When they became insane their poetry ceased to appear. Shelley was,'' like Cowper, a victim of periodical insan- ity; the insanity alternated with literary productiveness. When Shelley saw "the woman with eyes instead of nipples," he could not write poetry. When his delusions of persecution were present, no masterpieces made their appearance. Coleridge was the prey of his own ideas, usually of outside suggestion, and for this reason his productions have a fragmentary character. He himself draws a pretty good picture of his mental state when he says:11 “Why need we talk of a fiery hell? If the will, which is the 346 Jas. G. Kiernan. law of our nature, were withdrawn from our memory, fancy, understanding and reason, no other hell could equal what we should then feel from the anarchy of our powers." De Quincey's mental condition resembled that of Coleridge: the weak wills of both produced their mecon- ophagism. The apoplexy which produced Emerson's insanity destroyed his genius. The mind which evolved the essay on “Conservatism” became extinct thereafter. Poe, who resembles Swift in his liking for the physi- cally disgusting, manifested this liking most strongly after recovery from periodical insanity, which, in him, took the form of drunkenness. He analyzed his own mental state in his sane periods, and from such an analysis sprang the “Fall of the House of Usher," and the “Imp of the Perverse." In one of Poe's insane period she was dragged from one Baltimore polling place to another, and voted by ward-workers. From the resulting exhaustion he died. Saxe died the victim of melancholia, the consequence of “railroad spine,” and no poetry appeared after his railroad accident. Victor Hugo was the least demonstrably insane mem- ber of an insane family. His brothers, sisters, several ancestors and collateral descendants, were insane. He received a methodic training, and fell under the influence of the English dramatists. His insane tendencies were at once held in check, and afforded a safety-valve. At times his insanity converts intended sublimity into drivel. There is much in his “Les Miserables” and “L'Homme qui rit,” that is at once weak and insane. The poets are not the only men of genius whose lives. seem to bear out the dictum about genius being related to insanity. Oliver Cromwell,15 Peter the Great, William Pitt the Elder and Napoleon Bonaparte, among statesmen; Luther, Pascal and Swedenborg, among theologians; Plato, Socrates and Schopenhauer, among philosophers: Newton, Genius not a Neurosis. 347 among scientists; the elder Booth, John Wilkes Booth, Forrest, G. L. Fox, John McCullough and Bartley Campbell, among actors; Paginini, among musicians, are cited as evi- dences of the relation between genius and insanity. Oliver Cromwell suffered from the depression resulting from malaria. When free from malaria, his clear intellect shone pre-eminent even among the great intellects of the period in which he lived. Peter the Great was a paranoiac, in whom the con- servative maternal tendency gained the upper hand. The self-restraint consequent on his work in Holland and Eng- land proved peculiarly beneficial, as it always does to paranoiacs. William Pitt the Elder suffered, as I have elsewhere pointed out, 16 from acute gouty insanity. During his insan- ity he was worthless as a statesman. Napoleon Bonaparte's epileptic insanity marred his work. The failure of the Russian campaign, and most of his political blunders, were the result of his suspicional delusions and epileptic stupor. Luther suffered from austerities, overwork, and the con- sequence of the superstition of his time, and his deino- niacal hallucinations were the result of education and not evidence of insanity. Blaise Pascal had an imperative conception, which took fast hold on an enfeebled nervous system; in the proper sense of the term, he was not insane. Swedenborg's epilepsy at times gains the upper hand of the genius, and turns all it touches into bombast. Plato and Socrates were clearly victims of sexual per- version, and like most sexual perverts, had a dreamy, emo- tional, pseudo-ethical sentimentality, 19 which led to the Platonic love idea in one case, and made Xantippe miser- able in the other. Schopenhauer sprung from a family of imbeciles. The morbid element just tinged his mind with gloom, and his pessimism was the only consequence of race degeneration. He was not insane, but had the saturnine tendency so 348 Jas. G. Kiernan. often found in descendants of degenerate stocks, otherwise free from taint. Newton, it is clear from Locke's letters,18 was a quer- ulent paranoiac, whose scientific studies checked his insane tendencies, until premature senility set in. The elder Booth, Forrest and John Wilkes Booth, were all paranoiacs, and the psychosis very often marred their histrionic efforts. Fox, McCullough and Bartley Campbell were paretic dements. After the disease set in, histrionic power vanished. Paginini was a querulent paranoiac, but it must be remembered that music is one of the earliest arts in the history of the race, and like all such early acquired arts, belongs to the lower types of genius, and hence is the last to feel the effects of race degeneration. Of this, "Blind Tom,” Ludwig, of Bavaria, and numerous other musical imbeciles and paranoiacs, are evidence. Genius is not a product of morbid mind. In the ex- ceptional instances where the two co-exist the genius is evidence of a healthy conservative element struggling with the incubus of disease. Insanity may, in its emotional stages, touch the lips of a timid poet; but his song soon sinks beneath the disease. The best-balanced poets have been the greatest. Shakespeare's works are evidence of a well-balanced intellect. Nothing exists to impugn the sanity of Milton, Addison, Wordsworth, Tennyson, Klopstock, Goethe, Schiller, Burger, Filijaca, Camoens, Freiligrath, Longfellow, Dickens, Thackeray, Freytag, Rogers, Bacon, Galileo, Hartley, Willis, Sydenham, Darwin, Tyndall, Hæckel, Rush, or of most of the stars of literature and science. The Elizabethan dramatists were keen psychologists, and the examination for insanity which Ben Jonson12 brings on the stage denotes a rare knowledge of mental phenomena. Sophocles18 wrote his tragedies at a great age, and his sons called him into court to have him placed under guard- ianship as a dement. He refuted the imputation on his Genius not a Neurosis. 349 mental condition by reciting “Edipus Coloneus," which he had just composed, to his judges, who thereupon pro- nounced him mentally competent. The doctrine that genius is an offspring of disease is a dangerous one; it deprives literature, science and art of their elevating character, and excuses the excesses of the genius on the ground of irresponsibility; at once harden- ing the community and degrading literature, art and science. Such a doctrine should be enunciated only on the most well sustained basis. The subtle chain of associating power which constitutes genius in its highest and best sense, differs very decidedly from the disjointed condition existing in paranoia. "The highest poetic genius is closely akin to the highest scientific. Huxley's phrase, “the scientific use of the imagination," was the expression of a profound truth. ience. Such unity and decreability; at o BIBLIOGRAPHY. 1. La Psychologie Morbide. | 13. Cicero: “ De Senectute." 2. Medical Enquiries and Obser- 14. Journal of Nervous and Mental vations. Disease, 1881. 3. De la Folie. 15. Carlyle: “Life of Cromwell." 4. Cited by Winslow. 16. Journal of Nervous and Mental 5. Insanity. Disease, 1883. 6. Insanity. 17. Neurological Review, Vol. I. 7. Hume's Essays. 18. English Men of Letters Series : 8. Carlyle: “Heroes and Hero “Locke." Worship." | 19. For a good illustration of this,' 9. English Men of Letters Series: see Dr. Beumer's well ana- * Johnson." lyzed case of sexual perver- 10. Essays. sion.-Amer. Jour. of Ins., 11. Table Talk, 1883. 12. Silent Womaan. Intercommunication of Delusions by the Insane. By S. V. CLEVENGER, A. M., M. D., Chicago, Ills., Consulting Neurologist Michael Reese Hospital; Consulting Neurologist Alexian Brothers' Hospital Chicago; late Special Pathologist Cook County Insane Hospital. R. KIERNAN,* in commenting on certain cases of folie a deux, advanced the view that intercommuni- cation of ideas by the insane was far from being of infrequent occurrence. He cited several cases in point, one very striking instance being that of the intercommu- nication of delusions by a brother and sister of Knicker- bocker origin. Dr. R. L. Parsons,† later, reported several instances in which intercommunication of delusions by the insane occurred. Despite this corroboratory evidence Dr. B. Ball,I of Paris, hesitates to admit Dr. Kiernan's view, since, as he says, the insane have an antipathy to each other. It is undeniable that many of the insane perceive each other's mental condition, and hence tend to separate from rather than agree with each other. But it is also undeniable that in conditions in which abulia (paralysis of the will) is present, as in many cases of melancholia, mania, stuporous insanity, epileptic dazed states, paretic dementia moods, intercommunication of insane delusions results not only from the imposition of delusions by sys- tematized delusional lunatics, but also from the imbibation of delusions from each other, by the classes mentioned. Dr. Folsoms has reported the case of Freeman, of Pocasset, in which insane delusions were imposed on sev- eral lunatics. * Alienist and neurologist, 1883; Journal of Nervous and Mental Disease, 1880. + Alienist and Neurologist, 1884. L'Encephale, 1886. § Boston Medical and Surgical Journal, 1879. [ 350 ] Intercommunication of Delusions by the Insane. 351 Dr. Kiernan* has also reported several instances in which paranoiacs imposed delusions on other lunatics. Dr. J. T. Montgomeryt has reported the lay case in which an insane mother imposed an insane delusion on an insane son and some other lunatics. These cases are the most common and the most noticed in even the victims of the other psychoses men- tioned who interchange their delusions. Thus Clouston mentions the case of two epileptics who in the epileptic dazed state coöperated in an insane scheme of revenge. This has been evidently Dr. Kiernan's experience also, as witness his “Psychology of a Plot by the Insane." My own experience also tends to support Dr. Kiernan's view, as witness the following case: A patient suffering from confusional insanity, secondary to melancholia, who claimed that he was to be hanged the next day,|| was placed in the same room with an Italian who suffered from simple melancholia. One morning I asked him why he seemed so anxious, and he replied that he, also, was to be hanged, having imbibed the delusion of his room mate. The unsystematized delusions of persecution, of simple melancholia, having, in this instance, received a suggestion which, even though temporary in effect, was at least derived wholly from the other patient. It will be obvious that the very phenomenon which Dr. Ball doubts occurred in this case; and careful psy- chological analysis will demonstrate that such cases are as frequent in hospitals for the insane as one would ex- pect them, from well-known psychological laws, to be. • ALIENIST AND NEUROLOGIBT, 1833. + Amer. Jour, of Neur, and Psych., 1883. I Mental Diseases. Ş ALIENIST AND NEUROLOGIST, 1887. || Chicago Med. Jour, and Exam., June, 1884. Observations on Reflex Nervous Disturbances. By Willis E. FORD, M. D., of Utica, N. Y. Read before the Medical Society of the State of New York, Feb. 2, 1887. THE great progress made in almost every branch of medicine and surgery, during the past decade, may fairly be attributed to steady and systematic work along two general lines of investigation: the one giving exact- ness in physical diagnosis and the other giving definite pathological knowledge. Older writers described symptoms with a clearness and fidelity that may well be emulated in our day, but with- out a knowledge of the art of physical diagnosis and with few ideas of pathological anatomy, opinions could, at the best, be only shrewd guesses. To-day however, I ven- ture to say, that accurate and trustworthy observers of symptoins are rarer than expert physical diagnosticians. The pendulum has swung too far even from the old starting point. In the realm of nervous disease, and especially in so-called functional disorders, there is something of dis- advantage, it seems to me, in this tendency of the pro- fession. There is a large and important class of nervous dis- orders that cannot, as yet, be attributed to any definite and constant pathological conditions, though I have no doubt of the existence of a lesion in every instance. And it is equally true that some, if not most, of such ail- ments are not associated with any well marked physical signs. Expertness, however, in any particular line of phy- sical exploration begets in the possessor great confidence that he can discover the lesion, and hence even remote and constitutional symptoms come sometimes to be [352] Observations on Reflex Nervous Disturbances. 353 accounted for by the term reflex disturbance or reflex irritability. To accurately define the limits within which these terms may justly be employed would be too much to expect from any single paper on the subject, and in the short period allotted me, I shall content myself with but few observations bearing on this great subject, and I do so chiefly for the reason that it seems to me that such terms are made to cover conditions that ought to be viewed from an altogether different stand-point. Great expertness in the management of any single class of disorders is not only of the greatest advantage to the public, but of the first importance to the profes- sion that reaps the result of experience. That enthusiasm for, and zeal in the pursuit of a sin- gle affection, may cause a specialist to include as the effects produced by a single ailment, certain remote symptoms not strictly related, is but natural. That this has been done under the term reflex disturbances, I think can be conclusively shown. That peripheral irritation may produce symptoms in organs remote from and not in direct nervous communi- cation with the spot irritated is readily admitted. These symptoms are often out of proportion to the amount of peripheral injury, and are not mere reflections of sensa- tions, but are new and distinct phenomena. This pecu- liarity is observed chiefly in spinal nerves. The phenom- ena are called reflex phenomena and are supposed to be due to the influence of fibrillæ of the spinal cord in direct connection with the sympathetic nervous system. Physiological reflex acts are common enough, as in coughing, winking, sneezing, deglutition, vomiting, etc., which are conscious reflex acts, while the reflex movements of the intestines, the iris and the arteries are unattended by consciousness. Every act of this kind presupposes a stimulus, a centripetal nerve, a nerve center, an efferent nerve and muscles or glands. The stimulus, when applied to the peripheric extremity 354 Willis E. Ford. of a nerve, appears to act more rapidly and surely than when applied to the nerve in its course. Power says (“Human Physiology,” p. 23): "The vivacity and energy of reflex acts bears no relation to the amount of pain produced. * * * In man, in the same way, tickling will produce more vigorous movements than a cut. A stimulus which is so feeble as not to excite a reflex act may, by repetition, induce it.” And again : “Reflex actions are not irregular, but respond in a very definite manner tu particular stimuli.” Nowhere in modern physiological writings have I found reference to reflex phenomena other than as acts-not conditions or continuous alterations of functions—but as sudden, immediate and definite acts. I believe that diseased or injured nerves, if they impart any reflex influence, must cause manifestations that ought not to be mistaken. The inference would naturally be that in morbid states giving rise to reflex action the nerve centers behave in a similar manner. The peripheral injury, if sufficient to give rise to any immediate reflex disturbance, would manifest itself in an explosion; and a lesser cause might, by continuous action, create ultimately an explosion, but not a persistent perversion of function in a distant organ. The commonest examples of reflex nervous disturbance are seen in certain convulsive movements, partial or gene- ral, caused by peripheral irritation. Epileptic seizures have been produced by injury to nerve fibers, and have been permanently stopped when this cause was removed. The nature of the condi- tion called reflex disturbance seems to be instability of nervous control and not continuous perversion. It is to this fact chiefly that I wish to call attention in this paper. It is so much easier to say a given morbid condition is due to functional or to reflex disturbance than to deter- mine the exact pathological change, that many recent writers have fallen into the habit of using terms mislead- ing and tending to prevent investigation. Observations on Reflex Nervous Disturbances. 355 If it be true that all reflex phenomena must be in the nature of explosions, and not merely transferences of nerv- ous derangement, then the necessity for many of the oöphorectomies, nerve sections, repairs of cervices-uteri, as well as the wearing of prisms by people of good vision, removal of teeth, section of orbicular muscles, etc., will no longer be conceded. On the other hand, the study of convulsive disorders will receive a corresponding impulse. Schmedaman says: “So often as a young man con- sults me for cardialgia I suspect onanism” (p. 140 op. cit.); and Tilt seems to confirm these conclusions. Hughes says: “The reflex gangliopathic disorders of the heart too, connected with ovarian irritation in women of neurotic temperament, confront us every day (ALIENIST AND NEUROLOGIST, April, 1880). Dr. Stevens (ALIENIST AND NEUROLOGIST, Jan., 1882) says: “An in- jury to an eye, such as the thrusting of the point of scissors through the ciliary region, or the lodgment of a foreign body within the globe, or a grave disease which causes cicatricial degeneration of the front of the organ, so frequently induces reflex phenomena, of such serious char- acter in the uninjured eye that it is now universally con- ceded by ophthalmologists that such injured and diseased eyes are dangerous and must be sacrificed as a defence against the reflex or sympathetic disease in the remaining eye. But if an injured eye can set up a sympathetic irrita- tion which may be fatal to an uninjured one, then if the principle above stated be true, the same kind of irritation originating in an injured or diseased eye may also give rise to disturbances in distant organs—for instance, the kidneys, or the muscles of the extremities." I have quoted this last at length to show the loose kind of logic sometimes used in discussing reflex disturbances, and we are not surprised that in the same article a case of diabetes-insipidus is reported cured by removal of a diseased eye. It seems to me such statements ignore an- atomical facts as well as pathological knowledge. 356 Willis E. Ford. Dr. Emmett, in the last edition of his valuable work on “Gynæcology,” says: “After nature has repaired the in- jury (laceration cervix) by partially or completely filling the gap between the flaps by cicatricial tissue formed in the process of healing by granulation, marked reflex dis- turbance will sometimes be established.” He then men- tions cases of sub-orbital, pain facial neuralgia, etc. Dr. H. W. Longyear, of Detroit, has reported a case of persistent salivation, apparently due to laceration of the cervix uteri (Am. Jour. Obstetrics, Jan., 1883). And since the operation for closing lacerations of the cervix uteri has come to be regarded as so essential (and justly too I think) the medical journals are full of cases of so-called reflex disturbances, embracing neuralgias of distant parts- neurasthenia in all its forms and mental disturbances, cured by operations. It will easily be seen however, that in all these cases there has been a condition of marked depression of vitality-general ill health and bad nutrition, and to this condition rather than to any peripheral nerve injury, I believe such nervous symptoms ought to be attributed. As soon as an improvement in the general health was secured by vigorous treatment, including in these cases the repair of torn cervices and the consequent lightening of the uterus and relief from pelvic congestion, then the more remote nervous symptoms disappeared be- cause the large nerve-centers were better nourished. Dr. Goodell says (Am. Jour. Obstetrics, Jan., 1882): “ And this fact I have learned—that nervous exhaustion and spinal irritation will evoke symptoms which others as well as myself have referred to slight cervical tears, but which are in no wise dependent on these lesions." This seems to be from a source that commands great respect. I have operated during the past two years many cases of lacerated cervix and lacerated perineum, and at first did so chiefly for the purpose of relieving remote nervous symptoms, such as aphonia, neuralgia and depressed men- tal states, etc.; and I was struck with the fact that these nervous symptoms did not disappear until after the general Observations on Reflex Nervous Disturbances. 357 health had become markedly improved, and then they disappeared, if at all, in the same manner and under the same treatment that secured improvement in cases where there had been no laceration. My faith in reflex disturb- ances due to this and to other uterine disorders, excepting those phenomena in the nature of explosions, has rapidly diminished during this period. In the field of abdominal surgery I believe even graver errors are being daily committed. The number of ovaries removed during the past year is simply appalling. While great credit is due to the surgeons who have improved the methods of abdominal surgery so as to render the risk to the patient in the removal of diseased ovaries almost to a minimum, yet the great popularity thus secured for the operation has undoubtedly caused the sacrifice of many normal ovaries, or ovaries not diseased to the extent of requiring operation. Dr. Bantock, of London, told me last summer, that when one of the most distinguished operators in Great Britain was asked why he had removed ovaries that were apparently normal and in which even the operator did not pretend to discover any diseased con- dition, the reply was: “It is sufficient for me that I cure the case." Such operations cannot have the slightest pre- tence of justification except upon the ground of reflex disturbance. In cases of actual epilepsy it has not yet been shown that ablation of ovaries cures even a small proportion of cases unless the ovaries are extensively diseased, and yet epilepsy from reflex causes is readily admitted, as are other temporary and spasmodic phenomena. Fothergill says : “Reflex palpitation of the heart is a very common occurrence” (“The Heart and its Dis- eases,” p. 345). And further on he says: “Thus we find in women, ovarian excitement which not only provokes and maintains uterine disturbance and affects the catame- nial flow, but which sets up also gastric disturbance in the form of indigestion ; cardiac disturbance, as palpitation; respiratory disturbance, as cough, etc.” Here, it seems to 358 Willis E. Ford. me, a cause is assumed without discussing the other side of the question, as to whether these symptoms are not the result of a defective nutrition of the large nerve centers, and that this is the real cause of the phenomena including ovarian excitement. Indeed, the nervous disturbances of the heart under discussion, and here treated as reflex, are more frequently the result of emotional states, in which no peripheral nerves can be found to be at fault, and the ganglionic centers must be accused of the error. But the · little faith which the author really has, is shown in a later sentence where he says: “The subject of reflex palpita- tion is one on which, as yet, very little is known.” (Op. cit., 347.) Concerning so-called reflex paralysis, Strümpell says: “An attempt has been made to explain their origin from analogy with well-known physiological experiments, by the idea that a reflex inhibition is excited in certain motor regions by a sensory irritation arising in the diseased organs, a theory which has not yet been fully confirmed." (“ Text-Book of Medicine," p. 506.) He also says Leyden's hypothesis is somewhat more probable, which explains. these cases as resulting from an ascending neuritis. Eichorst substantially agrees also with this proposition. Among the affections that may, without question, be enumerated as due to reflex disturbance are epileptic seizures dependent upon painful cicatrices, phymosis, intestinal irritation in children, etc.; certain convulsive disorders accompanying hysteria, painful spasms in the calves of the legs, saltatory reflex spasms and abnormal increase of tendon reflex in many diseases of the spinal cord, such as spastic spinal paralyses due to the disap- pearance of influences which normally inhibit reflex. The reflex nature of the symptom called “tendon re- flex” is disputed by many, notably by Westphal, though Erb and many others maintain it is a true reflex. The purposes of this paper cannot, however, be subserved by going into the arguments concerning this still mooted symptom. Observations on Reflex Nervous Disturbances. 359 I will not weary the Society at this time, by a recital of my own cases illustrating my conclusions: that physio- logical facts do not warrant the assumption of reflex nerv- ous disturbance, except in cases of sudden explosion of nervous energy, that these manifestations are of short duration, that they are due to instability of ganglionic centers and are not merely transferences of disordered function: that many of the conditions commonly ascribed to reflex influences, are due to actual lesions of the cord, and finally that operative procedures for the relief of so- called reflex disorders often fail to relieve, because of the common misapprehension of the nature of reflex influences. PARANOIA IN THE FEMALE. RIET XANDE By Harriet C. B. Alexander, A. B., M. D., Chicago, Formerly Assistant Physician of Cook County Hospital for the Insane DARANOIA consists essentially in a mental twist which 1 may involve the logical inhibitions or the inhibitions of the emotions, and may have as a result, perverted reasoning, as in the systematized delusional cases, misap- prehension of the moral relations, as in the moral insanity cases, varied by emotional displays. As Dr. Spitzka has pointed out,* the mechanism of this twist is as follows: If an ascending series of animal brains, culminating with the human, be examined, it will be found that the white center of Vieussens, which in the reptilia and marsupials is almost exclusively devoted to - projection," grows with far greater rapidity than the cortical area, and cortical thickness and richness in cells. Therefore the chief factor on which the higher powers of the human brain depend is not the cortical development, as such, but the preponderance of the white substance due to the massive associating tracts. Although the projection tracts are also larger in man than in any other animal, yet so great is the preponderance of the associuting mechanism, that elimination of the former would not reduce the white substance of the hemispheres by one-half its bulk. Both projecting and associating fiber masses increase in nearly geometrical progression, from the lower animals to man, but the rate of progression of associat- ing fiber mass exceeds that of projecting tracts. Certain convolutions are almost, if not exclusively, connected with associating tracts, and enjoy, at most, but little direct connection with the bodily periphery. Such an area obtains the simpler registrations through its associating fasciculi, from such gyri as have received them through the projection system from the bodily periphery, and utilizes such registrations in the formation of its organic unity. Such cortical areas and their subsidiary associating tracts, when bound into the still higher unity of the entire hemispheres, constitute the substratum of the ego. A disturbance of the intricate anatomical relations involved in the material basis of the ego, must be accompanied by a disturbance of the ego, or may even render an ego an impossibility. On accurate connection of projection areas with projection areas, and of these with “abstraction "areas, the faculty of logical correla- tion depends. The correction of the countless errors made during a lifetime is possible, only through an influence analogous to inhibition, exercised by the associating fasciculi, and the proper aim of every really educational system is to develop this control of the various cor- • Jour. Nerv. and Ment. Dis., 1881. [ 360 ] Paranoia in the Female. 361 tical screens on each other; a correction which, with approaching maturity, is delegated to the abstraction” field. It is in full accord- ance with this that aberrations in gyral development, in the proportion of the cerebral lobes to each other, and in the symmetry of the hemi- spheres, are found in paranoiacs. It must be obvious that heredity is very apt to check the proper development of this intricate anatomical mechanism, and that similar effects must, at times, result from irregular evolution of puberty, prolonged constitu- tional affections in youth, and the menopause, and that the results of such influences are a perversion of the men- tal inhibition. The mental phenomena of paranoia in the female resemble, markedly, those manifested by the male. This will be obvious from the following case : A. D., a Canadian, came of a neurotic ancestry on both sides. In early childhood, her intellect was seemingly below that of the average child in regard to her appreciation of her surroundings. She was dreamy, moody, and allowed younger children to boss her around. In childhood she was somnambulistic and subject to "night-terrors.” These “terrors ” were succeeded by beautiful visions of an erotico-religious type at puberty; the patient, at the same time, had anomalous vagino-uterine sensations, which she ascribed to a love-potion, sent into her system by an air-gun by an old man desirous of marrying her. She be- lieved herself to have been impregnated in the same way, and resorted to abortifacients to remove the product of conception, which was in her “heart, lungs and throat.” Under the inspiration of voices, she became addicted to secret vice as a means of placating her persecutor; clitori- dectomy was performed with partial success. About this time she went to see a criminal whose crimes had at- tracted much attention in her neighborhood, and imme- diately recognized in him an ideal hero who had been cherished by her. She suffered much persecution on his account; electricity being used to produce anomalous pel- vic, abdominal and pulmonary sensations. Obscene thoughts were enforced upon her by this means, and at times she was thus compelled to utter them. She, at this time, paid 362 Harriet C. B. Alexander. much attention to the study of electricity, and through its means discovered the principles of several inventions; most of them based on a discovery of perpetual motion. About the age of twenty-eight her persecutions were renewed; her sister taking an active part in these, the object being to compel her to reveal the secrets of her inventions. The same means were used for this purpose as had been used to remove her from her "persecuted hero" (the criminal aforesaid). She had, at times, olfac- tory hallucinations, during which she was markedly erotic. She ascribed her behavior under erotic excitement therefrom resulting, to the use of electricity by her ene- mies, and particularly by her sister. She later developed gustatory, visual and auditory hallucinations. Through a patent telephone her "persecuted hero” revealed to her that she was, as heiress to the Plantagenets, entitled to an immense fortune. Her sister having married about this time, her husband became enrolled among the patient's persecutors. He fixed up the steam pipes in such a way that electricity, conveyed through them, made holes in her lungs and her womb. By means of a tube charged with electricity, her brains were sucked out and returned addled with poison. When questioned about this last persecution she said, although it might be regarded by others as an insane hallucination, she could not ex- plain it except to the initiated. During her residence in the insane hospital these delusions were present. She frequently claimed that her head had been used as a telephone, and that her food had been poisoned, since, on sitting down to her meals, she felt an electric thrill. She at times had attacks of furor, which resulted from a visit from her sister. In her behavior she was quite dig- nified. The hypochondriacal delusions were, it is obvious, the outcome of anomalous sensations. The tendency to contract a marriage with a criminal was the result of a preconceived ideal, transmuted into an actual personage, as a result of public talk about noted people. The so-called erotomaniacs who persecute actresses and Paranoia in the Female. 363 other prominent women with marriage attentions, are instances of the same kind in the male. The history of forensic psychiatry contains many such cases. Accord- ing to Dr. Kiernan,* both Guiteau, and Funk, the book thief, displayed this psychical peculiarity. Meynertt and Spitzka have also called attention to it. The relative frequency of paranoia among males and females in Cook County may be judged from the following tables, which I cite from Dr. Kiernan :I TABLE I. Races. Male. Female. Total. NE 1960 ....... .......... ORAN GE 6 ARYAN. Teutonic. Anglo-Saxon, American English Scotch . Canadian Hollanders . . . German . . . " -American . Scandinavian-Danes . Norwegians 66 Swedes Celtic Irish 66 -American . " -Canadian . . Latin. French-American Italian . . . SHEMITIC Hebrew . NEGRO : : Total . . . c . AR WWNNE . . 0 ... o .. com WW 0 INNA .. eren . 92 148 Many of the female paranoiacs are liable to pass mus- ter for a longer period than the male, and as the female death rate in Cook County long exceeded the male, the psychosis is, in all probability, equally frequent in both sexes, since a great deal of what is called hysteria in the female is really paranoia. The patient whose history I have cited was long regarded as an hysteric. • Chicago Daily News, August 20, 1886. Detroit Lancet, Vol. VIII. † Psychiatrisches Centralblatt, 1877. 1 Neur. Review, Vol. I.,:No. 1. 364 Harriet C. B. Alexander. TABLE II. Civil Condition. Male. Female. Total. . Married-childless " children born dead majority died infants " survived infancy Unmarried . . . . . Total . . . . . . . TABLE III. Children in Family. No. of Survived Died in Families. Infancy. Infancy. 5 children in Family . . Boco ser ........... ........... ........... -One ಜವಹ=ಸತಿಳಿಯ CIA NOS Total . . . 102 . . 263 . As will be seen from the above tables these paranoiacs are by no means infertile, and the women are especially liable to marry. But the offspring of such marriages are but too often moral and intellectual monstrosities. Dr. Mays* says about the paranoiacs' children: “These unfortunates, if not idiots, epileptics or lunatics, are liable to grow up with querulous, explosive tempers; with feeble powers of self-guidance; weak in temptation; unstable, self-indulgent, vicious and hysterical. They form the bulk of what are known as the defective classes.” Dr. Kiernant has said: “The paranoiac's child may be an epileptic, a periodical lunatic, a chronic hysterical fe- male, a paranoiac, imbecile, idiot or congenital criminal, or congenital pauper.” • ALIENIST AND NEUROLOGIST, January, 1887. † Jour. of Ment. and Nerv. Dis., 1886. Paranoia in the Female. 365 The dangers from the female paranoiacs are, in this respect, much greater than from the males, since the mother exerts the most influence on the offspring, and many of them display attractive talents in special direc- tions, and exhibit an abnormal reserve and prudery, which is often mistaken for maidenly modesty by the male, who is very frequently a lunatic of the same stamp, since, as Bannister,* De Monteyel, † Kiernant and Mannings have pointed out, these patients often exhibit an intermarrying propensity. • Jour. of Ment, and Nery. Dis., 1882. | L'Encephale, 1833. | Detroit Lancet, Vol. VIII. $ Austral. Med. Gaz., 1885. STATE MEDICINE.* By JUDGE Amos G. Hull, New York, President of the Society of Medical Jurisprudence and State Medicine. MENTLEMEN: For the honor conferred in electing J me your presiding officer I can only return sincere thanks, with the promise that I will discharge my duty impartially and unselfishly, and according to the best of my ability. The unanimity with which the honor was conferred adds force to my obligation and unspeakable weight to my gratitude. We enter upon our duty under a cloud of grief, occa- sioned by the death of our lamented late president, Dr. Frank Hastings Hamilton. But he has left landmarks of his wisdom and the brilliant light of his example, to guide our feet while we seek to tread the paths of that great science which were rendered luminous by his footsteps. His unselfish career was leading us along the line of great usefulness. Let us not pause. This society has a brilliant future before it, if each member will discharge his duty. We have learned doctors among us, who will become public benefactors, equally as eminent as he, who will yet wear robes of honor as royal as any that were ever worn by him. If Dr. Hamilton were living and in health, he would be here to-night, in this very place, reading his third inaugural address. You can judge of my embarrassment in being called to be his successor, as your presiding officer. I can only invoke your kind indulgence and assistance while I attempt to discharge the duty which you have so generously and confidingly imposed upon me. First permit me to call special attention to some of the valuable papers that have been read during the past year, as well as some that were read the year before. * Inaugural Address, delivered before the Society, January 13th, 1837. [366] State Medicine. 367 The first paper read last year was by Dr. Hamilton, January 14th, on the question: "What are the Legal Lim- itations of the Right of Private Judgment in Surgery? Does the Omission to employ Antiseptics justify an action for Malpractice ?” I was retained last fall by a surgeon residing in Pittsburgh, who formerly was in practice in New York, to prepare a brief and opinion on the identical question. He had performed a surgical operation, on a hand, that had been crushed by machinery, without using antiseptics. He feared trouble, and was threatened with a suit for malpractice. The facts, which I have not the space here to insert, led me to the conclusion that there was no legal responsibilty against the surgeon which could form the basis of any successful suit for malpractice, and advised accordingly. Access to the paper of Dr. Hamilton would be of great value to any lawyer having occasion to prepare an opinion on that subject. It is a very im- portant and interesting question to the thoughtful mem- bers of both the medical and legal profession. On the same evening Charles H. Kitchell, Esq., read a paper on “The Social Evil.” He discussed a subject on which many forbear to write, with such delicacy of lan- guage and purity of sentiment as to commend the paper to the favorable consideration of all who would seek to promote the public good. Among the sound views with which his paper was replete, was this: That in order to advance moral reforms we must cultivate a healthy public sentiment. That it is difficult to enforce any law against public opinion. That instead of depending entirely, as some do, upon the enactment of laws to correct evil, we must bend all our energies to the creation of a pure and healthy public sentiment. He opposed the enactment of laws for the regulation of the evil. The paper was dis- cussed by E. H. Benn, Esq., Dr. Hamilton, Hon. William Barnes, Mr. Russell, Dr. Spitzka, Dr. McLaury and Dr. Harwood. At our last February Meeting Dr. Spitzka read a pa- per entitled "A Sham Board of Charities,” which discussed 368 Judge Amos G. Hull. the necessity of proper State supervision of the insane, and its lack in Illinois. March 11th, 1886, Dr. Hamilton read a paper entitled “ Cremation of Human Bodies Not a Necessary Sanitary Measure,” which created an animated but friendly dis- cussion. The paper was prepared in opposition to a proposed bill that had been suggested by some of our very active and distinguished members, including Mr. Benn, Dr. McLaury and others, who desired the passage of an act by the Legislature, requiring the cremation of persons who have died of certain infectious diseases, and also of those who are buried at public expense. I think my brother lawyers will agree with me that we were quite unprepared to learn from the lips of so eminent a mai, that students and others could be the attendants for years in dissecting-rooms where six or seven hundred bodies were dissected annually, and visit morgues and receptacles for the dead, and battlefields covered with decaying and unburied animal remains with so much impunity in regard to health. It seems to me that the arguments contained in that paper, which you all no doubt have read, will go far to convince this society that we had better not urge the passage of the proposed law. The April meeting was occupied in the discussion of the following question : “In the Absence of any Uniformly Accepted Definition of Insanity among alienists is it wise to establish a Legal Definition ? " which was discussed by Dr. Spitzka, Mr. Russell, Dr. Harwood, Judge Pratt and Dr. Parsons. The May meeting was occupied by the discussion of Mr. Kitchell's paper on the subject of “The Social Evil.” On the oth of June the paper of the evening was, “The Attitude of Legal Medicine vs. Hydrophobia,” by Dr. Spitzka. Nothing has come before the society more opportunely. The paper was accompanied by actual demonstrations upon living and dissected animals in the presence of the audience: the paperr was a great public benefaction. About that time a serious panic was spread- State Medicine. 369 in localities in other States, on the subject of hydro- phobia. The doctor, who never fears to breast any storm, where the interests of science or humanity are involved, nipped the panic in the bud, by demonstrating that a vast amount of so-called hydrophobia was lyssophobia; and by showing that there was no sufficient evidence that the children that had been sent from Newark across the ocean, to be treated by Pasteur, had ever been bitten by a dog that was suffering from well authenticated rabies. The fact that such a stand had been taken by so learned a man was noticed extensively by the press; it caused the public to pause and think; it arrested the progress of the "scare.” This society would have had reason to con- gratulate itself upon its work, if it had occurred that, during its labors for a whole year, no eminent public ben- efaction had been accomplished, except the results of that one paper. Dr. Spitzka was ably and eloquently sus- tained by Dr. Brill, who read a paper the same evening, taking much more radical ground on the subject than the author of the paper; by Dr. Dulles, of Pennsylvania; Dr. Quimby, of New Jersey; Dr. Daderian, who spent many years in Constantinople, and had there studied the subject, and by several others. September 30th, a me- morial meeting was held in honor of our lamented late pres- ident, Dr. Frank Hastings Hamilton; the memorial address of the occasion, read by Dr. Leale, was an able, eloquent and deserved eulogium. Appropriate and well-merited tributes were also paid by Judge Pratt, W. H. Russell, Esq.; Charles H. Kitchell, Esq.; Hon. William Barnes, Dr. Johnson, Dr. Wight, Dr. Flint, Dr. Wood, Dr. Boze- man, and W. M. Schrady, Esq. At our October meeting a very valuable, interesting paper, was , read by Dr. Daniel Lewis, upon “Chloral-Hy- drate as a Poison,” which was discussed by Dr. McLaury, Dr. Hammond, Dr. Wood, and Dr. Newman. The same evening Prof. Wm. A. Hammond read an excellent paper on the subject, “ Abnormal Conditions of 370 Judge Amos G. Hull. Uncertainty,” which was discussed by Dr. McLaury, Dr. Wood, E. H. Benn, Esq., and W. H. Russell, Esq. At our last November meeting a paper was read by Dr. Cyrus Edson, entitled “A Plea for the Enforcement of the Law in relation to Adulterated Foods.” The paper was illustrated by specimens of unwholesome food, and of many of the ingredients that enter into the adulteration of both food and wines. The paper was also illustrated by stereoscopic views. It was discussed by Drs. Brill, Leale, Wood, Jacobus and Harwood, and by Messrs. Barnes, Cooper, Kitchell, Russell, Benn and Osborne. The subject opens a very broad field of thought con- nected with that branch of science which comes within the purview of our society, denominated State Medicine. I have thus given a very imperfect synopsis of some parts of our work during the past year. I shall herein- after have occasion to refer to one or two papers that were read in 1885. Let us now contemplate, for a few moments, what we propose to do during the year upon which we have entered. First.—Let us write over the portals of our hall, in large and luminous letters, this inscription : “WHOEVER ENTERS HERE Must Come To Work." This society is established, not only to promote and advance our indi- vidual knowledge of that branch of science referred to in our charter, but to give us the ability to aid individually, and as a society, in promoting the public welfare. No intelligent and educated man, with a good heart, sound mind, and educated brain, is so poor in this great realm of fifty millions of people, that he may not be, in a meas- ure, a public benefactor. But in order to make his ben- efactions eminent, he must have a well-trained brain, he must be unselfish, and he must love the sweet influence of doing good. Second.—We must see to it with the utmost vigilance that none but first-class papers are read. Third.--We must be careful that we admit to our membership none but good, studious, thoughtful and con- State Medicine. 371 scientious men, who are willing to work-men who feel an interest in the science we are striving to advance. Fourth.—We must make vigilant, aggressive, unrelent- ing war on quackery, empiricism, charlatanism and shams of all kinds, whenever they show their heads, either in medicine or law. All these evils derive their sustenance from public credulity. An eminent thinker of the last century, who, with all his faults had some virtues, wrote this epigram : “Incredulity is the source of all wisdom.” If he had said, incredulity is the source of much wisdom he would have been nearer the truth. Human credulity is one of the most vexing obstacles with which science has to contend. She is the handmaid of ignorance and superstition. She often assumes the most bewitching and seductive mien. She sits in the lap of the lazy. She often empties the pockets of the rich. She rides on the whirlwind of panics, and frequently enters the pulpits of the sanctuary. She smilingly walks into the sanctum of the editor, but to make havoc of the press. One blast from the bugle of true science sends her flying to the realms of obscurity for a time, but she will return again to vex mankind until generations shall be born wiser than the past or present. It is the business of this society to sound those bugle blasts often. We have vast opportunities for doing good; but to do good we must work. There is no room for lazy drones in this hive. Fifth.—We must so arrange the curriculum of our studies, our work, our papers and our publications, as to embrace, as far as modern science will permit, the whole domain of medical jurisprudence and State medicine. Sixth.—We must reduce that curriculum to such a system, that men of science, outside of our society, will be eager to read papers before us. Seventh.–We should have a board of censors, or a committee appointed by the trustees, or by the society, to whom papers should be submitted before being read, if the 372 Judge Amos G. Hull. society should so order, to the end that none but the very best should be accepted. That would draw to us some of the best talent of the country. That course being pur- sued, in a short time our publications would be eagerly sought for by the members of both professions, and would eventually become a source of revenue to the society. Our very worthy ex-secretary, Dr. George W. Wells, has had much to do with medical societies for more than a decade, and has been a careful student of medical juris- prudence, wrote me a private letter, a few days since, relating to the affairs of, this society. The letter con- tained so many good suggestions that I have prevailed upon him to permit it to be made public, which I shall hand to the secretary, and shall crave the permission of the society to have it read during the evening, that it may be spread upon the record of our proceedings. We cannot too strongly impress on the two professions the value and importance of the science which this society was organized to promote. The distinguished Dr. Rush, as long ago as 1810, delivered an address in the University of Pennsylvania on this science, in which, after enumerat- ing the different subjects embraced therein, and urging upon the doctors and lawyers then present, the importance of a thorough knowledge of all the branches of the same, uses the following forcible and eloquent language: I beg you to recollect the extent of the services you will thereby be enabled to render to individuals and the public. Fraud and violence may be detected and punished; unmerited infamy and death may be pre- vented. The widow and orphan may be saved from ruin; virgin purity and innocence may be vindicated; conjugal harınony and happiness may be restored; unjust and oppressive dervands upon your fellow-citizóns may be obviated; and the sources of public misery in epidemic diseases may be removed by your labors and your testimony in courts of justice. We have had no papers within the last three years on the following subjects, viz: “Presumption of Survivorship,” “Legitimacy,” “Age and Identity," “Infanticide," “ Doubt- ful Sex,” “Disqualifying Diseases,” “ Impotence and Ster- ility,” and on “Poisons,"-only the paper of Dr. Lewis. We have had many on the subject of “Mental Aliena- State Medicine. 373 tion,” and several on questions relating to different branches of State Medicine. We are often asked the question, What is the differ- ence between Medical Jurisprudence and State Medicine? The great Dr. T. Romeyn Beck says: “if a general term be necessary to include both these sciences, I should pre- fer that used by the Germans, viz., State Medicine;" but he nevertheless defines Medical Jurisprudence to be “that science which applies the principles and practice of the different branches of medicine, to the elucidation of doubt- ful questions in courts of justice.” But State Medicine relates more particularly to hygiene and sanitation. There is good reason why one of the most important branches of medical jurisprudence, viz., Mental Alienation, should have been prominently discussed. Dr. Wells thinks too much, I do not. The fact is that questions relating to Mental Alienation have been so outrageously handled, and the subject so infamously abused by quacks and charlatans from the medical profession, and by shysters and rascals in the legal profession, during the last twenty years in our courts of justice, that medical expert testi- mony has frequently been brought into public con- tempt. Both professions have been at fault. Ignorant, dishonest and corrupt lawyers have often placed on the stand, doctors, as expert witnesses, who were the veriest humbugs and frauds that ever disgraced any calling, for the purpose of swearing away the property, the liberty and the lives of men, and again using the same experts to screen the blackest and most infamous of criminals from punishment. Sad to say, the lawyers on the other side have often been so ignorant and so weak, as to be unable, by cross-examination, to strip the hide from such bogus experts. It is to correct such abuses that so much has been said of late on the subject of mental alien- ation and medical evidence. The subject has not been discussed too much. New and interesting phases of men- tal alienation are constantly demanding our attention. There are four subjects to which I desire to call 374 Judge Amos G. Hull. special attention, for the purpose of obtaining the official expression of the society, either for or against the pro- priety of legislative action thereon. ist.—On the mode of executing the death penalty, or abolishing it altogether. 2nd.-On medical expert evidence. 3rd.—On the social evil. 4th.—On the subject of further legislation respecting the adulteration of food, wines, liquors and medicines. At the eighteenth regular meeting of the society, held on the gth day of October, 1884, a paper was read by Dr. Brill, entitled "An Argument against the Hangman's Bung- ling.” The society has never listened to a more thoughtful, temperate and well-considered paper. The paper aroused public attention and reflection. A few months thereafter the Governor of the State called the attention of the Leg- islature to the subject. On the 13th day of May, 1886, an act was passed (chap. 352 of the laws of that year), as follows: SEC. 1.-Elbridge T. Gerry, of New York ; Dr. A. P. Southwick, of Buffalo, and Matthew Hale, of Albany, are hereby appointed a commis- sion to investigate and report to the Legislature of the State of New York, on or before the fourth Tuesday of January, 1887, the most humane and practical method known to modern science of carrying into effect the sentence of death in capital cases. SEC. 2.-Such report shall be in detail, accompanied by drawings and specifications of any appliance recommended by such commission for that purpose, together with the cost of construction and maintenance and prob- able durability. SEC. 3.–The Governor is authorized to fill any vacancy in the com- mission occasioned by the death or resignation of a member thereof. In Dr. Brill's paper and the discussion which followed, a copy of which is in the second volume of our “Pro- ceedings " (now on table). Several plans were suggested for executing the death penalty, which were deemed to be less revolting and less barbarous and cruel than hanging It was suggested by some who took part in the dis- cussion, that if we could not get the Legislature to pass a law changing the form of executing the penalty, we State Medicine. 375 ought at least to ask for a law prohibiting the publication of the barbarous, brutal and demoralizing details of such executions. The argument in that discussion took sub- stantially this drift: It was said that time was, in this State, when executions for capital offences were permitted on the hills and plains, where thousands could be present. The result was that around the gallows there would assem- ble a vast multitude of people. Some for mere curiosity, a few for pity for the condemned criminal, but a great majority to gratify a morbid desire to see a brutal sight, to witness something barbaric, cruel and revolting. It was contended that the effect was found to be extremely demoralizing. Philanthropists were instrumental in procuring the passage of an act by the Legislature prohibiting public executions, and directing that the criminal be hung within the walls of the prison, or a yard adjoining the prison. The law allows the Sheriff to permit to be present, the District Attorney, Clerk, two ministers of the gospel, two physi- cians and twelve reputable citizens. Instead of obeying the law the Sheriff, in the case mentioned, had summoned three hundred persons, and there were actually permitted to be present somewhere between five hundred and a thousand people. The leading paper of Brooklyn, a paper of great in- fluence, which is read perhaps in ten thousand respectable families, published four columns of the details of that hor- ribly disgusting execution, to be circulated among its readers. Hence it was argued that what the Legislature sought, in its wisdom, to shut out as far as possible from the eye, as being a demoralizing and brutal sight, was paraded before the imagination with all the coloring that astute and imaginative reporters could depict. It was con- tended that the press should be restrained from publishing such details. Some one cried out: “Would you abridge the liberty of the press ?” The answer was: “The liberty of the press is now abridged by law in many respects. It may not publish obscene literature; it may not publish the doings of lotteries; it may not publish that which 376 Judge Amos G. Hull. was CU- tends to a breach of the peace.” It was contended that what was too often published respecting the execu- tion of criminals has a demoralizing effect upon certain classes of men, and was unfit and improper reading for youth. The temper and sentiment of the people seem to de- mand some change of the law on this subject. On the 8th of January, 1885, a committee was appointed to urge the proposed legislation, consisting of Dr. Brill, Dr. Spitzka, Dr. Wight, Hon. Wm. Barnes, C. H. Kitchell, Esq., and W. H. H. Russell, Esq. I do not understand that the com- mittee has been discharged. I earnestly urge upon the committee and the society the importance of pressing upon the Legislature the passage of a wise and discreet bill, either changing the form of executing the penalty, or prohibit- ing the publication of the details of executions, or abol- ishing capital punishment entirely. On the question of medical expert evidence my views remain unchanged. I am opposed to any legislation ap- pointing a board of experts. My views at length have heretofore been expressed, and need not be repeated here. Such papers as those which Dr. Hamilton and Dr. Spitzka have read here on the subject, and the discussions thereon, together with the exposures in the press, the elevation of the standard of learning at the bar on the subject, to- gether with learned cross-examination, all united, will form an alembic which, in time, will purge away the dross called “Bogus Medical Experts." But it is due our dis- tinguished ex-president, Hon. Wm. Barnes, who in his valedictory address proposed a short bill on this subject, which may be found on page 280 of the second volume of our “ Proceedings" for 1883 and 1884, that some action should be taken on his proposed bill, one way or the other. In respect to the “Social Evil," I think we should adopt the Fabian policy, and let that matter severely alone. In my judgment, the arguments advanced by Mr. Kitchell in respect to the mode of suppressing or limiting the evils of that vice, are unanswerable. State Medicine. 377 On the question of further legislation upon the adul- teration of food, wines and medicines, I would urge the society to encourage and promote all such amendments to our sanitary laws as will give them force and efficiency. But let us be careful and not rely too much upon legis- lation as a panacea for all the evils that affect the State. Let us remember that it is no easy matter to change the policy and uproot the traditions, or overthrow the senti- ments of an empire like the State of New York. Let me remind some of our active, worthy, and very useful members, who often spring to their feet to recommend legislation, that the people are generally averse to innovation. The time was, when there was a decree of the Roman Decemvirs, that when a Locrian proposed any new law, he should stand forth in the Assembly of the People with a cord around his neck, and if the law was rejected the innovator was instantly strangled. Lastly, gentlemen, permit me to congratulate you upon the useful work you are accomplishing, and upon the friendly courtesy which uniformly characterizes your de- liberations. I can only add, esto perpetua. The Relation of the Nervous System to Hæmophilia, Malarial Hæmaturia, etc.* SECOND PAPER. By C. H. Hughes, M. D., St. Louis. IN a paper read before this society, in November, 1884, after having shown from the testimony of all observa- tion and the best accepted authority, that there is no constant capillary degeneration or microscopically discov- erable blood change in this affection, I characterized it as an hereditary or congenital neuropathic affection of the sympathetic system, in the following introductory lan- guage : We must look, therefore, to the sympathetic system, of which the most important is the vasomotor nerves and their nerve center, for an intelligible explanation of the phenomena of hemorraphilia, for under the healthy influence of the sympathetic fibers distributed to the arterial walls, these blood-vessels are kept in a state of normal tonic contraction and contracti- bility. The tonic contraction of the muscular coats of the arteries, even to the smallest arterioles, as they ramify and are lost in the miputer capillary system, divested of their external coat of connective tissue, and finally of their middle muscular coat, to the fusiform transformation of its fibers, is under nervous influence; and although the terminal branches of the sym- pathetic nerve, like the muscular coat of the arteriole, may no longer be traced in the capillaries, the capillary circulation is under the influence of the nervous system, not only through the vis a tergo of the heart's pulsat- ing impulse, wbich, by multiform ramifications has been modified into a continuous flow, but by the reciprocal contraction with propulsive power of the arterial walls. “The sympathetic nerves exert an influence on the muscular coats of the arteries similar to that of the cerebro-spinal nerves on the voluntary muscles " They cause contraction of these vessels, a diminished flow of blood through them, if stimulated, and relaxation and an increased flow through them if divided or lowered in vital tone. If the flow of blood in a terminal arteriole is augmented through diminished contractile power and consequent dilation or dilatability of its walls, there will of course be a flushed capillary or distensible arteriole system, ready to burst or bleed profusely under slighter causes than * Read before the St. Louis Medical Society, April 16, 1887. [ 378 ] Hæmophilia. 379 would excite bleeding in a capillary system supplied by arterioles possessed of greater integrity. In bæmophilia it is the impairment or comparative paresis of the habitual tonic contraction of the arterioles, the diminished tone of the circular fibers, which are the capillary sphincters as much so as the ordi. nary sphincters, which keep certain outlets of the body closed without voluntary effort, that is at fault. It is this weakened influence of the vaso- motor power that permits certain other forms of hemorrhage of this kind, as of the stigmata. The suspended tonicity, as Dalton calls it, permits of the “ action of an arrest." Section of the sympathetic fibers of the carotid plexus, for example, which go to the distributions of this artery, causes relaxation of the blood- vessels, increased circulation, reddening of the venous blood, and increased salivation, while galvanization of their peripheral extremities precisely re- verses results through excited contractility. The effect of dividing the sympathetic, then, is to paralyze the mus- cular coats of arteries supplied by its filaments. “Owing to the paralysis, the arteries no longer offer their customary resistance to the blood-pres- sure coming from the heart. Their relaxation admits a larger quantity to the capillaries of the corresponding regions, and the causes are increased local circulation.” Somewhere in the spinal cord and in the medulla ob- longata, extending perhaps a little above (Schiff and others), nearly to the tubercula quadrigemina, but not to include them, or more widely scattered in the cerebro-spinal axis (Brown-Sequard, Vulpian and others), as shown by the influence of cross-sections upon vascular tonicity, is the nerve cen- ter which is probably chiefly at fault in the hemorrhagic diathesis, and this condition is amenable to such treatment as will impart tone and restore the vasomotor vigor which in this disease seems impaired.-Vide Weekly Medical Review, December 20th, 1881, pp. 517, 518. Wickham Legg, in his article on the subject of Hæmophilia, in Quain's “Dictionary,” speaks thus of the anatomical characteristics, or rather of their absence, in this disease: “No morbid appearances have yet been found with any constancy. The blood-vessels examined with the microscope have shown no change. The blood is apparently unaltered.” This I consider the true characteristic of hæmophilia. Neither the vessels nor the blood show a characteristic change, while in all other hemorrhages there is either a vascular wall or a blood change to account for the mor- bid phenomena, and this justifies us in locating the disease in the only organism which can justly be heid accountable for the abnormal phenomenon. If the agents are not at fault we must look for the failure in the 380 C. H. Hughes. principle, and hold the power which might prevent the hemorrhage—the arteriole walls and blood being healthy -accountable for the lapsus morbi. If neither the structure of the capillary walls, dissevered from their nervous connection, nor the normal consistency of the blood is at fault, then we must find in the mech- anism of nervous control the true causa morbi; and we need not, in order to understand this disease, here discuss the question whether there are vaso-dilators in the capillaries which overcome the weakened vaso-con- strictors, or whether the power of contractility resides inherently in the arteriole walls without the necessity of nervous influence, as Poole, contrary to the popular view, maintains. The fact is, in hæmophilia the normal contrac- tile capacity and arteriole tonicity in the capillary walls is so impaired through evidently inherent conditions of the ganglionic centers, which preside over vasomotor in- hibition, that blood exudes through the meshes of the capillary walls under circumstances of local irritation, or heart pressure or psychical influences which do not or- dinarily cause this phenomenon in the majority of mankind. The extraction of a tooth, the prick of the vaccinator's lance, the lancing of a gum or an abscess, the scratch of a pin, the bite of a leech, the cutting of the frænum linguæ, or the removal of a nasal polypus, a high altitude, gymnastic exercise, an over-stimulating meal with wine or brandy, which specially strain the capillary arteries and weaken vasomotor control, may start a fatal hemorrhage in a hæmophiliac whose age is an assurance that he has none of those characteristic arteriole degenerations com- mon to later life, which dispose to sudden extravasations of blood. The early period at which the first evidences of hæmo- philia appear (often during the first year of life) precludes the reasonableness of the conjecture that the disease is due to undetected and undetectable vascular disease. Degenerative changes are not only seldom, if ever, found Hæmophilia. 38r at this age, but they would seem to be scarcely possible in a child not otherwise profoundly diseased. Hence, Legg's conjecture, that "it is most probably the vessels which are at fault, as in most of the other hemorrhagic diseases," about which we have the demonstrations of disease, is not justifiable. The fact in regard to hæmo- philia appears to us to be just the opposite, viz., whereas we have in all other hemorrhagic diseases adequate path- ological states of the blood or arteries to account for the existence of the hemorrhage, in this disease we detect, neither in the blood nor the arteriole wall, any sufficient cause. We must, therefore, look to impaired neural control of the arteriole caliber, through the vasomotor system, for the only sufficient explanation. Under this paresis of the sympathetic, so to speak, the arteriole caliber being with- out normal inhibitory neural control against dilation, the vis a tergo from the heart over-distends to the point of abnormal and often fatal exudation the arteriole capillary walls and the phenomena of bleeding becomes a possibility and a fact, without the necessity of evoking an unseen and undetectable disease of the coats of the vessels, or an impaired abnormal liquefaction of the blood, to account for it. We should find no difficulty in seeing this matter in this light were we not too prone to look always to the direct seat of a morbid phenomenon for its sole causative explanation. Th's was universal in the medical mind till the phys- iological neural phenomena of reflex transmission of symp- toms became an accepted fact and had one of its earliest, if not its earliest, applications to disease in the knee pain symptom of hip-joint disease, followed up by the knee phenomena of antero-lateral and posterior spinal sclerosis, and in the reflected cardiac and utero-ganglio- pathias, and in the gastric and laryngeal symptoms of affections of the medulla and pons. Neither the deficiency of fibrin theory, as accepted by Wood, Flint, Tanner, and others, nor the “delicate construc- tion and vulnerability of the vessels and watery condition 382 C. H. Hughes. of the blood” idea of Rokitansky are now tenable be- cause they have been disproved, and the blood coagulates well after being drawn from these patients, especially in the early bleeding. It would not be strange, however, if, as the period of exhaustion after a prolonged and fatal bleeding is reached, the blood should be thinner in fibrin; and this may explain why in some cases the fibrin has been found deficient. After the long continuance of the bleeding and con- sequent central nerve exhaustion it would not be strange to find the consistency of the blood altered as to the normal proportions of fibrin, and even of other essential ingredients, and it has so been found in some cases. In death from lightning and other violent shock, and after section of the pneumogastric nerves, the blood has been found to have lost its power of coagulability. On October 21st, 1884, while hæmophilia and pur- pura were under discussion before the Pathological So- ciety of London, Dr. Acland showed some specimens taken from a case of hæmophilia in a boy aged seven, and from a case of purpura in a girl aged thirteen. In none of the organs or tissues of the former case which were examined were any lesions of the blood-vessels found such as have been described, either as regards their distribution or structure. No abnormal relation was found to exist between the blood supply and the size of the vessels; but the blood, which was examined after much hemorrhage had taken place, was found to be more watery than natural, and the white corpuscles were greatly in excess. The tissues round the wound from which the fatal hemorrhage took place were healthy. At the same meeting, Dr. Wickham Legg said that he had read a paper before the society three years ago, stating that the examination of the tissues from a case of hæmophilia had revealed nothing differing from the nat- ural state (British Medical Journal, p. 938, Vol. II., 1881). The specimens he now showed had been prepared and examined by Dr. Klein, who was unable to discover any Hemophilia. 383 change, either in the vessels or tissues. The specimens were obtained from the body of a boy who died of epistaxis ; diagnosis of hæmophilia in this case was very clear, and the the family history to some extent characteristic. The ex- amination of the tissues had now been made in six cases; in four of these cases no change at all had been found; one in which changes were found was a case of exten- sive ichthyosis; the other was the case recorded by Dr. Percy Kidd, in which extensive changes in vessels were observed. Dr. Wickham Legg also showed specimens of joints from a case of hæmophilia. The condition of the joints had previously been observed in one case by Pon- cet, in one case by Sir William Jenner, and in one by himself; the same appearance was observed in all the cases. The first stage consisted in the extravasation of blood into the joint without any change in the structures of the joint. In the second stage, the synovial membrane was of a russet color, and there was slight erosion of the cartilage. In the third stage, the synovial membrane was deeply dyed and the cartilages exten- sively eroded and destroyed, so that the disease of the joint would seem to have its origin in the extravasation. There is no question about the consequences of ex- travasation, but they are simply sequelæ; nor need we doubt the existence in exceptional cases of accompany- ing vascular disease or blood change. It would not be unreasonable to expect these at certain times and in cer- tain stages, but the general absence of the local evi- dences of morbid change is the chief distinctive evidence to differentiate hæmophilia from purpura hæmorrhagica. The British Medical Journal, while discussing the malady of Prince Leopold, thus candidly states the case, as follows: “We do not know what is the malformation or disease which predisposes to such an easy escape of blood from its proper channels. The chemical con- stitution of the blood has been thought by some to be at fault, the smaller blood-vessels by others; but no chemical or microscopical investigations that have been 384 C. H. Hughes. conducted as yet have been anything but satisfactory, and, therefore, have been without result. One curious. fact, however, has been elicited from various observations. that have been made, and this is, that it is hereditary to a marked degree, and that it is transmitted along the male much oftener than along the female line." Let us now again recur to the physiology of our sub- ject. A little over a century and a half ago (1727) Pour- four du Petit, after cuiting out the ophthalmic ganglion of a dog, observed an increased vascular turgescence to follow in the vessels of the eye. The later similar experiments. of Claude Bernard, Brown-Sequard, and others on the cervical sympathetic have so fully confirmed the discovery of Petit that the phenomenon has become an accepted fact of modern physiology. If the ischiatic nerve of a frog be divided the relax- ation of the muscular coat of the arteries, on which the dila- tation of their caliber by distention with blood depends appears to be an effect of a section of special vaso-con- strictors, derived from the sympathetic, bound up in the ischiatic trunk, and not of fibrils derived from the spinal cord. Thus T. Wharton Jones, in a paper on “The State of the Blood and the Blood vessels in Inflammation," showed, in a communication to the Royal Medical and Chirurgical Society, in May, 1883, in the “Medico- Chirurgical Transactions," Vol. XXXV., and “Guy's Hos- pital Reports,” October, 1853, that if we lay open the lower part of the vertebral canal of a frog, and remove the roots of the ischiatic nerves with the corresponding por- tion of the spinal cord, so that all sensation, voluntary motion, and spinal reflex action in the posterior extreme- ties are abolished, the walls of the arteries are neverthe- less seen, on examination of the webs under the micro- scope, to retain their contractility; nay, they appear even more disposed to become contracted, so as to keep up greater than ordinary constriction of the caliber of these vessels. When, now, the trunk itself of the ischiatic nerve in Hemophilia. 385 the thigh, which comprises not only the spinal fibrils, sensitive and motor, the roots of which were with the cor- responding portion of the spinal cord destroyed, but also fibrils from the sympathetic nerve in the pelvis as yet unin- jured, was divided on one side, the skin of the extremity subjected to this part of the experiment was seen by the naked eye to become redder from general vascular fulness than that of the opposite extremity, and on microscopical examination of the web the arteries were observed to be relaxed and dilated by distention with full and rapid streams of blood injecting the capillaries and venous rad- icles. In the web of the opposite extremity, in which the trunk of the ischiatic nerve in the thigh was left uninjured, the arteries were, on the contrary, seen much constricted, some even to closure. This remarkable fact would appear to indicate something like the operation of inhibitory nerv- ous influence having been arrested by the destruction of the spinal roots of the ischiatic nerve and the correspond- ing portion of the spinal cord whence they originate, leaving the vaso-constrictors derived from the sympathetic in uncontrolled action. The electric irritation of the chorda tympani nerve gives a phenomenon different from that which immediately follows the peripheral stimulation of other nerves presiding over vascular and glandular supply. In this experiment, first performed by Claude Bernard, when the nerve is excited by electricity, the arteriole walls of the blood- vessels dilate, the submaxillary secretion is accelerated and profuse. This is exceptional and may be explained on the hypothesis of speedier exhaustion of central inhibition than we see elsewhere. The effect of a smart blow on the skin or of a sudden scald is something like it, but here there is more or less of capillary destruction. The action of a blister in its primary stimulation and final exhaustion of vasomotor tonicity, fol- lowed by relaxation and exudation of serum, is a thera- peutic illustration. But whatever view we take of the modus operandi of 386 C. H. Hughes. peripheral irritation on the capillary circulation, the fact remains that the movements of the blood current are presided over by a central nervous system mainly located in the sympathetic chain of ganglia and its fibrils, and that whether there be vaso-dilator as well as vaso-con- strictor fibers, or only vaso-constrictor fibers, and prob- ably inhibitory fibrils going beyond the vasomotor ganglia, and if arterioles permit the blood to extrude through their walls without our being able to detect appreciable struc- tural disease in them or in the blood current, the condition that permits this is disease, and this disease can only be in the nervous system. Since the pub- lication of my first paper on the subject, and since this paper was written (May, 1886), though it is only just now given to the medical press, papers have appeared accepting this view in part as the proper ex- planatory view of its pathology; among them a paper by Thomas Oliver, M. R. C. P., in the London Lancet. Whatever other pathological co-existences may be found, neuropathic or otherwise, in any case, I believe the essential pathology of this disease is in defective central action on the part of the vasomotor center, a view which Oliver accepts only in part. A defect- ive blood condition as to its fibrinous constituents and coagulability may precede or follow hæmophilia ; but this is certainly not an invariable or even a common causative condition. What is true of hæmorrhaphilia is true, in part at least, and in the chief part we think, of hæmorrhagic malarial fever, of purpura hæmorrhagica and certain erythemas, the two latter, according to E. Wagner, being closely related. In simple purpura and urticaria, hemorrhage takes place in the skin only. In malarial hæmaturia the san- guineous exudate is chiefly into the stroma of the kid- neys, the malpighian tufts, and the tubuli uriniferi; but, wherever it is, though the more remote cause be malarial Hemophilia. 387 toxæmia, the immediate is in the lost vasomotor control that allows arterial dilatations and permits of the fatal pressure of passive congestion and sanguinuric excretion. Dr. W. Allen Jamieson, lecturer on Diseases of the Skin, in the Edinburgh School of Medicine, in a review discussion of purpura and erythema in the Edinburgh Medical Journal for March, expresses the common feeling on these subjects when he asks, Why in certain cases of tubercular erythema hemorrhage occurs so constantly, so quickly, and so severely? and answers, that it cannot be explained by the youth of the patients, nor from their anæmic conditions; and concludes that, some hitherto unknown cause exists, as in hæmorrhagic smallpox. That hitherto unexplained cause is in the paralysis of vaso- motor control. A thoughtful and observant writer in the Texas Courier-Record of Medicine, Dr. Jas. A. Abney, of Tufkin, Texas, writing on malarial hæmaturia, strikes the true pathology in his second proposition, that, following the pre-existing toxæmia, “the resulting pathological con- dition is one of vasomotor depression, with consequent vascular expansion.” A survey of other fields of clinical observation, for which we have here neither time nor space, serves to confirm the conviction enunciated by us years ago, that the neural pathology is destined to reign pre-eminent in medical thought. 390 C. H. Hughes. to be written, and in these approximatory successful at- tempts at a signature the small letters were made four or five times the usual size in height and diameter. This young man has no history of epilepsy as it ex- isted in most of Hammond's cases; never had convulsions nor chorea in infancy or childhood, nor is there any evi- dence or history of genuine hemiplegia. The case appears to me to be in every way a distinctive symptomatic one, even more fully sustaining Hammond's claim for this dis- ease as a distinct pathological entity, than this author's own recorded cases. This case has contributed more than any other that has come under my observation to dissipate all skepticism as to its claim to separate nosological and pathological consideration. M. Charcot and others who have con- founded athetosis with post-hemiplegic chorea will not confound this case in like manner, as its antecedent his- tory will not justify such confusion. . I am now satisfied that the cases hitherto reported by me under the designation of persistent rythmical clonic spasm when I was unwilling to accept, with the full mean- ing of its author, the term athetosis, as descriptive of a distinctive neuropathological grouping, were cases of true athetosis. (Vide ALIENIST AND NEUROLOGIST, Vol. II., p. 662, 1881.) These cases were neither post-epileptic or post-hemiplegic, the movements were deliberate and the irregular contractions were characteristic, though not so marked as in the present case. They were designated and regarded as athetosic at the time, but not as athetosis, pure and simple. In the literature on this subject as contributed and collected by Hammond in the last edition of his work, there are now enough correctly recorded cases to satisfy the most skeptical as to the right of the term athetosis, I think, to be retained in the distinctive nomenclature of diseases, and the line is there clearly drawn, between the real and its resembling symptomatic states, and to this au- thor the reader is therefore referred for a fuller discussion Unique Case of Bi-Lateral Athetosis. 391 of this subject, which it were manifestly unnecessary to here prolong. Following is briefly the record of the history of this case, as entered in my case-book, April 19, 1887, the patient having at that time been several weeks under observation, though an active attempt at treatment was not begun before the date of beginning of the record. CASE.—Geo. E. M., age twenty years, American born, about nine years ago, met with an accident on the Cairo and St. Louis Narrow Gauge Railroad (now the Mobile and Ohio) causing injury by concussion and direct vio- lence. The train on which he was sleeping at the time of the accident broke through a bridge and was thrown off the track. He was taken from the wreck in an un- conscious state, but remained so for a few minutes only. He had two ribs broken and was hurt in the lower dorsal region, but not seriously enough to affect function of bladder, kidneys or bowels, or power of moving lower limbs. He was able to go out within six weeks after the accident, but had an incomplete brachial menoplegia. About one year after the accident contracture of the left forearm on the breast appeared and embarrassed movement of the right arm set in, so that he could not throw a stone easily or project it far from him. He “threw like a woman," he says, and could not make a full rotary movement. About four years ago, long after he had fully recov- ered the general use of the upper extremities, irregular contractions first appeared in fingers and flexors and ex- tensors of arms and forearms. About one year ago the left arm grew worse and the right arm became useless for three months, and had to be carried in a sling. He can hold nothing requiring strong coördinate movement in left hand. Has dropped things from both hands, and cannot cut meat with left hand, nor hold a fork. He can cut with the right hand by clinching the knife: 392 C. H. Hughes. in the hand as a dagger is held. Can put his left hand in a side pocket of coat but cannot easily get it out without assistance from the other, on account of the irreg- ular spasmodic position of the fingers. Cannot trim finger-nails of the left hand without great difficulty, be- cause of the irregular spasmodic attitude assumed by the fingers. . Was tongue-tied when an infant, but could never talk plain though frænum was cut by Dr. Boothe, of Sparta, Ill. About two years ago speech was much embarrassed. He cannot now say what he wants to fluently. He cannot whistle. He has some slight rhythmical :spasmodic movements of the obicularis oris, and levator and depressor anguli oris muscles, and some apparent re- mains of former slight paralysis of right side of face, ap- parently in his expression. Movements of tongue are only restricted by cicatrized and contracted frænum linguæ. Can handle pen and pencil, and makes out to do a sort of writing, by holding right fingers and thumb with left hand and steadying right arm against chest. Eye balls move normally. He was a bright boy before the accident, but became feeble-minded after the concussion of the accident, and was with Dr. Wilbur, at the Illinois State Institution for the Feeble-minded for several years, though his mother thinks was never dull enough in inind to have been sent there. His intellect is now quite good and his intelligence up to the common average, even above it probably, consid- ering how much and how long he has been afflicted and how little education has been given him. Has a markedly left splayfoot resembling talipes, from injury to instep and displacement of tibia on astragalus, caused by fracture of external malleolus, though both feet are turned out abnormally. Tendon reflex normal; both knees. No anæsthesia or hyperästhesia anywhere. Unique Case of Bi-Lateral Athetosis. 393 Can button and unbutton shoes and dress and undress himself, though clumsily and tediously. Has rhythmical movements of toes. Never had chorea or convulsions. This case is unique in that, it is double or bi-lateral, not associated with epilepsia, and resulted from cerebral concussion and shock. It is unique in the fact, that though feeble-mindedness was associated with it from the common cause, that has disappeared. It is unique in having some facial move- ments. When he is sitting with hands on lap, the left hand will involuntarily assume the position of a pointing hand, the index finger standing straight out and stiff, while the rhythmical movement in the other fingers and the thumb continue. It is unique from the further fact that it appears, after nine years, to be recovering, the spastic conditions hav- ing now almost disappeared, while only the deliberate contraction and extension remains, and this symptom is certainly much better. The case is still under treatment, and should a re- covery or death occur while under our care, it will be made the subject of a further communication. This case tends further to establish what Hammond has stated, and Oulmont and Brousse's cases confirm, that the disease is not necessarily confined to one side. It shows that athetosis is not a necessary choreac se- quence of hemiplegia, and that it certainly is not a post- hemiplegic chorea. It shows what other cases have shown, that a cause sufficient to produce paralysis may cause it, while, at the same time, it establishes the fact that like cases previously reported, it may come on after the paraly- sis is gone. It shows, also, how tardy a sequence it is to the original injury, and tends to confirm the conjecture that it is due to chronic degenerative change, rather than any sudden pres- sure, such as results from hemiplegic clot, emboli, or C. 394 C. H. Hughes. thrombi, though the improvement in this case might be thought to militate against the conjecture of chronic degen- erative atrophy`as was found by Ewart in one of Ringer's cases. The original causative injury in this, as in preceding cases of record, was in the head. It is not probable that in this patient any degree of softening about the corpus striatum, as was found in Lan- douzy's and Sturges' cases, exists. None of the other symptoms justify it, unless we assume the establishment of separation of cerebral tissue or vicarious neural function, neither of which however are organic impossibilities. My own opinion, for what little it may be worth, is that degenerative tissue changes in the motor area of the cortex and subjacent striate bodies have set in, as the chronic sequence of the railway concussion. This patient is and has been from the beginning of treatment on iodide and bromide of potassium, hypophos- phites compound, arsenic, strychnia, and when malarial symptoms have intervened, courses of quinine. The bowels have been kept open regularly with rhubarb. The accompanying cuts are illustrations of two atti- tudes taken at different times in the progress of the case, by the artist. They make the boy appear rather more fleshy in the chest and stouter in the legs and thighs than he actually is. LO O blue CITY HOSPITAL REPORTS, ST. LOUIS, MO. H. C. DALTON, M. D., SUPERINTENDENT. Unilateral Internal Hydrocephalus from Closure of the Fora- men of Monro_Death— Autopsy. By Dr. BRANSFORD LEWIS, Senior Assistant. [ MMA E., aged thirty-three, German, married, house- I wiſe. When brought to the hospital, May II, 1887, patient was in a stupor from which she could be aroused to consciousness but could not be made to talk. She lay quietly, with eyes open, seeming to perceive, but tak- ing little notice of, her surroundings. She would protrude her tongue slowly, only after much urging. There was no paralysis, and sensation was good. Physical examina- tion revealed no lesion of the heart, lungs, liver or spleen; bi-lateral laceration of the cervix, with retroversion of the body, of the uterus. Urine normal, except that the amount of phosphates was about doubled. Pulse 72—80; respiration 20—22; temperature 37.8° C. (100.1° Fah.) Tongue coated slightly. Pupils small, of equal size, quickly responsive to light; they would dilate consider- ably if the patient was aroused. Emaciation was ex- treme, with a corresponding loss of strength. Contents of bowel and bladder were passed involuntarily in bed. By the following day, she had emerged from her stupid state sufficiently to answer questions in unsatisfac- tory monosyllables; said that she had had typhoid fever for four weeks. Later, the following history was obtained from a friend of the patient who came to visit her; “She comes of a 'nervous' family; her mother has had (396] Unilateral Internal Hydrocephalus. 397 facial paralysis, and, like a paternal aunt, and also pa- tient's eight-year-old daughter, has been continually subject to headaches. An older sister has been in an insane asylum for a number of years, affected in a way somewhat similar to that of the patient; a younger sister is ‘peculiar;' a brother has the habit of sitting for hours at a time in a statue-like position. Patient herself has always been of a nervous temperament and capable of being greatly excited by small mishaps; this excitement almost invariably ending in one of her agonizing head- aches-the bane of her life. She has never been able to take coffee, tea, beer, etc., on account of the ill effects of stimulation. The pain, at such times, is located in the top and back of the head. It also comes on frequently without any apparent exciting cause.” She had been sick since the occurrence of an abortion six months ago, but had been confined to her bed only for about four weeks previous to her transfer to the hospital, during which time she had two similar attacks previous to the one from which she was then suffering. The first lasted about a week; the second, five days, and the third began on May ioth, the day before her entrance. She would lie quietly, speaking only at long intervals, and then generally irrationally. Twice she had looked wild ahd threatened to jump out of the window. Patient took food only when urged to do so. Some- times sweated excessively. Her temperature remained normal until May 17th, when it arose to 38.6° C. (101.5° Fah.); pulse 90. Between this and the time of her death, May 21st, it ranged from 37.8° to 38.6° C. (100° to 101.5° Fah.) Pulse only once went to 100; the rest of the time it was about 80 or 90. Respiration 20—24. Autopsy seven hours after death: The adjacent layers of the pia mater, where they dip into the sulci, and those separating the two hemispheres, were adherent. There was no thickening of the membrane. The right hemi- sphere was much larger than the left, and its convolutions seemed somewhat flattened, probably from compression. 