The Alienist and Neurologist , / (- . t THE yf lieni§t and If ecapologi§t A QUARTERLY JOURNAL ■ OF Scientific, Clinical and Forensic Psychiatry and Neurology. Intended especially to subserve the wants of the General (Practitioner of Jdedicine. "Quintam ego quidem video motas m or bo si fere omnes a motibus in systemate nervorum tta pendent, ut morH fere onnrs quodammodo Nervosi dici queant."—Cullen's Nosology: Book If,, p. 181—Edinburgh Ed. 1780. VOLUME XIX. Published and Edited by C. H. HUGHES, M. D., And an associate corps of collaborators. DAVID S. BOOTH, M. D., BU5INE55 MANAGER. ST. LOUIS: FVes» of Hughes &> Company 1898. CONTRIBUTORS AND COLLABORATORS. VOLUME XIX. ALBERT S. ASHMEAD, New York. W. F. BECKER, Milwaukee. DAVID S. BOOTH, St. Louis. SUSANNA P. BOYLE, Toronto,' Cana Ja. D. R. BROWER, Chicago. SANGER BROWN, Chicago. L. BRUNS, Hanover, Germany. S. V. CLEVENGER, Chicago. ARCHIBALD CHURCH, Chicago. CHARLES L. DANA, New York. HAVELOCK ELLIS, London, Eng. C. C. HERSMAN, Pittsburgh, Pa. DR. A. HOCHE, Strassburg. C. H. HUGHES, St. Louis. JAS. G. KIERNAN, . Chicago. DR. N. KRAINSKY. Charcow, Russia. SYDNEY B. KUH, Chicago. JOHN NOLAND MACKENZIE, Baltimore. W. ALFRED McCORN, Waverly, Mass. L. HARRISON METTLER, Chicago. HEROLD N. MOYER, Chicago. HUGH T. PATRICK, Chicago. GEORGE J. PRESTON, Baltimore. T. O. POWELL, Milledgeville, Ga. JOHN PUNTON, Kansas City, Mo. 1 EUGENE S. TALBOT, Chicago. INDEX TO VOLUME XIX. ORIGINAL C i Alcoholic Epilepsy. A Wrong Theory Misapplied to the Case of Arthur Duestrow 240 Auto-Erotism: A Psychological Study.. 260 Cerebral Syphilis with Wide Spread Involvement of the Cranial Nerves . 116 Degeneracy Stigmata as Basis of Morbid Suspicion 40 Degeneracy Stigmata as Basis of Mor- bid Suspicion 447 Degeneracy Stigmata as Basis of Morbid Suspicion 589 George Herbert Stephens, Crank or Crook 616 Heredity and Atavism 628 History' of Southern Hospitals for the Insane 56 Hysteria in Children 373 Hysteria in Relation to the Sexual Emo- tions 599 Incipient Melancholia. Its Diagnosis, Prognosis and Treatment 560 Lepra Anaesthetica (Original Research) 32 Limited Criminal Responsibility 573 Medical Service and Medical Fees 476 Melancholia of Leprosy 431 Pathology of Epilepsy 511 Progress in Neurology 436 Psychro-Aesthesia (Cold Sensations) and Psychro-Algia (Cold Pains) ... 251 The Early Diagnosis ol Progressive Paresis 1 The Milder Forms of Periodical Insanity 193 The Neurotic Salvage of Suicide 104 The Physiological and Pathological Re- lations Between the Nose and the Sexual Apparatus of Man 219 i The Sanitary Salvage of Our Soldiers in Cuba 457 i The Syphilitic Etiology of Locomotor Ataxia 583 The Virile or Bulbo-Cavernous Reflex 120 234032 IV Index. NEURIATRY— Arthropathy and Syringomyelia 143 Blood Treatment of Disease 146 Bremer's Blood Test of Diabetes 140 Cardiac Neuroses 131 Classification of Epileptics 136 Epilepsy and Auto-Intoxication 133 Locomotor Ataxia 144 Nervous Vomiting 145 Perspiration-Neurasthenia 145 Pleasure Without Other Sensations 142 Psychic Anesthesia 136 The Bechterew Treatment of Epilepsy.. 142 The Elevator as a Cause of Nervous SELECTIONS. Antikamnia for Pain of Otitis 487 Arsenauro and Diabetes 679 A Winter Remedy 301 Disease.. 144 The So-Called Bryson's Symptom Not a Sign of Exophthalmic Goiter 143 NEUROTHERAPY— About Ergot 681 A Mixture for Epilepsy 486 Amylolytic Ferments 487 Antikamnia 148 Antikamnia Abroad 486 Brain-Surgery 304 Cactina 304 Degenerates 310 Diet Treatment of Headache, Epilepsy and Mental Depression 680 Exercise in Exophthalmic Goitre 681 Full Doses of Nux-Vomica in Insuffi- ciency of the Ocular Muscles 302 Godding's Treatment of Paresis 302 Iodine in Treatment—Choice Between the Iodide of Potassium and the Iodide of Sodium 309 Personal Experience With Cannabis Indica 304 Reputed Sure Cure for Rattlesnake Bite 300 The Development of Serum Therapy 682 The New Treatment of Posterior Spinal Sclerosis 308 The Physiological Effects of Ovarian Juice 690 The Therapeutic Value of Arsenauro 307 Index. The Treatment of Vertigo Known as Meniere's Disease 300 Thyroid Medication in Myxedema 301 The Treatment of the Pains of Ataxia by Methylene Blue 307 PSYCHIATRY— Alcohol and .Old Age 313 An Example of Fatal Psychic Shock 149 An Insanity Plea 318 Future Development of Mind 310 German Law on Inebriety - 150 Hallucinations among the Sane 662 Mental and Physical State of Criminals Convicted of Sexual Crime 659 Ratio of Dipsomaniacs to all Insane 663 The Insane in England 150 The Prostitute's Prehensile Foot 319 The Skoptztes 148 The Treatment of the Insane in the Con- vents of Mount Lebanon 312 CLINICAL NEUROLOGY— Abscess in the Brain 324 Double Athetosis of Central Type 679 Early Recognition of Paretic Dementia 665 Erythromelalgia 674 Hsmaphllia Extraordinary 321 Inequality of the Pupils in Carcinoma of the Oesophagus 323 Laryngeal Paralysis in Locomotor Ataxia .v 663 Locomotor Ataxia and Aortic Disease 323 Nature of the Alterations in the Spinal Cord in Tabes _ 152 Nervous Dysmenorrhoea 674 Neurology in General Medicine 322 Neurosis of the Heart 667 New Theory of Cheyne-Stokes Respir- ation 324 Primary Disseminated Sarcomatosis in the Soft Membranes of the Central Nervous System 488 Pseudospastic Paresis With Tremor 488 Resection of the Sympathetic in Graves' Disease 674 Scheme of Three Levels in the Cerebrum 489 Sexual Origin of Neurasthenia and Psycho-Neurosis 673 Some Clinical Varieties of Persecutory Delusions 493 Stoker's Cramps 323 Systematic Exercise Therapy for Tabes 677 VI Index. Significance of Casts and Albuminuria . 320 Tendon Reflexes in Sciataca NEUROPHYSIOLOGY— 320 Has the Cellular Nucleus Independent Existence? 154 The Protecting Role of the Lymphatic Ganglion in Certain Infections 494 The Paranoiac 675 Timely Caution in Rhinology 676 Traumatic Amiotrophic Lateral Sclerosis 494 Unilateral Absence of the Cerebellum ... 666 NEUROSURGERY— Lumbar Puncture 151 NEUROPATHOLOGY— Absence of One-half of Cerebellum 326 Functional Neuroses 495 Nerve Control and Tumors 691 The Morbid Histology of Epileptic Idiocy and Epileptic Imbecility 152 Lesions of the Spinal Cord in Cases of Amputation of the Fingers 154 Nerve Control and Tumors 691 Non-Decussating Pyramids 156 Pituitary Body 325 Relation of the Nervous System to Dis- ease and Disorder in the Viscera.... 325 The Skulls of Voltaire and Rousseau ... 326 PSYCHOTHERAPY— Faith as a Remedy 327 CLINICAL PSYCHIATRY— Early Diagnosis of Insanity...., 485 HISTORICAL PSYCHIATRY— Ovid a Neurasthenic 486 EDITORIALS. A Description of the Lefoten Isiands and their Principal Products 352 A Doctor's Part in the Discovery of America _ 503 A Veterinarian Lieutenant-Colonel 697 A Vacant Instructorship 702 Alcoholism, Physiologic and Pathologic 338 Alcoholism as a Cause of Nerve Disease 497 Alienist and Neurologist 507 American Gynaecological and Obstetri- cal Journal 703 A Medical "Deri" to the Bacteriologists and the Toxines 329 A Medical Man in the Cabinet 171 American Medical Association 350 American AWdico-Psychological Asso- ciation 163 Index vii American Medico-Psychological Asso- ciation 504 Antikamnia Chemical Co 353 A New Book on Nervous and Mental Diseases 353 Ancient Conception of the Parasitic Origin of Disease (Germ-Infection) 502 An Unjust Claim Justly Contested 698 Answer of Prof. Behring to his Critics.. 703 A Proposed National Society for the Study of Epilepsy and the Care a^d Treatment of Epileptics 503 A Symposium on Insanity 337 A Therapeutic Warning 343 Bicycle Fatigue Delirium 336 Brain Desuetude 168 Breitung's Tympanoscope 167 British Medical Association 332 Bromidia 699 Change of Medical Education Center 501 Charge against a Publisher 694 Coming Round 178 Conferences of State and Provincial Boards of Health of North America 505 Conservatism in War 498 Damage of Daily Drink 160 Degeneration 502 Degradation of Military Medical Men 179 Denver and Rio Grande Railroad 507 Department of State Medicine for Germany 331 Didactic and Clinical Instruction in American Medical Colleges 499 Dietary Cranks 165 Doctors Versus the Declaration of Inde- pendence 352 Dr. Cruzius 353 Dr. E. L. Melius 181 Dr. Outten's Book 164 Education of Epileptics 335 Eleventh International Congress of Hygiene and Demography 182 Enlighten the People 159 Ernest Hart Dead 167 Expert Testimony in Criminal Trials 351 Eye Strain in Health and Disease 163 Fate of the First Woman Doctor in America 347 First Pyramid Builder a Physician 506 Good Taste in Medical Journalism 333 Harvey,William, as Seen in His Day 700 Heredity 339 Hodgdon, Dr. Alex. L. 703 viii Index. Hospital Construction, Etc . 182 Insanity in Pennsylvania 183 International Medical Congress at Mos- cow 172 Iquirvn, Toniquinin, Laxiquinin 352 Is the Emperor of Germany a Paranoiac 502 January North American Review 178 Langsdale's Lancet 704 Last Slap at the Expert Witness 180 Medical Expert Testimony 164 Medical Experts 348 Medical Influence in Public Affairs 333 Medical Men in War 496 Medico-Psychological Association An- nouncement 180 Meeting of the American Medical Asso- ciation 506 Micro-Organism and Portal Cirrhosis.. 703 Motality in the Medical Corps 701 National Pure Food Congress 183 Neurotherapy of the Mammoth Cave Air .-00 New Medical Journal 181 New York Medical Times 348 North American Journal of Diagnosis and Practice, and a Fee 332 North American Medical Journal of Diagnosis and Practice 351 Not Born to Die 333 Patent on Antitoxin 692 Peacock Chemical Company 704 "Pediatrics" for 11898 334 Percussion of the Skull 349 Professor Forel Resigns 353 Psychiatry and Neuriatry in France 181 Psychical Salvage and the Sin of Suicide 171 Public Money and the Drug Business .. 344 Quebec Medico-Psychological Society ... 700 Regarding Advertisements in the Alien- ist and Neurologist 164 Rest for the Weary 496 Roentgen Rays and Military Surgery ... 353 Rush College and the University 343 Rush Medical College 352 Rush Monument Fund 500 Seguin, Dr. Edward C 6% Sousa's Debut 1S1 Status of the Army Medical Staff 701 Substitution and Renewals of Prescrip- tions 170 Success in Medical Journalism 346 Index. ix Symposium on Brain .Tumors 347 The Temper of the Insane ..... 330 The Aphasias and Their Medico-Legal The Wallace Food Company 331 Rel»tions350 I True Americanism 702 The Dangerous Ovary 702 Touch Paralysis 169 The Field of the Alienist and Neurolo- Training School Commencement 507 gist for 189S 15/ Unadvised Renewal of Prescriptions 163 The Pope's Physician 178 . . University of the State of Missouri, The Practice of Medicine 158 Columbia 353 W MEMORIAM. Dr. William Pepper 705 j Dr. J. Q. A. Stewart 357 CORRESPONDENCE. American Medico-Psychological Asso- Some Curious Nervous Phenomena Asso- ciation 354 ciated with a Condition of Phimosis 354 REVIEWS. An Epitome of the History of Medicine 186 Medical Libraries 707 Arsenauro and Mercauro; Clinical Rec- Mutual Relations of the Railway Sur- ords as Reported in Medical Jour- geon and the Neurologist 508 nals 362 Practical Uranalysis ana Urinary Diag- Chapin on Insanity, a Compendium ol nosis 707 Insanitv 365 Primer of Pychology and Mental Disease 707 Clinical Lectures on Mental Diseases 707 _ . . , _ Rubaiyat of Doc Sifers 186 Crime and Criminals 368! Sajous' Annual and Analytical Cyclo- Current Thought 187 paedia of Practical Medicine 365 Daydreams of a Doctor 367 solution of the Proprietary-Medicine Emmaus 186 Question 366 Hugh Wynne 184 stirpiculture, or Improvement of Off- Medicine 367 j spring Through Wiser Generation.. 187 x Index. Studies in the Psychology of Sex Studies in the Psychology of Sex The American X-Ray Journal The American Medico-Psychological Association Three Little Books The Medico-Legal Aspect of Eroto-Cho- relc Insanities The Monthly Cyclopsdia of Practical Medicine 367 The Nervous System and its Diseases. 364 The North American Journal nf Diagno- sis and Practice 366 The Past, Present and Prospective Treatment of Insanity in the State 185 359 360 366 367 187 of New York 362 The Pathfinders 368 The Sixth Annual Report of the Shep- pard Asylum, Baltimore,Md 363 The St. Louis Medical Gazette 508 The Survival of the Fittest 358 The Toledo State Hospital....: 368 The Universal Medical Journal 367 The Well-known Butler Hospital 368 The X-Ray Journal 368 Transactions of the American Micro- scopical Society 364 Transactions of the Medical Society of the District of Columbia 363 THE Alienist and Neurologist. VOL. XIX. ST. LOUIS, JANUARY, 1898. No. 1. ORIGINAL CONTRIBUTIONS. THE EARLY DIAGNOSIS OF PROGRES- SIVE PARESIS.* By DR. HOCHE, Strassburg. Private Docent in Psychiatry and First Assistant of the Psychiatric Clinic at Strassburg. EXPERIENCE teaches that in the majority of cases the beginning of progressive paresis is not recognized by the attending physician. It may be said that most pare- tics, when received at the psychiatric clinic or insane hospital, have passed through a stage of weeks, months or even longer duration, in which, because an incorrect or no diagnosis was made, they were deprived, to their own injury and that of their families, of such professional advice and direction as their already recognizable morbid mental condition should have received. Of the reasons for this, notorious deficiency in diagnostic ability of numerous physi- cians—the small degree of psychiatric knowledge, the •Transiated by Dr. W. Alfred McCorn. Assistant Physician Illinols Eastern Hospital for Insane. [1] 2 Dr. Hoc he. slight practical perception for morbid mental states—will first begin to disappear after a change is effected in the present method of medical instruction and examination; the other exists in the real special difficulties, which are met with in the early diagnosis of progressive paresis in many cases. The expert psychiater also finds it quite often necessary, especially in his ambulating cases, to record the diagnosis: "progressive paresis," with an interrogation mark and the proviso that repeated examinations and observation of the further course will furnish the definite decision. In such doubtful cases a certain diagnosis is, of course, not to be expected of the practitioner; but it can be demanded of the family physician, the physician in official positions, as well as the indications for trachectomy or for perforation of the living child, etc., that he must have an opinion as to the bearing of certain physical and mental changes, which gen- erally precede with a greater regularity than suspicious indications, the outbreak of the incurable mental disorder. Herein are embraced positive facts. To-day even the opinion occasionally asserted by academic defenders of clin- ical disciplines, that for deciding the question whether any- one is mentally sound or insane the "healthy human under- standing" suffices, in its consequences revenges itself severely on the patients in the early stage of progressive paresis, who are so unfortunate as to have to appeal to the "healthy human understanding" of their physician in their psychical disease. The numerous masks under which this disorder may occur in its beginning, the similarity which the incipient forms of severe organic disease of the nervous system pre- sent to other relatively harmless functional affections, make it essential to know exactly those differential diagnostic signs, which almost without exception permit the physician to make the diagnosis so early that serious social injuries are spared the patient and his relatives and to make it with such subjective certainty that the responsibility for the institution of thorough measures (removal from office or society, commitment to an institution, disfranchisement, etc.) may be undertaken. The Early Diagnosis of Progressive Paresis. 3 In the following pages I will attempt to present the present state of our knowledge in the diagnosis of this most practically important early stage of progressive pare- sis in the most concise brevity. Exhaustive literary references, which would occupy too much space for no reason as to the material to be consid- ered, are omitted; also restriction will be exercised in the choice of points to be discussed, this depending on their practicability. What are we to understand by the early diagnosis of progressive paresis? To be able to limit our task in this respect we must first briefly refer to the question as to the nature* of pro- gressive paresis. Of the influences whose mode of action we know only imperfectly and of whose relative frequency opinions dis- agree (syphilis, head traumatisms, physical and mental excesses), the clinical type most often developed in middle age, rarely earlier or later, three or four times more fre- quently in men than in women, which is slowly progressive or abrupt, whose principal symptom is the deterioration of the intellectual force even advancing to dementia, with simultaneous psychical anomalies recognizable in all. Coincident with this progressive development of a dementia numerous motor and sensory symptoms of irrita- tion and degeneration occur, in whose distribution to almost all parts of the nervous system the anatomical character of the disease is expressed. The more rapid or slower course of the disease is practi- cally to be regarded as incurable and usually terminates fatally in a few years from the time a positive diagnosis is possible; the total duration usually exceeds the popular statement of "two to three years." As an anatomical basis we assume a chronic, appar- ently primary atrophy, of the nerve elements, which is unequally distributed to the cranial contents, the spinal •The definition of the disease which the latest monograph gives (v. Krafft-Ebing in Nothnagel's Specielier Pathologic und Therapie. Bd. IX; Thell II; 1894. page 5) is by no means to be regarded as exhaustive. 4 Dr. Hoche. cord and the peripheral portions of the nervous system. Ot all the common organic diseases of the nervous system the anatomical process of progressive paresis possesses the greatest extent. The extraordinary diversity of the clinical types, which the incipient stage of the disease presents especially, is explained by the difference in the functional value of the part usually affected, by the diverse occurrence of the degeneration process in this or that part with respect to time and the varying tempo of its advancement. The most constant anatomical symptom, the extensive degeneration of the nerve elements of the cerebral cortex, corresponds to the most constant clinical symptom, the pro- gressive mental enfeeblement. In many cases this purely progressive mental enfeeble- ment is the prominent psychical symptom until the end; in other cases active dispositional anomalies in the sense of exalted or depressive emotions of all grades accompany it, coincident with concepts of corresponding import (grandiose delusions, hypochondriacal and melancholiac delusions), more often sense deceptions also; markedly intensified emo- tions occur in the states of so-called psychical excitement. The majority of the cases present peculiar, episodical attacks, possibly occurring in all stages of the disease, known as the "paretic seizures," which in general mani- fest wide differences; they paroxysmally induce clouding of the consciousness, varying from the mildest, moment- arily unnoticed absence or very temporary attacks of ver- tigo, even to severe coma, with or without convulsions, frequently with residuary, but usually temporary, motor and sensory manifestations of defect, and almost always fol- lowed by a further sinking of the intellectual level. Perhaps some of the previously mentioned episodical states of psychical excitement belong etiologically to these "seizures," whose anatomical basis is to be regarded as temporary circulatory disturbances in the brain or small hemorrhages, or also locally accelerated degeneration of the nerve elements. The paretic changes in speech and writing are a com- The Early Diagnosis of Progressive Paresis. 5 bination of intellectual and purely motor disturbances; to the purely motor belong the pareses of the muscles of the face, tongue, pharynx, larynx and extremities accompanied by tremor and finer or courser twitchings. The weakness of the latter occurs in cases dependent on cerebral changes in form of unilateral or bilateral hemi- paresis; the motor derangements of the extremities, of the legs especially, due to morbid processes in the spinal cord, manifest manifold conditions, which depend on the topo- graphical distribution of the anatomical processes. There is found (Furstner) in 62% of the cases a disease of the lateral and posterior columns, usually with marked implication of the first; in 24% a disease of the posterior columns only and in 14% that of the lateral columns alone. Accordingly the purely spastic symptom complex in the lower extremities with active tendon reflexes and dorsal clonus is frequent, at least somewhat more frequent the ataxic paraparesis with absent patellar reflex, the most fre- quent the so-called paretic gait usually accompanied at first by increased, then absent, reflexes, which is due to the paresis and disorders of co-ordination, and in whose origin cerebral influences may co-operate. Circumscribed simple or degenerative muscular atrophy, especially in the upper extremities, may be of spinal or peripheral origin. Localized sensory degenerative manifesta- tions in the legs, and possibly violent pains, are a conse- quence of disease of the posterior roots and posterior col- umns of the spinal cord; general anaesthesia or more fre- quently analgesia is of psychical origin, and due to defec- tive apperception (loss of the faculty of attention). Dis- orders of the bladder and intestines owe their origin to the same defect in the cases where these anomales are not of spinal origin. The significance of the disorders of innervation of the pupils, especially of the wanting reaction to light is that in them the early relatively slight, even scarcely perceptible central interruptions of conduction (by degenerative pro- cesses), become outwardly manifest in the complicate mech- anism. For the pathological spinal process we possess the 6 Dr. Hoche. correspondingly fine reaction in the condition of the patel- lar reflexes, in whose changes at least the influence of cerebral derangements may be concerned. The diagnosis of a fully developed case of progressive paresis, in which many or the majority of the symptoms mentioned, are present, is made very easily and can only fail from gross ignorance or careless examination; but usu- ally a less apparent prodromal stage precedes this well- marked condition, whose duration may be one to three years, possibly longer; indeed, we have reason to assume that the beginning of the anatomical process may have existed for years in a lingering manner, without these tan- gible symptoms directing the diagnosis in a definite direction. Symptoms diagnostically very different belong to this prodromal stage. We know those, which supplementarily, after the disease has fully developed, acquire their signifi- cance as early paretic symptoms from which alone the diagnosis could not have been made earlier; we know others, "premonitory" (Sander) in the strict sense, which attain great early diagnostic and hence prognostic value by their presence before the beginning of paretic psychical enfeeblement can be proven or by the fact of their occur- rence at a certain age, or certain other combinations to be considered later; finally we know those which in like man- ner belong to the prodromal as well as to the stage of the fully developed disease, whose presence may cause the bounds of both to appear as voluntary. The symptoms belonging to the prodromal stage of pro- gressive paresis in the broadest sense will be the subject of discussion; for the expert psychiater the description will seem to exceed the bounds of "early diagnosis;" but for the average condition of general medical practice, according to our present experiences, a correct diagnosis of progressive paresis, which is made in the prodromal stage, is as a rule a very early one. It is best to begin with a discussion of the several early symptoms and thus add a differential diagnosis of the most common types in which the physician generally meets with the beginning progressive paresis. The Early Diagnosis of Progressive Paresis. 7 A few brief remarks as to the significance and conse- quences of the early diagnosis may form the conclusion. The very earliest signs which may precede the begin- ning of the abnormal psychical manifestations for ten years, are those belonging to the symptom complex of tabes, of which the most important are: Reflex pupillary immobility, absence of the patellar reflexes, lacerating pains, optic atrophy; hence arises the question whether in these cases it is not simply a matter of tabes, in whose course a pro- gressive paresis is developed. Thus the general question as to the relation of tabes and progressive paresis is entered upon and to avoid later obscurities and repetitions it is necessary to here briefly outline the point of view we will take in the question. The majority of alienists see in progressive paresis an independent disease, which in a certain portion of the cases is developed in individuals already tabetic, and in another portion, without the typical clinical type of tabes needing to be present, the anatomical process in the spinal cord shows a distribution more or less identical with the tabetic; the rest of the cases, the majority, among which besides other things are found those accompanied by purely spastic manifestations, has nothing to do with tabes accord- ing to this opinion, in spite of several common organic nervous symptoms like the reflex pupillary immobility. Contrary to this view is another theory, which has recently acquired an increasing number of followers in France and Germany, as it seems, namely, that an identi- cal morbid process is at the foundation of tabes and pro- gressive paresis, besides the common and exclusive etiology of the preceding syphilitic infection, which according to its iocalization causes the one or the other, or both combined, to appear, then, that in a certain measure every tabes is an incompletely developed paresis, or progressive paresis, represents one of the possible varieties of tabes. At this time an exact proof of the one or the other theory cannot be adduced; if the second is accepted as correct, all its hypotheses, especially that of etiology, would better satisfy classification and theoretically simplify 8 Dr. Hoche. matters; the unbiased estimation of the preceding facts, but especially the consideration of the clinical course affords no sufficient basis to justify for practical purposes the identification of tabes and progressive paresis; the truly complicated conditions are not readily explained by the theory of identity. The following facts are the actual material in this question: Tabes and progressive paresis in common are etiolog- ically related to syphilis; differences of opinion exist as to their frequency. Common to both, further, is the apparently primary degeneration of the nerve elements. Progressive paresis is developed in the course of a cer- tain number of cases of tabes, but which generally is of a peculiar form, from the slowness of its advancement and, psychologically, by the simple uncomplicated progressive dementia. A certain portion of the cases diagnosable as progres- sive paresis manifest an affection of the posterior columns of the spinal cord; it is an open question whether it is topographically identical with the typical degeneration of the posterior columns of tabes. The other degenerative spinal processes present in pro- gressive paresis (disease of the lateral columns) are not found in simple cases of tabes; their dependence on cere- bral influences (in a form of secondary degeneration) is not proven. There is a large number of cases of progressive pare- sis, which anatomically and clinically do not possess the slightest similarity to tabes in their spinal symptoms. Psychical derangements are developed quite often in old cases of tabes, but which do not belong to progressive paresis; simple dementia or hypochondriacal paranoia especially. These facts make us, by ignoring all possible theoret- ical opinions, practically conform diagnostically, as well as prognostically, to the proposition that in tabes and progres- sive paresis we have two different forms of disease which Hie Early Diagnosis of Progressive Paresis. 