398 Bransford Lewis. The right lateral ventricle was greatly dilated in all directions, causing an encroachment on the fifth ventricle which in its turn pressed into the left lateral ventricle. The limits of the anterior and posterior cornua were proportionately lengthened so that at their extremities a much thinner layer of brain tissue than normal formed their walls. The ventricle contained 100 c. c. (3 1-4 oz.) of clear serum. Its ependyma was of a light yellow color, very much thickened, and could be scraped off in large pieces. What appeared to be a prolongation of the ependyma, forming the walls of a cyst, ruptured in the act of opening the ventricle, took its origin at the junction of the septum lucidum, corpus striatum and optic thalamus-just external, and slightly anterior to the natural site of the foramen of Monro. This membranous structure was about the size of a pea, was easily torn, and was attached to the ventricular floor by a pedicle. The foramen of Monro was not to be found, notwith- standing the repeated and careful search made for it. That of the left lateral ventricle was present. No macroscopic abnormal appearances of the brain tissue were discovered. The only other departures from the normal noted in the rest of the examination were marked congestion of the abdominal viscera and extreme retro- version of the uterus. Hilton* records cases somewhat resembling the above. In his cases, the accumulation of fluid was caused by obstruction in the iter a tertio ad quartum ventriculum, and was consequently bi-lateral. Some of the symptoms described by him were noted in this case—such as dis- turbances caused by excitement or stimulants, or probably, as he says, from the increased pressure coincident with the dilatation of the blood-vessels. The conditions found—the thickening of the ependyma, etc.,-would seem to indicate a chronic imflammatory process, which might explain a resultant closure of the foramen of Monro by cicatrization, the original cause • “Rest and Pain," page 25, 1879. Unilateral Internal Hydrocephalus. 399 being ascribed to the hereditary tendency to nervous disease. The usual causes of internal hydrocephalus-tumor cerebri, inflammation of the choroid plexuses, closure of the cerebro-spinal opening, etc., could not bear on this case, as the fluid was confined to one side. SELECTIONS. PSYCHIATRY. Idiot SAVANTS.-Dr. Langdon Down, in British dled- ical Journal, applies this name to children who, while feeble-minded, exhibit special faculties which are capable of being cultivated to a very great extent. One youth was under my care who could build exquisite model ships from drawings, and carve with a great deal of skill, who yet could not understand a sentence, who had to have his food dissected for him, and who, when writing to his mother, copied verbatim a letter from “The Life of Captain Hedley Vicars," by Miss Marsh, although it had not the slightest appropriateness in word or sentiment. Another has been under iny care who can draw in crayons. with marvelous skill and feeling, in whom, nevertheless, there was a comparative blank in all the higher faculties. of mind. Extraordinary memory is often met with, asso- ciated with very great defect of reasoning power. A boy came under my observation who, having once read a book, could evermore remember it. He would recite all the answers in “ Magnall's Questions” without an error, giving in detail the numbers in the astronomical divisions with the greatest accuracy. I discovered, however, that it was simply a process of verbal adhesion. I once gave him Gibbon's “Rise and Fall of the Roman Empire” to read. This he did; and, on reading the third page, he skipped a line, found out his mistake, and retraced his steps. Ever after, when reciting from memory the stately periods of Gibbon, he would, on coming to the third page, skip the line and go back and correct the error with as much regularity as if it had been part of the regular text. Later on, his memory for recent reading became less tenacious, but his recollection of his earlier readings never failed him. Another boy can tell the tune, words, and number of nearly every hymn in “Hymns Ancient and Modern.” Often memory takes the form of remembering dates and past events. Several children under my observa- tion have had this faculty in an extraordinary degree. One boy never fails to be able to tell the name and ad- dress of every confectioner's shop that he has visited in [400] Selections. 401 London-and they have been numerous—and can as read- ily tell the date of every visit. Another can tell the time of arrival of all the children at an institution, and could supply accurate records in relation to it if needed. An- other knows the home-address of every resident who comes under his observation, and they are by no means few. The faculty of number is usually slightly developed with feeble-minded children, whilst memory is fairly well developed; and yet I have had under my observation cases where the power of mental arithmetic existed to an astonishing extent. One boy, about twelve years of age, could multiply any three figures by three figures with per- fect accuracy, and as quickly as I could write the six figures on paper; and yet, so low mentally was he that, although having been for two and a half years in the almost daily habit of seeing me and talking to me, he could not tell my name. Another boy, who has recently been under my observation, can multiply two figures by two figures; while another can multiply rapidly two figures by two figures, and a short time since could multiply three figures by three figures, but since an epi- leptiform attack has lost this faculty to some extent. None of them can explain how they do it; I mean by what mental process. It has appeared to me, however, when by rare chances they have made a mistake, and some hesitation has arisen, the plan has been to clear off the multiplication of the higher figures firsi. Improvisation is an occasional faculty. I had a boy under my care, who could take up a book, pretending to read—an art he had not acquired, and improvise stories of all kinds with a great deal of skill, and in any variety, to suit the sup- posed tastes of his auditors. Memory of tune is a very common faculty among the feeble-minded; they readily ac- quire simple airs and rarely forget them. I have had one boy under my observation who, if he went to an opera, would carry away a recollection of all the airs, and would hum or sing them correctly. In none of the cases of “idiot savants ” have I been able to trace any history of a like faculty in the parents or in the brothers and sisters, nor have I had any opportunity of making a ne- cropsy, except in one instance. This was in the case of a boy who had a very unusual faculty, of which I have never since met another example, namely; the perfect appreciation of past or passing time. He was seventeen years of age, and although not understanding, so far as I 402 Selections. could gather, the use of a clock face, could tell the time to a minute at any part of the day, and in any situation. I tried him on numberless occasions, and he always answered with an amount of precision truly remarkable. Gradually his response became less ready. * * * his health became enfeebled, and the faculty departed. At a necropsy I found that there was no difference in his cerebrum from an ordinary brain, except that he had two well-marked and distinct soft commissures. * * * All these cases of “idiot savants” were males: I have never met with a female. [The remarkable musical prodigy, Blind Tom, whose history is omitted here, should have a place in Fame's Temple of “ Idiot Savants."] recently lite the influence has recalled entitled "' INFLUENCE OF THE EMOTIONS ON THE GENERAL HEALTH.— In a most interesting and valuable thesis, recently pub- lished by M. Alphandéry, and entitled “Moral Therapeu- tics,” the author has recalled several historical examples of the influence of the emotions upon health and even life itself. Joy, he has shown, may not only occasion deep modifications of the system, but may even cause death. He cites, in proof of this, the case of Chilo, the Spartan, Ephorus of Lacedæmon, ranked among the Seven Sages of Greece, who is said to have died from joy while embracing his son, who had won the great prize in the Olympian Games (B. C. 556). Aulus Gellius tells us that Diagoras of Rhodes died in the same manner and from the same cause. The consul Juventius Thalma, colleague of Tiberius Gracchus, as narrated by Valerius Maximus, died of joy on reading the announcement that the Senate had decreed him a triumph. Sophocles, after reaching ex- treme age, wrote a tragedy which he read before a public concourse. The crowd remained silent for a moment, and then proclaimed him, with one voice, Tragic Victor. The joy was too great for the old man, and he fell forwards, dead. To come to more modern times, Pope Leo X., we are told by Montaigne, upon hearing of the capture of Milan (which he had long desired) entered into such trans- ports of joy that he fell into a fever which killed him. Sudden grief, a great disappointment, anger or chagrin, may produce similarly disastrous results, history again fur- ishing numerous well-known examples. Isocrates died suddenly of grief on hearing of the battle of Cheronea. Terence died ot chagrin from the loss, Selections. 403 by shipwreck, of a large lot (one hundred and eight) of comedies translated by him from Menander, and the manu- script of which he had sent by sea to Rome. Horace survived the death of his friend and benefaetor Mecænas, but a few days—"died of a broken heart." Sibouyah, an Arabian grammarian of the eighth cen- tury, died of mortification because he was vanquished in a discussion held before Haroun al Raschid. Andreas Vesalius died of remorse caused by having commenced an autopsy on a man whose heart he found to be still beating. Pope Clement IX. died of chagrin at the loss of the Island of Candia. Amaury, accused of heretical tendencies, in 1209, died of remorse, because he had disavowed his real opinions when questioned upon them. Ximines, in 1517, died of worry over approaching disgrace. Cheke died (in 1557), like Amaury, of sorrow, at having pretended to be con- verted from his real religious views. Valentia, the philoso- pher, having been accused by the pope of falsifying a passage in Saint Augustine's writings, died of chagrin. The poet Sarazin (1654) died of shame for having sub- mitted to a blow from Prince Conti. We need not, however, go to history, for instances of this sort. There is scarcely a physician of middle age who cannot recall at least one instance coming under his own observation, where death was due solely to the emo- tions. The phrase, “ died of a broken heart” is no doubt often used carelessly or misapplied; but that sorrow, remorse, shame and worry, drag many a man and woman to premature graves is as true as that cholera or diph- theria does so, though not of course, to the same extent, so far as numbers go.–St. Louis Medical and Surgical Journal, Dec., 1886. LARVATED INSANITY AND PARANOIA.—Dr. Conolly Nor- man (Journal of Mental Science, April, 1886) describes under this title two clear cases of paranoia with positive logical perversion from the outset. The first was that of a man who had a severe fever (kind not stated) with pro- tracted delirium at ten years of age. Dr. Conolly Nor- man says: “How far a severe illness in childhood was the starting point of mental degeneration it is impossible, with such scanty evidence, to say. The delusions appear in a curious gradation. First, the fundamental tone of 404 Selections. the character is exaggerated self-esteem. Then appears a delusion of inventive capacity, i. e., inteliectual superiority ; then a delusion as to fortune and family, and finally, delusions as to relations with the Deity. Not till the appearance of these last does he violate the laws of soci- ety. The man exhibited delusions of exaltation for twenty- five years, during which time he occupied a position of considerable trust; he was, no doubt, often engaged in duty, requiring much self-command. He had habitually the charge and carriage of arms, and must have often appeared in the witness-box, sometimes, without doubt, in cases of a grave nature. He was, however, the uncon- scious butt of his fellow-policemen, although superior to them in education; he was appointed policeman at twenty. He had delusions of being heir to a large estate in Kildare, but worked well for twenty-five years ; in 1879 he was sent to an insane hospital. He had suddenly become silent, and this was succeeded by an hallucinatory period ; he improved, admitted his delusions, and was discharged, but six months later was readmitted with delusions of inspiration. He was discharged in 1881. “The second case was that of a young man who, upon an intense predisposition, either inborn or acquired at the period of puberty, developed, through the agency of a com- paratively slight exciting cause, well organized delusions of persecution; to avoid his persecutors, he fled from home and entered the army. Here he succeeded and rose to a post of special responsibility, having been for a time entrusted with arms and also, what some would count a more delicate charge, the distribution of money. Again, driven by delusion, he vanished from among his friends, and again became a soldier and entrusted with large sums. A sexual delusion with a certain degree of arrest of gen- ital development seem to indicate that sexual aberration may have existed. A delusion that the devil was in his pocket and that he got rid of him by leaping across a stream pointed in the same direction. Perpetual leaping across streams would have the appearance of an impera- tive act but for the explanation offered by the patient, which after all refers to one instance only. Much of this patient's conduct, in his more lucid conditon, his callous selfishness and ingratitude, his determination to live on his relatives, and his readiness to abuse and annoy them, recall recorded cases of moral insanity. Had either of these patients during a long course of years been charged Selections. 405 with a grave offence-each of them suffered from delusions very apt to lead to crime ; each of them was in a position which gave facilities for crimes of violence, and had an attempt been made to claim irresponsibility on the ground of insanity, an immense amount of evidence would be at hand to invalidate the plea. In the second case such a defence would not have been thought of; he lived largely at a distance from his friends, and his command over himself is still so great that, except under peculiar circumstances, it is next to impossible for a stranger to induce him to betray what would be legally recognized as insanity.” The report of these cases indicates that Dr. Conolly Norman is a good clinician, but illustrates, also, the bad effect the Philistinism of Blandford and similar works has had on British psychiatry. The social dangers resulting from such teachings are well illustrated in these two cases. OVARIOTOMY IN INSANITY.-Dr. Percy Smith (Journal of Mental Science, July, 1886,) reported the case of a thirty-three-year-old woman whose brother had died of phthisis. Menstruation had always been somewhat irreg- ular and scanty. For about two years deafness had increased. The attack of insanity dated from about six months before, and began in her making remarks about passers-by, and imagining that when they scratched their faces, lifted their hats, or blew their noses, that those actions were directed to her. These ideas gradually led her to think she was a person of importance, and every- body took notice of her; she became troublesome, struck her mother, and threatened to drown herself; she thought that some person had injured her ears by placing a tele- phone in them. On admission she was in good general health, but had an ovarian tumor reaching to the umbili- cus; was restless and untidy, constantly looking out of window as if expecting a visitor. Thought the Marquis of Hartington took a great interest in her, and wanted to marry her, etc. Constantly complained of the smell of dead bodies in her room at night, and of telephones in her ears. In December the tumor reached above the umbilicus, and caused much discomfort; it was decided to perform ovariotomy. The tumor consisted mainly of one large cyst, with a considerable amount of solid material in the pelvis, and sprang from the left ovary. The right ovary was normal in size and appearance, but somewhat erform and caused her the tun 406 Selections. hard; it was left in situ. . Six hours after operation she was restless and talkative, and was kept quiet by morphia. She still talked about telephones and the Marquis of Hartington; she, however, never complained of bad smells. Fifteen days after the operation she recognized her med- ical attendants and nurses by their names, said what she had said before was all fancy, and wrote sensibly to her mother. Ten days later she seemed quite rational and happy; the only thing noticeable was, that she changed rapidly from one subject to another. It was hoped that she was on the way to cure. Six weeks after operation, she became fidgety again, and said that the Marquis had said she was not to wear the belt that had been ordered for 'her. Subsequently her mental condition became worse, and though in good general health, she is very deluded. She does not complain of bad smells, and denies any when questioned. She is restless and incoherent, but is much more tractable than on admission, and writes fairly sensible letters to her mother. She has menstruated since the operation. The patient is now apparently hope. lessly insane, yet the olfactory hallucinations have entirely disappeared. Dr. Savage has pointed out the presence of smell hallucinations in persons with sexual delusions. The history of the case is imperfect. The temporary improvement under an operation is not an uncommon matter in chronic cases. The relation between sexual delusions and olfactory hallucinations is only what was to be expected, since in the lower animals sexuality and odors are in constant association. FÈMALE DISEASES AND INSANITY.—Dr. Delia E. Howe (Kankakee, Ill., Insane Hospital Report, 1885-6) states that disease of the female generative organs existed in thirty-five per cent. of the female insane admitted during 1885-6. Twenty per cent. of those who recovered received a course of local treatment. Dr. Howe further says: “Uterine and ovarian disease are sometimes causes of insanity, which makes it important carefully to discriminate, so that in cases where special treatment is required (as is so often the case), it may not fail to be secured. “Where female pelvic organ disease is suspected an examination should, if possible, be made, even though, as frequently occurs, a course of local treatment may in many cases be deemed impracticable, or unnecessary. Of five hundred and eighty female patients 35.8 per cent. Selections. 407 were cases, the diagnosis and treatment of which could not be complete without such examination. Over 33 per cent. were actually suffering from organic diseases of the pelvic organs. In many cases the disease was slight, easily cured, and seemed to exert comparatively little influence over the psychoses. A majority of the cases were chronic, and could only be palliated, not cured, either on account of the patients' mental state or the condition of the afflicted organs. A few refused to sub- mit to treatment. Many of the patients acknowledged gratefully the relief given by the treatment.” [These results tend to corroborate those obtained by Dr. Margaret Cleaves (ALIENIST AND NEUROLOGIST, 1884), and are in full accordance with those of Wigglesworth and others.] A CASE OF NERVOUS CONTAGION.—Dr. Kreuser relates the clinical history of a family which furnishes a curious example of induced mania. A girl, eighteen years old, began to suffer from religious melancholia, with delusions of obession, and having no treatment soon became in- sane. She passed whole days and nights praying and making her parents pray also. A few days later the family shut up the doors and windows, and all sat around the table with Bible and Prayer-Book before them. The father and mother pounded on the table with their fists and cried continually: “If it is right, so must it be.” Everyone who tried to enter the house was driven away with blows. The most violent of all was the younger sister of the patient first seized. Finally the neighbors became alarmed at the state of things and made a regular assault upon the house, finally gaining admitance, and then carried the inmates off to a hospital. Here the patients gradually became quiet, and were restored one after another.–St. Petersburger Medicinische Wochenschrift, No. 36, 1886. [This had better been styled “A Neuropathic Family un- der a Neurotic Strain.”-Ed.] Suicide in CONGENITAL IMBECILES.—Dr. C. S. Cobbold (Journal of Mental Science, October, 1886) reports six cases of suicide in congenital imbeciles. In all the cases there was either no perceptlble cause, or it was very trivial (loss of a cat being named as the cause in one case). The feeble "ego” of the imbeciles, like the feeble “ego” of the child (Griesinger) was readily overpowered by imperative conceptions or trivial irritations. 408 Selections. Typhoid FEVER AMONG THE INSANE.—Dr. R. Percy Smith (Journal of Mental Science) has lately reported sev- eral cases in which typhoid fever exerted a beneficial influence on insanity. In the discussion on this paper Dr. Moody said that he could recall sixteen cases of typhoid fever among the insane: in many marked improvement took place and was permanent. NEUROTHERAPY. Notes ON THE SUCCESSFUL MANAGEMENT OF WRITERS' CRAMP AND ALLIED FORMS OF SPASMODIC PARALYSIS, BY INDUCED FRANKLINIC ELECTRO-MASSAGE.—Until a compara- tively recent date only indifferent success has attended or followed the various therapeutic procedures for the relief and cure of this intractable affection of the nervous sys- tem controlling the voluntary muscles concerned in the skilled habitual movements of professional manual dex- terity. Book-keepers, pianists, engravers and others suf- fering with this form of paralysis have generally sought complete relief in vain. The chief remedy prescribed had been absolute rest of the overworked groups of muscles and, internally the use of tonics, conjoined with central and peripheral gal- vanism and centripetal faradisation, until Beard taught that inaction was not a necessity for relief. The inade- quate success attendant upon this plan, though Beard in his lifetime claimed much from electricity alone in these forms, led Charcot and the German neurologists to recom- mend manual massage; and a certain masseur became well known to European neurologist savants for his skill in the cure of writers' cramp by his massage method. The writer had long employed electricity, galvanic and faradic, general and local, in the treatment of this disease, and the success of Schott's massage measures in- duced him to imitate them with the far preferable and more readily applied induced static muscular gymnastics. With this agent, carefully adjusted to the needs of the affected muscles, this formidable incoördination neurosis of the skilled muscle inovements peculiar to artisans, pianists and penmen, and the conjoint use of the constant current constitutionally applied, with such general rem- edies as may be indicated, can be cured, and the physi- cian need no longer be disappointed in its management. Selections. 409 area anche che si motocikal bludingual amb Beginning in writers' cramp, with a constant galvanic current from the motor area in the head to the terminal expansions of the digital branches of the median ulnar and radial nerves, and concluding the séance with a fara- dic massage by which the individual and combined move- ments of the affected fingers and thumb are reproduced by the contracting current. The faradic contractility was extended also to every possible movement of the fore- arm, with the view to promote general muscular powers and nutrition. While we had thus, after long and tedious treatment, conjoined with general tonic and neurotic conservative, internal therapy, and a judiciously enjoined cerebral hy- giene, succeeded fairly well with our cases, the substitu- tion of the induced static interrupted current for muscular gymnastics has made results far more certain and satisfac- tory,—so certain and satisfactory, in fact, as to induce us to conclude that the majority of these cases are periph- eral, contrary to our former opinion. Under this treatment the quickest cure we have to note is that of a prominent rail:vay official, who recovered so as to again sign the papers of his office after five days' daily treatment; and a telegraph operator, who, resuming his instrument after three days, considered himself per- fectly well in one month thereafter. The average treatment is six weeks, when given every second day. I believe all cases of this not long ago unmanageable and whether of central origin or not, a necessary part of a grave cerebral disease, can be perfectly cured in this manner, and by this form of electro-massage.—By C. H. Hughes, M. D., Med. and Surg. Jour., Dec., 1886. ACTION OF COCAINE ON ANIMALS.-Dr. Bignon, of Lima (American Practitioner and News) from a series of experi- ments on the dog and man, has noted the following results: 1. That cocaine produces only temporary physiological effects in doses from twenty to fifty centigrams when ad- ministered by the stomach, on condition of its being absorbed in small divided doses (of five centigrams each hour). 2. It acts principally on the renal secretion in slack- ening that function, interfering with the elimination of the products of oxidation, and thus producing the first symp- toms of slight uræmia. 410 Selections. 3. In large doses, given at once, it produces anuria, which is followed by grave uræmic accidents, nervous attacks, convulsions, etc. 4. The paralyzed kidney generally regains its function two or three hours after the absorption of the alkaloid; then follows considerable diuresis, which is the more active the longer the duration of the anuria, and relief to the organism. 5. Cocaine is only indirectly toxic., when the dose is sufficiently high to prolong the anuria to the point of uræmic poisoning. 6. If the diuresis should quickly remove the toxic phenomena, the general stimulating action continues none the less for a long time afterwards: it lasts about twenty- four hours (in a dose of fifty centigrams to be given in the course of the day). During this time the phenomena of oxidation continue to go beyond the normal average. In a word, denutrition continues.-W., in American Lancet. SPLENIC TISSUE AS A THERAPEUTIC AGENT.—Some curi- ous experiments have recently been made by Dr. Predazzi with the pulp of the spleen, with a view of determining its value, if it has any, in the treatment of anæmia. A mixture was made containing brandy, one and one-half ounces, splenic pulp, four and one-half ounces; and emulsion of bitter almonds, ten and one-half ounces ; the whole to be taken in the course of the day with the meals. Five patients with chlorosis were treated with this mixture, and in the course of from one to three weeks the following results were observed by the author (Deutsche Medicinal Zeitung): 1. Rapid improvement in the general health, and in- crease in the number of the red blood globules. 2. A speedy and permanent cure of the functional disturbances of the nervous system, digestive and urinary organs and circulatory apparatus. 3. Increase of arterial tension and of the body weight. The patients were, however, put at the same time upon a nourishing and regulated diet, and it is, therefore, somewhat difficult to say how much of the benefit was derived from the spleen pulp, and how much from the good food, to which the patients were doubtless not accustomed. We venture to suggest, however, that the latter was at least equally as potent for good as the chopped-up. spleen.- Medical Review. Selections. 411 CIMICIFUGA AS A NEUROTIC TRANQUILIZER.- Dr. Corson is persuaded that none of the other remedies in general use for chorea, not excepting arsenic, have half the value of black snake-root. Its effect is, he thinks, that of a “quieter of the general nervous system," and he has found it, in half-teaspoonful doses of the fluid extract, a charming remedy for insomnia. Ringer and Phillips regard cimicifuga as an excellent tonic of the nervous systein, and especially suitable for cases characterized by failure of coördination.— Exchange. (Cimicifuga is an old remedy which went out of com- mon use with the advent of the bromides. It has been tried, and as compared with the bromides and chloral for neurotic tranquilization, it has been found wanting, and been superseded. The writer of this was taught to use cimicifuga, valerian and serpentaria in infusion in chorea, epilepsia, hysteria and the nervousness of typhoid and other fevers, before better remedies supplanted them, in neurotherapy; but an infusion of the three sorts makes an excellent vehicle for the bromides.] THE TREATMENT OF NEURALGIA BY CHLOROFORM Dif- FUSION.- The Medical Record calls the attention of its readers to a method recently proposed by Adamkiewicz for the relief of this troublesome affection (La Riforma Medica, No. 25, 1887), in the following language: “The experiments of Wagner had shown that, if the positive electrode were impregnated with a solution of cocaine, the passage of a constant current produced an intense anæsthesia of the skin. This fact led the author to try what effects could be obtained by chloroform ap- plied in the same way. He found that simply saturating the electrode was insufficient, as the substance evaporated so rapidly that frequent renewals were necessary, thus causing interruptions in the application. He therefore devised an electrode containing a receptacle for the chlo- roform, which was allowed to escape only very slowly, so as to keep the surface of the electrode constantly moist. This diffusion electrode,' as it is called, consists of a metallic cylinder, containing the chloroform, and closed by a diaphram of carbon, which is a good conductor and at the same time allows the drug to leak out slowly. “The cathode is applied at an indifferent point, while the anode, the diffusion electrode, is placed over the seat of pain. The patient complains at first of a slight burning 412 Selections. sensation, but this gradually passes away as anæsthesia becomes complete. It is important not to employ a cur- rent of too great intensity. It is best to begin with a current of moderate intensity and to increase it gradually until the limit of tolerance is reached. This limit is usu- ally from three to seven milliampères. “This method has given very satisfactory results in neuralgia of the fifth nerve and its branches, in intercostal neuralgia, and in rheumatic pains. It would appear, also, to be a convenient means of producing local anæsthesia, as the anæsthetic area extends for a considerable distance around the point of application of the electrode.” ANTIFEBRINE.—Concerning antifebrin (the product of the action of acetic acid on aniline at a high temperature), introduced from Kussmaul's clinic at Strasburg, Dr. Wm. Osler, of Philadelphia, in the Canada Medical and Surgical Journal, thus records his experience: “We have been using it for the past three months, and find the action tolerably constant. A dose of eight grains (in warm water or in spirits and water) will usually reduce the temperature from three to six degrees. There is sweating, often profuse, but not more than after thallin and antipyrin. In the twenty-five cases in which it has been given in my wards, it has failed three times, two cases of pneumonia and one of peritonitis. It does not disturb the stomach, has not once caused vomiting, and even where the temperature has fallen seven degrees in three hours there have not been symptoms of collapse. Cyanosis, noted by some, has not occurred. It is a cheap drug; Merck's, which we have used, is only 60 cts. an ounce, while thallin is 75 cts. and antipyrin $1.50." ETHER AND CHLORIDE OF METHYL IN NEURALGIA.- Abadie claims (Annales D'Oculistique, July-August, 1885) to have obtained with chloride of methyl brilliant results in nervous asthenopia with orbital and peri-orbital neural- gia, by the employment of chloride of methyl by the method of Debove. The methyl is kept liquid under powerful pressure in a metallic vessel. A stop-cock is opened and the vapor rushes out.' This is sprayed upon the skin of the closed lids and surrounding parts. Intense cold and a local anæsthesia are produced. In a number of cases Abadie has had the very best results. In one Selections. 413 case of rebellious facial neuralgia he effected a cure after fifteen sprayings made once a day.- Medical Times. [The methyl is less objectionable about the eyes, but with the eyes well protected with a handkerchief or pledget of cotton or a soft sponge, it is not in the least superior to the rhigoline or ether spray with which the profession has been for years familiar. We have used both effectu- ally for twenty-five years in practice.—Ed.] CODEIA IN DIABETES.—In a paper read before the British Medical Association, Dr. R. Shingleton Smith states that this remedy is almost a specific for diabetes. It should be given in doses large enough to produce physiological effects. Dr. Lauder Brunton advises that it be given in one-fourth to one-half grain doses three times a day. Other eminent men give it, however, in much larger doses. - Canada Journal. (One-half to one grain doses, ter die, with half-grain or more of aloin and the muriate and bromide of ammonium, ten to twenty grains of the former and twenty to thirty grains of the latter, in syrup hypophosphites, Fellows' (with strychnia) have proven successful in our experience in severe cases with marked melancholia attonita. Systèmic Electrizations, static and galvanic, however, have always been conjointly used by us.—Editor.] METHYL CHLORIDE IN NEURALGIA.—Dr. Dudley Tait (Kansas City Medical Index) says that methyl chloride is of value in all neuralgiæ. Its sole indication is pain. It gives good results in treatment of pain in pulmonary affec- tions, in acute and chronic rheumatism, and also in occu- pation diseases, like writers' cramp. In trifacial neuralgia care should be taken, but it is not counter-indicated. One application often suffices; exceptionally several ap- plications are necessary. The majority of neuralgiæ are definitely cured by it. Cure has sometimes been obtained in neuralgiæ symptomatic of Potts' disease, pelvic tumors, etc. The transient pigmentation which sometimes follows its use, disappears in a few weeks. The analgesic prop- erties of methyl chloride are probably due to its action on the superficial terminal expansions of the dermal nerves. ANTIPYRIN IN MIGRAINE.—Dr. Sprimon has stated in a Russian medical journal, quoted in the London Medical 414 Selections. 15, and, as a fit, the durationis Record, January 15, 1887, that he uses antipyrin in all cases of hemicrania, and, as a rule, obtains excellent re- sults. Given at the height of a fit, the drug only partially relieves pain, but does not shorten the duration of symp- toms (especially when the patient remains on his legs all the while). But when administered during the period of prodromal phenomena, antipyrin almost invariably cuts short the paroxysm within an hour, and allows the patient to immediately resume his occupations. The dose re- quired is one scruple. In delicate persons, or in those liable to giddiness, it is better to divide the dose in two parts and to give the second portion (if necessary) about half an hour after the first. THE SULPHATE OF SPARTEIN AS A CARDIAC STIMULANT seems to have won its way to a permanent position in cardiac therapeutics. Since Germain See reported favor- ably upon it, Hans Voigt, Dr. Nothnagel's Clinic, of Vienna, has given a good account of it. He found that small doses (from the fortieth to the sixtieth of a grain) slows the heart's action, and increases the firmness and fullness of the pulse: given two, three or more times daily, for a week, and without unpleasant results. Like digitalis, it is best to diminish the dose, or withdraw the remedy altogether for a few days, and then resume its use as at first. It sometimes accelerates heart-beats at first, and has diuretic action. ANTIFEBRINE IN EPILEPSY.—Dujardin-Beaumetz consid- ers antifebrine one of the most powerful moderators of the cerebro-spinal centers, and uses it in the treatment of epilepsy. CALABAR BEAN FORMULA FOR EPILEPSY.- Extr. fab. Calabar . . . . gr. vijss; Spir. æth. . . . . . f 3 jss; Aq. amygd. amar. (sive aq. mentha pip.) . . . . . f3vss, M. Sig.-Five to eight drops, t. d., for children; eight to fifteen drops, t. d., for adults.-Pharm. Zeitschr. f. Russland. POTASSIUM BROMIDE IN RHEUMATISM.—The Medical Summary states that a young lady under treatment for acute articular rheumatism received, through an error, ninety grains of potassium bromide, and in twenty-four hours thereafter was able to go about. Rheumatism is in Selections. 415 many cases a trophoneurosis, and it is hence hardly sur- prising that the bromides should exert an influence on the disease. At the same time it should be remembered that the potassium salt is a decided cardiac depressant.—Med- ical Standard. ParaLDEHYDE AND URETHAN.-In regard to its chem- istry, method of preparation, etc., I quote from a letter of Prof. C. O. Curtman, of St. Louis, to Dr. P. O. Hooper: “Paraldehyde is the condensation product of ordinary aldehyde and hydrochloric acid, hence (CH. CHO). It is formed by adding to pure aldehyde a small amount of hydrochloric acid, when the condensation takes place with evolution of heat. (With even a small amount of sulphuric acid, the reaction occurs with explosive violence.) The product is cooled by ice till it solidifies, is then pressed to free it from acid, etc., filtered off and finally distilled. It boils at 253.7° F. It dissolves in 8.3 parts of water at 55.4° F., less in hot water. Distilling with sulphuric acid reconverts it into ordinary aldehyde.” Dujardin-Beaumetz says of it: “In strychnia poisoning, delirium tremens, and uræmic convulsions, paraldehyde is superior to chloral.” Cervello says: “Paraldehyde affects the cerebrum, the spinal cord and the bulbus, successively abolishing the reflexes, causing anæsthesia and sleep by anæmiating the brain and cord. It is eliminated by the lungs. It is not a cardiac poison.” I may add, that in no instance have I seen interference with respiration result from its administration. At the Lunatic Asylum we have used the drug as a hypnotic to allay excitement, and to control epileptiform seizures in one instance. The results obtained have been very grati- fying. It is administered in doses of from 30 to 75 minims. I, however, usually give 3j. A single large dose acts better than frequently repeated small doses. In simple insomnia, in 3j doses, it has acted for me like a charm, while in mania accompanied by great excitement, the results have been almost uniformly satis- factory. When the solution is freshly prepared and is administered without more than momentary exposure to the atmosphere, sleep, in nine out of ten cases, has been produced in from three to fifteen minutes. In the few instances in which no effect followed its ingestion, it was repeated in one hour and the desired result produced. The sleep produced is sound, refreshing and to all 416 Selections. appearances natural; it lasts from three to eight hours, and in my experience has never been followed by nausea, headache, anorexia, constipation, or any symptom of de- ranged function. In recurrent mania attended with great excitement, restlessness and persistent insomnia, it has seemed to me to shorten the duration of the paroxysms. In such cases it was administered nightly and sometimes had to be re- peated, but in no instance has a tolerance been estab- lished. In one case of acute illness, where the patient was much emaciated, very weak, wildly delirious, and suf- fered from persistent insomnia which chloral failed to relieve, a single dose (3j) of paraldehyde produced a natu- ral sleep of eight hours' duration, from which the patient awaked refreshed and improved. On the two succeeding nights he received the usual dose, and each time with like results. On the fourth night he slept soundly without a hypnotic of any kind, nor did he require one subse- quently. Again: in a woman, the victim of chronic mania, who was also in the last stages of pulmonary tuberculosis, paraldehyde produced sleep and quietude repeatedly and without untoward effect. I have used it but once to con- trol the paroxysms of epilepsy. The history of that case is as follows: The patient, who has suffered from epilepsy for years, having two or three attacks weekly, suddenly had an increase in the number of paroxysms. For two days he had from one to three seizures hourly, and became totally demented. Potassium bromide in heroic doses had no influence over the seizures, while 3j of paraldehyde caused a complete cessation in less than twenty minutes ; this cessation was accompanied by a sound sleep of six hours' duration, from which the patient awakened im- proved in every respect. In epileptic mania in which paroxysms of epilepsy were not numerous, I have used paraldehyde for its calm- ative and hypnotic effects, and in only one instance did failure result. In that case the patient was taking f. e. ergot and potass. bromid. for the epilepsy. In several instances, I have awakened the patient within a half- hour or an hour after the ingestion of the drug, and found he would talk sensibly, but as soon as he was left undisturbed, he relapsed again into sleep. In a case of chronic mania in a man who has a lesion of the mitral valve, compensatory hypertrophy of the Selections. 417 heart having taken place, the paraldehyde gave most ex- cellent results. I would state parenthetically that chloral has frequently been administered in this case without ill effects. Sometimes chloral produces a state of intoxica- tion which forces the patient to occupy the recumbent posture, but neither allays excitement nor produces sleep. In this class of cases paraldehyde is invaluable. The method of administering paraldehyde is important. It can be given in mucilage, syrup or whiskey, preferably in whiskey. At the Lunatic Asylum we give one part paraldehyde in three of whiskey. No difference in the · action of the drug is perceptible when mucilage or syrup is used as the menstruum, instead of whiskey. Whiskey disguises the taste and in a great measure conceals the exhalation of the drug on the breath. This exhalation, when not obviated by whiskey, is almost intolerable, and continues for several hours. I have noticed it twelve hours after the ingestion of the drug. Paraldehyde must be kept in glass or rubber-stoppered bottles, and must be taken as soon as poured out; other- wise disappointment will follow its use. That paraldehyde will supersede chloral I do not be- lieve, but that it will rank as a good, reliable hypnotic, particularly where chloral and opium are contraindicated by personal idiosyncrasies, I am confident. Another fact: paraldehyde is not an analgesic, and in insomnia due to pain is worse than useless. Now, a few words on urethan, another hypnotic, which promises to be as valuable as paraldehyde. Urethan puriss. (NH, CO, C, H;) is the ethylic ether of corbaminic acid; comes in white crystals, odorless, easily soluble in water, and has a sweetish bitter taste. Its hypnotic value has been tried in cases of rheumatism, gout, catarrh, neuralgia, skin diseases with irritation, gen- eral restlessness and sleeplessness. As a rule the results were excellent, no unpleasant after-effects having been caused in a single instance. Urethan is an analgesic, as is shown by its action in gout, rheumatism, etc. Its action is chiefly on the cerebrum, and it has no influence on the medulla oblongata or cord. No interference with the ac- tion of the kidneys or bowels has been noticed. The dose of the drug is 15 grs. I have used it only in insomnia of mania, and have found sleep result uniformly after the ingestion of the above-named dose. As toxic symptoms have never as yet been produced by the drug, 418 Selections. I can tell you nothing of them, nor of the amount neces- sary to produce them. I have seen sleep, apparently natural, as the only result of the administration of urethan. If the promises which urethan holds out are fulfilled, it will prove an addition of very great value to our materia medica. Dr. H. Williams, M. D., Assistant Physician Ar- kansas State Lunatic Asylum, “ Journal of the American Medical Association, January 22, 1887.”] COCAINE AN ANTIDOTE TO STRYCHNINE.—Bignon finds that dogs to which strychnine is given by the mouth, in doses of not over two milligr. per kilo., can always be saved by hypodermic injections of cocaine, the injections being continued until the poison is completely eliminated. This succeeds even after the first access of tetanus. Three milligr. per kilo. of strychnine always killed, but death is much delayed by cocaine.-Medical Abstract. PicRATE OF AMMONIA IN MALARIA.—Dr. H. M. Clark, an East Indian surgeon, in a recent issue of the Lancet, concludes that in all varieties of intermittent fever, and in malarial neuralgias, picrate of ammonia is a valuable substitute for quinia. It does not produce headache, deaf- ness, tinnitus, nausea, etc., nor disorder the digestion. The dose is smaller and the cost is less than quinia. (But it does color the urine and conjunctivæ yellow. -Ed.] lodoFORMIZED COLLODION IN NEURALGIA.—According to Dr. J. S. Jewell (Neur. Review) a mixture of one part of iodoform to ten or fifteen of collodion, spread repeatedly upon a neuralgic surface to a thickness of one or two mil- limeters, is an effective neuralgia remedy. If the first appli- cation does not cure the neuralgia the remedy should be continued. It is especially valuable in trigeminal neural- giæ and in spinal irritation. CURE FOR RHEUMATISM.—As a remedy for intercostal neuralgia, intercostal rheumatism, muscular rheumatism, or lithemia, Drs. Fulton and Halley (Kansas City Medical Record) have found great benefit from the following: Lithium bromidi 3ij, ammoniæ mur. Zijss, aq. dist. ziij; sig. a teaspoonful every half-hour. This prescription, they say, will usually give relief, in two hours. Selections. 419 KAVA-KAVA AS A HYPNOTIC.—Dr. Ghillany, Vienna (Wiener Med. Woch.), states that an alcohol extract of kava-kava has proven of value as an hypnotic. Dr. Kiernan (Chicago Medical Review, 1881, suggested that in the insomnia resulting from conditions of exhaustion this drug would give results of value. NEURO-PATHOLOGY. THE SPINAL Cord IN THE INSANE —Dr. R. S. Stewart, Senior Assistant Medical Officer of the Glamorgan County Asylum, Wales, has written a very valuable thesis on this too often neglected department of psychiatry. - * * * * * * * * * * Dr. Stewart found changes in the cord of every case examined. The principal microscopical appearances noted, were changes in vascularity of the soft membranes and of the gray substance, changes in the white columns sug gesting sclerosis and qualitative and quantitative changes in the cerebro-spinal fluid. Beyond slight congestion in one case and thickening in another, the dura presented little appearance of alteration. In regard to the soft mem- branes, in twelve cases there was increased vascularity, more pronounced over the lumbar enlargement, and, as a rule, more so posteriorly than anteriorly. The cerebro- spinal fluid was found in excess in fourteen of the twenty cases. In four of the five cases of general paralysis, the mi- croscope revealed marked changes in the lateral columns, which were in every instance bi-lateral. In no case were the anterior columns affected, and in but a single instance were the posterior columns affected to such a degree as to give rise to ataxic movements during life. In four cases there were lesions in the columns of Goll, and in one there was distinct atrophy of the cord as a whole. Dr. Stewart continues the discussion of his examinations at considerable length, and draws the conclusion that in all the forms of insanity in the cases he examined, the most constant alteration of the spinal cord was a degen- erative atrophy of the nerve cells of the gray substance, and that this lesion appeared to correspond closely in nearly every case with the degenerative process described by Charcot as “pigmentary degeneration, or that condition 420 Selections. associated with pigmentary atrophy.” Systematic degen- erations of the white columns of the cord appeared to be constant lesions of general paralysis, and similar degener- ations were of frequent occurrence in other forms of insanity.- Journal of Insaniiy, January, 1887. THE IMMEDIATE CAUSE OF DEATH IN MALIGNANT CASES OF FEVER.–At a recent meeting of the Medicc-Chirurgi- cal Society (The British Medical Journal) Dr. C. H. Wil- ley read a paper on this subject. The cases under consideration were those of scarlet fever and small-pox in which unconsciousness and death ensued at an ex- tremely early stage. The pathology of this condition had not been explained. The conclusions to which Dr. Willey had arrived were based on clinical observations and post- mortem examinations in twenty-five of these malignant cases. The chief factors in the investigation appeared to him to be that the fatal symptoms were, in each case, those of a rapidly failing circulation, and that, after death, the heart-chambers, especially the right, were completely filled with white, jelly-like clot, which was, he said, clearly of ante-mortem formation. The failure of the circulation (particularly in small-pox cases) ensues with great sud- denness, and the question arose, Was this failure or the thrombosis the primary condition? Evidence from the main symptoms, and from such invariably accompanying ones as pulmonary ædema and copious diarrhea, Dr. Wil- ley said, goes to show that a failure of the circulation is the primary cause of death, and, further, that not only is the heart paralyzed, but the entire arterial system-in fact, a total collapse of blood-pressure throughout the vascular system is brought about with more or less suddenness by a functional failure of the sympathetic nervous system, governing, as it does, the cardio-motor and vasomotor functions. The pulmonary ædema and the profuse intes- tinal flux are due to the same cause; they are undoubt- edly associated with a greatly diminished blood. tension in the arterial system.--New York Medical Record. AN INQUIRY INTO THE CONNECTION BETWEEN THY- ROIDECTOMY AND MYX@DEMA.—The committee appointed two years ago by the Clinical Society of London to inquire into the nature of myxædema has completed its work in so far as concerns the general ætiology, symptoms, and morbid anatomy of the disease, and the main result Selections. 421 is that the most constant, if not the only constant, change found after death is atrophy or morbid destruction of the thyroid body. The only part of the investigation as yet incomplete is that relating to the effects of removal of the thyroid body for disease, and the committee. is about to issue a circular letter of inquiry to all surgeons known to have performed the operation. This letter, which con- tains a description of the disease and a photograph of a typical case, asks the recipient to state whether the “cachexia strumipriva” of Kocher (the “myxædéme opéra- toire” of Reverdin ), which is believed to be the same disease as myxædema, has been observed after a total or partial removal of the thyroid gland. We are requested to state that the committee is particulary anxious to obtain as many answers as possible, and that cases in which no symptoms of myxædema have followed extir- pation of the thyroid body would be at least as valuable as those in which they have. Any surgeon who finds himself omitted, or who has performed the operation without reporting the result, should communicate with Dr. Felix Simon, 39, Wimpole Street, London, W., who is acting for the committee in this matter.-Brit. Med. Jour. The NATURE OF EPILEPSY.-Hughes (ALIENIST AND NEUROLOGIST, January, 1887,) regards epilepsy as a condition of psycho-motor and vasomotor irritability whatever may be its exciting cause, and in treatment seeks to control the irritable psycho-motor area and disordered vasomotor centers by prolonged therapeutic control and steady reconstruc- tion, till their normal tone is reëstablished. Spitzka (Medical Standard, February, 1887) takes a similar view in the following language: “Epilepsy is a diseased state of the encephalon, without a palpable char- acteristic lesion, and manifesting itself in explosive activity of an unduly irritable vasomotor center, leading to a com- plete or partial loss of consciousness, which may be pre- ceded or followed by various phenomena, expressing the undue preponderance of some and the suspended inhib- itory influence of other cerebral districts." 422 Selections. _At a recent mitated that by meanSymph surro NEURO-PHYSIOLOGY. THE INFLUENCE OF NERVES ON THE SECRETION OF LYMPH.—At a recent meeting of the Academy of Sciences, M. Serge Lewachen stated that by means of an aspirator, which insures a free and constant flow of lymph surround- ing the lymphatics of the saphena vein, he can now prove that, if under any nervous influence a certain modification in the circulation of the blood ensues, it always deter- mines a variation in the secretion of lymph. On stimulat- ing the vasomotor nerves (constrictors and dilators), modification in the quantity of the lymph results. These modifications are identical, whatever nerves are stimulated. M. Lewachen considers these changes to be in direct connection with the circulation in the corresponding limb. In a second communication read before the same institution, M. Lewachen stated that he had sought to ascertain if similar modifications in the circulatory system, occurring under the influence of the vaso-dilator and vaso- constrictor nerves, determine variations in lymphatic secre- tion of the same intensity or a different intensity. This investigator made experiments on the tongue. It is known that vaso-constrictor fibers of the hypoglossus nerve and vaso-dilator fibers of the lingual nerve are sent to the tongue. On stimulating either the hypoglossus or the lingual nerve, separate action of each variety of the vasomotor fibers can be produced. Except the lymphatic vessel under observation, M. Lewachen severed all collateral vessels on the side of the tongue on which he was ex. perimenting, and ligated the lymphatic vessels. The fol- lowing results were obtained. Section of the hypoglossus nerve was followed by an increased quantity of lymphatic. secretion; stimulating the peripheral extremity resulted in a decrease of the secretion of lymph. Section of the lingual nerve is not constant in its effect. Stimulating this nerve greatly increased the secretion of lymph: this increase continues after section of the hypoglossus. If electrical stimulation be increased until lymphatic secretion reaches its maximum, section of the hypoglossus is with- out effect. The lymphatic secretion is more abundant when the lingual nerve is submitted to a maximum of electric stimulation, than it is when the hypoglossus nerve is cut. Thus, the action of the vaso-dilators is more pow- erful : this is owing to the fact that the vaso-dilators have a more powerful action on the circulation of the blood, and also have a direct action on the walls of the vessels, Selections. 423 which perhaps tends to modify their permeability.Cor. Med. Times. ced in this bodis is the con The HEAT CENTER.--At the recent session of the Helvetian Society of Natural Sciences, at Geneva, Pro- fessor Girard gave an interesting account of some late experiments of his in Schiff's laboratory to ascertain the location of the heat center. These experiments, which were made on hares, have led him to conclude that the cerebral center of thermogenesis is the corpus striatum Every lesion affecting this body in its median part pro- duces a pronounced hyperthermia, which does not result from spasm of the vaso-constrictor nerves of the skin, but from an augmentation of caloric production. Electric excitation of this region, which is followed by a marked augmentation of heat, justifies the assertion that the hyperthermia is a phenomenon of excitation and not of paral- ysis. Moreover, after puncture and irritation of this region of the cerebrum, there was a considerable increase in the quantity of nitrogen excreted in the urine, indicating an increase of the organic combustions; this was accompanied by notable emaciation of the animal. Girard considers. the thermogenetic centers as including not only this median portion of the striate body on both sides, but all the subjacent parts to the base of the brain. There is here, according to him, an apparatus whose excitation increases the production of animal heat, and which prob- ably concurs under physiological conditions to regulate heat productions. In answer to the question, “Is the artificial hyperthermia thus obtained identical with fever ?'" he answers, “No.” Augmented heat production and diminished heat emission, such, in his view, are the two necessary factors of that pathological calefaction which constitutes fever. But the last of these factors was want- ing in his experiment.— Boston Med, and Surg. Jour. NEURO-ANATONY. MEASUREMENTS FROM SKULLS OF THE SEVENTH CENTURY (Prof. Dight's Conclusions).—An interesting contribution to anthropological science has recently been offered by Prof. Dight in the Journal of the American Medical Asso- ciation. This observer has been enabled to secure meas- urements of a collection of human skulls preserved in an. 424 Selections. old monastery, near Jerusalem, and which are supposed to have belonged to the Christian monks of the seventh century. From ninety-one specimens, of which careful measurements were taken, and from a comparison of the same with those of the same race to-day, lie has deduced the following conclusions: “1. The Caucasian skull has, during the past thirteen or fourteen centuries, increased in horizontal circumfer- ence 1.72 inches, and to a less extent in height, and not at all in width, and has gained in cranial capacity 3.7 cubic inches. 2. From the fact that our skulls have not gained in width it follows that this gain in capacity of 3.7 cubic inches is due to their increase in height and length, which, bearing in mind the plan of development of the brain, implies an increase in size of the upper and anterior parts of the brain—the exact parts which, on a priori grounds, we should expect to increase by edu- cation and civilization, since these parts of the brain specially preside over the moral and intellectual functions. 3. The lower portions of the brain, being the parts whick specially preside over the selfish propensities, or the so- called inferior functions, and which give breadth to the head, being called into activity less as education and civilization advance, have failed to grow as rapidly as other and more exercised portions of the brain; hence the non-increase in width of our skulls." These deductions, which seem to have been accurately and scientifically formed, will no doubt be read with in- terest by those who have made a study of this department of science, having, as they do, such an important bearing upon the questions of evolution and race development. It will be admitted that the comparative abundance of material in Europe allows of a much more extended ex- perience in this direction, than has ever yet been acquired, and that the results which it might be possible to secure would justify further investigation.- Medical Register. A REMARKABLE RECOVERY FROM INJURY TO THE ATLAS.- The Medical News, Nov. 27, 1886, has the following re- markable record : The late James C. White, a prominent gynæcologist of Buffalo, met with an accident while riding in a stage- coach, Dec. 17, 1837. Forty-five, days after the receipt of the injury, a piece of bone came from the throat, coming Selections. 425 proced its ho the atl out through the mouth, as a consequence of ulceration. This bone was a front segment of the atlas vertebra, a little more than an inch on the superior margin, a little less below, with the facette which received the odontoid process. It is probable that the transverse ligament re- tained its hold on the two extremities of the remaining fragment of the atlas, thus protecting the spinal marrow from injury.. [Prof. White lived nearly fifty years after this accident. He was well and suffered no ill effects from the injury when we last saw him, about six years ago.-ED.] fragme, its hos probe facer on that of muence o NEURO-SEMIOLOGY. TEMPORARY PARALYSIS OF THE RADIAL NERVE IN THE INITIAL STAGE OF LOCOMOTOR ATAXIAS.—Prof. A. Strümpell (Berl. klin. Woch.) reports an interesting case of this na- ture. Briefly the history of the case is as follows: B., æt. fifty-five, a waiter, was suddenly seized with paralysis of the left hand. On a Sunday afternoon he was reading a newspaper which he held in his left hand. All of a sudden the paper dropped from his hand, and he then learned that he had lost power in it. He had never ex- perienced any pains or abnormal sensations. On examin- ation, it was found that all the muscles supplied by the radial nerve were paralyzed, the sensibility of the forearm and hand was intact, and the electrical excitability of the paralyzed muscles, with both currents, was quite normal. The author found some difficulty in accounting for the paralysis; the most plausible theory was that it was due to alcohol, but its sudden appearance and the absence of pains and other signs of alcoholism strongly opposes that theory. On further examination, ho'vever, it was found that the patient had the Argyll-Robertson pupil, the sensibility of the feet and legs was somewhat diminished, and there was absence of the knee-jerk on both sides. On repeated questioning, the patient confessed to having had for some time past,“ tearing pains” in the legs and a weakness in the bladder. A history of syphilis could not be obtained. Under four weeks' treatment with electricity the paralysis disappeared, without any change, however, in the other tabetic symptoms.-N. Y. Med. Journal. [The case is of considerable interest, as bearing upon the recent pathological researches of Pitres and Vaillard 426 Selections. on the condition of the peripheral nerves in tabes. In our last report on General Medicine, we gave an abstract of their work in this direction, and we would ask our readers to compare it with the clinical history of Strüm- pell's case. -Ed.] Is the KNEE PHENOMENON A REFLEX Act?—Dr. Lom- bard (American Journal Medical Sciences) has re-investigated the question whether or not the patellar tendon jerk when struck is a reflex act. “The main argument against its being so is that it requires only .03 to .04 of a second, while the reflex act requires Il. The chief point in favor of its reflex origin is that the vigor of the reaction depends on the integrity and health of the spinal cord. The ex- planation that the phenomenon is direct muscle effect, but that the spinal cord must send down a shower of reflexes or keep up a healthy tonus to have the act result, is very unsatisfactory. Dr. Lombard found that the act follows after the same interval, when the muscle is electrically stimulated or the tendon struck, but that the interval is much longer (four times as long) when a reflex contraction is excited by rubbing the skin Hence it is argued that the phenomenon is a direct muscular stimulation, and occurs too quickly to be of a reflex nature. In one case an after-jerk, followed at an interval that suggested a reflex origin, was recorded: but this compound nature of the response, though carefully looked for, was not again ob- served. The explanation of the relation of the knee-jerk to the spinal cord cannot yet be given.” CLINICAL NEUROLOGY. PERSISTENT PATELLAR REFLEX WITH DEGENERATION OF POSTERIOR COLUMNS OF THE CORD.-The Neurological Review makes note of an interesting report made by Dr. Westphal (Arch. f. Psych u. Vervenkrankh., Bd. 17, 2) concerning the post mortein findings in the spinal cords of patients that had, during life, clear signs of degen- eration in the posterior columns of the spinal cord, with preservation of the patellar reflex. From the clinical stand-point, such cases are at present far from being new; but to have them brought to such exceedingly careful post mortem tests as is true in the cases of Dr. Westphal, is up to the present uncommon. Before death, in the ue into sucht far from the ord, Selections. 427 case under consideration, a rather remarkable cyanosis of the terminal phalanx of the fingers made its appearance. *The color was distinctly blue-black within the best-marked areas. The same was true, to a less extent however, of the toes. Upon examination after death, the disorder was found in what Dr. Westphal calls the posterior “root-entrance zone" (Wurzeleintrittzone), instead of the root zone of Pierret, and others of Charcot's school. For the latter em- braces a much larger sectional area in the posterior column than the term used by Dr. Westphal, to which the disease in Dr. Westphal's cases seems to have been chiefly limited. Such cases, both from clinical and morbid anatomical stand-points, point to the posterior columns of the spinal cord as being the seat of finer perpendicular subdivisions than has been hitherto suspected. Quite recently we have had a case of tabes, presenting in a most exquisite manner, in the three outer toes of the right foot, the cyanotic phe- nomena mentioned by Dr. Westphal. As already intimated in a former number of the journal, we have met with a large number of cases of diseases of the spinal cord, pre- senting such peculiar groupings of symptoms as to neces- sitate hypothetically the admission of tracts in the cord for the existence of which up to the present moment there are no anatomical or physiological proofs. In other words, the study of systematic diseases of the cord, affecting limited perpendicular streaks, or bands, in the same, has thus far only fairly begun; and one of the legitimate stand-points of study, from which advancement of our knowledge in this direction is to be expected, is that of the clinicist. Thus from former skeptical sources comes confirmation of the clinical stand-point taken by Dr. Hughes in this journal in 1880. NEURO-SYMTOMATOLOGY. The EYE IN SUSPECTED Nervous DISEASES.-Spitzka (Medical Standard, April, 1887) says that: “ The physi- cian in examining a suspected case of nervous disease, should as a matter of routine note the following: 1. The absolute diameter of the pupil in moderate illumination. 2. The equality or inequality of the pupils. 3. The direct reflex action of the pupil under light. 4. The consensual or indirect reflex of the pupil under illumination of the absold as a matters a suspected says that: ASES: -Spitzka 428 Selections. other eye. 5. The contraction associated with accommoda- tion and convergence. 6. The reflex dilation of the pupil, resulting from painful cutaneous impressions. Reflex Tri- doplegia or the “Argyll-Robertson pupil," as this symptom is called when associated with preserved accommodative mo- bility, that is, where the pupil is as immovable as a frozen opening, no matter how brightly illuminated, or how deeply shaded, but contracts when the finger is approached to the nose, is found as a symptom in the following con- dition. A. Tabes Dorsalis—(Posterior Spinal Sclerosis, sometimes called Locomotor Ataxia). It is an important early symptom of this disease, and always present in ad- vanced stages. In certainly ninety-nine out of a hundred cases of tabes, the Argyll-Robertson pupil, and abolition of the knee-jerk are the first exact signs of a process which is to culminate in ataxia; I have observed it to antedate all the other reliable symptoms of the disease by from a year to six years. In a minority of cases the symptom does not remain pure, the accommodative motion becoming equally paralyzed. My assistant, Dr. N. E. Brill, is about to publish the report of a remarkably ex- ceptional case, where, with some of the symptons of tabes, there was accommodative, but not reflex paralysis of the pupil. This case is in direct conflict with the rule, and constitutes, in my opinion, rather a curiosity in medical literature, than an invalidation of the general law. (Pari- naud, in a verbal communication to Leval-Picquechef- Des Pseudotabes, Lille, 1885, p. 118-states, that in some pseudo-tabic disorders the very reverse of the Argyll-Robert- son pupil is found. True tabes.-Light-reflex abolished: accommodative and convergence contraction preserved. Pseudo-tabes.—Light-reflex preserved: accommodative and convergence reaction abolished.) B. Paretic Dementia- (Progressive or General Paralysis or Paresis of the Insane, Paralytic Dementia). It has been observed in a large pro- portion of sufferers from this disease, often antedating the development of its other physical and mental signs. Moeli, who examined hundreds of cases with special reference to this point, ventures the suggestion, that if it were not for the early fatal termination in this disorder, it would ultimately develop in a much larger proportion. However that may be, it seems to preponderate among those who owe their disease to syphilis, alcoholism, or who early develop marked spinal complications. Constitutional Syphilis.- Gowers, Erb, Moeli, Uhthoff and myself have found the Selections. 429 Argyll-Robertson pupil either alone or associated with other ocular paralyses, in persons afflicted with constitu- tional syphilis, and who had no other signs of nervous disease. In a few of these cases, the subsequent history revealed the development of either tabes dorsalis, paretic dementia or other organic brain disease. In others no such sequel occurred. In one such case both the pupillary reflex and the knee-jerk were abolished. It is therefore not advisable to jump at a diagnosis on the grounds of pupillary anomaly alone. D. Concussion Accidents.-Sev- eral vague observations are recorded in the older literature of disturbed pupillary reaction after railroad accidents and other shocks. I have myself seen pupillary dilatation with immobility under illumination, in one such case. Oppen- heim has accurately described one of isolated reflex irido- plegia after a similar accident. Reflex iridoplegia occurs with other organic nervous disorders and alcoholism, but not often as symmetrically and regularly as it does in the condition named. EDITORIAL [All unsigned Editorials are written by the Editor.] • Public and Professional Credulity respecting the Less Demonstrative, Non-Violent Insane. Dr. Janim Strong, the superintendent and physician of the Cleveland, Ohio, Asylum for the Insane, very perti- nently remarks, in a recent report, that: “many more people are ready to form and express opinions on mental than on bodily disease, although the former presents a much more knotty problem for solution," * * * .and very truly says: “If clearer views respecting the diagnosis of insanity were more generally entertained, it would be of inestimable value to a portion of the insane themselves, through the suggestion of early treatment, and would prove also a great blessing to friends of the in- sane, through the increased number who would be restored as a result of such early treatment.” He, like his confrères before him and contemporary, makes note of the great number of preventible suicides constantly occurring, and tells a fatal truth which speaks not well for the intelligence of the medical profession generally concerning the premonitory symptoms and incubative stages of mental derangement, or of public appreciation of competent expert professional opinion on this subject. It is the saddest of all sights and the direst of all mis- fortunes to see a person afflicted with a non-violent, non- demonstrative and not generally recognized form of insanity, go without treatment or judicious regulation of conduct, left to their own disease-perverted impulses, under the idea that they are not insane-only a little singular-until their best interests, personal or pecuniary, or both, are sacrificed, and a brain which might otherwise be cured is allowed to bear a mental scar for life. Ap- propos of this sad subject, a letter now before us, from a distinguished author and insane asylum superintendent, con- tains these sadly true and truly sad words for the welfare of the insane, whose condition psychiatry, if untrammeled by blind prejudice or ignorance of the true intent and pur- pose of science toward the mentally maimed, would much [ 430 ] Editorial. 431 more improve than is now possible, under such adverse influences. But true science, in the beginning, has ever had to battle against the opposition of the populace. Public opinion yields at last, to be sure, as it will in this matter, but only step by step, as the light of truth shines too brightly to be longer withstood. This eminent writer says: “I am sorry to say an enormous amount of prejudice exists in this country against the whole system for the care and treatment of the insane, and any monomaniac, a temporary insane person, who has been in an asylum for he or she has been improperly incarcerated (as these lu- natics call it), appears at once to gain the public sym- pathy, and too often the prejudiced sympathy of judge and jury, no matter how insane such persons may have been when certified and sent to an asylum, and no mat- ter how great the desirability that such persons should have been so sent. We have had several cases during the past two years or thereabouts (to go no further back) in which series of actions or single actions, of a most vexatious and improper nature, have been brought against medical men concerned in lunacy cases; against both medical men who sign certificates of insanity and medical men who receive and detain such certified persons under care and treatment.” * * * “In fact a very large number of the best medical men who have duly considered the subject and who realize how utterly unprotected they are in the exercise of a difficult office and duty, do now decline to certify persons as being insane in any cases whatever; one result of all this being an increase of suicides in the early stages of insanity; another being the deferring of curative treatment and care in the curable stages.” It seems like a cruel thing to permit the evils of the present public distrust of the highest-minded and best- informed men in the profession—to work its own cure, but it looks as if it were the best remedy for a while. If those whose only aim and avocation is to rescue the mentally wounded in life's battle, are to be treated as though they were only assassins of human liberty, they had better withdraw from so unwelcome a service until society and the law shall repose more confidence in the integrity of their purposes and value of their opinions. Perhaps it would be ultimately as well to let the 432 Editorial. populace and popular physicians who concur with it, attend to the question of commitments of the insane. Let the mild-mannered lunatic go on in his folly. Let the quietly-suspicious and the undemonstrably homicidal go on till tragedies enough occur to excite alarm for public safety if they have not so done before and a cry comes up for expert knowledge, to tell the people who the dangerous lunatics are, before their insanity is hope- lessly confirmed in suicide or murder, or arson, or other flagrant outbreak. Many decimating epidemics of disease had to sweep over the land before the necessity of quarantine was generally acquiesced in. Vaccination, now so popular, but still fanatically opposed in some quarters, had to fight its way through popular and even professional op- positon and much public suffering, to recognition of its utility. Galileo was spurned and Servetus burned for their benefactions, and the medical expert in psychiatry, in some instances, fares no better to-day, for speaking the truth before courts of justice. Real expert alienists, skilled in the symptomatology of psychical aberration in its obscurer phases, where only expert knowledge is required, have too often subjected their opinions to public and judicial contempt. Would it not be well to let society suffer a while from the conse- quences of its folly in regarding only the flagrantly insane and demonstrably violent mad, as fit for asylum restraint, till it finds out that the most dangerous of lunatics are often the mildest-mannered beings at times, for a while, in the progress of their malady. More Correct Views in Regard to Hysteria.- When Charcot first suppressed a paroxysm of hysteria by firm pressue on the ovary, and McLane Hamilton succeeded in doing the same thing with a hysterical male by firmly compressing the testicles, the reputed utero-ovarian origin of this disease, which has been handed down from Hippocrates, seemed to have gained new confirma- tion from modern facts, notwithstanding neurologists had long controverted, and by innumerable contradictory facts the exclusively gynecological view, not denying, however, the sometimes exciting influence of utero-ovarian conditions in the excitation of the hysterical paroxysm, though these were often vasomotor, and, of course, of nervous origin; and as often, if not more often, secondary than primary, Editorial. 433 the vascular sequences of a morbid neural impression on the vasomotor center. But now comes the testimony of Renault, of Paris, that continuous compression of any superficial nerve, especially the supra-orbital, will abort a paroxysm, just as a profound and violent psychical impression, as of threatened violence, or a superficial cutaneous shock, as of a dash of cold water, through their well-known reflected, indirectly-transmitted impression on the vascu- lar tonus through the vasomotor system. Renault's method, as described in E'Abeille Medicale, is as follows: “The patient's head being firmly held between the hands of the physician, he places his thumbs on the incisura supra-orbitalis and makes gradually increasing pressure. The effect is said to be as follows: The patient begins to contract her facial muscles as if in pain, gives vent to short screams, makes four or five short inspirations, the thorax remains fixed in inspiration, the dorsal and nuchal muscles contract to hyper-extension of the spine. · Now a deep expiration takes place, the muscles relax, the paroxysm is over. The pressure may have to be repeated, as a new paroxysm may come on after a short time, and resorting to it early may intercept the attack. The sooner the paroxysm comes under the treatment the more rapidly will it be broken up by the manæuver.” It is a little singular, however, how shocks of this kind may both execute and dispel hysterical paroxysms, yet such are the clinical and therapeutical facts. The new view, or, rather the newer view, of hysteria, for which medical science is indebted to the researches and scientific skepticism of neurology, respecting the blind reception of current, but unproved, medical views, is well put forth in a recent editorial, of New York Med- ical Review, based on the contribution of Mr. de Berdt Hovell to the London Lancet, September 4th, 1886. Mr. Hovell's protest against the exploded gynecolo- gical view of hysteria is not a neurological prejudice but the honest conviction of “a shrewd practitioner” of long practice and experience, upon whom a light not altogether new, but new to him, is dawning : “He thinks the theory that localizes the disease in the uterus is the mere survival of medical demonology, which located ill-humor in the spleen, blue-devils in the liver, and the soul in the pineal gland," and 434 Editorial. claiins for hysterical patients more fairness of treatment and more discrimination. He attributes many of the cases "to deticient or depres- sed nerve-power, with all that this implies in the way of pain, irrita- bility, inability for locomotion, etc.," and maintains that if we are to deal with them effectually we must “set aside all consideration of the organs of reproduction, which most probably are not concerned, and transfer our attention to the moral nature." Mr. Hovell gives several cases in which there was a distinct history of shock or exhaustive work to explain the break-down in the nervous system. On this the Record makes the followiny pertinent remarks: “He live in days when the nervous system is getting its full share of attention from pathologists and physicians, and when even gynecologists are finding out that the uterus, and even its appendages, which are now blamed by some for everything, are not such culprits as has been supposed. Mr. Hovell will admit that the cases of so-called hysteria do occur chiefly, though by no means exclusively, in women. In their organization there is something speciaily favoring the occurrence of this state of disease. It may not be in the special organs of the female si m'ich as in the spe irl nervous system. Mr. Hovell deserves credit for insisting on this point, and he may well be satisfied to know that the drift of opinion among physicians is toward the acceptance of his views. Women are more finely s'rung than men. They are more liable to pain or pains of all sorts from mere functional causes. Such a constitution is perplexing to the physician, but it has to be considered and not treated as a sort of crime, as has too often been the case.". The fact is the sphere and habits of woman, she being either over-worked and over-worried or habitually over- emotionally excited, and more in-doors and sedentary in her life than man, with the most trying of avocations, because usually sedentary, in-doors, and comparatively profitless, uninvigorating and uninspiring, or without occupation at all, and a prey to emotion and ennui or gaiety; these, coupled with the natural physiological strains put upon her by menstruation, utero-gestation, child- birth, lactation, and the menopause, are sufficient to make her nervous organism less resistive to break-down in nerve nutrition and consequent functional stability, with- out assuming an inherent feebler cerebro-spinal and gan- glionic organization than man possesses. Under all the circumstances of woman's environment in civilized society and its customs so trying to the health of the sex, her nervous endurance is wonderful. Her trials seem rather to have trained her through the centuries to endure more than man could stand under similar circumstances. Put the social restraints on man which her environment enjoins on woman, hedge him about with the conventionalities and the proprieties, as Editorial. 435 she is hedged about, which interfere with the free play of her physical power out-of-doors, from her childhood up, and the other adverse circumstances, to say nothing of the physiological demands, and we should see plenty of hysteria in the male, as we do see it developed in him when he is subject to a life of effeminate surroundings, as an equally debilitating influence, to say nothing of woman's special and peculiar function. She would get along with them like the wild Indian squaw, who gets plenty of fresh air, if she gets less tender consideration from the sterner sex, than her civilized sister, and she would not become neurotic from the strain of any nat- ural function. Pseudo Medical Experts and Amateur Alien- ists.-America is peculiarly cursed as well as peculiarly blessed. She has plenty of everything and to spare. Smiling abundance greets her people on every hand. Genius, real and specious, abounds; superiority and medi- ocrity stand side by side; the genuine and the spurious go hand in hand. The profession of medicine and the municipal laws are so liberal in this liberal country that no more than the alphabet of medicine is a prerequisite to a medical degree in some schools, while the highest standard is required in others, and these graduated doctors are all equal before the law and the courts, and the influence of medical opinion goes with the weight of numbers and the greater confidence of opinion. Before the courts, in many states if not in all, a medical man's own opinion of his expert capacity is taken as the legal test of competency, the jury being left to decide as to the relative weight and merit of the medical opinions. Under such rulings cheek and the plausibility and confidence of limited special knowledge often ruin a bad medico-legal cause against moral justice, while technical legal justice may be given, and an execution, an incarcer- ation or a fine may be lawfully but unjustly visited upon ation ustice may be against moralWledge ofiensibility and an act of cine may been, and an Under such a state of affairs it is gratifying to see the legal profession realizing the fact that before courts, in medical expert capacity, “a little knowledge is a dan- gerous thing," and seeking to bring about a remedy. The presidents of the two New York medical-legal soci- eties have taken up the subject in late addresses. Mr. 436 Editorial. t covers and say ned, if he Clark Bell discerns the injustice of the time-honored “knowledge of right and wrong” test, and interposes, in behalf of justice to the insane, against the unjust rulings of courts which make a knowledge of right and wrong the test of mental soundness and mental sanity, and indi- rectly against those narrow amateur alienists, who, without clinical experience, when they pose as medical experts in psychiatry before courts and juries, make themselves solid with court and people by adopting the popular miscon- ception of the clinical attributes of mental lesion and proclaim it as scientific fact. It covers up much ignorance to join in the cry of “Crucify him,” and saves the pseudo-expert from having his qualifications questioned, if he concurs with the crowd. The people applaud the expert who takes their view of the case (and the less real scientific knowledge of the obscure phases of mental disease possessed the greater will be the likelihood of such concurrence). They proclaim the pseudo-expert right, the victim of his unconscious or conscienceless ignorance is removed, vengeance is satis- fied and the legal crime is soon forgotten, and so is the false expert and his crime against humanity and science. Judge Hull, before the Society of Medical Juris- prudence, looks at the great wrong against disease, and especially the rights of the insane before the courts, in a still broader light. He arraigns the false expert and the legal system which permits fraudulent expert opinion in our courts, without gloves, and good fruit must come of his address. The man who is ill, or presumptively, has rights before our courts as well as he who is well, and greater claims on the law's protection, because of his helplessness. The rights and interests of the sane are guarded well enough by the law. The rights of the insane to liberty are over- zealously guarded by the courts, to their harm oſten, by giving them liberty when they should have curative re- straint and a chance to be saved in mind, and not allowed to drift by freedom from treatment into hopeless dementia, but the insane man's rights are often jeopardized and taken away through the undue weight allowed the confi- dent and popular testimony of the glib-tongued amateur alienist and false expert, who tells confidently about the symptomatic evidences of insanity, as he conceives but never sees it. Giving the State the benefit of his theoret- ical notions for scientific facts, and they being much in Editorial. 437 accord with the popular conception, the jury acquiesce and science is wronged, and the prisoner is outraged in the name of science sanctioned by law. Why should not the law ask a man by right of what clinical experience and specially trained medical observa- tion, he assumes to pass an expert opinion as to the na- ture and the existence or non-existence of mental aberra- tion ? In the name of the often-outraged rights of the insane, as sacred as our own, let the law guard them in their helplessness and give them a fair chance in their afflic- tion. The insane violator of the law to-day may yesterday have been a piliar of the State, a shining light in the body politic. Give him a fair chance; do him justice, by free legal protection, and his affliction and his malady may leave him and he may return again, clothed in his right mind, to the usefulness of rational life. He is more likely than the real criminal to become a useful and honorable member of the body social and politic. The International Medical Congress.- Before another issue of this JOURNAL shall have gone forth to its readers over the world, the congress will have met in Washington, received the cordial fraternal welcome America's physicians are preparing for it, finished its scien- tific work for the year and cemented anew the bond of friendship and fraternity existing throughout the world among all true physicians. A few who invited the congress may not be there to greet its members, but we hope they will. We hope the few individual declarations of this kind will be reconsidered and revoked. At all events the congress will be heartily received by the American pro- fession as a body. The army will be there to honor them, though a few deserters may be in the rear, and a few “wounded in spirit.” But by September we hope to see all the wounded restored to the ranks and all the deserters from the camp brought back, not in ambulance or chains and under guard, but cheerfully returning (led by silken cords of love, as it were,) to welcome to our common country our common friends, who have been invited to accept the hospitality of our common household. We will put our family jars in the closet where we keep our skeletons (if we have any on hand in September), 438 Editorial. Ame.come to the wont tongs to Ownow it int will loc and set our best viands on the table. We will lock that closet and bury that key or throw it into the sea, and hang out the latchstrings to our hearts and homes, as Americans are wont to do when guests whom they esteem come to their doors. Americans know how to make up after a .war as well as how to fight. This the world knows. We are not fighting over who shall run the congress now but for funds to run it hospitably and creditably to the American good name for cordial hospitality. Send on your funds, gentlemen, belligerents, to the finance committee, and your swords shall be turned into knives and forks and something for them to work on, and you shall make plowshare furrows into the affections of our coming guests, and pruning hooks to cut off the asperities engendered by the incipient late lamented un- pleasantness among ourselves. Everybody is going to the congress, and everyone is going there in good humor too. In the Section in Psychological Medicine and Nervous Diseases (president, Judson B. Andrews, M. D., Buffalo, N. Y.) the following titles of papers have been presented for this Section : “The True Nature and Definition of Insanity ;” “Lunacy in Scotland;” “Nervous Degener- ation and Syphilis ” (selected as a subject for Discus- sion); "Locomotor Ataxia and Syphilis ;” “Original In- vestigations in Cerebral Syphilis, with Miscroscopic Prep- arations, etc.;" Relation of Syphilis to General Paralysis ;" “State Policy in Relation to the Construction of Buildings for the Insane ;” “Hospital Arrangements and Classifica- tion as relates to the Care and Comfort of Patients ;" “ Modern Hospital and Asylum Structures for the Insane ;" “The Borderland and Early Symptoms of Insanity;" “ The Religious Delusions of the Insane ;" "Mental Man- ifestations of Insanity caused by Sunstroke;" “The Remis- sions, Intermissions, and Manifestations of Insanity in an Individual;" “General Paresis, Its Varieties and Differen- tial Diagnosis ;" “Legal Relations of Epilepsy ;" "Obscure Forms of Epilepsy ;” “Sleep;” “Miliary Aneurismal Disease of the Spinal Cord and Brain Axis ;” “Deformity of the Brain in its Relation to Congenital and Inherited Mental Disease;" “ Cases Illustrating the Prow-shaped Cranium with Neurotic Disease;" “Remarks on the Etiol. ogy and Pathology of Thomsen's Disease ;" "Tendon Keflex in Hemiplegia ;” “Hyperästhesia;” “Castration as ar State Policye;" · Hoe Care ander Editorial. 439 a Remedy in Nervous Affections;" “ Occupation in the Treatment of Insanity;" “ The Treatment of Neuralgia from the point of View of the General Practitioner;" “The Disease of Inebriety and its Treatment;" “The Physiological and Therapeutical Effects of Currents of High Tension (Franklinization);" “The Private Treatment of the Insane, as Single Patients, in England ;" “Mental Diseases Produced by Changes in the Vessels at the Base of the Brain ;” “An International Classification of Insanity;" "Monomania ;" “ Cocaine Inebriety ;" "General Paralysis in Dogs.” Several titles are yet to be received. Among the foreign physicians who contribute to the foregoing list of titles of papers to be read, or who in- tend to be present and participate in the scientific work of the Section, are Sir James Creighton Brown, Drs. Rudolf Arndt, Buiswanger, George Fielding Blandford, Bouchereau, Francis Pritchard Davis, Maurey Deas, J. Langdon Down, Edward East, A Eulenberg, E. T. Girt- strom, V. Hinze, Megalhaes Lemos, H. Rooke Ley, E. Mendel, Wm. Julius Mickle, Arthur Mitchell, O. Muller, M. Rosenthal, George H. Savage, Seymour J. Sharkey, J. Beverly Spence, Valdemar Sternberg, D. Hack Tuke, John Batty Tuke. Communications relating to papers, discussions, etc., should be addressed to the Secretary of the Section, Dr. E. D. Ferguson, Troy, N. Y. Consciousness in Epilepsia.-Bannister, in an in- teresting brochure on this subject, presents some recent confirmation from his own personal observation among the patients of the Kankakee Asylum, of a fact more than once recorded in these pages. We are glad to find Dr. B. calling renewed attention to this subject, for it is one that ought not to be lost sight of. In the April, 1880, and April, 1881, numbers of this JOURNAL, Dr. B. will find confirmatory though antecedent records of the facts insisted upon in his interesting paper. The ordinary conception of epilepsy includes, as Dr. B. observes in the paper before us, “the idea that con- sciousness is lost during the attack, and in many of the definitions of the text-books an absolute loss of conscious- ness is made an essential and characteristic feature of the disease,” and correctly, of the typical grand mal. Ham- mond, Althaus and Da Costa consider consciousness impossible in epilepsy; but older classical writers, Laent, 440 Editorial. Delasiauve, Ludwig, Meyer, Hoffman and Schræder Vander Kolk, with Eccheverria, we think, and Russell Rey- nolds, concede consciousness to be a not impossible factor. Unconsciousness is not the absolutely essential factor in epilepsy claiined for it by most authorities, as was said in these pages in 1881: “The doubting Thomases may place their mental digits in the holes which clinical facts make in their fanciful formularies of the nature of epilepsia, and must modify a definition of the disease which includes unconsciousness as its sine qua non symptom. “A more or less prolonged state of central non- impressibility to excitation--a delayed mental activity and tardy response to peripheral impressions which ordinarily excite the motor and ideo-motor centers of the cortex into action,” must take the place of the unconsciousness symptom of epilepsy. This is the chief characteristic of an epileptic seizure, whether or not unconsciousness is associated with it, though unconsciousness usually exists, and might be called the clinical feature of grand mal. . In the Weekly Medical Review, of February 5th, is the record of a unique case in which the psychical stroke came first, the motor excitation following, the primary ateriole spasm first shutting off the nutrition from area of consciousness in the brain, and next from the motor region, or perhaps not affecting the cerebral motor areas but only cutting off the communication between them and the upper and lower portions of the cord. . The irritation seemed to pass from the brain to the spinal motor areas, psychical inhibition at the same time being cut off by some interruption in the channel of downward conduction. In this case consciousness returned before the spasm would begin, and remained during the spasmodic stage, the psychical and psycho-motor areas of the brain not being, as is usual, simultaneously involved. Consciousness per- sisted, while both sides were convulsed. Consciousness existed, in this case, in a stage of epi- lepsia in which unconsciousness is ordinarily the most profound. The case shows clinically what has been proven by experimental physiology and by cases of unilateral epi- lepsy and cases of petit mal, that the convulsive phenom- ena and the psychical phenomena are distinct and often · clinically separable symptoms, and while it does not prove Editorial. 441 consciousness during the whole epileptic paroxysm it is another demonstration of its possibility, and is confirma- tory of the previously proved fact that consciousness may exist in real epilepsy. The question of consciousness is one of location and area of cerebral irritation in this disease, and not one of epilepsia. In short, the diagnosis of epilepsia cannot longer be allowed to hinge solely on the existence, or non-existence of unconsciousness, unless we raise an artificial standard of epilepsia and name the clinical variation something else. Gowers, Hammond and others to the contrary notwithstanding. We may agree to consider the typical grand mal as characterized by sudden unconsciousness, and the other, no less real phase of the malady in which unconscious- ness is absent or doubtful, epileptoid, but it is unwarranted in the present state of our knowledge of the pathology of epilepsy. And it never will be warranted unless some revolution in our ideas of the pathological nature of dis- ease takes place, to rule out from being categoried as epileptic in its nature the many manifestations of epilep- sia in which unconsciousness is either an absent, a sec- ondary, or at the least, not a prominent feature. Memoranda on Antipyrine in Psychiatry and Neurology.-The therapeutic value of this recently- introduced neurotic antithermic remedy, which, in fever, evidently acts purely upon the center and source of heat excess in the disturbed cerebral heat center, has proven so marked in our experience in other respects than as an antipyretic, that we feel constrained to attest its newly- found virtues, for the benefit of the many readers of the ALIENIST AND NEUROLOGIST engaged in the practice of psychiatry and neurology, as well as for the general prac- titioners who, by reading the ALIENIST AND NEUROLOGIST, take an interest in the neurological aspects of medicine in general. We record with satisfaction its value as an anodyne and tranquilizer in neuralgia and hemicrania,- not so posi- tive or prompt as opium in neuralgia, but soothing without previous excitation, and in neural irritability much more efficient and permanent without constipation or other after ill effects. As a hypnotic it is not so sure as chloral nor so certain and prolonged as chloral and the bromides in full 442 Editorial. doses; but no headache has followed its use thus far in our experience; and after a day or two of the hypophos- phites and bromide of ammonium it has sometimes acted like a charm in sending a restless, nervously exhausted patient off into a refreshing and satisfying sleep. ' In melancholia, after valerian, opium, hypophosphites and the ammonium bromide salts, it has, on several occa- sions, given us satisfaction as a sleep inducer. In high states of maniacal excitement it has not answered well; cannot be compared to amorphous hyoscyamin, hypodermically, or chloral by the mouth; but it answers pretty well for occasional day-time use. In the insomnia and fitful somnolency of febrile delirium we have been pleased with it. In hysterical perturbation of mind and spasm of the glottis it has acted well in the one instance in which we gave it a trial; and in another, of metastatic spinal and ovarian hyperusthesia, it promptly brought relief. In an epileptic psychosis, complete and prolonged for ten days, we have given it a very satisfactory trial, the patient being now free of delirium and having had no return of epilepsia, sleeping well on it every night. This patient had incomplete one-sided paralysis and dilated pupils. He is now recovered of these also. But an inter- mittent heart-beat has appeared, one beat losing in four or seven. In epilepsia with and without automatism we can record its value. It seems likely to prove a really efficient rem- edy in epilepsia, gravior and mitior, for it will postpone and suppress the paroxysms. In the cardiac irritability of ganglionic neuratrophia and insomnia and in cardiac dyspnwa, anxiety and pain without appreciable organic lesion, it has acted well as an ano- dyne and mild hypnotic after digitalis, valerianate of ammonia and the ammonium bromide. This is our experience, so far as we have gone, with this really valuable remedy. It seems safe and unobjec- tionable for internal use, and will doubtless well sustain a more extended trial of its virtues as an anodyne, antifeb- rile hypnotic and moderate antispasmodic. Less than a gramme (or fifteen-grain dose) is of little value, either for anodyne or sleep-producing purpose. We may add that we are now employing antipyrine as an alternative remedy, with good effect, in cerebral congestion, after aconite and gelsemium, and believe it worthy of more extended trial Editorial. 443 in this direction. A good menstruum for its administra- tion is syrup of tolu and peppermint water, a drachm or two of each to the dose. Tho Morbid Motor Restlessness of Mania.- Dr. Zenner, in a recent lecture at Cincinnati College, re- ferred to John Snyder, of Dunkirk, whose marvelous feats of walking have interested the medical profession as well as the public. Dr. Zenner said that to him the man seemed perfectly rational, and was certainly not an im- postor. During the forty-eight hours that he was watched by the students of the Ohio Medical College, he walked all but seven hours, and did not lie down at all. He says it does not rest him, but makes him tired and un- comfortable to sit down. The disease then is not in the walking, but in the uncomfortable sensation on account of which he walks. Weston walked 5,000 miles in one hundred days; but this man has walked almost 25,000 miles in five hundred days, and is no more tired than when he began. His gait was such as to cause the least possible fatigue. Snyder has been called a walking maniac, and may or may not be such. Psycho-motor restlessness and impulse to constant motion till profound fatigue overtakes this area of the brain and muscular exhaustion inclines to rest, is a common feature of mania In the long corri- dors of our insane asylums may be seen always a certain number of patients walking continuously up and down and objecting to be interfered with until after a certain exhausting expenditure of motor force. The remedial philosophy of the long out-door walks and physical labor, especially in shop or farm and garden, so generally favored and employed by asylum superin- tendents, is founded on this fact of morbid psycho- motor restlessness. It is better to encourage it to the point of physical fatigue, that nightly sleep may follow or be more readily induced by both or hypnotics, than to attempt its restraint by irritating physical or personal resistance. En- couraging and regulating this activity to the point of physiological muscular fatigue, in a good sustaining at- mosphere, is a rational therapeutic procedure of no mean value in the successful management of mania, and the indulgence of the walking propensity to satiety may prove the mental salvation of John Snyder. The rationale of non-restraint is largely based on the motor restlessneunded on this pued by asylun non-reston John Snydto satiety 444 Editorial. physiological benefits which follow voluntarily-induced fa- tigue, a kind of fatigue which is much more salutary in its influence over both the sane and the insane mind un- congenially or coercingly accomplished exhaustion. Dr. C. L. Dana, on the Relation of Lithæmia, Oxaluria and Phosphaturia to Nervous Symp- toms, says: 1. There is no such thing as lithæmic or uric acid, oxalic or phos- phatic diathesis. 2. There are, however, morbid conditions of the nervous system, which are associated with excessive acidity of the urine, and excess of uric acid in the urine. The morbid nervous eymptoms in these cases are those of gastric neurasthenia, lighter forms of spinal irritation, great nervous irritabilty, vertigo, headaches, bad sleep, hypochondri- asis, etc. 3. The lithạmic state is rather allied to gout and rheumatism than identical with either. 4. The lithæmic state in question, associated with nervous symp- toms, is generally brought on by some overstrain or draining of the nervous system, or by some chronic poisoning of it, as by malaria or lead. It is probably a trophic or metabolic neurosis, comparable to diabetes. 5. Oxaluria is generally only a form or indication of lithæuia. When oxalate of lime occurs in abundance, with deposits of earthy salts, it has no clinical significance. 6. Phosphaturia, or an excessive deposit of earthy and alkaline phosphates in the urine, may be only apparent, and due to deticient acidity of the urine from excess of vegetables or fruits in the diet. But an excessive discharge of phosphates may accompany conditions of functional nervous depression and irritation. It indicates, in these cases, a disturbance of digestion, due, perhaps, to some perversion of the innervation of the digestive organs. If kept up, the loss of phos- phates and undue alkalinity of the blood may react upon the nervous system ; but in the vast majority of cases phosphaturia is only an evi- dence of indigestion. 7. It is of great importance, for the purposes of diagnosis and treat- ment of chronic functional nervous disorders, that a careful study of acidity and alkalinity of the urine be made, and that the proportion of urates and phosphates discharged be estimated. Thus marches steadily on to its destined general recog- nition, the neural pathology for which we have so long contended, as a rational explanation of otherwise inexpli- cable morbid phenomena. It will come in time (as this JOURNAL at is birth predicted) to reign supreme. The soil is being prepared, and the fruits already gathered attest its richness. Editorial. 445 Nervous Cardiac Debility (Neurasthenia Vaso- motoria).-Under this caption Vineberg, in his “Report .on Medical Progress" (New York Medical Journal) pre- sents the following: Dr. O. Rosenbach (Ctrlblt. f. klin. Med., 1886, No. 48) would indicate by this term a pure neurosis of the heart, without any organic change, which commonly obtains as part of the phenomena of general neuras- thenia. It is an affection of early adolescence and of the age of puberty, and occurs mostly in anæmic or nervous constitutions. Severe bodily or mental exercise, excessive use of alcobol, coffee, tobacco, etc., violent emotional excitement leading to melancholia, are important ætiological factors. The affection exhibits two well-defined stages-first one of excitement and then one of depression. The first stage is character- ized by rapid changing congestion of the face and hands, by paræsthesia of the skin of the chest and upper extremities, and by hyperästhesia of the cardiac region, in consequence of which pericardial anxiety and palpitation occur without any appreciable cause. In addition, there are often insomnia, anorexia, constipation, and frequent micturition. The heart's activity and pulse-rate are seldom increased. In the second stage the patient suff-rs from continued marked paleness, great psychi- cal depression and lassitude. Palpitation and arierial pulsation are felt in spite of lowered heart-power and weak pulse, the general reflex ex- citability is enormously increased, and the patient suffers from head- ache, dizziness, faintness, anorexia, etc. Important as a means of differential diagnosis are the etiology and the absence of any organic iesion; the continuity of the symptoms, while in real disease of the cardiac muscles or vessels there are always exacerbations; the absence of signs of congestion; and the slightly changed respiration, notwith- standing a subjective feeling of dyspnoea. Certainly, a long-continued neurosis of the heart may result in disease of its muscles or arteries; 'but in the majority of the cases one can succeed, sooner or later, in allaying the neurosis. Considerable energy and moral management are essential in the treatment of these cases. Electricity and hydro- pathic cures are not to be recommended. Together with hygienic and dietetic treatment, bromine preparations, iron, quinine, ergotin, and especially cocaine (gr. } twice daily), are useful. This is an old condition under a new name. It is simply neuratrophic cardiac gangliopathy, and was recog- nized and described by Tilt as a cardiac gangliopathy of anæmia and chlorosis. The Death of Dr. John Fulton, of the “Canada Lancet."--The medical profession of our northern sister province, and the profession of the country, sustain a great loss. He will be especially missed in the ranks of medi- cal journalism of North America. Fulton was always faithful to the welfare of the profession of Canada and the 446 Editorial. great British-American or American British Northwest. His journal was a model of terse and apropos selections and original papers, made in cosmopolitan and fraternal spirit, and characterized always by fidelity to the true wants and needs of the science and art he loved and la- bored for Dr. William Osler, who knew him so long and so well, pays the deceased physician and journalist the following historical tribute of his worth to the profession, in a con- temporary journal (the Canada Medical and Surgical Journal): The late Dr. John Fulton, of Toronto, was the first really success- ful medical journalist which Canada has produced. From 1826, when Xavier Tessier issued his ambitious Quebec Medical Journal, to 1870, when John Fulton took in hand that rickety suckling, the Dominion Medical Journal, the profession had sought in vain for a man who com- bined business talents with editorial capacity. As editor of the British-American Medical Journal, Hall had been conspicuously success- ful, but increasing expenditure and diminishing receipts twice caused him to give up the struggle. The Montreal Medical Gazette, the Upper Canada Medical Journal, the Medical Chronicle, La Lancette Canadi- enne, the Provincial Medical Journal, and L'Abeille Medicale, died of inan- ition. Primce vice defective; no digestion ; tabes mesenterica; good head, no nourishment; in other words, plenty of editorial matter, but no cash in the till. The business interests had never been given first place. Dr. Fulton made the Canada Lancet a success by able management and by fostering the pecuniary as well as the literary interests. He saw there was a fine field in Canada for a pushing journal, and he entered in and took possession. His life has a lesson for us all-the lesson that success cometh neither from the east nor from the west, nor yet from the south, but is found in a close attention to the every-day details of life, no matter how trivial. s relations toll be openedRoyal Hospitäivisions : Ninth International Medical Congress.- It is proposed to give one of the sessions of the Section in Psychological Medicine and Nervous Diseases, during the meeting of the Medical Congress, to a discussion on syph- ilis and its relations to insanity. The discussion will be opened by Dr. George H. Savage, Senior Physician Bethlem Royal Hospital, Lon- don, England, and will embrace the following divisions : 1. Idiocy, imbecility, moral perversions due to in- herited Syphilis. 2. Insanity associated with Acute Syphilis, (A) Physi- cal, (B) Moral. Editorial, 447 3. Syphilis producing Epilepsy, with or without Insanity. 4. Syphilis producing Mental Weakness, (A) with, (B) without Paralysis. 5. Syphilis as associated with general paralysis of the Insane. 6. Pathology, as represented by coarse changes like gummata, or slighter ones as seen in Arterial disease. Several of our English confrères have arranged to take part in the above. Those who intend to engage in the discussion of one or more of the above “questions,” should send notice to the secretary. The time allowed for each paper in discussion is ten minutes. Tabular and bibliographical material can appear in the printed paper, but it is respectfully suggested that the matter prepared for reading be as illustrative and pointed as possible. Clinical observations, post-mortem appearances and conclusions will be specially applicable. Papers relating to Syphilis and Nervous Diseases will also be read during the same session. Some Cases of Beri-Beri.–Under the caption “ A Rare Disease,” Science for May 20th, presents the following interesting facts and figures on the subject: The ship Albana recently arrived in New York from Manila. Of her crew of nineteen, seventeen became ill on the voyage, four of whom died. Five of the patients were removed to the Long Island College Hosptal, where the diagnosis of beri-beri has been made. This disease has already been referred to in Science as a rare one, not occurring in this latitude except when imported from Japan, India or other countries. It begins with fever, and pain in the loins and extremeties: these are soon followed by paralysis of the lower, then of the upper extremeties, and sometimes extend to the muscles of the trunk, particu- larly those of respiration. The disease is in reality a mul- tiple neuritis, involving especially the spinal nerves. The prognosis is usually considered grave, though the statistics of the Japanese navy would indicate that the mortality is not so great as is generally supposed. The cases that re- cover require considerable time, however, for regeneration of the affected nerves. The medical director-general of 418 Editorial. the Japanese imperial navy has just published a report on this disease as it occurs in that branch of the service. In 1878 there were 1,485 cases, with 32 deaths; in 1879, 1,978 cases, with 57 deaths; during 1885 there were but 9 cases; and in 1886, only 3 cases, none of them being fatal. This remarkable result is attributed by the director to the iniprovement in the food furnished to the sailors. The few who contracted the disease in recent years had not had the benefit of the improved food. m neuropathi maintained inty, read a “ The Role of the Nervous System in the Causation of Vitiligo.”—On the 6th of February, 1886, Dr. Ohmann-Dumesnil, of this city, read a paper on the subject, in which he maintained that the nutrition was at fault from neuropathic causes, and that the peripheral pigment changes are clearly due to central nerve condi- tions. The view was fortified by convincing clinical and pathological facts in his own experience and from the literature. The paper appeared in full in the April num- ber of the ALIENIST AND NEUROLOGIST. This subject has attracted the attention of a Paris correspondent of the June number of the American Lancet, and here is what he says: DR. LEBRUN ON VITILIGO OF NERVOUS ORIGIN. If vitiligo is not always accompanied by objective phenomena it may, in certain cases, point to the existence of a central or peripheric lesion, which would bave otherwise passed unobserved, thereby caus- ing a completely moditied prognostic and treatment to be adopted. The skin always denotes the state of the nervous system. If a patient presenting patches of vitiligo be carefully examined, a lesion of the nervous system, either central or peripheral, appertaining to the spinal marrow or ganglionic system, will in most cases be detected. It would be of importance to determine whether cutaneous affections of tropho- neurotic origin indicate a predisposition to certain nervous affections which appear periodically. The reader can find all of this and much more in Pro- fessor Dumesnil's interesting article, together with a very complete reference to the present and pre-existing litera- ture on the subject. The Knee Phenomenon Symptom.-- American and English neurologists have not generally (Hammond perhaps excepted) accorded to this sign the significance accorded it in tabes dorsalis by German students of neu- rology. And now Westphal, who more than any other Editorial. 449 German neurologist, except perhaps Erb, has kept pro- fessional attention fixed on this symptom as of important value in posterior spinal sclerosis, reports a case in which though the sign was absent, the characteristic lesion of locomotor ataxia was proven, post-mortem, to have been present in the posterior root entrance zone of the cord. Dr. Seymour Sharkey has also lately been led to doubt the complete diagnostic value of this "sign,” and makes record of his clinical incredulity in one of his Galstonian Lectures (vide “Spasm in Chronic Nerve Dis- ease, London, 1886,) in the case of a man suffering from extreme debility and anæmia, who came to his out- patient room, who not only had very extensive knee-jerks, but as marked knee-and-ankle clonus as Sharkey ever saw. He was sent into the hospital, and after two days' rest in bed Dr. S. was unable to elicit even the slightest clonus. The reader will find antecedent testimony to the same effect in the first volume of this JOURNAL. (Vide “A Clin- ical Inquiry into the Diagnostic Significance of Absent Patellar Tendon Reflex," by C. H. Hughes, Jan., 1880.) Miliary Aneurism and Cerebral Hemorrhage. -The alleged relation between miliary aneurism and cer- ebral hemorrhage, claimed by Charcot and his followers, has received some confirmation, likewise some opposition, at the hands of recent investigators. In the discussion anent this subject, the spinal cord seems to have been overlooked. There are but few cases of miliary aneurismal change of the cord-vessels recorded, and excepting an obscure case by Hebold, none in which any clinical sig- nificance could be attached to it. It is now however an- nounced by Drs. A. Koehler and E. C. Spitzka, of New York city, that in one family this change is the basis of an hereditary spinal disease. In two generations of this family cases of a disease simulating a typical multiple sclerosis in almost every particular were found. In one case, a fatal termination afforded the opportunity of mak- ing an autopsy. This revealed an intense disseminated miliary aneurismal change in the entire cord. It was less marked in the pons, and least in the cortex. There were no hemorrhages, but some evidences of disturbed tissue nutrition were discovered in the white substance. A full report of the clinical and anatomical facts is announced for the Section of Psychology and Neurology of the In- ternational Medical Congress. 450 Editorial. “Morphiomania,” says DeMontyel, in L'Encephale, “may always be treated by abrupt withdrawal of the drug, except in conditions when such methods are contra- indicated by the vital forces of the patient, or concomitant pathological phenomena. The method should also be abandoned if reactionary collapse result." Yes, Monsieur, it can be done in certain powerful organisms; but what can be done ought not always to be done if a better, safer and more agreeable possibility appear. If a man be not too high from the ground the ladder may be taken suddenly away and he may strike the ground with only a moderate concussion, but it were bet- ter, in most instances, to let him descend the ladder to terra firma. Opium in chronic meconophaghism is an in- truder which it were better to eject quietly and without violence, from its tendency in the organism that too sud- denly it strikes back as it goes out, like the rebound of a fire-arm,—that is, the organism feels the force of its envi- ronment when opium goes out suddenly, just as the cannon receives the shock of the rush of the surrounding air to feed the suddenly-made vacuum. The “Medical Standard” maintains the sprightly and able character it assumed in the initial number, and gives evidence of more than ordinary editorial industry and ability. No. 3 begins with an able and practical paper by Spitzka, on “The Importance of the Pupil in Suspected Nervous Disease," and this paper is followed by the fol- lowing valuable contribution from well-known and capa- ble sources: “ Antiseptic Vaginal Tamponnement, by Dr. Jas. H. Etheridge, Chicago; “Strophanthus," by Prof. E. S. Bastin, Chicago; “ Tubercular Mimimicry of Opium Poisoning," by Dr. W. T. Belfield, Chicago; “Bromine in Hepatic Contraction," by Dr. J. S. Jewell, deceased, Chicago. Delegates to the Congress in Washington.- It was announced several weeks since that Dr. Leopold Servias, of Antwerp, had been appointed by the Belgian Government as representative to the congress in Washing- ton. More recently we learn that Deputy Surgeon-General Jeffrey A. Marsten, M. D., of the British Army, has been designated a representative by his Government; and the Government of France, through the Academy of Medicine, Editorial. 451 has designated as representatives Drs. Charpentier, Du- jardin Beaumetz, Leon Le Fort, Trélat and Vallin. From all directions, at home and abroad, the indications of a very large and interesting congress are of the most grati- fying character.— Journal of Amer. Med. Asso. Dickens' Fat Boy a Narcoleptic.—The Medical Standard thus commits itself to the theory that Dickens' fat boy was a typical narcoleptic: The diseases of the most prominent persons have been discussed by historical nosologists, but none of these cultured gentlemen seem to have been attracted to the case of the fat boy of the “ Pickwick Pa- pers," who performed most of his duties while asleep. He was clearly a case of narcolepsy ; the sleeping sickness which has been so exten- sively discussed by Drs. C. L. Dana, C. H. Hughes and other neurolo- gists of late. It would be of much medico-literary interest to know where Dickens saw the narcoleptic whom he described in Pickwick as the fat boy. Officers-Elect of the Society of Medical Juris- prudence and State Medicine. -The following officers were elected at the last annual meeting of this society, held in New York city: President, Amos G. Hull; Vice-President, Dr. E. C. Harwood; Secretary, Dr. E. C. Spitzka; Corresponding Secretary, Dr. Jean Chauveau ; Treasurer, R. C. M. Page; Trustees, Drs. N. E Brill, H. J. Boldt, J. M. Jacobus and Wm. M. McLaury; Lawyers D. McLean Shaw, C. H. Kitchell, E. H. Bean and the Hon. S. V. Cooper. Cerebral Anæmia and Uræmic Convulsions.- Anæmia of the brain, according to Fleischer, of Erlangen, plays a prominent part in the induction of the convulsions we find associated with uræmia. He has reached this conclusion after a series of ex- periments on the pathology of the kidneys, etc., presented in an interesting essay before the German Congress of Inner Medicine recently held at Wiesbaden. Canadian Medical Association.-The nineteenth annual meeting of the Canadian Medical Association will be held in Hamilton, on August 31st and September ist. This date will enable members to attend also the meeting of the International Congress which will be held in Wash- ington on the 5th of September. 452 Editorial. The New York Medical Record says: "There is something in the atmosphere of St. Louis which gently turns the thoughts of medical editors to puns." This is not the record of New York atmosphere. No breezes of of wit come this way from there. “The Minute Structure of the Corpora Striata and the Thalami Optici," by Dr. Vittorio Marchi (prize essay of the Royal Institute of Lombardy), will ap- pear in the October number. J. B. W. Lansing, M. D., of Bay City, Michigan, a graduate of the New York College of Physicians and Surgeons, 1885, has been appointed Assistant Physician at the Eastern, Pontiac, Mich. G. F. M. Bond, M. D., formerly Clinical Assistant at the New York State Lunatic Asylum, Utica, N. Y., has been appointed Assistant Physician at the Winnebago, Wisconsin, Asylum. IN MEMORIAM. JAMES STEWART JEWELL, M. D.—Dr. James Stewart Jewell, one of the most assiduous cultivators of neurolog- · cal medicine, which this or any other country has pro- duced, died on the 18th April last, at Chicago, after a long and painful illness. Born September Sth, 1837, he had nearly completed his fiftieth year, when he was called away from those labors that he loved so well, and which, notwithstanding an illness that would have stricken most men down, he continued to perform almost up to the last day of his life. Dr. Jewell was of Scotch and English ancestry. His primary education was obtained at Galena, near which place he was born, and was supplemented by his own strenuous exertions during respites from work on his father's farm. He often mentioned to the writer of this, the difficulties under which he suffered, during this period of his life, both from poverty and lack of time to do all that he wanted to do in the way of mental improvement, but, like many others who have made names for them- selves, obstacles only served to stimulate him to renewed exertions. One of the happiest moments of his life, as he said to me, was when he found himself in Chicago with his small box of clothing on his shoulder, trudging through the streets of the city, an embryo medical student, in search of a cheap boarding house. The world was before him, he was entering upon a new life, and with a heart full of hope he felt confident of success. The following day found him matriculated as a student in the Medical Department of what was then the Lind University, now the Chicago Medical College. On graduating he began the general practice of medicine in Williams County, but two years afterwards he moved to Chicago, being appointed Professor of Anatomy in the college that had given him his degree. Exhibiting marked predilection for neuro- logical medicine, he took great interest in those branches of medical science bearing particularly on that depart- Anent of the healing art, and even during his service as an assistant surgeon in General Sherman's army, all the moments he could take from his more imperative duties, were devoted to the study of such works on nervous dis- eases as he could obtain. Eventually he was appointed [ 453 ] 454 In Memoriam. Professor of Nervous and Mental Diseases in the Chicago Medical College, the chair being especially created for him. From this time on, he gave himself up, as much as possible, to the special study and practice of neuro- logical science. Probably little was, as yet, known of him outside of his city and State, till the appearance of the Journal of Nervous and Mental Disease, of which he was founder and first editor. The first number of this periodical took American and foreign neurologists by surprise. The strength of its Original Department, the research and knowledge exhibited in its reviews, and the extent of reading shown in its extracts of the current neurologi- cal and psychological literature of the world, were a rev- elation. The journal at once took the first rank among periodicals of its line, and subsequent numbers only served to deepen the feeling of admiration with which the first issue was received. Dr. Jewell was, with the writer of this notice, one of the founders of the American Neurological Association, and was for several years, successively elected its presi- dent. His visits to the East made him many friends, for no one could come in contact with him without being struck with his innate gentleness and keen sense of what was due to himself and others, his learning, and the tol- erance with which he regarded views upon all subjects diametrically opposed to those which had become part of his nature. No one ever had more persistence in adhe- sion to what he deemed right, or more ready to renounce opinions that were shown to be erroneous. In the course of his life he had almost, by his own unaided exertions, become intimately acquainted with the French and German languages, and a journey which he took to Europe, Asia and Africa, served still more than his other educational advantages to enlarge his ideas, and to crown him with that spirit of literature which was one of his most striking characteristics. Dr. Jewell never published any elaborate work, but he was, at the time of his death, engaged upon several treatises, one of which was near completion. It is to be hoped, that under the editorial supervision of some one or more of his co-laborers, these volumes will, at no dis- tant day, be laid before the medical profession. For several years he had suffered from a complication of gastric and pulmonary disease, which, while causing In Memoriam. 455 great bodily disturbance, seemed to interfere to only a slight extent, till towards the end, with his mental powers. Over a year ago, fretting under the idea that he was not fully employing his time, the Journal of Nervous and Men- tal Disease having passed out of his hands, he started a new journal, The Neurological Review, but after a year he found this too great a tax upon his strength, and he was forced to suspend its publication. In a letter received from him only a few days before his death, he informed the writer that his health was improving, and that he hoped ere long to issue a work on neurological medicine, to which he had devoted an immense amount of labor. In less than ten days afterward he died. That Dr. Jewell will be greatly missed by the small band of American neurologists to whom he had endeared himself, goes without saying. We, here in the East, had come to look forward to his yearly visits with a degree of pleasure, which was always increased when we had him actually with us. Genial, fond of society, with a keen sense of humor, never giving offence, warm in his friend- ships, a peace-maker when peace was required, but ready to vindicate himself and those he loved when occasion came, he was a man whose regard and esteem were worth obtaining and keeping. To the writer of this slight notice, he was as dear as a brother, there was no restraint upon our confidences; our intercourse was as free as though we were, in fact, of one blood, and his death has left a void which no living man can fill. WILLIAM A. HAMMOND. The ALIENIST AND NEUROLOGIST would add its testimony of the worth of the deceased to psychiatry and neurology, and its appreciation of the loss these high departments of medical research and endeavor have sustained in his untimely demise. Dr. Jewell had an exceptional enthusi- asm, founded on unbounded industry and diligently-ac- quired knowledge. He was learned in neurology through hard and constant work, and lived for his work. It is painful that he has been called away so soon from the glorious and fruitful work he loved so well. He filled a peculiar place, and filled it so well that we know of no American neurologist who can fitly fill it. Dr. Jewell was in every sense a good physician. His life was one of charity to his brethren and towards mankind. The reward of the just in the great hereafter must be his. REVIEWS, Book NOTICES, &C. INSANITY AND THE CARE OF THE INSANE. By Clark Bell, Esq, President of the Medico-Legal Society of the City of New York. Read before the Medico-Legal Society of New York, March 9, 1887. This is a very good paper for a lawyer to write. The review of the literature of the subject is fairly good, considering its source, but, of course, not wbat would be expected of a medical expert in psychiatry. It maintains, and most justly, we think, that: The legal mind should be brought nearer to the medical view of in- sanity, and true tests of responsibility will follow in trua sequence. . And that proper care and continement, in an asylum for insane crimi. pals, so-called, is much better for our civilization, and far more so for a lunatic, than the scaffold. As to inganity and crime, the author contends that the law Bliould advance with the progress of science, pari passu. He asserts that, “ seventy per cent. of the inmates of asylums can discriminate between right and wrong, and know that such and such an act is against the law, and will bring punishment;” and maintains that, “ It is a disgrace to our civiliza- tion to bang the insane who coinmit homicides." The author contends that, “ It is a simple mockery of justice to say that on an affidavit of two physicians, who may have never seen a case of insanity, a citizen can be placed in an asylum, as insane, for, five days, without the order of a court or judge.". But there are some cases so urgent that justice must be mocked at in this way or else the insane mau's right to life and the future pursuit of happiness-higher rights tban mere present liberty-must be sacrificed, and the rights of the sane about him, and dependent upon him, violated. There is a conflict of rights when an insane man is kept out of an asylum, and from the immediate care and treatment his case demands, by a tedious judicial process. The law can irake, and does make, the sworn certificate of two physicians a judicial process, and very justly, we think, in most cases, We tbink the author has misquoted Locke in the following proposi- tion: “Madmen do not appear to have lost the faculty of reasoning, but having joined together some ideas very strongly (wrongly ?) they mistake them for truths, and err as men do who argue from wrong principles." And the following seems to us to be an unlawful invasion of the province of Medicine. He gives this as the answer, if called upon as a witness, to give his own opinion as to insanity and responsibility: Clark Bell: "Insanity cannot be exactly defined medically, from lack of present knowledge of its pathology. Legally considered, it may be re- garded as a disease of the brain or nervous system, which prevents the free exercise of volition. ( 456 ) Reviews, Book Notices, &c. 457 "The test of responsibility under the law for a criminal act, when the defence of insanity is interposed, should be, clear knowledge of its nature, consequences and penalty, with volition unimpaired by disease of the brain or nervous system. "If a man commits a crime, understanding its nature and penalty, under the law he is responsible, unless suffering from a disease of the brain or nervous system, which prevents the free exercise of his will- power. If acting under a delusion which dominates his volition, he is not responsible for bis act. He is the victim of his disease". Vide ylso p. 413, Dec. number, Med. Leg. Jour., 1881. Vol. II, No. 3. The care of the ineane is next discussed under the heads : 1. Should they be confined in hospitals ? 2. Mechanical restraints. 3. Tbe best methods of care, both as to incurables and acute or doubtful cases. The author favors placing the barmless incurables in familier, opposes mechanical restraint and advocates music for the cure of the insane. The general tone of the paper is healthy and progressive, and it is gratifying to see a lawyer taking so much interest in this subject. The teachings of Cabannis, in regard to the somatic view of insanity, and the labors of Chirurgi, bave been overlooked by the autbor. They were both pioneers, and Chirurgi preceded Pinel and Conolly in striking off the madınan's cbains. The paper concludes with the following eloquent plea for the lunatic arraigned for capital crime: " It is a glaring, horrid, lurid spectacle in this age, so near the close of the nineteenth century, to see erected near the tribunals of a free peo- ple, a scaffold, on which the law suspende, from a mistaken or distorted Qotion of its own majusly, the dangling form of a lunatic hereft of rea. son, as punishment for a supposed crime. "I think it was Charles Siunner, who said twenty-five years ago, that he knew no sadder sight than a woman for sale, upon the auction block.' “The war bas effaced that picture from our view, washed it away with rivers of blood. To me, it is far more revolting, after the advancing ligbt which science has thrown upon the subject, for a quarter of a century since the Massachusetts Senator spoke, to see the legalized judicial killing of the insane for alleged homicides ! “ That the revolution which will efface the latter may be as bloodless, and yet as complete, must be the hope of all philanthropic hearts." May the time come speedily when the eyes of the law may be opened to the wrong done the insine by the judicial “ right and wrong test” of mental responsibility, and justice yet be done the victims of disease in our courts, even though behind the cloud of mental darkness and dis- ease-impelled actions an abstract knowledge of right and wrony appears. THE NURSING AND CARE OF THE INSANE. By Chas. K. Mills, M. D, Professor of Diseases of the Minil and Nervous System in the Phila- delphia Polyclinic, etc. This is one of a series of manuals or practical lessons on nursing, published by J. B. Lippincott Company, Philadelphia. The matter of 380 C. H. Hu principle, and hold the power hemorrhage—the arteriolewa! -accountable for the lapsus ; If neither the structure of 1 from their nervous connectio: of the blood is at fault, the anism of nervous control t need not, in order to u discuss the question whet the capillaries which over strictors, or whether the inherently in the arteriol. nervous influence, as Por maintains. The fact is, in h tile capacity and arter is so impaired throug! the ganglionic centers hibition, that blood capillary walls under heart pressure or p dinarily cause this pº The extraction lance, the lancing a pin, the bite of linguæ, or the rer gymnastic exerci: brandy, which : weaken vasomo in a hæmophil none of those mon to later of blood. The early philia appes the reason due to u Degenerat 118 ich er- ias tate rese num cting perior iently ipheral i above nalleous, condition of foreign sitively the na tympani, diseased parts. of pledgets of of air and dust is val. After accomp- oduces itself, and the be part of the surgeon. possibility of opening a he external ear, which an- red to this procedure for tachian canal attend- result was in every 458 Reviews, Book Notices, &c. portions of the volume presupposes a degree of intelligence and learning possessed by very few of those following nursing as a profession. For this reason it may not become a popular book. By the more intelligent class though it may be read with protit. The best chapters are on “The Nursing and Care of the Insane," wherein are to be found much practi- cal instructlon and many valuable suggestions. The book will give the intelligent nurse an idea of the magnitude of neurology and of his or her own littleness, if he undertakes what many nurses do, to become a medical adviser. Pages eleven and twelve contain therapeutic fallacies, from our view of practice. The author then speaking of the cure of hysteria, neurasthenia and other functional nervous disorders, reminds the nurse that these patients sometimes undergo a method of treatient which involves, among oiber things, more or less seclusion from all but physicians and attendants and continement to their rooms for weeks or months, almost isolated from the rest of the world, etc. Now, while this is the practice of some neurolo- gists, in most cases of bysteria or neurotrophia, or neurasthenia, it is not the best. It is an especially bad way to cure neurasthenia and a good way to develop melancholia, if there be latent the least taint of insane beredity. To separate hy:terical patients from their inost familiar, intimate and sympathizing friends, especially mothers, husbands, etc., is good practice, but entire and too prolonged seclusion is unnatural. The Weir-Mitchell plan may be and is injudiciously applied and carried to excess in some instances, even by its distinguished author, as we know by personal observation, some patients buving declared to us, on good ground we thought, that they would never again submit to such an ordeal. Respecting the use of batteries, we hope the author, in tbe next edition, will emphasize the fact that the nurse should only use the battery as be gives a dose of medicine, as directed by the physician, and no more or oftener, or less or less frequent. The battery, the dose of medicine and the scalpel, should all be on the same fooling. The danger of trained nurses is in that dangerous thing, a little learn- ing, but if the function is kept strictly executive of the physician's orders, and never administrative, they will be valuable aids in the practice of neurology. The times make the trained nurse a necessity, and if we have trained nurses we must have books like “ Mill's Nursing and Care of the Nervous and Insane, ” to aid in educating and training them. He who writes for the instruction of nurses should be careful not to advise them of methods of practice wbich are not generally employed. They should be taught, so far as practical, as little to be unlearned as pos- sible. It takes a liberal minded and widely skilled physician to write wisely for nurses. This book, if open to objection at all, might be said to be too wisely written for the average nurse. It is, nevertheless, an excellent manual for the most intelligent and ambitious of knowledge among nurses. It is a good book for students likewise, and may be read with special profit by young hospital internes Reviews, Book Notices, &c. 459 and beginners in medical practice. Every physician not a practical alien- ist, who may bave the care, even temporarily, of a melancholic or puerperal insane person, or of any form of mania, may read chapter four with decided protit. These precautions are familiar to all men accustomed to treat tbe insane, and ignorance of them on the part of physicians who, without previous clinical experience in asylums for the insane, have un- dertaken to treat insanity, bas resulted in many unexpected and avoid. able tragedies. Dawx OF A NEW ERA IN OTOLOGICAL SURGERY.-The great reproductive power of the Membrana Tym pani. A new method whereby the Eustacian Tubes may be permanently opened, dilated and treated. Dry Catarrh of the middle ear now amenable to treatment. Distress- ing and long-standing Tinnitus Aurinm relieved in a novel way. With Illustrative Cases. By Wellington Adams, M. D., late of Denver, now of 2829 Olive Street, St. Louis. This is an interesting and readable paper containing ingenious practi- cal suggestions, by an experienced authority in otology, and, as such, we cordially recommend it. By the author's methods of illumination, by means of an ingenious electric operating otoscope of his own invention, the drum membrane and the middle ear may be viewed and operated upon under intense magnifica- tion and brilliant illumination ; for class demonstration, these parts with their manifold affections, may be thrown upon a screen; and, further- more, operations in and around the middle ear may be thus witnessed as readily as operations upon any other part of the body; and to facilitate the dissemination and perpetuation of knowledge once attained, these parts may be photographed and printed. Dr. Adams applies medicated fluids and vapors to the tympanum through the external auditory canal. This he accomplishes by dissecting out two triangular segments of the membrana tympani, one in the superior and the other in the inferior portion of the membrane. He has frequently dissectid out the entire drum membrane with the exception of a peripheral ring or the annulus tendinosus and an oblique strip running from above downward and backward, and including the manubrium of the malleous, reaching the middle ear directly, accurately determining the condition of its lining membrane, diagnosing the presence or absence of foreign substances or growibs witbin the typanum, ascertaining positively the exact character of the pathological changes in the membrana tympani, illid applying treatment directly and advantageously to the diseased parts. During the treatment, the openings are retained by means of pledgets of absorbent cotton introduced therein ; and the entrance of air and dust is prevented by cotton worn in the external auditory canal. After accomp- lisbing these purposes the membrane readily reproduces itself, and the openings are closed without any interference on the part of the surgeon. Dr. Adams was the first to announce the possibility of opening a Eustachian tube impervious to air, through the external ear, which an- nouncement be now makes, having, in 1881, resorted to this procedure for the relief of a chronically narrowed and occluded Eustachian canal attend- ing a case of progressive hardness of hearing." The result was in every 460 Reviews, Book Notices, &c. way satisfactory. For this purpose he used a moderately stiff filiform bougie passed through a metallic tube with a short curve at the extremity, wbich he introduced into the middle ear. The metallic tube answers the purpose of stiffening and directing the course of the bougie. PERSISTENT PAIN AFTER A BDOMINAL SECTION.-Reprint from Gynecologi- cal Transactions, Vol. XI. By James Hunter, M. D., Surgeon to the Woman's Hospital, New York, etc. The author first discusses the causes of pain before operating under two leade, viz., those referable to the diseases of the ovaries and tubes, and tliose due to diseases of the peritoneum. In operating it is often impossible to remove the consequences of past inflammation, or to restore the normal relations of injured and displaced viscera, bence persistent pain after operating. Other satisfactory explana- tions are given, and the palliative and radical treatment of post-operative pain discussed. THE DOCTORATE ADDRESS delivered at the Semi-Centennial Anniversary of the University of Louisville, Medical Department, March 2, 1887, by David W. Yandell, M. D., Professor of Surgery and Clinical Sur- gery in the University. 18 characteristic, in style and matter, of that scholarly Louisville physi. cian, and abounds in retrospective information of the bright lights of Western Medicine, many of whom, in their latter days, illumed and adorned the medical world from Eastern colleges. Southern and Western Medicine, and especially the profession of Louisville, may well be proud of the record and impress of her sons at home and transplanted. RECOVERIES FROM INSANITY IN CASES ACCOMPANIED BY HEMA- TOMA AURIS. In the American Journal of Insanity for July, 1874, Dr. Macdonald introduces this subject with the following very correct statement of the attitude of this sign, as ordinarily held by authors, to prognosis, and as to the importance of taking a somewhat less hopeless view of insanity, associated with hæmatoma auris. The first of these cases occurred in the practice of Dr. William Teats, of tbe Coton Hill Institution, England, who reported it in the British Medical Journal, 1873. Dr. Van Deuken believes this to be the first case ever recorded. The subject was a woman, aged thirty-three years, admitted to Coton Hill Institution in January, 1870, suf- fering from acute mania, first attack of about three months duration, and characterized by marked suicidal, homicidal, destructive, and violent ten- dencies and improper language. The case was regarded as hopeless. This condition continued until August, 1872, when the excitement gradually subsided, and by the middle of November, she was considered perfectly sane. The second case, reported in the same journal by Dr. Needham, of the Bootham Asylum at York, was that of a young man, admitted to the Bootham Asylum in October, 1861, with acute mania of one week's dura- tion. At the end of twelve months no improvement had occurred, and the patient seemed to be rapidly drifting into dementia ; there had been bæ- matoma of both ears, with the characteristic effusion, absorption, and sub- Reviews, Book Notices, &c. 461 sequent disfigurement. Suddenly there was a change for the better; the excitement abated, babits and mental condition began to improve, and at the end of sixteen months the patient was discharged fully recovered, and up to the time of making the report, upwards of ten years, be bas re- mained perfectly well. The third case was observed by Dr. Van Deusen himself. A robust young farmer, aged twenty- ne years, was admitted to the Michigan Asy- lum in June, 1870. He was suffering from acute mania of about three weeks' duration; the attack was attributed to “ partial sunstroke and business perplexities," and was characterized by extreme violence, marked bodily agitation, and destructive tendencies. Five weeks after admission, well marked hæmatoma occurred in both ears, passing through the usual stages, and terminating in the characteristic deformity. “In October there was an abatement of the excitement, convalescence was establisbed, and he was discharged recovered, February 15th, 1871. His health bas continued good, as has been ascertained by occasional correspondence, and be has been actively engaged in business since his return home." These cases are presented in an interesting study of the subject, by Dr. Carlos F. Macdonald in the February Journal of Nervous and Mental Diseases, together with the following case, which occurred in Dr. Macdonald's own practice : Geo. C., alias P, aged eighteen years, convict, was admitted to the N. Y. State Asylum for Insane Criminals, April 16th, 1880, suffering from acute mania of a somewhat violent type and of several weeks' duration. He recovered, and was discharged from the asylum, November 11th, 1580; was readmitted on June 22d, 1881, at which time he was in a markedly maniacal state, continuing so during a greater part of the year. He was incoherent in speech, noisy, violent and tilthy, emearing himself with ex- crement, denuding lijs person, and openly masturbating; also attemptid self-mutilation. In August, 1881, compencing hæmatoma of both ears was observed. These developed rapidly, were apparently painless, and fluctu- ated indistinctly-the right being the larger. Toe swelling, in each, was confined to the concha, giving a very peculiar appearance. Absorption was rapid, and at the end of a month the tumors had nearly disappeared, leaving the usual induration and tbickening. At the same time the mental disturbance had gradually subsided, and convalescence was fairly established. The patient was returned to Auburn prison, recovered, September 30th, 1882, where he reinained entirely free from mental disturbance, as I ascertained through occasional visits to him, until the expiration of his term of sentence to penal servitude, March 220, 1884, when he was released. Dr. Macdonald makes the following criticism on Dr. Clouston: “ These four cases comprise, I believe, all that have thus far been re- ported, although Dr. Clonston, in his admirable work on Mental Diseases, referring to hæmatoma auris, says: I bave seen only three cases recover out of eighty cases who had hæmatoma auris.' (* Clinical Lectures on Mental Diseases,' p. 265. And again, the same author, in describing a case of ado- lescent insanity with hæmatoma auris followed by recovery, makes the fol- lowing statement: This was one of only about six patients that I have 462 Reviews, Book Notices, &c. seen wbere recovery took place after a hæmatoma uad formed, or even been ibreatened in any degree.' Op. cit., p 380. Just how Dr. Clouston would explain this apparent discrepancy, the writer is unaware; most likely it is a lypograpbical error." STUDIES FROM THE BIOLOGICAL LABORATORY OF Johns Hopkins UNI. VERSITY:-No.1 of Vol. IV. contains the following contributions: “On the Action of Peptone in Preventing Blood Coagulation," by John P. Camp- bell, A. B.; “ Note on the Specific Energy of the Nerves of Taste," by W. H. Howell, Ph. D., and J. H. Kastle, S. B.; “ The Influence of Warmth upon the Irritability of Frog's Muscle and Nerve," by Charles L. Edwards, A. M.; - Experimente in Regard to the Supposed Suction Pump’ Action of the Mammalian Heart," by H. Newell Martin, M. A., M, D., F. R. S, and Frank Donaldson, Jr., A. B., M. D.; "A New Dog- Holding Apparatus," by Charles Dawson. All the above studies are of special interest to physiologists. Messrs. Howell and Kastle say their experience with the animals experimented on bas led them to doubt very much the value of the exper- iments made by various observers upon dogs, with regard to the eff. ct of section of the glossopharyngeal or lingual nerves upon the sense of taste in different parts of the tongue or palate. The authors made a number of experiments also upon the benzoic sulphinide, saccharine, the substance from which the brom-sulphinide is derived, which gave them somewhat interesting results. With some per- sons this substance arouses only a very sweet sensation, whether placed on the tip or the root of the tongue. With others, however, while it caused a strong sweet sensation upon the tip, when placed upon the root in the re- gion of the circumvallate papillæ it caused first a sweet, then a bitter sen- sation, and frequently the two sensations rapidly alternated with each other, reminding one very much of the conflict of the visual fields, when two dif- ferent colors are thrown upon corresponding points of the two retinas; the stimulation of the two kinds of taste fibers in this case being so strong that neither one could oversbadow the other, and the mind perceived first one, then the other. They maintain that their results show beyond doubt that a chemically pure substance can arouse different taste sensations upon different parts of the tongue, a fact wbich goes a long way towards proving that each taste sensation is provided with its own set of nerve fibers. The action in this case is more interesting, perhaps, in that the two sensations aroused, sweet and bitter, are those which are universally acknowledged to be pure taste sensations. The results obtained by them can be explained by supposing that the brom-sulphinide stimulates both the bitter and the sweet fibers, and that upon the posterior portion of the tongue, where, as is well known, the bitter taste is most developed, the stimulation of the bitter fibers is so strong that only this sensation is perceived, while upon the tip of the tongue, where the bitter fibers are less numerous, the sensation aroused by the stimulation of the sweet fibers predominates, though, as was stated several persons were able to recognize both sensations. In several of the persons experimented on, the sensation upon the tip of the tongue was given as first slightly bitter and then sweet, and the Reviews, Book Notices, &c. 463 experimenters, toward the end of the experiment, were generally able to detect both these sensations in the order named, especially, if they knew that the brom-sulphinide was to be used. This seemed rather curious when they remembered that the reaction time of the tip of the tongue for quinine, according to the experiments of V. Vintschgau and Hönigschmied, is decidedly greater than for sugar. One would have sup- posed that in this case, if the substance was capable of causing both a bitter and a sweet sensation on the tip of the tongue, the sweet sensation would bave been developed first. The fact that it was not, seems to show that the reaction time, as determined for quinine and sugar respectively, cannot be accepted as true for all other bitter or sweet substances. They have met with but one person upon whom this substance has failed to give both a sweet and a bitter taste in the places described. In this case the sensation caused upon the circumvallate region was, as in other persone, intensely bitter, while upon the tip of the tongue the sensation was de. scribed sometimes as slightly bitter, sometimes as salty and bitterish. This was not owing to a lack of sensitiveness to sweet substances on the tip, since sugar gave a decidedly sweet sensation. AMERICAN JOURNAL OF PSYCHOLOGY.-G. Stanley Hall, Ph. D., Professor of Psychology and Pedagogics in the Johns Hopkins Univer- sity, the editor, makes the following announcement: “It is proposed to begin the issue at an early date, of a quarterly Journal, to be entitled "I he American Journal of Psychology.' “ The records of psychological work of a scientific, as distinct from a speculative character, have been so widely scattered as to be largely inaccessible save to a very few, and often to be overlooked by them. Several departments of science, often so distinct from each other that their contributions are not mutually known, have touched and enriched psychology, bringing to it often their best methods and their ripest in- sights. It is from this circumstance that the vast progress made in this department of late years is so little realized, and that the field for such a Journal is so new and the need believed to be so great. The Journal will contain: * I. Original contributions of a scientific character. These will consist partly of experimental investigations on the functions of the senses and brain, physiological time, psycho-physic law, images and their association, volition, innervation, etc.; and partly of inductive studies of instinct in animals, psycho-genesis in children, and the large fields of morbid and anthropological psychology, not excluding hypno- tism, and the field vaguely designated as that of Psychic Research; and lastly, the finer anatomy of the senses and the central nervous system, especially as developed by the latest methods of staining, section, etc.. “ II. Papers from other journals. Articles of unusual importance will be translated from other languages, or even reprinted from other English and American publications, in full or in abstract, if not gener- aily accessible. “ III. Digests and Reviews. An attempt will be made in each 464 Reviews, Book Notices, &c. number to give a conspectus of the more important psychological liter- ature of the preceding three months, and to review significant books, bad as well as good. “ Wbile articles of unusual importance in the fields of logic, the history of philosophy, practical ethics and education will be welcomed, the main object of the Journal will be to record the progress of scien- tific psychology, and special prominence will be given to methods of research. “ Among the readers whose studies the editor will bear in mind are these-teachers of psychology in higher institutions of learning; biolo- gists and physiologists; anthropologists who are interested in primitive manifestations of psychological laws; and physicians who give special attention to mental and nervous diseases. The advancement of the science will be constantly kept in view, and the Journal will be a record of the progress of investigations. “ The Journal will be published quarterly, and with as much regular- ity as the supply of material warrants. Each number will contain from 60 to 100 pages. The subscription price will be $3.00 a year, in advance. Single numbers $1.00. “Remittances and business communications should be made to N. MURRAY, Johns Hopkins University, Baltimore. “Scientific and editorial communications should be addressed to the editor." This new journal has our best wishes, and under its announced able management it ought to prosper. MENTAL EPILEPSY is the subject of an interesting essay, by L.. W. Baker, M. D., Sup't Family Home for Nervous Diseases, Baldwinville, Mass. Read before the Medico-Legal Society, Dec. 8, 1886. The author presents an analysis of Ecchiverria's cases as follows: “Of the 532 epileptics examined by Ecchiverria mental failure was evident in 70.3 per cent., and of this number 26 per cent.exbibited aitacks of mania lasting from a few moments to several days or weeks, ' and repeats the usual experience of observers, that, " The amount of mental failure varies greatly in different individuals, and is not always dependent upon the duration of the disease, although the liability of its occurrence is greatest when the attacks commence during early childhood.". He also gives the following generally accepted conclusions : “1. That attacks of mental epilepsy, may precede, follow, or take the place of severe or slight epileptic seizures. “2. Attacks of epileptic mania are usually unpremeditated, motiveless and accompanied by impairment of consciousness and temporary loss of memory. During this period the individual is irresponsible for bis ac- tions. "3. It is possible for an epileptic to automatically continue, during an attack, an idea or action begun just before the onset of the paroxysm, “4. It is important to distinguish between attacks of true epileptic mania and exhibitions of irritability and violent temper in an epileptic. • The patient who has clearly committed an attempt when not suffering Reviews, Book Notices, &c. 465 from an attack is partially responsible, but be has the right, after exami- nation into his mental state, to an extenuation of the penalty, and in some way proportionate to the degree of moral resistance which can be opposed.'-Le Grand-du-Saulle. " 5. The question of responsibility of an epileptic in criminal acts gbould be decided by a commission of medical experts appointed by the court for this special purpose. This commission should make its exam- ination and report previous to the trial. “6. Various mental disturbances may occur in an epileptic upon the cessation of attacks under treatment. These may have no relation to the drugs administered for the relief of the convulsive tendencies." Alienists familiar with all forms of epileptoid, as seen in every-day life outside of hospitals or receptacles for epileptics, will hardly acquiesce in the following: “ As a rule, epileptics are very impressible, disinclined to exertion, capricious in their tastes and feelings, and quick to take offence at slight causes. Even if the mental impairment is but slight, the finer sensibilities are usually blunted, and they are often careless in regard to their personal appearance, and indifferent in their observance of the proprieties of life, while vicious and criminal propensities are not infrequently present, ren- dering the individual unfit to mingle in society or unsafe to be permitted outside of asylum walls. This will do for a description of an immediately post-epileptic debate in some, but not for the general characteristics of epileptics. A DiscussION OF PARACELSUS.- Under the caption, “Little Devils in tbe Air," All the Year Round, thus discusses Paracelsus : 66 Who and what was Paracelsus? Is it a real name or the assumed name of a real personage? If assumed, what does it mean? If our read ers will follow us for a little, we will endeavor to throw some light upon a dark but yet curiously interesting subject. *** Paracelsus,' according to Robert Browning, thought, at the age of twenty, tbat knowledge was the summum bonum, and retired to a seat of learning to acquire it. But at twenty-eight he was still unsatisfied, and then made acquaintance with an Italian poet, who induced him to seek the summun bonum in love. Again he was dissatisfied and disappointed, and finally resolved to devote himself to know and to enjoy.' “ This, it must be confessed, is not very informing : 80 let us try another instructor. “Paracelsus,' says Dr. Brewer, is reported to have kept a small devil in the pommel of his sword, and he favored metallic sub- stances for medicines, while Galen preferred herbs.' Here, then, we may yather some light, for we gain a distinct impression of a medical practi- tioner upon reformed methods, with a spice of the supernatural. This, in brief, was the characteristic of the real Paracelsus, who was not quite the same personage as the Paracelsus of Browning. But what of that ? "Concerning the little devil in the pommel of the sword, old Burton who wrote the · Anatomy of Melancholy,' was also exercised. But be thought it not at all improbable, for, said he, •the air is not so full of fies in summer as it is at all times of invisible devils. They counterfeit suns 466 Reviews, Book Notices, &c. and moons, and sit on ships' masts; they cause whirlwinds of a sudden, and tempestuous storms, which, though our meteorologiste generally refer to natural causes, yet I am of Bodine's mind- they are more often caused by those aerial devis in their several quarters.' Cardan's father he avers had an aerial devil bound to biin for eight-and-twenty years;' others wear them in rings.' Why, then, should not Paracelsus 'wear' one in the pommel ot his sword ? “Why not, indeed, since, as Mr. Moncure Conway reminds us, in ages past every successive discovery of science and every invention of material benefit to man was believed by priest-ridden peoples to have been secured by compact with the devil ? As Prometheus was suppressed' by Jove, so in the Middle Ages, were many men engaged in legitimate scientific re- search suppressed' by the priests. The taint of sorcery hung around every effort to acquire knowledge out of the customary channels. We need only recall one instance in our own country- Roger Bacon, with regard to whom, in the priestly wbisper the cheruist's crucible grew to a wizard's cauldron.'" “ BRAIN."— Arrangements have been made between the Council of the Neurological Society of London and the Editorial Committee and Publishers of Brain, in virtue of which the journal has become the organ of the Society. The present Editorial Committee have resigned their functions and the Council of the Society, into whose hands the general direction of the work has passed, have appointed Dr. A. DeWatteville editor. The character of the journal will continue essentially the same as at present. - The publishers undertake the whole financial responsibility of the journal, which will henceforth be regularly sent, free of charge, to every member of the society. Dr. De Watteville asks your assistance and co-operation, to enable him to maintain for the journal, now representative of the scientific activity of the Neurological Society, the high reputation it has already acquired both at home and abroad. Macmillan & Co., 29 & 30, Bedford street, Covent Garden, London, are still the publishers. We heartily wish Brain the hearty support and prosperous career its high character as a representative neurological journal certainly merits. Under Drs. Bucknill, Buzzard, Crichton-Browne, Ferrier, Hughlings Jackson, J. Ross and DeWatteville, it has reached a bigher plane of scientific eminence and neurological utility than any other journal of its kind in the English language, and under the auspices of the London Neurological Society and DeWatteville's high attainments and literary ability it must continue a shining light in the bigher realm of medical literature. RULES OF THE NEUROLOGICAL SOCIETY OF LONDON, WITH LIST OF OFFICE BEARERS AND MEMBERS, 1887: A sample of brevity, worthy of imitation by medical societies, is before us. The officers for 1887 are as follows: Reviews, Book Notices, &c. 467 President, Samuel Wilks, M. D.; Vice-Presidents, Sir James Crichton- Browne, M, D., J. Hutchinson, M. D.; Council, A. Charlton Bastian, M, D., A. Broadbent, M D., T. Buzzard, M. D., D. Ferrier, M. D., T. Hughlings Jackson, M. D., G. J. Romanes, M. D., G. H. Savage, M.D, D. Black Tuke, M. D., A. E. Schafer, M. D., J, Sully, M. A.; Treasurer, J. S. Bristowe, M. D.; Secretaries, A. Hughes Bennett, M. D., A. de Watteville, M. D. The objects of this society are set forth in the two following sections: SECTION 2. The objects of the Society shall be to promote the advance of Neurology and to facilitate intercourse among those who cultivate it, whether from a Psychological, Physiological, Anatomical, or Pathological point of view. SECTION 4. Any one engaged in researches bearing on Neurology, or manifesting interest in such researches, shall be eligible for the Ordinary Membership. CLASSIFICATION OF MENTAL DISEASES: Presented in paper read at the meeting of The Association of Superintendents, at Detroit, June 14th, 1887, by H. P. Stearns: A-SYMPTOMALOGICAL. 1. Melancholia; 2. Mania; 3. Folie Circu- laire; 4. Dementia; 5. Primary Delusional Insanity. B.-A ETIOLOGICAL. 1. Epochal (Physiological): Insanity of Puberty; Climacteric Insanity; Senile Insanity. 2. Sympatheti: (Sexual): Puerperal Insanity; Masturbatic Insanity; Ovarian Insanity. 3. Toxic: Alcoholic Insanity; Syphilitic Insanity. 4. Neuropathic: Epileptic Insanity; Hys- terical Insanity; Choreic Insanity. 5. Pathological: General Paralysis; Insanity from Coarse Brain Disease ; Traumatic Insanity; Acute Delirium (Typhomania). 6. Other Less Frequent Genera and Species : Phthisical In- sanity; Rheumatic Insanity; Gouty Insanity ; Pellagrous Insanity; Post Febrile Insanity. A Daily EDITION. During the six days' session of the Ninth Interna- tional Medical Congress The Medical Register, of Philadelphia, will be issued daily. It will be full size, and will contain a complete report of the General Session and all of the Sections. It will at once be seen that tbis will offer to those who cannot attend the congress a chance to have a full report of the proceedings daily. This edition will be furnished for 50 cents for the six days, postage prepaid, to any address, or anyone sub- scribing to The Medical Register for one year ($3.00 in advance), will re- ceive the daily edition free. Address all orders to THE MEDICAL REGISTER CO., 1519 Walnut Street, Philadelpbia, Pa. PROF. HUNTER MCGUIRE, of Richmond, Virginia, wlio this year deliv- ered the annual oration on “ The Progress and Development of Medical Science," before the Alumni Association of the Jefferson Medical College, April 4, 1887, is considerably wide of the mark in attributing to Brown- Seguard the discovery of cerebral localization. Aside from this, the ad- dress is an eniertaining and scholarly retrospect of the brilliant history of old Jefferson. 468 Reviews, Book Notices, &c. REMOVAL OF SEBACEOUS CYSTS FROM THE SCALP BY GALVANO- PUNCTURE. By Frank R. Fry, A. M., M. D. Reprint from The St. Louis Courier of Medicine. The author explains his method of removing fifteen such cysts from the heads of two patients. The point be makes is that better success is obtained with the positive needle, either alone or in combi. nation with the negative, than with the negative needle alone. He does not claim that the destruction is accomplished by electrolysis alone, but by a suppurative process that results in the complete destruction of the cyst- well. ELEMENTARY MICROSCOPICAL TECHNOLOGY. Part 1. The Technical History of a Slide. By Dr. Frank L. Jones. This work is before us and we are gratified to find a work so thorough and creditable by our accom- plished microscopical sıvant and talented journalist confrere. The book is issued by the Medical and Surgical Journal Company and ought to meet with a large sale, if it sells on its practical merits. Two UNIQUE CASES OF INSANITY: Possibly EPILEPTIC.-Reprint from The American Journal of Insanity, January, 1887. By Theo. W. Fisher, M. D., Superintendent of The Boston Lunatic Hospital. Beyond their unique character, these cases are a suggestive and instructive study, both from the epileptic and psychical stand-points. They will be valuable to refer to by those studying these subjects. Mason's COMPEND OF ELECTRICITY, price, $1.00. P. Blakiston, Son & Co., successors to Lindsay & Blakiston, 1012 Walrut street, Philadelphia. It is worth more than the subscription price as a practical guide to the therapeutical employment of electricity. NOISES IN THE HEAD AND EARs. By Robert Barclay, A. M., M, D. Read at the annual meeting of the Mississippi Valley Medical Society, at Quincy, M., July 13, 1886. Reprinted from the Weekly Medical Review, St. Louis, August 28, 1886. ANOTHER VALUABLE CONTRIBUTION TO THE PATHOLOGY OF THE CER- EBELLUM has been made by E. C. Seguin, M. D., in a paper read before the New York Neurological Society, February 20, 1887. Following are bis diagnostic conclusions: The symptoms presented by these four cases varied somewhat in their grouping, yet were singularly harmonious. Let 118 consider them in order of constancy : 1. Lesion of the optic nerve, either as choked disks or secondary atro- phy, was present in all the cases. This is in striking contrast to my ex- perience with strictly cerebral (hemisphere) tumors, in which the optic nerves were affected only three times in ten cases. There is reason to be- lieve, furthermore, that choked disk is usually an early symptom of tumor of the cerebellum. 2. Headache was present in all cases. It was distinctly occipital and paroxysmal in cases II., III., and IV. Occipito-frontal, and never severe, in case I. In case IV., the pain was at first for several weeks a neuralgia of the occipitalis major nerve on the same side as the tumor. This is rather ditficult of explanation. Reviews, Book Notices, &c. 469 3. Vomiting. This was a very early symptom in cases II., III., and IV. It was a causeless vomiting, occurring almost always in the early morning; and was usually accompanied by occipital, or occipito-cervical pain. India gestion did not occur. I have recently seen two other cases (in cbildren) presenting the unmistakable symptom-grouping of cerebellar tumor, in which inexplicable vomiting was the only symptom (eyes not then exam. ined) for months. One little fellow had had his stomach washed out for supposed gastr'c catarrh for a period of at least two months, even after some distinctly cerebral symptoms had appeared. In case I. vomiting was never (?) present. 4. The walk was affected in all cases. In cases I. and IV., there was cerebellar titubation. This was typical in case I. In case II, there was simply staggering, with tendency towards the left. In case III. a diffused staggering, somewbat like that of alcoholic intoxication, was ob- served. It is to be observed that case I. is the only one in which the lesion destructively affected the vermis in its caudo-ventral parts. In the otber cases the vermis was more or less compressed. Consequently case I. goes to support Nothnagel's law that cerebellar titubation is character. istic of a considerable destructive lesion of the vermis. 5. Motor Eye Symptom.-In case I. there were various types of nystag. mus. In case II. there was conjugate deviation (without vision) to tbe left; that is, away from the lesion, contrary to what occurs in hemisphere lesions. 6. Paralysis.-Slight, but distinct right-sided paresis (not of face or tongue) was present in case II. The other cases presented only a diffused loss of power. 7. Ataria, strictly speaking, was present only in case II., affecting the right upper extremity. This, as well as the paresis, was on the same side as the cerebellar tumor. 8. Anæsthesia was found only in case IV. It was demonstrable on the left side of the face and on left fingers (opposite the tumor). 9. True vertigo. Subjective or static vertigo was not present in any case. It has always seemed to me that this was not a strictly cerebellar symptom, but one indicative of irritation, direct or indirect, of the acoustic nerves. Probably static vertigo also occurs from disturbances in the hem- ispheric circulation, as in galvanization of the cervical sympathetic. It might be added that, in the two living cases of cerebellar tumor above re- ferred to, vertigo is absent. 10. The bulbar symptoms shown at the close of life in case I. were evidently due to malnutrition (ischæmia) of the medulla by reason of the arteritis obliterans which affected the vertebral and basilar arteries and their branches. 11. Psychic symptoms were wanting in all cases. Researches into the Etiology of Dengue. By J. W. McLaughlin, M. D., of Austin, Texas. Read in the Section on Practical Medicine at the Thirty-Seventh Annual Meeting of the American Medical Association, St. Louis, May, 1886. Publications du Progrès Médical. Paris, 14 Rue des Carmes. Berbez 470 Reviews, Book Notices, &c. (P.) Hystérie et traumatisme. Paralysies, Contractures, Ortbralgies, Hys- téro-traumatiques. Volume in Svo de 127 pages. Prix 3.50. A Case of Injury from a Strong Electric Current By Harold N. Moyer, M. D., Assistant to tbe Chair for Diseases of the Nervous Systen, and Lecturer on Physiology, Rush Medical College. Nomenclature in Psychiatry. Monomania or Oligomania, Which? Paranoia, Wbat? By Ralph L. Parsons, M. D., Greemont-on-the-Hudson, near Sing Sing, New York. Leçons sur les Maladies du Système Nerveux, faites a la Salpêtrière. Par Professeur J. M. Charcot, M. D., etc. Tome troisième. Paris. Pages 377. Some Considerations Concerning Cancer of the Uterus, Especially its Palliative Treatment in its Later Stages. By Andrew F. Currier, M. D. Report of the Commission appointed by the Governor of Missouri to Locate and Prepare Plans for a Third Hospital for the Insane. Glycosuria and Melancholia. By C. H. Hughes, M. D., St. Louis.- Reprint from Weekly Medical Review, Oct. 20, 1883. Follicular Amygdalitis. By A. Jacobi, M. D., President of the New York Academy of Medicine. Genius and Mental Disease. By William G. Stevenson, M. D., Pough. keepsie, New York. Report of the Commissioners for the Care of the Indigent Insane of Nevada, 1885–86. THE ALIENIST NEUROLOGIST, Vol. VIII. | ST. LOUIS, OCTOBER, 1887. | No. 4. ORIGINAL CONTRIBUTIONS. Remarks on the Organization and Man- agement of Hospitals and Asylums for the Insane.* UNDER SINGLE AND DUAL HEADS. TOLPH By H. A. BUTTOLPH, M. D., LL. D., Short Hill, N. J. M R. PRESIDENT AND GENTLEMEN OF THE ASSOCIATION : W I regard it alike as a matter of expediency and of duty, at this time, to call the attention of members to the subject of “the Organization of Hospitals and Asy- lums for the Insane,” which is referred to in two of the “Propositions,” adopted by the Association in 1853, and reaffirmed with great unanimity, on several occasions since that time. The language on the subject, as expressed in Secs. 3rd and 4th of Propositions, is as follows: “3. The board of trustees (or managers) of every institution should appoint the physician, and on his nom- ination, and not otherwise, the assistant-physicians, the steward and matron. They should, as a board, or by committee, visit and examine every part of the institution • Read before the Association of Medical Superintendents of American Institutions for the Insane, at Detroit, Michigan, June 15th, 1837. [471 ] 472 H. A. Buttolph. at frequent and stated intervals (not less than semi- monthly), and at such other times as they may deem expedient; and exercise so careful a supervision of the expenditures and general operations of the hospital, as to give to the community a proper degree of confidence in the correctness of its management. “4. The physician should be the superintendent and chief executive officer of the establishment. Besides be- ing a well-educated physician, he should possess the mental, physical and social qualities to fit him for the post. He should serve during good behavior, reside on or very near the premises, and his compensation should be so liberal as to enable him to devote his whole time and energies to the welfare of the hospital. He should nominate to the board suitable persons to act as assist- ant-physicians, steward and matron. He should have the entire control of the medical, moral and dietetic treatment of the patients; the unreserved power of ap- pointment and discharge of all persons engaged in their care, and should exercise a general supervision and di- rection of every department of the institution.” The general and special principles upon which these Propositions are based are, that to be successful, there must be unity in the exercise of administrative power in the affairs of a hospital for the insane, to the same extent and for similar reasons, for example, as on the deck of a ship, where two captains would be an unheard of anomaly. Second, the head must not only be single for the sake of unity in administration, but the man must be a physi- cian, because everything relating to the control, care and treatment of insane patients has directly, or indirectly, a medical bearing, and questions can only be properly de- termined and carried out by a medical man, well adapted to and trained for the service. To be more specific, I would include attention from the physician, not only to the med- ical treatment in general, but also to many particulars- as to the proper extent of freedom of patients at all hours of day and night-to the association with others, whether Hospitals and Asylums for the Insane. 4737 . sane or insane—the adaptation of dress for health, for general good appearance; also such as may be required, in view of previous habits, to promote the self-respect, or even in a degree, to gratify the vanity of individuals, when the stimulus of such a feeling might divert atten- tion from morbid action and feeling, which constitutes the essence of disease, against which we are contending. Next, proper attention to labor and rest as a means of physical amendment-attention to the standard of clean- liness connected with bathing and other means—mental and bodily occupation-also aviusements in the use of sedentary or house games-exercise in walking, riding, dancing, etc., with the addition of more active field sports that may be adapted to the health and mental state of indi- vidual patients. In regard to the latter, it should be remem- bered that while foot and base ball are pleasant, healthful and safe exercises for some, they may be highly injurious or quite dangerous, on account of their violence, to others. Lastly, and perhaps chief of all in importance, are nutrition of body and rest in sleep, of brain, body and mind. In these, of course, are included careful attention, to the quality, variety and quantity of food and drink, supplied to the household in general, but especially, in regard to adaptation of both to the needs of the sick, and to those who have delusions leading to abstinence or to perversion of appetite in regard to quality or quantity of either, or both. Of rest in sleep, it may be said that it is equal in im- portance, as a means of recuperating brain and mental power, to the effect of nutrition in rallying bodily strength and vigor. It is also of great consequence to secure it, as far as possible, by a resort to simplest means and agencies, including mild exercise, quiet surroundings, the recumbent posture, etc., without frequent resort to, and habitual use of large doses of hypnotic remedies. Thus it is seen how delicate are the duties and how great the responsibilities of the superintendent of a large hospital for the insane; also how impossible it would be .474 · H. A. Buttolph. to have them successfully carried out on any other princi- ples of organization than those named by the association, in the Propositions quoted. In hospitals for the insane, the institution often becomes for a series of years, or for life, the only home of large numbers or proportions of their inmates, and hence, in administration, methods should conform to their convenience and necessities in all of the particulars mentioned. The chief physician should be chosen on account of his adaptation for performing the peculiar service required, and should be known and regarded alike by the inmates, the employes and the public, as the literal and profes- sional head of the establishment. Holding such relations to an institution for a series of years, the ways and wants, even the morbid fancies and fears of individuals become as familiar to him as do the personal peculiarities of families of children to their parents. Thus it may be said or assumed, that when a medical superintendent of an institution is aided by intelligent and loyal subordinate officers, and by well-chosen and trained employes, to fill the various sub-departments, it would seem difficult to devise or even imagine a system of administra- tion and care, better, adapted for treating large numbers of insane patients with efficiency, economy and success. It may be added in regard to the foregoing description of the line of duty of a medical superintendent, that in carrying out the system of general supervision, he need not spend a large portion of time in the personal oversight of details, but after conferring with subordinate officers or employes to the extent required on any given occasion, not infre- quently consulting with them in regard to best ways and means for accomplishing the end in view, the final decision is made by him, when assigning to each the special duty to be performed, he dismisses the subject from his attention. Thus is settled, perhaps, in a few minutes, the princi- ples and plan of action in regard to matters that may take a day, a week or a month to execute. Such and similar occasions for judgment and decision Hospitals and Asylumns for the Insane. 