9 possess numerous chief points of contact and coincide in the same individuals in a series of cases. Hence it is to our purpose to formulate the value of the early signs of progressive paresis belonging to the tabetic symptom complex: the so-called classic initial tabetic symp- toms, reflex pupillary immobility, absence of the patellar reflexes, lacerating pains and optic atrophy, may likewise be the early symptoms of a progressive paresis later; but the suspicion of the latter is first justified when one or more of the general cerebral symptoms to be fully discussed later— especially change of character, lowered intelligence, dis- orders of speech, convulsions—are associated. Following these preliminary remarks, the several early symptoms may now be briefly discussed. Owing to their importance and frequency the derange- ments of the pupils must be given the first place. They are found in more than half of the cases of pro- gressive paresis, often many years before the first appear- ance of the psychical symptoms, and also in cases which later in their spinal disease are not of the posterior col- umn type. In almost no other symptom is a correct technique of examination so essential as in testing the condition of the pupils; in almost no other is the simplest rules so often violated. In examining the pupils we consider chiefly their abso- lute size. The possibility of a previous iritis, of the existing effect of atropine, opium or eserine is to be taketi account of. In general, the pupils are larger in children and women, as well as in anemic, sensitive, nervous individuals; they become smaller with advancing age. Very small pupils of equal size are found as an early symptom of progressive paresis in conjunction with reflex pupillary immobility to be discussed later; very large and simultaneously immobile pupils hardly occur as an early symptom. In judging the size of the pupils a diffuse light of medium intensity is indispensable, but above all a sym- 10 Dr. Hoc he. metrical position of the light with respect to both eyes (window). This is equally necessary in determining differences in the size of the pupils; in a side illumination from a win- dow, e. g., in which one eye is in the shadow of the nose, a difference in the pupils is found in perfectly healthy persons. Even a slight pupillary difference in symmetrical illum- ination, with light reaction retained, is not always-a sign of an organic affection; it is quite often found alone or with other congenital asymmetries as one of the so-called signs of degeneration and possesses no more significance than these, yet in these cases is of theoretical interest. It is further found, even without loss of the light reac- tion, as a temporary manifestation varying in its intensity or between the right and left, e. g.; in migrain, epilepsy, in nervous conditions following accidental injuries, in simple psychoses. The condition of the absolute size of the pupils and their difference in retained light reaction are far inferior in significance to the symptom of reflex pupillary immo- bility, i. e.; absence of contraction of the pupils to light with retention of mobility in accommodation and convergence. The latter factor, the mobility retained as involuntary, differentiates reflex pupillary immobility from complete pupillary immobility due to peripheral lesion of the motor oculi, e. g., in syphilitic meningitis. The proof of reflex immobility signifies, according to the pathologico-anatomical considerations, that the central connections between the optic terminals and motor oculi nuclei, which serve to conduct the physiological reflex pro- cess, have been broken. The prosensual frequency of those affections in which occasionally reflex pupillary immobility is observed (multiple sclerosis, especially localized tumors or hemorrhages) is slight in comparison to the number of cases of tabes and progressive paresis, whose classical early symptom is the reflex pupillary immobility. "Sluggishness of the pupils" represents the transition from the normal condition of light reaction to the reflex immobility, a term, in whose employment circumspection is Tlie Early Diagnosis of Progressive Paresis. l1 requisite in pupils of small size, then in individuals approaching senility; the categories mentioned as possess- ors of specially large pupils, show a more prompt reaction than healthy men, even of middle age. We find sluggish- ness of the pupils as a pathological manifestation in differ- ent organic brain affections, especially in the numerous forms of hemorrhage or softening with dementia, etc., also in chronic alcoholism. In the latter, what is important in differential diagnosis, the sluggish reaction often becomes normal again after a few weeks abstinence. Reflex pupillary -immobility and sluggishness are found in progressive paresis on one and both sides; in the earli- est stages difference between the right and left as to promptness of reaction is almost the rule, and the diagnostic value of the absence of reflex contraction of one of the pupils is no less than the loss of this phenomenon on both sides. Difference in the size of the pupils, even of slight degree, with simultaneous sluggish or wanting reaction on one side, is of ominous significance. The diagnostic prop- osition that, all recent, apparently functional, neuroses and psychoses in men of middle age (25-55) are suspicious as to progressive paresis by proving reflex pupillary immobility or difference in the pupils in undoubted sluggish reaction, indicates the importance of an exact examination of the pupils. The examination as to quantity and quality of the light reaction demands not only a correct, but, if subjective certainty is to be attained, also uniform method; it does not suffice, as is so often seen, to briefly shade the eye to be examined, which is perhaps inspected in a dark corner of the room, with the hand held before it. Also the method of opening and closing the lid with the fingers is improper, because slight movements of the pupils may readily escape the examiner in consequence of the unavoidable movements of the bulb and the light reflex on the cornea occurring suddenly at the moment of opening the lid, while on the other hand the involuntary movement of accommodation of 12 Dr. Hoche. the pupils occurring almost always simultaneously may deceive as to the light reaction. The requirements which must be complied with for a reliable examination of the pupils, are, that the examiner can constantly and clearly see the pupils during the shad- ing and illumination of the eye, and that at the moment of illumination movements of accommodation, as well as of convergence, do not occur in the eye examined. The latter are not easily excluded in the insane. The shading hand, whose removal suddenly subjects the retina to the light of the window, must not be held in the visual axis, otherwise the eye will accommodate to it, but the eye must be half covered from the side of the light; the patient looks past the examiner at a distant point, then at the moment of illumination or shortly after the contrac- tion of the pupils is observed, or possibly the absence of this manifestation, reflex immobility. In insufficient daylight it is best to arrange for a light behind the examiner's head, possibly a brightly burning match, so that the eye previously in the shadow is sud- denly illuminated. In spite of the questionable result do not neglect test- ing the light reaction in the dark-room by a lateral lens illumination. Experience teaches that the more carefully the pupils are examined the fewer become the cases in which—except in tabes and progressive paresis—true reflex pupillary immobility is found. The examination of control in pupillary movement in form of involuntary motion in convergence and accommoda- tion is so simple that the patient is told to look at the tip of his nose or at a distant object which can be quickly moved toward him; then very slight contraction of the pupils is often observed, which in accommodating for a dis- tant point is replaced by dilatation. The want of consensual light reaction, i. e., the absence of contraction of one pupil when the other eye is illuminat- ed, may be the first symptom of a pupillary disorder; in questionable cases it is to be sought for. While reflex pupillary immobility with or without dif- The Early Diagnosis of Progressive Paresis. 13 ferences in size of the pupils is peculiar to these cases of progressive paresis, which are not of the posterior columnar type, we meet with a number of other early signs as a rule only as an indication of a tabetic symptom-complex previously or simultaneously instituting the paresis, namely; lacerating pains, girdle sensation, analgesia of the legs, gastric or other crises, optic atrophy, paralysis of the eye muscles of a temporary character usually. All that has been said of the symptoms is true as to the relation of tabes to progressive paresis. Lessened potency and mild vesical disorders are met with in the early stage without other tabetic symptoms. The condition of the tendon reflexes, especially of the most practically important patellar reflex, demands a some- what exhaustive discussion. It may be said in general, with the same precautions, its early diagnostic value depends on the fact that its definitely proven anomalies, for which careful examination is unable to furnish any other explana- tion, may suspicion paresis in any recent neurosis or psy- chosis, apparently functional, in men of middle age. Of the quantitative changes the complete absence of the patellar reflex is the most diagnostically valuable, because it is an absolute quantity, while the different degrees of its increase in their estimation depend on the examiner's judgment. In the latter, peripheral causes (muscular atrophy, neu- ritis, surgical diseases) are to be excluded before it is to be considered diagnostic evidence of a spinal disease; in the former, it is to be remembered that there is no normal quantity of the reflex muscular contraction of the quadri- ceps and also that in functional diseases 'exaggerated tendon reflexes occur. To justify the assumption of an organic cause of increased patellar reflex, corroborative facts must exist, namely, muscular spasms in the lower extremities or the proof of an evident dorsal clonus. The occurrence of three or four quickly exhausting contractions in the tense pero- neal muscle is not to be regarded as such in exact test, for it may occur in many surgical diseases accompanied by 14 Dr. Hoc he. muscular shortening, as also, e. g., in neurasthenia or hys- teria, etc. But in consideration of these restrictive precautions the proof of an increased patellar reflex has the same diag- nostic significance as that of its absence. Its absence proves, when peripheral causes are excluded, an interrup- tion of the reflex arc in the spinal cord, which in progres- sive paresis is located most often, according to experience, in the posterior roots or posterior columns; increase proves the presence of pathological processes above the reflex arc and in the pyramidal tract to the extent of the ganglion cells of the motor region of the central convolutions, even to a plane lying above the level of the spinal reflex phenome- non for the patellar reflex that indicates the height of the dorsal and lumbar cord; in progressive paresis the lesion to which we refer the increased tendon reflex in the lower extremities, is located most frequently in the lateral pyra- midal tract of the dorsal cord. In respect to the cases of progressive paresis beginning as typical tabes, increased reflexes are more frequent than their absence in the early stages of the disease tin the later stages this is changed); the cases with wanting reflex predominate, and for the simple reason that in the cases constituting the majority of combined disease of the lateral and posterior columns the interruption of the reflex arc in the lumbar cord prevents the reflex increased effect of the disorder of the lateral column. Unilateral changes, especially absence on one side, afford an important support in estimating the condition of the patellar reflex; if increased on one side the assumption of a somewhat earlier hemiplegia as reason for the increase depends on the proof of a simultaneous increase of the tri- ceps tendon reflex on the same side, which is rarely want- ing. A test of the patellar reflex, which in questionable cases demands care, should only be made on the bare leg; it is insufficient to strike a blow "in the region of the knee" through the trousers; when muscular contraction is insufficient to throw the lower thigh forwards the reflex can almost always be elicited by an at least perceptible or The Early Diagnosis of Progressive Paresis. 15 sensible contraction of the quadriceps, its absence should only be asserted when the attention at the moment of test- ing is diverted from the phenomenon in the leg by the well-known procedure of re-enforcement. To attain the Achilles tendon phenomenon, dorsal clonus, a certain technique is demanded; even a marked dorsal clonus may not be elicited owing to an awkward test. The recumbent patient's leg is supported with one hand in the popliteal space, with the other, which does not need to completely grasp the foot, in weak musculature, of the patient, with only two fingers a brief pressure upwards is made on the sole of the foot at the level of the small metatarsal bones, but without ceasing the pressure; if the organic conditions exist for the occurrence of the dorsal clonus, a series of rapidly repeated contractions of the pero- neal muscle, like the play of Wagner's hammer of the induction apparatus, at once begins, causing a plantar flexion of the foot; according to the degree of excitability, the phenomenon lasts longer or shorter, until the reflex is finally exhausted. In the milder forms of dorsal clonus this exhaustion occasionally occurs so quickly that in its demonstration the second or third attempt fails, while a well marked dorsal clonus was elicited the first time. In testing the tendon reflexes it is essential that a uni- form method be practiced to secure an objectively correct and subjectively certain judgment. In early diagnostic value the "paretic seizures" are very closely related to the reflex pupillary immobility and the condition of the tendon reflexes. The serious conditions, increasing to status epilepticus, which are peculiar to the seizures of the later stages, and quite often are the direct cause of the patient's death, are scarcely ever found in the prodromal stage. The most frequent are the epileptiform seizures in the form of petit mal; palor, syncope, sudden feeling of vertigo, brief loss of consciousness, or the mildest apoplectiform attacks, namely, temporary paresis occurring suddenly with vertigo or at night while asleep, possibly with very tran- 16 Dr. Hoc he. sient impairment of speech or a sudden feeling of numbness of one side of the body, even of one extremity only. Between the epileptiform and apoplectiform seizures, which have essentially a common genesis, there are clinical transitions, which make a strict separation appear voluntary. For the differential diagnosis of the early paretic epilep- tiform attacks from those common to genuine epilepsy, the following points are to be considered: The so-called epilepsia tarda, /'. e., the first appearance of one of the real attacks not belonging symptomatically to epilepsy, in middle age, is practically of little account owing to its great rarity. At this age symptomatic epileptic attacks are observed; after injuries to the head, in chronic alcoholism, in syph- ilitic and other neoplasms of the brain and its membranes, as well as in cases of premature atheromatous changes in the vessels of the brain. As these diseases can be excluded by the anamnesis, by careful investigation of the characteristic attendant symptoms, possibly by the results of treatment, as in syph- ilitic affections, hence epileptiform seizures at this stage of life must awaken the suspicion of incipient progressive paresis, which becomes almost a certainty, when reflex pupillary immobility or the early psychical changes of pare- sis, to be mentioned later, are traceable. In epileptiform seizures of this age, paresis as a cause for the existing disorder is perhaps more frequent than all the morbid conditions previously mentioned. Violent headache, especially in form of migrain, occur- ring periodically in the prodromal stage, perhaps preferably that form known as "orbital migrain," is very closely relat- ed to the epileptiform seizures. As true migrain is gener- ally common to the family or hereditary, beginning almost without exception in the individual's youth, so first and then repeated occurrence of attacks of migrain in middle age is a suspicious symptom, which may occur not only in progressive paresis, but also in tabes, epilepsy and in brain tumors. If such an attack of migrain does not in itself afford a The Early Diagnosis of Progressive Paresis. 17 definite diagnosis, it is at least a valuable warning signal for the physician and must not be put aside with the assumption that it is a matter of a harmless functional disease. In the presence of an abnormal psychical condi- tion questionable as to its import, such attacks of migrain may possibly turn the scale in the direction of a diagnosis of progressive paresis. The early apoplectiform seizures are distinguished from other forms of hemiplegia caused by hemorrhage, embolism, softening or tumors by their usually abortive character at first, j. e., by their brevity and possibly slight extent of the paretic manifestations, but then also by the fact that even a repetition of the attack on the same side of the body does not always need to leave behind manifestations of gross disorganization. Frequently repeated apoplectiform seizures, which are attended by affections of the right extremities, generally pre- sent aphasic or paraphasic disorders of speech as sequelae of somewhat longer duration. Paretics in the early stage of the disease who have had an apoplectiform attack, often know nothing of an existing paresis, while simultaneous sensations of numbness, etc., worry them, or they are ignorant of an attack perhaps occurring at night, whose motor sequelae—the paresis—lead them to consult a physician. The early apoplectiform seizures may soon alternate with premonitory minute apoplexities, which in diseases of the cerebral vessels quite often precede severe hemiplegia, and the certain differential diagnosis between these two forms of disease is often impossible for a time; seizures of this sort, which occur in the beginning of the thirties, are always a suspicious paretic symptom, for at this age, except in syphilitic disease of the cerebral vessels and arterio-sclerotic contracted kidney, apoplectiform conditions due to vascular changes rarely occur. For the diagnosis of paresis it is true that apoplecti- form seizures, which have no evident etiology, turn the scale in favor of the assumption of paresis. The numerous modifications of the early paretic seiz- 18 Dr. Hoche. ures occurring in practice are by no means exhausted in what has been said; the diagnostic significance of the first occurrence in middle age is common to all special forms of manifestation, and if it is, at least in men, "only a faint," which occurs in apparent health and without a percept- ible cause. The examining physician must ask about these things, as the patients forget these episodes, or, just as their rela- tives usually do, refer them to the manifestations or sub- jective troubles, which cause them to seek medical aid. These symptoms, which not exclusively, but yet fre- quently in point of time and in causative connection, follow the seizures, the apoplectiform especially, the more or less extensive motor pareses are naturally to be mentioned after the early paretic seizures. In the early stage it is usually less a matter of marked variation in mere strength than of derangements of the finer forms of motion, hence for diag- nosis the muscles are to be considered which present slight variations, either in respect to the previous condition or in comparison between the right and left, namely, the mimetic musculature, as also the musculature of the tongue and larynx. As these groups of muscles combine their action in the formation of speech, we find among the early symptoms derangements of speech, in so far as it is a matter of the processes of articulation. The motor pareses in progressive paresis are usually accompanied by symptoms of mild irritation, tremor with spasms; perhaps in these symptoms of irritation is expressed that in the functional cerebral processes it is usually a matter of an active progressive process, not of a single terminal event (just as in spinal affections the fibril- lary muscular spasms possess diagnostic significance). Of the motor pareses variations in the innervation of the facial nerve are one of the most common early symptoms. In them, as in the slight variations in the size of the pupils, precautions are to be exercised in diagnostic valuation. Few faces of well persons permit exact test as to the determination of asymmetry; in epileptics, in individuals The Early Diagnosis of Progressive Paresis. 19 hereditarily predisposed and also without this factor we find asymmetries of the facial bones, and consequently, or also independently, asymmetries of the mimetic action are so often found that it is necessary to ascribe diagnostic sig- nificance to slight facial variations only when tremor or spasms simultaneously exist in the affected side or a corre- spondingly localized apoplectiform seizure is anamnestically provable (just as we have seen slight variation in the pupils become of diagnostic value through another symp- tom, pupillary sluggishness or immobility). The symptoms of irritation of the mimetic musculature occur the most plainly in speech or protrusion of the tongue, and espe- cially in the zygomatic and chin muscles; contrary to the extensive tic-like spasms, as we see them, e. g., in many neurasthenics or in some cases of neuroses after accidents; in these early paretic symptoms of irritation m the facial muscles it is only a matter of a brief vibration in this region, a short mimetic "heat-lightening," best comparable to the short restless spasms which are seen about the mouth of healthy people when they speak during emotion. Latent mimetic symptoms of irritation are usually plainly recognized emotions (fortunately it is usually easy to pro- duce voluntarily emotions in the patient on examination). Vibrations of the facial muscles are as often seen in alcoholics as in paretics. Deviations of the tongue to the left or right are found early, but also after seizures; severe pareses with inability to protrude the tongue belong to the later stages. Tremor of the tongue and the fibrillary restlessness of its musculature, as well as the tremor of the hands, are usually not to be differentiated from the corresponding appearance in severe neurasthenia or chronic alcoholism. However, tremor becomes of greater diagnostic significance, when after a seizure it occurs only in the affected side of the body. Changes in the voice, e. g., in timbre, corres- pond for the larynx in diagnostic significance to the tremor and spasms of the visible musculature; a peculiar "bleating" not previously present, in the perhaps monotonous voice most commonly occurs early, especially during emotion, 20 Dr. Hoche. The special "speech derangements," i. e., the articu- latory disorders due to paresis and lack of co-ordination, are usually very early provable in their first indications. Therefore they are to be especially considered, possibly by the employment of difficult combinations of words, but which do not necessarily consist of articulatory snares, like many of the sentences usually recommended (the majority of nervous persons stumble over these, particularly during a medical examination). The best method of quickly becoming informed as to the speech is by having the patient read aloud. In a diagnostic estimation of a definite articulatory speech derangement it is to be remembered that numerous excitable persons hereditarily predisposed, and neurasthenics with acquired excitability, have mild articulatory difficulties during emotion. Whereas an articulatory impediment of speech of recent origin, according to the statements of relatives, especially after a subjective seizure, is of greater diagnostic importance. In the early changes in writing it is a matter of two differently operating causes: one consists possibly of abnormal innervation (paresis and manifestations of irrita- tion) in the hand and forearm, the other is psychical (lack of attention, loss of memory, lowered aesthetic feelings). Thus result, often quite early, very characteristic written evidences in the irregularly, hastily formed letters, unequal deviations from the line, blots, etc., besides absence of punctuation, erasures, omission or duplication of words, etc. In questionable cases where beginning paresis is sus- pected, for examination it is essential that specimens of the patient's recent and earlier writing be submitted, especially of those individuals who by occupation were accustomed to write clearly and accurately (school teachers, bank officials, government clerks, etc.) if valuable, conclusions are to be expected. In ignorant persons who are not accustomed to writing, little of early diagnostic value is to be derived from their writing. The writing of chronic alcoholics may often have the The Early Diagnosis of Progressive Paresis. 21 above characteristics, and is scarcely to be distinguished from that of the early stage of paresis. All the early symptoms previously mentioned are organic and capable of being subjectively determined; ere we pass to the discussion of the early psychical anomalies a few of the more common subjective symptoms may be briefly mentioned, which at least are usually supplementary, yet retain their significance as early paretic symptoms from the standpoint o< the assumed diagnosis, while in themselves occuring alone, they possess only a limited early diagnostic value owing to their ambiguity. They are; neuralgiform pains in the distribution of the trigeminal and occipital nerves, vague pains in the extrem- ities, without being "lacerating," diffuse headache, or feel- ings of head pressure, finally derangements of sleep, even to complete, long continued insomnia. The headache and insomnia are characterized in incip- ient progressive paresis by their special resistance to ther- apeutic measures; the neuralgiform, vague pains have scarcely anything characteristic. The psychical symptoms strictly are here presented last, contrary to the usual custom. In the developed disease they so characteristically control the clinical picture, are so uncertain and protean in the early stage, and for the cer- tain diagnosis in the prodromal stage the difficulty in examination consists in the demonstration of the organic, symptoms* which for this reason were first discussed. The expert psychiater, for whom every sixth or seventh patient is a paretic, often makes the diagnosis very early with subjective certainty; simply from the peculiar general impression of a psychical personality, whose individual com- ponents are often hard to formulate; for the physician little versed in psychiatry that is the normal method of diagnosis or rather it should be that a suspicion of incipient progres- sive paresis excited by these anomalies, receives its confir- •The contrast of "psychical" and "organic" symptoms ts really a perversity. I do not doubt that almost all "psychical" symptoms of progressive paresis owe thelr origin to "organic" changes. Perhaps It wouid be more correct to say "iocal symptoms" or something similar. instead of "organic." However the connection as to what is meant is sufficiently ciear. 22 Dr. Hoche. mation by the certain determination of objective, compre- hensible symptoms from those above presented. We will now review the most important of the early psychical changes. We often find subjective changes, an intense feeling of illness, in a certain measure a present- ment of coming trouble, and also often thus comprehended by the patient, or a painful mental depression, which may be wholly objectless, i. e., not needing to be united with concepts of corresponding color. • This more or less plainly marked trait may be com- mon to the severe neurasthenic and melancholic hypochon- driacal states of the prodromal stage. But it is more common that the first psychical changes, even if apparent to those about, are not comprehended by the patient. One of the earliest manifestations in this respect is a changed reaction of the individual to the impressions of the world, particularly a generally increased irritability, be it to noises or the contrary, be it the mere daily oppositions to the will. The misproportion between the cause and intensity of the anger thus induced, the exploding rage, is likewise found in severe functional neurasthenia, but with the differ- ence that in the neurasthenic's emotional outbreaks the tendency to pass into disgust of longer duration, dissatis- faction, etc., is absent in progressive paresis. Marked depressive emotions without proportional cause also occur; the complete loss of equilibrium in attacks of despair from trifling causes, to which many paretics are prone in the early stage, may be compared to the condition known as "drunken distress." manifested by many predis- posed, but not sick individuals during intoxication; in the initial stage paretics quite often make wholly unexpected, yet intentional suicidal attempts in such sudden fits of displeasure; I knew a no-ways demented, usually very proper paretic, who got into a dispute with his wife at dinner in regard to a wine market, arose, hurried away and threw himself in the lll. These emotions of paretics are less persistent; the increased irritability runs parallel with heightened lability, and the insignificance of The Early Diagnosis of Progressive Paresis. 23 the causes which produce the change is also characteristic. Premature loss of memory and judgement occuring grad- ually with lessened intensity of the higher (aesthetic, logi- cal, ethical) feelings is due to the lowering of the general faculties, observed as an initial symptom, in the occupation or business, the carelessness, etc., but especially the fre- quent harmless or gross breaches of customs, morals, or of the law even—occurrences which have long damaged such patients' reputation, ere they were recognized to be ill by the family or their physician. The depreciation in function of the motor phase of mentality is early manifested in the inability for long continued, close attention, as well as in the patient's torpid manner lacking the initiative, which often occur years before the beginning of changes noticeable as serious mental anomalies. The proof of the presence of these symptoms, which in their totality form the complex of psychical enfeeblement, give other, possibly early psychical anomalies their charac- teristic shade, which is expressed by the addition of the adjective "paretic" and may readily be distinguished from the corresponding disturbances in functional psychoses. So we name the most important symptoms, paretic euphoria, paretic grandiose ideas, paretic melancholic or hypochondriacal delusions, paretic states of excitement. The frequent combination of euphoria with paretic grandiose ideas, i. e., indiscriminate concepts as to the per- sonal faculties, position, financial ability, etc., often lead even in the early stage to those acts in which lie the social danger of an unrecognized progressive paresis. These included the cases in which as (apparently) the first symptom of the disease, orders and purchases are made far in excess of the conceivable demand, lavish expenditure to no purpose occurs, silly projects, preferably matrimonial, are undertaken; these often occur when the patient is being treated in a sanitarium or Kniepp cure for "nervous irritability" and where they have the same freedom of action as on their "travels for their health," which perhaps has long exceeded the faculty of decision owing to their mental condition. 24 Dr. Hoc he. When one hears or reads in the paper that a man of heretofore proper conduct has given orders for his own per- sonal use (to choose an actual case) for fifty cheeses, three hundred dozen cigar holders, a cargo of champagne or a carload of quinine, the suspicion of a progressive paresis must at once arise; such and similar things are committed almost only by paretics. The morbidly falsified idea of their own ego in relation to the world may naturally be orally expressed in grandiose ideas. The grandiose ideas of paretics are readily distinguished from those of paranoia, negatively by the want of a pre- ceding (to be anamnestically determined) development, by the absence of system and the stability of the concepts, positively by the simultaneous psychical weakness. The last fact also psychologically distinguishes the exultation of the paretic from the true maniac, except that the majority of alleged "manias" in men of middle age are not manias, but early phases of progressive paresis. The proof of psychical enfeeblement is the decisive differential diagnostic sign for the melancholiac and hypo- chondriacal ideas of the paretic and renders possible the recognition of modifications of the psychical picture not enumerated, even without attendant local symptoms. But the earliest stage of paresis may be hidden behind the mask of functional psychoses and neuroses, which need present none of the paretic traits at first or for a certain duration of the disease. For the correct diagnostic estimation of this condition the knowledge of the fact is important that, except in paranoia and epileptic mental disorders, recent simple psy- choses in men are relatively rare at the period of life, which presents the maximum frequency of progressive paresis; whereas in women the functional psychoses at the same age present a higher frequency, in great part owing to the influence of manifold prejudicial agencies arising from propogation, while progressive paresis, as stated above, is three to four times as rare in men. An apparently simple mania or melancholia, which occurs very often at this stage of life, unless it is a phase The Early Diagnosis of Progressive Paresis. 25 of a periodical or circular mental disorder long since proven anamnestically, with respect to the above fact of itself must awaken the suspicion of progressive paresis, and, in the interest of prognosis, lead the physician to make a very careful physical examination. Inversely, in women, a mania, melancholia or hallucinatory confusion does not as a rule conceal a progressive paresis, much less so as progressive paresis in women generally, but not always occurs in form of a slow, insidious progressive dementia. In cases of mania, melancholia or hypochondriacal depression the expert psychiater will often make a correct diagnosis with no paretic traits; the person of less psy- chiatric experience possesses in the proof of organic local symptoms the requisite diagnostic cue. At a time when the nature of progressive paresis was very little known, as also to-day, the warning is proper not to make a favorable prognosis of maniacs with very contracted or unequal pupils. The differentiation between the early stages of pro- gressive paresis and neurasthenia presents very much greater diagnostic difficulties, which in many cases may be insur- mountable at the moment of the examination. A series of symptoms is common to both diseases; feelings of illness, irritability, vertigo, in effect apparently similar if also of a very different origin, lowered ability, disorders of sleep and digestion, tremor in the face, tongue and hands; both have their maximum frequency in middle life; both preferably affect intelligent, active persons; excesses figure in the etiology of both, be it in pleasure, be it intellectually, and a formula suitable to many cases, but not to be proven in all, expresses this commonality, in that it says: ceteris paribus, etiologically, a progressive paresis is developed in those formerly syphilitic, a simple neurasthenia in the non- infected. Clinically we observed in both diseases the two following modalities:— Neurasthenia "precedes the progressive paresis," i. e., a neurasthenic, in whom for a long time the most careful examination can discover no true paretic symptoms, later becomes evidently paretic, perhaps after an apparently normal interval has intervened, or the progressive paresis 26 Dr. Hoche. "begins as neurasthenia," i. e., an attack of disease recog- nizable as paresis presents among other symptoms those which are peculiar to the severer forms of neurasthenia. Under the presumption of a careful examination the latter condition is the most frequent; the majority of paretics present, not at the time of admission to the hospi- tal, but so long as they can be treated outside, the type of neurasthenia (plus more or less paretic symptoms). The differential diagnostic signs, which are to be taken into account in the absence of organic local symptoms, are in part anamnestic, in part consist of the conditions found on examination; functional neurasthenia is a constitutional disease, which emerges from its latency under the influence of external pernicious agencies, in which, if the disease is fully developed, mild nervous anomalies of long duration, even from youth, may be ascertained from the patient; a severe neurasthenia occurring suddenly in a previously healthy man without ascertainable heredity, for which neither a traumatism or physical diseases (e. g., influenza) can be made accountable, must hence awaken the possibility of an incipient progressive paresis. The neurasthenic depression is secondary, the result of unpleasant sensations or fears; it is susceptible at times of being diverted or corrected; the paretic's depression is primary, more intense, less susceptible, less interrupted by normal as well as euphoric phases. The neurasthenic observes and reports his symptoms in a painfully exact manner, also those which only exist in his imagination as, e. g., the loss of memory; the paretic presents objective defects in the same function, but of which he is uncon- scious. Functional neurasthenia, except the increased irri- tability, does nor present the changes of character in the sense of lowered aesthetic and ethical feelings, which early complicate the paretic type of neurasthenia; sudden, unpleasant emotions, especially spite and anger, do not have, as mentioned, the tendency tormenting the neuras- thenic to pass into depression, which is hard to overcome and lasts for hours or days. It is true of the other symptoms that in functional The Early Diagnosis of Progressive Paresis. 27 neurasthenia a series of phenomena is observed, which in paresis are of organic foundation, as, e. g., tremor of the face, etc., but that neither an increased tendon reflex accompanied by dorsal clonus, neither pupillary immobility nor apoplectiform seizures, neither spastic disorders nor objectively demonstratable diminutions of intelligence, occur. It is one of the most suspicious psychical symptoms when a debilitated neurasthenic suddenly becomes euphoric or develops grandiose ideas. The majority of paretics, who come to the physician in extreme anxiety that they might be paretics, are not such. In spite of the presence of numerous differential diag- nostic signs it must be stated that there are cases, which even on an exact examination in this respect do not permit of definite decision as to whether it is paresis or neuras- thenia at this time. Similar difficulties, if perhaps not so frequent as in neurasthenia, are presented in the differentiation of the early stage of progressive paresis from the various condi- tions in chronic alcoholism. Besides paretics in the initial stage are often considered by the laiety and physicians as simply "drunk," yet condi- tions quite often occur which do not permit of a definite diagnosis at the moment of examination. In chronic alcoholism we find symptoms which it has in common with progressive paresis, the insomnia, dimin- ished intelligence, blunting of the higher feelings, loss of energy; we find tremor and spasms in the face and extremities, possibly epileptiform or epileptic seizures, often absence of the patellar reflex in consequence of peripheral neuritis. If the disturbances in the tongue and face, and so those of speech, are very pronounced, a type very simi- lar to progressive paresis may result and there is in fact—at least in literature—an "alcoholic pseudoparesis." When however from these cases those are excluded which are simply true paresis in an inebriate complicated by several alcoholic symptoms (ideas of jealousy, active sensory deceptions) and further exclude those which have nothing to do with paresis, but are to be considered as 28 Dr. Hoche. chronic alcoholic mental enfeeblement with very intense local symptoms, nothing now remains of the "alcoholic pseudoparesis." Besides the variations in the speech derangements (usually not characteristic in alcoholics) the presence or absence of the reflex pupillary immobility must be regarded as the most important differential diagnostic factor; on careful examination, chronic alcoholics very rarely present real reflex immobility. As a rule several weeks of enforced abstinence affords a further diagnostic fact; when the motor symptoms of irri- tation generally lessen, while the sluggish pupils begin to react better and the intelligence materially improves. 'Difficulties often attend the practically important differ- entiation of beginning progressive paresis from certain ner- vous conditions after accidents. In so far as it is a matter of simple neurasthenia fol- lowing traumatism, what has been said applies here; but there are cases, without a cranial injury necessarily having preceded, in which besides apathy, mental depression, ver- tigo, hemiparesis, tremor with spasms in the tongue, face and hands, possibly articulatory speech disorders are found, while a certain torpid, obstinate condition prevents testing the intelligence, cases which may be exactly like certain types of progressive paresis, and yet do not belong to them; it is found that these patients present the same picture after three or four years without having become demented, etc. It is well then after a severe accident to be cautious as to the diagnosis of progressive paresis in the cases in which neither reflex pupillary immobility or a progressive intellectual defect is to be proven. The differential diagnosis from senile dementia and the various forms of dementia after apoplexy very often fail in practice; the majority of cases, which, according to my experience, are brought to the clinic with the diagnosis of "progressive paresis," belong to these two categories. An age limit is not to be fixed for the diagnosis of senile dementia in view of the cases of senium praecox and abnormally late development of paresis; it is also to be The Early Diagnosis of Progressive Paresis. 29 stated that the slowly developed paretic dementia in old cases of tabes, e. g., is not to be distinguished from senile dementia. In general slight material will at first indicate senile dementia. In the cases of questionable senile dementia without tabes the organic local symptoms are decisive. Practically there is no great difference whether, e. g., the dementia of a man in the latter part of the fifties is regarded as a late paretic dement or as an early senile. What distinctions exist between the apoplectiform seiz- ures of progressive paresis and those of arterio-sclerosis, has already been set forth; besides it is to be considered as a differential diagnostic sign that those with arterio-sclerotic seizures do not present in the intervals the degree of intel- lectual disturbance as the paretic, that in spite of possible euphoria, grandiose ideas are not developed and the patellar reflexes are almost never absent. The differentiation from multiple sclerosis is often diffi- cult in the latter stages of those cases whose development has not been observed; it may be very questionable at first whether a spastic paresis present as a single symptom is the initial phase of a multiple sclerosis or a progressive paresis; the distinction occurs as soon as evident intellect- ual disturbances are noticeable, which in multiple sclerosis is to be expected later and then only slightly pronounced; attacks of vertigo, common to both diseases, are not a dif- ferential diagnostic sign; true nystagmus is almost never found in progressive paresis. The sort of speech disturbance is not always decisive. A differentiation of beginning progressive paresis from diffuse syphilitic processes of the cortex is not possible at present, also rarely "ex juvantibus"; antisyphilitic therapy, which may be successful in gumma, e. g., only slight effects the diffuse processes. The diagnosis of tumors consists in the proof of positive tumor symptoms, first of the choaked disc. The conditions described as "encephalopathia saturna" are as yet too indefinite to be exactly diagnosed; the 30 Dr. Hoche. anamnesis and proof of lead symptoms (blue line, neuritis) play the chief role in these cases. We have now discussed the most important symptoms whose establishment may aid in the early diagnosis and the more common condition in which beginning progressive paresis may occur; "completeness" has not been my pur- pose; it is neither to be attained in the initial disease manifestations occurring in new modifications "daily, not to be regarded as practically necessary; who examines his patients must be able to diagnose progressive paresis; I hope to have presented the principles of the diagnostic methods. In conclusion a few remarks as to the significance and consequences of the early diagnosis of progressive paresis. Irrespective of the general significance to mankind the establishment of a disease whose diagnosis is attended by an absolutely unfavorable prognosis illustrates the practical significance of the early diagnosis socially to the individual according to the extent and kind of relations he has with the world. Who has had experience as to what mischief is caused and can be caused when men in authoritative posi- tions, like military or government officials, like judges, etc., who have in keeping numerous existences or functionate as officials in responsible positions, are not recognized to be paretic, who does not understand the unconcern with which numerous physicians, perhaps in official positions of trust oppose a disease which can usually be early recognized by the average possession of corresponding knowledge and some diagnostic care that social damages are prevented; the same is true of those family physicians, who with indifferent or detrimental interferences (to which doubtless belong the hydropathic treatment in beginning progressive paresis) fritter away the initial stage and thus afford the patient sufficient time to squander his property and ruin his repu- tation. As it is true that the diagnosis immediately determines the prognosis so it is also true that an early diagnosis per- mits what is to be attained therapeutically. Not that by medicinal agents a marked retardation of The Early Diagnosis of Progressive Paresis. 31 the degenerative process in the nervous system is to be expected; that it is in no way to be hoped for, from the repeatedly recommended antisyphilitics; but the conse- quences of the early diagnosis can and should be that the most important therapeutic factor, absolute rest, is procured which favors the occurrence of remissions and may effect an improvement, which makes it possible for the patient to return to his occupation for a time. This rest, the removal from excitement and excesses, to which the disease of itself disposes, is not to be afforded the patient at home, except under the most favorable con- ditions; the hospital is only to be considered usually, where the duration of life is prolonged by proper care, prevention of suicide, etc. Besides the commitment to a hospital cer- tain duties accrue to the physician by the early diagnosis of progressive paresis, e. g.; in respect to the best prevention of marriage, often euphorically planned in the initial stage, expert evidence in cases of accident, as well as the event- ual motion by the family for the patient's disenfranchise- ment. The certificate of its necessity, owing to the ability to dispose of property being impaired or destroyed by the mental condition, is made by the physician, who is almost always made responsible by a certain diagnosis of progres- sive paresis. Complete disenfranchisement protects the patient and his family from financial losses, which otherwise frequently occur by the purchases, orders or contracts of the paretic in the initial stage. In opinions as to disenfranchisement, as well as in criminal affairs, it is not only a matter of proof to the judge of a quantitatively more or less pronounced intellectual defect, but the certain establishment of the fact of the existence of the serious organic brain disease to which the numerous disturbances occurring in the emotional and voli- tional functions—the "ability to dispose of property" on the one hand, the "freedom of the will" in the legal sense— may usually appear principally as exceptional. LEPRA ANAESTHETICA.* (Original Research.) By C. C. HERSMAN, M. D., Pittsburgh, Pa. Lecturer on Mental and Nervous Diseases Medical Department of the Western Pennsyl- vania University; Alienist South Side Hospital of Pittsburgh; Member Staff St. Francis Hospital of Pittsburgh (Insane Department); Member American Medical. Pennsylyania State, Allegheny Co. and South Pittsburgh Medical Societies; Hon- orary Member W. Va. State Medical Society; Formerly of the West Va. Hospital for Insane. JUNE 29th, 1896, A. D. W., was sent by one of the sur- gical staff to the neurological department of the South Side Hospital, of Pittsburg, and placed under my care for treatment, no diagnosis having been made. He gave the following history: American, aet. 40 years, fourth child, married, has one child, aet. 14 years. Three brothers and one sister living, two brothers died in infancy. Father's death caused by accident; mother, brothers and sisters in good health. Further family history negative. Patient has led a life of more or less dissipation, but enjoyed good health in earlier years. In 1878 he went to Brazil, South America, with an engineering corps. In a short while the company became insolvent and left their corps stranded. Patient found employment for a while around Para, Brazil, but in a few months was stricken with a malady, which was diagnosed and treated as malaria; a severe attack. In about ten or •Read before the South Pittsburgh Medical Society, Sept. 6th, 1897. [32] Lepra Anaesthetica. 33 eleven months he received aid from home and returned to the states, as he termed it. In 1885 while engaged in 'tending bar, he noticed gradually coming in his eye-brows a dusky red color, which soon began to thicken into a welt or hive-like condition. The eye-lashes and eye-brows began to drop out and the beard became very thin. The skin gradually thickened until it was thrown into folds on the forehead and face, constituting the peculiar appearance that has given the name Leontiasis (like a lion) to the disease. This thickening has made the face to appear broader, and has caused it to become mask-like, almost expressionless. His physiognomy is so completely changed that he would scarcely be recognized by his intimate friends. The depres- sion in the nose was caused bv a fall from a wagon. The alae of the nose and the lobes of the ears are enlarged. Later on the skin on the abdomen became so much thickened that it was thrown into folds on attempting to bend forward. About six months later he felt a numb- ness and burning coming in his hands, with inability to grasp objects. This disappeared in eight or nine months. Three or four months later pain began in the spine and left shoulder, extending down the arm. In a few months the first and second phalanges began to contract until they were rigidly fixed. In three or four years the- median and musculo-spiral nerves were attacked. About this time a severe conjuncti- vitis set in. Four years ago he pared what he thought to Lbe a corn on the sole of his foot (ball of the toes, he called it) which did not relieve the trouble. Afterward he had the third toe removed. Eight or ten years ago a macular eruption appeared on his arms, body and legs (white and bronze). The spots on the body have mostly disappeared, but are abundant on the extremities. Present condition: Pain in left side and legs (main nerve trunks.) Chronic conjunctivitis and episcleritis, com- plete and rigid flexion of the first and second phalanges of the fingers; middle finger of right hand amputated. Fol- lowing injury: Anaesthesia of hands and arms to elbows, 34 C. C. Hersman. and of feet and legs to knees; left foot much swollen and distorted; third toe amputated. Thenar regions and palms of hands very-much atrophied. Skin of face in folds; nose broadened, giving the expression, facies leontina; eye-brows almost obliterated, whiskers scant, center of moustache gone and hair on head thin; white and bronze spots abundant on arms and legs. In some of the white spots the skin is very much atrophied, showing a decidedly sunken or pitted condition. The spots range from a small size to two or three inches in length, by one and one-half to two inches in breadth. The spots are anaesthetic. Clippings with scissors and forceps can be taken without pain. Nose: The patient gives a history of having exper- ienced difficulty in breathing through the nostrils for past eight or ten years. He has also suffered from frontal head-ache during that time. Has had hard, crust-like formations in nostrils, which he used to remove, when it was likely to be followed by considerable bleeding. Some time ago^ (indefinite) pieces of bone came away from nostrils, from both sides at different times. Physical inspection reveals a "frog face" nose. The nasal septum has been entirely absorbed. Portions of the middle turbin- ated bones are missing, only the stumps of each remaining; these are probably the bones he speaks of having come away. These, as well as -other parts of the nasal canal, are covered with inspissated crusts. Upon removal of the secretions, the entire naso-pharyngeal surface presents a typical picture of chronic atrophy. Necrotic patches are present over remains of middle turbinateds and elsewhere. Patient was given an atomizer containing Dobell's Solution and instructed to use it three times a day; expressed him- self as feeling much relieved in a few days. Pathology and Bacteriology: A section from the tissue marked brown spot when stained by the Ziehl Neelson method showed bacilli in clumps scattered through the deeper layers of the corium. Sweat glands and hair follicles were not seen in this minute specimen. The epidermis did not show any alteration. A section from the tissue marked white spot showed no bacilli. Lepra Anaesthetica. 35 The bacilli mentioned above behaved toward the stain in the same way as tubercle bacilli. They were undoubt- edly leprosy bacilli. They were not found aggregated in dense masses in "lepra cells" as is sometimes seen in tubercular leprosy under favorable conditions, but scattered as in the anaesthetic forms. Lepra bacilli were found plentifully in the secretions from the nose and eyes. My friend, Rev. S. A. Hunter, M. D., (Ph. D., LL. D.) has the following to say on leprosy: "During twelve years practice in China, I saw many cases of leprosy. In the province of Shautung, our cases come mostly from two dis- tricts, which lie in the southern part, and are contiguous. So far as my observation goes there is no well established line of demarcation between the tubercular and anaesthetic varieties. Both forms often co-exist in the same individual. Anaesthesia is a well marked feature in every case. The disease begins almost always in the forehead and eye- brows. When it develops in the hands first, it soon after affects the face I cannot remember having seen any case in wnich this was absent; in fact, the loss of the eye- brows in connection with the formation of tubercles, dis- coloration and disordered sensation is regarded by the Chi- nese as pathognomonic. The segregation of lepers is not practiced in China; on the contrary, they are allowed full rreedom and privileges. The so-called leper villages are not composed exclusively of lepers, but are villages where lep- rosy is known to exist to a greater or less extent. In my opinion, leprosy is the disease of a district caused by a spe- cific baccillus, which finds its appropriate nidus in the soil. The reasons for this belief are the following:— "1st. The great centers of leprosy have remained such throughout the historical period. The centers of the disease three thousand years ago are still centers of leprosy to-day. Dr. Edkins has shown conclusively that the old centers in China were the'same as they are now. The same is true in Egypt, Syria and India. "2nd. Heredity seems to play little part in the propa- gation of this disease. Careful inquiry has established the fact that in the leper districts of China new cases arise in 36 C. C. Hersman. families hitherto free from it; and families with several cases in one generation are exempt from it in the next. The lep- rosy commission in India after prolonged and exhaustive research declared that it cannot be considered an heredi- tary disease. "3rd. Contagion as a cause has been given up. Con- stant contact with lepers in families and asylums, without contracting it, shows it to be non-contagious. On the other hand there are strong reasons for believing that it is infectious. But the continuous occurrence of cases without the opportunity of infection in certain districts, calls for some other adequate cause. "4th. The prevalence of leprosy in Europe in the middle ages, which was attributed to the return of the Crusaders, points to the disease of a locality contracted under the conditions of soldier life in the East, in the mediaeval period. On the other hand, its subsequent deca- dence in European countries, and ultimate eradication in some, simply by the establishment of leper asylums, cases arose, and the disease died out. In leper producing dis- tricts, on the contrary, new cases are constantly arising, and the disease perpetuates itself in each generation. Although it does not seem to be extending, it still lingers in its old haunts, with a marked persistency. "As to the method of treatment, while undoubted benefit can be derived from baths, inunctions and tonics, yet the disease, except in its first stages, is incurable. It is a curious fact that Chaulmoogra seeds, which have been known in China for centuries, as leprosy seeds (Ta Fung Tzu) and reputed "to effect its cure, should now have become a popular remedy for the disease vvith European physicians, in the form of the oil, used both externally and internally; whereas, its use for that purpose has long ago ceased in China. Thus, the forms of medical practice repeat themselves like history in recurrent generations." Contagion. This man has lived with his wife and daughter, occupying the same bed since the inception of the disease; also, one brother has slept with him frequently. So far, there are no signs of contagion. Lepra Anaesthetica. 37 In Nanking, lepers are not isolated, but live with their families and mingle freely with the people. They come and go, stop at inns and tea-houses, ride on chairs and on donkeys, sit in the dispensaries and chapels, buy and sell, and manufacture articles of use. We can always infer contagion, that is, there has always been another person in the family or neighborhood; but, if so, how is the con- tagion introduced? Dr. Robt. C. Beebe, of Nanking, says t must be in some way not readily induced, from the fact that lepers are constantly mingling with the people and only a small portion get the disease. The most plausible way is inoculation. It is not uncommon for a leper to have scabies also, and many of them have it before the leprosy. Dr. Beebe thinks it very possible that the Acarus Scabiei to be the medium. In some parts of China donkey riding is the usual method of conveyance. Imagine a foreigner taking in hand the reins of a donkey which a leper had lecently handled, disengaging a leprous Acarus Scabiei from a drop of pus left on the cotton strings, or reins, taking up its abode between the fingers. Prudence would, at least, caution us to be careful. Osier says that it is contagious in the same sense as syphilis; that the closest possible contact may exist for years between parent and child, without transmission of the disease. Morrow states that in the majority of cases the disease is propagated by sexual congress. Osier mentions a case of inoculation having been successfully done. He also says that in anaesthetic leprosy there is a peripheral neuritis due to the attack on the nerve fibers. In the case here reported the musculo-spiral and median nerves were undoubtedly involved, showing that the attack is not nec- essarily confined to the peripharae. Fox says that the fear of the disease spreading in an intelligent community is without foundation. Taylor says the disease is never observed in infantile .ife. Dr. W. H. Park (China), however, reports a case, a boy, Aet, eight years, admitted to the New Brunswick Lazaretto, and Dr. McGowan saw a case in a leper village near Hanoi, Aet, four years. However, there is no authen- 38 C. C. Hersman. tic congenital case on record so far as 1 am able to find. Treatment. Chaulmoogra oil is mentioned with painful regularity by our American authors as a cure, and with the same frequency we are admonished that the cure is very doubtful. The same has been used in China for centuries in the form of the seed. Dr. Douthwaite, who has had a wide experience in Chekiang and Chefoo, China, uses Creolin and Glycerine, equal parts for local application, with apparent good results. In my case I used Creolin and Glycerine locally, and internally I gave Nux Vomica, beginning with ten drops three times a day, gradually increasing it to forty drops. The case did remarkably well up to September 15th, when 1 saw it last. He left my care at that time and went to look after his business—sewing machine agent." Recently I have learned (March, 1897) that he, from exposure, during the fall and winter, has broken down, almost blind, lungs affected, a helpless wreck. Conclusion. It is thought by some that the disease enters through the skin only, from the fact that the parts covered by the clothing are affected last; and that those wearing shoes and stockings all the time never have it in the feet. I have quoted, preferably, those writing for the Chi- nese journals. They have had better opportunities from long service and association with the disease in its native haunts. Many of our authors have no experience except from short stays at the Lazaretto. Such experience cannot be as valuable as that obtained under more favorable cir- cumstances. Our Medical Missionaries give the most satis- factory clinical reports 1 am able to find. Although it is a disease of centuries it is passing strange how little is known of it. It is thought by some that the Leprosy Con- ference which is to meet in Berlin, October, 1897, will accomplish nothing more than to thresh over the old straw. Note.