475 by the superintendent of an institution with any number of inmates from one thousand down to one hundred, are occurring every hour and turn of a day, many of which, however, are so plain to a well-trained mind in regard to practical detail, as not to require more than a moment's thought for their proper decision. Here it may be added that the advantage to the su- perintendent, of having a variety of thoughts, feelings and interests in the pursuits of each day, can scarcely be es- timated, as without this he would frequently need days and weeks of additional absence from home and from duty, for purposes of recuperation. This indeed was my own experience, as, during the forty-two years of service as assistant-physician and as superintendent, I seldom went from home for other than business purposes, yet I enjoyed almost unbroken health during the entire period. Cut off from this resource, however, and restricted entirely to the routine and details of professional work, within the house, and without the mental change and bodily exercise, connected with some attention to outside affairs, but few indeed of the super- intendents of this or of any country, would maintain vigor- ous health as they have done and now do, for periods of service varying from ten to twenty, thirty and forty years. I will now state what is very well known, that nearly all of the one hundred or more public institutions of this country, State and corporate, are organized and are working well on this plan. This has been the practice in New Jersey from the date of the opening of the first institution, near Trenton, in 1848, and with which I was connected, as superintendent, for more than twenty-nine years; also, in the second at Morristown, from its opening in 1876, until the close of the year 1884. Dr. BUTTOLPH'S RESIGNATION AND WITHDRAWAL FROM THE ASYLUM, IN ACCORDANCE WITH REQUEST OF MANAGERS. At the annual meeting of managers for that year, 1884, on November 14th, without a word of censure or 476 H. A. Buttolph. complaint, to justify their action; of apology, for the rude method adopted, or even of explanation of their course, and after I had given more than thirty-seven years of faithful service to the State, in the two institutions named—I was, by resolution of the board, requested to resign my position as superintendent, and vacate my place of residence in the house, on the ist of January, 1885, or in about six weeks, which was done. From an article in the Newark Daily Advertiser, pub- lished the day after the meeting, and written or inspired by one of the managers, as was understood, I gained my first impression of the object of the movement, which article was, in part, as follows: The annual meeting of the board of managers of the Morris Plains Asylum was held on Thursday, all the members being present except the president, George A. Halsey. Important action was taken looking to the thorough reorganization of the general management of the asy- lum. The duties devolving upon the superintendent and his two assistants have been too great. Steps were taken to have a hospital staff of five physicians appointed, one of which shall be the medical officer in charge of the interior of the asylum. Then it is proposed to have a business manager, who shall take charge of the farm, of the buildings and the business department, and purchase the supplies. He shall act independently of the medical officer, and be responsible only tients in the institution. It is intended to make the medical depart- ment of this, one of finest institutions in the country, equal to any in the world. The executive medical department will be separated en- tirely from the business department. Elsewhere, as with a flourish of trumpets, it was stated that “the managers proposed to place the medical department under the care of a competent alienist of ad- vanced views on insanity, and of national reputation." At the following session of the Legislature a special act was passed, at the urgent request of the managers, authorizing the reorganization proposed. forming to the law for appointing a dual head, were adopted, and it is presumed that great efforts were made to secure the services of an officer to be known as Hospitals and Asylums for the Insane. 477 “ Medical Director,", in keeping with the high standard proposed in advance. As this was not accomplished, however, my first and second assistants have, in turn, held this office. The first appointed resigned at the ex- piration of one year, with the understanding on the part of the public, that it was impossible for him to hold the office longer without greatly compromising his self- respect. Of the bad working of the dual system, as carried out in 1885, I have already given illustrations, in an open letter, in pamphlet form, addressed to the managers. Since then, according to reliable outside accounts, matters have gone, and are going, from bad to worse, so far as the administration of the business man, or warden, is concerned; and particularly in his relations with the medical staff, whose claims for due recognition he ignores, sustained, of course, by the managers as a body, in his in- terpretation of the law and by-laws defining his rights and duties under them. As they were apparently intended to make him, to a very large extent, the governing head of the establishment, this is natural, though of course, it shows, the impracticability of the dual system, in an asylum for the insane. Indeed, to escape from the increasing em- barrassment, not to say disgust, of continued service under the humiliating circumstances now existing in the institution, that is, the arrogant claims of the warden for superiority of power and privilege over the medical staff, at every turn of the day, one of the most experienced and desirable medical assistants, has recently resigned his place in the institution, and taken service elsewhere, while others, for similar reasons, may soon follow his example. The sentiment of the managers appears to be, that the medical service of a hospital for the insane should conform substantially, to that in use in hospitals for sick and surgical cases, where the dual system may be carried out more successfully. A brief comparison, however, of the organization and management of the latter will show this to be impracticable. 478 H. A. Buttolph. Persons enter the latter, usually for short periods, to receive treatment for physical ailments only. A system with this object can be fully carried out in an establishment having the requisite number of young medical men and of advanced students, as resident offi- cers, acting under the advice and control of a staff of distinguished visiting physicians and surgeons, and aided by skilled employes in the several departments. While this relieves the necessity for the prolonged presence of the visiting officers, the main object of whose calls was to diagnose and prescribe for obscure cases, or to per- form difficult or dangerous operations, etc., etc., the business man, or warden of such an establishment, aided by clerks, can readily make the necessary purchases of supplies, keep the accounts, take care of and distribute stores, under the general direction of a responsible board of trustees or governors as they are sometimes called, and for attending to its financial affairs. It may perhaps be inferred—that knowledge, arising from observation or experience, or both, of some of the gentlemen, in regard to the easy working of such a system of management in a hospital for the sick, but with far less knowledge of what is required of the superintendent and his assistants in hospitals for the insane—may have led them to pro- pose the dual system, with its multiplied woes in the latter. Of course they could not, or did not appreciate the practical impossibility of applying a system devised for and well adapted to the relief of sick but sane peo- ple, to another class who were equally sick but also insane, and in consequence, requiring an entirely different system of treatment, care and control, on this account. With the best possible selection of a business man, even, for a small institution, to exercise controlling influence in regard to affairs relating to the insane, and which should be influenced or fully controlled by medical men, things. might be bad indeed from simple ignorance of affairs. relating to them. When it occurs, however, as in this case, that a man with Hospitals and Asylums for the Insane. 479 early dissolute habits, who had little knowledge of business beyond that of a clerk, and who for years had proved himself highly unsatisfactory in performing the duties of steward in the institution, from want of promptness, method, judgment and truth in the management of affairs, and finally, when such a man, by a prolonged system of misrepresentation of the acts of his superior officer, wormed himself into the confidence of the board of man- agers, who, in their hopeless infatuation in regard to his character as a business man, had placed him in chief control • of one of the finest institutions of this country, with a thousand or more inmates and employes to suffer from his radical faults, the nature and extent of the calamity can only be faintly imagined, but not fully and truthfully described. While I make no specific charges or insinuations against his present methods of business in the absence of definite knowledge, it is, of course, well known to the managers that under the old regime, and as a measure of increased safety, the by-laws governing the action of the steward required that, “No order of his shall be paid by the treasurer, unless it is accompanied by the bill of items for which the order was given, and unless the bill or order was countersigned, endorsed or approved by the superintendent.” Under the present system, beyond the comparison made between vouchers and goods when re- ceived, which was always done before by the steward or by a person delegated by him for the purpose, there is absolutely no knowledge, check, or even inquiry in regard to his business transactions, until the paid bills are pre- sented to the auditing committee for examination, weeks, and often months after the goods were paid for or pur- chased, so long indeed, that no proper knowledge of cur- rent prices at the time, nor of discounts that should be made, can be known. Nor can men acting as an auditing committee, however well qualified they may be for dis- charging the particular duty assigned them, seeing that bills are associated with proper vouchers, correctly footed, etc.; yet, that no other officer than the warden, either in Hospitals and Asylums for the Insane. 481 Recurring again to the original thought and action of the managers, it may be safely assumed that the founda- tion of their first mistake or blunder was, that some of the medical members of the board believed, from their observation or experience in the practice of general hos- pitals for the sick, that its methods, with certain modifi- cations, could be made available in the conduct and management of hospitals and asylums for the insane as well. This was so radical an error as to be explained only by the want of proper judgment of the necessary dif- ferences in the arrangement and methods suited to the treat- ment of sane and insane patients. As these points have been previously discussed at considerable length I will not allude to them now, except so far as relates to the dual headship to be created under the reorganization proposed. An example of this had existed in a neighboring county asylum for the insane, under the conduct of a warden and visiting physician at first, but subsequently, a resident physician was appointed. For a time this method (to outside parties) seemed to go on successfully, though in the end, this prototype of their system proved a most wretched and disastrous failure. As the business man or warden, in that as in the State asylum, claimed and en- joyed, according to his estimate, great superiority in responsibility and trust, over the physician, and was sup- ported in his interpretation of the regulations by his superiors, so the physician had small chance of a respectable recognition in any quarter. To make the story brief, however, it may suffice to say, that differences of views and of claims in regard to the vexed questions between them, soon engendered feel- ings of jealousy and envy, then of passion and strife, ending in repeated quarrels, and finally, an early abandonment of the system, if such it might be called. At an early day after, the county authorities “reorganized” their system, by appointing Dr. L. S. Hinkley as medical, superintendent and chief officer of the institution, with provision also for assistant-physicians, steward and 482 H. A. Buttolph. matron. Under this arrangement, and, in a new building, the institution rapidly improved in its character and standing, and is now one, if not the best-managed county asylums, of which I have definite knowledge. As an almost perfect parallel in organization and bad- working of the first edition of that, I will mention that for Cook County, Illinois; the latter, however, having the ad- vantage or disadvantage of triple rather than dual heads. My information in regard to the latter was obtained from a special report of an investigation of its management, made by the State Commissioners of Public Charities, Frederick A. Wines, Secretary. It may be added that it was made at the request of the governor of the State, and in a thorough and intelligent manner. The commis- sioners state that the practical difficulties in the working of the institution arose from faulty organization, resulting in the want of unity in administrative power. As a rem- edy for this they recommend that the administrative power be concentrated in a medical head, giving as reasons why a medical man should be at the head rather than a business man, that “in a medical institution, every question to be decided has a medical bearing, which a non-medi- ical man may not perceive, and that the final word on every subject, should be spoken by the physician, from which there should be no appeal.” NOTE.—Since the foregoing paper was prepared, information is re- ceived from an article entitled, “ Remarks on Some European Asylums," by Fredrich Peterson, M. D., of the Hudson River State Hospital for the Insane, at Poughkeepsie, New York, and published in the American Jour- nal of Insanity. Dr. Peterson, after describing his observations in regard to various English asylums, states that, "he was told that only three or four asylums now existed in Great Britain, where the insatisfactory system of having two beads is now in vogue.” Again, in speaking of the management of a single institution, whose name is given, "That the administration is of an obsolete character-that there is a steward in charge of the business of the institution, while a physician is the medical head of each of the two divisions for men and women.” Hypertrichosis, due to General Disease of the Nervous System.* WITH AN ILLUSTRATIVE CASE. By A. H. OHMANN-DUMESNIL, A. M., M. D., of St. Louis. IT is now a well-established fact that a large number I of cases of skin disease is seen whose cause can be traced to some organic or functional disorder of the nerv- ous system. In fact, they seem to be rather the local manifestations of some neurotic disorder than diseases per se, and constitute symptoms whose underlying causes are sometimes far removed from the integument itself. This fact is so well known that it would be a work of super- erogation to attempt to enumerate the dermal affections of nervous origin. It is also well known that certain diseases affecting or changes occurring in the liair are frequently due to neu- rotic influence, such as cases of alopecia areata. That the hair will suddenly blanch, under intense nervous excitement, the authenticated cases on record prove be- yond the possibility of all doubt. It is a matter of observation, moreover, that, in certain cases of chronic insanity in women, there is developed a well-marked tend- ency on the part of the hair of the face and forehead to grow, and to grow profusely, so much so that the patients become bearded. What the reason can be, which underlies this strange perversion of growth, has not yet been satis- factorily determined. A careful consideration of the above is what led the writer to formulate an opinion, which subsequent results proved to be correct, in the case about to be related. The case is one to which no precedent has been found • Read before the Mississippi Valley Medical Association, July 15th, 1887. [483] 484 A. H. Ohmann-Dumesnil. after a careful search of dermatological literature, of a rather limited extent it is true, although not incomplete to any marked degree. Case.—About a year and a half ago, Dr. I. N. Love, of St. Louis, consulted me in regard to the condition of the face of one of his patients, he having accompanied the lady to my office. Upon inquiry, I learned that Mrs. X- , aged twenty-eight, had possessed a remarkably clear complexion and fine skin. She has brown hair, dark brown eyes, and stated that previously her skin was un- usually fair and that she was markedly free from any excessive hair growth, Dr. Love corroborating this state- ment. At the time of examination, the skin was dark, yellowish and somewhat roughened, although to a slight degree only. The sides of the forehead, the sides of the face and the upper lip, principally, were the seat of a per- ceptible growth of hair, whilst the lanugo hair of the whole face appeared to be somewhat more marked than normal. This growth had developed in a comparatively short time. The hairs were dark brown in color, fine and silky in tex- ture, and varied in length from one-quarter to one-half of an inch. Although the growth could not be called thick, the hairs were situated quite close to each other, and the margin of the hairy portion of the skin was pretty sharply defined against the other. This growth proved to be quite a source of distress to the patient, who had formerly ex- hibited a certain amount of pardonable pride in the purity of her complexion. She desired to be relieved of her trouble by some local means, having learned of some of the methods employed by dermatologists for the extir- pation of hairs. As is my general custom, I proceeded to interrogate my patient as to the details of her general condition, habits, etc., before giving an opinion. My interrogatories elicited the fact that there existed considerable nervous trouble. It had been pronounced spinal irritation by some, and neurasthenia by others. It appeared to be a malnutrition of the entire nervous system. The food that Hypertrichosis. 485 should have been appropriated by the nervous tissue seemed to be diverted and converted into adipose tissue. Whilst the patient gained in weight, she lost strength and nerve force, and, in short, her nervous system was being subjected to a slow process of general starvation. Having satisfactorily settled this point, the opinion I gave was that local treatment of the hypertrichosis would be worse than useless, that all that was necessary was to administer assimilable nerve food, and, in all probability, as the nervous system approached more nearly to a normal standard, the offending hairs would diminish in number and eventually completely disappear at about the same time that her nervous affection did. Under the management of Dr. Love, the normal func- tions of the nervous system were gradually restored, and in January, 1887, I was gratified to learn that the patient was restored to a state of complete health. In addition to this the abnormal growth of hair had gradually disap- peared. Upon examination, not long since, her complex- ion was found to be as good as it had ever been, no vestiges of the hypertrichosis remaining, thus confirming the prognosis that had been made. She also looked and felt better, having lost a considerable amount of the adi- pose which had accumulated so rapidly during her nervous trouble. Some interesting questions naturally suggest them- selves in connection with this case. Whilst it is certainly not sound logic to deduce general conclusions from iso- lated cases or from a single observed fact, it still seems reasonable to utilize such a fact for this purpose, when the relations of cause and effect appear as plainly defined as they do in the instance given above. One question which suggests itself is: Why was the face the particular seat of this growth of hair in preference to other portions of the body? It is a difficult matter to answer this ques- tion, and although it may be suggested that this is prob- bly due to the fact that the face being so much exposed is subject to greater stimulation, and that stimulation or 1 486 A. H. Ohmann-Dumesnil. irritation will, in some cases, produce a perceptible growth of hair where only lanugo existed previously, as has been observed, for instance, at a site where a blistering plaster had been previously applied, we must not forget that in this case the hands, at least, were as much exposed to this stimulation as the face, and still did not exhibit any sign of hypertrichosis. We are also taught that hypertrichosis follows injuries to nerves, but remains only to disappear as soon as the nerves are restored ad integram. There might exist a lo- cal perversion of nutrition, causing an increased growth in quantity without any perceptible decrease in the quality of the hair. Another interesting question is: Why was there an in- creased growth in the hair of the face and not a dimin- ished growth in the hair of the head? In other words, would it not appear more probable that a starvation of the nerve tissues should entail alopecia rather than hyper- trichosis ? Although this might be expected the facts in the case point to the contrary condition. There seems to be but one explanation possible in this case. It is known that the hairs are low in the scale of vitality, and very little pabulum is necessary to supply all their needs. A greater quantity than necessity actually demands will often be taken up and utilized. This is what, in all probability, took place. By some means or other, there was diverted to the face a certain quantity of food refused by the nerve tissues, and this was made use of by the epidermal tissues, thus increasing the growth of hair, the quantity of pigment and the thickness of the epidermis. The object of this short paper has been to direct atten- tion to a condition which may not be an uncommon one. It is of some little importance, insomuch that in cases where the condition described exists, it will obviate the necessity of resorting to painful local measures, whose value can be nothing but. doubtful when the fons et origo of the trouble is left untreated. It relegates the treatment of such cases to the domain of the neurologist, and by Hypertrichosis. 487 being promptly and thoroughly managed, so as to place the nervous system at par once more, may save many disappointments and an unnecessary expenditure of time and patience. It is even preferable to wait until the nerv- ous system is once more normal, with the certainty that the hypertrichosis will persist. For, in such a case, the influence of the nerve disturbance in the production of the hairy growth can be estimated, a less number of hairs may have to be removed, and, without doubt, the patient will be in a much better condition to submit to the neces- sary manipulations to ensure a radical destruction of the hair papillæ. Insanity or Mental Derangement.* REMARKS ON ITS NATURE, CAUSES, CLASSIFICATION, PATHOLOGY AND SYMPTOMATIC FORMS. By H. A. BUTTOLPH, M. D., LL. D., Short Hills, N. J. MENTLEMEN OF THE ASSOCIATION: The phrase U "Mental Derangement," instead of Mental Disease, as frequently used by authors and teachers of this period, is preferred from the obvious fact that the mind never was and never can be properly considered as diseased, but only its physical organ, the brain, on which it depends for its manifestation in this life. To establish this view of the subject beyond reasonable doubt or ques- tion, it is only necessary to state, that, if the mind, con- sidered by all as immortal, is subject to disease, it must, also, be liable to decline and death, a view quite inadmis- sible. On the other hand, while for the want of a better term, we hold to the existence of a functional relation, between the brain and the faculties of the mind; we are obliged to admit that we are wholly unable to compre- hend and explain the mode of action of the former, by which thought and feeling are manifested; in other words, that at a point near the beginning of the inquiry, we have reached the very confines of human observation and perception, of the ways and methods of the Creator, in evolving mind through the agency of organized mat- ter. In point of fact this view has not always been taken by physiologists and theologists of former ages. The lat- ter, in particular, often regarded the mind as an independ- ent entity, too ethereal and spiritual to be associated with gross matter in any form. * Presidential Aldress, read before the Association of Medical Superintendents of American Instituiioas for the Insane, at Detrit, Michigan, June lith, 1837. [ 488 ] Insanity or Mental Derangement. : 489 In more modern times, however, men of all shades of philosophical and theological opinion have, tacitly, if not always fully and plainly, admitted their belief of such relation. For a considerable period of time the brain was re- garded as a single and homogeneous organ, and the mind, in its various powers, as one and indivisible. While the recognition of the connection between matter and mind, in this life, was a long step in advance, yet, in the form in which it was held, as above stated, it was impossible to account for the phenomena that occurred, either in the physiology of the former or philosophy of the latter. The universal observation and belief was, and is, how- ever, that independent of any and every circumstance and surrounding of individuals, there has existed at all periods and among all peoples, a wide natural difference, in the strength and activity of the mental faculties of the race of man. The inference, hence, arises, that as the mind is wholly dependent upon the brain, for its mani- festation in this life, it must, of necessity, receive from it all modifications that appear, in the relative strength or weakness of the faculties of individuals. To account for such diversities, various but ineffectual methods have been resorted to, the chief of these being, that it was to be accomplished by the radiation of the brain power, in the direction, and in aid of the most highly developed faculties—an explanation in the highest degree unphilosophical, not to say absurd-it be- ing in direct opposition to the universal axiom of physi- ology, that “every organ in the animal economy performs a separate function, and vice versa, that every separate function is executed by a distinct and independent organ.” The truth of these propositions, in regard to the brain and nervous system, was established many years ago, by an overwhelming amount of evidence in regard to the former, by Dr. Gall, and of the latter, by Mr. Charles Bell. After the discovery was made by Gall, that the faculties of the different cerebral organs, could be 490 H. A. Buttolph. ascertained during life, by comparing the development of individual parts of the brain with the manifestation of in- dividual mental powers, he proceeded to demonstrate by, incontrovertible deductions, from facts, observations and analogies, that the brain, although apparently existing as a unit, every part of which was concerned in fulfilling a single function, consisted, in reality, of an aggregate of. parts, each strongly resembling the others in structure and appearance, yet being essentially distinct, and en- dowed with a different function, and that the obstacle which had so long retarded the discovery of this fact, arose chiefly from preceding inquirers having grouped a variety of parts as one, and looked for functions common to them all, a research in which it was impossible to succeed. In precise accordance with this philosophical proced- ure by Dr. Gall, Bell, in his first publication, wisely pre- paring the way for the unprejudiced reception of his discoveries, by establishing the same principle as his. guide, and under its influence bringing forward facts, ar- guments and analogies to prove that the nerves of motion and sensation, although running blended together in com- mon sheath, and in appearance, constituting a single nerve, all the fibers of which served for the same purpose, were also, in reality, distinct organs; one serving for sen. sation, and the other for motion, each capable of acting independently of the other, and each separately liable to disease; and showing, by parity of reasoning and with equal success, that most of the difficulties that had pre- vented the earlier discovery of their separate existence and uses, had arisen from blindness to the principle of a single organ being able to execute only a single function, and the having constantly confounded together as single, what more accurate observation proved was double, alike in structure and in function. The analogies between the discoveries of these emi- nent men go even farther than this, and afford additional presumptive evidence of the accuracy of both. Many Insanity or Mental Derangement. . 491 circumstances, in health and disease, had seemed to render it more than probable that the apparently homogeneous bundles of nerves were of a compound nature, each ele- mentary part having a separate use; and the suspicion had accordingly been entertained by reflecting men, before its truth had been placed beyond the reach of contradiction by Mr. Bell. In like manner, similar reasons had oc- curred to induce a general belief before Gall appeared to demonstrate the fact, that the central mass was an aggre- gation of many independent parts, each having its own separate use. In accordance with this law of distinct func- tion, it is observed that every nerve possesses a constitu- tion, adapted with an express relation to the object which vt is destined to fulfill. The optic nerve representing one of the five special senses, and therefore, being intimately associated with the mental functions of the brain, is con- stituted to perceive light, and light alone; the acoustic, to take cognizance of atmospheric vibrations and these alone; the gustatory, nerves, of tastes cnly; the sensitive neives, of sensations, and the muscular nerves to direct voluntary motion; but no single nerve can serve for any other of these purposes than the one which has been assigned to it. The optic nerve, if placed in the ear, wouid remain insensible to sound; and the acoustic, ram- ified on the eye, would remain insensible to light; and the same in regard to all others having specific offices to fulfill, and special endowments to qualify them for the purpose. A multitude of well-known facts have thus forced the .conviction upon most physiologists, that the brain is the organ of the intellectual and moral faculties, and of the various animal appetites; and that none of these can be acted upon, except through the medium of a correspond- ing change in these central organs, just as the eye must always be affected before sight can transmit its impres- sions to and from the mind. But it is noticed that different passions and intellec- tual powers appear in succession, and therefore, each must 492 H. A. Buttolph. have a part of the brain or organ of the mind appropri- ated to its own operations; for, if one organ served for all, then the universal principle remaining the same, all ought to arrive at maturity equally early, which we know not to be the case. Thus the perceptive powers are invariably in full ac- tivity long before the reflective begin to operate, and no rational man would seriously address an infant in the language of abstract reasoning, and accordingly, the art of the teacher consists in adapting his instruction to the expanding powers of the pupil's mind. The same remark applies to the successive appearances of the moral senti- ments and the animal propensities, and particularly, to that very important faculty among the latter, relating to the propagation of the species, and which only becomes active at the age of puberty. Plurality of the organs will alone explain the difficulty, and hence, reason authorizes the belief. Pathology is equally abundant in demonstra- tive proof of the plurality of the cerebral organs, though neither it nor the microscope can be resorted to success- fully for making original discoveries of the mental organs, but only for confirming results of discased action. The phenomena of dreaming, a portion only of the organs and faculties being in an active state, partial idiocy, partial insanity, injuries of the brain which do not affect all of the mental faculties, insanity affecting one or a few fac- ulties, cases of apoplexy followed by loss of memory of names without apparent deficiency in other respects, are all at variance with the unity, and in harmony with the plurality of cerebral organs. Some object to the brain being considered as an aggre- gate of parts performing distinct functions, that this is impossible because there is no visible partition separating them from each other, but the same objection having been erroneously urged against nerves, now demonstrated to be compound, shows how little weight is to be attached to our notion of what ought to be in opposition to what is. There is, in point of fact, a greater similarity between Insanity or Mental Derangement. 493 the different mental functions, than between sensation and motion, and yet we find the nervous fibers performing the latter, inextricably intermixed in apparently a single bun- dle. Again, although long disputed, it was ascertained that the three nerves of the tongue subserve taste, motion and touch; and the difficulty is not greater in regard to the brain, than it is to them or the spinal nerves, for it was inability to distinguish any boundary between their constituent parts that alone prevented their separate func- tions from being sooner demonstrated. It might be use- ful, or at least interesting, did space permit, to discuss, at some length, the modes of investigation employed previous to the time of Gall, and to explain the sources of their failure. But the fact that nothing was accomplished by their employment, and that after the labors of two thousand years the mental functions of the brain remained enveloped in mystery, except so far as revealed by Gall's method, is all that is required to demonstrate their insufficiency. Anatomists have failed in their attempts by dissection, because structure alone does not reveal function, and that if it did, the brain has been almost as little known as the uses it subserves. Metaphysicians have made the attempt in another way, but they have failed to trace the con- nection of the mind with the cerebral organs, because consciousness, from which they drew their inforination, does not even inform us that we have a brain at all, much less what are the number and uses of its parts. Aside from this, it would not in any case reveal more than the operations of our own mind, and nothing, cer- tainly in regard to others, which in the strength of differ- ent faculties, may differ greatly from our own. Hence, reflection on consciousness, as a method of studying the attributes of mind, is, in the highest degree, uncertain and unreliable. Medical men have engaged unsuccessfully in the same inquiry through pathological investigations, because injury or disease of any part of the brain, however small, stirs up morbid sympathies and constitutional disturbance in 494 H. A. Buttolph. proportion to the original irritability of the patient, and not merely in proportion to the local injury; and, besides, the ability to observe what mental faculties suffer from disease of particular cerebral parts, presupposes an ac- quaintance with the number and nature of these parts, or in other words, with the very things we are in quest of. Physiologists have heretofore failed, and I venture to predict, will always fail, and from precisely the same cause, in their efforts to discover the mental functions of the human brain, by the aid of experiments on the brains of the lower animals. On the other hand, it was claimed by Gall and his disciples, that he succeeded, to a great extent, in locating the mental organs of the brain by ob- serving what mental manifestations accompany great en- dowments of particular cerebral parts, or by studying the relation of organs to function in a state of health. This is, in fact, the method by which physiologists have, in nearly all instances, ascertained the uses of other organs and parts of the body. This was specially true in regard to the discovery of the function of the heart or the circulation of the blood, by Harvey, in 1619; and long after its anatomical structure was known. As an instance of the conservative tendencies of professional men, in the adoption of new and important truths in physiology, it may be stated, that this great discovery was for a long time contested from all sides, with the greatest acrimony, and it was remarked by Hume, as "evidence of obstinate adherence to preconceived opinion, that no physician in Europe, who had reached forty years of age, ever, to the end of his life, adopted it.” It was also reported, as a “great triumph for Harvey, when such an anatomist as John Rolan, of the faculty of Paris, who had been one of its most violent opponents, voluntarily suc- cumbed, and became one of its warmest advocates, during the same century.” In view of the acknowledged limitation of human powers aided only by scientific processes, in divining the true physiology of organized parts, both in the animal , 495, Insanity or Mental Derangement. and vegetable kingdoms, this would appear to be the natural, if not, indeed, the only possible method of arriv- ing at the truth in regard to them. In keeping with this view, also, as showing that a degree of confidence is placed in the method alluded to, I quote the language of Dr. D. Ferrier, a high authority, though not a disciple of Gall, as follows: "To show that there is no localization of mental functions, it is necessary to demonstrate that the same parts may be destroyed in both hemispheres, without producing mental disturbance.” “But has this ever been shown?” “I can- not,” says Ferrier, “find the faintest approach to evidence which would justiſy such a conclusion.” On the con- trary, in speaking of the comparative value of the vivisec- tion of animals, as a means of advancing knowledge of the physiology of the brain, he states: “Florens' conclu- sions are, I think, answerable for many erroneous notions which have leng dominated cerebral physiology and pathology. “One great fallacy has been the assumption that the results of the experiments on frogs, pigeons and other animais, low in the scale, are at once, capable of applica- tion to man without qualification; an assumption which vitiates the conclusions of numerous physiologists of the present day.” “The very fact that there exists such patent differences between the effects of destruction of the cerebral hemispheres in different orders of animals, ought, one would think, to inspire caution in the applica- cation to man, of results obtained only by experiments in the brains of animals low down in the scale." I will also add, that it would be the same in principle, in re- gard to any species of animals, the highest, as the mon- key, the one usually chosen for experiment, being im- measurably inferior to man, when the intellectual and moral faculties are brought into view, in the comparison. We adopt, then as a fundamental principle of the phys- iology of the brain, that it consists of a plurality of parts, each being specially endowed for its office. Also, that the 496 H. A. Buttolph. mind consists of a corresponding number of innate primi- tive faculties, which, with the organs of the five senses, are designed to put man in relation to the Creator, to his fellow-man and the physical world in which he is placed. Thus we are put in possession of a key that will enable us to judge correctly of his mental constitution, alike in health and disease, or in the natural and disordered states of his faculties. Hitherto a distinction has been made be- tween the morbid derangements of the external senses and the internal faculties. The organs of the former hav- ing been long known, every disturbance of their functions has been justly described as an affection of their material organs, and by this the treatment has always been regu- lated. On the same principle should the organs of each internal faculty or feeling receive attention, indicating, as it would, not only the existence and locality of the dis- ease, but also whether functional or structural in character and stage. With this view of the physiology of the brain, the mystery as to how a man may be insane in one faculty or feeling and sound in all the rest; and, consequently, when a different organ is diseased, the faculty or feeling that is deranged may be different, and yet that the disease it- self may remain exactly of the same nature, is plainly revealed. Inflammation affecting the eye disturbs vision, and af- fecting the ear disturbs hearing, because vision is the function of one and hearing of the other, and requires in both the same kind of treatment. Widely different from this is the mode of procedure of those who doubt or deny the plurality of the cerebral organs and maintain the brain to be a unit, every part serving equally to maintain all the faculties. On this principle it is impossible to explain how it happens that in a majority of instances, a few only of the mental powers are deranged, while the others re- main sound. For if the whole brain were the single organ of mind, every part of it ought to concur in every mental operation, and all the faculties of the mind, of Insanity or · Mental Derangement. ' 497 which it is said to be the instrument, ought in every case to be equally deranged. To account for the variety of forms which derange- ment of so many mental faculties and organs may assume, the advocates of the unity of the organ of mind are con- strained to create a new malady, for every change in the character of the mental symptoms, which would be of no value either in the diagnosis or treatment of the disease. One of the best illustrations of this, also of the absurdities into which some of the most learned of the by sound principle, is the classification of “mental diseases,” so-called, proposed by Dr. Good, which inclu- ded the formidable number of six genera, fifteen species and twenty-seven varieties, each, of course, being held to be different from the other, and to require some differ- ence in treatment; and yet, when examined with the aid of an improved physiology, the disease of the brain in all, would be found to be essentially the same; the mental symptoms varying only with the office and number of the organs and faculties involved. While some improve- ment has been made in this respect, or, in regard to the nature and number of the classes, into which cases of insanity have been thrown, yet, the distinctions have, in nearly all cases, consisted as before, merely of varieties in the character of the mental symptoms, rather than in any supposed difference in the existing disease of the brain, from which they originated. Until this fault in the habits of observers is corrected, there would seem to be little prospect of amendment in practical views in regard to the pathology of the disease, and, consequently, little progress made in its treatment, as based thereon. Indeed, it has been frankly admitted, by various modern authorities of high standing, specially by Ferrier, who remarks: “Beyond the fact that the brain is the organ which is directly or indirectly diseased in insanity, we are yet in the most profound state of ignorance regarding the intimate pathology of this condition. 198 H. A. Buttolph. “Post-mortem examinations reveal morbid conditions as to vascularity, or various forms of degeneration in the nerve-cells, neuroglia, etc., but with the exception per- haps, of general paralysis of the insane, we have yet to find out whether there are any morbid appearances spe- cially characteristic of special forms of mental derangement, or, whether there is a definite relation between the locality of the lesion and the symptoms observed," He farther states: “We cannot be sure whether many of the changes discovered are the cause or the result of the disease, or whether the two are conjoint results of a common cause." “ It is no disparagement of the many valuable researches, which have been made in the pathology of insanity, to say, that we are only beginning to learn its rudiments." “ Until the various morbid appearances discoverable in the brains of the insane are translatable into their sub- jective signification, the morbid anatomy and pathology of insanity run in parallel lines which never meet." I will here venture to remark, that the reason why morbid anatomy and the pathology of insanity have run in parallel lines which never meet, as above stated, is the acknowledged fact, that the mental functions of the parts affected, are unknown, and farther, that they cannot be ascertained by the aid of pathological inquiries, which reveal only the results of diseased action in the part. It is here assumed that the original function, or as it regards the mind, is only discoverable by Gall's method of procedure, the comparison of the organs or parts in a state of health, with the strength of the mental faculties dependent upon them for their manifestation. When this is accomplished, it is presumed that morbid anatomy of the brain and the pathology of insanity will run in such converging lines as to meet, thus explaining the phenom- ena of every well-observed and authenticated case of mental disorder. I will also remark while on this topic, that if so very little reliance can be placed on morbid anat- omy and the pathology of insanity, by one so justly Insanity or Mental Derangement. 499 distinguished for accuracy of observation and skill 'in ex- periment as the author above named, what progress can be expected from the pathological inquiries of many others, who, with only a tittle of his qualifications for success, attempt to add to the results of his investigations in this important line of work. On the contrary, if dem- onstrated, as claimed, that the correct physiology of the brain can be discovered by more natural and certain methods than those adopted by pathologists and vivisec- tors of the brains of animals, why should not the latter be willing to attempt either to verify or disprove such results by an appeal to nature, rather than to waste one thousand, one hundred, or even ten years in vain attempts at re-discovery by means which, in the hands of skilled inquirers like Ferrier, Eckert, Charcot, Richet, etc., have proved unsuccessful because unsuited, and therefore im- practicable for the purpose. SYMPTOMATIC FORMS OF INSANITY. Mental derangement in the present limited state of knowledge in regard to its pathology, may, perhaps, be advantageously considered in reference to its symptomatic forms. While it is not presumed that a definition, by way of description, can be made so minute as to describe all cases, or so comprehensive and general as to include all that should be considered; yet, I venture to offer it for what it may be worth, for both objects. Mental derange- ment consists of a changed, unbalanced and uncontrollable state (by the will, and under ordinary motives) of one, of many, or of all the faculties of the mind, resulting from disease of the brain and its membranes; which may be functional or structural in character, partial or general in extent, continuous, intermittent or impulsive, and recurrent in its manifestation. The forms of disease of the brain on which insanity depends, in a general way, are three, viz., with morbidly excited, depressed and perverted action, while the sympto- matic forms based upon them, may be equal to the number -500 H. A. Buttolph. of the individual organs of the brain, through which the faculties are manifested, together with numberless varieties resulting from combinations in action of many diseased organs. When to these are added, also, the varieties resulting from the disturbed state of the nerves of the special senses (which are always to be associated with the organs of internal faculties), and still farther, with morbidly perverted states of the nerves of sensation and muscular motion, the possible number of the symptomatic forms of mental disorder, will fully equal the multiplied phases in the mental character and lives of sane people, which, of course, are practically unlimited. It is thus apparent, that efforts to classify cases, on the ground of difference in mental symptoms without ref- erence to the primary faculties, must be, for all purposes of study or treatment, as practically impossible and use- less as would be attempts to perform a similar work of subdivision into classes, of the population in general, for social, educational, business and other purposes. On the contrary, it should be the object and effort in cases of insanity, to observe, classify and treat, func- tional and structural disease of the brain itself, on the same general principles and by similar methods of in- quiry, as are followed in classifying and treating diseases of other organs of the body, as the lungs, the heart, the stomach, the kidneys, etc. In regard to the latter, it is the invariable practice, so far as possible, by proper ob- servation and by slow degrees, to discover the physiolog- ical purpose or use, of organs and parts, and then, by all available pathological inquiries, to ascertain the nature and number of diseases, and consequently, of pathologi- cal conditions, to which they are subject. When these two objects have been successfully accomplished, and then only, can medical practice be placed upon a scientific rather than an empirical basis. These statements, it will be observed, however, are only truisms which all admit, in regard to the treatment of disease, in every organ and part of the body. In a Insanity or Mental Derangement. 501 few instances the healthy or physiological purpose of organs of the body are partly inferable from their anatomical structure—as the bones, blood vessels, etc.—to be confirmed, mainly, by observation of their uses in ac- tion, but to some extent also, by the result of disease, as shown by pathological inquiry. In others—indeed, in the vast majority of cases of living things, whether belonging to the animal or vegetable kingdom-the physiological use, is to be ascertained primarily, by comparing the ap- pearance with results of its activities, rather than by scientific knowledge of its intimate structure. In these, as in former instances, pathological inquiries by any and all the methods in use, are in point to confirm the cor- rectness of physiological views; and, as such, they should be estimated at their true value, and prosecuted accord- ingly. In either and in all cases, however, when the object is to classify disease, showing varieties and differ- ences, reference should be had to the actual character and number of diseases to which the organs and parts of the brain are subject, and not merely to the variety of mental symptoms, developed by changes in their func- tional action or otherwise. In keeping with this view, when speaking of other bodily organs, the lungs for ex- ample, we mention pneumonia as one of its diseases, and we consider the nature of this affection as of primary importance, and not the several symptoms in detail. To apply these views and principles to the brain and its functions, the object of the present inquiry, I would state, that as this organ belongs to that class, whose chief physiological purpose, the manifestation of the mental faculties is not revealed by its anatomical structure, this must first be ascertained, as heretofore stated, by observ- ing the relations that exist between its comparative de- velopment, and the strength of the mental faculties, as they appear in individuals and in classes of men. The second practical point in the inquiry is the fact, that as the brain is nearly uniform throughout in its ap- pearance and structure, though composed of organs with 502 H. A. Buttolph. variously modified faculties or functional activities, it is subject to comparatively few distinct types of disease ; and hence, that the number of classes of cases, based upon them, and showing as they should, different and distinct pathological conditions, are very few and such as would naturally result, in different stages, from the three forms of diseased action mentioned. Guided by this, the only true principle in classifying disease in every organ of the body, including the brain, the work of the nosolo- gist in defining and multiplying classes of the latter, according to authorities quoted, and the principles here set forth, is almost, if not entirely, nil. On the other hand, if the attempt be made to recognize and classify all the symptomatic forms of the disorder, according to the physiological method of estimating their number, it is evident that they would be found too numerous, and often too much alike, to justify and render possible their separate consideration. In this state of things, a resort should be had in treating classes, and individual cases, to such general principles as would meet the circumstances of each, tak- ing into view the character and stage of the morbid action present in the brain, and the number, office and influence upon others, of the organs and faculties in- volved. While this may appear to some as an act of too great generalization in the treatment of cases, yet, if the ground taken in regard to the plurality of the organs and fac- ulties be true and accepted, the reason for general subdi- visions, based, not on disease of the brain itself, but on mental symptoms, variously modified and complicated by their nature and number, there would seem to be little motive for their continuance in future; as, whether con- sidered in relation to the establishment of a uniform system of statistics of insanity, or the more scientific treatment of disease of the brain on which it depends, the results would be alike uncertain and unsound. Insanity or Mental Derangement... 503 PROPOSED CHANGE OF METHOD. · I now venture to suggest another method of describ- ing and treating cases and conditions, without statistical tables, based, as heretofore, on symptomatic forms of disease. In doing this, I assume that in all cases of in- sanity, the brain or its membranes, or both are affected, as before stated, by morbidly increased, diminished or perverted action, which may be functional or structural in character, partial or general in extent, continuous, inter- mittent or impulsive, and recurrent in its manifestation. In view of the prevailing uncertainty of knowledge in re- gard to the pathology of insanity and the impossibility of classifying cases as based thereon, according to former methods, I make allusion, in a general way, to its causes and their mode of operation in producing symptomatic forms of the disorder. These, as heretofore, may be di- vided into remote or predisposing, exciting and proximate. To the first or predisposing, which includes hereditary transmission of tendencies, I will only refer in passing, as they are generally understood and admitted. The second or exciting may be arranged under two heads, as local and functional. The local embrace injuries to the brain from external violence—from intense cold or great heat, from the direct rays of the sun or from other sources ; from tumors, from exostoses, from apoplexy, from epilepsy, from palsy, from toxic agents of all kinds, including al- coholic stimulants, morphine and other powerful narcotics, etc. Of the second or functional class of causes, it should be stated that to properly understand their mode of operation, the twofold functions of the brain, as the center of sen- sation and nervous energy, and as the seat of thought and feeling, should be kept in view. As the former or seat of sensation, it is constantly stimulated or acted upon by whatever is passing in every part of the body, and is thus liable to disease from its many sympathetic relations. It should be remembered, however, that the influence of this class of causes is small, and the cases arising from them very few ccmpared with the other. 504 H. A. Buttolph. The large class of functional is frequently, though im- properly, spoken of as moral causes, or those supposed to operate on the mind itself, and was formerly much used by those who adopted that hypothesis. The term functional, having direct reference to the action of the brain in developing the mental faculties, is appropriate because natural. It is easy to understand, physiologically, how func- tional action becomes an exciting cause. In health, the effect of exercise is to increase the activity of the blood- vessels and nerves of a part, and to augment their func- tional power. When these are naturally increased, their condition is that of temporary excitement, and if the extra stimulus be withdrawn in time, and an interval of repose be allowed, strength and nutrition is improved, and the superfluous excitement subsides. If the intervals of action aré too short, or the periods of excitement are too long continued, or too frequently repeated, it will no longer sub- side from mere repose. At this stage, the power of the will for deciding correctly, and for controlling the instru- ments of action is lost, showing that a state of disease of the brain exists, and that disorder of the mind has resulted therefrom. In this condition, unless the affection is removed by medical treatment, aided by a proper reg- imen, the functional disease sooner or later becomes structural or chronic, from which recovery may seldom be expected. Functional excitement in the cerebral organs may arise in two ways; either from internal and spontaneous activity, in which the mind is held too long and intently as before described, or, from the stimulus of external objects or relations, which is still more common. The affections of the brain which disturb the manifestations of the mind, may be divided into two great classes; the first being those which are acute in character, rapid in progress and dangerous to life; the second, which are more chronic or slow in their progress, are compatible with more prolonged existence. Of the first are fevers, Insanity or Mental Derangement. 505 phrenitis, hydrocephalus acutus and apoplexy; and, of the second, the various affections which give rise to insanity, are familiar examples. In the former, which are attended by local symptoms of too great intensity, to have their seat for a moment in doubt, the derangement of the intellectual powers, is at once ascribed to morbid changes going on in the brain or organ of the mind. But in the latter, when the local symptoms are not so severe, the connection between their phenomena and their cause in the brain, may be unperceived and denied. Having thus seen that mental derangement is not a specific disease, but a symptom of an existing cerebral affection, it follows, that although the terms, mania, monomania, melancholia and moral insanity, may be used to designate particular mental forms, assumed by the symptoms, yet, that they ought to be entirely discarded as names of diseases, since their use serves to perpetuate the error which has long been the bane of medicine, of supposing them really to belong to and designate specific states, and requiring in many or most cases, specific treatment. In their places we ought to be able to speak of diseased states of the brain, which disturb the mental faculties, just as in the case of the lungs, instead of speaking of dyspnea as a specific disease, we speak only of the local or organic affection as pneumonia, or pleuritis, ptosis, ophthalmia, cataract, etc., not of simple blindness or obscurity of vision, which, as a disturbance of function, is common in a greater or less degree, to all diseases affecting these parts, whatever their nature or causes. While it may not, in the present state of our knowledge, be possible to carry out this principle very far, yet, it will be an advantage to keep the facts, as stated, constantly in view, as a stimulus to greater exer- tion in this direction. PROXIMATE CAUSES. In speaking of proximate causes, the first and most comprehensive division, includes the numerous cases in 506 H. A. Buttolph. which the mental disorder is connected with increased action in the blood-vessels of the substance and mem- branes of the brain. In this condition its progress is generally rapid, the mental disturbance great, and the termination speedily fatal, unless timely and active assistance is given. When it becomes chronic, its advances are slower, the disorder of the mind may be less violent and general, but the event, although more remote, may be almost equally serious. Another division of cases, as connected with a proximate cause and condition of brain, is in many 'respects the opposite of that just described, and may properly be termed asthenic, or with diminished or weakened vascular action. This may be attended with as much mental ex- citement and fury as the other and may be confounded with it. Its true nature, however, can generally be deter- mined by taking into account the condition of the patient, the beginning and progress of the symptoms and the effect of debilitating causes. Such patients may suffer from high nervous excitement and from varying degrees of conges- tion of the brain, but seldom from disease of a more active character. In the third form, the nature of the brain disease is so essentially changed and modified, as to show morbid perversion in the character of the mental symptoms, which may apply alike to the intellectual faculties, to the higher sentiments and to the lower animal feelings, but more particularly to the two latter classes. It should be added, also, before leaving this branch of the subjeci, that while all of the organs of the brain, whatever may be their relative size or development, are subject to attacks of disease, thus giving rise to disorder of their functions, yet in proportion as they are large or very large, with cor- respondingly strong functional or functionating power, are they liable, through internal activity or the influence of external causes, having relation to their functional office, to become over-excited and uncontrollable by the power of the will. In such cases the general health is impaired by Insanity or Mental Derangement. 507 the exhausting functional activity of the brain, but espe- cially in consequence of disturbed nutrition and the loss of rest in sleep. FUNDAMENTAL PRINCIPLES. These are, that the brain consists of a congeries of organs, endowed by the Creator with power to develop and manifest a corresponding number of innate mental faculties, each destined to fulfill a specific office in the mental group, and, together with the organs of the five or special senses, constituting the mind as a whole, capable, when fully understood, and correctly interpreted, of ac- counting for all mental phenomena, alike in health and, in disease. CONGENITAL AND DISEASED STATES OF THE BRAIN THE PRIMARY BASES OF CLASSIFICATION. 1. Unsoundness of Mind from Congenital Defects in the form, size or quality of the Brain Substance. The forms of these are idiocy, imbecility and cretinism. These may be partial or general in their effects, on one or many, or on all of the mental faculties of every class. 2. Insanity, with acute disease of the brain or its membranes, or both, accompanied, usually, by pain in the head, a generally febrile state, with increased frequency of the pulse, loss of appetite and sleep, checked and dis- ordered secretions, etc., etc. Also shown by disturbed states of the special senses; by exaltation of one, of many or of all of the faculties of the mind; which may be con- tinuous, intermittent or impulsive, and recurrent in char- acter. 3. Insanity, with chronic disease or depressed action, accompanied by some of the constitutional symptoms re- ferred to in the last, but in milder form, and shown by chronic depression and disorder of one, of many or of all the faculties of the mind; which may, also, be continuous, intermittent or impulsive and recurrent like the second. 508 H. A. Buttolph. 4. Insanity from morbidly disturbed and perverted action of the brain, with or without fever, pain etc., and shown by morbid perversion of one, of many or of all the faculties, but far more frequently, of those of the affective class only. While this form of derangement is more apt to be partial in extent, yet it is subject in its progress and termination, to the same variations as the others : covering or embracing all the modifications of so-called moral insanity. It will be observed that the basis of the primary classification is, first, from congenital deficiency; and, sec- ond, the character of the morbid action on which it de- pends, at least, so far as is how known. It seems proper in this connection, to recall attention to the exciting causes heretofore named, as efficient in developing the disease, and, particularly, to the list given under the head of Local Causes, some of which bear so important a relation as to have been made to represent classes, as epileptic insanity, toxic insanity, etc., which, with the view here taken, is considered highly questionable; as they would appear to represent causes, rather than forms of insanity. Reference is also made to what has been stated and explained in regard to the sec- ond or functional class of causes. Georget states: “The causes that tend to derange the organization of the brain, by the exercise of its o'xn functions, are the most frequent, or, we might almost say, the only ones capable of pro- ducing mental alienation." I will also venture to add, that when the forms of disease given in the classification named, are taken in connection with the efficient local and functional causes described, a valuable degree of knowledge will be obtained, in regard to their history, diagnosis, pathology and treat- ment. It will, also, be more fully revealed how it is pos- sible to have nearly unlimited variety in the symptomatic forms of the malady, based upon or arising from differ- ence in the mental functions of parts of the brain affected, while the nature of the disease in many, or all, remains Insanity or Mental Derangement. 509 essentially the same. Farther on, however, this will be quite apparent from illustrations to be given of other symptomatic forms, as connected with disorder of the faculties, singly and in combination with each other. EXTERNAL SENSES. As the five external senses are naturally and inti- mately associated in function, with the internal faculties, I refer briefly at this point, to their office and agency in health and in disease. While they mediately, or through connection with the organs of the perceptive and other internal faculties (this being specially true in regard to the sense of sight), have a wide range of influence, in securing perfect mental processes, yet, it should be re- membered that the immediate sphere of their activity and influer.ce is very limited. Thus the eyes perceive light, the ears sound, the taste savors, and the sense of touch or feeling notices forms, roughness and smoothness, dryness, moisture and temperature. They do not of themselves, in any case, form or convey ideas to the mind, in regard to the qualities, relations, or even the exist- ence of external objects; this being the primary office of the perceptive faculties, whose organs are located in the lower frontal region of the brain. The functions of the latter, enable man to recognize the existence and individuality of persons and objects, embracing their form, size, weight, color, locality, order, number, etc., the usual properties possessed by physical bodies, whether organized or otherwise. Holding such intimate relation to the internal organs of the brain and faculties of the mind, in their healthy state, their con- nection with and influence over them, when the latter are in a state of disease, must be highly important. While they are themselves subject to various diseases, yet, on account of their external situation, they are bet- ter known, and therefore, better treated, than are the diseased organs of the internal faculties, with which they are in such direct functional relations, and whose condition 510 H. A. Buttolph. is chiefly known, through mental symptoms. Thus in optical illusions, in which one, several or all the or- gans of the perceptive faculties may be involved, the seat, severity and extent of the disease is revealed, by a knowledge of their mental functions, which is of much value, as an aid to correct diagnosis and treatment. Again, in cases in which hallucination of hearing exists as a disturbing symptom and complication, although the seat of the disease may not be so definitely known by the mental symptoms, as in the first instance cited, yet that this symptom arises from disease of an internal organ of the brain, rather than an external organ of sense, is quite certain; and, to account for its continu- ance or return, as often happens, after other signs of mental disorder have partially or wholly disappeared; it is only necessary to suppose the continuance or renewal of morbid action in the part affected, similar to or simu- lating, in effect, the functional activity of the sense in question. Morbid changes in the senses of touch, taste and smell not infrequently occur during attacks of mental derangement, giving rise to increased, diminished or perverted sensibility in the first; while the other two may be so changed from their original healthy purpose or function, by internal disease of the brain, as to induce the sub- ject to tolerate, even, to enjoy morbid departures from their true functional office, of the most unnatural and revolting character. The brain, as heretofore described, consists of a con- geries of organs having specific mental functions, which may be considered in a general way as belonging to the anterior, superior and posterior regions, being represented respectively, by the intellectual faculties, including the perceptive and reflective, the moral and religious senti- ments, and the animal propensities or selfish feelings. While the organs in each of the several regions named may suffer from disease separately, inducing derangement of corresponding mental faculties, or what has been called monomania, yet the disease seldom continues thus local Insanity or Mental Derangement. 511 for any considerable period, but extends so as to embrace adjoining or surrounding organs, giving rise to mental symptoms that show the combined disorder of some, of many, and in not a few instances, of all the faculties of the mind. Hence, the prevailing type of the disease will depend, to great extent, on the nature of the cause and the condition and function of the parts affected, and will be characterized by exaltation, depression or perversion of function, as the case may be. DISORDER OF THE PERceptive Faculties. Disease located in this region may affect one, several, or . all of its organs, giving rise to mental symptoms correspond- ing to the seat and function of each. In one case there will be great and uncontrollable activity and alertness of the faculties; in a second, dullness of perception or loss of memory of persons, places and things, slowness of speech, etc. In the third, there will be changed or perverted functions, as in mistaking the identity or individuality of persons and things about them, seeing objects multiplied in number, or distorted in form, size, posture, color, etc., as in delirium tremens; or if the organ of Weight is in- volved, the effects of disturbed equilibrium will follow, as in states of intoxication and sea-sickness; also, as is most probable, in the unsteadiness of gait, to which persons af- fected by general paralysis of the insane are subject, that disease, in the early stages, being mainly confined to the anterior cerebral region. The organ of Number is also liable to be separately diseased. This is very well illus- trated by the case of a young English man reported by Combe from the French, who had a nervous attack every other day, during which he neither heard or saw any- thing, as was verified by experiment, and who yet occu- pied himself particularly with mathematics, arithmetic and logarithms, and solved with ease new and difficult prob- lems. This seemed to arise from the organ of Num- ber being active when the other powers were lost : generally, however, the power of calculation is diminished. 512 H. A. Buttolph. A marked case of the morbid activity of this faculty was observed in a young female patient in my own care, who for several months passed much time daily, under ap- parently an uncontrollable impulse, to count in a rapid manner. The tendency to this gradually subsided, and with other symptoms, finally disappeared. Persons with extreme natural development, showing decided but par- tial genius in this faculty are reported, as the cases of Zerah Colborn, George Bidder and others; while in con- trast with these, may be mentioned persons with extreme natural deficiency in the strength of the same mental power. Among the best examples of the latter, may be mentioned the case of Mr. George Combe, of Scotland, the most noted advocate of the doctrines of Gall and Spurzheim, author of the “Constitution of Man,” etc., and whose views in regard to mental and moral science and philosophy were, perhaps, more advanced, better defined, and more extended in their application to the affairs of men, than those of any man of any country or age, pastor pres- ent. Notwithstanding his great mental power and achiev- ments in this line of inquiry, he had occasion to deplore the lack of development, and consequently of natural strength of the faculty of Number, now being considered. He states: "Arithmetic has always been a profound mys- tery to me, and to master the multiplication table, an in- surmountable task. I could not now tell how much eight times nine are, without going to work circuitously and reaching it by means of the tens; yet for seven years I studied arithmetic. The faculty in me is, in fact, idiotic, and the organ is very small. Were my other powers in like condition, I should be totally unfit for the ordinary business of life.” The organ of Tune is often found diseased in the insane, giving rise to very singular manifestations in persons who in health had no musical ability. Doctors Rush, Pinel, Esquirol and others, mention this fact. Dr. Rush often visited with much pleasure, a young woman, on account of her exquisite singing and poetical imagi- Insanity or Mental Derangement. 513 nation, although before the invasion of insanity, she had never shown any taste for music or poetry. In another case mentioned by Dr. Combe, from his own practice, as a very remarkable instance of excitement of this organ and faculty, which was accompanied by most intense craving for musical indulgence, which, at last, overcame all the restraints of debility and external circumstances, and impelled the patient to leap out of bed, lay hold of a guitar and give vent to her feelings in bursts of melody and song, which, perhaps, in her best health, she could scarcely have equaled, and in which the organic seat was distinctly indicated, by severe pain felt the two previous days in the exact situation of the organ. In this case the functional excitement was so great, as to have caused alarm in the friends from the apprehension of its being the first stage of delirium. Cases of extreme organic strength occur in this organ, showing partial genius in the development. Instance the widely known case of the colored man and pianist, Blind Tom, and others, which not infrequently occur, while the contrary extreme of congenital deficiency in this organ and faculty, is well illustrated in the case of persons, with minds otherwise well developed, who regard musi- cal sounds only as noise; others, who are unable to distinguish one familiar tune from another, as Old Hun- dred from Yankee Doodle, which lack of power, I have been told by a member of this association, and who has acted as one of its most distinguished presidents, was his misfortune; and yet, I fear that he will not feel bound by the logical consequences of the admission. Color blindness, so-called, consists not in defective or disordered action in the organ of sight, as some have maintained, but rather, in congenital imperfection in the organ of Color, which receives and modifies impressions from without, as do other organs of this class. Disease in the organ of Locality was shown in the case of a gen- tleman of sixty-two, who had perfect recollection of per- sons and events, enjoyed good health and perfect sight 514 H. A. Buttolph. and hearing, who failed to recognize the place where he had lived for twenty years, not even his own house. When riding away from honie, he recognized acquaint- ances, conversed rationally on all subjects, yet on return- ing to his house, he had no recollection of ever having seen it before, enquired who lived in it, and was sur- prised to find that his family had arrived before him. Marked activity of the organ of Language is often met with in the insane, giving great volubility and fluency of utterance, which are not soon forgotten by the victims on whom they have been inflicted; while, at other times, words are either misplaced, used sparingly, or wholiy suppressed, as in the case of aphasia. In regard to the existence and locality of the organ of this faculty, I quote remarks by M. Duval, “in a paper read to the French Anthropological Society, on Gambetta's brain, which was much under size as com- pared with those of Cromwell and Cuvier—the first weighing but 1161 grammes, while the latter weighed, respectively, 2000 and 1829 grammes. The peculiarity of Gambetta's brain, M. Duval stated, was, that it was particularly well developed in that portion of its structure where most undersized brains are found to be defective, that is, in the third frontal convolution. The folds in this exhibited uncommon richness and variety of com- plication. He concluded by pointing out how the pecu- liarity of structure and configuration noted in this case, gives credence to a well-known theory of Broca's, who localized the oratorical faculty in the third frontal convo- lution.” To this it may be added, that Gall's localiza- tion of the organ of Language, was the same as Broca's, but was applied, as would be natural and necessary, to both right and left frontal lobes. It may, with propriety, be farther added, also, that the existence of a functional relation between a definite and fixed organ or part of the brain, and the faculty of speech, as claimed by Broca, and tacitly admitted by many, if not all other physiolo- gists of the present day, goes very far in showing by Insanity or Mental Derangement. 515 analogy, what may, or rather, what must be the truth in regard to the dependence of other mental faculties on regions and parts of the brain, for their manifestation ; also, that had the method used by Broca and his school, for localizing organs of the mental faculties, been as well adapted for making original discoveries, as were those used by Gall, results by the latter, might have been more largely comfirmed by them, prior to the present day. Illustrations in regard to increased, diminished or per- verted action of the organs of this class, might be mul- tiplied indefinitely, but those already cited, may suffice for the present object. DISORDER OF THE REFLECTIVE FACULTIES. The faculties of this class, consisting of Causality and Comparison, are the highest mental powers, and by virtue of their important office and relations, take precedence over all others. They receive impressions from the exter- nal world through the agency of the five senses and per- ceptive faculties just considered. They develop ideas, perceive the relations of objects and subjects each to the other, and form judgments and volitions in regard to them. They also receive impressions and promptings from the organs of the various sentiments and propensities to be described hereafter, and form conceptions for grati- fying or restraining them, as circumstances may require. Each and all of the faculties of this and other classes are constituted to be specially impressed by objects and sub- jects in nature, to which they severally relate, and to work harmoniously together when duly developed and trained for the purpose. When suffering from attacks of disease they may be excited, depressed or perverted in function. When morbidly excited it constitutes what Pinel called reasoning insanity, in which state the increased power of reasoning and expression of individuals is some- times most remarkable. This also occurs as a temporary increase of mental 516 H. A. Buttolph. strength and activity, from the excitement of fever, in de- mentia and in congenital imbecility. The strength of this class of faculties, positive and relative, gives the measure of the ability, and consequently, of the responsibility of an individual in the walks of life in which he may engage, or into which, by its exigencies, he may be forced. The disordered states from disease, of the five senses and of the observing faculties combined, are called false perceptions, and are shown largely by illusions and hallucinations of sight and hearing; while the deranged states of the re- flective faculties from disease of their organs, to whatever objects or subjects they relate, are called false judg- ments or delusions. This, however, does not apply to cases in which error in judgment arises from the preter- natural activity from disease of the organs of other classes of faculties; these being explained on the principle of correct reasoning from false premises, and while the rea- soning faculties themselves are unaffected and sound. In this case the insanity is, of course, only partial, but is, nevertheless, genuine and disabling in its effects on the diseased organs and disordered faculties invoived. The evi- dence of this is, that there exists a morbid departure from the usual character, temper and habits of the individual. When the organs of the reflective faculties are affected, causing derangement of their functions, false judgments will be made from correct premises. Again, when the organs of the reflective, perceptive and affective, are alike in- volved in disease, false judgments are formed from false premises, in which case the mental disorder is complete and universal, and the responsibility of the subject is, for all purposes, totally destroyed. There are many circumstances under which the organs of the reflective faculties may become diseased from functional causes; but, perhaps, in none are they so liable to be injured, as by too prolonged attention to subjects by which they are over-stimulated and fatigued, without being able to reach satisfactory con- clusions. Thus, the study of abstract and metaphysical theories, about which an ingenious person may reason Insanity or Mental Derangement. 517 plausibly, without ever arriving at determinate results, will often excite the organs of this class into sleepless and uncontrollable activity and disease. This is especially liable to occur with men, whose reflective faculties greatly pre- dominate in strength and activity over the perceptive, which latter, by supplying the proper data for reaching more speedy and correct conclusions, would greatly relieve the mental strain incident to the inquiry. Another and familiar illustration is the case of persons who, without proper data, and in ignorance of fundamen- tal principles, attempt to make mechanical inventions, including the long-sought, but illusory problem of discov- ering and applying the principle of perpetual motion. In such cases, so much interest is felt, and such prolonged attention is given to the inquiry, that the ideas become confused and fixed, when the mind can neither be suc- cessfully applied to the subject, nor voluntarily withdrawn from its contemplation. These, perhaps, may be offered as fair examples of what have been called cases of monomania, as applied to the reasoning faculties. It should be remarked, however, as heretofore stated, that while the disease is thus local in the beginning, yet by functional sympathy, or continuity of texture, it may soon extend and involve the organs of other faculties, which, acting in combination with the first, give rise to mental symptoms widely differing from the original, while the nature of the brain disease, whether functional or structural, remains the same, and may be treated on the same general principles in all. DISORDER OF THE AFFECTIVE FACULTIES. Under this general head allusion will be made to faculties other than those of the perceptive and reflect- ive classes, which have heretofore been described, and illustrations given of their disordered states. The affect- ive faculties are numerous and highly important, as they place man in relation to the Creator and his works, to his fellow-man; also, in harmony with the necessities of his. 518 H. A. Buttolph. condition as an organized animal being, in common with animals of lower grade. They are all dependent upon separate organs or parts of the brain for their manifesta- tion in this life; have specific functions by virtue of spe- cial endowments, and are therefore, to be considered, some as highly exalted in office and character, and all as wisely and well adapted by the Creator, to qualify man for his sphere of action in this world. While they are to be regarded only as blind instincts and impulses to action, and not as knowing faculties, yet, as they are influenced by objects and subjects that relate to man, they furnish the desires which prompt him to action; also the feelings, which regulate conduct. The reflective faculties, without being able to alter their nature, judge of the motives presented by them for consideration and ac- tion, taking an extent of view in each case, proportioned to their strength, for acts of judgment and volition. When they are well and harmoniously developed and trained to exert only their proper influence upon the reason, accord- ing to the standard of the individual, the best attainable results are realized. If, however, through the undue strength and unregu- lated activity of some or many of the faculties of this class, the reasoning powers are led to inisjudge, in regard to the proper course of action to be taken, or, as in cases here- tofore stated, they weakly or wickedly yield to the prompt- ings of unlawful desire and impulse, acts of folly and imprudence to be regretted, or of crime to be deprecated and punished, under the natural, or by the civil law, will follow, according to the nature or gravity of the offence committed. It may be repeated in this connection, that the measure of the responsibility of the subject in any given case, will be, in the abstract, in proportion to his ability, through natural endowment and previous training, to understand and keep the law inviolate, by resisting temptation. The third occasion, and the one to which special atten- tion is here drawn, is that in which some of the natural Insanity or Mental Derangement. 519 desires and impulses have been rendered preternaturally strong and uncontrollable in action by disease, thus de- stroying the accustomed balance between them and the reason or will-power. In this case, a state of insanity is produced, not from derangement of the reflective faculties, but from their having decided under the influence of false premises; in other words, from the unbalanced condition of one or many of the sentiments or propensities, or both, from disease of their organs. As the varieties in natural character and the conduct of individuals depend, very largely, on the strength and activity of the organs of this class, singly and combined, so the phases of mental disorder, from their diseased state are equally various and multiplied; thus rendering an effort to classify them, as a means of distinguishing their pathological state, as useless and impossible in the latter, as would be their association in classes, for a physiolog- ical purpose in the former. While the practical question, as it regards the treatment of cases, must be determined principally, by the general character of the morbid action in the brain, yet, in not a few instances, it must be mod- ified, on account of the very depressing effect of disease of particular organs, on the other mental and bodily functions of individuals. The view I here wish to incul- cate and to impress, in the interest of correct diagnosis, prognosis and treatment, is that cases of disease, in which the affective faculties are specially involved, are to be classified, as far as possible, by the character of the morbid action present in the brain, rather than from varieties in the mental syınptoms. I would, therefore, as the terms mania, monomania, melancholia and moral in- sanity, do not uniformly, indicate the nature of the exist- ing disease in the brain, discard them from use, as un- meaning and unsuitable for the purpose. I would have each case, whether single or combined in development, stand by itself, as it can have little relation or resem- blance, in mental symptoms, to those with different functional offices to perform. Recalling the statement 520 H. A. Buttolph. that the affective faculties are expressly constituted to be in relation to objects, subjects and circumstances incident to the present life of man, I hereafter propose to give illustrations of the fact, and to show that the true ground for the rational classification of cases in which these fac- ulties are concerned, is the character or type of disease in the organs on which they depend, as acute, chronic or depressed, and perverted action, and allowing the mental symptoms in each instance of disease in single or in sev- eral organs combined, to indicate the number and office of the organs affected. Through knowledge thus derived, of the character of the existing physical disease, also, of the organs and faculties involved, we shall be prepared to apply the correct medical, mental and moral treatment, under the most favorable circumstances possible; and, without the danger of being diverted from the true course of action, by an artificial classification, based only upon mental symptoms, which are and must ever be, practically unliinited in number and in variety of form. Although the faculties now being considered are em- braced under the general head of “ Affective,” yet, for a more perfect understanding of the functional office of their respective organs, it should be explained, that they represent the strength and variety of each man's desires and impulses, in regard to all objects and subjects to which they relate,—to religious feelings in reference to the Creator and the future life; and to moral, social and domestic feelings, relating to man in his present state. To these should be added the self-protecting and self- regarding faculties, whose purpose or office should be well understood, as they all require either guidance, grati- fication or control, as the case may be, through the agency and mandates of the reason or will-power. With the full understanding, thus reached, of the dependence of the several classes of faculties, the perspective, reflective and affective, upon special organs or parts of the brain, for their positive and relative strength in manifestation, it will not be difficult to make a comparatively fair and just esti- Insanity or Mental Derangement. 