—On Sept. 2nd, 1 saw Mr. VV. The distortion of the nose is much increased, the necrosis advanced, the folds in the face enlarged and his sight gone. He presents a very much advanced picture from September, 1896, when Lepra Anaesthetica. 39 he resumed his business. His cough is possibly not so bad as a few months ago. He does not seem to be in an advanced stage of lung affection. He has been under no special treatment since September,. 1896. BIBLIOGRAPHY. 1 am indebted to Prof. E. G. Matson, M. D. and Dr. T. L. Disgue for assistance in Pathological and Bacterio- iogical examination; and Rev. Stephen A. Hunter, M.D., (Ph. D., LL. D.) for articles published by Chinese mis- sionaries and to the authors quoted in the body of the report. DEGENERACY STIGMATA AS BASIS OF MORBID SUSPICION.* A STUDY OF BYRON AND SIR WALTER SCOTT. By JAS. G. KIERNAN, M.D. Fellow of the Chicago Academy of Medicine; Foreign Associate Member French Medico- Psychologic Association: Professor of Forensic Psychiatry, Kent College of Law. THE meteor-like career of Byron has been a stock proof for decades of the origin of genius in degeneracy. The degree to which the reality is obscured by fiction, is astonishing even in this fertile field of literary industry. Few careers are more deeply stamped with degeneracy in its contrasted lurididity of seeming gifts with the somber gloom of defect. To Macaulay's summing up of Byron's career used as a hypothetic case, any alienist would answer that the subject is a degenerate in environment tending to increased degeneracy. The pretty fable by which the Duchess of Orleans illustrated thet character of her son the Regent might, with little change, be applied to Byron. All the fairies save one, had been bidden to his cradle. All gossips had been pro- fuse of their gifts. One had bestowed nobility, another genius, a third beauty. The malignant elf, who had been uninvited came last, and unable to reverse what her sisters had done for their favorite, had mixed up a curse with every blessing. In the rank of Lord Byron, in his under- standing, in his character, in his very person there was a strange union of opposite extremes. He was born to all that men covet and admire. But in every one of those eminent advantages which he possessed over others was mingled something of misery and debasement. He was •Read by titie before the Chicago Academy of Medicine, Dec 11th. 1897. tMoor's Life of Lord Byron, Macaulay's Essays. [40] Degeneracy Stigmata. 41 sprung from a house ancient indeed and noble, but degraded and impoverished by a series of crimes and follies which had attained a scandalous publicity. The kinsman whom he had succeeded had died poor, and, but for merciful judges, would have died upon the gallows. The young peer had great intellectual powers; yet there was an unsound part in his mind. He had naturally a generous and feeling heart; but his temper was wayward and irritable. He had a head which sculptors loved to copy, and a foot the deformity of which the beggars in the streets mimicked. Distinguished at once by the strength and by the weakness of his intellect, affectionate yet perverse, a poor lord, and a handsome cripple, he required if ever man required, the firmest and the most judicious training. But capriciously as nature had dealt with him, the parent the office of forming his character was intrusted with, was more ^ capricious still.fi-She passed from paroxysms of rage to par-^js*^ oxysms of tenderness. At one time she stifled him with caresses; at another time she insulted his deformity. He came into the world; and the world treated him as his mother had treated him, sometimes with fondness, some- times with cruelty, never with justice. It indulged him^***'"' without discrimination. He was truly a spoiled child, not merely the spoiled child of his parent, but the spoiled child of nature, the spoiled child of fortune, the spoiled child of fame and the spoiled child of society. His first poems were received with a contempt which, feeble, as they were, they did not absolutely deserve. The poem which he published on his return from his travels was on the other hand extolled far above its merit. At twenty-four he found him- self on the highest pinnacle of literary fame, with Scott, Wordsworth, Southey, and a crowd of other distinguished writers, beneath his feet. There is scarcely an instance in history of so sudden a rise to so dizzy an eminence. Every thing that could stimulate, and everything that could gratify the strongest propensities of our nature, the gaze of a hundred drawing rooms, the acclamations of the whole Nation, the applause of men, the love of lovely women, all this world and the glory of it were at once afforded to a youth to whom nature had given violent pas- sions, and' whom education had never taught to control them. He lived as many men live who have no similar excuse to plead for their faults. But his countrymen and his countrywomen would love and admire him. They were resolved to see in his excesses only the flash and outbreak of that same fiery mind which glowed in his poetry. He attacked religion; yet in religious circles his name was 42 Jas. G. Kiernan. mentioned with fondness, and in many religious publications his works were censured with singular tenderness. He lampooned the Prince Regent; yet he could not alienate the Tories. Everything seemed to be forgiven to youth, rank and genius. Then came the reaction. Society, capricious in its indignation as it had been capricious in its fondness, flew into a rage with its forward and petted darling. He had been worshipped with an irrational idolatry. He was per- secuted with an irrational fury. Much has been written about those unhappy domestic occurrences which decided the fate of his life. Yet nothing is, nothing ever was posi- tively known to the public, but this, that he quarreled with his lady, and that she refused to live with him. There have been hints in abundance, and shrugs and shakings of the head, and "Well, well, we know," and "we could if we would," and "if we list to speak," and "There be that night an they list." But we are not aware that there is before the world substantiated by tangible, or even by credible evidence, a single fact indicating that Lord Byron was more to blame than any other man who is on bad terms with his wife. The professional men whom Lady Byron consulted were undoubtedly of opinion that she ought not to live with her husband. But it is to be remem- bered that they formed that opinion without hearing both sides. We do not say, we do not mean to insinuate that Lady Byron was in any respect to blame. We think that those who condemn her on the evidence which is now before the public are as rash as those who condemn her husband. We will not pronounce any judgment, we cannot, even in our own minds, form any judgment, on a transac- tion which is so imperfectly known to us. It would have been well if, at the time of the separation, all those who knew as little about the matter then as we know about it now, had shown the forbearance which, under such circum- stances, is but common justice. We know no spectacle so ridiculous as the British public in one of its periodical fits of morality. In general, elopements, divorces, and family quarrels, pass with little notice. We read the scandal, talk about it for a day and forget it. But once in six or seven years our virtue becomes outrageous. We cannot suffer the laws of religion and decency to be violated. We must make a stand against vice. We must teach libertines that the English people appreciate the importance of domestic ties. Accordingly some unfortunate man in no respect more depraved than hundreds whose offenses have been treated with lenity, is Degeneracy Stigmata. 43 singled out as an expiatory sacrifice. If he has children, they are to be taken from him. If he has a profession, he is to be driven from it. He is cut by the higher orders and hissed by the lower. He is, in truth, a sort of whip- ping-boy, by whose vicarious agonies all the other trans- gressors of the same class are, it is supposed, sufficiently chastised. We reflect very complacently on our own sever- ity, and compare with great pride the high standard of morals established in England with the Parisian laxity. At length our anger is satiated. Our victim is ruined and broken-hearted. And our virtue goes quietly to sleep for seven years more. This opinion of Macaulay seems but a rhetorical ampli- fication of Magnan's* description of certain degenerates. The predominant feature in the degenerate is the dis- harmony and lack of equilibrium, not only between the intellectual operations, properly so-called on the one hand, and the emotions and propensities on the other, but even between the intellectual faculties themselves. A degenerate may be a scientist, an able lawyer, a great artist, a poet, a mathematician, a politician, a skilled administrator, and present from a moral standpoint profound defects, strange peculiarities and surprising lapses of conduct. As the moral element, the emotions and propensities are the base of determination, it follows that these brilliant faculties are at the service of a bad cause, of the instincts and appetites which, thanks to the defects of the will, lead to very extravagant or very dangerous acts. In other cases the opposite occurs. Degenerates of irreproachable character show strange lacunae in their intellect. They have a feeble memory. Sometimes they cannot understand figures, calcu- lus, music or drawing. In a word, an otherwise normal individual's intelligence is lacking as regards certain facul- ties. The perception centres are unequally impressionable, unequally apt to gather together impressions, only certain impressions are registered and leave durable images; certain relations, certain associations between different centers, are perverted or even entirely destroyed. Macaulay in that more philosophic spirit of the born historian ably contrasted the scion of degenerate heredity with his environment, yet his contradictory parallels of defect and gift might be carried farther. An intense idolator of Pope, Byron freed English poetry from the artificiality stamped upon it by Pope and his followers. This was done •Annals Medico-Psychologigues, January, 1886. 44 Jas. G. Kiernan. unconsciously since Byron's great poem was formed upon Pope's "Dunciad." The continental literary world of Europe looks upon Byron despite his blows at the formal French school as a continentalized Englishman. Lombroso* with characteristic regard for race labels based on tongue, puts Byron and Virchow into the same category as depar- tures respectively from the English and German types, yet neither belonged to the type to which Lombroso assigned him. Virchow as his name betokened was of Sclavonic type, like Skoda, Rokitansky and dozens of leaders of so- called German thought. Byron was of that mixed Celto- Scandinavian stock which intellectually dominates the so- called Anglo-Saxon race despite its rigid adoration for posi- tivism of the Gradgrind fact type. The Scottish . Lowlands and the English Northumbria were settled by Scandinavians whose love of beauty is evident in the Sagas. This blood was mingled with that of Gymric Celts like those who wrote the Mabinogion and Caelic Celts, whose ballads according to the "judging eye of Spenser contained the pure gold of poetry."t Byron was an outcome of this strain. In him the blood of the , poet-statesman, the Celt-Scandinavian James l. of Scotland mingled with that of the Scandinavian Buruns. To the same stock may be referred Ramsay, Scott, Hogg, Burns, Campbell, Hume, Adam Smith, Macaulay, Home, Smollett, Hugh Miller, Ferguson, John Hunter, Hutton, Black the Chemist, Blind Harry, Erskine, Carlyle, Macintosh, Faraday, Huxley, Tyndall, Aytoun Jeffreys, James Watt, Dryden, Mackenzie, McClintock, Burke, Hogarth, Parnell and the galaxy of names with which the Scotch, Scotch-Irish, Nor- thumbrian English, Norman Irish, Celto- and Danish Irish have enriched the gallery of Anglo-Saxon greatness. Take this stock from American science, art, literature and states- manship and an enormous gap results. The Byron family were descendants on the paternal side from the Buruns, who either as the old vikings or as the Norman filibusters under William the Conqueror, exem- •Man of Genlus. tMacaulay's History of England. Degeneracy Stigmata. 45 plified the Scotch proverb that "a ganging foot is aye get- ting." The Buruns who went to Livonia were as success- ful in "squatter sovereignty" in Russia as their kindred in England. In the Byrons in the 17th, 18th and 19th cen- turies the wild blood of the Berseker revived from time to time. An additional defect came from an alliance with a family in which vehemence, impulsiveness, waywardness and ability appear most strongly; the Berkeleys who shocked even the very complacent period of the "Restora- tion." The Berkeleys, however, had many qualities higher than the purely licentious beings by whom they were sur- rounded. The direct line of the Byrons became extinct in the Elizabethan epoch. An illegitimate son of the last scion of the old Buruns succeeded to the property by deed of gift. The mother of this illegitimate scion was subsequently married to his father. Her son became knight of the Bath under James I. Charles I made the grandson of this knight Lord Byron. He died early. He was socceeded by a brother who had a family of ten children. The eldest who became the third Lord, wrote "Spring poetry." The fourth Lord brother of the poetaster had many children. The eldest of these was a licentious, quarrelsome, vindictive man, feared or hated by everybody, known as the "mad and wicked Lord Byron." There was no crime of which he was deemed incapable. Under circumstances that to modern ideas strongly suggested murder, he killed his relative and friend Chaworth who, however, was an equally practiced duelist and was superior in swordsmanship to Byron. He was a morose husband, an arbitrary and tyrannical father, a harsh landlord and a hard master. He hated his son and grandson and transfered this hatred to the poet—' 'the little boy Aberdeen," as he styled him. Having built mock forts about the lake in his park and put a fleet of toy gun-boats on the water he used to amuse himself with mock fights of a naval character, the toy ships firing away at the fort, which returned the fire. When he was weary of this childish game the old man used to lie on the ground and gossip with the crickets, whom he loved far more than "the ittle boy Aberdeen." Wh en the crickets were troublesome 46 Jas. G. Kiernan. he used to whip them with a whisp of hay. The crickets are said to have left the Abbey in a body, as soon as our human friend was dead, and never to have returned thither. Here was illustrated the zoophilism, that morbid love of animals, which so often coexisting with misanthropy, consti- tutes the antivivisectionism of the degenerate of to,-day. His sister Isabella, an eccentric poetaster, married Lord Car- lisle, the poet's guardian's father.* The artistic tendency of the fourth Lord Byron inherited from his mother (a Cha- worth) produced some landscapes. His son Richard copied Rembrandt's "Three Trees" so skilfully that the copy was bought erroneously for an original by a connoisseur. Though the earlier book exposed him to charges of inaccuracy on matters about which he was bound to be exact, Admiral Byron's famous "Narrative" of adventures on the coast of Patagonia and "Voyage Round the World" are, according to Jeafferson of no common merit. On literary grounds they were favorite reading with the author's grandson who, after throwing Don Juan on the sandy fringe of Haidees isle, says: , And need he had of siumber yet. for none Had suffered more, his hardships were comparative To those related in my grand-dad's "Narrative." In addition to the poet's poetic tendency derivable from the races to which Byron belonged, such tendencies were pres- ent in his immediate ancestors. Byron's grandfather, the Admiral, married his paternal first cousin, Sophia Trevanion. From this union which doubled the Berkeley blood came the poet's father "Mad Jack" Byron. He was a handsome man who became a captain in the guards, but his character so developed itself in degeneracy as to alienate his family. In 1778 he seduced Amelia .D'Arcy, daughter of the Earl of Holderness, in her own right Countess Conyers, wife of the Marquis of Caer- matheR, afterwards Duke of Leede. Mad Jack boasted of his conquest. The Marquis to whom his wife had hitherto been devoted refused to believe the scandal afloat. An intercepted letter containing money for which "Mad Jack" •The Real Byron by Jeafferson. Degeneracy Stigmata. 47 was always clamoring, left no doubt. The pair eloped to the continent. After the Marquis obtained a divorce they were married. The heartless profligate made life wretched to the woman whem he was peculiarly bound to cherish. From this union came Byron's half sister. A year after the death of his first wife "Mad Jack" entrapped Miss Cath- erine Gordon of Gight, who with considerable estates had an over-weening pride in her descent from James I of Scot- land through his daughter Annabella, and the second Earl of Huntley. The property of the Scotch heiress was soon squan- dered by the English rake. In 1786 she left Scotland for France and returned to England toward the close of the fol- lowing year. January 22, 1788, Mrs. Byron gave birth in London to George Gordon, sixth lord. Shortly after, pressed by his creditors, the father fled to France where he died in August, 1791, in his 34th year. Accordihg to the poet his father was insane and killed himself. The suicide' has not been clearly established, but circumstances point to it. The marriage was unfortunate in bringing together two degen- ate stocks. The poet's maternal grandfather, a victim of periodical melancholia, drowned himself at 40. Other mem- bers of the family were suicides. Miss Gordon was a woman of very unbalanced temperament. At the thenterjn Edinburgh she went into convulsions shrieking about her love to "Mad Jack" on seeing Mrs. Siddons as Juliet. She half-worshiped, half-hated her blackguard husband and fell into grand hysteria at his death. Her mental defects were the theme of comment by the poet's school fellows: "Your mother's a fool," said a school boy to Byron. "I know it," was his curt reply, followed by a ominous silence. A more exasperating mother for a sensitive passionate child cannot be imagined than this vehement undisciplined woman, who had fits of ill-temper hourly and who rarely passed a week without a wild outbreak of hysteric rage. Lavish of kisses to the child when good humored, she was lavish of blows when he incurred her capricious displeasure. In a later stage of his infancy instead of fearing, he hated her. Once after pouring coarse abuse and profanity upon 48 Jas. G. Kiernan. him she called him "a lame brat." At this the glare came from the child's eyes that so often flashed from them in after time. Whilst his lips quivered and his face whitened from the force of feeling never to be forgotten, he was silent and then said with icy coldness: "I was born so, mother," and he turned away from the woman who dared not follow him. The scene was in the poet's mind when he told the Marquis of Sligo that it was impossible for him to love Mrs. Byron as a son ought to love a widowed mother. The scene was still in his mind when three years before his death he wrote the first words of "The Deformed Transformed." Bertha—"Out, Hunchback!" Arnoid—"I was born so, mother." Miss Gordon reached the lower clase of Scotch women rather than a scion of royalty. She was prematurely obese. Her features had that exaggeration of the Scotch type which constitutes arrest of facial development. By no means devoid of the shrewdness and ordinary intelligence of inferior femininity she was capable of generous impulses to the persons, whom, in her frequent fits of uncontrollable fury she would assail with unwomanly violence. Mrs. Byron's early education was remarkably neglected at a time when Scottish young ladies of her station were exceedingly well educated and the contrast between them and the women of the lower class was enormous. She found that her husband to whom she had sacrificed her fortune was the meanest kind of a profligate who did not hesitate to leave her practically penniless, burdened with her own infant and the daughter of "Mad Jack's" first wife whom she seems to have treated with all the kindness possible to an ill-regulated nature. In her characteristics however, she certainly did not resemble the later Stuarts who were a species of confidence operators. Byron as a child was sullen and defiant of authority, but singularly amenable to kindness. On being scolded by his first nurse for having soiled a dress, without uttering a word he tore it from top to seam, as he had seen his mother tear her caps and gowns. Her sister and successor Degeneracy Stigmata. 49 in office, May Gray, acquired a permanent hold on his affection. To her training is due the Biblical knowledge he possessed. He was peculiarly inquisitive and puzzling about religion. Byron's political opinions were undoubtedly influenced by his mother who believed that the sufferings of the people fully justified the strong measures adopted to "crush tyrants." Mrs. Byron with the courage of her convictions avowed herself a "Democrat," and in the hear- ing of Tories' prayed for the time when all oppressors would be called to account and punished accordingly to their deserts. Byron was taught by his mother to abhor tyrants and regard the poor as extremely ill-used people, who would be as prosperous and virtuous if despots and plutocrats would but leave them alone. As a Calvanist May Gray had no great reverence for Kings, but the mother had clearly a share in the formation of the child's charac- ter. When Byron was born, the obstetrician in attendance was John Hunter, the great biologist. The condition causing Byron's after lameness was clearly congenital since John Hunter instructed Mrs. Byron as to the shoe the child would require when able to use one. The inability of the Scotch surgeons to comprehend the general principles of Hunter's prescriptions led to a shoe being made under Hunter's supervision two years after. The lameness which occasioned the poet so much distress was due to contrac- tion of each tendon Achilles according to Jeafferson. Both feet may have been equally well formed, save in this sinew till one was subjected to injudicious surgery. The right was, however, considerable smaller than the left. Instead of being congenital, the slight contraction of the left tendon Achilles may have been the result of the patient's habit of stepping only on the fore part of the foot, so as to accommodate its movements to the action of the other extremity. Though it may not have existed in the earlier years of his childhood, the contraction of the comparatively normal sinew was noticed by Trelawny when he made the post mortem examination of both extremities at Missolonghi. The right tendon, however, was so much contracted that the poet was never able to put the foot flat upon the ground; always using for it a boot made with a high heel. This foot was so considerably distorted as to 50 Jas. G. Kiernan. turn inwards, a malformation that may have been caused altogether by the violence with which the foot was treated by the less intelligent of the boy's surgeons, and more especially by Lavender, a Nottingham quack. Byron's lameness was of a kind far more afflicting to the body and vexatious to the spirit than the lameness of such an ordinary club-foot as disfigured Sir Walter Scott. With a club-foot to plant firmly on the ground, Byron could have taken all the bodily exercise needful for the natural correction of his morbid tendency to fatten. He would have moved about awkwardly and to the derision of his least generous playmates; but he would not have been debarred from participation in all of their manlier sports. Instead of musing or moping for hours together on the famous tombstone he would have distinguished himself in the Harrow playing grounds at cricket, and even at leap- bar. A few years later instead of standing sadly in the corners of London ball-rooms, eyeing enviously the young men whirling round with fair partners, he would have fatigued himself in the gallopade and delighted in the waltz, which he affected to abhor as unfit alike for men and women. Better still instead of taking most of his out door exercise in the lazy yacht or easy saddle, he would have been a bold climber of mountains. To the question why Byron did not bear his lameness as bravely and cheerfully as Scott bore his lameness, one answer is, that whilst the Scotch poet suffered from nothing worse than a club-foot Byron endured a lameness far more trying to health and spirits. Had Sir Walter been con- strained to pick his way through life on his toes "hopping" about like a bird (to adopt Leigh Hunt's way of sneering at a comrade's grievous affliction), he would certainly have been less happy. And had Byron been able to walk about like a man, albeit with a club-foot he would have been less often stricken with melancholy and moved to breathe the fierce breath of anger. Nichols,* an equally careful but more judicial biog- rapher, shows more appreciation of the influence of the mental state when he remarks: A physical defect in a healthy nature may either pass without notice or be turned to a higher purpose. No line of his work reveals the fact that Sir Walter Scott was lame. The infirmity failed to cast even a passing shade over that serene power; Milton's blindness is the occasion •English Men of Letters. —Byron. Degeneracy Stigmata. 51 of the noblest prose and verse of resignation, in the lan- guage. But to understand Pope we must remember that he was a cripple; and this Byron never allows us to forget because he himself never forgot it. His sensitiveness oh the subject was early awakened by unfeeling references, "What a pretty boy Byron is," said a friend of his nurse. "What a pity he has such a leg." On which the child with flashing eyes cutting at her with a baby's whip cried out, "Dinna speak of it." In the height of his popularity he fancied that the beggars and street sweepers in London were mocking him. He satirised and discouraged dancing. He preferred riding and swimming to other exercise, because they concealed his weakness and on his death bed asked to be blistered in such a way that he might not be called upon to expose it. The Countess Guiccioli, Lady Blessington and others assure us that in society few would have observed the defect if he had not referred to it; but it was never far from his mind and therefore never from the mouth of the least reticent of men. Trelawney's account is the most authentic: 1 saw Byron lying in his coffin; impelled by curiosity, I sent the servant out of the room and uncovered the foot of the dead man. The mystery was solved; both feet were clubbed, and his legs withered to the knee, but the right foot was the most distorted, while the right leg was also shorter than the other. It is clear from these differing accounts that the condition was in part congenital, otherwise John Hunter would not have prescribed so early for it. It is also obvious that the deformity was exaggerated by later unskillful treatment noticeably by the quack Lavender, whom Mrs. Byron with the usual degenerate prediliction for the occult, selected. The influence of the poet's mental sfate, for finding references to his deformity where none were intended is evident in the remarks of the Countess Guiccioli and Lady Blessington. Sir Walter Scott's lameness, due to a post febrile paralysis, seems to have been always slight and to all intents and pur- poses was recovered from early. Commenting on these contrasted narratives, Dr. F. S. Coolidge, one of the leading Chicago Orthopaedist, remarks: Trelawney's account of Byron's deformity as seen after the poet's death is the most authentic. Both feet 52 Jas. G. Kiernan. were clubbed, the right more than the left, and both legs were withered to the knee. The right leg was shorter than the left. That the deformity was congenital is shown by the fact that John Hunter observed it at Byron's birth. It was undoubtedly double congenital talipes equino-varus; the deformity being worse in the right foot. Jeafferson's claim that the right alone was deformed and that the left became so by walking on the toes to accommodate the gait to the deformity, is untenable since the right leg was shorter than the left, and toe-walking on the left would have increased the difference in length and of necessity the lameness. Moreover, it would have swelled the calf muscles into goodly size, whereas Trelawney explicitly states that both legs were withered. The deformity of Sir Walter Scott was clearly due to anterior poliomyelitis, leaving a group of muscles in one leg paralyzed. This disease usually attacks healthy children. Good health and cheerfulness in after life are usually preserved, except in very extreme cases. Con- genital club-foot unquestionably arises from different causes. It is so frequently an accompaniment of severe forms of mal-development and of congenital brain defects, that there can be no doubt that imperfect constitutional development is one of its causes.]] That the deformity, with the many limitations to a wefl-rounded life, that it involves, may tend to create morbidness to a certain degree, is perfectly true, but extreme morbidness is far more likely to be an addi- tional symptom of the degeneracy which in certain cases is the underlying cause for the deformity. Under Dr. Coolidge's analysis and from the standpoint of the alienist, the student of Byron's career is compelled to take into account, therefore, the possibility of an under- lying state due to degeneracy. The question arises in what particular neuroses did the degeneracy existent in Byron find such expression as to lead to suspicional irritability. As I have elsewhere shown,* vanity and jealous suspicious- ness are exceedingly common in degenerate children. The mental life swings between periods of exaltation and depres- sion alternating with brief epochs of healthy indifference. Psychic pain arises from the most trivial cause and finds expression in emotional outbursts. The child is peculiarly liable to the ordinary fears of childhood intensified by the degenerate state. If in addition to these fears, there be •Alienist and Neurologist. July. 1897. Degeneracy Stigmata. 53 some tangible physical defect around which they may be centered, then that physical defect renders them a fixed idea which would not otherwise occur. This condition is further intensified through injudicious brutal reference to the defect by those in whom the child's natural instinct of refuge taking cause it to confide. A healthy mental back- ground would throw off these morbid fears. A sound mater- nal care would destroy them. In Byron's case not only was the last absent, but its very reverse was present. The brutality with which Mrs. Byron referred to her son's lame- ness could not but be echoed by her inferiors. Although May Gray to no mean extent supplied the proper refuge, still this could not offset the maternal influence. In addi- tion to these factors another element has to be taken into account. The evidence of the co-existence of a special neurosis producing a suspicional irritability was decades ago thus summed up by Madden:* Whether Byron's epileptic diathesis was hereditary or not, the question of its existence is beyond dispute. He had no regular recurrence of its paroxysms like those that belong to a confirmed case of the primary form of this dis- ease, his seizures were generally slight, occasioned by mental emotion or constitutional debility, induced by the alternate extremes of intemperance and abstemiousness. In boyhood, the most trivial accident was capable of producing sudden deprivation of sense and motion. On one occasion a cut on the head produced what he calls a "downright swoon." A similar effect was the consequence of a tumble "in the snow at another time. In later life the same con- stitutional tendency is to be observed. One evening on the lake of Geneva with Mr. Hobhouse an oar striking his shin caused another of those "downright swoons;" he calls the sensation a very odd one, a sort of grey giddiness first, then nothingness and a total loss of memory." At Bologna in 1829, he thus describes one of those attacks in one of his letters: "Last night I went to the representation of Alfieri's Mirra, the last two acts of which threw me into convulsions; I do not mean by that word a lady's hysterics, but an agony of reluctant tears, and the shocking shudder which I do not often undergo for fiction." This attack appears to have been of graver nature than the description of it implies, for a fortnight after we find him complaining •Infirmities of Genlus, Vol. II, p 91. 54 Jos. G. Kiernan. of its effects. He was seized with a similar fit at witness- ing Kean in Sir Charles Overreach and was carried out o the theater in strong convulsions. At Ravenna in 1821, in some occasions of annoyance, he says he flew into a paroxysm of rage which had all but caused him to faint. And the same year complaining of the effects of indigestion he says, "I remarked in my illness a complete inaction and destruc- tion of my chief mental faculties. I tried to rouse them, but could not, and this is the soul. I should believe that it was married to the body, if they did not sympathize so much with each other." Ellis, the American artist, alludes to a convulsive and tremulous manner of drawing in a long breath as one of Byron's peculiarities; and we are informed by Lody Bless- ington whose accurate observation of Byron's character we have reason to place great dependence upon, that any casual annoyauc^e gave not only his face, but his whole frame a convulsive epileptic character. In all cases of degeneracy, the environment especially during childhood is of peculiar interest to the student. May Gray, Byron's nurse, with that intense altruism and deep sense of justice (frequently miscalled charity) so often pres- ent in Scottish Calvinistic women, even of the lower class (which is so akin in its predestinarian spirit to the similar justice of the determinism of evolution) saw at once the source, and the causes of the intensification, of the heredi- tary defect of her nursing for whom, she always cherished the deepest affections. In the cant of plutocracy, which to-day echoes the law and order cant of the Stuarts, Bourbons and George the III (the most crazy and meanly trickiest of trie Hanoverians), it is too often forgotten that the per- sonal liberty principles of the Americans of the Revolution came to them not merely from the Puritans, the republican Hollanders and Huguenots, but largely from the Scottish Republicans, whether resident in the lowlands of Scotland or the North of Ireland whose spirit glows in the verse of Burns: The rank is but the guinea stamp, The man's the gowd for a' that. The influence of Mrs. Byron's republicanism on the poet would have been feeble but for the sterner, deeper republicanism of May Gray, which was of the type that Degeneracy Stigmata. 55 founding the United States expressed its ideal in Emerson's vision: "When the church is moral worth, When the statehouse is the hearth, Then the perfect state is come, The republican at home." To May Gray's training intensified by his mother's vehemence is due Byron's deep-seated sense that while: "The name of commonwealth is past and gone, Still one great ciime in full and free defiance Yet rears her crest unconquered and sublime. Above the far Atlantic—she has taught Her Esau-brethren that the haughty flag, The floating fence of Aibion's feebler crag, May strike to these whose red right hand has bought Rights cheapiy earned with blood." I have dealt at much length with the source of repub- licanism in Byron as Byron's republicanism has been con- sidered a cant like that of Caligua, and hence among his mental stigmata of degeneracy. In Great Britain and Ire- land, however, it should be remembered that the hereditary nobility of the Continent does not exist; good family does not mean ennoblement, and descendants from noble families are often not merely commoners but often fall into very inferior social status. This fact has been excellently utilized by Hardy in the family history of the milkmaids of his dra- matic "Tess of the Dubervilles." The same condition is illustrated in the fact that next to Tennyson, the poet, the nearest legitimate collateral descendant of the Plantagenets was a sexton at Wapping named Plant, who with the poet had therefore a greater hereditary claim to the British throne than Queen Victoria or the idol of the modern Stuart hysterics, Princess Mary of Modena. Byron's republicanism, was there- fore a healthy outcome of early environment. (7b be Continued.) HISTORY OF SOUTHERN HOSPITALS FOR THE INSANE.* By T. O. POWELL, M.D. Medical Superintendent, State Lunatic Asylum, Milledgeville, Georgia. 7IRG1NIA now has four asylums for the insane—three v for whites and one for colored. The names of these asylums were changed in 1894 to State Hospitals. In 1769 the House of Burgesses in the colony of Vir- ginia provided for a building for the insane at Williams- burg, the capital of the colony. The institution was offic- ially called i"The Hospital for the Reception af Idiots, Lunatics, and Persons of Insane and Disordered Minds." It was in dimensions 100 feet by 38 feet. At a meeting of the Court of Directors September 14, 1773, the hospital was examined and found finished. Mr. James Gait was appointed keeper, and "after he agreed to accept the said office, the court delivered the charge of the said hospital to the said James Gait." The keeper had entire charge of the hospital, subject only to the Court of Directors—as the , superintendent now has. He attended to all the business, expended all money, and the visiting physician was sent for only when the keeper ordered that he should be. Mr. Jomes Gait, the son of Mr. Samuel Gait, was born in 1741, probably at "Strawberry Banks," a farm near Old Point Comfort owned by his father. He had had the advantages of education and travel, and was noted for his integrity, and later for his patriotism. He held the posi- tion of keeper until the hospital was suspended from lack of funds during the revolutionary war, and when the insti- •Belng a section of Presidential Address before the fifty-third annual meeting of the Medico-Psychological Association at Baltimore, Maryland, May, 1897. [56] History of Southern Hospitals for the Insane. 57 tution was reopened after the war he was reappointed, and remained in office until the time of his death, December, 1800. He was succeeded as keeper by his son, Mr. Wil- liam T. Gait, who held the office for twenty-six years, to the time of his death. He was educated at Williamsburg, and was noted for his kindness to the patients and his associates. He was mayor of Williamsburg when Lafayette made his second visit to America, and received him offi- cially when he visited the old city. In January, 1774, Dr. John de Segueyra was chosen a member of the Court of Directors, and it seems was the visiting physician. In 1784 the Court of Directors met for the first time after the war, passed resolutions as to repairs to be made to the hospital, an enclosure put up around it, etc. From the records it seems that no patients were received into the hospital after it was suspended until after the Court of October, 1786, at which time Mr. James Gait was reappointed keeper and Dr. John de Seg- ueyra appointed visiting physician. In the meantime the few remaining patients had been taken care of in the town. In 1789 the Court of Directors paid Drs. Gait and Barrand a bill—probably for attendance, in absence of Dr Segueyra—and in 1791 Drs. Gait and Barrand, who prac- ticed together, were appointed visiting physicians, and Dr. Segueyra retired on account of poor health. Dr. Barrand had been a physician's mate to Dr. John M. Gait in the war, and afterwards they practiced together. After a few years Dr. Barrand moved to Norfolk, and Dr. John M. Gait still held the position at the hospital, assisted by his son, Dr. Alexander D. Gait. Dr. John Gait was younger brother to Mr. James Gait. He was born in Williamsburg in 1744, educated at William and Mary College, and received his medical education at the schools of Edinburgh and Paris. He served for a time in the Hudson Bay Company, was associate physician in the asylum at Williamsburg for many years, and had a large private practice. He was a promi- nent medical officer during the revolutionary war, was senior field surgeon at the end of the war, and had charge of the sick soldiers for some time after the war in the hos- 58 T. O. Powell. pitals established in Williamsburg. He compounded and gave to the patients all medicine after he was appointed attending physician to the hospital. Dr. Alexander D. Gait, the son of Dr. John M. Gait, was born in 1771 in Williamsburg, was educated at William and Mary College, and at Oxford, England, and received his medical education in London, being the private pupil of Sir Astley Cooper, and attending lectures and the hospitals there. He was associated with his father as visiting phy- sician to the Hospital for the Insane in Williamsburg. He introduced what he called the "gentle treatment" for the insane—endorsing Pinel. His private practice was even larger than his father's. He was a philanthropist, and "went about doing good." The poor thought he was paid by the state for attending them. He, on one occasion, refused half of the largest fortune in Virginia in order to stay all night and nurse a poor, sick, drunken, free negror who had no one to take care of him. He also prepared and gave to the hospital all medicine used. He, like his father, was for many years one of the Board of Directors of William and Mary College. He was a distinguished army surgeon in the war of 1812. DR. JOHN M. GALT, THE SECOND. Dr. John M. Gait, son of Dr. Alexander D. Gait, was born in Williamsburg and educated at William and Mary College and at the medical schools in Philadelphia. He succeeded his father as physician to the hospital. The Board of Directors waited a number of months until he had graduated to offer him the position, so well was his unusual ability recognized and appreciated, although he was so young. He was born in 1819, and when in July, 1841, he was appointed superintendent he was only twenty-two years of age. He was the first Medical Superintendent, and brought many changes to the institution. He took many of the duties that formerly belonged, to the keeper. He introduced all the gentle treatment for the insane— probably more than had ever been used for them in any institution in the world. He, like the other members of his family, was philanthropic. He refused many times to allow Histoiy of Southern Hospitals for the Insane. 59 his salary to be raised, fed many patients from his table, etc. He greatly loved and pitied the patients and when, in May, 1862, the Union troops came and took possession of the town and hospital, and the guard at the gate refused to allow him to enter, his anxiety about the patients was so great that he could neither eat nor sleep for several days and nights, and it was thought this caused his death; and so this wonderful man was lost to the world in his forty-third year. He thoroughly understood all the lan- guages usually taught in the colleges of that day—spoke and read fluently more than twenty different languages— Greek, Latin, Spanish, French, Italian, and in addition, Sanscrit, Arabic, German, Danish, Swedish, etc. He wrote on many subjects, and among his papers were found letters from the leading medical publications begging him to write for them. Dr. Gait was a gentleman of the highest schol- arly attainments. He was inflexibly true to his convictions of duty. The following words of his own composition form a fitting memorial of his character: "God has given us the desire of fame for the good of our species. True fame, then, resulting from the desire to make our names known by doing some great good, is worthy of being; it is following out the great purpose of our Creator. It makes no difference that we shall be slum- bering in the quiet grave when all that is good to which we have given rise is accomplished. We have followed out the destined end of our being; we have exercised rightly the talents which have been entrusted to us for the good of mankind." Searching literature on the treatment of madness he compiled a work on that subject which was at the time standard authority abroad as well as in this country, though now almost forgotten. He was one of the first to recognize the value of employment in the treatment of the insane. Such a calamity was his death that we yet feel his loss. In the record of the Gaits, lasting nearly a century, we find the only parallel in America to the justly famous Tukes of England. During Dr. Gait's incumbency three buildings were 60 T. O. Powell. added to the institution—one for women and two large ones for men. Back of the hospital proper there was a large building connected by a covered way. In this were con- fined some of the worst, female patients. Both classes were provided alike with all the necessities and comforts. By the federal authorities Dr. Wager of the Fifth Pennsylvania regiment was appointed superintendent of the hospital, and held the position to the end of the war. Dr. Leonard Henley, formerly of Blockley, had been elected by the directors to succeed Dr. Gait. He was informed by the federal authorities, however, that he would not be allowed to hold the position; but after the war his appointment was reaffirmed by the board. In a short time he was again displaced by the military and the position given to Dr. Garrett, who was succeeded by Dr. Petticolas, and at the death of Dr. Petticolas a short time after his appointment, Dr. Brower was appointed; after him came Dr. Black. Then came Dr. Wise, and about twelve years ago, Dr. Moncure, the present superintendent, was appointed. During the time of Dr. Brower the middle and oldest part of the asylum was burned, and about eleven years ago, during Dr. Moncure's superintendency, there occurred a large fire, burning most of the buildings which were standing at the close of the civil war. Detached buildings (which Dr. John M. Gait always advocated) have been erected, giving increased capacity to the institution. On the site of the first building is now an infirmary almost finished. Across the street is a large executive building. There are now accommodations for five hundred and fifty patients. STAUNTON, VIRGINIA. The distance of the asylum at Williamsburg (several hundred miles) from the western parts of the original great commonwealth of Virginia called for the erection of a sec- ond institution of the same kind, and the General Assembly passed an act in 1825 providing for the establishment at Staunton of the Western Hospital for persons of unsound mind, and appropriated $10,000 for the erection of suitable buildings. Four acres uf land were purchased near Staunton History of Southern Hospitals for the Insane. 61 and in 1828 under Dr. Boys, the asylum was opened for the reception of patients. Dr. Boys remained in charge of the hospital for eight years, and there were only seventy-nine patients received, of whom there were discharged thirteen. In 1836 Dr. Francis T. Stribbling, a young man only twenty-six years of age, was made visiting physician to the hospital. He found the asylum, as was that of Williamsburg, in charge of a keeper, Samuel Woodward, whose wife acted as matron. There were only forty-five patients in the hospital. The young physician was not superintendent, but only employed to visit the institution and give such medical attention as the patients might need. He found the hospital, as most institutions of the same kind were at that time, a mere prison-house where people of unsound mind could be kept, and found no effort made to secure their recovery. He visited the best institutions in the Northern States and consulted with their superintendents, and decided on an advanced movement in the management of the asylum. He proposed startling changes, and found an intelligent Board of Directors who concurred in his views. Land was bought that the patients might find employment in farming; work was provided for the idle hands of the female patients. Amusements were introduced, and appropriations were secured for the enlargement of the buildings. A chapel was built, and the equipment of a well-furnished institution was provided. The visiting physician was made superin- tendent, and a full staff was appointed. The asylum which contained when he came only forty-four patients, in twenty- five years had in its care over four hundred. The war came on; provisions were scarce and hard to get, but by a wondrous Providence there was no want in the institution. At the very close of the war a cavalry raid swept upon the asylum and bore away nearly all its supplies, but the loss which would have entailed much suffering at an earlier date, was repaired, and the afflicted inmates knew no real want. The good man who had given his life to care for these sufferers lived till July 23, 1874, having reached the ripe age of sixty-four, and leaving behind him as the result 62 T. O. Powell. of intelligent devotion to his work an asylum equipped with every needful provision, and conducted upon the wisest and most humane methods. Dr. Curwen well says of him: "To talents of a very high order he united unblemished integrity." He was a man of warm and generous feelings, inflexible firmness, and had such grace and serenity as won the confidence and affection of all brought in contact with him. Not to superintendents alone has all the credit of earnest and successful effort been due. In many instances assistant physicians have served for long periods of years, rendering meritorious services which deserve commemora- tion in this connection. Dr. William Hamilton served the Staunton Hospital faithfully as assistant physician for more than thirty years. On account of his extreme modesty and diffidence he was little known outside of the institution. He was a high-toned gentleman, a learned and efficient alienist, devoted to his work, loving his patients and beloved by them. He contributed not a little to the success of this institution. Dr. Robert T. Baldwin succeeded Dr. Stribbling. He was born in Winchester, Va., elected superintendent Sep- tember 24, 1874, and died in Staunton November 14, 1879. He was a faithful and conscientious public officer, a man of decided character, charitabie, with much warmth of friendship, and complete unselfishness. Dr. A M. Fauntleroy succeeded Dr. Baldwin. He was born in Warrenton, Va., July 8, 1837; was a graduate of the Virginia Military Institute, an alumnus of the Univer- sity of Virginia and the University of Pennsylvania; assist- ant surgeon in United States Army, 1860, and surgeon C. S. A., and President of the Board of Directors of the West- ern State Hospital. He entered upon his duties as super- intendent of the Western State Hospital, January, 1880, and continued as such until 1882, when he was succeeded by Dr. R. S. Hamilton, who served two years, when Dr. Fauntleroy was re-elected, and served his second term of two years. Dr. Fauntleroy was an able and efficient superintendent, much beloved by all. He was a very History of Southern Hospitals for the Insane. 63 capable surgeon, and before becoming superintendent was regarded as one ot the ablest physicians and surgeons in Virginia. Dr. Conrad followed him. Dr. Conrad was sup- erintendent for three years, and very attentive to his duties. Dr. Conrad was succeeded by Dr. Benjamin Blackford, of Lynchburg, Va., on the 22nd of April, 1889. The capacity of the institution has been increased to eight hundred and fifty-seven beds. The grounds have been beautified, and the needful requisites for a well-kept hospital have been provided. CENTRAL STATE HOSPITAL, PETERSBURG. Until December 17, 1869, the colored insane were cared for in the Eastern Lunatic Asylum at Williamsburg. The law provided that "no insane slave should be received or retained in either asylum so as to exclude any white person residing in the State." On the above named date (Dec. 17, 1869) at the suggestion of Dr. Stribbling, and by order of Major-General Canby, military, commander, an asylum for the colored insane of the State was established near Richmond. Dr. J. J. DeLameter was appointed superin- tendent and physician. When the State was re-admitted into the Union the governor re-appointed Dr. DeLameter, who continued in office until July, 1870. On the opening of this hospital there were seventy- two patients transferred from the Williamsburg Asylum. This hospital Was known as the Howard's Grove Hospital. June 7, 1870, the General Assembly of Virginia passed an act authorizing the establishment of the Central Lunatic Asylum near the city of Richmond for the reception and treatment of colored persons of unsound mind, the expenses of said asylum to be provided for and paid in the same manner as in similar institutions in the State. The Board of Directors of this new asylum held their first meeting on June 15, 1870, and elected Dr. Daniel B. Conrad, of Win- chester, Va., superintendent. Dr. Conrad took charge of the institution July 1, 1870, and remained in charge until September 3, 1873. Dr. Conrad in 1886 was appointed superintendent of the Western Lunatic Asylum at Staunton, and remained in charge of that institution for three years. 64 T. O. Powell. Superintendent Conrad in his first annual report urgently recommended the appointment of a committee of the legis- lature to examine into and report regarding a site and the erection of an asylum for the colored insane of the state. At that time the asylum was located temporarily at How- ard's Grove, near Richmond, and the buildings were all of wood, with only fifteen acres of land attached. This prop- erty was leased for a term of years by the state. By sev- eral enactments of the legislature, a permanent institution for the colored insane of Virginia was finally located at Petersburg, and opened for the reception of patients in April, 1885. At that time there were four hundred insane negroes in the state, all of whom were provided for in this institution. Dr. Randolph Barksdale, upon the resignation of Dr. Conrad, September 3, 1873, was elected superintendent, which position he held until March 9, 1892. At that time the Readjuster and Republican parties got charge of the state government, and forthwith proceeded to turn out all asylum officers who were not of their political faith. Dr. David F. May, a prominent Republican politician, was appointed superintendent in Dr. Barksdale's stead, and held the position until April 15, 1884, when Dr. Barksdale was recalled. In the meantime Dr. Barksdale was assistant physician under Dr. Gundry at the insane asylum, Catons- ville, Md. After twenty-one years of faithful and efficient service as superintendent, Dr. Barksdale's health failing, he resigned in October, 1896, but was persuaded to remain as consulting physician. Dr. Wiiliam Francis Drewry, who had served awhile as second assistant, and for nine years as first assistant physician, was unanimously promoted by the Board of Directors to the superintendency to fill the unexpired term of Dr. Barksdale. The Central State Hospital is beautifully located on a hill three miles from Petersburg, and consists of a large center building on the Kirkbride plan, and two separate buildings, one for epileptic patients. There are now in the institution eight hundred and forty patients. The institu- tion has an abundant supply of pure water, and is lighted History of Southern Hospitals for the Insane. 