521 mate of the natural. ability, and therefore, of the responsibil- ity of individuals, alike, in states of health and of disease. The diseased state of a single organ, to whatever class or coterie, so to speak, of the affective faculties to which it may belong, and whether arising from acute, chronic or perverted morbid action, has been called mono- 1 mania; but, as every single organ of other classes, or, of the perceptive and reflective are also liable to be thus affected, and as each differs from the others in functional office, it would be more definite and practical, as it regards the diagnosis and treatment of cases, to distinguish the disease at once, so far as possible, according to the organ and faculty involved, thus giving to it a local habitation and a name, corresponding to the organ and region affected. In justification of the objection made to the use of the terms mentioned, as representing classes of the insane, it may be farther remarked, that as the ac- tive desires and impulses of the mind, in a state of health, are but the expressed wishes for exercise and gratification of the affective faculties, single or combined, so their deranged state, from the same kind of morbid functional action, of their respective organs in the brain, is substantially the same, in each of the phases repre- sented by these terms; that is to say, by exalted, depressed or perverted functional action in one, or in all of the or- gans of this general class. Thus the morbid action of a single organ would be called monomania, acute or chronic, and, without regard to the fact of its belonging to one or another group of faculties, as the moral, the religious, the social or animal, while the mental symptoms in different cases, would vary according to the mental functions of the organs affected, whether acting singly as in the beginning, or in combination, at a later pe- riod. An extension of the same type of disease as in the first, embracing other organs, and characterized by symp- toms of more extended physical disease and mental disorder and excitement, would be called partial mania, which might be acute or chronic, and show greater or 522 H. A. Buttolph. less vascular or nervous excitement or perversion of func- tional action, indicated by the changed or perverted character of the mental symptoms present. Here again the mental symptoms vary so much on account of the mental functions involved, that a more correct idea of the seat and nature of the disease can be formed, if the fact be stated as to which of the faculties is most affected, or whether many or all of the several classes are involved ; thus making it mixed in form and general or universal in extent. In the latter case, natural feeling, moral restraint and sound judgment are all overturned, and the patient raves violence, blasphemy and folly by turns, or passes, in the course of short periods, through the phases of out- ward character, from the tumultuous agitation of infuri- ated rage, to the deepest dejection and melancholy; and it is in such circumstances that the remark of Esquirol, that “Mania, monomania, melancholy and dementia suc- ceed and alternate with each other, the disease itself re- maining the same,” is especially exemplified. It is most obvious, however, that in a condition like this, in which the fire of disease burns so rapidly and widely over the brain as to embrace nearly all of its organs and functions, within brief periods; yet that the very changes observed in mental symptoms, during its progress to and from the organs of one region or sub-region to another, shows that they vary in passing, not from any change in the type of the disease in the brain structure, but, according to the mental functions of the part or parts affected at any given point or period; thus demonstrating the inutility, not to say absurdity, of an attempt to characterize the disease by the use of terms and titles that have no definite rela- tion to its pathologi'. To show that there is neither mystery or impossibility in the occurrence of frequent and widely extended changes in the aspects of insanity, arising from the succession of morbid action as affecting different faculties, in examples given, I would call attention to the fact, that in health the faculties of whatever class also become interested and Insanity or Mental Derangement. . 523 active in succession, according as they are stimulated, by subjects and objects to which they naturally relate; and this, whether resulting from the spontaneous activity of their respective organs, or from their being presented to: the attention from without, through the usual channels of the special senses and perceptive faculties. Thus, through the influence of the accomplished orator, the various men- tal faculties of an individual, as the perceptive, reflective and affective, may be excited in turn and in quick succes- sion to the highest degree of rapturous applause for the good and successful, to the greatest degree of sympathy, of grief and despair for the unfortunate, or to the most de- termined resolution and positive indignation against the deeds and the doers of wrong. In another instance, the same kind and degree of morbid action attacking or affecting the single organ of Cautiousness, whose morbidly excited state, on account of its function, is shown by anxiety, fear, apprehension or despair, according to the degree or intensity of disease in the physical part, would be called melancholia. In still another form, unwisely called moral insanity (under the impression, by some, that the symptoms only or mainly show moral depravity), the various mental organs are af- fected by disease with only moderate excitement, but by much perversion of feeling. There are great varieties in the mental symptoms in different cases, and persons are often so essentially changed in their habits of thought and feeling, in action and expression, as plainly to indi- cate that they have undergone great variations in charac- ter, and this too, chiefly from the fact, that the propensities or animal desires and impulses, have become exceedingly strong, or quite uncontrollable, from disease; while the moral and religious feelings, the social and domestic qualities have been weakened, disordered and perverted in a marked degree. These cases appear under various aspects or phases, resulting from the different combinations among the men- tal organs to which they are subject, giving rise to great diversity of opinion and expression as to their true 524 H. A. Buttolph. character with acquaintances, friends and physicians; but especially with courts and juries, when responsibility for crime is involved. Thus the paralyzing influence of dis- ease in this class of cases operates, in a degree, like that arising from congenital deficiency and unbalance observed in another class of cases. The latter, however, as before stated, are to be regarded as states of incapacity and unsoundness, rather than of mental derangement, based primarily on disease of the brain. In either case, how- ever, an apt illustration is furnished of the liability to failure, on the part of the intellect, to judge correctly from false premises, which occurs when the normal balance between the reason and the affective faculties is lacking, through original defect in development, or lost afterward, as in this case, through disease in the same organs; and whether characterized by excitement, depression or per- version in their functions. This, however, is but a single illustration, though a strong one, showing the necessity of having the natural balance in the faculties maintained, alike in health and in disease. Difficulties not infrequently arise in attempts to distin- guish between acts of crime, in which the power of the will is dominated and overcome by mere passionate excitement, and others, in which a similar result has occurred through disease in the organ. As a general rule, however, nearly absolute safety against mistake can be secured in the latter, by carefully noting changes, if any, in the health, habits, character and conduct of individuals when charged with crime. Before closing the discussion in regard to varieties in disease and symptoms, it appears proper to re- call the fact, that insanity in all its forms, whether in examples given or otherwise, is liable to appear as con- tinuous, intermittent, impulsive and recurrent, and this at regular or irregular stages of its progress, according to the nature of the case, and the idiosyncracies of the in- dividual. In view of the interesting character and practi- cal importance of the disease in the latter or impulsive form, I give the history of a single case, reported by Dr. Insanity or Mental Derangement. 525 Marechal, in which a lady unhappily married, who nursed her infant for three months, when she became sad and taciturn, and was often in tears. One day, sitting near the fire, she exclaimed with eagerness and agony, “Snatch the child from me, or I will throw it in the flames !” and then confessed that for a “ length of time she had been strug- gling against an almost irresistible impulse to destroy the child, and that approaching a window or fire, the desire always returned.” Very many cases have occurred to show that, as in this, the desire to destroy the infant, was almost the first symptom of insanity noticed, the reason seeming in other respects entire, yet the mother would have been executed as a criminal had the act been accomplished, in- stead of being submitted to medical treatment to be restored to health. In this, and in similar cases, the power of long suppressing the appearance of aberration, in conduct and in conversation, until the disease becomes chronic, arises the acknowledged greater difficulty of curing disease, when only single organs and faculties are involved. In this case there is no evidence of difference in the pathology of the disease, from the other examples given, except that arising from the number and functions of the mental organs involved. Instances almost without number could be given of the disordered states of the affective faculties, either singly or in combination with others, showing to how large an extent, in disease as in health, they exercise a strong, even controlling influence, in acts of will and volition; and, hence, that any system of nosology that denies or ignores the existence of a fun- damental relation between them and corresponding organs in the brain, or that attempts to explain the philosophy of their action in another way, must, of necessity, prove insufficient and untrue. EXAMPLES OF DISORDER OF Religious SENTIMENTS, ETC. Many illustrations might be given of the deranged state of this class of faculties, which consists of Veneration, Marvelousness or Spirituality, and Hope, through whose 526 H. A. Buttolph. functional action, aided by revelation, man is made a re- ligious being, and placed in relation to the Creator and a future state. In some instances a single one of the group is disturbed in function at the beginning, but in most cases, the disease soon extends to embrace others; also one or several of the organs of other classes, thus modi- fying and complicating mental symptoms accordingly. Religious fanaticism, or excessive and ill-directed Vener- ation and Spirituality, was long regarded, and still is in many regions and nationalities, as a most fruitful source of insanity, and a pure example of a functional cause. It was so frequent at one time in France, that out of many cases of which Pinel could procure information, “nearly one-fourth arose from religious enthusiasm carried to ex- cess.” Says a prominent writer, “The greatness and ex- cellence of the object, and the satisfaction which the soul experiences, in giving itself up to the contemplation of the Almighty, excite too lively a sensation, and produce in the brain a tension too violent and too continued to be supported for a long time without injury, and soon throws the mind into fanatical madness and exhausts the body.” Pinel further remarks: “In every country and in every form of religion, fanaticism or blind, misdirected zeal, is a frequent cause of loss of reason.” If it be true, as thus appears, that the excessive indulgence in de- votional feeling may induce cerebral disease and madness, particularly in susceptible subjects and in those whose interest in religious truth and practice have long remained dormant, instead of attempting to conceal the fact, as is sometimes done, from false fear of bringing religion into danger or reproach, we ought, by every means, to make it generally known, that the evil may be prevented. When fairly examined, however, the danger is seen to arise solely from an abuse of religion; and the best safeguard is found to consist in a right understanding of its principles and submission to its precepts. In some instances, it would appear, that spirituality exerts greater influence over religious conception, than veneration itsell. It also Insanity or Mental Derangement. 527 gains credence to the true and the false prophet; favors. superstition and idolatry, but is essential to belief in the doctrines of refined religion. Swedenborg believed himself miraculously called to reveal to the world the most hidden mysteries. He states: “It pleased the Lord to manifest himself to me, and appear personally before me, to give me a knowledge of the spiritual world, and to place me in communication with angels and spirits, and this power has been continued with me till the present day.” Swedenborg, say his- biographers, “was a man of unquestioned sincerity, but one of the most extravagant enthusiasts that ever lived." If the moral and religious feelings are changed by diminished and perverted functional action, with a morbidly excited state of the passionate feelings, then blasphemy and imprecation take the place of devotion and benevo- lent tendencies previously existing. When Hope and Veneration are the faculties to which the functional ex- citement extends, brilliant anticipations of a happy futurity inark the character. Under such a form of disease, a lady mentioned by Pinel evidently labored, who became insane in consequence of her husband's misfortunes, and who found delightful consolation-first in long meditations and prayers, and subsequently, in ecstatic fits, during which she believed herself raised to the bosom of the divinity, and which, from excessive cerebral activity, ter- minated in unequivocal insanity. Among the functional causes of cerebral disease and mental derangement, says Dr. A. Combe: “The over- activity of Cautiousness, an organ second in size to none, stands pre-eminent. Under the present state of society, there is, perhaps, no faculty, which is called so often, so powerfully and so permanently into states of morbid ac- tion, and from which so frequently results nervous dis- order, and it may be added, when fully developed, into the lowest depths of despondency. When the excess of its activity is only moderate in degree, it produces. 528 H. A. Buttolph. hesitation and indecision, attended by over-anxiety on nearly all subjects and occasions, connected with the business, health and the movements of individuals. Timidity, ap- prehension, fear, despondency and despair, are the different degrees of intensity of this faculty, roused to a higher and higher degree by disease, till the cerebral organ at last gives way, when the most somber melancholy ensues. The wide prevalence of hypochondriacal affections, which embitter existence by the gloomy depression to which they give rise, and which are shown to have for a com- mon feature, a morbidly active Cautiousness, is another and convincing proof of the influence of excitement of function in inducing cerebral disease. In a marked in- stance of this kind, the disease was brought on by the combined anxiety about the health of a valued relative and fear about the success of business. The cerebral ex- citement thence resulting, indicated itself by unequivocal signs-determination of blood to the head, sleeplessness at night, restlessness by day, epistaxis and apoplexy. For a time the misery and wretchedness were so over- powering, that the idea of suicide often presented itself, but was fortunately resisted. When to the diseased state of the organ of Cautious- ness is added that of Conscientiousness, we have melan- choly developed in its most intense form with self- accusation, in which persons become morbidly conscien- tious, even in regard to acts that are only incidental and without moral character. As an instance of the latter, I mention the circumstance of once inquiring of a female patient of this class, who was disposed to blame herself for constant acts of wickedness, what she had done that day for which she would accuse herself? She reflected for a moment and replied, “I turned that chair around,” pointing to one in the room where she was. A good example, also, of this form of derangement, was that of a clergyman who accused himself of all the crimes ever laid to the charge of Napoleon Bonaparte, and considered him- self the most depraved of human beings. Another had Insanity or Mental Derangement. : 529 many a miserable night in the apprehension of passing the evening of an honorably-spent life in prison, from fancied inability to satisfy his creditors. In both of these gentlemen the organ of Conscientiousness was largely developed, and its activity conspicuous when in health. I would here recall the fact that the disease affecting these organs and producing an acute disorder of their functions is the same in kind as that producing high or maniacal excitement, as it is usually called when affecting others of different functional office. Hence, the distinction heretofore made between mania and melancholia, sɔ far as disease of the physical part is concerned, in the begin- ning, is quite groundless. It should be remembered, how- ever, that disease in organs whose disturbed functions are shown by anxious fears, as in the latter case, or with pining regrets following loss of gratification, as in other instances, exercise a highly depressing influence upon all other mental and bodily functions; and, in regard to the latter classes in particular, torpor is produced in every irritable part, as the digestive organs, the circulating and absorbent system, etc., leading, of course, to the necessity of a corresponding modification of treatment in the later stages. As an example of the extraordinary effect on the mind in general, of sudden and great fear (or the intense func- tional action of this organ). I mention a case given by Prof. Willard Parker, in his lectures, in which a young lady was instantly thrown into a state of extreme mental imbe- cility on finding a skeleton concealed in her bed. She was found soon after playing with the figure, in a totally blank state of mind and feeling, showing that when the functional power of the organ was overwhelmed and de- stroyed by shock, that no feeling of fear remained. Farther illustrations by cases might be given, showing the effect of disturbed function in other primary organs of the brain, acting singly or in combination, and representing various symptomatic forms of insanity. A brief allusion, 530 H. A. Buttolph. however, connecting organs with functions, must now suf- fice. The feeble development and perverted action of the organ of the Love of Life, leads, in some instances to suicide, while the contrary state is attended by anxious. fears of death. Sexual desire and impulse may be vari- ously and strongly affected in the insane by being highly excited, greatly perverted, much depressed or wholly suppressed, according to the type and stage of disease. Appetite for food and drink depends also, on a mental organ in the brain, giving rise to many peculiarities in the appetites and habits of individuals in health, and in states. of disease; favoring in one case, great excess; in a sec- ond, deficiency in quantity; while, in a third, may exist, extreme perversion of appetite, as to the kind or quality of food taken or desired. The tendencies in this organ in regard to drinks, result, with other causes, quite as various in health, but more disastrously in disease, than those relating to food. They include a natural love or aptitude for stimulants, habits of intemperance, ending often in delirium tremens, also in insanity, more or less prolonged and modified in its phases, including dipsomania, so-called. The organs of the domestic feelings, also, of the love of offspring, may suffer from excited, depressed or perverted functional action, showing endless variety in the character and hab- its of persons regarded as sane, and an equal variety in those reported as insane; while the complication in the moral management of the first and the medical and other treatment of the second, is about equally difficult and unsatisfactory. Irregularities and abuses in the acquisition and use of property are common alike with the sane and the insane, often leading to difficulty in distinguishing be- tween acts of lawless abuse in one and insanity or morbidly excited or perverted action in the other; and called theft or kleptomania, according to the theoret- ical or other views of the observer. Excessive, but sometimes deficient action in the defensive faculties, tend- ing, in one instance, to exhibitions of passionate resent- Insanity or Mental Derangement. 531 ment, violence and even bloodshed; but in another case or stage, to the other extreme of. mildness, through the suppression of passionate impulse, from temporary loss of functional power in the organs involved. Morbid exhibi- tions of pride, obstinacy and vanity, occur, as the result of disease in the several organs affected. From the sketches given of cases and conditions, it is clearly evident that the forms of mental disorder, to which the affective faculties are subject, and known by the old-time appellations mentioned, are substantially the same, so far as the pathology of the disease in the brain is concerned, subject only, or mainly, to modifications re- sulting from the grade of diseased action present, and the number and office of the mental organs involved. If this be true, and if, through such agency alone, the mental symptoms and phenomena can be explained (though practically unlimited in number and variety of form), why should we continue to value and to collect statistics, founded on a basis thus shown to be unsound, and withal, misleading to the practitioner, while it inevitably obstructs the progress of improvement in this most important branch of medical inquiry? Uterine Disease as a Factor in the Pro- duction of Insanity. By ALICE MAY FARNHAM, M. D., Assistant Physician, Willard Asylum for the Insane. THE medical, scarcely less than the scientific world, 1 has its “glass of fashion and its mould of form.” Not so many years ago as to be beyond the memory of the oldest inhabitant went forth unto the medical world an edict, that nearly all of those ills to which feminine flesh is heir are due either to disorders of the female reproductive organs, or so influenced by these organs as to constitute a peculiar class of diseases. The wide- spread popularity of the idea soon became evident. Mental and nervous maladies, with their obscure mani- festations and their ill understood pathology, seemed to offer a rich field for the practice of the fashionable spe- cialty. And the alienist and neurologist beheld his hysteri- cal, melancholic and maniacal patients torn from his grasp and, by the wave of public opinion, cast into the hands of his brother practitioner, the gynæcologist. Dr. Skene* expresses himself in these words: In the literature of the past we find the gynæcologist pushing his claims so far as to lead a junior in medicine to believe that if the sex- ual organs of women were preserved in health, insanity would seldom occur among them. The doctrine of the importance of the uterus in influ- encing both the bodily and mental health of woman is not a recent one. Aristotlef affirmed that the womb traveled through the body, giving rise to all of the hybrid symp- toms of so-called hysteria. Jacobus Primrose, in his “Diseases of Women," pub- “Gynæcology and Insanity,” Archiv. of Med., Feb., 1880. † Quoted in “Diseases of the Nervous System," by Samuel Wilkes, M, D., p. 362. [532] Uterine Disease in the Froduction of Insanity. 533 lished in Rotterdam, 1655, mentions uterine disease as a cause of epilepsy, melancholia, heart trouble, disorders of the spleen, stomach and head. Esquirol* Prichard, † Tuke, I Carlieu, $ Clouston,|| mention disorders of the female re- productive organs as important in the etiology of insanity. Dr. Storer, in his “Insanity in Women,” gives great prominence to the influence of the uterine system upon the mind; and an enthusiastic gynæcologist expresses himself in the following words: It is conceded that kleptomania, pyromania, dipsomania, homicidal and suicidal impulses and the morbid displays of pregnant women may have their starting point in uterine disease with more unanimity and certainty than puerperal mania, for the latter is often as much an in- sanity of general bæmic and neuric exhaustion, anemia and shock as of retiex irritation. That the stand-point of the above writer is an ultra one we must at once confess. Yet, in the complex asso- ciation of the uterine and nervous systems it is often impossible to trace the connection of cause and effect. Notwithstanding this, it may not prove unproductive of profit, in the following pages to endeavor to trace the relation existing between disorders of the brain and the female genitalia. In such consideration we are first natu- rally led to the observation of insanity of puberty. THE INSANITY OF PUBERTY, The period of puberty is fraught with perils, physical, moral and mental, to the developing human being. But even in this transition, thanks be to mother Nature, the majority of children pass safely through the crisis, exhib- iting but slight changes in disposition, nervous irritability or hysteria. But less fortunate are those unhappy beings cursed with a neurotic heredity. Often in them at this. • Q.loten in " Amenorrhees as a Cause of Insanity," by S. W. Duckworth Williams, n Journal Nervous and Mental Diseases, Vol IX, p. 316. • Trellise on in-arity,' quoted in above, "Manual of Psychological Medicine,' pp. 286, 489, 578. ş" Bulletin de l'academie de Medicine,'' 1861, p. 479. #" Clinical Lectures on Mental Diseases,' p. 473. T“ Mora! Insanity' by C. 11. llughes, in Journal of Payehological Medicine, Vol. VIII. , p. 61. 534 Alice May Farnhamn. season the seeds of mental disorder that have lain latent, spring up, and by their noxious influence poison the mental and moral nature of the child. For, as remarked by Clouston:* The insanity of puberty is always a strongly hereditary insanity; it, in fact, never occurs except where there is a family tendency toward mental defect or toward some other of the neuroses. Its immediate cause may be irregularity in the coming on of the reproductive or menstrual function; its real and predisposing cause is heredity, having for its object this higher physiological law, that the reproduction of the species is stopped when the inberited tendency to brain disease ac- quires a certain strength in any individual. Mental alienation at the age of puberty is by no means rare. Epilepsy, melancholia, mania and dementia, may develop, although Clouston, in examining one hun- dred and eighty cases of insanity of puberty and adoles- cence, found but forty cases of melancholia, the renainder being cases of mania. The insanity of puberty is therefore one of motor disturbance. Spitzka confesses that personally, among one hundred and eighty-seven private patients ex- amined by him he found but three cases of the insanity of pubescence. But he states that the records of a pauper institution “yielded the high figure of nearly five per cent. of this psychosis.” I That females are more prone to insanity at this period than males is not proven. Clouston considers the danger greater for boys, while the reverse is the opinion of Bucknill and Tuke.|| Authorities seem to consider the prognosis of this form of insanity favorable, although patients are apt to have a return of the disease at other critical periods, for in- stance, during pregnancy and the grand climacteric. Although possessing but incomplete notes of two cases of insanity of women occurring at the age of puberty, their citation may prove of interest. * “Clinical Lectures on Mental Diseases,' p. 525. + " Clinical Lectures on Mental Diseases," p. 65). | "Insanity," p. 127. $ “ Clinical Lectures,' p. 550. li “Psychological Medicine," p. 265. Uterine Disease in the Production of Insanity. 535 Case of Mrs. W. H.—No hereditary tendency to in- sanity known. At the time of puberty she had an attack of mania, but made an apparently perfect recovery. Some years elapsing with no return of her malady, her parents allowed her to marry. She remained perfectly well until the birth of her first child, when mania again appeared, and she became so violent that she was sent to the Mai- son de Sante. · And there, although twenty years have elapsed, she still remains, unrecovered. CASE OF J. H.—Æt. thirty-one years; occupation, teacher; no known predisposition to insanity. She first men- struated at the age of sixteen years. Epilepsy developed simultaneously with the catamenia. Three years later her mental deterioration became marked, and in 1880 she was admitted to Willard Asylum for the Insane. At that time the epileptic attacks occurred at each . period of menstruation. For five months after her admission she had amenorrhæa, but the history does not relate whether her mental state was affected by this condition. She has never, as far as can be learned, suffered from dysmen- orrhæa. Pelvic examination showed a uterus rather small and slightly retroverted; a “pin-hole os.” No other peculiarity noted. INSANITY OF THE CLIMACTERIC. In the eyes of the laity the “change of life” occupies an important place in the production of insanity. Medical authorities, however, are not agreed as to the influence upon her mental condition of this era in the life of woman. Dr. Reid* states that of seven hundred and three cases admitted to the Hanwell Asylum during a period of eight years only eight cases were due to the change of life. Clouston, out of three thousand one hundred and forty- five cases found one hundred and ninety-six cases of “Puerperal Insanity,” by James Reid, in Journal Psychological Medicine, Vol. I., p. 129. 536 Alice May Farnham. climacteric insanity.* Tilt,† in examining five hundred women, found four hundred and fifty-nine suffering from some form of nervous irritability. Maudsleyf and Skaes attribute to insanity of the menopause a peculiar type- melancholia, with gloomy delusions of an extreme char- acter. Other writers have found mania, epilepsy, hypo- chondriasis and irresistible impulses, to originate at this time. But the testimony seems to place the climateric among the predisposing rather than the exciting causes of mental disorder, although there may exist notable ex- ceptions. In many of the reported climacteric cases other disturbing factors, as ill health, intemperance and domes- tic troubles co-existed. In a number of others hereditary predisposition and previous attacks of cerebral disturbance were present. In my examination of Willard records, comprising more than four thousand cases, I unfortunately failed to note any but those cases in which the mental alienation was ascribed to "change of life," uncomplicated by other ex- citing conditions. Of the entire number of admissions I found only ten that were thus classified. Five of these were cases of mania, two of melancholia, three of demen- tia. In six there was an hereditary predisposition to mental disorder; in two the heredity was unknown, and in two cases no heredity. The question naturally presents itself, What pathological conditions underlie the appear- ance of insanity at the menopause? Is it cerebral con- gestion, as advocated by some, or cerebral anæmia, as affirmed by others? or yet, as was maintained by Drs. Todd and Cormack,ll due to the retention in the system of " poisonous material ? Each of these theories has had its day. The present theory of reflex excitability is most popular. This briefly formulated is as follows: The ovaries, after long years of service, have not the • “Clinical Lectures on Mental Diseages," p. 563. + “ Change of Life,” by Tilt, p. 165. i Quoted in Tilt's “Change of Life," p. 188. $ "Climacteric Insanity in Women," by Francis Skae, in Edinburgh Medical Journal, February, 1895. ! Quoted in Tilt's "Change of Life," p. 203. Uterine Disease in the Production of Insanity. 537 ability of retiring into a graceful old age, but becoming irri- tated, transmit their irritation to the abdominal ganglia, which in turn transmit the irritation to the brain, pro- ducing in the cerebral tissue disturbances that exhibit themselves in extreme nervousness or in an outburst of actual insanity. Many of the women suffering from climacteric insanity have previously had attacks of mental disorder, and the great physiological change has proved too much for their unstable mental equilibrium. In the notes of the following cases hereditary tendency, exhibiting itself in the condition of general mental instability, will be noted. CASE OF W. H.-Belonged to a neurotic family. She was a queer-tempered child, but grew up into a fine healthy woman. When about fourteen years of age, at the establish- ment of menstruation, she was in the habit of walking the floor at night, weeping and wringing her hands. However, with the exception of a younger sister, no one seemed to recog- nize anything peculiar in her conduct. Although a sufferer from dysmenorrhæa she never consulted a physician, but at the coming on of the menstrual period would often have attacks of what she called "glooms.” This lady never married, seeming to dislike all masculine attention. When she was about forty she began to change in this respect, and indeed seemed to court attention rather than to shun it. She fell into a condition of profound gloom, disliking exertion and her ordinary occupations. After this had lasted, progressively increasing, for several weeks, she suddenly one day became violently insane at the dinner table, and it was necessary to send her to an asylum. Here the violent condition was succeeded by an almost idiotic state, which lasted for several months. During this time she never menstruated, and it was supposed that she had reached the menopause. In about six months the func- tion was resumed, and was regular for nearly a year. Its return has been accompanied by great mental improve- ment. Her memory and her old love of order are 538 Alice May Farnham. restored, although she chooses to call herself a child, and declines to interest herself in family affairs or to take up the burdens of life. Her periods of greatest excitement correspond to her menstrual epoch. . Case of Mrs. B. C.—Sister of the above, and wife of a clergyman. With the exception of an attack of puer- peral mania, after the birth of her third child, from which attack she made a speedy and complete recovery, her mental health seemed excellent. She led for twelve years an exceedingly useful and busy life, but her health began to fail again. She suffered from severe floodings and in- somnia. Mindful of the fate of her sister, she consulted a physician, but too late. She is now the victim of melancholia, although her friends think her condition is improving. AMENORRHEA. The importance of amenorrhea as a factor in the pro- duction of insanity in women is a question upon which there is no uniformity of opinion. That amenorrhea and insanity frequently co-exist is an established fact. Whether, as maintained by Esquirol* and Prichardt and Hood, I as a cause of the mental disorder, or, as asserted by M. Voisin,ß as a result of the mental disorder, is a point that is still undecided. It is probably a mere physi- cal symptom of a general disease affecting both body and mind. Tuke,ll speaking of suppressed menstruation, re- marks: Although often only an early symptom of the disease when set down as a cause, there remain a large number of cases in which sup- pressed or irregular menstruation is the true cause of the attack-about ten per cent. of the female admissions. Clouston mentions amenorrhea as an occasional cause * Quoted in “Amenorrhea as a Cause of Insanity,” in Jour. Nery, and Ment. Dis., Vol. IX., p. 314. + Ibid. I “Statistics on Insanity," quoted in the above. $ M. Voisin Prize Essay, Paris, 1826. || “Psychological Medicine," p. 286. I "Clinical Lectures," p. 474. Uterine Disease in the Production of Insanity. 539 of insanity. Suggesting, however, that general deteriora-: tion of the health may in many cases prove the exciting cause of mental alienation; absence of catamenia still further aggravating the existing mental condition. Vari- ous theories have been advanced as to the relation of amenorrhæa to insanity. Many authorities consider the sudden cessation of menstruation productive of congestion of the brain. One writert considers that contaminated blood retained in the system acts as a poison upon the tissues, especially the brain, producing severe constitu- tional symptoms. The same author states that the amen- orrhæa following mania is probably due to condition of general anæmia As to the form of mental disorder pro- duced by absence of the catamenia, mania, melancholia and dementia have each been attributed to this cause. Though it has been averred that melancholia and amen- orrhea are much more frequently associated than mania and amenorrhea, in searching the literature of this subject I have not found a large number of recorded cases. The famous case of Pinelf is so well known as to have become classic : A girl, who from the age of ten years was in a state of incoherence with suppression of the catamenia, one day on arising from bed she ran and embraced her mother, exclaiming, “ Mamma, I am well!" The catamenia had just flowed spontaneously, and her reason was immediately restored. S. W. Duckworth Williams narrates a series of six cases, comprising two cases of melancholia, three of ma- nia and one of dementia. In each case he considered the mental condition due to amenorrhæa, and acting upon that supposition, treated each with an emmenagogue pill of iron and aloes. The cases of mania and melancholia were restored to health with the return of menstruation, + H. Sutberland, "Menstrual Irregularities and Insanity,” West Riding Lu- natic Asylum Reporte, II, 1872. I Quoted in “Amenorrhea as a Cause of Insanity,” by S. W. Duckworth Williams, in Jour. Nery. and Ment. Dis., Vol. X., p. 316. § Ibid. 540 Alice May Farnham. but the mental condition of the case of dementia remained unchanged. In many cases of mania where menstruation continues the period of greatest excitement corresponds to the men- strual epoch, and is apparently increased by it. And, as remarked by Dr. Sutherland;* in cases where mania and menorrhagia co-exist the mental excitement is almost con- tinuous. Again: In many cases of melancholia so marked is the condition of general anæmia that the re-estab- lishment of the catamenia could hardly be accomplished without a restoration to health and a new, a rich blood supp'y. In examining the case books of the Willard Asylum, I found six cases of insanity in women where the mental alienation was attributed to amenorrhæa. Two of the cases were due to sudden suppression from cold bath- ing during menstruation. In one there was an hereditary tendency; in the other none. The form of insanity in both cases was dementia, and the patients did not recover their mental health. Of the other four cases no particulars of the inception of the disorder were given aside from "suppression of menstruation.". In two cases there was hereditary predisposition; in two none. Three were cases of mania, one of which was periodic; one a case of chorea with mental disturbance. The history of the latter case is as follows: i CASE Of L. T.-A healthy girl of eighteen years ; had, with the exception of a great aunt, who became insane at the climacteric, no hereditary predisposition to insanity. L. T. first menstruated at the age of twelve years. The establishment of menstruation was accompanied by no un- due disturbance of physical or mental health. In July, 1882, during a menstrual period, she became chilled. The flow ceased, and one week later slight choreic move- ments were noticed. These soon became general. Her mind seemed affected from the first. The chorea lasted for about four weeks, then gradually ceased. After its * "West Riding Lunatic Asy,um Reports," Vol. II., 1872, p. 53. Uterine Disease in the Production of Insanity. 541 cessation her mental condition grew worse. At times she was dull, stupid and silent; at others, loquacious but in- coherent, repeating a sentence again and again. Some- times she was violent and boisterous and very active and destructive. She was always worse at the time when inenstruation should have occurred. She grew steadily worse, became oblivious to the “calls of nature." She had many delusions, one of which was that she was black, and all around her were black. In September, 1882, at the time of her admission to the asylum, she was quiet and reserved. She would an- swer questions, though slowly and with much hesitation. Her eyes appeared peculiar, from a slight divergent stra- bismus. Conjunctiva was markedly congested. She was very pale, and had an anæmic cardiac murmur. Her condition remained for some time unchanged. During October and November she was given strychnia mixture and aloes pills. She complained of some spinal pain in the cervical and dorsal regions. In the latter part of November the galvanic current was applied to the cervical sympathetic. December 6th, galvanic current was ex- changed for the faradic. The anode was applied to the lumbar region, the cathode to the ovarian. December 28th, menstruation was re-established, and January 26th patient was discharged recovered. CASE OF A. C.-Was rather late in menstruating; showed great irritability as well as gloomy forebodings, before the establishment of the catamenia. Afterwards she seemed perfectly well for two or three years. At the end of that time menstruation became scanty and melan- cholia with suicidal tendencies developed. She was ordered abroad by her physician, and on the voyage became very sea-sick. Flooding was brought on. She at once improved mentally. Menstruation became regular and she regained her mental health. She remained well for a number of years, marrying and passing through one pregnancy, con- finement and lactation with no mental disturbance, great 542 Alice May Farnham. care being taken of her health during that time. In her second pregnancy, however, deeming precautions were no longer necessary, she overworked, nursing a sick child. Nevertheless, she passed safely through her labor; but, when her child was two weeks old, she was seized by convulsions followed by mania, and in about one week died, having in that time made several attempts upon her life. In this modern age of luxury and comfortable living asceticism has passed away, and men have learned that, not by the practice of bodily mortifications can they hope to keep the brain in a healthy condition, but that so intimate is the union of mind and body that one cannot suffer with- out causing misery to the other. It thus happens that distant organs, by a diseased condition, causę cerebral irri- tation, prejudicially affecting other organs. Between the reproductive system and the brain is the law of reaction and reaction best exemplified. And uterine and ovarian diseases are supposed to act us a potent cause of insanity in women. According to some statistics, from one-twelfth to one-sixth of the entire number of insane females owe to this source the cause of their mental alienation. Ovarian disease, uterine displacements and inflammation of the cervix-each is credited with adding its quota to the great number of the "mentally dead.” The obscure class of nervous manifestations known under the general name of “hysteria,” were formerly thought to be due exclusively to uterine or ovarian mal- adies. But observation has shown that so-called hysteria is not confined to the female, and even in her is frequently in- dependent of any disturbance of the genitalia. Dr. Albert Peuch, of Nimes, France,* has reported a case of typical hysterical attacks in a woman in whom neither uterus nor ovaries could be discovered. Scanzoni, in his examination of hysterical cases, found from nineteen to twenty per cent. with no lesion of the sexual organs.†. . “Gaz. Obstet. de Paris,' quoted in Gaz. Hospitaux, Aug. 23, 1873. | Jolly, on “Hysteria,” Ziemssens' Cyc., p. 483, Vol. X V. Uterine Disease in the Production of Insanity. 543 Jolly* is of the opinion that only one-half of the cases. of hysteria suffer from uterine disease. Gowerst found ovarian tenderness present in one-half of his cases of hystero-epilepsy. Dr. Matthews Duncan, I in a recent meeting of the British Medical Association, expressed doubt as to the universality of disorders of the genitalia in hysteria. Dr. Allen McLane Hamiltons thinks that the influence of the uterine disease in hysteria has been largely over- rated. Dr. Charles K. Mills,|| in an article on hysteria, says: The alleged uterine origin of hysteria has been entirely disregarded in the definition. This has been done intentionally. It is high time for the medical profession to throw off the thraldom of this ancient view. The truth is, as asserted by Chambers, that "hysteria has no more to do with the organs of reproduction than with any other of the female body; and it is no truer to say that women are byterical because they have wombs than that men are gouty because they have beards." Dr. H. C. Wood, in speaking of neurasthenia in women, says: In not a small proportion of the cases of uterine disorders which are often locally treated, I believe the local disease is largely the ex- pression of a general condition. This subject assumes great importance when we con- sider the question of ovariotomy for the relief of severe cases of hysteria or insanity. Many startling cures brought about by oophorectomy have been reported in the journals. But on investigation of the subsequent history of such case, relapses are frequently found to have occurred. In Battey's** collection of oophorectomy cases from the year 1872 to 1881 epilepsy is said to have been present in twenty-six cases, and relieved in two-thirds of that * Jolly, on “Hysteria.” Ziemssens' Cyc., p. 481, Vol. XIV. † Quoted in “Hystero-Epilepsy," by Frederic Bateman, M. D., in Jour. Nerv. and Ment Dis., Vol. XI., p. 6. | Quoted in "Hystero Epilepsy," by Frederic Bateman. $ “Epilepsy,” by Allen McLane Hamilton, in Pepper's Cyc., Vol. V., p. 357. || “Hystero-Epilepsy,” by Chab. K. Mills, in Pepper's Cyc., p. 208. I "Neurasthenia,” by H. C. Wood, in Pepper's Cyc., Vol. V., p. 357. • Contribution to the “Study of Hysteria,'' by H. C. Walton, in Jour. Nery. and Ment. Dis., Vol. XI., p. 430. 544 Alice May Farnham. number. Probably Dr. G. L. Walton approached the truth in this matter when he said :* In the majority of cases of hysteria the cerebral difficulty is prob- ably a constitutional one, and the ovarian tenderness, which rarely fails, is merely a local hyperästhesia, and in such cases no more can be expected from the removal of the ovaries than from the removal of a sensitive spot on the spine or scalp. With an idea of arriving at some conclusions in regard to the relative value of the uterine disease as an etiological factor in the production of insanity, I conceived the idea of comparing the result of the pelvic examination of a cer- tain number of the female patients of Willard Asylum with the same number of mentally healthy women of the same pauper class. The task proved to be a somewhat difficult one, and instead of the hundred cases that I at first planned to examine I succeeded in obtaining examinations of but thirty sane women. I hope, however, in the future to enlarge the number. The cases were obtained from an almshouse and penitentiary in this State. The ages of the persons examined were from seventeen to sixty years. Some were healthy; others suffered from various disorders, as rheumatism, phthisis. In fact, in all particulars except in mental condition, the county house and penitentiary cases were as nearly as possible the prototypes of their less for- tunate sisters behind asylum walls. The result of the examination was somewhat surprising. Out of thirty men- tally healthy women but four were found in whom the pelvic organs were in a condition of health. Out of the same number of insane women, taken seriatim from the patients in two wards, six were found in whom the pelvic organs were in a condition of health. At the end of this article will be found a table showing the lesions found. Were uterine disease really so powerful an agent in the production of insanity it would be a matter for wonder, that, with the alarming prevalence of such disorders, so few women exhibit profound nervous disturbances. So there- fore, if we grant that women do become insane from dis- * Contribution to the “ study of Hysteriu," by H. C. Waliun, iu Jour. Nerv. and Mental Dis., Vol. Xl., p. 430. Uterine Disease in the Production of Insanity. 545 orders of the reproductive organs, we are compelled to admit the existence of other factors, as a weak constitution, a neurotic heredity, a body worn out by ill health or do- mestic worries. Each of these may produce a great sensitiveness of the nervous system, and the uterine mal- adies superadded, furnish the “straw that breaks the camel's back.” Doubtlessly reproductive diseases in women often modify the manifestations of the insanity. As in the case of a woman at present in this institution, who, with ovarian tenderness and a uterus enlarged and retroflexed, had de- lusions of pregnancy. As the local condition improved under treatment the delusion became less prominent, and perhaps has disappeared altogether, for when questioned, instead of her former loquacity on the subject she now maintains a complete silence. Dr. Sutherland,* in the West Riding Reports, says that of the one hundred and sixty-two maniacal women under his charge ninety-nine had periods of excitement which could be referred to the catamenia period. Association between the menstrual periods and the mental condition may be traced in the following cases: CASE OF F. G.-Aged forty years; married. Her father died of phthisis, her mother of paralysis. She has a sister who is insane. Five years ago the patient, who had before shown no abnorinal mental state, became, at the time of a menstrual period, confused, sleepless, and obscene in her habits and conversation. Since that time she has had periods of excitement at each menstruation, during the intermenstrual time being quiet and comparatively 'sane. Such was her condition at the time of admission, 1882. April, 1883: She has passed several months with no period of excitement at the time of the catamenia. During 1884 she had periods of great excitement, and was, at menstruation, erotic, abusive and extremely irri- table. Has metorrhagia. * "Menstrual Irregularities and Insanity,” by Henry Sutherland, West Riding Lunatic Asylur. Reports, II, 1872, p. 53. 546 Alice May Farnham. 1885: Less excitable, but maniacal attacks periodic. 1886: Patient's mental condition has improved. Three months ago she had a maniacal period lasting for several months. At this time her period of greatest excitement was during menstruation. 1887: For nearly a year she has had no maniacal at- tack. Is quiet and industrious. At present she, however, seems on the verge of another outbreak. For eight months she has had local treatment for uterine disorder. When treatment was begun pelvic examination showed a uterus- anteverted and measuring four inches, a cervix lacerated and follicular. The local condition has greatly improved. CASE OF Mrs. W. H.—This patient married rather late in life. She was of a very “queer” and fretful disposition, and belonged to a neurotic family. Her father suffering from anterior spinal sclerosis, and one brother being insane. After the birth of her second child recovery was slow. The perineum was badly, torn and no attempt at repair was made. After two or three months she became insane at a menstrual period, and it was then shown that before marriage she frequently had been maniacal at such times. She recovered, but, in order to preserve her mental health, is obliged to have almost complete rest during menstrua- tion. Yet she has borne two children with no mental disturbance. In the study of the relation of the mind and the female genitalia, as set forth in this paper, the following conclu- sions may be drawn : 1. That while the female reproductive organs and the brain are closely associated, oſten acting and reacting upon each other, uterine disease alone is seldom or never the cause of mental alienation. Other conditions, as hereditary predisposition to insanity, poor bodily health, or mental worries, one or all furnishing the necessary adjunct to the development of disorders of the mind. 2. That in insane women irritation of the genitalia often gives a peculiar character to the mental condition. And, Uterine Disease in the Production of Insanity. 547 . . . . . . 3. Menstruation, like any periodic lowering of the standard of the general health, frequently acts, in cases of mania, as the excitant of the most marked maniacal outbursts. WILLARD Cases. Alms House Cases. Anteflexion of uterus and lacer Anteflexion of uterus and lacer- ation of the cervix.... ......... 1 ation of the cervix...... ....... 1 Anteversion of uterus............. 1 Anteversion of uterus............... 1 Atresia of vagina .................... 1 Cellulitis (old)............. .. 11 Cellulitis (old).. ....................... 2 Cellulitis (old) and uterine atro- phy............... ................... 1 Cellulitis (acute) and ovaritis... 1 Endocervicitis and uterine sub Endocervicitis and uterine sub- involution .......... ....... 1 involution ....................... 1 Endocervicitis ................. Laceration of the cervix........... 2 Laceration of the cervix........... Laceration of cervix and lacer Laceration of cervix and lacer- ation of perineum.............. 1 ation of perineum ............... Laceration of cervix and lacer- ation of perineum uterine polypus.............................. Laceration of cervix and pro- | Laceration of cervix and pro- lapsus of uterus...... lapsus of uterus.. Laceration of cervix and retro Laceration of cervix and retro- version of uterus.... version of uterus. ............ 1 Metretis............ Laceration of perineum ............ Laceration of perineum and an- teflexion of uterus........ ..... Laceration of perineum and uterine subinvolution......... Prolapsus of uterus............ Prolapsus of uterus.................. Retroflexion of uterus......... Retroflexion of uterus.............. Retroversion of uterus ............. 3 Retroversion of uterus and en Retroversion of uterus and en- docervicitis .............. ...... 1 docervicitis......... .......... 1 Retroversion of uterus and can- cer of cervix .... Subinvolution of uterus......... Subin volution and endocervi- citis ....... 1 Subinvolution and anteflexion of uterus ............................ Tumor (ovarian)...... 1 Tumor (uterine fibroid) ........... 1 Normal........ ...... 6 Normal. Total.. Total .... ...... 1 ..... 81 PROCEEDINGS OF THE FORTY-FIRST ANNUAL MEETING OF THE ASSOCIATION OF MEDICAL SUPERINTEN.. DENTS OF AMERICAN INSTITUTIONS FOR THE INSANE. The Forty-First Annual Meeting of the Association was called to order at 10 o'clock a. m. of Tuesday, June 14, 1887, in the Council Chamber of the City Hall, at Detroit, Michigan, by the President, Dr. H. A. Buttolph. The following members were present during the sessions of the Association : J. B. ANDREWS, M. D., Buffalo State Asylum for the Insane, Buffalo, New York. R. BARKSDALE, M. D., Central Lunatic Asylum, Petersburg, Virginia. E. O. BENNETT, M. D., Wayne County Asylum, Wayne, Michigan. W. J. BLAND, M. D., West Virginia Hospital for the Insane, Weston, West Virginia. G. ALDER BLUMER, M. D., State Lunatic Asylum, Utica, New York. J. E. BOWERS, M. D., Hospital for the Insane, St. Peter, Minnesota. J. P. BROWN, M. D., Taunton Lunatic Hospital, Taunton, Massachu- setts. C. B. BURR, M. D., Assistant Physician, Eastern Michigan Asylum, Pontiac, Michigan. D. R. BURRELL, M. D., Brigham Hall, Canandaigua, New York. H. A. BUTTOLPH, M. D., Short Hills, New Jersey, J. H. CALLENDER, M. D., Hospital for the Insane, Nashville, Ten- nessee. MICHAEL CAMPBELL, M. D., Hospital for the Insane, Knoxville, Ten- nessee. John B. CHAPIN, M. D., Pennsylvania Hospital for the Insane, Phila- delphia, Pennsylvania. DANIEL CLARK, M. D., Asylum for the Insane, Toronto, Ontario. C. K. CLARKE, M. D., Asylum for the Insane, Kingston, Ontario. F. H. CLARKE, M. D., Assistant Physician, Eastern Lunatic Asylum, Lexington, Kentucky. GEORGE F. Cook, M. D., Oxford Retreat, Oxford, Ohio. EDWARD COWLES, M. D., McLean Asylum for the Ingane, Somerville, Massachusetts. [548] Proceedings. 549 JOHN CURWEN, M. D., State Hospital for the Insane, Warren, Penn. RICHARD DEWEY, M. D., Eastern Illinois Hospital for the Insane, Kan- kakee, Illinoig. JOSEPH DRAPER, M. D., Asylum for the Insane, Brattleboro, Vermont. A. STANLEY Dolan, M. D., Assistant Physician, Asylum for Insane Criminals, Ionia, Michigan. B. D. EASTMAN, M. D., Lunatic Asylum, Topeka, Kansas. 0. EVERTS, M. D., Cincinnati Sanitarium, College Hill, Ohio. W. B. FLETCHER, M, D., Hospital for the Insane, Indianapolis, Indiana. L. A, FROST, M. D., Assistant Physician, Hospital for the Insane, Jacksonville, Illinois. J. Z. GERHARD, M. D., Pennsylvania State Lunatic Hospital, Harris- burg, Pennsylvania. H. A. GILMAN, M. D., Hospital for the Insane, Mount Pleasant, Iowa. W. B. GOLDSMITH, M. D., Butler Hospital, Providence, Rhode Island. W. A. GORTON, M. D., Danvers Lunatic Hospital, Danvers, Massachu- setts. EUGENE GRISSOM, M. D., Insane Asylum, Raleigh, North Carolina. G. H. Hill, M. D., Hospital for the Insane, Independence, Iowa. L. S. HINCKLEY, M. D., Essex County Asylum, Newark, New Jersey. HENRY M. HURD, M. D., Eastern Michigan Asylum, Pontiac, Michigan. H. A. HUTCHINSON, M. D., Western Pennsylvania Hospital for the In- sane, Dixmont, Pennsylvania. J. G. Johnson, M. D., St. Joseph's Retreat, Dearborn, Michigan. Edwin A. KILBOURNE, M. D., Hospital for the Insane, Elgin, Illinois. W. M. KSAPP, M. D., Hospital for the Insane, Lincoln, Nebraska. 0. H. Long, M. D., Asylum for Insane Criminals, Ionia, Michigan. W. H. Mays, M. D., Asylum for the Insane, Stockton, California. J. D. Munson, M. D., Asylum for the Insane, Traverse City, Michigan. CHARLES H. Nichols, M. D., Bloomingdale Asylum, New York City. EDWARD B. NIMS, M, D., Lunatic Hospital, Northampton, Massachu- setts. GEO. C. PALMER, M. D., Asylum for the Insane, Kalamazoo, Michigan. R. J. PATTERSON, M. D. Bellevue Place, Batavia, Illinois. Fosier PRATT, M. D., Kalamazoo, Michigan. H. K. PUSEY, M. D., Central Lunatic Asylum, Anchorage, Kentucky. J. D. ROBERTS, M. D., Eastern N. C. Insane Asylum, Goldsboro, North Carolina. THOMAS F. SAVAGE, M. D., Assistant Physician, Asylum for the Insane, Kalamazoo, Michigan. R. E. Smith, M. D., Asylum for the Insane, No. 2., St. Joseph, Missouri. H. P. STEARNS, M. D., Retreat for the Insane, Hartford, Connecticut. J. T. STEEVES, M. D., Provincial Lunatic Asylum, St. John, New Brunswick. H. A. TOBEY, M, D., Asylum for the Insane, Toledo, Ohio. H. B. WILLIAMS, M. D., Assistant Physician, Little Rock, Arkansas. P. M. WISE, M. D., Willard Asylum for the Insane, Willard, New York. W. L. WORCESTER, M. D., Assistant Physician, Asylum for the Insane, Kalamazoo, Michigan. 550 Proceedings. The minutes of the last meeting were read and ap- proved. Hon. M. H. Chamberlain, Mayor of Detroit, having been introduced to the President of the Association by Dr. Henry M. Hurd, Chairman of the Committee of Arrange- ments, his Honor was in turn introduced to the Association, whom he addressed extemporaneously: Mr. President and Members of the Association of Medical Superintendents of the Insane Asylums of the United States and Canada-It gives me pleasure to welcome you here this morning to the city of Detroit. I presume most of you are acquainted with our city, and have been here often before. I have no doubt, during your pleasant stay, that your friends in the city will take this occasion to show you through our city and its surroundings; that you will have the opportunity of viewing one of the prides of our city-our beautiful river and its many attractions. You will also be able to observe the energy, growth and activity of our city; our beautiful homes on the broad streets, and our palatial business houses; also the manufacturing interests that we have here-all of which cannot fail to be matters of interest to gentlemen so largely connected as you are with the material prosperity, and at the same time, with the wants and the condi- tions which affect the human race. While glad to receive you bere, I was not aware that there was any particular condition of the citizens of Detroit that required, at ibis time, a visit by you, gentlemen. I do not know that there is any occasion for medical experts to pass upon the sanity of the people of Detroit. I think, as a whole, our growth, since 1300, has shown that we are fairly a sane class of people. There may be, and probably is, some special need for you while you are here, and I would recommend to you, gentlemen, to use your ability and your peculiar fitness and expertness upon some of our citizens. I think there may be occasion for it. Some of them cannot be called entirely insane, but I think they are inclined to be a little cranky on some subjects, wbich, I believe is the next thing to insanity. For instance, we have a class among us who believe that wooden pavements are the greatest thing for real economy and the beauty of our city, as well as the sanitary conditions. Now, I think while you are here, it may not be out of place for you to look out a little for these fellows: I think they are a little inclined to be crazy, and if you can do the city any good in correcting this fault, you will confer a blessing by your visit. Then we have another class of cranks here, wbo believe that there should be no enterprises in the way of building up our city, and this class has a few advocates among a people known as the Knights of Labor. They hold that we should build up no manufacturing enterprises; that there should be no extension of that element in the city. The argument they use is, that by expansion, increasing the price of property, it is going to make it harder for the laboring classes to obtain homes among us. Now, such a stand-point, after the marked growth of our cities, seems to be a thoroughly crank idea, and if you come in contact with any of these Proceedings. 551 gentlemen while here, and you can aid the city in getting that idea out of their minds, I think you will confer a favor upon us. The city of Detroit is a beautiful city. I believe it stands high in the ranks of the cities of the United States. I would not detract one particle from its beauty, from the grandeur of its river: from our broad and shady streets; from the healthy condition of our inhabitants and all the condi- tions of things which make Detroit, pre-eminently a city of residences, but still I think that some of our people have got a little cranky on that opinion; and in their enthusiasm for the beauty of Detroit and for its resi- dences, they have gone to a condition of things, which, unquestionably, is unsurpassed; to the idea tbat we should throw out everyıbing wbich antagonizes, in any way, the making of it a place to live in. Of course, the hum of machinery, the whirl of traffic, and the energy and other con- ditions of a great commercial city, are not the pleasantest associations for some retired millionaire, who wishes to be quiet by himself. But I have been under the impression that the city of Detroit, and all cities, were made first for business-intended for business, witb incidental residences- not for residences with incidental business. Now we have a class of peo- ple here, I am inclined to believe, who think that our city should be for the purpose of residence, with incidental business. I think they are very eranky upon that subject, and I call upon you to give this class of people your attention. I might enumerate several other classes we have; but, as a whole, the people of our city, I can assure you, are perfectly save-as sane a class of people, I think, as you will find. They are capable and energetic, and are doing as well for the city of Detroit and its surroundings as can possibly be done. In calling your attention to these few things that surround us—and I presume in most communities, they are far in excess of what we have-I thought it wise this morning, seeing that you are here in your oflicial capacity, to point out the few instances we have, Again I say, 8 peaking on behalf of the city of Detroit, I extend you a hearty welcome. We are aware that there is no body of men, perhaps, in these United States, who, to-day, are more closely identified with the hu- manity of the country than yourselves. Such being the case, a city which has never failed to express its humanity and its charity in all cases, extends to you a hearty welcome to our midst. We trust that while your stay is with us it will be of a pleasurable and satisfactory character. I assure you that our citizens will follow your proceedings closely and carefully, and that they will trust and believe that your deliberations will produce good results for mankind, as we are aware that such has been the character of your previous meetings. We are glad to see you come together to confer for the good, not only of the people of our own country, but for the entire human family. Dr. Buttolph responded as follows: Mr. Mayor and Citizens of Detroit: Gentlemen-On behalf of the Associ- ation of Superintendents, whom you this day honor with kindly and hospitable welcome to your prosperous and beautiful city, I have to respond with expressions of obligation and of grateful thanks. 552 Proceedings. This auspicious beginning of the important work of the convention, surrounded and encouraged by such friends, surely betokens pleasure in its progress, and we may hope, success, as to the result of present and prospective effort. Of your State it may be briefly but truthfully stated, tbat, in addition to its extended agricultural, manufacturing and commercial resources, its institutions, scientific, literary and philanthropic, in design, construc- tion and organization and management, are among the foremost to be found in the West, and, indeed, compare favorably with those of any other State or section of our common country. To the members of the Association I have to remark, at this opening exercise of the week, that while we have very much to rejoice over, as connected with our chosen specialty, in the acbievements of tbe past, yet, in view of the extended and complex nature of the subject, in its various bearings, a greater work still remains to be accomplished in the future. Among the most important questions now open for investigation, are the correct identification of pbysical development and physical disease on which mental unsoundness and insanity primarily depends; also, the true interpretation of the still more interesting mental and moral phenomena, that arise with every changing aspect of symptoms in the disease. Notwithstanding the eminent success that has marked the progress of those who have wrougbt in this field, yet the interesting and highly im- portant fact, as to whether all of our leading methods of procedure are wholly correct, still remains to be demonstrated by future inquiry. Let us, however, still pres3 forward with hope in the ascendant. On motion of Dr. J. B. Chapin it was Resolved, That the Mayor of Detroit, the officers of the medical institu- tions of the city of Detroit, the members of the medical profession and the representatives of the press be invited to attend the meetings of the Association. Dr. Foster Pratt then read the following address of welcome, which was listened to with great interest by the members : Mr. President and Gentlemen-On behalf of the medical superintendents and managing boards of the hospitals for the insane in Michigan, I hare the honor to bid you a cordial welcome to the chief city of our State. You are welcome to our attentions and hospitalities because you represent an important feature of the humane work of the several States of our Union and of the Provinces of our neighboring Dominion. You are wel. come because your official positions, at home, are evidence of your scien- titic attainments and personal worth, of wbich, after acquaintance, we need no other proof. We welcome you for your work's sake" and because of what you have already accomplisbed for the relief of suffering humanity. We welcome you to the Forty-first Annual Conference of this Association, established by yourselves and your predecessors, because its very aims and purposes show you to be striving, through increase of Proceedings. 553 knowledge, to make yourselves and the institutions over which you pre- side, a yet greater blessing to the world. Gentlemen, individually and collectively, you are welcome to Detroit and to Michigan. You bave already observed that Detroit is “no mean city:" though not our political capital, she is, by age, our true metropolis, or “mother city." as well as our chief city in population and commerce. Her magnificent site, by the side of her majestic river-the outlet of the three northernmost of our great lakes-was discovered and announced to the world in 1610, three years after the first settlement at Jamestown, in Virginia, and ten years before the landing of the Pilgrims. For one hundred and fifty years French missionaries and fur traders, together with the native Indians, used and occupied this river and this soil, a period full of thrilling and romantic interest, well worthy of historical study. Canada and Michigan having been surrendered by France to England in 1760, after the Revolution in 1783, Michigan became by treaty the prop- erty of the United States, and a part of the great Northwest Territory; and ninety years ago next month, and very near where we are now met, the flag of the United States, for the first time, was raised over her soil, and afty years ago last January, she became the twenty-sixth State, the last of the second group of thirteen, in the American Union. In 1830 Michigan Territory had a population numbering 31,639. In 1880 she stood ninth, by numbers, among her sister States, showing in 1884 a population of 1,853,658. By the tenth census, though ninth in num- bers, she ranked first, of all the States, in the annual products of her lum- ber, salt, copper and iron; tbird, in wool; fourtb, in wheat, buckwheat, potatoes, hops and sheep; seventh, in the number of her dwellings, the value of her farms, her dairy products, the number of ber manufacturing establishments and her rate of mortality. In health, she was surpassed only by Oregon, Minnesota, Nevada, Florida, Iowa and West Virginia. She has held the same rank, in this respect, for over forty years. By our latest State census, in 1834, our population was 1,853,658, of whom (in round numbers) 1,357,000 were native-born and 486,000 foreign- born, the foreign element being about one-fourth of the whole. The same census disclosed some facts of signific int importance to you. I ask your attention to the figures. The “ parent nativity" of our entire population was carefully tabu- lated, with tbese results: 900,000 (in round numbers again) had foreign fathers : 839,000 had foreign mothers, and 975,144 (or more than half our entire poppulation) came of parents one or both foreign-born, The total number reported insane was 2,644, a total apparently too small. Of these 1,504 were native-born, and 1,037 foreign-born. Of the insane, 374 were traced to native-born parents, and 389 to foreign-born parents; but the “parent nativity "of 1,834 insane was reported as unknown. One familiar with the history, the physiognomy and the speech of patients in our northern asylums will not hesitate to decide to which class, native or foreign, the great majority of this 1,834, of unknown par- centage, must trace their origin. This much is clear: one-fourth of our population furnishes two-fiftbs of our insane; and it is more than probable that more than one-third of 554 Proceedings. insane now chargeable to those of native birth, had foreign parents. Tbis is no accidental result in a single class of defective population, for nearly the same results are found among the blind, the deaf and dunib, the epi- · leptic and the idiotic. Nor are such results confined to Michigan. They have been recently found to exist, also, in New York and Massachusetis; and it is now evident that they will be found in all other States, where the foreign element is large, whenever the subject is investigated. In the census of 1850, the foreign-born population of the United States furnished scarcely any more defective people tban our native-born. But, in 1880, among the foreign-born (who were one-eighth of our population), were found one-third of our paupers, one-third of our criminals ond one- third of our insane. The cost, great as it is, to States and counties, of car. ing for these classes of buman oftal, much of it dumped on us by foreign agency and tolerated by our own folly, is a matter of small importance compared with its certain and deplorable effects on the mental, moral and physical future of our people. But turning, now, from the cases of increased and increasing insanity in Michigan, permit me to speak of some of the features of her policy in mitigating the evil. Michigan has about three thousand insane. Two thousand are cared for in her State institutions, about five hundred in county hospitals and private asylums, and the remaining five hundred are scattered; some at home, but more, we fear, in jails and poor-houses. Early in her history as a State, Michigan began to feel the stirrings of humanity on behalf of her helpless unfortunate. The Michigan Asylum for the Insane, authorized by legislative act in 1848, and located at Kala- mazoo, began operations in 1859. The Eastern Asylum, at Pontiac, was opened in 1878. The Northern Asylum, at Traverse City, two hundred and fifty miles north, opened its doors in 1885. The Asylum for Insane Criminals, located at Ionia, and opened in 1885, cares for: First, Those committing crime after development of insanity, and sent by courts to asylums. Second, Those who, convicted of crime and sent to prison, develop in- sanity while serving sentence. Third, Patients committing homicide or developing homicidal impulses while under treatment or at large. Some of our State methods, which seem to be unique or peculiar, may be worthy of mention: First, A pauper, maintained at a State Asylum, wholly at county cost, for two years, becomes thereafter a State charge. This provision secures better treatment and care for the indigent class. Second, The three managing boards of the three asylums proper, are required by law, to meet in joint session, at one of the asylums, at least twice in each year. This promotes harmony and unity in institutional management, unity and concert of action in general plans for future work, new structural developments or new general policy. One of the important functions of these joint sessions, is the establishment, in June of each year, of the weekly cost or charge, per capita, of maintenance for the succeeding year. This provision of law also promotes harmony among institutions, Proceedings. 555 and makes the cost alike to State and counties-and to all, except private patients, who pay for special advantages. Third, What, for want of a better name, we call the colony plan, has been recently approved by our Legislature. It does not consist in farming out patients to private families, under State surveillance, as at Gheel; nor is it a construction of cottages in a cluster or village, in close connection with the main institution, as at Kankakee. It seems as yet to unite all the advantages and avoid most of the disadvantages of these two systems. The plan contemplates home-like houses, large enough to accommodate thirty, forty or fifty patients of similar conditions, located like farm- houses on farming lands, in groups, a mile or two away from the asylum proper, but connected with it by telephone and subject, in all respects, to i18 central control. The class of patients selected for such accommodation, are mostly of the chronic, with some of the acute and convalescent classes, whose liability to serious disturbance is not great, whose physical health is generallv good, and who are in a condition to labor and to be benefited by it. This plan bas been begun and is now in progress of development at Kalamazon. In a limited way, as employed in dairy and general farm work, it has proved, in its mental, moral and pecuniary results, a gratifying success. For a fuller elaboration of this scheme I must refer you to the paper by Dr. Palmer, Superintendent of the Asylum at Kalamazoo. And now, Mr. President and Gentlemen, if, in Michigan, we bave had any success in caring for the insane which others desire, we will tell you all our secrets, if we have any, and we will cheerfully impart all we know. This, please to remember, is no part of our proffered hospitality, but sim- ply the inadequate tender in payment of a just debt; for we have learned, in past times, of you, and cheerfully acknowledge our great obligations to your wise counsel and valuable experience. But just now, and above all else, it is our highest pleasure, as it is our grateful duty, to bid you wel- come to Detroit, welcome to Michigan, and welcome to all we can do to promote your comfort and pleasure. We wish you a pleasant, a profitable and a prosperous meeting. On motion of Dr. Nichols, the President was author- ized to appoint the usual standing committees. On inotion of Dr. Roberts, a recess of fifteen minutes was taken to enable the members to register. On motion of Dr. Hurd, the members of the boards of trustees of the asylums at Kalamazoo and Pontiac were invited to take seats with the Association. Dr. Chapin introduced Mr. D. A. Ogden, a member of the board of trustees of the Willard Asylum. After recess, the President announced the committees as follows: COMMITTEE ON NOMINATIONS—Dr. W. B. Goldsmith, of 556 Proceedings. Rhode Island; Dr. J. T. Steeves, of New Brunswick; Dr. Richard Dewey, of Illinois. COMMITTEE ON TIME AND PLACE OF NEXT MEETING- Dr. C. H. Nichols, of New York; Dr. H. P. Stearns, of Connecticut; Dr. G. H. Hill, of Iowa. COMMITTEE TO AUDIT THE Accounts Of The TREAS- URER—Dr. J. Z. Gerhard, of Pennsylvania; Dr. L. S. Hinckley, of New Jersey; Dr. J. P. Brown, of Mass. COMMITTEE ON RESOLUTIONS—Dr. P. M. Wise, of New York; Dr. E. B. Nims, of Massachusetts; Dr. M. Camp- bell, of Tennessee. The Committee on Nominations made the following report, which was, on motion, unanimously adopted : For President-Dr. Eugene Grissom, of North Caro- lina; Vice-President Dr. John B. Chapin, of Pennsyl- vania; Secretary and Treasurer-Dr. John Curwen, of Pennsylvania. Dr. Hurd, from the Business Committee, reported the following programme as the report of the committee, for the order of proceedings : TUESDAY, JUNE 14, 1887– OPENING SESSION AT 10 A. M. 1. Calling the Society to order by the President, Dı. H. A. Buttolph, of New Jersey, and reading of minutes of last annual meeting. 2. Address of welcome, by Hon. M. H. Chamberlain, Mayor of Detroit. 3. Address in response, by the President of the Association. 4. Address in bebalf of the boards of trustees of Michigan asylums for the insane: “ The Asylum Methods of Michigan.” Dr. Foster Pratt, Kalamazoo, Michigan. 5. Appointment of Business Committee. Appointment of Nominating Committee. Appointment of Committee on Time and Place of Next Meeting. Appointment of Committee to Audit Accounts of Treasurer. Appointment of Committee on Resolutions. 6. Recess for Registering Names. 7. Report of Nominating Committee and Election of Officers. 8. Report of Business Committee. 9. Adjournment. Proceedings. 557 AFTERNOON SESSION AT 2:30 P. M. Address from the retiring President, H. A. Buttolph, M. D., LL. D., New Jersey. “Insanity or Mental Derangement, with remarks on its Na- ture, Causes, Classification, Pathology and Symptomatic Forms." Paper—"A Psycho-Medical History of Riel." Daniel Clark, M. D., Toronto. Discussion. Paper—“ Conditions of Early Life Favoring the Development of Insanity." Richard Dewey, M. D., Kankakee, Ill. Discussion. EvenixG SESSION AT 8 P. M. Paper--" The Laws of Habit in Mental Disorders." Edward Cowles, M. D., Somerville, Mass. Puper—"The Classification of Insanity.” H. P. Stearns, M. D., Hartford, Conn. Paper--" Etiology in the Classitication of Insanity.” J. Draper, M. D., Brattleboro, Vt. Abstract of Paper on “ Classification." R. L. Parsons, M. D., Sing Sing, N. Y. Discussion. WEDNESDAY, JUNE 15, 1887—Morning SESSION AT 9:30 A. M. Paper—"" Trephining in Insanity Caused by Injury to the Skull." W. B. Fletcher, M. D., Indianapolis, Ind. Discussion. Puper—“Goitre and Insanity." C. K. Clarke, M. D., Kingston, Ont. Discussion. Paper—" Illustrations of the Localization of the Cerebral Functions." W. L. Worcester, M. D., Kalamazoo, Mich. Discussion. Adjournment at 12 M., to take carriages at the invitation of Parke, Davis & Co., to visit their laboratory. AFTERNOON SESSION AT 3 P. M. Paper_" Communicated Insanity." W. B. Goldsraith, M. D., Providence, R. I. Discussion. Paper_Laparotomy in Insanity.” H. M. Quinby, M. D., Worcester, Mass. Discussion. Puper—“On the Organization and Management of Hospitals and Asylums for the Insane under Single and Dual Heads." H. A. Buttolph, M. D., LL. D., Short Hills, N. J. 558 Proceedings. Discussion. Reception at Abstract Parlors, at 8:30 P. M., given by the Medical So- cieties of Detroit, under the auspices of a committee of arrangements, con- sisting of Drs. Lundy, Shurly, Emerson, Maclean, Walker and Brodie. THURSDAY, JUNE 16, 1887. Excursion to the “Rushmere," at St. Clair Flats, by Steamer “ Saphop," at 8:30 A. M. Dinner at the “ Rushmere." Return to Detroit at 5:30 P. M. EVENING SESSION AT 7:00 P. M. Paper—“A Memorial of Dr. Jobn P. Gray." J. B. Andrews, M. D)., Buffalo, N. Y. Paper—" Obituary of Dr. E. R. Chapin.” J. Draper, M. D., Brattleboro, Vt. Report of Committee on Necrology. Reception at the residence of General and Mrs. R. A. Alger, corner of Fort and First streets, for the members of the Association, at 8:30 P. M. FRIDAY, JUNE 17, 1887-MORNING Session at 9:30 A. M. Paper—“Report of a Case.” John B. Chapin, M. D., Philadelphia, Pa. Discussion. Richard Gundry, M. D., Baltimore, Md. Paper—“Paranoia." Discussion. “Are Dipsomania, Kleptomania, Pyromania, etc., valid forms of Men- tal disease? Do Uncontrollable Impulses to use Stimulants, to Steal, to Burn, etc., Develop Independently of Other Evidences of Insanity ?" Discussion opened by 0. Everts, M. D., Cincinnati, Ohio. AFTERNOON SESSION AT 2:30 P. M. Paper—“A Few Observations on the Treatment of Epilepsy.” Gershom H. Hill, M. D., Independence, Iowa, Discussion. Paper—“A Report of a Case.” John S. Butler, M. D., Hartford, Conn. Paper—" Nursing Reform for the Insane." Edward Cowles, M. D., Somerville, Mass, Discussion. Paper—" The Colony System for the Chronic Insane." Geo. C. Palmer, M, D., Kalamazoo, Mich. Discussion. The Best Method of Providing for the Chronic Insane." Discussion opened by P. M. Wise, M. D., Willard, N. Y. Proceedings. 559 EVENING SESSION AT 8 P. M. Paper-"Gastric, Secretory and other Crises in General Paresis." Henry M. Hurd, M. D., Pontiac, Mich. Report of Committee on Resolutions. Reports of Committees. Final Adjournment. On motion, the Association adjourned to 2:30 P. M. The Association was called to order at 2:30 P. M., by the President, Dr. Buttolph. The President read his address. On motion of Dr. Callender, the thanks of the Asso- ciation were tendered to Dr. Buttolph, for his able address. Dr. Buttolph then introduced to the Association, Dr. Grissom as his successor in the office of President, and Dr. Grissom expressed his thanks in the following well- chosen remarks: GENTLEMEN OF THE ASSOCIATION—The language that conveys the ordinary emotions of life has no ir ubic in its tones or eloquence in its speech adequate to express our gratification at the approval of those whom we honor or esteem. When I recall the grand international char- acter of this body-the oldest medical organization of this country, whose limits are co-extensive with North America, and whose fostering care is extended in behalf of the insane among 70,000,000 of human beings; when I see before me the men whose names are synonyms of humanity and benevolence, from tbe rugged shores of the Atlantic Coast to the star- spangled prairies of the great West; from the enchanted land where the palmetto guards its tender grace reflected from the Mexican Gulf, and the magnolia breathes its greeting to the passer-by, to the great lakes of the Nortb, the mighty pools of pure water, from whose crystal depths are re- flected our national greatness; when I remember that the venerable forms of Woodward and Bell, and Ray and Gray, and Kirkbride, have occupied this seat of honor, and recall tbeir illustrious cotemporaries and successors, who, alike with then, won the grandest laurels, I feel indeed that I stand upon ground consecrated by the purest devotion and loftie:t sympathies for our fellow-men. It is high noon in the life of any man who, in the providence of God, is called as a representative of an assembly of such men—the leading spirits of the crowning work of reform in the great Western World, Your kindness and contidence lie deep in my bosom; and I should be gratified if I could be able to render you a service commen- surate with the compliment which this position bestows. Dr. Daniel Clark then read a “Psycho-Medical History of Louis Riel." 560 Proceedings. Dr. Nichols: I wish to express my obligation to Dr. Clark for his able paper. Having been an expert witness in the Riel trial, he appears to have studied the defendant's mental bistory with conscientious thorough- ness, and I cannot but hope tbat his masterly exposition of his mental condition at the time of the rebellion which he headed, will have its effect in bringing about tbat good time for which we sigh, when such cruel trav. esties of justice, as appear to have taken place in this case, will cease to be enacted, even in the remote provinces of an en.ightened government. Dr. Richard Dewey next read a paper on the “Con- ditions of Early Life Favoring the Development of Insanity." Dr. Hill; I was very much interested in the paper and in the manner of reacbing the subject. I think the first thing we all bave to do in treat- ing diseases is to try and ascertain the cause of the disease, and see whether it can be removed or not. It is also our duty as philanthropists to ascer- tain to what extent insanity can be prevented; and, therefore, to reach out in all directions and find the nature of causes. lthink, by efforts of this kind, we can, in course of time, reach some very valuable conclusions. On motion, the Association adjourned to 8 P. M. The Association was called to order at 8 P. M, by the President, Dr. Grissom. Dr. Cowles read a paper on the “Laws of Habit in Mental Disorders." Dr. Stearns read a paper on the “Classification of In- sanity.” Dr. Draper read a paper on “Etiology in the Classi- fication of Insanity." On motion, the Association adjourned to 9:30 A. M., Wednesday, June 15. The Association was called to order at 9:30 A. M., on Wednesday, by the President. The President called over the names of the several gentlemen named in the programme for reading papers, and none of them being present, the President announced that discussion on the papers read yesterday was in order. DR. EVERTS: Mr. President-I do not know that I can entertain the members present, but I have listened to the papers with a great deal of Proceedings. 561 interest. I do not remember any special disagreements of opinion or statement that occurred to me at the time of the reading that would justify me in any effort to criticise, or do otherwise than commend. I thought Dr. Dewey's paper was so filled with indications of good work in tbe right direction, that I discussed bis paper mentally and said it was well con- ceived and presented, and would require no further discussion. The papers on classification are also very able. The trouble with the whole business of classification is that we do not know enough. It has seemed to me that the old classification of “Mania, Melancholia and De- mentia," as simply indicating the prominent characteristics of conditions, is about the best we bave been able to do, thus far. I do not see that we can do any better with a so called pathological classification, because we do not know enough about the relation of phenomena to natural conditions to associate the characteristics of thought, feelinys, or ideas, with partic. ular pathological conditions expressed thereby, and, therefore, cannot make a classification of that kind with advantage to ourselves as practi- tioners, or to science. Insanity is a general disease; seldom if ever result- ing from a single or specific cause. While a man is still insane-still raving or mentally obtuse and inactive, no man can look into his skull, see into his brain, or feel it; and there is no method of testing its condition except by the eyloptoms. Therefore, a simple physiological classification is more convenient than any other, with scientific men. The great diffi- culty of discussing this matter, as of other matters that we do not know much about, is that our discussions are necessarily endless; we go around and around, and come back to the same old ground. I expect that Carlyle was about right when he said, “ It is an indubitable malefaction for any man to set his tongue wagging when he has nothing to say." Dr. Gerhard from the committee to audit the accounts of the Treasurer, reported: Your committee appointed to audit the accounts of the Treasurer respectfully report that they have examined the account and have found it correct. The Association is indebted to the Treasurer, ninety-six dollars and twenty-seven cents. The committee recommended that an assessment of five dollars on each member be made, so as to enable the Association to pay the Treasurer the amount due him and have sufficient money in his hands to pay the necessary expenses for the year. Respectfully submitted, J. Z. GERHARD, Chairman. On motion of Dr. Chapin, Dr. C. T. Wilbur, of Kala- mazoo, was invited to take a seat in the Association. Dr. Fletcher read a paper on “Trephining in Cases of Insanity Caused by Injury to the Skull.” Before the discussion, Dr. Pratt introduced to the As- sociation, Dr. T. R. Buckham, of Michigan, who was invited to take a seat in the Association. 562 Proceedings. Dr. Frost: The paper of Dr. Fletcher is very instructive, and I have a specimen here that will illustrate one point bearing upon Trephining, viz., the point of external depression may not be the point of exostosis upon the inner table of the skull. The man from whom this specimen was taken was a patient at the Hospital for Insane. He had been home on a visit, and while returning, jumped from the train, striking his head upon the corner of a railroad tie, producing fracture of the skull at this point ſindicating). The point of practical importance to wbich I wish to call attention is this: The point of exostosis upon the inner table is about seven-eigbths of an inch from the point of depression upon the external table. It would be natural to apply a trephine around the external depression, and unless very large, would fail to remove tbe exostosis. It is very evident tbat the only way to find ibe exostosis would be to introduce a bent probe and feel around for the exostosis after the first button of bone is removed. Of three operations that I have observed, none have been successful, and the case may be that the exostosis was not removed, which possibly might have been different had a probe been introduced and the exostosis located. DR. WORCESTER: I have no experience in this operation, but would merely say, as having some bearing upon the success of it, that there is one patient in the Michigan Asylum at present, who has been twice tre- pbined on account of injury, followed by epilepsy, without any apparent benefit; not in the institution, but before bis admission. DR. DRAPER: I would like to inquire of Dr. Frost if this patient was an epileptic? Dr. Frost: No, sir. After recovery from the injury about the only symptoms were two: he had great pain over bis right eye at the location of the injury, and be also had double vision. There was no very material: change in him. It simply illustrates how the point of exostosis can be different from the depression on the outside. DR. EVERTS: There is no question of the fact that traumatic injuries of the head are frequently causes of insanity, Dr. Fletcher's cases certainly justify the operation. When we consider the character of the persons that are so affected, and when we corsider the general progress that bas been made in surgery, lessening to 80 small a deyree the danger to life in opera- tions of this kind, I have no question that the operation will be more fre- quently resorted to in the future than it has been in the past. The diffi- culty of exactly locating the osseous injury, internally, should not prevent the operation. The life of such a patient is not worth saving: it is better that he die, so far as we can judge Therefore there should be no hesita- tion in the experiment. If successful, we have done very much; if unsuccessful, we have lost nothing. DR. GOLDSMITH: Mr. President-1 have no experience to offer on this point, but it seems to me that the cases which Dr. Fletcber cites are in- structive, and that his experience is a very exceptional and remarkable one. I have tried to use care-as I presume every one here has-in exam- ining the heads of such cases, but I never cbanced to have a case of Proceedings. 