65 with gas from its own plant. The farm attached consists of three hundred acres. All the colored insane of the state are well cared for in this hospital. The annual appropria- tions of the legislature amply provide for the proper main- tenance of the institution. At the centennial ceremonies of the Williamsburg Asy- lum in 1873, Governor Walker called attention to the fact that Virginia in her deep poverty had established the first asylum for the poor colored man ever organized. SOUTHWESTERN STATE HOSPITAL, MARION, VA. The large section of Southwestern Virginia was remote from the asylum at Williamsburg, and from the one at Staunton, and a hospital to be located in this section was first incorporated November 29, 1884, under the name of Southwestern Lunatic Asylum. Several counties in South- west Virginia offered sites, and competed for the location, but the present site in Smith county was selected on account of its commanding and elevated position, and on account of the abundant supply of almost pure free-stone water which would flow by force of gravity all through the buildings from a spring two and a half miles up in the mountains—with an estimated capacity of three million gallons of water daily. The liberal people of Smith county also offered to furnish 208 acres of excellent land to the state free of cost should the asylum be located there. In 1887 a hospital with capacity for two hundred and seventy- five patients was completed at a cost of $160,000 for build- ings and furnishing. It is beautifully located 2,250 feet above the level of the sea. The outside limit of accom- modation was soon reached, and additional room was pro- vided from time to time until at the close of the fiscal year 1896 the number of patients was three hundred and twenty- six. Dr. Harvey Black was elected superintendent in March, 1887. The first patients were admitted May 17, 1887. Dr. Black died October 19, 1888, and was succeeded by Dr. R. J. Preston, who is still in charge. The institution is well equipped for its work and all the modern methods for the care of the insane are used. There are regular religious 66 T. O. Powell. services, amusements and employment provided for the patients. DR. RICHARD S. STEUART, AND THE MARYLAND HOSPITAL FOR THE INSANE. During the session of the legislature of 1827-28, Dr. Richard S. Steuart (then in the active practice of his pro- fession in Baltimore, and deeply interested in the cause of the insane) obtained with the aid of his friends, the pass- age of the law which established the "Maryland Hospital for the Insane." Prior to this period, the Maryland Hos- pital, established in 1797, had been a general hospital, including the sick as well as the insane, and had been leased by the state to Dr. John McKenzie and others who carried it on as a private enterprise, and under contract with the United States government received sailors of the navy and general marine. At the first meeting in April, 1828, of the Board of Visitors, consisting of members from Baltimore and the various counties of the state named in the act dedicating the hospital entirely to the treatment of the insane, Dr. Richard S. Steuart was elected president of the board and medical superintendent of the hospital. His early experiences in this capacity were most interest- ing, and if they had been written up would be equal to the famous stories in Warren's "Dairy of a Late Physician." He found insane men and women chained to the floor and resting only upon filthy straw, who had not been out of their cells for years. This condition he immediately under- took to reform, and striking off the chains from the limbs of these wretched creatures, he inaugurated a more humane treatment, which was the beginning of a new era in the care of the insane in Maryland. He obtained the services of the Sisters of Charity, and appointed as his assistant and resident physician the late Dr. William Fisher. Dr. Fisher was succeeded in 1838 by Dr. William H. Stokes, afterwards and for so many years the medical superinten- dent of the Mount Hope Retreat for the insane. During the first ten years of the service, finding the buildings too small, and illy adapted for the treatment of the insane, Dr. Steuart again applied to the legislature for the means to History of Southern Hospitals for the Insane. 67 enlarge and improve the hospital and, after a severe and exhausting struggle, obtained from the state a small appro- priation with which the west wing was erected, thereby doubling the capacity of the house and relieving the over- crowded condition of the old east wing and centre building. During several years of this early period, Dr. Steuart car- ried the expenses of the institution upon his own shoulders, becoming personally responsible for the debts of the hos- pital, trusting to the legislature for reimbursement, a large part of which he never received. About the year 1850, Dr. Steuart, with the consent and co-operation of the Board of Visitors, commenced his plans for the building of a new insane asylum, and went before the legislature with his petition for the means to purchase a suitable site for the erection of an institution adequate to the increasing demands of the period. He spent one year in examining every possible available local- ity, and finally decided upon the beautiful and most appro- priate spot where now stands the Maryland Hospital for the Insane at "Spring Grove," in Baltimore county, the original name of the place. But here arose a difficulty. The state had appropriated the sum of only $5,000 for the purchase of a site, and this chosen site (a farm of one hundred and twenty-three acres, overlooking the city and harbor of Baltimore and the surrounding country) could not be obtained for less than $25,000. Nothing daunted, Dr. Steuart closed the bargain, paid the $5,000 on account of the purchase money, and undertook to raise the balance by private subscription. He headed the paper with his own name and $1,000, and from personal friends during the ensuing six months he obtained the balance in sums rang- ing from $1,000 down to $25. This $20,000 was presented to the state as an offering to the cause of the insane. During the following winter Dr. Steuart again undertook to obtain from the legislature the means to erect the new asylum for the insane at Spring Grove. This proved more difficult of accomplishment than any of his previous under- takings. Between the circumscribed views of the average egislator and the obstructive tactics of a corrupt political 68 T. O. Powell. lobby, he had well-nigh despaired of success when he called to his aid that distinguished philanthropist, Miss Dix, of Massachusetts. Most cordially did she respond to his call, for the cause of the insane had been her life work, as it had been Dr. Steuart's also. She established herself in Annapolis, and worked night and day until the object was accomplished and the appropriation obtained. The act included the appointment of a commission of five to build the new hospital, and included Dr. Richard S. Steuart of Baltimore, Gen. Benjamin Howard of Baltimore, Dr. Wash- ington Duvall of Montgomery county, Col. Hanson of Fred- erick, and Dr. Humphries of the Eastern shore of Maryland. The actual work was begun during the year 1853, and had progressed nearly to completion when, in 1861, upon the breaking out of the war, all work was suspended and so remained until 1866, when building operations were resumed and carried on to completion in 1872. As origi- nally designed, as soon as the new hospital was finished and ready for occupancy, the patients were all transferred thereto, and Dr. Steuart took charge as President of the board and medical superintendent, with his cousin, Dr. Wil- liam F. Steuart, as resident physician. It should be men- tioned that the original "Board of Visitors" was made by the act creating them, perpetual, that is, having the right to fill vacancies in their board whenever such occurred, and Dr. Steuart continued uninterruptedly to act as President of the board and medical superintendent from the time of the creation of the board up to 1862, when owing to the political feeling created by the war then going on, a num- ber of the members of the board, including Dr. Steuart, were suspended because they declined to take the oath presented to them by the federal authorities then in power in Maryland. Such members as could and did take the oath were at that period continued in charge of the old hospital on Broadway, with Dr. John Fonerden as medical superintendent and Mr. Enoch Pratt as President of the board. Dr. Fonerden had been the assistant and resident physician from the time of the resignation of Dr. William H. Stokes to take charge of the then new Mt. Hope Retreat, History of Southern Hospitals for the Insane. 69 established by the Sisters of Charity when they left the Maryland Hospital. Dr. Fonerden's incumbency covered a period of some twenty years. As soon as the war was over and the Democratic party returned to power in the state, the old board were all reinstated, and Dr. Steuart resumed his office as President and medical superintendent. He occupied this position, therefore, at the time of the removal to the new hospital and until within a few weeks of his death which occurred July 13, 1876. He, therefore, served the state—deducting the five years of the war—continuously for forty-three years. The first years of his service were without com- pensation of any kind. Later, he accepted a small salary, and only from the time of his taking charge of the new hospital did he receive a salary which compensated him for his time and services. Dr. Steuart was an enthusiast in his work, and gave the best efforts of his life to the cause of the insane. The reforms in the management and treat- ment of the insane which hi' instituted and carried out were far ahead of their day. and have continued to bear fruit to the present time. The humane and scientific treatment inaugurated under his management fifty years ago, will compare favorably with that of the present day in any hos- pital or in any country. Dr. Steuart was a native of Maryland, and both his father and his grand-father-were physicians. He was born in 1797, educated at St. Mary's College, graduated as a physician from the University of Maryland in 1822, and died in 1876, at the age of seventy- nine years. Before closing this brief sketch, it should be again mentioned that it was through Dr. Steuart's influence with Mr. Johns Hopkins—for many years a member of the Board of Visitors as well as a personal friend of Dr. Steuart —that the present site of the Johns Hopkins Hospital was chosen for the location of that magnificent gift to the State of Maryland. Dr. Steuart was succeeded by Dr. J. L. Conrad, who had held the position of resident physician for some time. He remained in charge until March, 1878, and was succeeded by Dr. Richard Gundry in June of that year. Dr. Richard Gundry was an Englishman by birth, and 70 T. O. Powell. was educated in Canada and at Harvard. He was a sup- erintendent of asylums in Ohio for twenty-three years, where he did most admirable work. He was elected to the superintendency of the Maryland Hospital in 1878, and held that position until he died in 1891. He was a man of remarkable ability, a great reader, a fine writer, and a deep thinker. Dr. Rohe succeeded Dr. Gundry, and on his being put in charge of the newly-projected Second Hospital for the Insane, he resigned and was succeeded by Dr. J. Percy Wade, who is now superintendent. The hospital has now four hundred and ninety-five patients, of whom forty-seven are colored. The water supply is abundant, and the hos- pital is heated by steam and lighted by electricity. There are one hundred and thirty-six acres of land, fifty of which are in cultivation and twenty-eight in grass. The buildings are handsome and commodious, and the equipment required for.a first-class hospital is provided. The Second Hospital for the Insane was decided upon in 1894, and an estate near Sykesville, Md., consisting of seven hundred and fifty acres, was selected, and arrangements were made for the erection of buildings consisting of a group of detached cot- tages or pavilions with a service building. In July, 1896, the first patients were received, and at the close of the fiscal year there were twenty-three patients. The hospital is in its infancy, but every provision has been made for its future efficiency. Dr. George H. Rohe is the superin- tendent. While I have not attempted in this paper to give an account of the private asylums for the insane in the South, and have confined myself to the state institutions, I feel that an exception ought to be made in the case of two institutions, the Mount Hope Retreat, near Baltimore, and the Sheppard Asylum for the Insane. The Mount Hope Retreat is an institution for the insane conducted by the Sisters of Charity. Up to 1840 these good women had charge of the insane in the Maryland Hospital, but they then established an independent institution. Dr. Stokes so well known for his many excellencies, was the attend- ing physician for nearly fifty years. Dr. Stokes was born History of Southern Hospitals for the Insane. 7l at Havre de Grace and educated in Baltimore. He spent a few years in Mobile where he passed through two yellow fever epidemics, then traveled in Europe and studied in Dublin. Returning to Baltimore in 1842 he was chosen as attending physician to St. Vincent's Asylum, which was subsequently called Mt. Hope Retreat, and remained in charge until shortly before his death, which took place in 1893. He was a man of fine attainments, and had con- ferred upon him many of the honors of his profession. He was an old school Maryland gentleman of courtly dignified bearing, somewhat reserved and quiet, but always warm- hearted. He was succeeded by Dr. Charles G. Hill, who is now superintendent of the Retreat. This is a private institution, but it is most elegantly equipped. It has hand- some well-finished buildings, large grounds, and is admir- ably conducted. It has at the present time . nearly isix hundred patients. The grounds are ample and beautifully laid out. KENTUCKY. Among the early physicians to asylums, Dr. Samuel Theobald, for several years attending physician to the East- ern Kentucky Lunatic Asylum at Lexington, was notable. About 1830 he published an account not only of his insti- tution, but also of the care of the insane in Kentucky prior to the establishment of the asylum for the insane.* Dr. Theobald says that in the early days Kentucky, like most of her sister states, provided for her insane paupers by the appointment of one or more individuals to take care of them upon terms fixed at the discretion of the judge before whom the case was presented. For this purpose the state paid $15,500 in 1822 and $18,000 the following year. The disadvantages of the existing system were so apparent, and the needs of better provision so great, that in 1821, Governor Adair said in his message to the legisla- ture that the old system of supporting the insane had proved to be wholly inadequate to the purpose of restora- tion to mental soundness. He therefore proposed that the state establish an asylum for the insane, giving as an addit- •Transylvania Journal of Medicine 1829-1830. 72 T. O. Powell. ional reason that, "if only one out of twenty of those unfortunate beings, laboring under the most dreadful of all maladies, should be restored, will it not be a cause of great gratulation to a humane and generous public." Governor Adair also urged as one reason for establishing a State insane asylum that "it would prove highly beneficial to the medical school of Transylvania University, which would in time repay the obligation by useful discoveries in the treat- ment of mental maladies." In 1822, in consequence of this appeal, the legislature of Kentucky, for humane and politic motives, decided upon the establishment of an asylum for the insane. The sum of 510,000 was appropriated for the purpose of carrying the act into effect. The commissioners appointed in accordance with the act proceeded promptly to the selection of an advantageous site containing about sev- enteen acres, and having thereon a spring of never-failing water. The tract selected had also a large and handsome brick edifice which had been constructed about the year 1817 by an association of individuals as a private hospital, called the Fayette Hospital, for the diseased of every char- acter; but the company had failed in this humane inten- tion and the building remained unfinished and unoccupied. Having purchased this property the commission pro- ceeded immediately to have the building finished, and such additional improvements made as were then deemed ade- quate to the object in view. On May 1, 1824, the house was opened for the reception of patients. The commission of ten deputed to carry into operation the act relating to the asylum "were required scrupulously and carefully to examine the case of every subject brought to the asylum, distinguishing by all means in their power between such persons as might be sick or imbecile only, and such as were actually insane or of unsound mind—admitting only the latter. Also carefully to distinguish maniacs, or persons who are dangerous, from such as are quiet and peaceable, making orders for their confinement or otherwise. The first day of May ensuing the passage of the act was fixed as the period at which all laws committing persons of unsound mind to the care of committees, and charging the History of Southern Hospitals for the Insane. 73 treasury of the state therewith, should cease; and that thereafter the care and safe keeping of all such persons should be confided to the lunatic asylum." The commission was further invested with full power to discharge restored patients. It was further enacted that no person should be supported at the asylum at the public charge who had an estate for his support. Andrew Stainton was made super- intendent and Dr. James C. Cross was appointed resident or house physician. The medical faculty of Transylvania University, then a famous medical school, in a spirit of humanity and liberality which reflects much honor on them, tendered their services gratuitously as consulting physicians. In a short time Dr. Cross resigned. He was succeeded by Dr. William L. Thompson, who also had a short service. Dr. Theobald became attending physician in January, 1826, and served several years. The laws of Kentucky in 1842 still allowed the quiet and peaceable to be maintained at their own homes out of the public treasury. There was also considerable prejudice against hospital establishments so that few but the worst cases either of paupers or the wealthier class were sent to the asylum. The asylum was primarily intended for the insane poor alone, but for some years before 1842, had received several other patients from Kentucky and other states at the cost of two dollars and fifty cents per week. Dr. Bush was physician to Lexington Asylum in 1841 and his report, according to Dr. Jarvis, showed great improve- ment in the care of the insane and the legislature was inclined to grant desired appropriations. It is interesting to note that tickets of admission to the asylum were issued to the members of the medical class of Transylvania Univer- sity. The faculty of the medical school had the hospital in charge until 1844. It was a mad-house for the safe-keep- ing of lunatics rather than an asylum for their care. With the coming of Dr. J. R. Allen in 1844 there was a decided change for the better. He remained in charge until 1855, when he was succeeded by Dr. W. S. Chipley who held the place for fifteen years. Dr. George Bryant, Dr. Chenault, Dr. W. D. Bullard and Dr. F. H. 74 T. O. Powell. Clark all had short terms, and January, 1896, Dr. W. E. Scott, the present superintendent, was appointed. We learn from a report of Dr. Scott, that the farm consists of two hundred and fifty acres of land; that there were in the asylum in September, 1896, seven hundred and ninety-one persons, of whom one hundred and twenty-eight were col- ored. The buildings, Dr. Scott reports, have some of them stood for eighty years, and should be removed and better buildings erected. WESTERN KENTUCKY LUNATIC ASYLUM. The foundation of the institution was laid in 1849. The building was opened for patients in September, 1854. It was burned in 1860, rebuilt in 1861 and 1862, and re- opened in 1863. The first superintendent was Dr. Samuel Annan, who was in charge from 1855 to 1857. He was succeeded by Dr. Francis G. Montgomery who remained in office until 1863, when he was in turn succeeded by Dr. James Rodman, who was superintendent of the institution continuously to April 20, 1889. Then Dr. Barton W. Stone was appointed superintendent. He continued in office until January 30, 1896, when he was succeeded by Dr. Ben Letcher, who is still in charge. The cost of the buildings as they now stand is about $310,000. They have a capacity of five hundred and fifty patients. The asylum has been overcrowded with patients for the past ten years and now has an insane population of six hundred and twenty-five. The first provision for admission of colored patients was in February, 1879. The colored population is now about one hundred and twenty-five. The Eastern Kentucky Asylum admitted all the colored insane of the state up to February, 1879. At the present time all asylums admit the colored insane of their respective districts. CENTRAL KENTUCKY ASYLUM. The asylum now know as the Central Kentucky Asylum was opened in August, 1893, under the care of Dr. C. C. Forbes. The buildings, which had been designed as an Industrial School for Juvenile Delinquents, were adapted to the uses of the hospital, and when the institution began its work, had a capacity for one hundred and seventy patients. History of Southern Hospitals for the Insane. 75 Dr. Forbes remained in charge for nearly five years. Dr. Gale succeeded him and remained in charge for nearly five years more. Dr. Henry K. Pusey, who followed him, was in charge of the institution for two terms, from 1884 to 1886, and from 1891 to 1896, Dr. Burns succeeding his first term. Dr. H. F. McNary is now in charge.* The institution, as will be seen, has had a number of superintendents, but perhaps to none of them was it as much indebted as to Dr. Pusey, who was in charge of it for two terms and whrfdied while he was super- intendent, on December 2, 1896. Dr. Pusey was a recog- nized authority upon hospital architecture and sanitation, and he was one of the first to favor the building of houses for the insane no more than two stories in height. The Board of Directors of the Lakeland Asylum for the Insane testified their appreciation of him by passing suitable resolutions, and by naming the latest addition to the asylum buildings "Pusey Hall." The sentiment of the legislature, largely influenced by him, became more and more liberal, and appropriations of a more generous kind were made, until at the present time the institution'has one thousand two hundred patients under its care, white and colored. It is well equipped in every respect, has electric lights and a full water supply, commo- dious and attractive buildings, and large grounds of five hun- dred and fifty acres, of which seventy acres are in the garden. There is a building for colored patients, of whom there are now two hundred in the asylum. WEST VIRGINIA. When West Virginia was a part of the present State of Virginia it was decided by the general assembly to establish an asylum for the insane in the far west of the state, and Weston was selected as the point. The first report of the directors was made in 1859. The asylum, though completed, was not opened for some years. The war came on, and the State of West Virginia was separated from the old State. It was not until 1864 that the institution began its work. During the war the State of Ohio had received in its asylum at Columbus the insane from West Virginia. Before the war •Dr. McNary died May 12, 1897. 76 T. O. Powell. they had been sent to Staunton and Williamsburg. As soon as the West Virginia Hospital was able to receive them, the patients came from each of these institutions. Dr. Hilis, of Columbus, Ohio, was the first superintendent, and retained his place until 1871, when he was superseded by Dr. Cam- den. Dr. Hilis had been superintendent of the Asylum for the Insane at Columbus, and after leaving the asylum he traveled extensively in Europe, and then returning to Ohio became superintendent of 5 Reform School for Girls. He died about 1890. Dr. Camden was in charge of the institution until 1881, about ten years, when he resigned, and was sup- erseded by Dr. Bland, who remained in charge for two years only. Dr. Lewis, who succeeded him, was in charge for five years, and was followed by Dr. W. P. Crumbacker, the present superintendent. The institution rs well equipped. The buildings are commodious and attractive. The section in which they are located is picturesque and healthful, and the provisions for the insane ample to meet all demands, since the establishment of a second hospital at Spencer. There are now in the asylum at Weston nine hundred and thirty-eight patients. The asylum at Spencer was completed in 1893. The buildings are of brick and stone, with slate roofs and iron stairways, and the asylum is equipped with everything necessary and convenient. The buildings are heated and ventilated with the fan system, and with a capacity for a temperature of seventy-two degrees. The asylum is cap- able of providing for four hundred and fifty patients. It has one hundred and fifty acres of land connected with it, and the buildings have cost up to this time over $200,000. The institution has in it now two hundred and thirty-five patients and is under the superintendency of Dr. W. D. Row. It is located in a healthful mountain town, and, with every- thing favoring health of body and mind, it is admirably adapted to do the work for which it was designed. NORTH CAROLINA. The public benefactress of the insane, Miss Dix, vis- ited North Carolina to interest the people in making some provisions for the proper care of the insane. There were History of Southern Hospitals for the Insane. 77 at that time but few great railroads in the state, and she was compelled to undergo the great inconvenience and even hardship of the primitive means of travel to visit the remote mountain counties, but no hardship or privation for a moment deterred her. While a favorable public sentiment to some extent throughout North Carolina had been awak- ened by her efforts, when the legislature assembled she met with great opposition from the small politicians of that body. Hon. J. C. Dobbin, afterwards Secretary of the Navy, was Speaker of the house. She attempted to secure Mr. Dobbin's co-operation and valuable aid by interesting his wife in the cause. Mrs. Dobbin became deeply inter- ested in the enterprise, but unfortunately died during the session of the legislature, and before she had succeeded in greatly interesting her distinguished husband in the good work. Failure now appeared to be inevitable. Miss Dix, not discouraged, and with the ready tact of her sex, appealed pathetically to him in the name of his wife, and as a memorial to her to arouse himself and give his great influence in behalf of his afflicted fellow citizens. He went to the hall of the house, descended from the chair to the floor, and it is said made the most eloquent and effective speech ever delivered before a North Carolina legislature. It took the body by storm, and from that moment the establishment of the hospital was an assured fact. A bill was passed in 1849 establishing a state hospital for the insane to be located on a beautiful river near Raleigh, and named in honor of the distinguished lady, Dix Hill. Dr. Strudwick, of Hillsboro, was elected first superin- tendent, but declined, feeling himself incompetent by reason of the fact that he had no experience in the care and treat- ment of the insane. Dr. Edward C. Fisher, an assistant physician at the asylum in Staunton, Virginia, was then elected superintendent of construction. When he assumed supervision of construction the massive stone foundation of the main building had been laid and the walls of the cen- tral portion and north wing had been completed and cov- ered. The original plan did not permit all that might have been desired; it, however, embodied the main features most 78 T. O. Powell. to be desired in a hospital building for the insane. Through- out the process of construction the work of Dr. Fisher was characterized by careful economy and conscientious and untiring faithfulness to the duties incumbent upon him. On October 1, 1855, he was elected superintendent and physi- cian of the North Carolina Insane Asylum. The first patient was admitted by him to the asylum on February 22, 1856. Dr. Edward Fisher was superintendent and resident physician until July 7, 1868. During the period of re-con- struction he was removed for political motives by the Republican party, but about 1871 he again became con- nected with the asylum for the insane at Staunton, Vir- ginia. In 1881 during the readjustment turmoil in that state he was again removed from his active life work,vs but was restored to his place in 1884 and remained until his death. He was the pioneer of the work for the insane in North Carolina, and there is no sadder chapter in the his- tory of the institution at Raleigh than his displacement. He was a competent alienist, a gentleman, modest, bright, noble and blameless, and his life was one of long useful- ness. He was born in Richmond, Va., in 1809, and died at Staunton in 1890. Dr. Fisher was succeeded at Raleigh by Dr. Eugene Grissom, and he by Dr. W. R. Wood, who served one term and resigned, and he by Dr. George L. Kirby, who is still in charge. The present capacity of the institution is four hundred and twenty patients. Much of the credit of this institution is due to Dr. Francis Taylor Fuller. He was the first assistant physician for nearly forty years. The following extract is taken from the North Carolina MedicalJournal, October, 1893: "Dr. Fuller was born in Granville county, North Caro- lina, June 14, 1835, and died September 14, 1894. He was educated at South Lowell Academy, in Orange county, afterwards teaching school for a time before commencing the study of medicine. He graduated in the Medical De- partment of the University of Pennsylvania in the spring of 1856, and in a short time thereafter he was elected assistant physician in the North Carolina Insane Asylum at Raleigh, and entered upon his life-long work. For twelve History of Southern Hospitals for the Insane. 79 years he served as assistant physician to that excellent, intelligent, Christian gentleman, Dr. Edward C. Fisher, superintendent, who was a model of all that was required in a man to administer to the mental, moral and physical diseases of those under his care. For twenty-one years he was the assistant physician under Dr. Eugene Grissom, of Granville county, who succeeded Dr. Fisher in 1868. Dur- ing all these years his intelligent, faithful service was justly appreciated by these gentlemen. No man was ever more faithful and devoted to his work than he. He loved the institution and its inmates and devoted his life to their welfare. He was an intelligent, high toned, Christian gentleman, honorable and upright in everything." MORGANTON, NORTH CAROLINA. In 1875 a new asylum was erected at Morganton in the western part of the state. The State Hospital at Morgan- ton in the mountain region, commands one of the finest landscapes to be found in the South, and shows a death rate so low as to be of general remark in the reports. It is built of brick on the Kirkbride plan, having a frontage of nine hundred and eighteen feet and a depth of forty feet. Dr. P. L. Murphy, having been elected superintend- ent in December, 1882, has been in continuous charge since its opening in April, 1883. Attached to this institution is a large and finely conducted farm, which has been a source of profit to the state and of incalculable usefulness to the patients in supplying them with an elective employment suited to the former life of the greater number and recre- ative to all. All modern appliances in construction and design are found here. The present capacity of the insti- tution is seven hundred and eighty-five. The number of patients is, male, three hundred and forty; female, four hundred and twenty-five. The cottage plan, as advocated by Dr. Murphy, has been endorsed by the present legisla- ture, though no appropriation will be made until 1898 to provide for the large number of insane in the Morganton district now in the jails and poor-houses or confined at home. Congregate dining-rooms have been erected in the rear 80 T. O. Powell. of each wing of the main building. The non-restraint system prevails. The record of cures for the past year is over fifty per cent.; the average for the entire period is about forty-two per cent., and this despite the fact that upon the opening of the hospital it received by transfer from the parent institution at Raleigh all the chronic insane resident in the Western district. The water supply of the hospital is abundant, and great care is taken to preserve its purity, the whole water-shed being the property of the state, much of it being in original growth timber. A hook and ladder company has been organized from the employees of the institution, and a large reservoir affords quick com- mand of water in case of fire. Besides this, fire-proof sec- tions are built between the wings and the administration building so as to isolate and confine to one section any flame that may break out. The complete ventilation of the entire building is effected by rotary fans in the engine room. This institution has the reputation of being the model institution in the South, both in construction and administration. EASTERN ASYLUM FOR COLORED INSANE, GOLDSBORO. The large number of negroes in the eastern portion of the state, and the great increase of insanity among them, made larger accommodations necessary, and an asylum exclusively for the colored insane was decided upon. In March, 1875, the general assembly of North Carolina appro- priated $10,000 to provide a branch asylum for the colored insane at Wilmington, to be subject to the same superin- tendence, rules and regulations as the institutions for the whites at Raleigh, where some negroes had been under care since emancipation. The act also provided that the expenditure for each patient should not exceed two hundred dollars per annum. As the directors empowered to carry out the purpose of this act were unable to effect a lease of the Marine Hospital building at Wilmington, the first steps toward establishing a separate hospital for the colored insane of North Carolina were temporarily obstructed. They finally located the Eastern Hospital, as it is called, two miles west of the city of Goldsboro, on an eminence near Little River. The History of Southern Hospitals for the Insane. 81 building was completed and ready for the admission of pa- tients August 1, 1880. The buildings are commodious and handsome and have a capacity of four hundred and twenty- five patients. The present number is three hundred and eight. There are attached to this institution three hundred and twenty acres of land, but much of it skirts the river, and being subject to overflow, is not cultivated. The amount farmed is one hundred and seventy-five acres, and the pro- ducts are such as are consumed by the population of the asylum. The institution is in successful operation and doing a good work. Dr. W. H. Moore was the first superintend- ent, but served only a few months, when he died. Dr. J. B. Roberts was elected his successor, and served for six years. He was then succeeded by Dr. J. F. Miller, who is still in charge. SOUTH CAROLINA. In the early days of the South Carolina colony, as was probably the case in all the colonies, the insane, whether free or slaves, were cared for in almshouses where such existed, but the pauper insane, white and black, were pro- vided for and supported at the expense of the parish. Dur- ing the excitement before the revolutionary war concerning the stamp act, it appears from incidental allusion that a mad-house, as it was called, existed in Charleston, but we have no definite information about ,i1^ In 1821, through the combined efforts of Mr. Farrow of Spartanburg, and Mr. Crafts of Charleston, the legislature passed an act appro- priating $30,000 for the erection of an asylum for the insane, and a school for the deaf and dumb, in Columbia, the State capital. The commission appointed to investigate the sub- ject reported that the association of the two classes in one institution was impracticable. The whole amount was expended in the erection of an asylum for idiots, the insane and epileptics. Not until 1828 was the institution ready for the reception of patients, when its doors were opened alike to pauper and pay patients, the paupers being supported by the counties. The institution was managed by nine trustees, or regents, who were residents of Columbia. Dr. James Davis, for many years an eminent practitioner of the 82 T. O. Powell. city, was made visiting physician, and a layman was made superintendent. Of Dr. Davis (born in December, 1775; died August 4, 1838) it was written: "He was a man of genius and learning, and would have been distinguished in any intellectual pursuit to which he had directed his atten- tion. Devoted to his profession, he brought to his practice a rare combination of all the qualities requisite to success— knowledge, sagacity, energy and enthusiasm. He was the earliest and most zealous and most efficient contributor to the foundation and success of the Lunatic Asylum." In 1835 Dr. D. H. Trezevant succeeded Dr. Davis, as visiting physician, but like his predecessor, he was able to give the institution only a small part of his time. The undertaking was largely an experiment, and although receiv- ing pay patients from adjoining states, its means of support were very limited. The people had not learned to appre- ciate an institution of this kind, and for eight years the asylum had a feeble life. In that time it had three non- medical superintendents. In 1836 a change was made by the election of Dr. J. W. Parker as superintendent and res- ident physician, but Dr. Trezevant continued his services as visiting physician. These two gentlemen continued to serve the institution in their respective capacities until 1858, when Dr. Trezevant resigned. Dr. Parker continued his connec- tion with the institution for forty-two years. Upon the board of regents had been many of the most broad-minded and public-spirited citizens of the state. In establishing an asylum with the experience of only one state as a guide, it was natural that errors were made by South Carolina. The chief mistake was in locating the institution within a city upon a square of four acres. It's location has always been an obstacle in many ways to its success, and although from time to time great efforts have been made to remove the asylum to the country, it has never been possible to obtain legislative sanction to the step. Errors of construction were also made, which to this day menace the health of the patients who occupy the old building. This was erected according to the ideas of inexperienced men in the first quarter of the century, and still remains in many ways History of Southern Hospitals for the Insane. 83 unchanged. While the institution served for years as a home for many insane not only of South Carolina, but also of North Carolina, Florida, Alabama and Mississippi, it also performed the important service of warning the other Southern States to establish their asylums in the country. In the fifties, increase in the number of insane demanded the erection of new buildings in Columbia or elsewhere. After long and bitter controversies between the regents, the asylum officers themselves, and the members of the legis- lature, it was most unfortunately decided in 1856 to con- tinue the urban policy by building on land separated from the old building by a city street. This step practically committed the state to the policy of maintaining her insane within a city. The appropriations permitted the erection of only the first section of the south wing before the war, and by slow additions a building on the linear plan, accommo- dating four hundred and fifty patients, was completed in 1885. The institution was most creditably maintained during the civil war through the energy and foresight of Dr. Parker, the superintendent. In passing, it may be remarked that the maintenance of our insane hospitals during the four years' struggle is an important chapter in the history of these institutions, and is most worthy of separate mention in our chronicles. During the period of reconstruction Dr. J. F. Ensor suc- ceeded Dr. Parker as superintendent. Dr. Ensor discharged his difficult duties with fidelity, even to the point of getting supplies on his personal credit when the Governor of the State refused his endorsement. Under his advice South Carolina adopted the principle of state care for all pauper insane as early as 1870. In 1876 Dr. P. E. Griffin succeeded Dr. Ensor. Under his administration the institution purchased more land, bringing the total acreage up to three hundred and fifty. Additional wards of brick were added to the new build- ing, until it was finally completed. Dr. J. W. Babcock suc- ceeded Dr. Griffin in 1891. As the last three gentlemen are still living, further comment upon their work is omitted. To-day the institution consists of the old building, accom- modating two hundred patients, the new building with four 84 T. O. Powell. hundred and fifty beds, nine wooden pavilions for colored patients, a cottage for Miss Dix, accommodating thirty white women of the quiet class, three buildings for officers and families. Within two years the old style name of asylum has been changed to State Hospital. There are four infirmary wards, and a training school has been in operation since 1892. By the purchase of adjoining property and the closing of streets the whole hospital has been brought into one enclosure, and the grounds afford ample room for exercise and recreation. The institution is lighted by electricity, and gets its water supply from the city. The property consists of three hundred and fifty acres, of which two hundred and thirty acres are fertile farming lands. The crops produced aid materially in the support of the insti- tution. A brick structure now being built for colored men bears the honored name of Parker. The hospital is dis- charging a useful function in the state, and is meeting with what legislative aid it asks for- and deserves. The last report shows a daily average of eight hundred and fifty-four. GEORGIA. Up to 1837 Georgia had made no provision for the care of her insane. They were not many, but they were fearfully neglected. That year there came to Milledgeville a Northern philanthropist, whose object was to petition the legislature to do something for them. "No blarinfj trumpet sounded out his fame; He lived, he died—I do not know his name" Milledgeville, the town in which the legislature met, had a small faculty of distinguished physicians, Drs. White, Fort, Case and Green, and he solicited and received their hearty co-operation in his worthy effort. These physicians, aided by Drs. Phillips and Arnold and Judge Harris, who were members of the legislature, appealed^to that body for assistance. The legislature yielded somewhat reluctantly to their entreaty, made an appropriation, and apppointed a commission. The commission bought for a small price forty acres of sterile pine land located on a high hill overlooking the town, and situated about two miles from it. Plans for buildings were secured and work was begun, but in the History of Southern Hospitals for the Insane. 85 early part of 1842 none of the buildings were finished. It was a time of great financial depression, and the state was burdened with debt so that the legislature ordered all work to be confined to one building. This was made ready to receive patients, and in December, 1842, the first patient was admitted. The plan of self-support was adopted. The counties were to pay the expenses of their pauper patients, and the friends of patients who were able to pay were to provide for their dependents. This plan was changed to State care of the pauper insane about 1846. Up to 1877 patients were received from other states, but at that time the general assembly passed an act sending all non-resident patients to their respective states, on account of the over- crowded condition of the institution. During the same year an act was passed making the institution free to all bona fide citizens of the state. This act also provided that relatives of patients could deposit with the steward funds for extras to be used by the patients individually, but no part of this was to go to the support of the institution. When the institution was first opened it was in charge of a layman, and a physician was employed only when his services were needed. These methods were gradually changed. In 1843 Dr. David Cooper was elected superin- tendent. He was a man of ability, but of great eccentricity, and was entirely unacquainted with the real demands of his work. Had he known these demands, he would have found it difficult in the state of things then existing to have com- plied with them. He retained his position three years, and during that time had but few patients. The attention of the trustees had been directed to Dr. Thomas F. Green as one who was likely to succeed with a very unpromising enterprise, and he was persuaded to accept the superinten- dency. Dr. Green was the son of an Irish exile who was in the rebellion of 1798. His father was a physician, a man of high culture, and was professor in the State Uni- versity. Dr. Green was born in Beaufort, S. C., in 1803. He received his general education at the State University in Georgia, and medical, at Charleston, S. C. He settled in Milledgeville as a physician, and was a successful and pop- 86 T. O. Powell. ular practitioner when he was chosen as superintendent of the asylum. The patients he found in the asylum were of the worst possible description. Only those who were a burden at home, and for whose recovery there was no hope, were sent to the asylum, which being regarded as a mad- house, inspired the people with terror. While Dr. Green had a difficult task before him he was admirably adapted to perform it. He was a man of kindest heart, most genial manner, and of great enterprise and energy. He soon secured the confidence not only of the patients, but of the people of the whole state as well. He succeeded in obtaining appropriations year after year, in making improvements, in securing a suitable corps of attend- ants, and in every way providing for the treatment of the insane. He had helpful assistance in the visit of Miss Dix in 1852, and, being himself a man of great intelligence, his own measures were eminently wise. He remained in charge of the asylum from 1847 fo 1879, when in the beauty of a happy and serene old age, with eye undimmed and undi- minished mental vigor, he suddenly passed away. His monument was the magnificent institution which he had watched over almost from its foundation. For twenty years Dr. Green and myself had been associated as colleagues in the management of the asylum, and when he died I was selected to take charge of it. 1 have been in charge for nearly twenty years, and in connection with the institution for thirty-five years. In none of the exciting political cam- paigns of the state has there been at any time any decided interference with this benevolence, and the legislatures have generously and generally granted all the requests made by those in charge. The asylum is charmingly located. A magnificent view is had from every direction, and perhaps in no part of the land is there a better health record. The completion of the second building in 1847 enabled the trustees to make markedly beneficial changes in the asylum. The female patients were placed in the new building, thus entirely sep- arating them from the males. This enlargement also offered greater facilities, and the increased appropriations of money Histoty of Southern Hospitals for the Insane. 87 for maintenance enabled the authorities to make many improvements, the substitution of white attendants for negroes, who had formerly discharged this duty, being one of them. In 1849 it was found urgently necessary to make additional provision for the insane of the state. Plans and estimates were submitted to the legislature for enlarging the asylum accommodations. The plan contemplated a large, showy building to be erected in front of the existing wings, and additions to the latter which would make the structure in the shape of the capital "E," or, as it is called, the Kirkbride plan. The legislature appropriated $10,500, and in 1841 $24,500 for the enlargement of the institution. Every dollar of this appropriation was expended upon the foundation of the present center building before the walls had reached the surface of the site. Supplemental appro- priations were made as follows: 1853, $56,500; 1855, $110,000; 1857, $63,500; 1858, $30,000. The building was completed in 1858. In addition to furnishing quarters for asylum officials and necessary offices, it provides accommo- dations for a large number of patients, each patient occu- pying a separate room ten by twelve feet. This building, as all others attached to it, is divided into sections or wards, each provided with a dining-room, parlor, etc., and all mod- ern improvements. In 1870 and 1871 an appropriation amounting to $105,855 was voted for enlargement of the asylum. This sum was expended in enlarging the main building. In 1881 at the urgent solicitation of the board of trustees the legislature decided to erect two separate build- ings for white convalescents, one for males and the other for females, and appropriated $165,000 for this purpose. In 1883 a supplemental appropriation amounting to $92,875 was voted by the legislature. In 1893 the legislature, after an urgent appeal from the board of trustees, voted $100,000 for the erection of additional buildings for white and colored insane. The building for whites has a capacity for six hundred patients, and the two annexes to the building for negroes will afford accommodation for about three hundred patients. The emancipation of the negro population in 1865 88 T. O. Powell. necessitatsd asylum accommodations for the insane of this race. In 1866 the legislature apppropriated $11,000 for an insane asylum for negroes. The building was located on the grounds of the asylum for the whites. In 1860 addi- tionalTaccommodations for this class being deemed necessary, the legislature appropriated $18,000 for enlargement of the building for negroes. In 1879 the legislature appropriated $25,000 for the same purpose, and in 1881 an appropriation of $82,166 for a new building and heating apparatus for the same was made for the colored insane. These several enlargements provided for five hundred and forty-one negroes. The overcrowded condition of the negro building, and the urgent demand for care of a number of negro insane who could not be admitted for want of room, caused the board of trustees to begin enlargement by adding two annexes one hundred and twenty-eight by thirty-one feet each, four stories high, to the existing negro asylum. These additional buildings, as above stated, provide accommodation for about three hundred patients in the negro institution. We have at the present time six hundred and twenty-five negro patients. There have been made from time to time large pur- chases of land adjoining the asylum until the institution now has over three thousand acres in one body. The institution has its own water works, the water being furnished from a bold stream on its own grounds, and has, besides, a well nine hundred and sixty feet deep, much of it through solid rock. The institution has a training school for nurses, and a well-equipped laboratory under an efficient neuro-pathol- ogist. The non-restraint system has prevailed for many years. There are at the present time over two thousand one hundred patients in the institution. The asylum com- prises a number of buildings as follows: First, the main building. The front presents a handsome, showy brick structure, three stories high, of Grecian architecture. With the exception of the capitol building in Atlanta the center asylum building is the handsomest edifice in the state of Georgia. Besides the superintendent's apartments, rooms for visitors and offices, the building accommodates about History of Southern Hospitals for the Insane. 89 five hundred patients, with necessary nurses, etc. Second, two brick buildings for convalescents, three stories high, accommodating one hundred and forty patients each and nurses. These are located on each side of the front of the center building, about five hundred feet from the latter, and about one thousand feet apart. Third, two brick detached buildings, three stories high, in the rear of the center edi- fice, accommodating about one hundred patients each. Fourth, two one-story wooden detached buildings for patients too feeble to ascend to the higher floors, accommodating forty patients each. Fifth, the building for negroes located a quarter of a mile in the rear of the building for whites. This is also of brick, three stories high, and like the build- ing for whites, provided with all modern conveniences. It comfortably provides for six'hundred and fifty insane negroes, besides the supervisor and attendants. About a mile dis- tant from the asylum proper is located the contagious diseases hospital which, as its name indicates, is reserved for treatment of any contagious disease which may be brought into the institution. It accommodates sixty patients and attendants. In addition to the above described build- ings, the new building for whites accommodates six hundred patients. The total cost of the land and buildings is more than one million dollars. ALABAMA. Miss Dix began to agitate the foundation of an asylum for the insane in Alabama in the autumn and winter of 1849. The State Medical Association came to her aid in 1851 and 1852, and through their efforts a bill was intro- duced and passed appropriating $100,000 for this purpose. When this was exhausted $150,000 more was appropriated. The foundation of the building was laid in 1852, and it was ready for occupancy in 1860. The buildings were designed on the Kirkbride plan, and were calculated for three hun- dred and fifty patients. When the institution was ready for opening, and a superintendent was to be chosen, the trustees selected Dr. Peter Bryce, at the instance of Miss Dix, who had met him in Columbia, S. C. He was a young man twenty-six years old when he came to take charge of 90 T. O. Powell. the new enterprise. Dr. Bryce belonged to an excellent South Carolina family, and had been educated at the South Carolina Military Academy. He then graduated in medicine in New York, and afterwards pursued his studies in Europe, especially in Paris. As soon as he returned to America he was selected as assistant physician in the State Lunatic Asylum of South Carolina. Subsequently for a short time he occupied the same position in Trenton, N. J. Although quite a young man, he was selected as the first superin- tendent of the Alabama Insane Asylum. He at once evinced especial fitness for the position to which he had been chosen. He was remarkable for the skill with which he organized and managed an institution of this kind. Possessed of a mind of high order, he had had advantages of unusual value. He, however, had been in this position but a year when the war began, and the great difficulty which all the superintendents found in those trying days, he was com- pelled to meet. He did so successfully. During the darker days of reconstruction he held his place, and amid all per- plexities safely found his way through. He inaugurated great improvements, and during the thirty-two years of his administration he brought the asylum to the front rank among the institutions of its kind. When he died in 1892 there were eleven hundred patients in its care. The legis- lature of Alabama testified its high appreciation of his ser- vices by changing the name of the Alabama Insane Hospital to "Alabama Bryce Insane Hospital." His last resting place is the lawn in front of the institution to which he had devoted his life. This great and good man remarked upon his death-bed that it was "probably a good time" for him to die. He had seen the successful result of his life work, in the excellent name and good condition of the hos- pital, secured almost wholly through his own energy and good judgment. After Dr. Bryce's death, Dr. J. T. Searcy, of Tusca- loosa, who had been president of the board of trustees, was elected superintendent, and is now in efficient charge of the hospital. From his last report it appears that there are about one thousand two hundred and fifty patients now in History of Southern Hospitals for the Insane. 91 the institution. The same general industrial system, by which the patients are employed toward their own support, that has characterized this hospital for a number of years, is maintained with increased success. This hospital over fifteen years ago under Dr. Bryce adopted the non-restraint system of managing patients, which is still advocated and maintained. The institution has a training school for nurses, and a well-equipped laboratory conducted by an efficient neuro-pathologist. The sad fact hitherto noted of the great increase of insanity among negroes demanded separate build- ings for them. As is usual, they are supplied with colored nurses who are under the direction of white physicians and supervisors. There are now about three hundred and fifty negroes in the asylum. About one hundred negro men are colonized about two miles from the main buildings, and have shown the experiment to be a successful one. They are contented, are the healthiest class of patients under this management and by their farm labor contribute largely to the support of the institution. MISSISSIPPI. It was not until 1846 that Mississippi proposed to do anything for her insane people, and then the ideas of the legislature were exceedingly contracted. The bill for the establishment of a hospital consequently failed, but two years afterward was passed. The Governor suggested an appropriation of $3,000, thinking that would be sufficient, and the people of Jackson offered a lot of four acres. The legislature, however, had more liberal views, and appropriated $10,000, and as the lot of four acres was too small, another not far from the city was purchased. The $10,000 was soon expended, and then it was discovered that the work was defective and the expenditure lost. About this time that remarkable woman, Miss Dix, visited the state of Mis- sissippi, and appeared before the legislature and secured an appropriation of $50,000. To this was added another $75,000. Then $30,000 more was found to be needed, and finally the $10,000 intended for the running expenses of the asylum was expended on these buildings. The buildings were at last ready, but there was no money for the main- 92 T. O. Powell. tenance of the patients. The trustees, however, came to the rescue, and giving the Governor sufficient bond to indemnify him in case the legislature refused to reimburse the treasurer, he consented to make the needful advance, and the asylum was opened for the reception of patients in 1855. From 1855 to 1878 there were six different superin- tendents. The first was Dr. W. S. Langley, who served for three years. He was succeeded by Dr. W. B. William- son, who was superintendent one year only and was suc- ceeded by Dr. Robert Kills, who remained in office about six years. Dr. A. B. Cabaniss who succeeded him was superintendent for three years, and was followed by Dr. W. B. Deason who remained in office twelve months. He was succeeded by Dr. W. B. Compton, who was superintendent for eight years. Dr. T. J. Mitchell, the present superin- tendent was elected in 1878. The buildings are commodious, and there is room for over eight hundred and thirty patients, of whom nearly four hundred are colored people. During the year 1892 the center building was consumed by fire, but has since been rebuilt. The demand for accommodation having been too great for a single institution, another was established in Meridian, known as the East Mississippi Asylum. This institution was opened for the reception of patients in 1885. Dr. C. A. Rice was superintendent, and Dr. J. M. Buchanan, assistant superin- tendent. Dr. Rice retained his position for five years when he was succeeded by Dr. Buchanan, who is still in charge. The asylum had a capacity for two hundred and fifty orig- inally, but has since been enlarged, and is now capable of accommodating three hundred patients. There are now in the asylum two hundred and eighty patients. The asylum is built of brick, three stories high, on the Kirkbride plan. It is heated by steam, and water is furnished by a deep well with a capacity of one hundred thousand gallons per day. The patients of the asylum are exclusively white. These two well equipped institutions meet the present demands of the State amply. TENNESSEE. As early as 1830 the attention of the general assembly History of Southern Hospitals for the Insane. 