563 epilepsy in which there was evidence of fracture of the skull, or in which this operation would seem to be indicated. I have been accustomed, too for years, to see a great many autopsies of insane patients, and I have not seen any skull of an epileptic which showed evidence of previous frac- ture. One of the most important points of Dr. Fletcher's paper seems to me to be the importance of appreciating, at the time of the head injury, the possible effect of this injury on the brain. I do not think that a surgeon should feel the slightest satisfaction in saving the life of a patient who has a fractured skull unless he has removed all pressure from the brain. The risk of subsequent disease of the brain is so great that no amount of risk to life from the operation should deter the surgeon from making sure that all depressed bone is removed. DR. DRAPER: I wish, Mr. President, that Dr. Everts would modify one statement that he made. I do not think he meant to put himself on record that we were justified in acting on the principle in any case that an insane person's life is not worth saving. DR. EVERTS: I should be very happy, indeed, to make any concession that would please the gentlemen, but certainly what I meant was, that we were to take any risk for the purpose of benefiting the hopeless insane. DR. DRAPER: I was afraid the reporters would get you wrong. That satisties me. DR. BUCKHAM: I had a case, a boy about twelve years of age, who was struck on the head with a crow-bar, and a short time afterward- about three or four months-came to me. He was suffering from an epi. leptic seizure, and his parents said he was growing exceedingly morose, and they were fearful of his becoming insane. The epileptic seizures were frequent and severe. I found, on pressing that particular point, it caused him a great deal of pain. At the time, we found the bone depressed. It was lified up, and he never had an epileptic seizure afterward; or, rather, after trephining he had no epileptic seizures at all, and the morbid, dis- agreeable, cross feeling that he had exhibited before died out, having been caused by this abnormal condition. I think he was not insane then, but if the depressed bone had remained there, he would have become insane. DR. ROBERTS: Is it desirable to trephine in cases of long standing? I can well see how recent cases can be benefited by it. I have in my care, now, some four or five cases of insanity, brought on by traumatic injuries -injuries directly through the head, but they are of long standing-from five to twenty years—and I would ask: Would it be desirable to make the experiment, as Dr. Everts says, on those cases? Would we have any hope of success in such cases as those ? DR. FLETCHER: All my cases were of several years' standing, with, I think, the best results from them. We had to be experimental, because we could not always tell where the injury was located. In some cases there were no serious marks on the skull; but, I think, I should take the risk in all cases were there was constant irritation at any portion of the skull, and then I should operate. DR. CAMPBELL: I wish to refer to a case in the hospital over which I preside. A man who was injured six years since about the crown of his head had a depression, and a surgeon trephined, to remove the pressed 564 Proceedings. bone. He was subject to seizures of dementia, and after the healing of the wound he had another seizure and was sent to the hospital in a perfect state of dementia, and did not know anything. After remaining there about three weeks, be, as he expressed it, “ came to himself.” He did not know how he came there. That man made a recovery; or bas had no retury of the dementia for about five months. Dr. Pratt: How long after the injury ? Dr. CAMPBELL: Six years, now. DR. FLETCHER: Has that case been reported ? DR. CAMPBELL: No, sir. He was operated on by Dr. Berlin, of Chat- tanooga. DR. FLETCHER: I have now gained three or four cases that are not reported. DR. CAMPBELL: I bave another case that I could report, I think one of interest; but unquestionably no difference, one way or the other, came from the operation. DR. EVERTS: I would simply call Dr. Fletcher's attention to a case of Dr. Athon's. I do not know whether he has that or not. DR. FLETCHER: No, sir; and it is not to be found in any of the reports, but I heard that he had operated on two cases. DR. EVERTS: He operated on one or two cases. The man I refer to had been an insane patient during his time, and partially recovered; he afterwards came back, and Dr. Athon operated on him in his office and sent him out to the hospital. He died of intlammatory action. Dr. C. K. Clarke read a paper on “Goitre and In- sanity," which was then discussed. DR. GOLDSMITH: I think this paper ought not to pass without dis- cussion, as it presents most interesting information with regard to goitre in this country. I would like to ask Dr. Clarke if he has noticed any hered- itary influence with regard to goitre in his neighborhood? Does it run in families? DR. CLARKE: In one case we have two brothers in the asylum, and each of them has a large goitre. That is the only thing I have noticed as bearing upon this point. DR. GOLDSMITH: Is the locality about Kingston one in which you have small changes in population? Do they intermarry, as in Swiss families ? DR. CLARKE: In the eastern district there is a good deal of that sort of thing. There is a great deal of intermarrying there. DR. GOLDSMITH: You spoke also of the fact that goitre rarely was present among the recent admissions. Do I understand you that it usually developed in the asylum, or simply that it was rarely found in patients who were ingane but a short time? DR. CLARKE: In nearly every instance it developed during asylum residence. DR. GOLDSMITH: That seems to me, Mr. President, to be rather a striking fact and different from the history of goitre in other countries Proceedings. 565 where it perrades families and is often developed before adult life. Most of the doctor's patients, I take it, are adults before they come to him. You do not receive many children? DR. CLARKE: No, sir. Dr. GOLDSMITH: I do not know that there is any definite knowledge as to the conditions wbich favor goitre. The locality about Kingston does not seem to be mountainous, as is the case with other goitrous regions of the world. Tbere is one interesting fact which the doctor did not mention, prob- ably because it had no direct relation to the subject of bis paper, but which seems to me very interesting in this connection. I refer to the mental failure which surgeons now know is likely to follow extirpation of the thyroid gland. In these cases the doctor speaks of the insane having been peculiarly liable to goitre. That may be the case. I should think it more probable that the same conditions that made them predisposed to insanity predisposed them to goitre. The fact is probably familiar to the mem- bers of the Association, that, a few years ago, surgeons quite frequently removed the thyroid gland in cases of disease of its structure, but I believe it is now rarely done because they recognize the fact that dementia in likely to follow. If the insanity in the cases mentioned preceded the goit- rous disease in point of time, it might be thought tbat the disease abol- ished the function of that gland, whatever it is, and the mental degeneration followed in the same way that it does upon the extirpation of the gland by surgeons; but that does not seem to have been the case, and I only refer to it as an exceedingly interesting fact, which points to the probability of a peculiar relationship between the functions of the thyroid and the brain. Dr. Long: I was not paying very strict attention at one point of the doctor's paper, but if I understood him correctly, he said that possibly ma- larial influence has something to do with it. Do I understand correctly? DR. CLARKE: Yes, sir. Dr. Long: I think, in Michigan, malaria is quite prevalent, but in my limited experience, goitre has been a rare thing with the insane; how- ever, our other superintendents, who have had more experience, can say as to that. DR. Mays: I am glad that Dr. Goldsmith called attention to the probable cause of goitre as due to intermarriage of relatives. It is found, in the Swiss Alps, in certain portions very much isolated, where intermarri- age bas been carried on for centuries, tbat goitre is much more prevalent; while in other localities similarly situated, geologically, goitre will be found to be absent. I think that injures very much the limestone theory as to the origin of goitre. We bave goitre developed, in California, in some of the isolated regions, and I think upon investigation it will be found that intermarriage of relatives and consanguinity is the cause. DR. BLUMER: I would like to ask whether Dr. Clarke can inform us- if, in the neighborhood of Kingston, there are cases of cretinism, and whether, in his asylum, he has noticed cases of myxcedema in connection with the extirpation of the thyroid gland ? In Swiss asylums, I believe the marked inter-relationship between goitre and myxædema has been 566 Proceedings. established. It has been observed that myxædema has followed such ex- tirpation, pointing to disease of the peripheral nervous system. DR. CLARKE: I bave never heard of any such cases. DR. PRATT: I would like to ask whether he noticed any predominance of any particular race? DR. CLARKE: No; I have not been hunting up statistics in regard to that. DR. FLETCHER: After seeing in the announcement of this meeting that there was to be a paper on this subject, I examined the patients in the Indiana Hospital, and found that out of sixteen hundred patients present we have nine well marked cases of goitre, and they are all among the for- eign population; four out of the nine are Germans (two of them sisters, by the way,) and the others are Irish and French. Now we have a very ma- larious district, -Indiana is supposed to give rise to almost all the fevers of the country,—but we do not find goitre among our native diseases. I believe all the cases are associated with heart disease. Dr. Worcester read a paper on “Illustrations of the Localization of Cerebral Functions." Dr. Barksdale, of Virginia, exhibited to the Associa- tion a large collection of articles, beads, glass, pebbles, etc., taken from the rectum of a female who died in the Central Lunatic Asylum, of Virginia. Dr. Grissom then read a paper on the “Case of Wal- ter L. Bingham.” During the reading Dr. Grissom said: I have a read a somewbat uninteresting account of a personal case with a view to elicit, if an investigation was proposed, the views generally understood, from the facts upon wbich it was predicated. I corresponded with a number of distinguished gentlemen of the United States in this specialty, and others, and asked distinguished scientists, in the form of a circular letter, whether or not they could describe to me what differentia- tion there was, either in the brain, or other organism, of deaf mutes. I wanted them to designate, if any existed, the connection between the deaf- muteism and insanity. Very much to my surprise the answers from most distinguished scientists in the United States revealed the fact that very little or no examination had been made. Is there any connection between deaf-muteism ànd insanity? The Doctor then resumed the reading of his paper, and at its close said: I do not know that the Association attaches as much importance to this line of investigation as would suggest itself to my mind. It seems, if there is any theory connected with the investigation of insanity in which there has not been a sufficient effort made, it is in this direction; as to whether or not the deprivation of any portion of the senses is necessarily Proceedings. 567 connected with the deprivation of the proper mental powers, or any dis- ease that embraces the functions of the brain. And, while the individual case recited, is of itself of little consequence, the investigation, it seems to me is one to which we might afford very properly to devote some time. DR. GILMAN: During the past two years, we have admitied half a dozen cases of deaf mutes into our hospital. Five of these cases have seemed to be chronic in character. All of them have been mild, and have given very little trouble in caring for them while in the hospital. One of the cases made a good recovery, apparently, returned bome, and has re- mained convalescent since. There did not seem to be any peculiar irri- tability in any of these cases that was marked, and I saw notbing that would lead us to believe that there were pathological characteristics dif- ferent from other cases of insanity which were admitted. I have been very inuch interested in Dr. Grissom's paper, from the fact that tbis man Bingham was, at one time, at the institution at Council Bluffs, in our State. I bave also been interested in the line of thought which Dr. Grissom bas directed, in connection with insane deaf- mutes. DR. TOBEY: I do not know that I can add anything to the doctor's paper, except to report a very extraordinary case that I came in contact with at the Columbus Asylum; and it has some bearing, I tbink, on the question that Dr. Grissom has presented. We had in tbat institution a man, who was about twenty-six years old, when admitted. He was blind after he was six months old, so be said ; and when he was about two years old he received an injury from pulling a vessel containing hot water over him, scalding him, which made him a permanent cripple. At the age of thirteen, he was taken to the Columbus Blind Asylum, and admitted as a pupil there. When he was about seventeen years old, he started to go up stairs with his teacher one day, and suddenly sank down; they carried him up to his room, and he could neither speak nor hear, but was conscious, 80 he said. He remained in that condition for one month; could neither see, hear nor speak. Sud- denly, one day, his vision came to him like a flash, and he was frightened at the appearance of persons about him. He was transferred to the Deaf and Dumb Asylum, where he remained until twenty-two years of age. He was educated and intelligent. He went home, and in about a year his hearing came to him as suddenly as his sight bad, but he had lost a part of his language. About a year after that he became insane, was taken to the Columbus Asylum, and was there about two years, when I left that institution. This was an unusual case, and seems almost incredible. I have spoken to several superintendents on the subject, conferring with them, as superintendents of different asylums, in regard to this case of insan- ity, and they have heard his experience. I heard of his recovery about six months after I left the asylum, except he was inclined to be melancholy and had seizures of epilepsy every six or eight months. I simply report the case as an unusual one and as, perhaps, baving some bearing upon the case mentioned by Dr. Grissom, in his paper. DR. GRISSOM: I should be glad to hear the result of any microscopic 568 Proceedings. investigations that may have been made of the brain of deaf mutcs. Per- haps some of the institutions-Dr. Blumer's, for instance-where micro- scopic work bas been extensively pursued, may have included in its scope the post mortem of this class. The purpose of my inquiry is to ascertain if there is any physical differentiation in the brain structure of congenital deaf mutes, compared with other classes. And perhaps, further, it would be of interest to know what are the anatomical peculiarities of the organs of hearing and speech, if any, of the deaf and dumb. Those of us in the rural districts are more or less dependent upon in- vestigations in the centers and cities, for many facts which post mortem opportunities witbhold from us. This seems, too much, an unexplored field of inquiry. DR. Nichols: I have made no particular investigations into the dif- ference, if there be any, between the anatomical structure of the brains of deaf mutes and the brains of sane and hearing persons. My own strong impression is that there is no difference in most cases; that the deafnees comes, in the large proportion of cases, from the destruction of the mechanical apparatus of hearing, without necessarily affecting the brain. Most deaf mutes I have met wita are rather clever, intellectually. They are apt to be a little peculiar. Because of the absence of the sense of hearing and their inability to understand what is said by persons about them, there is apt to grow up in their minds a certain sus. picion in respect to the intentions of such persons, and the indul- gence of suspicion in respect to individuals seems to beget a sus- picious and rather irritable habit of mind. Of course, if deaf- muteism is congenital, it may be and is, perhaps, rather likely to be attended with more or less cerebral defect. I think all congenital absence or defect of the senses is. My own experience is the prin- cipal ground of my impression in regard to the want of connection between cerebral defect and deaf-muteism. In the care of something more than nine thousand cases of insanity I recall but two deaf mutes among them, and neither of these bad any constitutional cerebral defect nor any intellectual defect, except that which had come naturally from the absence of one of the senses. DR. ROBERTS: In Dr. Grissom's preliminary report, he speaks of Dr. son's opinion as to the catarrh producing the mental defect in Mr. Bingbam. We must recollect that that part of the history was obtained from the mother or the family physician, of Mr. Bingham. But on that point I will state that I have been investigating this matter some in connection with Dr. Grissoin, and that I had correspondence with Dr. Robinson, directly. I did not mention Mr. Bingbam's name at all, but put the question to him as to the probability of catarrh producing a mental defect, and the cbaracter of the defect; and in a lengthy reply, Dr. Robinson said that he had known of one case where the catarrh did produce insanity, and it was of such a description that I thought he alluded to this case. In my investigation of the matter I opened correspondence with several on the question of the medical jurisprudence of this case, as Dr. Grissom had done before, and I was surprised to find that there are no reports Proceedings. 569 of cases bearing directly upon tbis point; but there are reports of cases of the uneducated deaf mutes, and of their irresponsibility. Formerly an uneducated mute was considered irresponsible; but since the establish- ment of schools for their education, there bas been a change of opinion in regard to this matter, but I bave not been able to find any case bearing directly upon this one; and, at my suggestion, or rather in correspondence with Mr. Clarke Bell, who is President of the New York Medical Legal Society, that society bas iindertaken to investigate the matter, and have a eommittee appointed to report upon the question ; and we may look for something from them in the near future, I think. DR. GRISSOM: When did they submit this subject to the committee for investigation ? DR. ROBERTS: I do not know, sir. The committee has been ap. pointed; and, in fact, I believe I was appointed a member, although I have done no work. Dr. FLETCHER: I have been very much interested in this case. We bave, I believe, tbree cases in our institution. I have at my room a speci- men of the arterial circulation of the brain of a person who was a deaf and dumb paralytic; and although I preserved that brain so far as to tracing out the entire circulation, the specimens which I happen to have with me I have never carefully traced out on that point; neither did I examine, microscopically, the sections relating to it, with that object in view. But I shall be happy to show the doctor the specimen, and show that the vas- cular supply was not interrupted in that part of the brain. The remark- able fact in regard to this case, in comparing it with ordinary brains, was that it was much larger than usual, I think weighing some fifty-seven and a half ounces, freed from the membrane; but the arterial system is very defective. You take all the branches-for instance, take the Sylvian artery, which in some cases will give off some sixty different branches—in this case there were but five or six branches. Although a very large supply of white and gray matter, there was very little distribution of blocd to that brain. With that specimen I have others, and we may trace right from that to see if the arterial supply was not affected in that portion of the brain. Dr. HURD: I remember, during my asylum experience, two deaf mutes, who were insane. One was a man who had been thoroughly edu- cated in an institution for the deaf and dumb. Previous to coming to the asylum he bad been under treatment for a former attack of insanity and had recovered. He afterward relapsed, and was sent to the institution with which I am connected. After about a year he made a second recovery, and for the last six or eight years has been able to live at home. Another one, a female, did not recover, but went into a state of permanent demen- tia. Her mental trouble began when at an institution for the deaf and dumb. We always bave, I think, in our institutions, deaf mutes who are con- genital idiots; whose minds are congenitally defective, and who are in- capable of education; who are insane and irresponsible, and yet show none of the symptoms, or mental manifestations, of the insane educated deaf mute. As I understand Dr. Grissom's inquiry, it is in reference to edu- cated deaf mutes—those who bave considerable mental training, and who 570 Proceedings. do not suffer from congenital difficulty. In these latter cases, I think if the brains were carefully examined it would be found that the difficulty was entirely with the hearing apparatus, or with the means of conduction of sounds, and not with the brain itself. I am aware it bas been argued that a certain uniformity in the character of the delusions of the congenital deaf-pute points to a definite brain lesion, or brain defect. My own ex- planation of such uniformity of morbid mental manifestations is found in the peculiarities of the deaf-mute which bave their origin in his imperfect education and subsequent peculiar mental development. The adult deaf- m ite educated or uneducated has a very peculiar mind. He does not possess the means of correcting false judgments that all have who hear, and be- comes retiring and self-concentrated, and tenacious of false ideas. Unable to converse fully with his fellow-men, his mental development is, at best, defective. As a result of social isolation he becomes unsocial, suspicious, and inclined to arrive at incorrect conclusions. I do not think that he is any more liable to become insane than the blind person; but when he be- comes insane, bis insanity is apt to follow a certain course. He becomes violent, impulsive, and is inclined to complain that be is talked about. In this respect he is a good deal like a convict in a prison, and has many of the same characteristics. From my point of view, deaf mutes may beconie insane just as blind persons become insane; but deaf-muteism is not, in itself, any great predisposing cause of insanity. I also think that deaf- muteism, while it may modify responsibility, does not abolish it. On motion, the Association adjourned to 3 P. M. At twelve o'clock, the members took carriages, to visit the Laboratory of Messrs. Parke, Davis and Co., and, after being driven through the finest part of the city, visited that large and excellent establishment in all its parts, and after partaking of a bountiful collation, returned to the Hotel. The Association was called to order at 3 P. M., by the President. Dr. Goldsmith read a paper on “Communicated Insanity," which was discussed by the members. DR. HURD: Mr. President and Gentlemen-A few years ago I reported brietly a case of communicated insanity in connection with a family living in Gnesee County, Michigan. The facts of the case are these: A woman, a person of excitable mental organization, became insane. She had suttered from a previous attack, and, in consequence of failing physical health and general debility, had a second attack of insanity. Her husband was an epileptic, who neglected and abused her until she was obliged to seek refuge with her mother. Her mother was, at best, a per- son of feeble intellect. She had borne a large family and had been a vic- tim of manifold furtunes. Her husband was an inebriate; several of her Proceedings. 571 . children had been insane, and one or more of them had been deficient mentally. I mention these particulars to show that the whole family was neurotic and predisposed to develop insanity. The woman who became insane bad a married sister, living in the same family, who had come home to help take care of her. This woman was deformed in body, but had con- siderable brightness of intellect and a strong vein of superstition. She explained the insanity of her sister to be due to the macbinations of her husband, whom she believed to exercise witchcraft over her, to put spells upon her, and the like. Among other things, she believed that a watch which he carried possessed magical power. In one instance, at her Bug- gestion, the watch was taken from him, when he was asleep, and put under the pillow of a sick child. He soon awoke, missed the watch, seemed in great distress, and made such a clamor that it was returned to him. As soon as it was restored to him he became quiet, but the child grew worse and soon died. This was proof positive, to the sister, that the sick child had also been killed by witclicraft. The family then combined, at ber suggestion and instigation, and threw bim out of the house. This, however, was but the beginning of serious trouble; all the members of the family, some twelve or fourteen in number, soon became impressed with the idea that they had all been bewitched through the same agency. They immediately stopped up the windows and doors, and, to break the spell, began to fire silver through the windows. They were informed by the sister that spiritual agencies, like mesmerism and witchcraſt, could not be dispelled by ordinary iron or lead bullets; it was necessary to shoot silver, and as long as their money lasted there was an active fusi- lade. All the glass in the house was shot out, and, as they were exceeding- ly poor, the money soon disappeared. The sufferings of the insane woman, however, were not relieved. She was exceedingly maniacal, and, of course, was not quieted by this treatment. They thought that her husband must be somewhere in the neighborhood, and was still exercising a baneful influence over bis wife; they accordingly bent all tbeir energies to preserve the life of this woman until he had exbausted bis power of witchcraft. "They repeatedly cut ott the ends of her fingers and toes, under the belief that if the blood continued to run, her life would be saved. At the end of a week or two—I think these demonstrations lasted two weeks- & physician visited the house, to see the insane woman, and was stabbed with a knife by her sister. The anthorities were summoned, and the two women were arrested and committed to the asylum. The mother and several of her children and grandchildren were taken to the poor-house, two or three sons were taken to the jail, and the nest was broken up. The other mem- bers of the family, when taken away from each other, soon lost their de- lusions, or became ashamed of them, and returned to their work. The two women, however, who came to the asylum with wbich I am connected, were under treatment for some time. The woman who had the systematized delusions of witchcraft, maintained her belief in witchcraft, in a modified form, up to tbe end of her treatment; but after a couple of weeks began to acknowledge that she had a delusion about it, and was unwilling to talk about the matter. She finally became very anuch ashamed when allusion was made to it, and at last began to believe 572 Proceedings... that her sister had not been bewitched, but was “actually insane." She improved rapidly and was soon removed by her husband. The woman who suffered from maniacal excitement, when brought to the asylum, made comparatively slow improvement, but at the end of five or six months was well enough to be taken from the institution. DR. GIlmax: In reference to this case reported by Dr Goldsmith, I would ask if it were not possible that the influence of the husband upon the wife might have induced her to believe what he said in reference to the sacrifice wbich he was to make, or to his belief in a full resurrection; and whether the loss of sleep, night after night, and week after week; also the excessive religious enthusiasm which was, perhaps, manifested by this knot of men and women who believed as he did, might not have caused the irritation which resulted in the insanity of the wife, rather than to have been communicated to her by her husband ? DR. GOLDSMITH: I would say in regard to that, that I had some com- passion upon the audience and did not read everything I had written upon the subject. I am not sure whether the woman was insane previous to the end of her first month in jail or not. She certainly was on very dan- gerous ground and I believe very much as the doctor bas suggested, that she may have been only a fanatic after the death of her child, when she was greatly tried by doubt; and, subsequently, when she had a short pe- riod of mental confusion. But after the first month in jail'I consider ber unquestionably insane; but the fact is that the evidence of her insanity is simply that her mind was merely a reflex of her husband's for more than two years following, and she recovered as he recovered. If he had re- covered a year sooner I think it probable that she would have done so. She entertained his beliefs whatever they were. DR. GILMAN: I had an instance of the kind that did not end as this did. The man became insane with delusions, and the wife entertained the same delusions while he was with her at their home; but his insanity was promptly recognized and he was removed to the liospital for treat- ment, and before many days bad elapsed the wife was entirely well. There was no evidence of insanity in her case afterwards, although her de. lusions were similar to his while he remained with her. He was removed to the hospital, and she immediately appeared saue from that time; and he, after several months, made a good recovery. DR. GOLDSMITH: I have no doubt tbat if this man had been removed to the hospital previous to the death of his child his wife would not bave been in ane. I feel confident of that. DR. GILMAN: In this instance that I mention, I found the cause of the temporary derangement of the woman was the loss of sleep and the anxiety in reference to her husband, and in re erence to his condition, per- haps, and all of the surroundings which would induce insanity; and when he was removed there appeared to be no pathological condition in the case of the woman. DR. STEARN3: Mr. President-It seems to me that we may fairly question the appropriateness of the term “Communicated Insanity," as used in connection with tbe case presented by Dr. Goldsmith. It seems Proceedings. 573 to me that upon almost any theory of insanity, or at least upon that the- ory with whic, we are all in accord, it would be very difficult to conceive in what manner one person could communicate insanity to another. In a word, this theory implies that insanity arises from, and is dependent upon some physical derangement, or pathological condition of that por- tion of the brain which is immediately concerned in the thought-process, and we could about as reasonably expect that a person could communi- cate lameness, or paralysis to another, as insanity. I am inclined to think that the case admits of another explanation. It apppears that these two persons lived together not only in the ordinary intimate relationsbip of husband and wife, but that the mind of each one was a sort of mental reflex of that of the other; tbat there was an unusual degree of unity and harmony in their general course of conduct and belief, and this extended to the particular form of religious belief which pre- vailed in the community about them. This was one of fanatacism and absurd in the extreme to every boly except those who were under the immediate influence of the leaders. It was attended with more or less of excitement at all times, and sometimes with a great deal of it; the nervous system was kept upon a pretty constant strain with expectancy and anx. iety. Now, such an atmosphere of excitement, and such conditions of daily life are most unfavorable to mental balance, and not unfrequently lead on to the development of ins:inity, and it is evident that in conse- quence or them the husband became ins:ine. In the case of the wife there was the additional effect which resulted from the horrible tragedy and the continement for a month in the jail; also from the worry, loss of sleep, and foreboding which came in consequence of it all. Such causes alone would be quite sufficient, especially when operating upon a sensitive nervous system already weakened by excitement and strain, even in a strong person, to induce derangement of mind. It seems to me that these two cases were caused in some measure by like influences, and that the calling one of them a case of communicated insanity" would be rather a fanciful use of language. DR. FLETCHER: This case recalls to mind one that I remember read- ing of in the Journal of Insanity, among the first numbers, about a family in Maine, by the name of Pinkham; and I hope some of the gentlemen who are familiar with it will give some of the details of that case. I believe, in the first instance, the father, laboring under some religious delusion, pro- posed that they should give up all their property and sacritice their children; and, if I mistake not, the children entered into that common be- lief, and the father and nother did kill five members of the family, and then committed suicide. Another case that occurred in Indiana, within the past three years, is where three Germans, two brothers and a sister, living a little more isola- ted than the rest of the community, and persons of very ordinary educa- tion, if educated at all. One of them, the older brother, conceived the idea that the devil had taken possession of the farm and that they could not raise good crops until they had succeeded in unearthing the devil, who was to be found under a certain boulder in their barn-yard. The elder brother commenced digging, and rolled up great boulders,-it was in a 574 Proceedings. boulder drift region-worked hard for several days, and then his brother was possessed by the same belief, and finally, the sister also; and the three of them were engaged there, for more than six weeks, in making an ex- cavation, removing about twenty feet of the surface, the hole being about fifteen feet in depth. You would be astonished at seeing the size of those boulders that were brought to the surface and rolled out with the expecta- tion that they would roll out the boulder he was under. It became a matter of such public importance that the neighbors had them arrested and sent to the hospital. Two of them recovered from their delusions in the course of two or three months,- I think the sister first-probably from a complete cbange of surroundings and the improvement of the diet. They picked up in flesh, and after a while all acknowledged it was a delusion. Whether the brother exercised an influence which brought on insanity in the other two, is a question. They all labored under precisely the same delusion; they all believed in the presence of a devil under the boulder, and en- deavored to get him out. DR. HINCKLEY: The discussion of the paper of Dr. Goldsmith brings to my mind the cases of two brothers, that occurred some twenty years ago, in New Jersey; one brother about twenty-five years old, and the other two years older. The younger brother hecame suddenly demented, and the older brother, who had exhibited for him much sympathy, and had always been quite strong, nursed him for a period of six weeks. At the end of that time the family removed the younger brother to an asylum. The older brother suddenly manifested the same symptoms as the younger brother, and they were both removed to the asylum at Trenton, remained there for a number of years; in the end were removed to their home, and are now under my observation. The symptoms are very much alike in both cases. The history shows that there is no hereditary mental disease or neurotic tendency; but the cases are so much alike that they attract attention in the matter of symptoms, one constantly imitating the other. If the younger brother is sitting at the table and stops eating the other brother will immediately stop also. We found it necessary to remove one from the other in order to allow either to get proper sustenance. That is all there is about the case that seems to have any bearing on the com- municability of mental disease. Dr. Pratt: It is well known to our profession that there are classes of diseases which are, or may be, reproduced in children, and sometimes in adults. In some having a sensitive, nervous temperament, by sympathy, and in others by a somewhat unusual tendency to imitate. During the course of my professional life, I have known of several cases of permanent stammering,-a stammering that continued through life-wbich resulted from imitation, the original stammerer having been a boy or girl of strong mental and personal characteristics. The habit of the original stammerer seemed to imprese itself, with their other personalities, on their play- mates and associates. It is well known to the general practice, also, that a person subject to chorea, appearing upon the streets, is quite apt to develop in certain sen- sitive, nervous temperaments, especially in children, the same or similar manifestations. I had one such case under treatment for nine months, Proceedings. 575 which originated in this way. I know a young man of some twenty-four or twenty-five years of age, who began to stammer when he was five, sim- ply from sympathy or imitation; in his case, probably, the result of an imitative nature. Now, this being true in reference to the influence of persons, one upon the other, it is easy to understand how we might bave wbat is called communicated insanity,”-imitated insanity, or sympathetic insanity. I can readily understand how, in the imitative or sympathetic relations ex- isting between husband and wife, that impressions may be communicated from one to the other, resulting in morbid mental manifestations which may become quite prominent in both. It is no uncommon thing to ob- serve religious excitement beginning in one person, the husband or the wife, which is communicated to, or manifested by, the other. All of us who have bad practice in localities where some remarkable religious ex- citement may have developed, have seen cases of this sort; and, although this excitement may not have often developed into what may properly be called insanity, its effects go far to demonstrate the fact that sympathy or imitation, or,.if you please, the magnetic power which one person has over the other, may become the cause or means by which morbid conditions or manifestations may be transmitted from person . to person. DR. Cowles: Mr. President-Without going into details in this case which has greatly interested Dr. Goldsmith and his colleagues in Massa- chusetts, I would like to say that I was struck by the observations of Dr. Stearns upon one aspect of it. Looking at the case from a purely physical point of view, bere were two persons under similar conditions, as to their conviction and common beliefs. They were intelligent persons, the woman evidently so; the same intluences produced like effects in both. From this point of view the question is suggested: Which was the one who was first insane? If I understand the purport of the statement in regard to that particular act, the woman first suggested the sacrifice of the child in the manner of Abraham. I am not able to give any testimony as to the frequency of the occur- rence of such cases of communicated insanity except in a negative way, as I have never met with any that were distinctly marked. I bave, how- ever, in several instances, taken pains to separate patients from association with each other, women particularly. There was something in the du- plicative character of the acquired delusional idea, or insane conduct, that suggested the imitation of hysteria. The cases were hysterical in nature and the imitations were transient. A part of this paper and what has been said of it, suggests to me to remark upon a case, the antithesis to it, of a curious kind. One of the cases wbich I had the honor to report to the society, two years ago, was of a young lady who for ten or fifteen years had been the subject of a fixed idea. This woman, for years, simply entertained the idea, or allowed herself to be dominated by it, that all of her acts would in some way, cause injury to a distant friend, whom she had not seen for years; and in order to avert a possible calamity to her friend, she would imprecate such a calamity upon herself by awful forms of oaths an imprecations, 576 Proceedings. thereby placing herself in the position of making a vicarious atonement and seeming to save herself from the possibility of inflicting the injury, upon her friend. It came about, after a long time, that she began to suffer a great degree of the depression and remorse peculiar to melancholia, and she had the usual feeling of having done wrong in what she had done in making use of this pretext to gratify her desires as to her actions, and at the same time satisfying her conscience. She was compelled to punish herself, and to adopt a system of denial of every pleasant and agreeable thing, as agreeable companions, etc. Near her room was an old lady who had to be ted and to be coaxed and persuaded by the half hour at a time.. She felt that she ought to suffer as much as anybody else suffered. Sbe looked about for ways and means by which one could suffer, and refused food, with the idea that she ought to compel herself to be fed, -to be sub- jected to the indignity of being fed by a nurse,--and it was necessary to discontinue the neighborhood of these two persons. It amounted really to this: She undertook to acquire a delusion; I will not go into detail, however, to make it plain,—she tried to have a delusion which should pre- vent her from eating. Another effort of bers, in the same direction, came from her feeling that she ought to suffer the worst of all possible punishments, here and hereafter. She was perfectly familiar, being a very intelligent woman, with the actual nature of delusions, by her observations of two or three years in the asylum, with other patients about her whom she had studied. She was familiar with the delusion that one had committed the unpardonable sin, and she ireditated over tbis. She said to herself, “I must have committed the unpardonable sin! What is it? If I have not committed it, I ought to suffer as much as if I had.” She proceeded to imagine the punishment that would belong to the commitment of that sin and to subject herself to denials accordingly. But she could not quite grasp the idea of committing the sin against the Holy Ghost, and after two or three weeks the idea was abandoned. She bad sincerely tried, and failed to acquire two of the most common delusions of the insane. Dr. Long: I do not wish to occupy the attention or detain the As- sociation; but I have in mind a case very similar to the one reported by Dr. Goldsmith. About five or six years ago, I was called to see a lady, the wife of a laborer, in a family that I had some acquaintance with. They were, perhaps, of the average intellect of persons in their station, the hus- band being a common laborer, and lived quite comfortably, The Salvation Army had invaded the city about two weeks before, and they had been regular attendants at the nieetings. The husband asked me to call and see the wife. I went there and found her very much excited and nervous, and she said she felt inspired to kill her children,-they had three children,-in fact, she said that it was imperatively necessary that they should be sacri. ficed. I prescribed for her, and suggested the calling in of a neighbor to look after her. I then told the husband that she was insane, and must be watched very closely. I directed her not to be left alone with the children. He expressed the opinion that there was no necessity of the neighbor be- ing called in, as he could attend her himself; he thought she was some- what nervous from attending these meetings too closely. I noticed Proceedings. 577 nothing abnormal about the husband except, perhaps, his failure to fully realize the grave condition of his wife and the danger to the children, as he did not think it necessary to watch as closely as I advised. I called the following day, about the same hour; found the wife unchanged so far as her delusions and homicidal tendencies were concerned. On the following morning I was summoned to see the husband. I found him possessing the same delusions as the wife, fully as much excited and as fully determined to kill his children. At the end of one week they were both transferred to the Michigan Asylum for the Insane. In six months from that time, the wife made a good recovery, and now, at the end of five years, the husband is still in the asylum, and I am just informed by Dr. Palmer that, in his opinion, be never will recover. If I understood Dr. Stearns correctly, be said he could not con- ceive of communicated insanity leading to organic change. Here, cer- tainly, is a case that bas proceeded to organic change in the brain, and cer- tainly is entitled to be regarded as a case of communicated insanity if any case can so be considered, though I do not wish to be considered as ad- vocating that insanity is contagious. In the case cited, the insanity began with the wife. So far as I could learn from neighbors and acquaintances, the husband had never shown any signs of insanity; within forty-eight hours from the beginning of the wife's attack, the husband is attacked with the sanie form of insanity, possesses the same delusions and homicidal tenden- cies; therefore I regard the attack of the wife as the exciting cause of the husband's attack, though I bave no doubt that he was weak-minded, yet, I think it possible that without the exciting cause he might have gone through life without an attack of insanity. DR. ANDREWS: I wish to say a word in favor of Dr. Stearns' position as outlined in his remarks, which seem to me to be correct, and to offer the only explanation of these (aser. I cannot conceive of insanity being communicated, if by insanity we mean wbat I think all of us do mean at the present time, a disease, a path- ological condition of the brain. In regard to the cases whose history has been given by Dr. Goldsmith, it is much easier to believe that they became independently insane and that tbere was merely a coincidence of time as to the outbreak of the dis- ease, than to believe that it was communicated. They were both subject to the same influences and the same environments, and the fact that their delusione happened to be of the game cbaracter does not prove any com- munication of the disease, but simply shows that under similar conditions, similar delusive ideas were originated. • Some of these cases of so-called communicated insanity are those in which there is a powerful impress of the insane delusions of one, upon an- other peculiarly susceptible person, and not a matter of disease at all. It is not an unusual thing for a wife to accept fully the ideas and beliefs asserted by an insane husband and to enter into them in the most positive manner; or, on the other hand, if the wife is the stronger man of the two, for the husband to accept her insane ideas. Another explanation occurs,—that in some of these cases we do not have genuine insanity; that the person is not really suffering from cerebral 578 Proceedings. changes which characterize that disease, but simply entertains a false belief. We all recognize these conditions as we see them in the existence of such theories as Spiritualism, Mormonism and the like, and people are often controlled by them as fully as if they were morbid delusions. The fact that when these people are separated from each other, they regain their normal mode of thinking and views of life, shows that the condition depends upon the acceptance of a false belief, and is not an in- sane delusion. To conclude: I cannot conceive of communicated insanity any more than I can of any other form of disease in which we do not recognize in- fection or contagion. DR. NICHOLS: Mr. President-I have had recently under my care the case of a woman, one of two single sisters, both between thirty and forty years of age, of a highly nervous temperament, and belonging to a family of wealth and culture. I do not recall tbat there is any insane heredity in their cases. In conse. quence of an aflliction in the family, I think, one of them became first insom. nious and, in my judgment, gradually became actually deranged. The other, who had the weaker mind of the two, though not a person of par- ticularly weak mind, followed the morbid bistory of the first as nearly as a sare person could imitate another. The conduct and delusions of the second sister, who was the younger of the two, became the same as those of the first. The family was advised-very wisely I think,-that these sisters should be separated as a necessary condition to their recovery. One of them was sent to me and made a good recovery, and the one that remained at home is reported to have made an equally good recovery. Now it seems to me that the conclusion of Dr. Goldsmith in respect to the etiology of the second of these cases is the correct one, though I reason a little differently, perhaps, in respect to it, from what he does. The distinction between a delusion of insanity and a delusion of super- stition or ignorance is well understood by us all. We all agree that real insanity, insanity whose victim cannot control its manifestations, is the result of a morbid condition of the brain. There is a difference of opinion -a matter not susceptible of proof-as to the proportion of cases of insan- ity in wbich there is, at the outset, an organic disease of the brain, and those in which there is only a functional disorder of that organ. If I rec- ollect correctly, an eminent cerebral pathologist bas lately said that in only five per cent. of cases of insanity that occur is there organic disease of the brain at the very outset. I have supposed tbat the per. cent. of organic disease at the outset was larger than that, but I am not sure of it by any means. Now, in the case reported by Dr. Goldsmith, the mind of the busband was so intensely exercised upon a religious subject, in such a way and for such a tinie 88 to disorder the man's brain function and thereby derange his mind. That seems to have been the judgment of most, if not all, of those who investigated the case, and it may fairly be taken for granted that such judgment was correct. The wife was also of a deeply relig. ious nature, and though stronger than he, perhaps, intellectually, she nat- urally sympathized strongly with her husband, as she was constantly Proceedings. 579 subject to his teachings and influence. She was also subject to the same fanatical religious associations and teachings, outside of their roof, as be. At the time of the horrible killing of the child she, probably, had not passed the line that separates sanity from insanity, but the cerebral excite- ment and susceptility bad become very great. It could not, under the circumstances, have been otherwise. Then came the death of her loved, innocent child, at the hands of its father, her husband, and when she found that the child did not return to life, as in the ecstasy of the fanatical faith to which she bad been wrought up, she probably, for a short time, thought,-perhaps really expected-and recognized that it was not only hopelessly dead, but the terrible tragedy of its death, it is no wonder that the agony of ber grief and of her remorse, perhaps, for not rescuing her child from her busband's purpose, caused her, in the lapse of a month, to become doworigbt insane. Her recovery and the limited manifestations of the mental disorder while it lasted, indicate to my mind that the dis- ease was not organic. Sympathy and association are powerful agencies in leading susceptible minds,-particularly those of the young-into lines of morbid thought, feeling and action, which in turn become essential links in the chain of causes of active, mental derangement; and, while I would not erect such cases into a separate class for the sake of indicating an inter- esting peculiarity in their etiological history, they may appropriately be called cases of sympathetic insanity. As Dr. Andrews remarked, I take it that none of us would for a moment subscribe to the doctrine that insanity is contagious and is communicated from one person to another, as small-pox is. Dr. GOLDSMITH: Mr. President-I rige simply to say that I appre- ciate the propriety of the criticism of the term “ Communicated Insanity." It is the one almost universally used in the English language, and I select it because of its utility. Very likely others can be found that better de- scribe the condition. The remarks of some of the gentlemen would seem to imply that I think the active person the sole cause of insanity in the passive person in a case of communicated insanity. This would of course be absurd. I believe tbat one cause alone practically never produces in- sanity. There is always an association of causes. The husband and wife were in this case both subjected to the same conditions, but it seems that the influence of the husband was the most efficient exciting cause of the wife's insanity, and determined the form of the disease. The very un- usual fact is that the influence of the mind which was working pathologi- cally seemed to mould the other mind just as is common with minds that are working normally. Dr. B. D. Eastman read a paper on “Mesmerism versus Fascination." A communication from the Sister Superior of St. Joseph's Retreat, at Dearborn, inviting the Association to visit that institution, was read, and referred to the Business Committee. 580 Proceedings. On motion of Dr. Hurd, the thanks of the Association were returned to the Sister Superior for the invitation. Dr. Buttolph read a paper on the “Organization and Management of Hospitals and Asylums for the Insane under Single and Dual Heads." On motion of Dr. Callender it was unanimously Resolved, That this Association endorses emphatically the clear and forcible exposition and vindication of the propositions of the Association, announced in 1853, 'in regard to the singleness of the responsible headship of a medical officer in the organization of hospitals for the insane. Dr. Nichols: Mr. President-In 1876 a committee was appointed to collate the propositions and resolutions of the Association, adopted from the time of its organization to that date, in regard to the organi- zation of asylums and hospitals for the insane, their management, and other important questions that bad claimed the consideration of this body, and have them printed in a paniphlet. That was done, and a copy furnished all the members of the Association at that time. I hold a copy of that important pamphlet or book in my hand. Since their original distribution a good many gentlemen have come into the Asso- ciation, and it may be that some of the new members have not had a copy and may like one. The Secretary informs me that he has a large number on hand. I suggest that he be requested to furnishi a copy to all the members who do not possess one. Dr. Curwen signified his intention of sending a copy to each member of the Association. Dr. Hurd announced the order of proceedings for the evening and Thursday. On motion, the Association adjourned to 7 P. M. The members spent the evening socially, in company with medical men of the city, at the Abstract Parlors. The Association spent Thursday, June 16, in a delight- ful excursion, by steamboat, to St. Clair Flats, partaking of a bountiful dinner, provided for them, and returning to the city at 5.30 P. M. The Association was called to order at 7 P. M., by the President. The Secretary stated that letters had been received from Drs. Schultz, of Pennsylvania; Bancroft, of New Hampshire; Paine, of Massachusetts; Booth, of New Proceedings. 581 Jersey; Channing, of Massachusetts; Parsons, of New York; Bucke, of Ontario; Strong and Richardson, of Ohio; Quinby, of Massachusetts, and Pike, of Provos City, Utah, giving reasons for their inability to attend this meeting, and expressing their regret. Dr. Curwen, from the Committee on Necrology, reported that the memorials of deceased members would be inserted in the minutes. Dr. Nichols, from the Committee on Time and Place of Next Meeting, reported in favor of the Hygeia Hotel, at Fortress Monroe, on the third Tuesday of May, 1888; which was, on motion, adopted. On motion of Dr. Chapin, the President was authorized to appoint the Business Committee for the coming year. Dr. Andrews made some remarks on the International Medical Congress and the intended organization of the Psychological Section. Dr. Andrews then read the following memorial of Dr. J. P. Gray: DR. JOHN PERDUE GRAY, The subject of this memoir, died at Utica, New York, on the 29th day of November, 1886, at the age of sixty-one years. Of the circumstances attending his death we make this brief note. The initiatory cause of his final illness, was the result of an attempt made by an insane man to assassinate him, in March, 1882, immediately upon his return from Washington at the conclusion of the trial of Guiteau for the murder of President Garfield. The bullet passed through his face, under the floor of the nose, paralyzing some of the nerves of the face and mouth, and producing stenosis of the nasal pas- sages, which seriously interfered with his breathing. It also caused a neuralgia, from which he was, for a long time, an almost constant suf- ferer. This injury, with the nervous strain and responsibility of the protracted trial, combined with the continued performance of the duties of his position in the asylum, perceptibly impaired his health, and were powerful factors in producing the fatal results. In January, 1886, the Board of Managers of the asylum gave bim a leave of absence for six months. A portion of this period was passed in the South, and the remainder in a foreign tour, undertaken in the hope of improving his health. He returned in October, seemingly ben- efited by the change, and again resumed his labors, but under peculiarly trying circumstances. Early in November business called him to Balti. more, whence he returned, much prostrated, and suffering from a re- currence of the disease, which was so soon to prove fatal. From this 582 Proceedings. time it was evident that little hope could be entertained of his recovery. He slowly failed, from blood-poisoning, induced by disease of the kidney, and died in uræmic coma. It is not our intention to give a full sketch of his life, but only such facts as may indicate the direction and extent of his labors, and the sa- lient points of his character. Dr. Gray was one of nine children, and was born on the sixth of August, 1825, at Half-Moon, Centre County, Pa. He was educated in the common school, in Bellefonte Academy and Dickinson College, and re- ceived his medical degree from the University of Pennsylvania, in the class of 1848. After a period of two years' service in the Philadelphia Hospital he was chosen, on account of his qualifications and ability, the junior assistant in the State Lunatic Asylum, at Utica, New York. He passed through the higher grades of second and first assistant, and in July, 1854, was elected the superintendent of the asylum. At the early age of twenty- nine years he was thus placed in a most responsible position, at the head of what was then the largest asylum for the insane in the country. He became the successor of Drs. Brigbam and Benedict, whose skill and abil. ity had given the Utica Asylum an enviable reputation. This Dr. Gray not only sustained, but widely extended, by improving the old and originating new measures of administration. Accepting unreservedly the view that insanity was a physical disease, the medical care of patients assumed the highest importance, and the institution was made, more completely than ever before, a hospital for the nursing and care of patients as sick people. The influence of the pre- dominant idea was felt in every part of the asylum. To the strictly medical treatment of insanity he gave special consider- ation; the medical bistory of patients was more fully sought out and recorded, and the resources of the pharmacopæia were employed with a belief in their efficacy in this as in other forms of disease. The moral treatment, by employment, amusement and mental occupation was early given a prominent place. One of the methods introduced by Dr. Gray was the establishment of the Opal, a paper contributed to and published by the patients in the asylum. This was continued until the tbird issue of the tenth volume, and proved of great interest and value to the patients, and was also a source of revenue. Its exchanges reached as high as three hundred newspapers and periodicals annually; it added several hundred volumes to the library, and hundreds of dollars to the amuse. ment fund for patients. His labors were always in the direction of prog- ress, both in material improvement and administration, as well as in the treatment of patients. The organization, making subordinates individu- ally responsible to heads of departments, and these in turn to the super- intendents as the highest authority, resulted in improved order and dis- cipline and increased efficiency. The Utica Asylum, under his control, be- came the model for many of the institutions subsequently erected, and later, a school of instruction, which has furnished a larger number of men equipped for the specialty than any other asylum in the country. Early in his career as superintendent, and while most men would have been fully occupied with the details of management, he enunciated Proceedings. 583 : the principles which bave since largely guided the State in the care of the insane. In the resolutions possed by the Superintendents of the Poor, in 1856, we recognize his hand. These were, that the State should make ample provision for all its insane, who were not in condition to reside in private families; that none should be cared for in any county poor and almshouse; that the proper classification demanded for the care of the insane could only be secured in establishments constructed with special view to their treatment; and finally, that the curable and incurable should not be cared for in separate institutions. In accordance with these views, he urged the erection of two State hospitals for the insane, 80 located, that, in conjunction with the Utica Asylum, they would most fully meet the needs of the people of the State. In the discussion of the question of separate institutions for the acute and chronic classes of the insane, which excited deep interest in the pro- fession, Dr. Gray bore a notable part, and one which gave him great prominence. Ile maintained then, as always, that it was the duty of the State to provide for all of the insane the best medical care, and to remove the county poor-houses to asylums properly equipped with every means to promote recovery. Although overruled by the establishment of asylums for the chronic insane, he lived to see his plays carried out in the erection of the Hudson River Hospital, at Poughkeepsie, and the Buffalo State Asylum, at Buffalo, to accommodate the patients in the eastern and west- ern divisions of the State, respectively. : Another movement in which Dr. Gray was identified as the originator, and which he carried to a successful issue, was the removal of children from the poor-houses to the various orpban asylums, and their support in them at public expense. This reform, first inaugurated in Oneida County, has been adopted in the other counties of the State, and has been of inestimable benefit in rescuing children from the associations and de- gradation of life in the poor-houses, and giving them the advantage of training and education, which has made valuable and independent citizens. This philanthropic work entitles him to rank as a public benefactor. The separation of the convict and criminal insane from other patients, and treatinent in an institution constructed with special reference to their isolation and safe-keeping, was largely, if not entirely, due to the efforts of Dr. Gray. For several consecutive years in his annual reports, he called the attention of the Legislature to this important subject, and to this added bis personal influence with those in authority. His appeal was at last successful, and resulted in establishing the Criminal Asylum at Auburn, of which he was appointed one of the commissioners in locating and erecting the buildings, and afterwards served in this capacity for sev- eral years. The wisdom of this action has been fully sustained, and the example has been followed by other States where the numbers of this class warranted the expense of their separate maintenance. . Subsequently he was made one of the commission to locate both the Willard and Buffalo Asylums, for the latter of which be furnished the plans, and was one of its Board of Managers until it was in full operation. • The subject of the causation of insanity has always received the careful 584 Proceedings. consideration of alienists. In the asylum under Dr. Brigham, and for some years under Dr. Gray, the two classes of causes, moral and physical, were recognized as productive of the disease. The moral causes were given a largely predominating position, and included all of the cases in wrich there had been a history of any emotional excitement or disturbance, wbile to physical causes were attributed only the small number of cases which were tbe result of injuries or deformities of tbe head and like material in- fluences. Upon more prolonged observation and reflection Dr. Gray became convinced of the incorrectness of this theory and practice, and satisfied tbat moral causes alone were not sufficient to produce disease. He believed that it was only when physical healb was affected tbat insanity resulted, and that this change was really the cause of the emotional disturbance. From this time forward be regarded plıysical causes only as producing insanity, and recorded none but them in the tables of cansation. This wae deemed a most important step, as it gave the first place in treatment to therapeutic measures and divorced the subject more fully from the influ- ence of the metaphysical theory that insanity was a disease of the mind. * Rest, putrition, medication-could then be presented in truth, as the re- lief of sorrow." Insanity a physical disease due, strictly to physical causes was one of the distinctive learures of his belief and teacbings. Dr. Gray was the first in this country to recognize the importance of and to introduce special investigation into pathological conditions existing in insanity, and to the Utica Asylum belongs the credit of having the first special pathologist appointed on its official staff. This course has been, not only fully endorsed by the specialty and profession, but such interest bas been created in the subject that several asylums have now such an officer regularly appointed and at work in this line of rescarch. However great the success and credit Dr. Gray deservedly gained for his labor in the directions already mentioned, it was in the field of medical jurisprudence, as an expert in insanity, that he attained the greatest tri- umpbs of his life. Beginning with the Parish will case and the trial of Tyler for murder, one of the first in which epilepsy was pleaded as a de- fence, bis course is fairly marked out by recalling the list of prominent trials throughout the State. A few of these are, the trials of Heggie, of Buckhout, of Ruloff, of Walworth, of Montgomery, of Dillon, of Gaffney, of Waltz, of Mancke, for murder, and the Vanderbilt and Fillmore will case 8. In behalf of the general Government during the war, he presided at the trial of Dr. Wright, of Norfolk, Virginia, for the murder ofa lieutenant of colored troops, and was a witness in the case of Stewart, tried for poison- ing a fellow soldier in the recruiting camp at Elmira ; and of Payne, one of the assassins of President Lincoln. He was many times appointed a com- missioner by the various governors of the State to whom a final appeal bad been made tor executive clemency. His aid was often sought by prosecut- ing officers and by the friends of the accused when there was a suspicion of the existence of insanity. On whatever side his services were employed, bis testimony was true to bio convictions of right, and always carried with it the force of being truthfully and honestly given. No imputation of be- ing influenced by any unworthy motive was ever cast upon his evidence. Proceedings. 585 He resorted to no subterfuges, clothed no mere theories in the garb of science, to excuse crime; yielded to no clamor, but always took his position and sustained himself upon the principles deduced from his broad knowl- edge and vast experience; and consequently, his opinions had the utmost weight with the judge, the jury and the people. He bore successfully the most searching questions of the best legal talent, at times lasting several days, and no exceptions to his testimony were ever made a ground of ap- peal to a higher court. The amount of labor he was called upon and often compelled to perform, against his most earnest desire, furnishes the best evidence of the value placed upon his services. There are few, if any, coun- ties in jhe State of New York in wbich be bas not appeared in the capacity of an expert in cases of insanity. The last and most trying case is still viv- idly in the memory of all. Upon bis conduct of the Guiteau case in which he was the princi- pal medical witness for the prosecution, may rest his reputation as the leading expert in insanity in the country. His testimony is a model of terse logic, of strong statement, of clear exposition of principles and facts of science, incontrovertible and convincing in its conclusions, a fit culmination of his labors. Dr. Gray also achieved success as a lecturer on insanity. For some years he occupied the chair of Psychological Medicine and Medical Jurisprudence in the Albany and Bellevue Medical Colleges. These lect- ures were undertaken not so much for his own honor and emolument as for the advancement of the medical profession. He believed that the specialty should be recognized in the curriculum of the colleges; that its importance demanded that instruction should be offered to the rising generation of medical men. His lectures were noted for their clearness and definiteness of statement, and for an eloquence and grace of style which attracted many bearers beside the students of bis own department. This success gave him the keenest pleasure, and is all the more remarkable as it is an observed fact that few men succeed as instructors who have not begun in early life. It is however an evidence of the versatility of his great power. More than any other person, Dr. Gray shaped the lunacy legislation of the State of New York, and it is largely to his influence with the commis- sion appointed to codify and revise the law, that we owe the present lunacy statutes, which surpass, in many respects, those of Great Britain, upon which they were in part modeled. In matters pertaining to other dependent classes his influence was also felt, as his advice was often sought by the Boards of Managers baving charge of the various cbarities, reformatories and prisons, by legislators, judges and officials. His opin- ions carried the weight of an authority, as they were based upon broad principles, and sustained by extensive knowledge and experience. As a writer, Dr. Gray was widely known to the profession, though he never published, as he was often importuned to do, any consecutive work upon the subject of insanity. He wrote many articles for the Journal of Insanity, and addresses before societies, which attracted attention and showed his ability as an author. The annual reports of the asylum were often important contributions to the specialty, as they contained, not only his views and ideas upon subjects of interest in the study and treatment of 586 Proceedings. disease, but also details of construction, organization and administration, of great value to those in charge of like institutions. That they recorded many of the methods employed for the occupation, amusement and moral treatment of patients, which are to-day heralded as steps of progress, is a strong tribute to his thoughtful, practical mind, and to the advanced ground which he occupied. In the death of Dr. Gray, the medical profession lost one of its strong great men, and one whom it has bonored by the niany offices and prefer- ments conferred upon him. He was successively chosen President of the Oneida County Medical Society, of the State Medical Society, of the State Medical Association, of the Association of Superintendents of American Institutions for the Insane, and of the Association of Medical Editors. He was an honorary member of the Psychological Association of Great Britain, of the Medico-Psychologique, of Paris; of the Society de Frenia- trica, of Italy, and of various other scientific bodies. He was President of the Psychological Section of the Centennial Medical Congress of 1876, and at the time of his death, held a similar position in the Ninth Interna- tional Medical Congress, to be held in Washington, in September, 1887. He also had conferred upon bin the title of LL. D., from Hamilton College. As a physician be held a high place in the regard of the profession and the public. He was readily approached; gave freely and willingly of his time to all, but especially to the younger members of the profession wbo appealed to him for assistance. In his practice he exhibited the same characteristics as in his conduct of public affairs. He possessed a compre- hensive knowledge of medicine, which, combined with ripe judgment, the power to note the salient points of a case, and to apprehend the relation between cause and effect, made him a safe counselor; inspired confidence in his decisions, and caused him to be consulted in the most important cases, both by physicians and those occupying the highest official and social positions. No better evidence could be given than the confidence thus reposed in him by those most competent to judge of his attainments in his profession. • Though fully occupied with the labors of his position, Dr. Gray found time for tbe exercise of the duties of a citizen, and as such was most highly respected. His patriotism was unquestioned and unbounded. Unable to enter the army from the position he held as superintendent of the asylum, he gave freely of his means and time in collecting money and obtaining recruits to fill the quota of the city. He was generous, liberal- minded and active in every charitable and public work which would relieve suffering or promote the interests of the community. He was domestic in his feelings and tastes, and loved to spend the time not urgently demanded by his duties, in his home, surrounded by his family and intimate friends. He was an affectionate husband and an indulgent father, a sympathizing friend in sickness, an admirable nurse, gentle as a woman in his care, and full of expedients for the relief and comfort of those to whom he ministered. Among the most notable characteristics of Dr. Gray were his readiness to appreciate, and ability to state, in a clear, forcible manner, the funda- mental principles of any question, his rare power of observation, his calm Proceedings. 587 and independent judgment and his strong convictions. These qualities, combined with an indomitable will, fully explain bis influence over otbers, and were elements of bis success. He had a wonderfully retentive mem- ory, both of persons and things, great affability of manner and kindness of heart, and a strong love for children, by whom he was always beloved. In conversation he was brilliant and instructive. From every place be visited and from every person he met he gathered information, wbicb it was his pleasure to impart to others. To all he was a cheerful and agree- able companion. Few people came into his presence without being im- pressed with these traits, and without recognizing the power and ability of the man. He was a natural leader of men, and would have reached the highest position in any walk of life he might have chosen. Though, like all men with true independence of character, he met with opposition and criticism of his administration, they rarely provoked him into controversy, or cbanged his course of action, but if attacked upon charges reflecting upon the probity of his official acts he never failed to defend himself successfully. Satisfied in his own mind of the correct- ness and integrity of bis conduct, under all circumstances he dared do what he felt was right and left the consequences to care for themselves. The full confidence of his friends in his honesty and ability united them in a generous support of bis management. Dr. Gray was a firm believer in the Christian religion and a member of the Reformed Church in Utica. His religious views, formed early in life, were settled convictions, and never a subject of question or doubt, They controlled bis life and conduct. In looking over his life-work tbere is a richness of labor and a fullness of success that rarely falls to the lot of man. In all the fields of action in which be bore a part, as the head of a great charity, a medical jurist, a lecturer, as the editor of the Journal of Insanity, as a pbysician, a citizen, and a friend, there were the evidences of great power, of strength of char- acter and generosity of disposition, wbich were the elements of his success, which made bim beloved, and wbich make his death a serious calamity to the community, to the profession and to his friends. What higher tribute could we give to bis memory? On motion of Dr. Andrews, a committee was appointed to prepare a series of resolutions in regard to Dr. Gray. The President appointed on said committee, Drs. Andrews, Daniel Clark and Callender. Dr. Grissom then made the following remarks: It is Wordsworth who says: One adequate support For the calamities of mortal lire, Exists, one only.-an assured belief That the procession of our fate, however Sad or disturbed, is ordered by a Being Of infpite benevolence and power; Whose everlasting purposes embrace All accidents, convertirg them to good. 588 Proceedings. When the sad tidings were flashed through the land that Dr. John P. Gray was no more, every heart in this body was struck with a sense of loss-proſound and irreparable. There are men who are powerful of and in themselves only-by the innate kingsbip of their natures. Place and position bave nothing to do with their influence upon fellow men. Whether adorned with the insignia of office or decorated by titular honors, or walking the “ cool, sequestered vale of life,” careless, apparently, of what others seek, they yet command by their very presence-they lead by the force of their great wills, they con- quer because no opponent can detect a tbought of surrender in their breasts. Of such men was Dr. Gray. Woen the annalist comes to reckon the services to science and to humanity of the vigorous intellect, the un- daunted spirit, and the clear intelligence of him whom we commemorate to-day, bigb indeed will be the position assigned him in the ranks of med- ical philosophy and alienistic literature. When the influence of the metaphysical school of thought, in its tbeo. ries of the causation and development of insanity was predominant, and almost universal in Europe and America, the facts upon which its theories were founded were incisively examined by Dr. Gray, and the conclusions boldly challenged. It is not necessary to remind tbis body of the brilliant discussions and papers with such giants as Dr. Ray embracing one view, and on the other side, he whom we lament to-day, the intrepid young champion of the the- ory that insanity is purely the result of physical disease, now so widely held, as to make us lose sight of the courage once involved in the declara- tion. Whatever may be the view of any in tbis body upon questions whose discussion is foreign to this solemn hour, there is no one who will not recognize the patient industry, tbe untiring investigation, the calm confi. dence in principle, the untlincbing adberence to what he deemed to be truth, the contempt for unreality and pretension, the bold advance in sci- entific thought, and the daring efforts to penetrate the unknown-set, on the other hand, the well-marked conservatism in methods of treatment, which characterized Dr. Gray. His distinguished position in the State, which is an empire of itselt, invited the slings and arrows of partisan and personal strife, and many and repeated efforts were made to embarrass his administration and lower the high and lofty plane of treatment he always demanded as the right of the sick and the suffering at the hands of their more fortunate fellow-men. Unmoved by the appeals of those who preferred expediency to jus- tice, and refusing to consent to the withdrawal of any privileges which could be conferred upon the afflicted who rested under the protection of his strong arm, he fought humanity's battle. Yet, doubtless, the long and harassing conflict was underınining the strength of the once robust form, weighed down with the responsibilities and cares borne so long and so well. At last, the shock of the assassin's bullet came, which, though not directly fatal, doubtless fell like an ax at the root of the tree. Like many of Proceedings. 589 our profession, and particularly of the specialty which I have the honor to address to-day, he fell a martyr at his post. Devoted to the best interests of this body, proud of its advance in sci- ence and the regard of mankind, kind and hospitable to its younger mem- bers, clear in judgment, faithful in counsel, decided in conviction, profound in knowledge, brave and generous, we shall miss him long. The poet has said: Take them, O Great Eternity; Our little life is but a gust That bends the branches of thy tree, And trails its blossoms in the dust. Let us not echo tbe melancholy refrain of such sorrow that bath no comfort, but rather say, with Charles Wesley, as we lay these sprigs of green upon the new-made grave of su much that was noble and was true: Pass the few fleeting moments more And death the blessing shall restore Which death hath snatched away; For me, thou wilt the summons send, And give me back my parted friend, In that eternal day. Dr. Andrews, from the committee appointed to prepare resolutions in reference to Dr. Gray, made the following report: Whereas, The Association of Medical Superintendents of the Insane in America has received the sad intelligence of the death of Dr. John P. Gray, Superintendent of the New York State Lunatic Asylum, of Utica, and formerly President of this Association; . Be it Resolved, Tbat this Association has heard, with profound sorrow, the announcement of the death of Dr. John P. Gray, and feels a deep sense of bereavement in the loss of one so distinguished, alike by his lofty abilities in his profession and his devotion to its interests. Resolved, Tbat in this melancholy event tbis Association has lost one of its most untiring workers and brightest ornaments ; science, a leader intrepid in thought and wise in counsel; the insane, a devoted and life-long friend, and all humanity a generous and courageous defender of the sor- rowing and the suffering. Resolved, That this Association desires especially to record its debt of gratitude to the distinguished dead for the conspicuous fidelity with wbich its interests were maintained, for so many years, in his editorial charge of the American Journal of Insanity, and the innumerable tokens of kindness received at his bands by the members of this body. Resolved, That the Secretary be requested to communicate these reso- lutions to the family of our deceased friend, with the expression of the sincere and heartfelt sympathy of this body in their great affliction. Dr. CALLENDER: Mr. President-Before the resolutions reported by the committee are put to vote, I am impelled to add a word. After the elaborate and eloquent eulogies read in our hearing, by Drs. Andrews and Grissom, perhaps nothing need be added, and I am sure nothing that I 590 Proceedings. might offer would be so well said. They have faithfully portrayed the professional career of our recently deceased associate, and justly analyzed the elements of his worth as a pbilantbropist, and the characteristics of his achievements in the specialty which have made the reputation to which we are doing honor. Certainly we all concede that in the death of Dr. Gray, American psy- chiatric medicine lost one of its most eminent figures, and when we reflect as one of the obituary papers stated, that scarcely three-score years had ripened on his head, and that he fell in the mid-career of his success and usefulness, there may, indeed, be properly applied to him the words of the great poet, spoken of another: “He should bave died bereafter." I ask pardon for detaining the Association, but from long association with him in the councils of this body and in other relations, I would do violence to my feelings did I fail to say this feeble word in corroboration of the tributes just paid his memory. The resolutions were unanimously adopted. Dr. Draper handed in the following obituary notice of Dr. E. R. Chapin : DR. EDWARD R. CHAPIN, For sixteen years Resident Physician of King's County Lunatic Asylum, New York, died in New York City, December 7, 1886, at the age of sixty- five. His birth-place was Salisbury, Connecticut. His mother was early left a widow, and subsequently married Dr. Wm. 11. Rockwell, for thirty- six years the Superintendent of tbe Vermont Asylum. Young Chapin was a youth of fifteen when he went to Brattleboro at the opening of the Asylum there, in 1836. In 1838, be entered the collegiate course at Yale, but was obliged to abandon tbis after one year on account of a trouble or his eyes. He became a student of medicine and graduated at the Medical Department of Yale, in 1842. He was appointed Assistant-Physician, the same year, at the Maine Insane Hospital, then superintended by Dr. Ray, which position he held for one year. He was then, for two years, con- nected with Bellevue Hospital, and subsequently, for four or tive years, located in practice in New York. In 1849 or 1850, he went to California as surgeon on a Panama steamer, and remained for two years or more in San Francisco, connected with a city hospital there, during which period he improvised, in connection wit, the general hospital, some accommodations for the insane, which constituted the first public provision made in that State for this class. Returning from California, he was for a year or two in service as surgeon upon Atlantic steamships, and, in 1856, entered tbe specialty again, this time permanently. He filled the position of Assistant- Physician at the Vermont Asylum for three years, when he was appointed Resident Physician at the King's County Lunatic Asylum, in 1838, which position he held until 1873, when he resigned, married, and henceforth retired from professional life. In 1871, be suffered an attack of pneumonia, from which he barely survived ; convalescence was protracted, and the following winter was spent by him in Europe. After his retirement in 1873, the summer seasons Proceedings. 591 were usually spent in New England, and the winters in the more genial climes of the Southern States or California. In the autumn of 1885 be went abroad with his wife, to spend the winter in Torquay. She died in Paris, in June, 1886, after a brief illness of double pleurisy, when the doctor immediately returned to this country with ber remains. He remained through the summer and autumn in Brattleboro, but almost immediately upon reaching New York, where he bad arranged to spend the winter, was seized again with a pneumonia which terminated his life in little more than a week. As a member of our fraternity, I would briefly refer to bis record of practical work. I bave searched in vain for any published papers or expressions of his individual views upon professional questions, save in his annual reports while in office, and in the procet dings of the meetings of tbis body, which he attended. His reports show bis devotion to the duties of his profession, his comprehension of the field of labor in which he was engaged, and, especially, his philanthropic and humane spirit. . In 1869, be discussed particularly “The Characteristics of the Insane," especially dwelling upon the fact tbat the insane character has impressed upon it by disease, idiosyncrasies, which distinguish the subject from rational persons in general, from bimselt when rational, and from other insane persons, and that the greater the loss of mental power the less clearly defined is the individuality. In 1872, after his visit abroad, he entered at length into the question of the “Use of Restraint,” and cites cases seen abroad wbich in this country would be deemed proper subjects for restraint. “These cases," he observed in concluding, “all tended to strengthen my previous conviction that instances do occasionally every- where occur in which the best interests of insane persons require the use of mechanical restrain18. Wbile, therefore, humanity seems not to justify the total abolition of such restraints in asylums for the insane, it certainly does demand that their employment shall never be left to the discretion of non-professional persons; but that they sball only, and in each partic- ular instance, be directed with the same care and thoughtfulness with which medicines are prescribed by the pligsician in charge of these estab- lishments." In his final report (1873) be comments at some length on “ Popular Fallacies Regarding the Insane.” “It seems not always to be borne clearly in mind," he says, " that insanity is a disease, and that it has its signs, symptoms, stages, marks and manifestations, as have other mala- dies, and, like them also, its diagnostic traits are not all necessarily present in every instance. And, further, insani y is never a passing whim or fancy, but ever and always a most significant fact; nor is it eccentricity, nor are half the world, as some carelessly assert, more or less insane. On the con- trary, it is a malady of comparatively rare occurrence, and few individuals -not so many as two in a thousand the world over, during their whole lives, are ever affected in the slightest degree with true mental disease." Ayain he writes : " There is an inpression quite common in the com- munity that persons once insane never become perfectly sound again in mind, or are, at least, so liable to a return of the disorder that they can never be relied on with the same confidence as before." This idea he 592 Proceedings. characterizes “as unjust and cruel as it certainly is erroneous." A third error noticed is “ the belief entertained by the sort of people that pin their faith to romances, that a person, not insane, may be easily thrust into, and kept in an asylum for an indefinite period.” This charge be refutes in convincing terms, and concludes by deploring the judicial proceedings often unwisely and unadvisedly instituted, declaring it“ an error to sup- pose that because patients are occasionally released from asylums by the courts, they are therefore wrongfully committed to or detained therein. For the most part these persons are of the convalescent class, and as soon as relieved would be removed by their friends; but having been brought before a court on the writ of habeas corpus, they are often discharged by the advice of the physician baving care of them, the physician thinking that, in many instances, since matters have proceeded so far, the patients would incur less risk of relapse by being allowed to go at large, than if subjected to the certain mortification their being remanded to the asylum would occasion. Not infrequently, however, these very individuals who have been raising heaven and earth, as it were, to regain their liberty, go volun- tarily back and request permission to remain in the asylum until they can be pronounced entirely well. This fact," he adds, “may serve as an illus- tration of the singular vagaries and inconsistencies of the insane mind, which few, who have not bad considerable intercourse with the insane, neither can nor will understand.” As a member of this body he will be remembered by many now pres- ent, although I find fourteen years have already elapsed since be last par- ticipated in its proceedings. In scanning the record of the meetings he attended I find he was little given to debate, but that his remarks always commanded respectful consideration, and evinced the soundness of bis views respecting insanity and its treatment. An unassuming man, be never failed to convey the impression of bis fitness for bis work, and of his possession of those qualities that enable one to perform his mission modestly, yet efficiently; and to his qualities of bead, those of the heart were combined, and enabled hiin to direct and advise those under his charge with both judgment and sympatby, securing thereby, both their respect and affection. Dr. Gilman then read the following short obituary notice of Dr. H. M. Bassett, of Iowa : DR. HIRAM M. BASSETT Was born in Obio and educated at the Western Reserve College. He was Assistant-Surgeon and afterwards Surgeon in Ohio regiments during the war. In 1865 he was appointed Assistant-Physician to the Iowa Hospital for the Insane, at Mt. Pleasant, Iowa, and served in that capacity until 1873, when for two years he was Superintendent. In 1875 he' resigned the position, but continued in the service of the State as Assistant-Physician until the time of his decease, which occurred February 28th, 1887, after a brief illness of one week, from pneumonia. Dr. Bassett was a most con. scientious and painstaking man in the discharge of his duty, and his death was a great loss to the hospital and State. He was much beloved by his Proceedings. 593 . associates, and a favorite with both patients and employes. Hundreds of homes in Iowa mouroed bis loss as one who had brought comfort and consolation to them, through his efforts, by the restoration to health of members of their households. Such devotion and self-sacrifice as was characteristic of Dr. Bassett deserves more than mere mention by tbis Association, and should be an inspiration to young men entering upon the special work to which he devoted bis life. On motion, the Association adjourned to 9.30 A. M., Friday. The Association was called to order on Friday morn- ing, at nine o'clock, by the President. The President announced as the Business Committee for 1888, Drs. Godding, Gundry, Moncure, Barksdale and Curwen. On motion of Dr. Hurd, it was Resolved, That the memorials of Drs. E. R. Chapin, Bagsett, Gray and Metcalf be inserted in full in the minutes. Dr. J. B. Chapin read the “Report of a Case.” Dr. G. H. Hill read the following paper on “The Treatment of Epilepsy:” A FEW OBSERVATIONS ON THE TREATMENT OF EPILEPSY. · I am of the opinion that epileptic insanity is incurable. First, on account of the fact that the cause of the disease, which manifests itself in epilepsy and unsoundness of mind, such as heredity and injuries to the nerves or brain, cannot be removed ; second, because the epilepsy is chronic before the mental derangement becomes sufficiently serious to demand treatment; tbird, so long as the patient is not permanently relieved of convulsions, the delirium, the confusion of mind and the irresponsibility of character, which usually attend the convulsions, will be repeatedly experienced; fourth, the chief reason why I think epileptic insanity is not curable is because this form of mental allenation is gradual in develop- ment, and consists of impairment of memory and reasoning faculties, in making morbid the sensibilities, in lessening self-control, in producing an irritable disposition, changes in mind which are likely to be permanent. It is undoubtedly true that the presence of epileptics, who are subject to frequent convulsions, in families where there are children or women of a nervous temperament, in the school-room or mingling freely in the society of any neighborhood, is deleterious; therefore I think it would be well if the State, in connection with the Home for Feeble-minded, or separately, would provide a place for such persons. After these sanie epi- leptics have become vicious and positively deranged, it seems to me they should be removed to an asylum for the insane. 594 Proceedings. The condition of the insane epileptic can be ameliorated and made more uniform by medication and special care. In the hospital of which I have cbarge, in a population of eight hun- dred there are sixty-three epileptics. Although some of these epileptice are uniformly composed, easily managed, and they are apparently harm- less, for the reason just stated I seldom urge relatives to take them bome; or in case the crowded condition of the hospital must be relieved, by sending incurables to the county poor-housus, I do not recommend the removal of epileptics. To obviate some of the disadvantages of having epileptics in a cura- tive institution and associated with other insane persons, they are classified in the upper wards of the building and with incurables whose bebavior and comfort will not be much affected by them. By baving watchful and constant care in an asylum, epileptics escape most of the accidents to which they are exposed during convulsions when they receive only ordi. nary care at home; they are also prevented, to a great extent, from rash and criminal acts. The first tbing to be done in treatment of any disease is to ascertain the cause and if possible remove it. Too often it is dis. covered that epilepsy is inherited, or that the individual was not endowed with a sound nervous system. Such predisposing causes cannot be erad- icated. Furthermore, the exciting causes of the disease which produces epilepsy are usually remote or obscure. Even though the history of a a given case points to a blow upon the head, the prognosis is unfavor. able, since the lesion is almost always of long standing, so that the tissue involved has changed permanently pot only in function but in anatomi- cal structure; tbat is one reason why, in my opinion, operations on the skull fail to produce the desired result. In the medical treatment of this disease, the bromide salts accomplish more good than all other remedies combined, and of them I prefer bro- mide of potassium. I bave given Brown-Sequard's mixture a faithful trial, but am not convinced that it is better than a solution of the bromide of potassium, if to the latter, Fowler's Solution be added when indicated by acne. The chief mental characteristics in this disease are irritability of temper and an impulsive disposition. The bromide diminishes this irritability of the nervous system and mind; it also produces a pulegmatic temperament which antagonizes impulsiveness. A sufficient quantity should be admin- istered from day to day to control mental excitement, also to prevent the patient from having convulsions, if possible; if not, to make them infrequent and less severe. After this is accomplisbed the dose may be diminished, but never stopped. Brown-Sequard and Voisin kept up the treatment at least three years after the last convulsive attack. In the con- tinuous treatment of this disease, I think a full dose at bed-time answers the best purpose, in order tbat the patient may be quiet at night and pro- cure an abundance of sleep, 80 that he may not bave any convulsions at hours wben he is less closely watched; when a dose of eigbty grains of the bromide of potassium tbus given, does not answer, another and, perhaps, a smaller one is given in the morning so that the doses are received about twelve hours apart, which almost always prove sufficient. Proceedings. 595 When the disease is well under control the single daily dose should be reduced to just enough to prevent the convulsions and keep the patient in a comfortable frame of mind. This remedy should always be well diluted. Belladonna may be added in certain obstinate cases with good effect. Strychine, quinine, phosphoric acid or iron may be used when indicated. The bowels should be kept open. Meals should be regular and not too hearty, especially at night. Excitement and excessive exertion must be avoided. Arguments and contradictions irritate, while quiet, but firm management, with kindness and complimentary language from the attendant accomplisbes almost as much as with children. At the time of a convulsion it is usually best to put a troublesome patient on his bed and keep him there or in his room until the effects of the attack bave passed away. Of course he should be closely watched. In case the patient does not rally from the fit, or passes from one to another in rapid succession, a full dose of the bromide should be administered by mouth or rectum; also the nitrite of amyl may be given repeatedly by inbalation. I may state that I have lost patients in the status epilepticus, from whom the bromides had been withdrawn a short time previous to the sudden and unexpected attack. J. H., was a farmer's son, single, when admitted to this hospital, in March, 1883, was sixteen years of age, and brought the following history: “Has had epilepsy for six years, and is now destructive, filthy and unmanageable. A few days ago killed a calf with a hammer, and not long since burnt a building. The disease is steadily increasing Epilepsy is said to have been caused by measles." . After he had been under treatment for four months it is stated in the case-book that he had many attacks of petit mal, besides at times is inclined to have many sham fits. His general health is excellent, After nine months' treatment the records state that he is irritable and quarrelsome, and unless kept saturated with bromides, has many convul- sions. General health, fair. During the second year of his stay at the hospital he was troubled greatly with acne on the face and neck. His health was otherwise fair. and he took great comfort in playing base ball during the summer months. In 1885 his general health continued fair, but he was still troubled with the eruption. In November of the same year the acne was worse than ever, and as he was having only his usual number of convulsions, and since his behavior was better than ever before, on the twenty-first of the month this regular dose of half an ounce of Brown-Sequard's mixture at bed-time was stopped, and in its stead was given fifteen grains of hydrate of chloral. He continued practically unchanged until Sunday afternoon, December 13, at three o'clock, when he was about to attend chapel service, he began to have convulsions. They followed one another in rapid succession and without an interval of consciousness until death at eight o'clock in the evening. During these five hours he had thirty-nine convulsive seizures. During the ten months of 1883, that the young man was in the hospital, he bad 454 fits, an average of forty-five each month; in 1884, the average per month was twenty-one, and in 1885 it was fourteen, not counting the number he had at the time of death. 596 Proceedings. I cite this case to illustrate what is often noticed-that vicious and unmanageable epileptics become steady and comfortable under the influ- ence of the bromide of potassium; also that the number of convulsions is greatly diminished by this treatment. The case also exemplifies the fact that patients having this disease who have long been under the influence of bromide of potassium are liable to have an attack of status epilepticus and to die if the remedy is withdrawn. Dr. Curwen read (for Dr. John S. Butler) a "Report of a Case.” HARTFORD, June 4th, 1887. Mr. President, My Dear Sir-I am exceedingly disappointed that I can- not be with the Association at the meeting in Detroit. One result of the "journey" from my birthday in 1803 to the 14th of June, 1887, is such a dim- inution of physical power as to put that from Hartford to Detroit beyond my reach. I submit as cheerfully as possible to this perhaps natural result. My hearty interest in the Association has in no degree abated since the memorable meeting of the thirteen in Philadelphia, in 1814. Of these, my long-time friend, Dr. Earle, and myself alone remain, but the influence of those, my ever honored associates, especially of Drs. Woodward, Bell, Ray, Kirkbride and Awl (with whom I was more especially intimate) still remains a large motive power with me. Whether present or absent, I have always watched the progress of the Association with unabating interest. While in the Boston Hospital in 1842, I read, in Samuel Tuke's intro- duction to Dr. Jacobi's “Hospital for the Insane,” that the reasons wbich Dr. Jacobi assigned for restricting the establisbments for the insane to two hundred patients appear very satisfactory, * * * this number being considered as being mainly of the curable class, he adds: “I had many years ago an opportunity of seeing the change from large to small classes, and was confirmed by it in the opinion I had previously formed, on com- paring the condition of the large companies of patients in one institution with the smaller divisons in another. "In the latter I generally found more of the patients engaged in some useful or amusing employment. Every class seemed to form a little fam- ily. They observed each other's eccentricities with amusement or pity; they were interested in some degree in each other's welfare, and contracted attachments or aversions. " In the large society the difference of character was very striking. I could perceive no attachments and very little observation of each other. In the midst of society, every one seemed in solitude; conversation or amuse- ment was rarely to be observed; employment never. “Each individual was pursuing his own busy cogitations, pacing with restless step from one end of the enclosure to the other, or lolling in slothful apatby upon the benches. It was evident that society could not exist in such a crowd." My own observation and experience, confirming these authoritative opinions, led me to cordially accept the proposition unanimously adopted in 1851, that the highest number that can with propriety be treated in one building is 250, wbile 200 is a preferable maximum; and to dissent as Proceedings." 597 decidedly from the propositions adopted at the meeting in Wasbington in 1866, especially the one adopted near the close of the meeting by a vote of eight to six, which accepted the enlargement of an institution to the extent of accominodating 600 patients. The 250 limit of 1851 gave way in 1866, 21 years ago, to the extension to 600, and that, since, has been advanced somewhat indefinitely. The International Record of April last, gives the number of inmates in 88 of our Lunatic Hospitals. 3t contain orer tbe last adopted limit of 600, 10 of these contain from 1146 to 1818 patients, while of all the 88, only 16 hold less than the original accepted number of 250. Permit me (one of the two "remainders" of 1844) to suggest to the Association a revisal of the tions have arisen, not only in regard to the question of numbers, but the very important and urgent one of “Classitication," this last, Webster lap- pily defines “to arrange in classes according to some common properties or cbaracters." In bis conclusion to his bistory of the “ Original Thirteen," our excel- lent Secretary correctly says, “that touch yet remains to be done to improve the condition of the insane, to enlighten the community on the proper treatment to be pursued, and to urge to the adoption of every available means which the science and art of the time can devise for the occupation, diversion, improvement, instruction and restoration of all clas- ses of the ingane.” This is in good keeping with the teachings of Dr. Arnold, of Rugby, “that nothing is so wrong as the strain to keep things fixed when the whole organization of law and order is one of eternal progress.” Proposing ere long to give to the profession my reasons for the “faith ibat is in me” in regard to the prevention, remedial treatment and classi- fication of the insane, I ask your present attention to one of my cases in the Retreat. Some years ago, a young lady of about seventeen years of age, of deli- cate organization, sensitive and nervous, and in frail general health, was brought from a distant city to our care, by her only and older sister. They bad been left motherless at an early age. The neglect of right- ful early training, the varying impulses of a wayward will, some sad hygienic mistakes-the result of educational neglect-made her committal to the Retreat a discreet and timely measure. After the formalities of admission, the sister, after giving the outlines of her case, besought me to give some little extra attention to my patient. " It is a terrible thing, sir,” she said, “ to leave this poor, sick, dear child, hundreds of miles from home, all alone among strangers.” I was ready to promise what she wished, hoping in some way to allay the not unnatural nervous excitement of both. After expediting their separation, I told the young lady that, being now under my professional care, she could better tell me all about her troubles somewhere out on the lawn. There, surrounded by those soothing influences which I have so vften found efficient aids to professional treat- ment, I at first led her attention to our beautiful surroundings rather tban to the details of her ailments, calling her attention to the varied scenery, 598 Proceedings. the pleasant changes of light and shade, and to tbe flowers, of wbich she seemed so fond ; occasionally alluding to the events of her long journey, and casually asking leading questions about her health-all tbis with the pleasant result of gradually substituting self-control and smiles for nervous agitation and tears. The songs of the birds attracted her attention. “I am so fond of music," she said. This I told her I was so glad to hear, because we bad so many musical parties. Disclaiming the rare musical merit I had heard she possessed, as I called for evidence, it came first in sad, and bye-and-bye in merrier notes. The noon-day bell put an end to our pleasant out-of-door visit. “ What is that for?" she asked. “ It is noon, and we must go in to get ready for dinner," I told her. “Noon!” she exclaimed. “How strange, how really absurd! Why, a little while ago, to be left here all alone, was to break my heart; and now I bave been out here, singing and laughing with you!" Thus came my sought opportunity. “No, this is nothing absurd; all this is hopeful to me; you have given me the key-note to the bistory of your illness; this opens to the good promise of your restoration to health and a happy future, if you will only trust yourself to my guidance and accept my teachings.” “Why!”sbe promptly answered, “ of course I sball do so.” After this I held the case easily in band. Right heartily did she hold to the faith so cheerfully professed. Her vivacity and kind-heartedness made her a favorite member of our family. In due time, after she had left us as recovered, the evidence of her permanent restoration to health, and to new purposes of life, coming to us through the echoes of “marriage bells," was accepted as a natural sequence of that morning on the lawn. I sball ever remain grateful to those liberal friends on record in the Report of the Retreat for 1861, who gave to my personal solicitation the ample means of developing the natural beauties of the lawn, the erection of the Museum, the Ives Amusement Hall, with many ornamentations which have since been found to be such efficient therapeutic remedies. Medicine is justly divided into “ Prophylactic, or the Art of Preserving Health," and " Therapeutic, or the Art of Restoring It.” Moral thera- peutics have a wide range; they are so effectual in allaying the undue excitability of the disordered mind, and in diverting the current of morbid tbought back into the natural channels of health. After the correction of those physical disorders (80 generally accepted as the “punctum saliens," or starting point, of insanity), I have often turned successfully to this department of therapeutics for that “ Medica- mentum gratia probaturn" of quaint old Parcelsus, the remedy approved by grace," for the means of restoring the sufferer from insanity to a right mind. The whole forenoon I gave this young lady was not wasted. I know not how it could have been more profitably, humanely, or scientifically employed. I met her aftewards more or less frequently every day, keep. ing quiet but careful watch over her progress. In my regular morning visits to the various departments of the house, it was my custom to have its inmates, who were well enough to leave their rooms, meet me in the parlor attached to their respective halls. Of course private and confidential interviews were frequently required. These every-day family-like gatherings proved far more than formal Proceedings. 599 yisits to each room. Such informal meetings, like many of my oldtime- visits in general practice, were so home-like and natural that their influ- ence readily drew out those genial and social elements of tbe heart which, in the most extreme developments of insanity, I have rarely, if ever, found beyond our reach. For here was possible that intangible permeation of a household not too large for the personality at the head of it.” The con- versations were easy and natural, often bringing out the mental peculiari- ties of one and another; these in turn leading to timely criticism, and then to frank and general discussion. The best result depended upon the discreet association of varied ele- ments. Judicious antagonisms worked better than similarities; the excited and melancholic amended each other, while the appeal to the judgment of the majority, confirming the best decision, benefited both. I have again and again traced the final results of successful treatment to such persuasive agencies, by which doubts were resolved, darkness light- ened, excitement subdued, and the better mind restored. Pleasant as were my visits to such associations, I often found that I could much more read- ily decide upon the best remedy for an excited maniac than meet, to their satisfaction or my own, the sharp questions presented by their ready wit. The personal influence of the Superintendent is naturally transmitted to the assistant-physicians, and by their concurrence, to all other employes. The best results in such a singularly complicated household can only be obtained when its various officials act in unity. Emerson says, “ The institution is the shadow of the man.” In such an one as that, the shadow, to be protective, must not be too thin. They are greatly in error who tbink that an attack of insanity neces- sarily eclipses all the faculties of the mind. This extremity of disorder is rarely seen. Frequently the one delusion (sometimes the many) is kept out of sight so ingeniously as to elude the unskillful observer. The his- tory of legal investigations, and the experience of experts in insanity, are full of such curious instances, and not the least are the illustrations of the ease with which judge and jury are sometimes misled. I record one of many cases illustrating that mania in the highest state of excitement is rarely, if ever, lost to the power of partial self-con- troi. A lady once under my care, a person of superior intelligence and mental ability, belonging to the highest circle of society, becanie so furi- ously insane that she was destructive and dangerous to approach, and obliged to be placed in a room without movable furniture. A member of my family, in the habit of making frequent visits to her, came to the ward to see her. The attendant said, "It is impossible for you to go to her room this morning; it is dangerous. (The lady had a beautiful bright scarlet shawl around her.) She will tear your sbawl to atoms." “ Well," she said, “I will risk it.” She opened the door, and met the patient very cordially, who at once exclaimed: * Oh! what a lovely shawl!” She caugbt it off, and wrapping it around herself, sat down on the floor with her visitor, and had a long, pleasant and amusing conversation. The visitor was most reluc- tantly parted with; the shawl replaced kindly and carefully by the patient. After her recovery, the lady often referred to this visit : "that shawl was so attractive," she said. 600 Proceedings. Dr. Edward Cowles read next a paper on “Nursing Reform for the Insane.” Dr. Hurd then read a paper on “Gastric Secretory and Other Crises in General Paralysis.” Dr Everts read, as the opening of the discussion, a paper: “Are Dipsomania, Kleptomania, Pyromania, etc., Valid forms of Mental Disease? Do Uncontrollable Im- pulses to Use Stimulants, to Steal, to Burn, etc., Develop Independently of Other Evidences of Insanity?”. His views were in the negative to these questions. The discussion of the several papers was then com- menced in the order in which they were read. DR. HURD: I would like to inquire whether Dr. Hill has made any use of borate of soda in the treatinent of epilepsy? DR. Hill: No, sir; only used it in a few cases, for, perhaps a month; but did not get any marked effects from it, and so did not persist in experimenting with it. DR. CLARK: I would like to ask Dr Hill whether he ever uses a mix- ture of bydro-bromic acid with the salts? I have always found that if you saturate the salts with the acid, half the quantity of the salt is all that is necessary. The alkali basis of the salts bas no particular medical qualities in any quantity in itself. There is no particular potrncy in sodium or potassium or armonium. It is the haloid element in the salt which is medicinal. I used, some nine years ago, nitrate of amyl pretty extensively, and I found in some cases that it helped materially to modify the fits. I did not find a case in which it really cured the disease, because I hold, with Dr. Hill, that epileptic seizures wbich are cbronic are bopeless; but I found that the fits were fewer in many cases, and that the intermissions were longer; and also that the fits were not as severe in some 88 when not under the effects of the drug. I found in all cases where we had a patient of full habit, that the nitrate of amyl did more harm than good, and that the seizures were more violent after the use of that remedy than in anemic cases; but that, on the whole, it bad a beneficial effect. That has been my experience in the treatment of sixty or seventy cases with the amyl. To those not insane, I have always recommended the use of this drug; and when in a glass bead of four or five drops in a bead, and carried in their vest pocket, such can break it upon their bandkerchief, and by that means use it immediately, wherever they happen to be, if they bave premonitions of the tits. Those who have done so have found it to be very convenient and bandy by carrying it in that shape. That has been my experience in the use of these drugs. DR. HINCKLEY: I would like to ask Dr. Hill if he ascribes the occur- rence of the status, in the case which he reports, to the cessation of the Proceedings. 601 treatment by bromide ? I had two cases in which the bromide was kept up very regularly after the appearance of the status epilepticus, and both cases died. DR. Hill: I am not so sure that it is the case, although it seemed so in three or four cases that I had, simply because they went off in this way a short time after the bromide treatment had been discontinued; but, like the doctor, we had patients die in a state of epilepticus who were on treat- ment at the time. Dr. Frost: I would like to relate one case, that of a man, and a min- ister. He forged a note, and by that means got into the penitentiary. From that institution he came to the hospital at Jacksonville, and remained about two years. He was a man of full habit. He bad epilepsy, and very severe attacks. He had as many as one a week, and sometimes more. In one of these attacks he was bled very profusely, and has bad but one since. That was fuur years ago. He seemed to improve right along. He recov- ered under the treatment a little slowly; but, as I said, he has had but one epileptic fit since. He has visited us several times, and expressed him- self as well and able to work at his trade every day, having learned a trade before becoming a circuit preacher. Dr. Cowle's paper on “Nursing Reform for the Insane," was the next in order. DR. FLETCHER: I would like, in the first place, to make an apology to Dr. Cowles, for an unintended breach of good manners. This morning when he commenced reading his very able paper, and exhibited a photo- graph or two, I was reminded that I had promised some friends of Dr. Hurd to bring a number of photographs of patients and their nurses. I brought the photographs over immediately, and they got into circulation, almost at the same time that the doctor's did. I am afraid that tbe doctor was annoyed by their being passed around. DR. Grissom: I have no doubt that the gentleman's patients were distinguishable from Dr. Cowle's nurses. DR. FLETCHER: I must say that, to me, the doctor's paper was most valuable. I think it was from him, some four years since, that I gathered the idea of haviny attendants trained to special work, and I have been trying to follow that out in a very feeble manner from that time, and giving a course of lectures to all my nurses who would voluntarily attend —that is, lectures by the medical staff. I consider that from the experi- ments a great deal of good has been done; and, in future, I shall compel the attendants to take complete course of instruction, whether they are willing or not. I am of the opinion that the relation of physician and attendant to the patient is like that of an architect and builder to a structure. The physi- cian supervises and directs to success; the attendant is the foundation and superstructure of that success. They are the ones who live night and day with the patients, and observe them. I have endeavored to instruct attendants to keep a careful note of cases in their own manner, giving them a general plan, desiring them to use their 602 Proceedings. own language and ideas in expressiog them; and I have been peculiarly interested in the reports 80 written out. At the same time, I have been trying to avoid letting any of the attendants get i be idea that they are physicians or surgeons. I cannot give them tbe liberty of preparing and administering the medicines, as is done in some general hospitals, but merely make them careful attendants, and friends and connsellors of the patient, leaving the physician and apothecary to discharge their own duties and the administration of medicine to the medical department. As I have said before, the paper has been extremely interesting, and I believe, to me, the most interesting I have ever heard. DR. CLARK: I would like to ask Dr. Cowles whether, when he hires nurses he examines them as regards their education ? A great deal of suc- cees would largely depend upon securing those who had sufficient educa- tion to appreciate the training, even in the most rudimentary branches. I wish to ask whetber any preliminary or ordinary education is required before admission to the hospital? I mean, to get at the fundamental facts, whether the nurses have received sullicient education to comprehend sat- isfactorily the lectures given? DR. Cowles: Every applicant is obliged to make her application upon the blank provided for the pnrpose, in wbich she writes answers to certain questions. The manner of writing these answers very often condemns her or satisfies us that she ought to have a fair trial. In various ways you get inferences; from the manner of making the application, in the inquiries accompanying it, etc. Then we have adopted very recently the practice of sending a private circular to the persons whom the applicant refers to for recommendation; a series of questions are to be answered confidentially. Additional infor- mation of much value is usually gained; then when the nurse comes, she is on probation for two months. We see some of them beforehand, by asking those who can, to apply in person; so that, really, there has been no trouble in making selections. If, after we have had them in the house, they do not seem likely to do well, they are advised to go away. DR. EVERTS: I would like to ask why it is that in all these training schools for nurses, in the statements that have been made before us and in . the books that we meet, they are in the “she” all the time. I notice that in Dr. Fletcher's class only one male attendant seems to have received the education. It strikes me that in the attendance upon the insane we should make a male nurse quite as important, if not more so, than the other. In my experience you can get a relatively better class of women as attendants in insane hospitals than you can men. But all these schools seem to be to educate women. Why is it? Do no men accept the edu- cation? Do they not stay long enough? Are they unwilling to adopt the profession? or don't you pay them enough? DR. Cowles: That question contains several items to answer. In the first place, the women are relatively better material--they lend themselves more readily and pliably to the work. It is easier to initiate a reform with them and get the new system established. As a matter of fact, in general hospitals the nurses are commonly or mostly women. There are compara- Proceedings. 603 CH tively very few men employed in such hospitals. There are women in every ward, and the men there deteriorated in quality under the training school system. They become mere assistants, “carriers of water," and the like, excepting a very few. In the general bospitals we rather wanted men that were simply docile, obedient, fairly intelligent, and naturally liked the service. In the care of the insane, it is as Dr. Everts says, we need the training of men just as much as we need tbat of women; but, with us, the women were in the spirit of it and the men were not. They looked upon it as women's work, and upon women as suited to be trained as nurses. As a rule, they had no particular desire to be trained to make a pro- fession of nursing. We had some experience illustrating this last year. We had a school for women, well-established, and it was thought to, be time to develop the training of the men. We had an improved corps of attendants, and early last fall it was announced to the men that, in order to carry out the wishes of the trustees and for the advantage of themselves as well as others, they were all to bave more explicit in-tructions in their duties; there would be no special study about it. The course of instruc- tion was to be continued for ten weeks. Every other week there was a lecture, thus providing five lectures for the men, who were divided into two alternating classes, giving them a series of talks on elementary anatomy, etc.; bow to act in emergencies in general and among ihe insane and things of that sort. In the alternate week they were required to read a half chapter in the class-book, written by a committee of the Britishı Medico-Psychological Society. Then the Assistant Physician met then. to talk over this balf chapter on which they had made preparation, as the topic, somewhat like a recitation. At the end of the ten weeks it was announced that a class would be formed for those who wished to be trained and take a diploma at the end of two years. Six men who had been long in the service joined the class. About ten men left the service in the next two or three months, because they were afraid of the change. They had been there some time and had plans for doing some other work in the future, and so did not intend to be nurses by profession; some thought if they stayed there and did not join the school, the others who did join would be preferred and have better places in the service. Five or six others went out because of business and family relations, in the ordinary way. All this was really fortunate for us, because their places were immediately filled by men willing to take the instruction; so a class of fifteen men was formed, who were willing to take the course of instruc- tion required for successfully carrying on the work, and they are doing well with it. DR. EVERts: Do you increase the pay of those who have been instructed ? DR. COWLES: Women now have reduced pay, compared with the former order of things, as pupils. After they graduate we pay them twenty-five dollars as graduates, instead of twenty dollars, for the third year's service. DR. FLETCHER: In answer to Dr. Everts I will state that we had seventy-two in the class, the first course; in the second course all the men 604 Proceedings. had dropped out but five. Of the seventy-two, they were about equally divided, males and females. At the end of the second course all the men had dropped out but one, and the only reason he had not dropped out was, he bad been under the doctor's special supervision for fifteen years. One reason men do not take lessons is because they expect to change positions as soon as the party changes. Another reason is, they will come in the fall and engage themselves to perform the service required at twenty to twenty-two dollars per month; spring-time comes, they see an opportunity to get West, and want to travel, and therefore go West; whereas the women stay all the time, unless in case of discbarge or get- ting married, or something of that kind. The women are paid eighteen dollars. After they graduate they are presumed to get twenty dollars, and after four years' service, twenty-two dollars a month. Dr. Cowles: There is an important point in regard to the economy of this system. I know it is a question which creates some apprehension on the part of those who contemplate its adoption. We pay our pupils, the first year, only twelve dollars a month, and the second year fifteen dollars a month. Then they graduate anıl have twenty-five dollars a month, and the result is that the aggregate cost is not increased. DR. HURD: What success bas the doctor had in the division of the ward service on the female side? I understood from a former paper tbat he, intended to provide each ward with a lower grade of attendants, who should do the menial work, as scouring, scrubbing, and keeping the wards in order, while the attendants were to be reserved for the higher duties. DR. Cowles: Our new arrangement was simply because of the pecu- liar class of patients we bave. Formerly,our attendants were required to do all the work the patients had to have done, including the scrubbing of the floors and everything of that kind. In oriler to give them time to be more as companions to patients, a ward-maid was employed in each pair of adjoining wards, containing two dining-rooms, stairway, etc.; the ward-maid was to do the menial work simply, what would be mostly done by patients in a State hospital. Actually our nurses have had to do more, if I am rightly informed, in the matter of housework, in the care of chambers and parlors, etc., than the attendants in those hospitals. The arrangement is very satisfactory and permits a great gain in the companionship of nurses with patients. On motion of Dr. Chapin, it was Resolved, That Dr. Palmer be requested to publish his paper in the American Journal of Insanity. On motion, the Association adjourned to 2 P. M. The Association was called to order at 2 P. M. by the President. DR. WISE: Mr. President-When the Chairman of the Committee of Arrangements notified me, a short time since, that I would be expected to open this discussion which could have fallen into much Proceedings. 605 better hands-it was my purpose to briefly outline the scope of the dis- cussion on the best method of caring for the chronic insane, with indi. vidual impressions derived from a practice in the State of New York, 'in which there are two large asylums for the chronic insane, a system of care which has now been in existence nearly two decades. These two asylums have grown to large proportions, and have established the system in that State. I will not make reference to the causes which led to the creation of the Willard Asylum, as they are historical. But it may be germane to the present discussion to refer to the seal of dis- approbation of the separate care of the classes of the insane, that is upon the records of the Association, without amendment since its affir- mance in 1866, in a series of resolutions which were almost contempo- raneous with the creation of the Willard Asylum. As the mind that moved the creation of this asylum and conceived its beneficent plan, is active with us, and the morning papers have stated him to be one of the debaters of the Association, it may be inappropriate for me to make any further allusion to this matter at the present time, further than to observe that whether the promoters of the Willard Asylum consid- ered the separate care of the numerically greater class of the chronic insane as the best method of care or not, it is certain that this is the first instance in which the question of the care of the chronic insane has been met in a comprehensive manner. Dr. Wise then read a paper expressing his views on the subject of providing for the chronic insane. DR. GRISSOM: If no other gentleman desires to be heard on this subject, we should like to hear from Dr. Pratt. Dr. Pratt: Mr. President-I had hoped that Dr. Palmer's prom- ised paper would give a broader foundation for a discussion of the various plans for caring for the chronic insane, and especially, a fuller description of what is now being done in this direction, and the results already reached under the “ Colony Plan,” formulated and proposed by him. There seems to be on the part of some, a fear, or feeling, or convic- tion that there is danger in separating chronic patients from the imme- diate shadow of the asylum. In our experience in Kalamazoo, so far as we have gone, the facts sustain just the opposite conclusion. We find among the chronic class, a great many who are exceedingly glad to get out of the sight of the asylum entirely.and they are very much better con- tented in a humbler building. We have quietly felt our way by testing the feeling of the patients, assuming, as we do very often in our personal and professional experience, that that is best which agrees best. Now we find that this class of patients greatly prefer the detached buildings to the asylum. We all recognize the fact that a change, of certain conditions and within certain limits, is good for everybody. We find that change is good for our private patients, in general prac- tice; that they enjoy it, and that they are actually benefited by it. Take the chronic insane who have been under treatment for years (and 606 Proceedings. half of our patients at Kalamazoo have been in the institution for five years or more): their surroundings seem to have lost all influence or power to stimulate new thought, or new feeling, or new associations; they have become accustomed to the wards, to the institutional life and policy, and they see the same set of people until they seem to have settled down into a more or less hopeless condition of stupidity. Now we find that moving them, or many of them, to the houses and cottages away from the asylum—there being an entire change of all their surroundings, putting them in houses where, under the supervi. sion of an attendant, they go and come like the hired men of a large farm house-has worked, in some instances, a marvelous change in the mental and moral condition of the patients themselves. This is purely the influence of change. We have buildings, or cottages, now in use, where we can accom- modate some of them instead of at the asylum; and, after they have tried both, their unanimous verdict is: “Let me go to the farm; I like it better there than anywhere else.” We bave no trouble at all about their attempting to escape, none whatever; and they are just as free, during the day, to go about the house and farm as the hired men on & great plantation. We have an attendant there supervising them, it is true, as we would have to bave if they were in a ward in the asylum. He is chosen largely because of his experience with this class of patients, and also because of his knowledge of farm work, and his ability to judge from day to day whether they should work or not. But to the main point which I rose to speak about: We find that our experience so far, I do not insist upon it as a final judgment—that our experience, so far, is that it is best to take many chronic patients from the central hospital, and place them in colonies on farms directly subject to the jurisdiction of the central institution, though removed from it. When we have fully realized our plans, we sball have farms and colonies, in close connection, by telephone and daily visitation and resident physicians, with the executive office of the institution. Now this subject is one of great interest and of general importance. The rate at which the chronic insane increase in such institutions demonstrates the necessity, in every State, and especially in the older States, of doing something for relief. Nearly fifty per cent. of our patients now at Kalamazoo are more or less of the chronic class; almost fifty per cent. have been there five years or more; and out of these four hundred practically incurable cases, we find that we shall have, at least, two hundred and fifty, whose labor can be made Jargely profitable to themselves and to the institution. As long as they are in the asylum wards, we cannot obtain the benefit of their labor with any advantage. The preservation of order and system in the asylums requires uniformity in the rules. But when the laborers are out, we make rules especially for them and not for the asylum ; and out of the four hundred, I say, we have about two hundred and fifty we can rely upon every day for some form of employment. Of this number we sball keep fifty or so at work in the tailor and other shops. We have started a system by which we expect to supply our inmates with Proceedings. 607 clothing, for all except private patients. We have tried shoe-shops for cobbling, and have also provided a place for the cleaning, refitting and manufacture of mattresses. We find, by these and other arrange- ments we have inaugurated, that we shall save to the institution several thousand dollars, annually, in the matter of expenses, and that the labor of patients, hitherto profitless, will be used to their manifest betterment, and to the more economical management of the institution as well. I do not know that there is anything that I wish to say more, at this time, on this subject. But, I hope, gentlemen, that your pro- gramme next year will be so arranged that this topic will come up: early in the session, for discussion, so that we can have time for a fulla consideration of it. I believe it will do more good than anything else you can now consider. Dr. Hill: How are your cottages to be erected for women ? DR. PRATT: The same as for men, although the colonies will be separate. We shall maintain, around the buildings for female patients, the customary care of the institution. The female colony will be maintained as a female department of the asylum. Dr. Hill: On the farm by themselves ? DR. PRATT: On a farm by themselves, where, already, a great many, with us, are manifesting a desire to engage in the culture of strawberries, raspberries and blackberries, and other small fruits; and in the care and raising of chickens and poultry, and in dairy work. We have plenty of water, brooks and small lakes, and all the needed facilities for doing these things, and we find that the patients take great satisfaction in doing them. Dr. Hill: Where will you keep your feeble and demented patients ? Dr. Pratt: We shall probably keep them in buildings erected near the asylum, especially for the purpose. If there seems to be danger of sudden or early dissolution in any cases, we will, of course, keep them in the asylum. Understand; we shall have an assistant- physician in each of these colonies, when fully developed, and, with communication by telephone, we can always be within easy reach of them. If anything arises requiring the return of a patient to the prin- cipal asylum, a transfer can be made at once. We propose to engage some of our females in the colonies in the manufacture of butter. We happen to have, at this time, two women among our chronic patients, who were born and reared on a dairy farm, and they are very anxious to take hold of this work. I have not the least doubt, from what I have seen them doing in other directions, that they will be quite efficient in certain parts of this work. We are saving on one farm, in the single article of milk, $2,500 per annum, and in other respecte also, by growing potatoes, peas, beets, and other vege- tables that we would have to buy. Our butter now costs about $8,000 per annum. We shall be able to manufacture on the other farm, nearly all our own butter; we have, now, no doubt about it. So if we do 608 Proceedings. nothing else in the new colony, were the women are to be accommo- dated in cottages by themselves, to say nothing about the humanity of the thing to the patients, the economical results will be a full interest on the investment, and a saving of so much to the general annual account of the asylum. • DR. PATTERSON : In regard to these very harmless patients, if they go out when they please and come in when they please, why not dis- charge them and send them to their homes ? DR. PRATT: Many have no homes, and their minds in many cases are too feeble to be entrusted at home. I think, too, in many cases, the homes they have are so nearly a hell, that they would be brought back in a short time, worse than ever, if they went home. And that is true of a great many of these men and women; they cannot endure the conditions of their homes at all, and we are directed by the law of our State to exercise our discretion in this matter. Whenever patients are likely to be benefited by going home, and have a proper home to go to we invariably send them, and, of course, are glad to do it. But when we know, to a reasonable certainty, that they are sure to come back within two or three months worse than ever, we think it better and more humane to keep them. DR. FLETCHER: How far away are these farms? DR. PRATT: One about two miles and one about three miles from the asylum. The latter was selected as near to the asylum as we could get it, as a purely grass farm--for dairy purposes solely-that is where we get our milk. There is no better place within three miles, for what is known to us as a grass farm. It is just as near to the asylum as the character of the surrounding soil permits. But the other is prairie land; a beautiful prairie, lying two miles southwest of the institution and bordered by hills and lakes. Our access to it will be by a private road, and without any exposure of patients to the gaze of the town, or the danger of crossing railroads, or anything of that kind; it is, prac- tically, a private way, and we shall, in summer time, use that private way to the beautiful places that we have for almost daily picnics from the asylum. So, while there will be a certain degree of communi- cation kept up between the asylum and the farms, there will be, for the latter, at the same time, an agreeable isolation. The colony offers a useful stimulus and encouragement to a certain class of patients at the asylum. We say to them: “When you learn to exercise proper con- trol of yourself in this or that direction, you can go there, too." They are often delighted with the promise and make efforts of self-control, because they want to go there. We have scarcely a chronic patient with intelligence and strength enough to engage in labor, who, after seeing those grounds, does not beg to go there. Dr. Gilman: I would like to ask Dr. Prutt how the separate cot- tages in this colony are lighted ? Dr. PRATT: They are lighted by kerosene lamps, enclosed in glass boxes, and the glass boxes enclosed in turn in grated frames, under lock and key, and the key solely in the possession of the attendant. Proceedings. 609 DR. GILMAN: What arrangement is there about the heating apparatus? Dr. Pratt: They are heated by steam in cold weather, and we find it works so well we shall continue to heat all other colony buildings in the same way. Our one colony building which was operated through the last winter, shows, that while the expense of heating is slightly more per patient than in the main asylum, yet the difference amounts to very little. DR. GILMAN: Do you find it necessary to have a special guard for the windows. DR. PRATT: No, sir; no guards, nor bars as yet. The windows are raised and lowered just as the patients please, and they sit up to and around the window just as freely as they wish. There is no one now in these buildings that we find it necessary to restrain. Such as are likely to give trouble, in this respect, are not selected for the colony life. DR. HURD: Where is the food accommodation ? DR. PRATT: The food accommodations are all on the ground floor. All the sleeping accommodations are upstairs, except in the farm part of the house, occupied by the farmer and his wife. DR. GOLDSMITH: Are there no guards in regard to sleeping accom- modations? Can they go out and come in ae they please? DR. Pratt: During the day male patients can go in and out as they please, and there is no more restraint at night than in an ordinary farm house, except the supervising care of the attendants. Dr. Gilman: Do you suppose there is no danger in that respec relative to the patients ? DR. PRATT: No, sir; none yet appears. I said, a while ago, we shall maintain a guard and the same care at night around the female colony as at the main asylum. DR. FLETCHER: Will you give the probable estimate of cost of those buildings ? Are they of wood or brick ? Dr. Pratt: We constructed the first building of wood, to accommo- date about thirty, at a cost of about $6,500, and we can accommodate, if necessary, forty there, but it would crowd them too closely. We can accommodate thirty very comfortably. It is now proposed, however, at the suggestion of the Committee of the Legislature, that the other houses be of brick. The cost of building with brick will be about two thousand dollars more than if built of lumber. DR. CHAPIN: Where will the patients dine? Dr. Pratt: We expect to have different arrangements wlth regard to that. At the dairy farm, patients and family all dine together in common in the dining-room of the farm house; that house being the same, in nearly all respects, as a large farm house, pure and simple, a home and not an asylum at all. When we get ready to build the colony houses for women, we are considering whether we will have, between each two, a dining-hall, to which they can resort from both 610 Proceedings. buildings by a covered walk, or whether we shall give each house its separate table. The belief is pretty general among us that they should eat at their own home. The patients like that. DR. Hurd: Is it your intention to send any but chronic cases to the colony ? DR. PRAtt: These will constitute the majority. We shall send a few cases of convalescents, to avoid producing the impression that life at the colony is, practically, a condemnation to a life-long, living death. We shall mix in a few convalescent patients, and perhaps some recent cases, of harmless characteristics-just enough to take the curse off-50 that none shall say we have none but incurables there. We do not want the patients to have that idea, and we do not want their friends to have it. So we have planned; and we now have some convalescents at the colony, who are entirely restored to reason, but not sufficiently restored in physical health to go home. We have some mixed in now, and we propose to have more. We have already discharged from the asylum and sent home, directly from the colony, three or four of this class. DR. CHAPIN : Do you say seventy-five per cent. of your cases are chronics ? DR. PRATT: I have given you the facts. As I say, nearly one-half of our patients have been in the institution five years or more, and we have other cases that we know are going to become chronic; but they have not yet reached that condition of quiet that makes it safe for us to trust them away from the asylum. DR. CHAPIN : Will, then, not a larger number become chronic? Dr. Pratt: Not more than the usual proportion. Until the Pon- tiac institution was opened, nine years ago, few chronics were removed except by death. Then, when Traverse City opened, all the patients, without regard to class, that belonged to that asylum district, were sent to Traverse City. That relieved us of some. Then, again, the opening of the Asylum for Insane Criminals enabled us to send away more. This is the only relief from chronic cases we have had in a bis- tory of thirty years, and a careful study of the institution, from year to to year, since its fifth year, shows that there has been a yearly increase of chronic cases-what we recognize among ourselves as chronic cases- of about five per cent. Many of these chronic cases live, as you know, to be very old. Now we do not think it wise, in an economical point of view, for the State, nor is it good for the recent cases, for whom we have little room, that we should permit these apartments that were originally intended for the treatment and cure of the disease, and not for the mere custody of the incurable, to be occupied by chronic cases. The buildings of our institution cost a tbousand dollars per capita for accommodations. We shall be able to accommodate the chronic patients, in our colony buildings, for about two hundred and fifty dollars each. DR. GILMAN: Will that include furnishing ? Dr. Pratt: No, sir, Furnishing is not included. DR. GILMAN: And heating and other things ? Proceedings. 611 DR. PRATT: No, sir; I am talking about the cost of building-in the main asylum, about a thousand dollars per capita ; in the colony about two hundred and fifty dollars. If the prices of labor and material do not change very much-do not rise--we will be able to provide buildings for patients at a cost of about two hundred and fifty dollars per capita. The conditions under which we labor, and by which we are embar- rassed, because of the accumulation of chronic cases in our institution, are similar to the conditions in most of the older asylums of the country. We have in Michigan, no Willard Asylum, as in New York, to which our indigent and chronic insane can be sent as they accumu- late. These difficulties are not so much felt in the newer States as in the older ones. What can we do? While we must sustain, with humanity and care, all these chronics, we must take care of them in such a way that the institution can be kept open for the proper care and treatment and cure of the acute cases. This is the problem to be solved. We are quite sure that our Legislature will not, for the next five years, make an appropriation to build another asylum; and yet we know, while we have some two thousand patients in our asylums, we have another thousand in the State that need the same care. Now then, instead of building a great asylum, we ask of our Legislature the privilege of adding, annually and cheaply, to each of the three asylums that now exist, as nuclei around which to develop arrangements by which we can, to a certain extent, relieve ourselves, and lessen the dif- ficulties of caring for these chronic cases. Every chronic case that goes out of the hospital proper makes a vacancy for a recent case. I think the time will come, too, when we shall provide for all the old epileptics outside of, but near to, the institutions; but we have not decided about that yet. We will not give that much consideration until we have got through with the other problem. DR. GILMAN: To what extent can you develop this system? Dr. PRATT: We have not ascertained that. We may have one, two or three thousand patients. We have got to wait and learn by experience how big a thing we can handle, safely and efficiently. DR. PATTERSON: How much cubic air space will you allow ? Dr. Pratt: There is a rule that governs nearly all our public boards. In the first place these dormitories, in which our patients sleep, are all above stairs; some with two, or three, or four, or eight, or twelve beds, for the men, and according to the necessity for each room, we increase the cubic air space, or increase, in connection with that, the efficiency of ventilation. Bear in mind that these patients are almost all rugged, healthy, hearty and strong people physically. DR. GILMAN: I gather, from the remarks of Dr. Pratt, that the largest amount of employment that is furnished this class of patients is upon the farm. Am I correct? DR. PRATT: The largest number employed, yes. We expect to employ about fifty in the shops proper. . 612 Proceedings. 12 . DR. GILMAN: I would like to inquire, during the long, dreary months of the winter, when the farm operations are comparatively lim- ited, what recreation or amusement these patients have ? DR. PRATT: The same as they have now in the asylum. DR. GILMAN: I suppose there will be an amusement hall ? DR. PRATT: They have checkers and cards, but as to an amuse- ment ball we have not got to that yet. DR. GILMAN : In every large institution they have an amusement hall, and during the long winter evenings the patients are entertained with different kinds of amusement, such as dancing, magic lantern entertainments, with instructive lectures, and so on. At this distance from the hall it does not seem that the patients who are in these cot- tages could derive benefit from the amusements. DR. PRATT: We propose to give them amusements of some kind also. DR. GILMAN: Also, on the Sabbath, we have additional exercises for these patients, and they might be debarred from these services. The doctor's remarks in regard to the employment of patients, it does not seem to me, need necessarily apply to the colony plan alone. During the past three or four years we have made provision, by additional wings to the Hospital for the Insane at Mt. Pleasant, Iowa, for four hun- dred patients. We have employed, during the process of building, about one hundred male patients, of the chronic class, largely in the construction of these buildings, in the carrying of bricks, mortar, stone and lumber; and all the work of the laborers has been performed by the patients. We have also employed on the farm and garden, in our stables, in the laundry and boiler house, and in all the ordinary work about the farm, these cases, from one to two hundred; and we have no difficulty in the matter of classification of the laboring class, by setting apart wards where these chronic cases make their home. They have the same liberties which are enjoyed by the patients in the colony plan, as has been portrayed by Dr. Pratt. We have also had wards in which the patients were all paroled and the doors thrown open, so that every patient of the ward could go out. But I must say, in reference to that matter, that I think it is educating a class of gentlemanly loafers; and the result is, when they return home, they feel they must continue the same practice of loafing, and the tendency is that they will be induced to do so instead of taking hold of their usual avocations as they did previous to their insanity. Consequently, I do not favor the parole plan very much; I believe it is vastly better that the patient should have some employment, some light work that is adapted to his condition physic- ally. I do not see any advantage to be gained by sending them away out, a long distance from the main building, where the physician will have to be called by telephone and compelled to ride two or three miles in order to reach them, in case of accident. Dr. Pratt: We propose to have physicians right on the grounds, when we get our plans all arranged. Proceedings. 613 The discussion having closed, Dr. Clark, from the Committee on Autopsies, made his report. DR. CLARK: Mr. President-Before this meeting adjourns, there are a few remarks I wish to make, which I had no opportunity to intro- duce at an earlier time. Owing to the importance of the subject, I do not feel inclined to postpone any longer what I wish to say, but will bring it now before the Association, if permitted to do so at this late stage of the session. I desire, if possible to bring about by common consent some uni-- formity in the holding of autopsies in all the asylums of the United States and Canada. In other words, to have a tabulation of post mortems in all our asylums, and to so arrange the records as in some way to classify the observations made at our post mortem examinations. I intended to be present at the meeting of the Association last year, but I was not able; and I see by the Proceedings that I was appointed Chairman of the Committee again. Dr. Schultz I have written to and received no reply, Dr. Bryce is now in Europe, and Dr. Andrews was willing to endorse whatever I did. Dr. Fisher wished us to accept the excellent tables which he has used for the last two years in his reports, as his contribution to the work of the Committee. I feel that there is a great field open for us here, that we have neglected to a large extent. When I consider that we have over 120,000 insane under the charge of members of this Association, and that about six per cent. of deaths, annually, would give about seven thousand bodies, it is quite evident that we do not utilize, as we might, the dead of our asylums from year to year. If, with that percentage of deaths, we could have only two thousand autopsies, and have them success- fully made, it is iny impression that much good would result from the effort. The tables which have come to my hands, such as Dr. Fisher's excellent table and others, have one lack which I think should not be overlooked. They give us the pathological conditions of those who have died; they classify these in their own way, each one having his own classification, and there are many classifications, as we have learned since sitting here; but none of the tables put the pathological in juxta- position with the psychical; in other words, record also the conduct and life-history of the patient. I think it is a great omission. It is not only important to know after death all the facts that you have met with in the dead body, but also to bring alongside of them the con- duct of the patient during life. In this way we put certain pathologi- cal conditions alongside of certain psychological manifestations, that should not be separated in our research. During life we trust largely to what the patient does and says and feels when we want a diagnosis of the case. Why not compare the living with the dead facts ? I have felt that this table, if it could be made, would also stimulate many of us to hold more post mortem examinations than we are accustomed to do, because of the greater interest which would be excited in our research. We could have three or four post mortems to one we have now, even if we are not all trained pathologists. 614 Proceedings. Some asylums are fortunate enough to have every facility for such work, such as Utica and the asylum at Boston. That is their good for- tune: we cannot all have such. We can all, however, use the micro- scope, but even ordinary examinations would be better than none; they would, at least, detect gross lesions in the brain and stimulate to further research. I think it would have a good effect upon the attendants, in respect to whose conduct there must be daily vigilance. If attendants had in their minds that one-fourth, or one-third, or one-half of the bodies of those dying in our asylums would be subject to a physical examination, the possibility is that they would not be likely to abuse patients, as many have the cunning to do on the bodies and in such places as they think will not be seen. I do not say this abuse is general, in speaking of the majority of attendants; but, as of other classes, there are always black sheep in every flock, and sometimes there are bruises made that could be seen in the post mortem, which might escape observation other- wise. If such were the case, and it was known that examinations would be made, I believe it would make bad attendants be more kind and careful. But that is only a side issue. If we bad even the coarse lesions carefully noted, and had the results of two or three thousand post mortems every year tabulated in some uniform way, it would be a great step in advance of our present methods. It is a field that has been largely neglected, but I am sure we are all anxious to cultivate it to the best of our ability. I bring before you printed tables which I mean to adopt. These only epitomise our post mortems, and are not intended to supersede the more minute details entered in our post mortem books. What I aim at, is to have tables so succinct that they could be put annually in our reports, and thus be within the reach of every one of us to compare and still farther tabulate. Too minute classifications are not practical, and we will have to use the generic terms instead of the multifarious and „specific names. No two patients are alike. They diverge in symptoms, yet as imperceptibly as the colors of the rainbow blend into one another. Until we have uniform minds, we cannot practically apply minute classifications. I have brought this matter up here as I conceive it to be of great importance, and I would like to hear from the Association upon the prac- ticability of carrying out the scheme as I have stated, or some other plan having the same object in view. DR. Grissom: How would it do to have this matter come up for special consideration at our next meeting, thus giving time for consid- eration and contemplation ? DR. CLARK: It would do very well. On motion of Dr. Wise, it was Resolved, That the Committee on this subject be continued, for the purpose of an early discussion of this matter at the next session. DR. EVERTS: We have come to the close of the session, and I wish Proceedings. 615 to make a few remarks, or make a motion. The man who looks back one day in his life, or one year, or thirty, and finds nothing in it to be discontented with, should recognize in the fact, pretty good evidence that he has not grown any during that length of time. Now, the reso- lutions that have been adopted by this Association, known as its “ Prop- ositions," and supposed to embody its wisdom, were, some of them, passed a good while ago. It seems to me that this Association has reached a point, where it may be well to review the past and see if it has grown any. If the “ Propositions "made by this Association thirty years ago are perfect, then there is nothing to be said-we have not grown. But, if we know more now than we knew at that time, it is well that we should review the acts of that time, and modify or change them in accordance with the present stage of progression, if we have made progress. Therefore, I move that a committee be appointed that shall review the past proceedings of the Association, and see if we have made progress in respect to the management and care of the insane. The motion was unanimously adopted. The President appointed as such committee, Drs. Everts, Daniel Clark and Pratt. Dr. Wise, from the Committee on Resolutions, offered the following report: The Association of Medical Superintendents of American Institutions for the Insane, at the close of this, their Forty-first Annual Meeting, and before separating for another year, desire to record their grateful appre- ciation of the hearty welcome and the generous hospitality tendered them by the medical profession, the municipal officers and the citizens of Detroit and its vicinity. Scarcely exceeded in attendance by any previous annual meeting in its history, it is exceeded by none in the fruitful work accomplished, and this, combined with a series of most enjoyable entertainments, will ren- der it a memorable time-mark in the annals of the Association. Resolved, That to the Mayor, Board of Aldermen and Common Council of Detroit, for the use of the Council Chamber and other rooms in the City Hall, in which to hold the meetinga; to the Press of the city for full and faithful reports of proceedings; and to Messrs. W. J. Chittenden & Co., of the Russell House, for courtesies shown to members and their ladies, the Association bas been placed under obligations, and tenders thanks to each and all of them. Resolved, Tbat the members, for themselves and in behalf of the ladies, are greatly indebted to Parke, Davis & Co., for the pleasant facilities pro- vided by them to view the city and to visit their large and complete laboratory; for their lucid and interesting exposition of modern pharma- ceutical processes and for their elegant collation. Resolved, That to the Medical Profession and Societies of Detroit, we tender our sincere thanks for their multiplied courtesies and bountiful reception. 616 Proceedings. Resolved, That to the “Friends of the Asylums of Michigan,” who have proved themselves friends of the asylums of America and partic- ularly of their representatives, we are under deep obligations for the many courtesies tendered the members and their ladies, and for the enjoy- able excursion on the river and lake, to Rushmere, and its accompanying entertainments; also to the Detroit Hunting and Fishing Association and the Lake St. Clair Hunting and Fishing Club, for the privilege of their beautiful grounds. Resolved, That to General and Mrs. Alger and family, we tender our earnest thanks for their gracious reception and the pleasant entertain- ment aftorded the inembers and their ladies at their beautiful city residence. Resolved, That the Association sincerely regret the unavoidable neces- sity of declining the cordial invitation of the Sister Superior of St. Joseph's Retreat, to visit the Retreat. Resolved, Finally, That it is the sense of the Association that the eminent success of this meeting is due, in great measure, to the earnest endeavors of Dr. Henry M. Hurd and his associates, of the Committee of Arrangements, to make it sich; to whom we tender our sincere and heart- felt thanks. DR. CLARK: I beg leave to second the resolutions, as one of the Norsemen of ibis continent. I take great pleasure in doing so, as a mem. ber of this Association. You have always treated us, from Canada, with great kindness whenever we bave attended the meetings in the United States, and we seldom have the opportunity to reciprocate. Upon Dr. Hurd's Committee of Arrangements a good deal has depended for the great success of the present session of the Association, and to Dr. Hurd very much of it is due. The fact is, the smaller the committee the better the work. Noah's Ark, you remember, was built under the direction of a committee of one. The motion being put, the resolutions were unani- mously adopted. PRESIDENT GRISSOM: Gentlemen of the Association, our work for this session is done. The excellent programme of the Committee of Arrangements has been carried out. I now take occasion to wish each and all of you a safe return to your homes, a speedy reunion with those loved ones that await you, and a re-entrance upon your professional and official duties with renewed vigor and interest. I beg leave to emphasize our thanks, for their cordial and generous bospitality and greetings, to the people of Micbigan-ibe great State of Michigan !ibe foster-mother of science and benevolence, and the mother of statesmen. Nothing remains for me to say, except to declare tbis Association adjourned, to meet at Old Point Comfort, on the third Tuesday of May, 1888 JOHN CURWEN, Superintendent. Proceedings. 617 The following obituary notices were forwarded to the Secretary after the adjournment of the Association. Obituary notice of Dr. W. T. Browne, prepared by Dr. W. H. Mays. DR. BROWNE. Dr. Browne was of Virginian birth and ancestry. He went to California in an early day, and practiced his profession with skill and success, first at Sonara, Tuolumne County, and afterwards in the city of Stockton. He was, in 1875, appointed Assistant-Physician of the Asylum at Stockton, and on the retirement of Dr. G. A. Sburtleff, in 1883, from the superintendency, Dr. Browne succeeded to that office and held it up to the time of its death. He had been a great sufferer, for many years, from disease of the heart, probably fatty degeneration; and, although his death was terribly sudden, it was in no wise unexpected by those who knew him best. Dr. Browpe was eminently fitted by nature for a commanding position among his fellow-men. He was a man of attractive presence, of great energy and force of character, of undoubted administrative ability, of generous and benevolent disposition and of cordial, sympathetic nature. He devoted himself, body and mind, to the amelioration of the people under bis charge, with an untiring earnestness which doubtless hastened the fatal end. The career of this able and zealous servant of the State was brought abruptly to a close, February 20, 1886, at the house of a friend, whom he was visiting in San Francisco. Memorial Minute, adopted at a meeting of the Trustees of the Butler Hospital for the Insane, on Friday, Decem- ber 18, 1885, and ordered to be entered in the Records, and to be published: JOHN WOODBURY SAWYER, M, D. John Woodbury Sawyer, M. D., Superintendent of the Butler Hospital for the Insane, died after a brief illness, on Monday, December 15th, 1885, at the age of fifty-one years. He was born in Danvers, Mass., November 5, 1834, and received his medical education at Harvard University, where he graduated as Doctor of Medicine in 1858. He was immediately, by the selection of Dr. Ray, appointed to the office of Assistant. Physician in this hospital, and here he spent the first two years of his professional life. He then entered upon the practice of his profession in Boston, and after the lapse of a little more than a year, he was appointed Assistant-Superinten- dent of the State Hospital for the Insane, at Madison, Wis. He had been engaged in discharging the duties of that position for nearly six years, when, on the resignation of the late Dr. Isaac Ray, he was chosen Superin- tendent of this hospital, and entered upon the duties of the office in Janu- ary, 1867. The choice was made in accordance with the recommendation of Dr. Ray, who had had charge of the hospital from its foundation. 618 Proceedings. From the day of his election to the day of his death, a period of nearly nineteen years, be bas discharged the diversified duties of this office with unremitting assiduity, with rare wisdom and distinguished success. As they look back over the long period of his connection with the bospital, the Trustees recall with unqualified satisfaction and with high and grate- fuil appreciation the varied and laborious services which he bas performcd in its behalf, not only in his judicious and tender treatment of its patients and his watchful oversight of its interests, but also in the careful keeping of its accounts and the successful management of its farm. In each of these several spheres of official service he has shown the utmost fidelity to every trust, a breadth of capacity and a soundness of judgment equal to every emergency, and withal a kindness of heart and an elevation of character whicb, in an unusual degree, bave secured the confidence, the esteem and the highest respect of those with whom he has been associ- ated. Under his watchful superintendence, and by his wise administration, the hospital has widened tbe sphere of its usefulness and improved its method of sanitary treatment; its resources and its provisions for the care and comfort of its patients have been greatly enlarged; it has thus acquired new titles to public contidence and esteem and has secured new friends in the new generation which has arisen since it was founded. The personal qualities of Dr. Sawyer were such as did not fail to endear him very strongly to those who were associated with him in the care of the hospital. His manners were gentle and winning; his cbaracter was marked by singular modesty, united with great firmness of purpose, by rare good judgment, by manly independence, by self-denying benevo- lence and by unfailing devotion to the duties he was called to perform. He bas died at a moment the most unexpected, of which those who loved him had received no premonition, and when his plans were broadest and his hopes were highest, in the full meridian of bis usefulness and his renown. The Trustees mourn his lose not alone as the loss of an accomplished and faithful Superintendent, eminent in his profession and honored in the community, but also as the loss of a personal friend, endeared to them by the graces which adorned his character and by the noble and generous services which filled his daily life. The Medical Jurisprudence of Mental and Nervous Diseases.* By S. V. CLEVENGER, M. D., Consulting Alienist and Neurologist Michael Reese and Alexian Hospitals, Chicago. INSANITY may be regarded from three prominent I stand-points : the philosophical, the medical and the legal. How soon there shall be consonance of views depends upon when there shall be general recognition of what is now known about mental diseases. Were the modern philosophical conclusions to prevail there would be no distinction between crime and insanity; society would simply adopt measures to protect itself against both as equally dependent upon faulty organization or function, and more attention would be paid to circum- venting the higher grade of criminals, who seldom figure as such-the demagogue, the social hypocrite and the un- scrupulous millionaire gambler. It will be long before the populace comprehends that unjust judges, a Senate crowded with Neros, and a feeble array of intelligence in the lower House, can work more disaster than Bedlams and jails let loose; but the trend of enlightenment is toward mercy to the weak and protection against oppressors. Dr. Wm. D. Robinson, Physician to the Eastern State Penitentiary of Pennsylvania (in a paper read before the Philadelphia Neurological Society, March 28th, 1887), says the major part of State prison offences are the acts of men born members of the crime class of people : “ They are one of the morbid excrescences from society, and in progeny reproduce their peculiar kind. As the cancer cell lodged in a neighboring gland develops a growth identical with its paternal source, so the offspring of the crime class belie not their origin. " These people very seldom reform, but in death end lives passed in crime and infamy. They have absolutely as little control over their natural inclination to wrong-doing as the contirmed periodical drunk- ard has over desisting from his spree. * Read befvre the American Medical Association June 9th, 1837. [619] 620 S. V. Clevenger. “They really see very little moral wrong in their crimes—the crime with them being detection. They truly believe that the man who as- sists in their detection and aids in their being brought under the law is much worse than they themselves. "Crime is unquestionably a monomaniacal infatuation with them. Statistics, attested facts, and direct attainable evidence, clearly war- rant this assertion. It is not an unusual case to have them acknowl- edge that they prefer the excitement of getting one dollar unlawfully to earning ten honestly." Dr. Robinson goes on to show that neurotic diseases, syphilis, and defects of the cranial contents exist among them. You are familiar with the disputations connected with the matter of responsibility in mental disease, and I will not trouble you with even a résumé thereof, but will ask your consideration of the philosophical view that criminal- ity is madness. It is not so long ago in the world's history that sick- ness of all kinds was regarded as a diabolical possession, and among some primitive people attempts were made, by harsh treatment of the patient, to scourge away the evil. When enough advance in reason had been made, the sick were no longer held responsible for bodily ail- ments, but insanity was not regarded as depending upon any of the diseases to which mankindw as subject; in fact it was not considered as a symptom of bodily disease at all. Finally, this concession was made, and mental disor- ders are in many countries classed as sicknesses for which the sufferer is not held to account, though in Illinois a jury still determines the extent to which the person is guilty of insanity, or, if we admit that the law recognizes insanity as a disease, then a lay jury merely makes a diagnosis. Magnan and other pathologists, Caruthers and other clinicians have demonstrated that many forms of inebriety depend upon defective organization. Criminality and drunkenness being the product of structural faultiness, it is as sensible to “punish ” the sick as the malefactor. In sickness, insanity and criminality, discipline is ab- solutely necessary; the delirious typhoid patient is pre- vented from leaving his bed and the rheumatic from eating Mental and Nervous Diseases. 621 unwholesome food. In the better class of asylums, the insane are promoted to better wards and more privileges as an inducement to cultivate self-restraint, and this iden- tical principle is operative to-day in the Folsom State Cal- ifornia prison, where a graded system of fare is adopted for convicts according to their behavior. That society is as yet unwilling to identify crime with insanity on the grounds of inexpediency, does noi dis- prove the identity, and is paralleled by the inability of our ancestors to accord irresponsibility in mental ailments. Objections without number can readily be raised against a recognition of crime as insanity; one of the logical con- sequences of which would be the abolition of the peniten- tiary as a reformatory institution. In considering this aspect of the question I would deny that reformation of criminality was accomplished by such imprisonment, and claim that the convict who had served his term had merely graduated as a criminal, with, of course, here and there exceptions, which are such in spite of the system, the tendency of which is to confirm and to harden the convict. The protection of the community, for the time being, that the incarceration affords, is obtainable through any method of sequestration, and is no argument in favor of the brutalizing punishments resorted to. Legal gentlemen may laugh at this Utopian fancy, but let me tell them that penologists and alienists (who are not politicians) affirm that a large percentage of convicts are demonstrably insane even from the stand-point of the layman. Else, why should there be a “Crank Depart- ment” in every such prison? I have known congenitally insane wretches to be forwarded to asylums after having been several years in prison, with the statement that the lunatic had become one from effects of imprisonment. Paretic dements, who in the beginning of their mental breakdown often commit larcenies, or outrages against decency, are condemned as criminals, and soon die in a convulsion or after a maniacal outbreak. I have heard the question “What difference does it make, since death 622 S. V. Clevenger. is inevitable, whether the patient dies in the penitentiary or asylum ?” The same might be urged in all cases in favor of an abolition of asylums and a return to the whip- ping, ducking and starvation methods of treating lunatics in recent centuries. Besides, ad hominem, would it make no difference to your family that the truth had been rec- ognized and you had been permitted to die as insane instead of as a convicted thief? The “insanity dodge" does not seem to have availed among poverty-stricken culprits when we can recall so many grossly insane patients converted into convicts. A pauper suffering from katatonia stabbed his wiſe in the most insanely brutal manner, exhibited all the pecu- liarities of that disease while in jail, but the political alienists and the jury forwarded him to the penitentiary, where he was placed in the “Crank Department." A six- teen-year-old girl, with hysterical insanity, who attempted to poison her parents, was also pronounced sane and sent to the same place. A paranoiac, with petit mal, who had shot two women for absurd reasons, was given six years in the pentitentiary. The illogicality of this sentence ap- pears in the nature of the offence if committed by a sane person, justifying, under present laws, a life-sentence, but the suspicion that he was not "well balanced” caused the term to be shortened. A life-imprisonment in an asylum would have been more rational. When insanity is suspected in a criminal the European method of preceding trials by an expert commission ex- amination saves great expense to the State and avoids the farcicalities so common in our American courts in similar cases; but as our peculiar institutions would, in nine cases out of ten, foist ignorant politicians upon us as members of such a commission, scientific alienists are not inclined to enthusiastically favor a change from the present faulty methods of lunatic inquiry. Many generations may come and go before the world can adjust itself to identify crime with insanity, but that eventually such a view will prevail, appears to me to be Mental and Nervous Diseases. 623 : inevitable as the outcome of progressive thought. When that time comes there will be no penitentiary, for the asy- lum will quarantine against all who cannot conform suf- ficiently to social requirements; there will, furthermore, be no practical politician, as we understand him to-day, for, recognizing him as a member of the crime class, his public treasury burglaries will be thwarted and the reason for his existence will cease. Alienists are too busily en- gaged in trying to convince the lawyer and the public that there should be no distinction between medical and legal insanity to undertake greater tasks, and it is this constant endeavor of higher knowledge to adapt itself to the conceptions of the period that causes such a thing as medical jurisprudence to exist. It was formerly treason against God, king and common sense to deny witchcraft. All that could be done was to prove the unfortunate not to be a witch. I am not so shallow as not to foresee that many con- siderations would arise under such an adjustment that would require a great revision of our statutes, but I be- lieve the code would be greatly shortened and that crim- inal lawyers would be few in number; the main ground for contention would be the fact of crime commission. Polemics, over accidental or designed acts would be ab- breviated when the only object of the law would be to prevent a recurrence, and while Nature's failure to dis- tinguish between a hand thrust deliberately or accident- ally into the fire ought not altogether be copied, it could be thought of in disposing of the man who jokingly points an unloaded gun at another, for that species of imbecility is as deserving of regard as any other. So much for the future, but as an evidence that en- lightened views are beginning to prevail, we may note that the Wisconsin Senate passed a bill to send convicted drunkards to insane asylums, in spite of the teachings of ecclesiastics that drunkenness is a crime and not a disease. As however, in the present, responsibility is not to be discussed in court rooms from the philosophical side, it 624 S. V. Clevenger. at least should be granted that the alienist is best able to consider the facts of insanity, even from the legal and lay outlook. At once then, it should be known that in- sanity cannot be dealt with as one and indivisible, any more than sickness in general. There are many kinds of insanity, and a knowledge of their phenomena is requisite to intelligent judgment. For example: take one of the circular or recurrent forms, such as katatonia, where the patient may be melancholic, stupid, maniacal, and then apparently rational alternately. Judge, jury and lawyers cannot pass upon such a case properly without a knowl- edge of these phases, and whether the lunatic is a kata- toniac or not. One with a head injury often becomes very intolerant of alcohol and upon occasion may commit some grave offence. These and multitudes of as well- established facts should be duly held up to view. There is such a malady as transitory frenzy, which may last hours or a less time, and during which suicide or murder may be accomplished. I reported one such case, where a poorly balanced female had, under large doses of some abortifacient, attempted to throw her- self from a window and cut her arm arteries with scissors. Had the onslaught been made upon some other person she would have had great difficulty in proving her tem- porary insanity, for it was of but short duration. Witness poor John McCulloch, the actor, wandering about with his delusions of grandeur and nearly every other evidence of paretic dementia, fully recognized as such by able alienists, who were unwilling to advertize their judgment and suffer the abuse of lay and medical ignoramuses, even though time would have sustained the verdict. The German alienists more particularly have advanced psychiatry to a footing with many of the more exact provinces of medicine. This is no less a truth because the fact is not generally known and that practitioners are often found, who, like Fordyce Barker, are capable of appearing as experts in toxicology, gynecology, surgery, ophthalmology and psychiatry. The recent dictum that Mental and Nervous Diseases. 625 the depths of one's attainments are inversely as their breadth, while needing some qualification, applies in such cases, for medicine has differentiated and its branches de. velop beyond the possibility of any single person attaining proficiency in all. The shoemaker may as well attempt to discuss the relative merits of Jurgenson and Waterbury watches as for the medicial specialist in one line to at- tempt judgment upon another. If some legislative provision were made for insane criminals and the criminal insane, as was suggested years ago by Dr. Dewey, of the Kankakee Asylum, judges and juries might see their ways clear to a more rational dis- position of such cases as popular condemnation impels them to pronounce “sane, but illy balanced,” “not insane but a 'crank,'” “responsible for his act, but of low grade intellect,” etc. Especially should medical men insist, not only that physicians only should be selected as superintendents of asylums, but if not asking too much, that they should know something of insanity. Recently, in Chicago, law- yers were allowed to nominate candidates for judgeships from among themselves. Why would it not be as well to permit physicians to select the heads of medical institu- tions, instead of relegating this power to saloonkeepers, gamblers and prize-fighters, some of whom, at least, are indicted thieves. At first glance it might seem advisable to compel all asylum officials to keep full records of all cases admitted, and to have some more careful method for the receipt and discharge of lunatics; but as brains and scientific ability cannot be legislated into the head of a medical politician the records kept by such an one would be valueless, and the liberation of dangerous paretics can only be pre- vented by the asylum physician knowing a little about in- sanity. The recommendation that respectable alienists should be appointed to superintend asylums would cover the points mentioned better than legislation would. The Illinois State Legislature has been appealed to with 626 S. V. Clevenger. regard to enacting some suitable punishment for attend- ants who illy use, wound or occasionally murder the insane; but time is taken up by fisticuffs among the honorable members and calcimining self-investigations concerning alleged steals. Then, as to the status of the expert in court: He is usually selected by one side, instead of by the judge, and theoretically is presumed to be unbiased. He is placed in a false position, because being the recipient of a fee from one side his allegiance would seem to be due to that side, and were his testimony harmful thereto, he would, with some show of justice, be considered as having be- trayed his trust. There seems to me to be but one honest position for him to assume, that of a partisan, who may coach the lawyer who engages him. If he can conscientiously, in addition to this, go upon the stand as an expert, his convictions should be freely expressed, and the lawyer should take his chances with such testimony, just as with that of any other witness whom he calls. Ray's suggestions are good: 1. That the expert should be asked if he gave his entire time to the study and practice of one branch of medicine, and if that one branch was psychiatry. 2. That the expert opinion should be rendered in writing, which would cause legal trickery to be harmless. These suggestions apply equally well to neurological cases, which are mainly actions against corporations for spinal injuries, wherein Ericson figures largely for the plaintiff against Page for the defendant. In a disorder that presents such a preponderance of subjective symptoms as spinal concussion, and in all other cases where simula- tion might be alleged, as in paralysis, contractures, etc., the value of faradic and galvanic tests of muscles and nerves should be more fully appreciated. Especially since, with the milliampere meter and Erb's electric charts, we have the means of graphically presenting the conditions ascertained in such a manner that the jury may readily comprehend. The True Nature and Definition of In- sanity.* By C. H. Hughes, M. D., of St. Louis. A MORBID process, which, engendering defect and 11 deranging or suspending the performance of normal functon in an organ, is none the less a real disease and is none the less entitled to be called such, because it hap- pens to begin or even to end in fætal life, than if it takes place solely or partly out of the womb. A disease des- tined to so damage the brain as to destroy the otherwise predestined normal harmony of the mental operations or suppress them altogether, so that they can never be dis- played, may be sown in the germinal seed and develop with the growth of the brain, evolution and dissolution going on together, the latter modifying the former so that a mental monstrosity is the result. · This is disease, destroying the power of normal mental display; and whether the destruction be complete or but partial, or whether it takes place within the womb partly or solely, or altogether out of it, it has the essential na- ture of, and truly is, insanity. For conventional consider- ations, but without good reason, a certain degree of this morbid implication, because beginning pre-natal or in early post-natal life, has been called idiocy, another degree im- becility. But idiocy is an insane condition of the organ of mind, none the less entitled to be so considered than de- mentia . simply because it displays itself at or nearer the beginning of organic existence and the incipiency of the display of mental power, while the latter, quite similar in its psychical symptomatic expression, is universally ac- knowledged by alienists to be a terminal phase of cerebro- mental disease. Both dementia and its closely allied morbid kindred, * Read before the Ninth International Medical Congress, September 6, 1887. [627] 628 C. H. Hughes. imbecility and idocy, are alike disease implicating the cerebro-mental mechanism in destruction at the conclu- sion of a pre-existing morbid process, the two latter being the degenerative outcome of subtile neuropathic influences affecting the nutrition and normal development of the psy- chical area of the cerebrum during intra-uterine, or infantile life. The former being the same or a similar thing (psychi- cally considered), displayed later in the individual's life history. The dissolution simply begins a little nearer the germinal life in the one case than in the other; but in both, through what we call hereditary entailment, the real cause of the organic dissolution, though the determining factor may be different, may ante-date through what we call heredity the life of the germ, and often does in both cases, as we have learned from critical observation and as we are likely to learn more and more, as our inquiries become more diligent and far-reaching, if what we have thus far discovered of the ancestral influences tending to the development of damaged cerebro-mental conditions be a just warranty for what we now assert, on the authority of the universally confirmed testimony of psychiatric science, regarding the essential causative potency of hereditary conditions. Indeed it is no longer gainsaid, as the most eminent of our confrères in psychiatry have proclaimed, that all cerebro-mental disease, whether it be shown in intellec- tual or moral aberrations or incapacity for the dispiay of the psychic powers (unless due to direct mechanical or toxic violence) ante-dates in some at least of its causative influence the individual in whom the psychic failure ap- pears to our view. Hence the dictum of the great Ray, and the confirmatory testimony of his colleagues, that insanity is usually the product of two or more genera- tions. To draw a distinction in states of cerebro-mental dis- ease, between powers arrested in process of evolution, powers destroyed, and powers undergoing destruction, is well enough for purpose of designation of different states er Nature and Definition of Insanity. 629 of cerebro-mental disease, but misleading and pernicious to a correct understanding of the real nature of insanity, if we mean thereby to obliterate the idea of a pre-exact- ing morbid process in the one case and retain it in the others. For all cerebro-mental disease is cerebro-psychi- cal cell evolution modified (delayed, arrested, retrograded,) through the morbid process. The distinction is in fact without an essential pathological difference, except in time and degree; and if it is made to signify more, it leads to confusion of our conceptions of the real nature of mental disorder, which is but a compromise of the men- tal powers through disease, implicating the centers of psy- chical display, whether that implication be one of limited derangement or general destruction of mental power, so far as the normal functioning of the mind is concerned; the damage is as real and the disease of brain as significant and seriously to be considered, whether the powers be simply diverted and deranged from their natural channel, through the perverting influence of disease and to the detriment of the individual, or whether they be totally obliterated from the same cause. The difference is in degree, not in kind, and is a difference rather of prognosis than of morbid nature. It is also one of diagnosis, but only in a limited sense, the determination of which may lead to difference in treatment, just as the differential diagnosis of an exan- thema may modify our remedial efforts, though we may know in the beginning of the different forms of eruptive fever that whatever may be the appearance of the cuta- neous exanthem after the incubation period has passed, it is the blood which is primarily affected, and when the precise nature of the trouble unfolds itself we know we have a blood disease to deal with. Just so in regard to every condition in.which the mind's manifestations are embarrassed by disease affecting the brain. In the case of the ordinarily recognized forms of mental disease which we may see in the incubation stages, we may note that the brain is affected long before we de- termine the precise character of the disease. The incipient 630 C. H. Hughes. symptoms of acute delirious mania are not always essen- tially different from those of ordinary acute mania, and a melancholia may be the precursor of a violent maniacal outbreak or of a terminal dementia paralytica. A phase of epileptic insanity and of folie circulaire may be precisely similar, and an appearance of dementia may usher in a form of mental malady in which high maniacal excitement is the sequel, though real dementia is rarely primary. A condition of imbecility may confront us, in the early stage of insanity, not materially different from congenital imbecil- ity, and may abide to the end of life with the patient; and so in regard to that undoubted form of constitutional insanity called paranoia by some, imbecility, moral mon- strosity, moral insanity, or primaire verrucktheit by others. In all these cases, and the many more, associated for instance with the paralytic and puerperal states, we sim- ply withhold our conclusions as to the form but not in regard to the nature of the malady. Why should we therefore seek to give to cases of cerbro-mental damage, in which the mind is a little more compromised in the beginning rather than towards the ending of life, a different meaning and a different nature? Obviously, we make in these cases a nominal distinction to signify too much difference, unless we make it with proper qualifica- cation; and the proper qualification in regard to idocy and imbecility would be one of insanity in which the mental powers are prematurely destroyed or greatly im- paired in the one instance and remotely or after maturity in the other. They are both states of insanity. They are kinds and degrees of insanity, as much so as the mental derangement of a congenital epilepsia, which, though a little tardier in effecting its damaging influence than the pre-natal influences engendering idiocy some- times are, finally destroys, after perverting, the mind and secures a place in our nomenclature as epileptic insanity, though the last state of epileptic idiocy is no better, men- tally or prognostically considered, than the early dementia of extreme congenital imbecility. Nature and Definition of Insanity. 631 To the terms idiocy and imbecility, as degrees and forms. of insanity, there can be no serious objection. To con- sidering them as separate morbid entities is without, thus far, any real pathological warrant, that would not cause our conception of insanity in general to be changed. To say that one is mind deranged and the other mind de- stroyed would vitiate our understanding of many well rec- ognized forms and features of mental disease. Where, for instance, with such distinction without essential difference in psychical symptomatic expression, would we place the final stage of general paresis, the last stages of apoplectic mental derangement, chronic epileptic insanity, paranoia and acute dementia ? If we seek to differentiate and de- fine these conditions upon a purely pathological basis, then these varieties of insanity are different diseases, and as much entitled to be set apart from other forms of insanity, which have a less defined and more indistinct pathology, as idiocy and congenital or early acquired imbecility. The differentiations of epilepsia, apoplexia and paresis, accompanied with psychical derangement, are appropriate enough as varieties of the cerebro-psychoses, but improper, if we dissever them in our minds from mental disease in general. The millennium in cerebral pathology has not come and is not likely soon to dawn upon us. The new light we have only brings into view more and more unexplored territory. When it does come we may then differently define all these varieties as special entities, including with them idiocy and imbecility and may then narrow the le- gitimate definition of insanity to more restrictive bound- aries than we now, from any neuropathological light before us, can reasonably anticipate. In the light of all present knowledge on the subject, the attempt to make distinct and separate pathological entities of idiocy, cretinism, imbecility and allied states, and exclude them from our definition of mental disease, embarrasses all effort at comprehensive definition, and cripples and 632 C. H. Hughes. misleads our understanding of the true nature and essential characteristics of disease involving the entirety of the mental display. Teratological defect (so-called), though itself the result of cerebro-pathic and neuropathic processes which modify the display of mind, is ruled out, as unworthy of a place in our definition of insanity, simply because we must have a nominal distinction for purposes of scientific desig- nation between certain marked states of cerebro-psychic functional display. This vicious and perverting precedent, which has led to the misconstruction of the nature of mental disease, must be swept aside in the interest of insanity defined on its true basis, of affecting, in whole or scientific exactness, and in part, the display of the normal mental functions and all states of perverted, damaged, suppressed or destroyed mental function due to injury of brain, classified and defined within their legitimate morbid realm, which is disease of brain aſſecting the mind so as to modify or prevent its normal manifestations. Then the place which exceptional cerebro-mental states find in our treatises on insanity, because they can properly be treated of nowhere else, will be recognized as the legitimate and proper place for their discussion and the anomaly of describing them in these treatises as dissevered entities will cease. They will take their place in the fam- ily of diseases, not as relatives in law, but as true neuro- pathic kindred, having a common paternity and progeny, as they do; for, do not the genealogical tables of our asylums for the insane and the homes for our idiotic and feeble- minded indubitably establish (if permitted so to speak) the neural consanguinity—the real neural kinship? I know that this view is open to objection, but the objections are mainly those of precedent and custom —and after we shall have become accustomed to the new usage, especially if thereby we remove the real stumbling-block which long habit of thought and expres- sion liave established, to a correct comprehension and broader definition of insanity, we shall feel ourselves well rewarded for having accepted the change and thus thrown Nature and Definition of Insanity. 633 out an erroneous differentiation from our nomenclature of morbid cerebro-mental states. Definitions of insanity, in the present state of our knowl- edge, as in the past, must of necessity have mainly a symp- tomatic basis, just as most other diseases are mainly defined—when pathology advances to the period of its greatest perfection, a period at present far remote, the defi- nition of mental diseases, as of diseases generally, may be different. But symptomatic evidence, in cerebro-mental disease, as in all other diseases, is less variable than the revealed evidences of their pathology. Symptomatic expression changes little, while new pathological evidence, as the substratum of symptoms, is being constantly unfolded. The supposed well known causes of symptoms are repeat- edly covered up in new discovery, or obliterated by them, and often only the symptom-groupings abide. The study of symptomatology gives us therefore the best and most en- during basis for the description of disease, as it is also the most natural. It will serve us as well in the definition of morbid cerebro-mental manifestation, as in the description of a vascular, glandular or muscular derangement; and to this we may properly add so much of the appreciable un- derlying pathology as may appear not to require revision, especially before the paper on which we record it is likely to get dry. We know that the brain is pachologically implicated in insanity, either in its circulation (vaso-motor mechanism), in its vascular apparatus as well as circulatory conditions; in its cells and ganglia, its neuroglia, or its meninges, in short, in some quality of its structure or in the mechanism that sustains its structure and functions or growth of structure. The brain is somewhere wrongly touched, either by direct or reflected impression, if the responsive mental operations are inadequate or unnatural, and we need no longer dis- cuss the question whether it is the organ of mind de- ranged, since it is known to be the organ of mind normally displayed. 634 C. H. Hughes. The undisputed pathological basis of insanity is therefore a morbid material impress, originating within the system and proceeding from the brain in abnormal manifestation. It may be as much insanity if the natural and normal psychical response to a healthy impression from without cannot be elicited by reason of the central disease, as the exaggerated or non-response to patellar tendon percussion is indicative of sclerosis located in the antero-lateral or posterior columns of the spinal cord, or of obstructed afferent or descending inhibitory neural transmission from other causes. Whether disease of the spinal cord be located in the motor or sensory centers, the meninges or medullary portion, it is spinal disease, and no affection, whether of this part of the cerebro-spinal axis though it be congenitally entailed as in spinal- bifida and displayed in arrested development or as shown in early Pott's disease, is designated otherwise than as a spinal disease, so likewise are all affections of the brain deranging mental function entitled to be classified as forms of insanity. These affection of the vertebral canal when they disorder the cord's function might even be termed insanities of the cord, and those widely differing forms of brain disease disordering mental function and commonly called insanity, may justly be re- garded as mental diseases, the few other forms which are excluded from the common appellation might with as much reason be included in it. Imbecility therefore, as well as dementia, are upon the same morbid footing. The trivial circumstance that the one appears earlier than the other should count for nothing against our estimate of its nature as a cerebro-mental affection. All cerebro- mental affections are of the nature of insanity and the term insanity should include them all. It may be inconvenient at times, in view of the ar- tificial distinctions which psychiatry has created between imbecile and idiotic states, to include what have been thus differentially designated as teratological defect. The ten- ant of the neuralogical home may be a disagreable and un- Nature and Definition of Insanity. 635 welcome one to recognize, but if it belongs naturally on the premises we cannot justly divest it of its birthright. We may assign it a separate, though not a dissevered place in the family and domain of mental disease. And this is what in practice we do. We can never treat of the subject of insanity as technically differentiated from these other cerebro. mental states without likewise discussing them and recognizing their undoubted kin- ship to mental aberration. We recognize and discuss the higher gradations of imbecility into paranoia and the aberrations of the affective mental life, and, drawing an arbitrary line which nature has not demarkated, we have called the mental derangement of the one pathological condition unsoundness, and the other insanity, of mind; as if the mind were sound in insanity and only unsound in these congenital or nearly congenital states; as if such arrest of healthy cerebral development as compromises and destroys mental integrity before it has matured, could be justly called healthy, while only that which de- stroys matured cerebro-mental integrity should be termed disease. We violate this precept every day, in the recog- nition of insanity in childhood and youth. We recognize insanity equally, as hereditarily predestined to mental obliteration, and as showing itself in idiotic and imbecile conditions oftentimes no farther removed from birth than we see it displayed in what we call the teratological de- fects in contradistinction. We cannot erect a scientific distinction between in- sanity and unsoundness on the hypothesis of arrest in the one case and destruction in the other of evolution, because in fact the underlying causes of both results is a morbid one, whether an ideational center, for example, breaks down after it has matured, or breaks down in process of maturation when, if it had been in a nor- mal and healthy state, it ought to have gone on to ma- turity. A process which dwarfs a cell or center of power in the organism below its natural physiological standard is morbid. The process of dissolution has begun 636 C. H. Hughes. somewhere antecedent when this is the result, as much so as if dissolution and destruction have only become apparent after full maturity. Maturity of an organ can- not be made an essential to the recognition of disease in it, for close upon maturity follows physiological decadence. Involution begins with completed evolution, especially in the microscopically discernible life of the organism. Pre- mature dissolution and consequently premature failure of ev- olution applied to the cell life, are the proper criteria of disease, and we find these exist in insanity and all kin- dred states of brain and mind, insanity, as now recog- nized by all, being a more or less teratological defective entailment, though usually manifest more remotely from the period of infantile life and early childhood than those states under discussion which have been differentiated from it. Insanity presents itself to our notice, prima facie, as a pure psychosis, and so the ancients considered it and some modern writers yet regard it, but deeper study of the subject reveals always inseparable physical conditions ; and from what we have learned of the uniform relation- ship between sound mental manifestation and healthy organism, we may now place the acknowledged and demonstrated and always demonstrable relationship be- tween mental soundness and brain integrity beyond discussion. We know, that mind, whatever be its real nature, is inseparably allied to organism in its manifestation, and we need not here concern ourselves with the discussion of its nature, for whether it be looked upon, as it is by some, as simply a force of matter, or as a psychic entity, insep- arably allied to matter and always dependent on the cerebral organism for the display of its powers, as others view it, it amounts to the same thing, and need not em- barrass our definition of mental aberration.* * Mind and brain, to Science, are inseparable. She cannot study one without taking cognizance of the other. Whatever possibilities may exist or be conceded to inind dissevered from the body, Science can only discuss mind in its tangible and material relations. The immaterial in man can neither be weighed nor measured by Nature and Definition of Insanity. 637 Mind is either a force of the brain or a force so inti- mately allied to this organ as to be practically inseparable from the brain in the display of its powers, so that mental function and brain power in the latter's psychical area at least, are practically coördinate, and may, for our present purpose, be considered as convertible terms. The definition of insanity must therefore be psycho- somatic, psychical because of perceptible change in men- tal function, somatic because of the invariable departure from the normal standard found in the brain, or indirect y through disease in the organism, disturbing the brain in its circulation, membranes, cells, neuroglia or general con- formation, associated with the psychical alteration. We know that wherever the ante mortem and post mortem search has been sufficiently thorough somatic as well as psychical aberrations have been found. Aberration from the normal individual standard of or- ganic functional life is disease; and if psychical derange- ment be dependent on such physical aberration it is in the nature of diseased function, whether the mind itself may be diseased or not, and whether that disease be hered- itarily entailed or subsequently acquired. - If insanity be defined on the basis of disease it must have the same symptomatic characteristics as disease in general, and this symptomatic characteristic is a compro- mise of function-a notable departure from the normal function of the organ (if the disease be acquired after the maturity of the organ) as compared with the established and natural character of function-an incapacity of full functional power, if the disease expend itself during the developmental period, as in intra-uterine life, in infancy, childhood or youth, before the natural character is evolved. The true essence of insanity, so far as we can com- prehend it, is an embarrassed or compromised function of any of the implements of scientific research, and mind, whatever it be; and, to avoid confusion and profitless discussion, we refrain from entering upon an inquiry into the nuture of mind here,-mind can only be understood by physical Science in 4ts relations, for it is otherwise intangible to Science. Its nature belongs to the Adomain of a higher philosophy. 638 C. H. Hughes. mind dependent on disease. The basis is disease, and the evidence is disordered mind in relation to brain diseased. If the brain and mind have matured and the mental character, which is a function of the brain and allied neural organism, be consequently established before the disease has attacked it, then we may take the individual character for comparison, and say with Combe, that "insanity is a de- parture without adequate external cause from the natural and healthy character, temper and habits when in health, that is the true feature of disorder of mind, in all cases,” but we need not, and indeed cannot, qualify our definition with the words prolonged departure as Combe did his. Combe's. qualification without adequate external cause, compels us to look within the brain for the cause, where it always resides in all cases of true insanity, though the morbid cause may only be indirectly there, and remotely in the liver or kidneys or heart, modifying the quality or quantity or regularity of the cerebral blood supply. The causes may be external to the brain but somewhere in the body. But if the insanity attack an individual before the mental character is matured or fairly established, our standard of comparison must be other than the individual character. We have then to take our standard of comparison from the family type, or the ordinary mental character, with re- gard to the proprieties of life prevailing at the particular age in the life station of the individual coming under our notice for our opinion. If mental disease begins to show itself in a child, or even so much earlier, and prevent that mind from developing into its proper inental character it is none the less disease because a character has not been formed with which to compare it. The standard of self- comparison therefore, while exceedingly valuable and prac- ticable for most of the forms of insanity which are displayed at or about maturity, is not practical in some other forms of earlier manifest cerebro. mental disease. The well kno'n and now universally recognized forms of he- reditary mental defect disease, seen in childhood and youth, and even sometimes apparent to the discerning 640 C. H. Hughes. heritage. It is sophistical and illogical to say no in- sanity exists, because the morbid mental change had its inception in the cradle, or antecedent to it, rather than after maturity. Insanity cannot be crowded out of ex- istence or the disease limited by such restrictive applica- . tion of a definition which is legitimately entitled to the qualification, and consequently more extended application which we here insist upon. If it were only true in point of facts, as Prichard says: “that insanity always involves that particular cir- cumstance which is supposed to be characteristic of it," but “unfortunately the reality is otherwise," we might make a very simple category of mental diseases, and designate a great many forms of insanity as something else, to accommodate disease to our definition, as psy- chiatry has often tried to do, but the disease comes up like Bancquo's ghost, and will not down at our bidding. We may, in restrictive phrase, define and re-define the status of mental aberration, and it will overleap our narrow boundaries, until we shall have become content to follow nature only, and describe it in a manner so comprehensive as to take into the family of insanity all true cerebro-mental diseases. The criticism of James Cowles Prichard, to which we have just reverted, was made under peculiar circum- stances. A new and undoubted cerebro-mental condition, worthy to be classed as insanity, was ruled out by the narrow view which made delusion in its narrowly ac- cepted sense, the essential criterion of mental derange- ment, and as previous definitions shut out the moral in- sanity of Prichard and the manie sans délire of Pinel, so present definitions may be used to exclude from recogni- tion not only the later discovered forms of mental dis- ease, but others undoubtedly yet to come before us for study and psychiatric classification. To obtain a just conception of mental aberration we must therefore consider the whole organism and the whole individual, for though approximatively, with Cabannis, who Nature and Definition of Insanity. 641 asserted that the brain secretes thought as the liver secretes bile, we may say the brain is as specially concerned in the display of thought as the liver is in the secretion of bile, or the stomach gastriç juice, it, like both these lower organs, has the blood and the whole physiological machinery of the organization behind it and inter-related with it in function. The more we study the inter-dependence of mind upon organism and organism upon mind, in relation to men- tal disease (whatever mind may be, whether a psychical “self-subsistent entity," as Sir William Hamilton calls it, or subtle physical force evolved by the molecular movement of neural matter), the more forcibly the maxim of Aristotle that the yv xn * (soul and life principle) resides in the whole, and the whole in every part of the nervous system, im- presses itself upon us, a view of the relationship of the psychical to the physical and the physical to the psychical which has both physiological confirmation and clinical proof. Not of course in the literal Aristotelian sense, which made the mind as well as the principle of organic life one and omnipresent in the organism, as much and as imme- diately at home in the great toe as in the encephalon, a doctrine sought to be revived by Laws,† and partly re- vived by Hammond, but disapproved by the one fact that sensation is not immediate, but for all practical purposes sufficiently approaching the truth, because of the intimate and multiform avenues of neural communication of the psy- chical area of the brain with the remainder of the organism, and the close and inseparable connection of mind and man in the inseparably blended functions of psychical and * Arist. IIepi kvx75, 1. v. 31. * * * Év ékatépw tõv popíwv απαντ’ ενυπάρχει τα μόρια της ψυχής, κ. τ. λ. “In the Greek Philosophers, the term yw xh (soul) comprehends, besides the sensitive and rational principle in man, the principle of organic life, both in the animal and vegetable kingdoms." The two, however, are not to be confounded. Vide Sir Wm. Hamilton's Lects, on Metaphysics, pp. 271-278, and Dr. S, S. Laus' Essay, infra. “Thesis on the Dnial Constitution of Man or Neuro-Psychology," Archives of Electrology and Neurology, November, 1883. 642 C. H. Hughes. physical life in the human being. So that while the brain is the especial organ of mind, through which it impresses and acts upon evironment, psychical function is in a man- ner associated with and dependent upon the entire body. The whole human organism is or ought to be a harmo- nious psychical as well as physical being. As the Neapol- itian neurologist, E. Morselli has recently very cleverly stated the fact: Every mental act, even the most simple, is the result of a very complex elaboration and association of precedent psychical states pro- duced by an inextricable train of psychological elements, the gross re- sult of an infinite number of elementary biological phenomena. The study of human and animal psychogeny parallel with that of neuro- embryogeny must lead us to admit that the smallest particle of the or- ganism participates in the most complex psychical phenomena, namely, the conscious mental act. From the point of view of psycogeny and ontogeny, the spirit is not only a function of the gray substance of the convolutions, but of all the encephalon, of all the central axis, of all the nervous system, of all the organism. From this view of mind in relation to organism must we study insanity. In this disease it is the individual that is affected, the ego that is morbidly touched through his organism, the self-feeling and consciousness that is al- tered by disease and this consciousness and self-feeling are the expression of diverse psychical states, which are the product of a multitude of impressions proceeding from all parts of the organism. So that while insanity always in- volves the brain in morbid expression it does not always begin there. The brain is neither always alone nor pri- marily at fault in mental aberration, but the mentality of the individual and all the conditions, physical and psy- chical, that enter into mental impression and expression, are often concerned in the phenomena of insanity. The restricting of insanity to the brain exclusively instead of to the brain and all the organic influences that operate upon it through its allied nervous system so as to influence the mind, has led both medical, legal and lay students of psy- chological science into too restrictive views of this disorder. The “knowledge of right and wrong" test of the Law, the Nature and Definition of Insanity. 643 delusion criterion of Medicine, that is, delusion restricted to morbid concept originating in disordered reasoning or in derangement of the seat of the special senses in the brain, has often misled justice and misjudged the victims of insanity when not thus markedly affected. To delusion in its broadest sense and newly defined as we now and here define it, not restricted to any special and formulated or formulatable concept or special sense percep- tion, there can be no objection. On the contrary, delusion, in this true and broader sense, is the real criterion of mental disorder. All insane appear to be thus deluded, and they give evidence of such delusive influence swaying them, if not in insane speech, at least, in morbid action, which speaks with equal force if not more forcibly, of character transformed, of self-feeling and judgment changed. Their actions often speak louder and plainer to the psychiatric clinician than words, for the latter may conceal rather than express the real feeling of the insane, no less than of the sane. If therefore we should group together all the phases of mental aberration with which psychiatry is familiar, and in- clude all forms in one broad and comprehensive classifica- tion, how should we formulate an expressive definition that should prove broad enough and not too broad, and narrow enough and not too restrictive ? Insanity being a condition of the organism, that ex- presses itself in change of mental character from what is natural to the individual or what ought to be his natural character, the real basis, cause, and essence of that altera- tion of the psychical nature is the true disease. In every insane person there must be, and always is apparent, if we study our patients aright, and scan their symptoms with the skillful discernment that comes from large clinical ex- perience in the observance and comparison of psychiatric symptomatology, a subjective morbid change in the organism (due either to ante-natal or post-natal conditions, but usu- ally to both), in the nature of deranged organic, or special sensation, perception or conception. · 644 C. H. Hughes. Insane impulses, are consequences or concomitants of morbid feeling, if they co-exist with consciousness; and if they do not, suspended consciousness is itself a dis- order of sensation, and disorder of sensation is, generally, delusional to the insane mind. Organic feelings deceive the reason and may prove as delusive as special-sense subjective perversions, misleading the intellect so that it acts in a manner neither natural to the individual nor to the normal type of that individual. The standard of comparison in insanity cannot always be self, but the normal self-type before the morbid ancestral departure. The hitherto recognized delusional insanities, because they reveal morbid mental aetion associated with subjec- tive mistaken concepts or perceptions, or pure intellectual delusions founded on illusion or hallucination of the special senses, are not the only forms of delusional insanity which should be recognized in psychiatry. Other subjec- tive sensations which are at the foundation of the mor- bid egoism and perverted impulses of insanity are equally delusive, such as the exaggerated muscular sense or feel- ing of strength, or vice versa, hyperästhetic or anæsthetic and other perceptional morbid states and motor subjective illusory conditions, and those undefined perversions of feeling displayed in melancholia and megalomania and sui- cidal and homicidal impulses, as well as the klepto, py- romaniacal, nyphomaniacal, and the yet unnamed morbidly erratic feelings, delusions of duality, of unilateral personality, accompanying personalities, etc., etc., which mislead the judg- ment and conduct of the insane. The organic feelings are as delusive as the perverted special-sense perceptions and as justly entitled to recognition, when perverted and delusive in their nature and influence on the mind. The organic conditions of the emotional forms of in- sanity, as of religious exaltation and insane enthusiasm, and the condition of the nervous system, in fact, in all psycho-sensory forms of mental derangement is in a sense delusional to the individual, and so modifies mental con- duct, though not delusional in the hitherto rcognized sense. Nature and Definition of Insanity. 645 The basis of insanity therefore is a delusive feeling and associated morbid impulse or conception ; an underlying per- verted feeling, special or general, dependent upon morbid organic conditions, and impressing itself on the conduct or mental character of the person affected by it. Delusion, in this broad sense and wide interpretation is the true nature, and constitutes the basis of a correct conception and defi- · nition of insanity. It finds expression in harmony with the deranged men- tal state which it induces and with which it co-exists, in imperative conceptions* and over-powering impulses to unnatural and singular speech and conduct, often well de- fined in classical, intellectual delusion, often vaguely, but no less certainly expressed to. the experienced psychiatric clinician, in conduct in harmonious, unnatural and incon- sistent with the natural character. Definitions of insanity describing a departure from natural habits of thought, feeling or conduct, are correct descriptions of the non-hereditary and most common forms of insanity; but the essental condition is the unusual, un- natural and misleading subjective impressions of the insane person, coupled with the resultant change of conduct or of reasoning, or both. This is delusion and its consequence on character, and this is insanity. Delusion, therefore, notwithstanding the antiquity of the criterion, is the real test of insanity, if we no longer unwar- rantably restrict its meaning to perverted special intel- lectual concepts, and the old-time special-sense delusions restricted to the five senses, but extend its meaning to any subjective morbid condition of the nervous system which misleads the mind or conduct. This latter phrase defines our conception of a delusion; and such delusive sub- jective morbid states of the organism are at the founda- tion of all insanity. It is the abnormal condition of the organism which deranges the normal display of psychical function. gives rise to imperative conceptions, when the • So l'ar as I know, Spitzka was the first to make record of imperative concep- tion as delusional, a view which the writer has long held and which, in this essay, he plainly considers fully tenable. way. 646 C. H. Hughes. delusion cannot be classically defined, and causes the de- parture from what we recognize in the individual, or in the healthy members of his family, or in mankind in general, as naturally healthy mentality. The victim of in- sanity is misled and perverted in the exercise of his psychic powers by conditions of the system induced by disease, either primarily affecting the intellectual faculties and dis- turbing the normal self-conscious relation to surroundings- usually first affecting the organic feelings, and secondarily influencing the reasoning powers—so that but for this de- gree of disease, the latter might act correctly, and the reason becomes under the dominion of the dominant morbid feeling, either a perverted or an abeyant servitor. Some- times, however, the reason seems first affected, and delusive concepts appear to precede the morbid change of feel- ing or action, but this is more apparent than real usually, Alienism has many symptomatic data, because of the many varieties of insanity and the many-sided observa- tions of the disease, but all of the data of mental aliena- tion may be formulated in one proposition, viz., morbid delusive perception and conception of subjective origin, caus- ing change of mental character as compared with former self or normal ancestral type, through organic conditions originating in disease within the system, and primarily or secondarily involving the brain. External motives play but a secondary part when they influence at all the men- tal conduct. Change of character in the mature healthy mind is the ultimate symptomatic expression of insanity; change of mental conduct the immediate. And repetitions of conduct, make character. Delusion, as we understand it, and of the kind for which we are contending, may originate in the muscular sense, in any tactile sense, in the thermal or general sen- sory centers of the brain, as well as at the seat of the special senses (so called), or in the more purely intel- lectual area of the psychical concepts; or it may be only definable in a vague abnormal unconsciousness of the pro- prieties due to environment, or undefinable and only ex- Nature and Definition of Insanity. . 647 pressed in conduct, speech or action, a negative delusive state in which consciousness of the impropriety of act or word, and normal psychical inhibition are momentarily abeyant and obliterated by the act, though they may be present before and after.* Change of function is the symptomatic expression of all disease, to which mental disease offers no exception; and, obeying the laws of hereditary transmission, it may, in its hereditary forms, exhibit only an abnormal aptitude, requiring an additional excitant factor to develop it into active morbid expression; or the inborn defect may be so great as to require only the natural organic evolution of growth to reveal it, or still greater, it may require not even this to unfold it, but may display itself in states of organic retrogression and nerve instability, so extreme as to be perceptible at the earliest period when the display of mind is perceivable at all—idiocy, congenital imbecility, and infantile insanity. These latter states are the extreme products of pre- existing insanity, the death stages of a previous mental derangement in which psychical function has been dis- ordered by disease. Here, however, function is not per- verted, but often ceases because of the cessation of the psychical cell-life—the cerebral substratum of mentality. Mental disease has pre-existed and may be said to still exist, but only in the sense that necrosis following an inflammatory process may be called disease. This is our conception, fortified into an unalterable conviction by long and intimate observation. The real nature and essence of insanity is this delusion, organic delusion dominating the mental character and perverting speech or conduct, or both. Under this definition all hitherto described or yet to be discovered forms of cere- bro-mental disease may, in our judgment, be included. * The micd is a sensori-psychic center, acting on impressions exciting it either from within or without the area of the encephalon. Its intellective, like its motor centers, are sensori-motor. Bastian's views, I think, are more tenable than those of Ferrler on this subject. Sensation and thought, though not necessarily conscious sensations, are ce-equal, 648 C. H. Hughes. In the display of every form of insanity known to us we see a marked perversion or alteration of natural perception, conception, volition or impulse, one or all combined. The underlying psycho-physical substratum of all this change of psychical character is a more or less perceptibly de- lusive state of physio-psychical organism, which causes a morbid departure in mental character from the normal self-type of the individual, immediate or ancestral, by which the individuality is in unnatural or unhealthy con- trast with his own or his family's natural and healthy type of mental character. The individual, under the dominion of morbid delusive impression is either not his natural self, in thought, speech or conduct, or not the personal- ity he ought naturally to have been had not disease, affecting his cerebro-psychical organism, effected an ab- normal and unnatural change in him. Insanity is a de- parture from the natural cerebro-psychical self-type, as it is or ought to be, when not changed by disease affecting the cerebro-psychical organism, as we have here ex- plained our conception of it, or an immediate or remote disease-induced change in what is, or ought to be the natural mental character. The underlying nature of that change is a delusive feeling (perception or conception). and consequent disharmony of conduct and thought in relation to environment. The sum of this cursory view of an almost boundless subject as we view it, is this: Mind is the representative and expressive sum of ag- gregate organism in vital action. This expression of the organism as a whole represents character.. All insanity is insanity of character. The chief characteristic of insanity is delusion as expressed in perversion of the character, whether that perversion of character be shown in morbid impulses or emotions, or in the classical, perceptional or ideational delusions, or in the many varieties of abnormal states of consciousness, by which the individual is placed, and acts out of normal harmony with what is or ought nat- urally to be his normal environment. Mind and con- Nature and Definition of Insanity. 651 terest, or his welfare alone, or together, would suggest and prompt him to do or refrain from doing. His actions may even have the semblance of entirely voluntary ones; judged independently of the deranged state of his mental organ- ism they may even have the abstract qualities of volun- tary deeds; or semblances of deliberation, postponement, and something of the appearance of motive, and yet be. those of a will shackled or driven by disease. Since insanity is not necessarily total destruction of mind, but only mind morbidly modified in its movements by underlying disease, neither premeditation nor deliber- ation, nor previously-planned purpose, nor ultimate motive, do necessarily destroy the possibility of insanity, though the display of these semblances of healthy mental action should add extreme caution to our conclusion of mental disease. Nevertheless, we do find overwhelming cerebro- mental disease to excite an over-mastering power in cer- tain directions plainly discernible to the eye of the skillful and expert alienist, when the general conduct of the in- dividual presents all the outward semblances, to the casual observer, of mental soundness. What is it then that we find in these obscure and in- teresting forms of mind deranged ? It is the underlying change in the organic feeling by which causeless suspicions arise, supplanting the previous healthy confidence, and the character and conduct changes in harmony with the morbid feeling, the conduct natural enough if the changed feeling were only a justifiable one, brought on by proper and natural external influences, instead of proceeding from within. Under this disease caused change of feeling morbid and groundless aversion takes the place of natural attach- ment, hate and violence the place in the heart of love and kindness, suspicion and distrust the place of confidence, fear the place of former courage, and morbid impulsions of normal conduct. Melancholia supplants the natural hope, and an in- numerable train of self-recriminations and morbidly unreal 652 C. H. Hughes. forebodings supplement the individual's natural character- istics. Lasciviousness takes the place, may be, of the natural chastity; impurity and wickedness dwell in the once pure and clean heart; arson, theft, murder, rapine, come into minds which in their sane, undeluded estate, would not entertain a thought of crime. But the change is in the organic feelings; and susceptibility to the impressions of environment; ând whether it be expressed in act of grosscst impropriety and crime, or in nothing so marked as to attract general attention, the insanity is the same. The experienced engineer may know something is wrong with his boilers, long before the passengers discover it in a destructive explosion. A flaw in the machinery, un- seen by others, may give him just alarm; and a rudderless ship, or one equally as bad off, with a drunken helmsman may appear to be going well enough and yet be going fast toward destruction. The "inhibition” at the helm that guides aright when wind and wave are adverse, may fail at a critical moment and all may be wrong, though appearing well to those not in position to properly know. It is so with many a mental bark launched or become unseaworthy on life's stormy sea, good enough for sun- shine and calm, and appearing well to those who only see it in a calm-so well that they would willingly and rather cheerfully and eagerly go into court and swear the vessel was sound. But as the testimony of the average passenger as to the sea-fitness of an ocean vessel is of but little value, so equally valueless is the opinion of a non-expert medi- cal or other person unfamilar by adequate and appropriate study and observation with the nature of the human mind in health and under the storm and stress of disease. There are blots upon the brain as there are blemishes in the construction and equipment of a sea-going vessel, which only those of certain experience and qualified to see and judge, can discern. In regard to the human mind in disease, the thing which the true alienist expert searches for most intently, is neither the ordinarily looked-for violence and delusion or generally bizarre conduct and unseemly Nature and Definition of Insanity. 653 speech, but the underlying transformation in the self-feeling, post or ante-natally acquired, which makes a change that only disease could have wrought; a something in the mental tex- ture and cerebral foundation, which impresses itself upon the psychical character in varying degrees and shades of de- parture from natural mental conduct, often markedly per- ceptible, as often scarcely appreciable to ordinary obser- vation. It is this that constitutes the true insanity; the altered character is its more outward sign. The true nature of insanity is not therefore in this or that aggregation of symptoms constituting a more or less prolonged departure from the ordinary and natural char- acter of the individual, but in the transformed mentality, wrought by immediate or remote ancestral disease, often and most frequently of both, which makes certain mental feeling and conduct at variance with the natural mental character possible ; a change which makes not only a symptom-grouping made up of morbid egoism, morbid aversion, morbid fear, distrust, hate, suspicion, dread or violence, special-sense delusion and insomnia, or the reverse of these, its characteristic, but many blendings of these, or a single one intensified, its distinguishing symptomatic feature. Insanity may be so plain in its manifestations that a fool may see it, or so obscure that only the wisest expert most familiar with its hidden mysteries may, after the most searching investigation, discover its obscure presence and subtle influence on the character of an individual. It is not in its plainest symptomatic aspect that expert judgment is required to detect it, any more than skilled observation is necessary to discover bad breaks in ordinary machinery. Anyone may discover when a cylinder head blows out or a piston breaks and the machinery stops short in consequence, but only the engineer familiar, by long experience, with his engine, can tell whether its movements are in every respect natural, and his quick eye and ear will detect deviations of motion the by- stander does not observe. And when he discovers some- thing wrong, he knows that the essential fault is not in 654 C. H. Hughes. the wrong movement, but in the disturbance in the mechanical adjustment. The fault may be found to have been in the original construction, in a loose bolt, or valve or overworn journal, or far away in the boilers or in their water supply, or under them in their fuel supply. If move- ment is wrong something is always found wrong in the organism, so the psychologist knows something is wrong in the organism of the brain, whose function departs from normal. We need not understand perfectly the intimate con- struction of every form of mechanical adjustment in order to comprehend the law that derangement of a mechani- cal device disorders function. So we need not insist on knowing the still obscure things concerning the brain and its function, mind, before we dare attempt to define healthy mental function and its opposite, insanity. The nature of mind, like the nature of its Creator is beyond our knowledge, but like the manifold evidences of the Creator's existence and wisdom, its functions and creations are plain enough, and we may modestly study them as we study the laws of nature and comprehend them, without fully understanding God. Before studying nature no one deems it necessary to enter first into a disquisition upon the character of nature's God; so to define insanity we need not try to define the nature of mind, except so much as we may see as the function of the brain in order to define insanity, nor need we construct any certain metaphysical conception of mind. The attempt to make of mind a certain definite entity and to frame definitions of insanity upon a metaphy- sical misconception, or rather inadequate, incomplete or partial conception of mind; and to describe something dif- ferent from that as insanity, underlies many of the failures at defining insanity. This and a searching after a definite symptomatology has been at the bottom of ail failures in this direction, and a definition once reached upon a symp- tom-grouping basis, it from time to time became neces- sary, as new and undoubted forms of cerebro-mental dis- Nature and Definition of Insanity. 655 ease came fairly into view, to make for them new morbid categories. Thus have imbecility and cretinism, idiocy, epilepsy and inebriety, in active continuous form, delirium- tremens, febrile delirium, etc., been excluded. Yet the insanity stage of epilepsy, delirium and in- ebriety and the constantly, abiding conditions of feeble- mindedness, congenital foolishness, hysterio catalepsy, etc., are conditions of insanity that should be embraced in every comprehensive definition of a disease in which the individuals relation and response to normal and natural environments is abnormal and unnatural. A cerebro-men- tal organism that responds abnormally to the impressions of its environment' is just as much an insane one whether its defect may have resulted after birth, in the process of extra-uterine development or in utero, from the kick of a brutal father, the imprudent tight lacing of a silly mother, or the intemperance or other vice-disease of either parent, or from blood-depraving and nerve-undermining causes not due to voluntary or accidental parental vice or crime, Arbitrary distinctions, without real difference ex- cept in some accidental or incidental causative circum- stances, are not justifiable, and a definition of insanity that must exclude pre-natal causative influences and make exceptions of intra-uterine accidents and congenital dam- age, is too artificial, narrow and unnatural to endure. The many definitions of insanity, all of which have had their day because they were incomplete and partial descriptions, representing each writer's more or less com- prehensive conceptions of mind and its symptomatological expression in disease or in its disordered state, have all had this fault of being too narrow or too broad. More definitions have accordingly sought to define what in the minds of different authors insanity ought to be than what it really is, and when new forms and phases of mental derangement have appeared, they have, if not squaring with these preconceived formula, been contested and denied a place for a time in psychiatry. It would be far better to have no such definite conceptions 656 C. H. Hughes. of mental aberration than to entertain views of its nature so circumscribed as to exclude from recognition new forms that must inevitably appear in the advance of civilization, insanity's chief great causative factor, and in the progress of psychiatry, which must take account of, and find an appropriate place for, the most erratic and varied forms of mental disease which are yet to be revealed, through the increasing and still to be increased intricacies of the cerebro-mental activities. Because, as culture advances and the arts of civilization multiply, the strain upon the brain increases, and the activity and number of its psychic centers grow and multiply. We may learn more of mind through physio-cerebral pathology than through its physiology alone, and reach more accurate conclusions than the metaphysicians did who ignored all pathological data. Psychiatry is still suffering in her definitions from the unnatural and abnormal influence of the metaphysics of the past. SELECTIONS. NEUROTHERAPY. AFFECTIONS OF THE HEART IN TABES DORSALIS.— Among the manifold visceral complications which not rarely attend typical tabes dorsalis, and which seize upon nearly all parts of the viscera with peculiar nervous attacks (crises), Leyden, of Berlin, thinks those that affect the heart are ordinarily the least studied and described. Nevertheless the heart and its nerves remain by no means unaffected. : In spite of the relatively frequent association of val- vular affections with tabes dorsalis, according to the author it is not quite possible to assume an intimate con- nection between the two, and to regard the first as an atrophic shrinking process affecting the valve. Both dis- eases are of themselves much too frequent to permit of such a conclusion. Of greater interest, according to the author, are the heart affections hitherto only rarely observed, which Leyden has already mentioned in his article upon tabes dorsalis, in Eulenberg's “Real Encyclo- pædia," and in addition to which he has since had oppor- tunity to make some further observations. These attacks are characterized by oppression in breathing, and pain, and a feeling of anxiety that arise and disappear suddenly. They bear an indisputable resemblance to angina pectoris; they can therefore be referred to a neuralgic participation of the vagus nerve. As, in general, all paroxysms arising in tabes affect sen- sitive and sympathetic nerves, so also these attacks of the heart-nerves have a different intensity and duration. These attacks in question are extraordinarily violent and can even be accompanied with such danger as to threaten life. Basing his conclusions upon reported observations (for which see the original), the author holds that in the course of tabes dorsalis the heart is affected by attacks which are analogous to the gastric, laryngeal, and bron- chial crises. They arise with painful paroxysms of changing violence. The complex of symptoms evidently corresponds with angina pectoris. The sufferers go about [657] 658 Selections. with pain in the neighborhood of the heart which not rarely radiates into the left arm. With this is joined a feeling of oppression in the breathing, at times a high degree of anxiety, suffocation, a feeling of annihilation, as well as vertigo, faintness, and often irregularity of the pulse during the attack, From its connection with tabes dorsalis, it is to be concluded, according to the author, that we have to do with neuralgic attacks within the sphere of the heart- nerves, and therefore with nervous angina pectoris, which, with Romberg, can be called neuralgia of the heart. Although the symptoms are not very violent, they can con- nect themselves with threatening failure of the heart. Ley- den thinks it cannot be easily explained how this arises, iniis- much as sufficient findings of autopsies are not yet in existence. In a case of Vulpian's (Rev'ile de Med., 1885, page 60) there were no striking post mortem phenomena recognizable in the heart. But that the vagus nerve can be attacked by the degenerative process is proved, par- ticularly by the investigations of Oppenheim, who found this nerve markedly atrophied in a case attended by vio- lent gastric crises. But according to the author, it could be suspected that such a profound degeneration of nerve fibers must call forth not only gastric crises but also car- diac attacks, especially since Oppenheim mentions that gastric crises are attended with severe pain in the præ- cordium and pains radiating in the left arm. In Vulpian's case, the attacks connected themselves with angina pec- toris, just as gastric crises do. Also other symptoms that are concerned with the cardiac nerves in gastric crises are observed, even the sensation of præcordial pain, and acceleration and irregularity of the pulse. In the author's cases, cardiac attacks are proved to occur independently of gastric crises.—LEYDEN. Allgemeine med. Central Zeitung, July 30, 1887. THE INITIAL SYMPTOMS OF TABES DORSALIS.—On account of the extraordinarily great importance that is accorded to the diagnosis of tabes dorsalis in its earliest possible state, Karger (Inaug. dessert. Berlin, 1887) has set himself the task of studying with particular diligence the initial symptoms of the disease. For this purpose he made use of the rich material of Mendel's polyclinic, and investigated one hundred and seventeen cases which he observed there, of which number he communicates sev- 660 Selections. investigation of other tabetic symptoms, inasmuch as the characteristic objective symptoms such as loss of the patellar reflex, Romberg's symptom, reflex rigidity of the pupil, cause no subjective troubles. In conclusion, the author cherishes the proper belief that in an early diagnosis, the chances for rational medical treatment and its successful result, are much more favorable.- Allgemeine med. Central-Zeitung, August 3, 1887. Periscope Medical and Surgical Reporter. FULLER (S. E.) ON THE PICRATE of AMMONIA IN MALARIAL FEVERS. -Having been for many years a sufferer from chronic malaria, and being at the time afflicted with an unusually severe attack, for which I had taken the usual remedies without receiving any benefit, I at once procured some picrate of ammonia, and began its use in half-grain doses (made into a pill with extract of gentian) three times a day. In three days' time there was marked improvement in all my symptoms. Had no more chills, pain in the head and back had left me, and I awoke in the morning without those terribly exhausted and irritable feelings which those who suffer from this disease so well know. This result encouraged me to make trial of the drug in several cases of similar trouble in which I had been using quinine, etc. I pre- scribed it for six adults, of both sexes, and kept watch of the effect. In all but one case the same marked improvement speedily resulted. I now began to notice a peculiar, deep orange color in my urine, without any change in quantity, and a chemical analysis of it showed that except for the change in color it was normal. Upon inquiry I found that the urine of all the patients was of this same orange color. Having taken the medicine myself, in doses as above mentioned for ten days, I decided to stop its use and watch for the disappearance of this color from the urine. To-day, May 24th, seven days since stopping the medicine, there is not the least improvement in the color of my urine, and the whites of my eyes, and the skin of my face generally, are the color of one mildly jaundiced. The same thing has occurred to all my patients who have taken the remedy for a week. One lady, to whom I gave the maximum dose, one and a half grains, three times a day for eight days, is now deeply jaundiced, the color involving not only the whites of the eyes and the skin of her face, but also the Selections. 661 skin of her neck and breast, from which, shading to a lighter color, it covers the rest of her body. In each case the tongue is clean, the bowels not affected, and appetite good.—Letter to Med. Record, July 2, 1887. Dr. Hughes, in a more recent communication (N. Y. Med. Record, Aug. 20. 1887) says of the jaundiced hue from picrate of an monia : “I have observed it both in sclerotics and in urine, but not so persistent or marked in my cases as appeared in Dr. Fuller's. All of my cases, having some neurotic trouble and the indications for ihe ammonia picrate being only incidental, were taking hypophosphites and ammo- nium bromide, and some iodide and arsenic. In those patients who happened to be taking muriate of ammonia with other treatment, the yellow tinge to urine and scle- rotics appeared very slight, and in some not at all; and in all, the subsequent administration of the ammonium muriate and suspension of the ammonium picrate cleared away the jaundiced hue in a few days. There was no cutaneous icterus in any of my cases. “I attributed the change to the diffusion of the color- ing matter of the picrate of ammonium through the tis- sues, as urinary examination showed nothing abnormal, and made this explanation (and still make it, when I use this salt) of this discoloration-phenomenon.”—Analectic. HUGHES (C. H.) ON AMMONIUM PICRATE IN THE NEU- ROTIC SEQUELLÆ OF MALARIA.—Bracconnet, some years since, reported excellent results from the use of potassium carbazoate (picrate) in malarial affections, and Dr. H. M. Clark has lately extolled ammonium picrate as a quinine substitute in the malignant malarial fevers of Asia and Africa. Every remedy which promises therapeutic power as a quinine substitute is eagerly seized upon by the neurologist, because of the untoward effects of quinine and its constitutional intolerance by certain neurotic indi- viduals. In malaria ammonium picrate has proven, in the writ- er's hands, a sufficiently salutary remedy to justify its commendation. Nervous patients, who feel cold or drowsy a part of every day, or every second or third day, or who are chilled by slight causes, and those who always feel tired and who give a history of antecedent malarial affection the previous spring or fall, are often markedly Selections. 663 appear longer after digestion is completed, with alcohol, than without it. “7. Among the effects of alcohol upon the functions of the stomach must be reckoned the accumulation often of large quantities of fluid that remain in the stomach, sooner or later to be colored with bile.” INSANITY OF CRIMINALS.—Dr. Robinson (Polyclinic, May, 1887) discusses insanity in the criminal class. He finds persecutional delusions common as well as what he calls “homicidal mania.” He is unacquainted with the fact that insanity is feigned by the insane. He cites one case in which a convict was pronounced insane by most emi- nent Philadelphia experts who, a month later, had a con- flict with his keeper, for which he was feigning, where- upon he admitted he had been punished. Any one who has carefully studied insanity must admit that this last circumstance is of little value, pro or con, as to the man's insanity. Dr. Robinson, in discussing the case of Joseph Taylor seems inclined to believe that pathological lesions alone are characteristic of insanity. The lesions in the Taylor case were teratological in character, like those found in paranoiacs, imbeciles, periodical, epileptic and chronic hysterical lunatics. The man was hence a victim of his organization. Dr. Robinson is of opinion that insanity results from simulation, but of late this is being extensively assigned as a reason why prisoners, whose insanity is disputed by penitentiary officials, have been found to be insane by competent authorities. In more than one instance paretic dementia has been alleged by prison authorities to have been produced in this way.-J. THE DYSPNEA OF ASTHMA, AND THE INLUENCE OF NITRITES UPON IT.-Dr. Thomas R. Frazer, of Edinburgh, in the American Journal of the Medical Sciences for October, records a clinical study of the cause of asthma, and the influence of nitrites upon it. He establishes the view that the dyspnea of asthma is caused by spasm of the bron- chial muscles, and points out the value of the nitrites in its relief, and that the best therapeutic effects are not obtained by the inhalation of nitrites, but by their adminis- tration through the stomach. The facts seem to justify the assertion that their administration in this manner in asth- matic dyspnea or orthopnæa is entitled to rank as one of the most valuable applications of pharmacology to the Selections. 665 The des jelly, partly owentirely. every large bone in to get away from the scene of the disaster. It was turned out to pasture, and soon recovered entirely. The dead horse was as soft as jelly, partly owing to the fact that every large bone in its body was comminuted. A short time after the accident the man was able to converse intelligibly, and stated that the last thing he remembered he was unbuckling the throat latch on the horse which was killed. Upon recovering consciousness, his attention was attracted by the struggles of the horse on his left. He was not conscious of any appearance of lightning or noise of thunder. His right arm, which was closest to the horse which was killed, was numb. Paralysis of sensation was complete, while the power of motion was retained. This condition was only noticed from the elbow to the finger tips. The left leg, from the knee to ends of toes, presented the same phenomena. To relieve these symptoms the arm was rubbed with “Magic Oil," and it was supposed that its effect was beneficial, because the surface in the course of an hour presented a hyperæmic appearance, and began to show signs of returning sensation. The leg was not treated at all, and it improved in the same way. Three hours after the accident the writer arrived on the spot, and found the injured man standing at the front gate. His face was flushed, his eyes congested, and altogether he appeared to be laboring under strong mental excitement. When he attempted to walk to the house, his left foot dragged like an ataxic patient's. The effort necessary to get from the gate to the door caused a mild choreic spasm, which subsided as soon as he sat down. He said he was sleepy, but had been advised not to lie down. As soon as possible he was put to bed, and a weak sedative solution administered, more to sat- isfy his mind than for any expected therapeutic effect. The pulse was 100; temperature, 102°; respiration, 23. No pain was complained of. If it had not been for two ideas which were not alto- gether irrelevant to the occasion, he would have soon passed into a sound sleep. The dead horse was one he had been working on trial with the intention of buying, and his conscience was much exercised on the subject of the responsibilty for the damage. The other source of dis- quietude was in regard to an accident insurance policy. He wanted to know if the company would pay him for loss of time if he should become disabled after having been 666 Selections. able to walk. With much persuasion he was finally quieted enough to go to sleep. On the following morning the patient was stiff and sore, and said he felt as if he had been beaten all over. The numbness in the arm and leg had somewhat abated, and he was able to get about the house without aid. A severe headache supervened during the day, and persisted for several days, when the characteristic symptoms of acute interstitial nephritis developed. At present (about one month from the time of the accident) he is rapidly improving.-J. E. FREE, M. D. Phil. Med. and Surg. Rep. HEREDITARY TREMORS.-Dr. C. L. Dana, of New York, in the October number of the American Journal of the Med- ical Sciences, calls attention to a peculiar hereditary motor disorder which has not heretofore been systematically described, but which he has seen and studied, in three families, and in all it produced a general clinical resem- blance. The affection consists of a fine tremor, controlled for a brief time, affecting nearly all the voluntary muscles, chronic, beginning in very early life, not progressive, not shortening life, not accompanied with paralysis or any other disturbances of nervous function. It resembles to some extent the tremor of paralysis agiians, still more a simple neurasthenic tremor. A most striking clinical feature is its marked hereditary or family type, and its traņsmission along with other nervous diseases. It begins in infancy or childhood, sometimes being brought out by an infectious fever. It continues without progressing in severity during a life-time, which it does not shorten. The family history will reveal neuroses or psychoses. The upper extremities are most noticeably affected, but it may involve the lead, neck, eye, laryngeal, or, in fine, any of the voluntary muscles. It ceases during sleep, and can be inhibited temporarily by the will. Everything that produces excitement or nervousness increases the tremor. It may be barely noticeable, except under some excitement, or the influence of alcohol or tobacco. It does not interfere with delicate co-ordination. It neither stops nor increases on ordinary voluntary movements; in this respect differing from the tremors of paralysis agitans, or multiple sclerosis. There may be with it slight con- tractures of the fingers, also developed early and non- Selections. progressive; but there are none of the forced movements, rigidity, paresis, subjective sensations, or vasomotor dis- turbances of paralysis agitans, while the head and neck are not so much affected, as in senile tremor. The tendon-reflexes may or may not be exaggerated. The tremor is most nearly like that occurring in neurasthenic states, or from poisons, only there is no general nerve exhaustion, and no muscular weakness. It is associated with other neuroses or psychoses, such as insanity, inebri- ety and epilepsy, and also with examples.of unusual talent or intellectual vigor. THE CARDIAC RELATIONS OF CHOREA.—In the October number of the American Journal of the Medical Sciences, Dr. William Osler, of Philadelphia, has carefully re-exam- ined 110 of the choreic cases treated at the Infirmary for Nervous Diseases between 1876 and March, 1885, the examination in every case having been made more than two years subsequent to the attack of chorea. In 43 cases the heart was normal, in 54 there were signs of organic disease, and in 13 there was functional disturb- ance. A study of these cases, Dr. Osler thinks, justifies the following conclusions: 1. That in a considerable proportion of cases of cho- rea-much larger than has hitherto been supposed the complicating endocarditis lays the foundation of organic heart disease. 2. In a majority of the cases the cardiac affection is dependent on rheumatism, and cannot be regarded as in any way associated with it; unless, indeed, we hold with Bouillaud, that in the disease, "chez les jeunes sujets, le caur se comporte comme une articulation.” 3. As the presence of an apex systolic murmur in chorea is usually an indication of the existence of mitral valvulitis, as much care should be exercised in this con- dition as in the acute endocarditis of rheumatism. Rest, avoidance of excitement, and care in convalescence, may do much to limit a valvulitis, and obviate, possibly, the liability to those chronic nutritional changes in the valves wherein lies, after all, the main danger. NEURALGIC HEADACHES WITH APPARITIONS OF UNUSUAL CHARACTER—Dr. S. Weir Mitchell reports, in the October number of the American Journal of the Medical Sciences, 672 Editorial, that two forms of tabes dorsalis existed-a true and a false one-one being a real posterior sclerosis, the other being due to vascular or other remediable pressure on the posterior columns of the cord, for during the past three or four years three of our cases consider themselves as having recovered, two as materially improved, out of perhaps twice that number that have remained stationary or grown worse. The cases which have recovered have been those of business men in whom business overstrain and excessive venery and tobacco conspired to cause the ataxia, with a probable but not positive antecedent his- tory in each case of obscure but apparently recovered venereal disease. We had not classified these cases as true tabes not- withstanding they came to us from their family physicians as such and with so many of the typical symptoms of true locomotor ataxia, but we are not assured that they were cases of posterior spinal sclerosis. And nothing but autopsic evidence could assure us of the true pathological condition, and when tabes dorsalis recovers (as when any other disease gets well) we must do without the post mortem proof. But now comes the proof which has so long been want- ing, and it comes through that prince of European observ- ers, Charcot, in a revelation as marvellous as some of the great French savant's astonishing facts of hypnotism. M. Charcot has lately given us a most satisfactory rec- ord of three cases, one of which was obliging enough to die of an intercranial disease and thus give science a chance to clear up the obscure subject of the curability of real tabes dorsalis due to sclerosis. The substance of Charcot's record as given by his interne, M. Babinski, is: One of Charcot's cases had had very severe lightning pains for more than ten years on two or three days of the week. She could do no work, but five years free from any symptoms. Another case had lightning pains, patches of anæsthesia, inco-ordination of motion and loss of control of sphincters. The symptoms had grown worse during ten years; then they became gradually better, and for the past four years they have been absent altogether. In the third case there was gray atrophy of the optic nerves and also attacks of lightning pains, gastric crises, and also entire loss of knee-jerk; but there was never any loss of motor co-ordination. M. Charcot used often to 674 Editorial. witness still not againsi insane man be hazarded upon the chance of his lawyer's possessing the requisite medical skill to establish the proper line of defence in disease; for when the question of disease is left to be determined in the ordinary way, by testimony of witnesses, essential factors to constitute disease may exist and still not be proven, either from reluctance of witnesses to testify against popular prejudice in time of great public excitement and outcry for ven- geance or other cause, or from legal failure to discern and establish the true features of disease when the plea of insanity is interposed. Lawyers sometimes endeavor to lay a foundation for the plea of insanity in eccentrici- ties and peculiarities rather than in disease. It may be the fault of the lawyer; it may be the inherent defects of the case, but whenever it is the fault of the former, injus- tice is done to the victim of disease. These disreputable things will cease in our courts when, for the determination of medical questions, medical methods are adopted. When for the ascertainment of disease something more than a mixed jury, of average intelligence, including all kinds of persons except physicians in active practice, which the law exempts, will be considered the proper tribunal. It is not reasonable to expect, in questions of mental disease, that the most scientifically correct opin- ions will always be most popular with a jury, especially if they be advanced views and not concurred in by the majority of physicians, just as it is not usual for the best and most deserving men to be selected for office in a popular government with unlimited franchise, when the votes of the wise and otherwise all count equal. Death of Dr. F. E. Roy.-Dr. F. E. Roy, so long the accomplished Superintendent and Physician-in-Chief of the Beauport Asylum, at Quebec, died in that city, on the 5th inst. His death leaves an untimely void in the ranks of the medical profession and in the social circles of Quebec, which will not soon be filled, and the place his decease has made vacant in his late happy home is vacant forever. Dr. Roy was a physician of large experience and gen- erous culture, an enthusiastic devotee in the department of psychiatry, learned, refined, kind-hearted and generous- minded in all his ways. None could know him but to esteem him, and none will mourn him more than his fam- ily and his patients. 678 Reviews, Book Notices, &c. any power. The hysterical woman who gives way to hysterical nervous impulse, thereby strengthens their hold upon the system so that in time sbe may lose all power of control over the lower nerve-centers What is true of the lower nerve centers and fibers is true of the upper ones. Intellectual acts, or thoughts and perceptions, tend to stamp themselves upon the centers connected with them, and when the function of the nerve-cell is connected with consciousness, the changes which occur in the nutrition give origin to conscious memory, i. e., to memory in the usual sense of the term." These views are in barmony with what most psycho-physiologists believe, from Herbert Spencer to Maudesley and all later writers. The following are his views on tobacco amblyopia: “ Toxæmic amblyopia is usually of organic origin, but as this lesion is directly produced by the poisoning and is likely to be recovered from, on removal of the poison from the system, the separation of toxæmic ambly- opias is of practical importance. The most common, and the most im- portant of the class, is the loss of vision produced by tobacco. In a large proportion of cases the excess in the use of tobacco, has been associ- ated with an excess in the use of alcohol, and there has been much discussion as to which of these agents was the cause of the optic derange- ment. The amblyopia is frequently present in those who smoke excess- ively but do not drink, and tobacco seems to exert the more potent influence. The victim of tobacco amblyopia shows no difficulty or awk- wardness in going about, but especially complains that vision is very bad in direct sunlight. He almost invariably sees better on dull days, and in the early morning and evening. If tbis be not noted by the patient himself, it may be shown by testing vision with type in full daylight, and again in a darkened room. An examination of the visual field will show tbat a great functional defect is in the center of the field, occupying an oblong or oval patch, which extends from the fixing point (corresponding to the macula lutea) out towards and often immediately beyond the blind spot (corre- sponding to the disk.) This central scotoma is relative, and not absolute; i. e., loss of vision in it is never complete. It is especially marked for the perception, for green and red in particular; the former is usually described by the patient as 'white' or gray,' and the latter as brown' or 'no color at all.' In most cases the scotoma is smaller than the visual field for central colors, green and red, and hence a zone is present beyond the scotoma in which these colors are observed. This is especially the reason that the patient will recognize the color of a large body, and mistake that of a very small one. The scotoma of tobacco amblyopia is invariably automatically symmetrical, occupying exactly the same position in each retina. It is believed by oculists to be chiefly due to the change in the peripheral portion of the nerve-axis. It has been asserted in the rare cases in which the scotoma is central and surrounds the fixation spot equally on all sides that the cause is alcohol. Dr. Edward states, however, that in all .cases of such scotoma which he has seen, the patients were smokers. And Dr. G. De Schweinitz bas reported an example of such scotoma in a woman who used neither alcohol nor tobacco, but made cigars, -and in whom the eyes became normal after she left the occupation. In investi- Reviews, Book Notices, &c. 681 given to these affections, and more than one-fourth of the book is given to tbis subject, a fact which indicates the progress Neurology is making in clinical thought. The author leans to the neuropathic theory of cancer, erroneously attributing paternity of this idea to Dr. Willard Parker. We may safely say that every subject in the book is well presented for the space devoted to it. It is a good practical epitome of the principle distinguishing features of the diseases treated of, and the physician who buys it will find it a con. venient and valuable ready-reference remembrancer of salient points in diagnostic differentiation. D. G. Brinton, 115 South 7th St., Philadelphia, Publisher. THE CURABILITY OF INSANITY AND THE INDIVIDUALIZED TREATMENT OF THE INSANE, is the subject of an interesting practical brochure by JOHN S. BUTLER, M. D., Hartford, Conn., late Physician and Superinten- dent of the Connecticut Retreat for the Insane; Honorary Member of the Medico-Psychological Association of Great Britain, Etc. Putnams Sons, New York and London, are the publishers, 16m cloth, 60c. This essay embodies the convictions of a life devoted to the practical study and treatment of the insane, and the author's conclusions and ex- perience will interest both the professional and lay reader and all interested in the proper disposal of cases of insanity. The segregate system has, in Dr. Butler, a strong and capable advocate. We bave long been in the habit of treating on the segregate family plan suitable cases of mental derangement, and in the cases selected have been quite as successful as wben we treated mental diseases only at Fulton. Segregation is as much to be considered in the psychotherapy of insan- ity as the aggregation. They both bave their proper place in the mind of the judicious psychiatric physician, and for suitable cases eitber method may have its advantages, and in certain cases become indispensable. TOE INDEX CATALOGUE OF THE LIBRARY OF THE SURGEON-GENERAL'S OFFICE, Vol. VIII., is on our table. Surgeon John S. Billings, the indefatigable compiler of this valuable work, and the distinguished Surgeon-General of the U.S. Army, Dr. Jobn Moore, under whose auspices this great work is conducted and goes on from year to year, will please accept our most hearty thanks and cordial commendation in bebalf of the many readers of this JOURNAL, who are also medical students and writers, and who so fully appreciate this great work whose value will increase as time goes by, and wbich will make the memory of the Surgeon-General and his distinguished aid immortal. This work will be the Wasbington Monument to American and cosmo- politan Medicine; and in the ages to come medical pilgrimages will be made to the Capitol to see it, as patriotic visits will be made to get a view of the other monument built in stone but no less enduring. Americans should be proud of this monument and of its founders and builders. THE RELATION OF INTEMPERANCE TO INSANITY has recently been the subject of investigation by Clark Bell, Esq., as appears from a paper before us wbich was read at the late International and Colonial Congress of Ine- 682 Reviews, Book Notices, &c. briety at London, July 6th, and later, before the September meeting of the Medico-Legal Society of New York. The result of Mr. Bell's inquiry into all authoritative experience is to confirm the testimony of Morel that the principal causes of insanity are intemperance and neglect of the laws of health.” The author concludes by recommending education of the public intel- lect up to the plane of Science on the subject, and suitable legislation based upon the fact that inebriety is a disease. The book ought to be generally read by lawyers and jurists. Lindsay & Blakiston's Physician's Visiting List, 1888, is a complete and compact account book and vade mecum of ready emergency facts for the busy practitioner. P. Blakiston, Son & Co., 1012 Walnut St., Phila. delphia, Publisbers. The Buffalo Lithia Waters in the Treatment of Diseases of the Nervous Sretem. By G. Halsted Boyland, M. D., M. A., late Surgeon, French Army (Decorated); late Professor of Surgery in the Baltimore Medical College, etc. Die Morpbiumsucht und ihre Behandlung. Von Dr. Albrecht Erlen- meyer. Dritte vermehrte und verbesserte Auflage. Mit 22 in den Text gedruckten Holzschnitten. Importance and Value of Experimental Research. By N. Senn, M. D., Milwaukee, Wis., Protessor of Principles and Practice of Surgery and Clinical Surgery. Trephining in a Case of Inter-meningeal Hæmatoma, with Hemi. plegia. Recovery. By S. T. Armstrong, M. D., Ph. D. Delirium Grave. By E. C. Spitzka, M. D., of New York City.