93 of Tennessee was called to the necessity of providing for the insane. An act was passed October 19, 1832, to erect a stone structure to cost $10,000. In 1836, $2,500 was appropriated by the legislature for completing and furnish- ing the institution, and again in 1838, $15,000 more was appropriated for its aid. The original site of this building was immediately in the vicinity of Nashville. It was of moderate capacity, and served as the State Lunatic Asylum until 1852. The first physician elected to take charge of the institution was Dr. John D. Kelly. The office of super- intendent was filled by a layman, and upon this method the asylum was managed ten years. Dr. Kelly was succeeded by Dr. John S. McNairy, who remained in office many years. In the progress of time the old institution was found to be of faulty construction as regarded the health, comfort, and security of the patients. In 1845 an act was passed author- izing the sale of the old asylum and the purchase of a new one. During the legislative session of 1847-48, Miss Dix visited Nashville, and seeing the deplorable accommodations for the insane, made a strong appeal to the legislature. As a result of her efforts, in February, 1848, an act was passed establishing a hospital for the insane. In the same year, two hundred and fifty-five acres of land were pur- chased in one of the healthiest localities in Tennessee about seven miles from Nashville. The site being secured, Dr. John S. Young was appointed superintendent, and Major A. Heiman, architect. The plans finally chosen were based upon those of the Butler Hospital of Providence, R. 1., which in turn were copied by Dr. Luther V. Bell from the asylum at Maidstone, England. The style of architecture is the castellated. The length of the building is three hundred and twenty feet front, east and west. The greatest breadth across the center is ninety-eight feet. The center building and the extremities of the east and west wings are four stories high. In March, 1852, Dr. W. A. Cheatham was made superintendent, and in the following month patients were removed from Nashville to the new institution. In 1855, two hundred acres were added to the asylum tract by purchase. In 1866, an asylum for the colored insane was 94 T. O. Powell. erected several hundred yards from the main building. In March, 1891, a fire destroyed the west wing of the main building, but this has since been rebuilt. There are now four hundred and eighteen patients in the asylum, of whom eighty-nine are colored—fifty-one females and thirty-eight males. Dr. Cheatham remained in charge until August, 1862, when he was arbitrarily removed from office by Andrew Johnson, the military governor of Tennessee, who appointed Dr. W. P. Jones superintendent. Dr. Jones remained in office until, injured by a blow on the head given him by a violent patient, he resigned and was succeeded by Dr. John H. Callender in 1869. Dr. Callender was continuously in office until 1894, when he resigned and established a private sanitarium in Nashville. Dr. John A. Beauchamp was his successor, and is still in charge of the institution. EASTERN HOSPITAL FOR THE INSANE, KNOXVILLE. In 1883, $75,000 was appropriated by the legislature to erect an asylum in East Tennessee on a tract of land near Knoxville, which had previously been secured for that pur- pose. Dr. Michael Campbell was appointed superintendent of construction. On the completion of the building he was elected medical superintendent, and is still in charge of the institution. The buildings have a capacity of from two hundred and fifty to three hundred patients, and cost with furniture, exclusive of land, between $200,000 and $300,000. The grounds include three hundred and five acres. The buildings are of brick in the Norman or castellated style of architecture, lighted by electricity, and heated by steam. The present number of patients is two hundred and eighty- two. , WESTERN HOSPITAL FOR THE INSANE, BOLIVAR. In 1886 a commission to select a site for the Western Hospital was appointed by the legislature. The commis- sioners, J. M. Lea, Dr. J. H. Callender and Dr. William P. Jones, selected a tract of three hundred acres, between two and three miles from Bolivar. The State paid $5,000 and the citizens of the county donated $3,000 to secure the tract. Dr. J. B. Jones was selected as superintendent of construc- tion, and on its completion was elected medical superintend- History of Southern Hospitals for the Insane. 95 ent. It was opened on December 24, 1889, for the reception of patients. The buildings cost $300,000 and have a capacity of from three hundred to three hundred and fifty patients. In 1895, $20,000 was appropriated for building an annex for negroes, providing for one hundred patients. The annex is now (1897) nearly completed. Dr. J. B. Jones died Novem- ber 15, 1890. He was succeeded by Dr. John E. Douglas, the present superintendent. Although so recently established the institution has as many patients as it can well accom- modate. LOUISIANA. For years as many as sixty insane patients were cared for in separate wards in the Charity Hospital at New Orleans. In the report of that hospital to the senate and house of representatives of Louisiana in 1845 it was strongly urged that provision be made for the insane then confined in the hospital. It was also recommended that the place chosen for the site of the proposed asylum be removed from the city where the "advantages derived from rural beauty and profound solitude can be obtained." Such appeals had their effect, and on March 5, 1847, the Governor approved an act to establish an insane asylum in the State of Louisiana. According to this act a board of five administrators was appointed to provide buildings and accommodations for the insane at Jackson. Not more than $10,000 per annum was allowed for the support of the institution. The asylum was ready for occupancy about the middle of November, 1848, when eighty-five patients were removed from the hospital in New Orleans to Jackson. In the first report of the board of administrators, dated January, 1848, we read: "The land on which the asylum is located is within convenient distance of the business part of the pretty village of Jackson, and at all times of easy access to the same; but separated from the noise and bustle of the village by a valley and small stream, which renders it sufficiently secluded to protect the patients from the annoying gaze of the idle and curious." There are about one hundred and fifty acres of land owned by the asylum, one hundred well timbered, and the balance enclosed for the use of the patients. The buildings of the 96 T. 0. Powell. asylum consist of two wings, each ninety-four feet in length and forty-eight feet in depth, three stories high. A sup- plemental act was passed in March, 1848, appropriating $20,000 for the completion of the building then under con- tract. I learn from an early report that employment was recognized as a valuable means of treatment, though for its bearing upon legislation the economical side was dwelt upon. Dr. Preston Pond was the first physician of the institu- tion and James King its first superintendent. This arrange- ment was in accordance with the practice of the first stage of asylum evolution. The institution also received idiotic and feeble-minded youth and criminals, probably from the beginning. Up to 1858 there had been more than six hun- dred admissions. The average number of patients had been, for several years, over a hundred. In that year the annual appropriations of the legislature for the support of the insti- tution were about $20,000, and there were in the asylum one hundred and twenty-four patients; of these, nine males and three females were pay patients. Among the state patients were eight free persons of color. Two-thirds, at least, of the patients were of foreign birth, principally Irish and German, and these were mostly brought from the city of New Orleans. Dr. J. D. Barkdull was superintendent in 1857. During the period of reconstruction, because of the injunctions upon the state treasurer against issuing the appropriations, it became necessary at times to raise funds upon the private security of the superintendent and others. At one period so great was the distress that the officers were tempted to throw open the gates and let the patients go forth to beg their daily bread. Dr. J. W. Jones was superintendent at the time, and it was mainly through his importunities that such a calamity was averted. In 1879, owing to the inadequacy of accommodation for patients at Jackson, the city of New Orleans was compelled to make provision for its own insane. There were also many insane confined in the parish jails. Brick were made in part by the labor of patients, and the foundation of the extreme west wing was laid and almost completed by 1882. Dr. A, Gayden was superintendent from to 1897, when he was History of Southern Hospitals for the Insane. 97 succeeded by Dr. George A. B. Hays, who is now in charge. MISSOURI. The State of Missouri began her work for the insane at about the time in which so many Southern institutions were established. State Lunatic Asylum No. 1 was located at Fulton and opened for the admission of patients in 1851, under charge of Dr. Turner R. H. Smith, of Columbia, Mo., who remained in charge until 1861 when, owing to the dis- turbed condition of affairs, the asylum was closed for two years. In 1863 it was reopened, and Dr. Smith was again made superintendent, but resigned at the end of his term in 1865. Dr. Rufus Abbott, first assistant, temporarily suc- ceeded until October 26, 1866, when Dr. Charles H. Hughes, of St. Louis, who had served for more than a year on the board of managers, was elected superintendent. He served the regular term of two years, and was re-elected for a sec- ond term of five years, but after serving three years he resigned, and traveled for a time to recuperate his shattered health. On his return he took up his residence in St. Louis, and began his professional life anew, founding the ALIENIST AND NEUROLOGIST in 1880, which he still edits, and engaging in the practice of neurological and psychological medicine. During Dr. Hughes' incumbency the institution was materially advanced in the direction of the needs of the modern hospital. Tramways were placed in the basement, a large gymnasium and bowling alley were built, improved cooking, heating and laundry apparatus were supplied, and post-mortems on the brain were conducted. He was a believer in therapy for melancholia, in music, labor, recrea- tion, a liberal dietary, and in the law of kindness to all. He says, "The dietary of an insane hospital should not only be wholesome, but substantial and abounding in variety. The clothing of a patient materially influences the result of treatment, music and recreation play an important part, and patients are frequently curative of each other." In those atonic states of the nervous system accompanying melan- cholia and hysteria, he said, in 1870, "No tonic proves so speedily and certainly reconstructive of weakened nerve power as nux vomica, iron and opium, combined as circum- 98 T. O. Powell. stances may require, with aloin and proto-iodide of mercury." Beginning at page twenty-three of his report for 1868, his chapter on "Treatment" is fully up to date, and is some- what in advance of the prevailing therapeutic skepticism of that time in our hospitals for the insane. He also in 1870 recommended separate provision and specially constructed hospitals for the epileptic insane, with rubber cushioned walls and floors, and without exposed heating coils. Dr. Hughes was followed temporarily by Dr. John How- ard, of Fulton, and he in 1872 by Dr. Smith, who remained in charge until his death in 1885. Dr. Smith was a Ken- tuckian by birth. He received his medical degree from Transylvania University. He removed from Kentucky to Missouri, and was engaged in the practice of medicine in Columbia when he was first invited to take the superin- tendency of the asylum. He was a man of fine presence, strong intellect, modest, firm and gentle; was conscientious and philanthropic, and in every way qualified for his respon- sible place. He was succeeded by Dr. W. R. Rhodes, and he by Dr. LeGrand Atwood, who was followed by Dr. R. S. Wilson. Dr. Warden, who succeeded Dr. Wilson, remained in charge until a few weeks ago when he was replaced by Dr. Coombs, a homoeopathic physician. During the month of April just passed, by an unpre- cedentedly autocratic edict of the Governor, this institution passed entirely into the hands of the homeopaths, members of the board being summarily removed for that purpose, the position of druggist being abolished, and the entire medical staff made up of young novices in psychiatry contrary to the statutes of the state which provide that the "Superin- tendent shall be a physician of knowledge, skill, and ability in his profession, and of special skill and experience with the insane." The asylum buildings are located on a tract of land of five hundred and forty acres; are of brick, built on the Kirkbride plan and are commodious and attractive. The asylum is supplied with water from a well one thousand feet deep, and has all the equipment necessary to make its work effective. It now has six hundred and twenty patients. History of Southern Hospitals for the Insane. 99 The growing population of Missouri, and its wide extent of territory, led the legislature to provide for a third asylum, which was located in Southwestern Missouri at Nevada. It was opened for the reception of patients in 1887. It was well equipped from the beginning. Its buildings are comely and commodious, and admirably designed for the work the asylum has to do. The asylum has under its charge at this time five hundred and seventy-seven patients. It is main- tained partly by the counties supporting the pauper patients, and partly by those who are able to pay. There is a large, productive farm connection. Dr. R. E. Young was its first superintendent, and he was succeeded by the present incum- bent, Dr. J. F. Robinson, a graduate of the Missouri State University and of Jefferson Medical College. The institu- tion seems to be well equipped and admirably managed. ARKANSAS. Up to 1883 the insane of Arkansas were confined in so- called poor-houses and jails. Then an institution for their relief was established, largely through the influence of Dr. P. O. Hooper, the present superintendent, who was presi- dent of the board of trustees. Dr. C. C. Forbes, who was superintendent of the hospital at Lakeland, Ky., was chosen superintendent, and held the position for over two years. Dr. Forbes having resigned, Dr. Hooper was placed in charge. New buildings were erected, and the asylum orig- inally designed for two hundred and fifty was enlarged until six hundred patients were housed within its walls. After holding the office of superintendent for nine years Dr. Hooper resigned. He was succeeded by Dr. Robertson, who vacated the office after a three years' term, and Dr. Hooper was again placed in charge. The institution is located at Little Rock, and receives whites and negroes alike. TEXAS. An act creating the Texas State Lunatic Asylum was passed August 28, 1856. In May, 1857, Governor Pease appointed as superintendent of construction, Dr. J. C. Perry, who, however, remained in charge for one'year only. The institution was located upon a slight elevation two and one- half miles north of Austin. The buildings were finished in 100 T. 0. Powell. the winter of 1860, under the supervision of Dr. B. Graham, who was an appointee of Gen. Sam. Houston. The insti- tution was organized and opened in March, 1861. A noble beginning was thus made, but its usefulness was destined to be hampered and checked for years, by war and its con- sequences. Dr. Graham was superseded early in the war, and from 1861 to 1869 nothing was done in the way of add- ing to or improving the buildings. In that time three or four different persons held the superintendency, and Dr. Graham in 1869 held his third commission. In that year the average number of patients was seventy, of whom three or four were colored. The law gave recent cases the pref- erence over those of long standing. In 1871 there was a combined hostility by the state comptroller and state treas- urer against the board of managers and superintendent. The credit of the institution was finally so impaired that there was danger of its being forced to turn patients out and abandon its work. Dr. G. F. Weisselberg, the superintendent, in 1871, memorialized the legislature for means to build, saying, "A state that can expend millions of dollars for public purposes such as railroads, should be able to spend i860,000 to found a home for this most unfortunate class of humanity." The legislature did not respond to this appeal. During the first eighteen years one thousand one hundred and eighty-nine patients were admitted. From the close of the war there were incessant but ineffective demands upon the legislature for the means to provide more accommodation. In 1879 Dr. W. E. Saunders, then superintendent, asked for $50,000 to complete the west wing according to the original plan. He was given gll.OOO for improvements, and out of this sum it was expected that the additional number of patients would be supported. The institution is badly crowded, and from the report of the superintendent it appears that more than half of the applicants for admission during the past year were rejected for want of room. The present legislature is making provision for a badly needed addition to the asylum. There are now five hundred and ninety-one white and one hundred and nine colored patients. The institution is sup- History of Southern Hospitals foi the Insane. 101 plied with electric lights and an abundance of water, by contract. There is a large farm and garden connected with the asylum. In 1883 an asylum was located at Terrell, in North Texas, and placed under the charge of Dr. D. R. Wallace. Dr. Wallace has had more experience, and perhaps has done more for the care of the insane, and served longer as superintendent, than any other man in Texas, his term of office being about thirteen years. The institution has a capacity of eight hundred and fifty patients, is well equipped in every way, and has been pronounced, says Dr. Wallace, an institution of typical excellence. Dr. Gaillard is at pres- ent in charge. The Southwestern Hospital for the Insane was located at San Antonio and opened for the reception of patients April, 1892. It has six hundred and forty acres ,of land beautifully located on the banks of the San Antonio river. During the last session of the legislature $170,000 was appropriated for new buildings to accommodate three hundred white and two hundred colored patients, and also an infirm- ary. It has an abundant supply of water from the river. The number of patients in the asylum at the'close of the last fiscal year was two hundred and seventy-one. Dr. W. L. Barker was superintendent for the first three years of the asylum's existence. Dr. Worsham followed him for one year, and now Dr. McGregor is in charge. FLORIDA. The insane of Florida were cared for in the asylums of other states—Georgia, South Carolina and Alabama, at the expense of Florida until 1877. Georgia had received the larger number of the patients, but the legislature of that state having ordered the return of the patients not resident citizens on account of the crowded condition of the Georgia asylum, Florida decided to establish an institution of its own. An old fortress with its barracks was chosen. It was located in the western part of the state near the Chatta- hoochie river, in the village of Chattahoochie. It had a capacity of two hundred and fifty patients, and has since been enlarged until it can provide for seven hundred and 102 T. O. Powell. fifty. There are at present within its walls three hundred and eighty-four patients. The asylum has had in the twenty years of its existence eight superintendents, and is now in charge of J. W. Trammell, layman, as superintend- ent, and Dr. L. D. Blocker, physician. ADDENDUM NO. 1. The ordeal that asylums passed through during the late war and the period of reconstruction can now be but faintly realized. The demand for soldiers called every able-bodied man to the front, which made serviceable male attendants hard to secure. Clothing was scarce, and worse than all, the food supply was so reduced that often real want stared the hospitals in the face; but through the wondrous providence of God, and the untiring efforts of the self-sacrificing officers, the patients were fed, clothed and sheltered. Upon the close of the war the overthrow of State governments added to the disorder. Another danger menaced the asylums in some of the Southern States, in that political interference appeared and proved hurtful to the institutions. It is but due, however, to some State governments dur- ing the reconstruction days, to say that they had hearts to sympathize with this afflicted class, and recognized the fact that politics should not interfere with the administration of hospitals for the insane. But the times were hard, State credit was low, and everything was uncertain. The administrative officers lived anxious and laborious days; but they stood bravely to their posts, and did what they could for the care and welfare of their respective charges, and at last came safely out of the stonn. We cannot over-estimate the credit due those noble humane men for their inflexible fidelity to their trust during the time of the turmoil. I have no knowledge of any hospital for the insane, save one, being closed either dur- ing the war or the reconstruction period. ADDENDUM NO. 2. In one particular alone does lunacy administration at the South differ from the same problem elsewhere in our country. What the race problem is to our whole section, so is the question of the colored insane to our specialty. Provision for this class has always been a separate and peculiar problem. Before the war there were, comparatively speaking, few insane negroes. Following their sudden emancipation the number began to multiply, and, as accumulating statistics show, is now alarmingly large and on the increase. This is not the place to enter into an inquiry as to the etiology but only to recognize the fact, and show how earnestly State administrations are striving to meet it. We have been confronted with the question of providing for a class emerging from servitude, of different race, habits, instincts, and training. The alien pauper insane of the great centers of population, North and West, may in a measure represent our insane negroes, the burden of whose sup- History of Southern Hospitals for the Insane. 103 port has fallen upon their former owners, themselves struggling to rise from the impoverishment of war. Those authorities who have given not only most thought to the sub- ject, but who have also dealt with it practically in our asylums, have been unanimous in the opinion, that the separation of white and colored patients is to the advantage of both races. The distinction has been made for social reasons alone. Consequently we find to-day in most Southern asylums four departments, whereas in other institutions two suffice. Virginia and North Carolina have entirely separate hospitals in the center of the negro popula- tion near the Atlantic seaboard. This policy has not been deemed advisable in other states, partly for economical reasons, but largely because the negro population is more uniformly distributed. Even the existence of insanity in negro siaves has been questioned. But insanity was common enough to require special provision for the care of insane siaves by the provincial council of South Carolina in 1745, and the pressing need of means for their accommodation is shown by the early records of our asylums as they were successively established before 1860. Prior to the civil war in the asylums of Virginia, Kentucky, South Carolina, Maryland, Louisiana and the District of Columbia, colored insane were received as patients. In those days the accommodations for negroes were probably not adequate, but a generation ago our predecessors began the work, which we of a later day have in some states been able to carry to the consummation so devoutly to be wished. Among the pioneers in caring for insane negroes may be mentioned Stribbling and Gait of Virginia, Chipley of Kentucky, Trezevant and Parker of South Carolina, Steuart of Maryland, and Nichols of the District of Columbia. Following their emancipation the negroes have become subject to the same penalties that other races have paid for liberty, license and intemper- ance. Among those penalties insanity is not the least. A recent estimate based upon the records at the census office shows that brain disease in the negro, as compared with the white, has increased from one-fifth as common in 1850 and 1860, to one-third as common in 1870, and one-half as common in 1880 and 1890. Or, stated in another way, the ratio of insanity per million among the negroes has risen from one hundred and sixty-nine in 1860, to eight hundred and eighty-six in 1890. Until a recent period, the Southern negro was in a great measure exempt from both insanity aud tuberculosis. To-day, associated with insanity, we find tuberculosis alarmingly prevalent among our colored patients, especially females. As a race their mortality is greater than among the whites. Medication is of little effect. The tendency of the disease is towards a rapid and fatal decline. If we cannot cure, possibly we may prevent. To this end isolation of tuberculous cases is the most rational method at our command. THE NEUROTIC SALVAGE OF SUICIDE A SEQUEL TO "SUICIDE" IN OCTOBER (1897) NUMBER OF THE ALIENIST AND NEUROLOGIST. By C. H. HUGHES, M.D., St. Louis. MY article on suicide, so cruelly and caustically criticised by some medical and more clerical critics, is a scientific view in a scientific medical journal, of the effects of self-de- struction on the welfare of mankind; the physiological salvage of the brain and nervous system of man, not on the moral aspect of the subject, showing that, like war, it is not all and always evil in its results upon the world; and, like murder, sometimes salutary, if not in general commendable. It is not an advocacy of suicide, but shows that, in view of what woes of nerve and mind degeneracy and wrongs from the depravity of degenerate criminals the world escapes through the timely self-inflicted death of the many moral and mental degenerates who commit self-destruction, it is often a blessing to the world even though it may be criminal in the individual who commits it, and painful and pitiful and sinful in special instances. Many a wrong works out for good in the world, as when two worthless people engage in a duel and each kills the other. The progress of Neurological science reveals to us how suicide has proven to the world, from a neuriatric standpoint, to have been a blessing in disguise in numberless instances by saving the world from a prospective progeny of insanity, imbecility and woes of mind and brain innumerable which spring from the loins of certain degenerates. Take, for in- stance, the Jukes family of Massachusetts, over seven hundred [104] The Neurotic Salvage of Suicide. 105 in number, every one in some way defective and degener- ate charges upon the state, as paupers, criminals, insane or idiotic, all estimated to have cost in the aggregate over four millions of dollars for their keeping. The state did not turn these defectives loose but kept them (too late however)from the harm of procreation. Suppose the elder Jukes' had commit- ted felo de se, would not their suicide have been a blessing? The more of the criminal and crank class who take themselves away from the world they only menace and damage with moral and physical evil, the better it appears for society. This is the fact as I view it, .but I am not an adviser of suicide. The state takes a life for a life, the law justifies and the courts approve. Suppose the criminal homicide under just remorse, does the same, shall we con- demn the just self-punishment? Is Hari Kari only justifiable in China? As usual on scientific matters, my ministerial friends go off half-cocked and see only the moral aspects of the case. Dr. Snyder, especially, and evidently without reading the whole article, pitched into me from the wrong aspect, and depicted a horrible state of affairs, because I see that the class of people who ordinarily commit suicide are not so much to be pitied as commended for the benefits they have conferred on mankind by not insisting on cumbering the earth with a nerve degenerate progeny; not all of them, to be sure, but many of them, enough to show that humanity has really been benefitted by their going. The shots of my clerical friends are about as true as those of a Saint Louis policeman, lately so graphically depicted in one of our Sunday papers—wide of the mark. When we may justly say of a man "he ought to be killed," and would wish to see him killed; if he should kill himself, why should we condemn him? Specifically I do not know when suicide in a particular individual is justifiable. That is a moral question I do not attempt to decide, because I do not know all of any single life, but I do know that suicides who individually may have com- mitted sin in the sight of God, because the command from Sinai is, "thou shalt not kill," have served their race 106 C. H. Hughes. better by dying than they would have done had they lived. Yet law, Divine and human, ordains that bad men shall be executed and Nature cuts off the unfit to live by premature death, by diseases, the results of vices, by cas- ualties, the results of crime, and by suicide. Good to the race comes from death, as well as life, death, self-inflicted, as well as from other causes. The individual moral aspects of the question do not come under consideration. It is not a matter of advocacy of morals that is before us, but of observation. It may be wrong for one to kill himself, it generally is wrong so to do, yet the act may prove a righteous and good deed for mankind. A man who shoots himself in anticipation of a resistless impulse to kill his wife and child, does a better thing than to destroy his wife and child and then shoot himself. Under his pleading l once performed a perilous opera- tion on a patient who had epileptic homicidal insanity from a head wound. In his sane moments, the man said with a painful shudder, "I would rather die now than risk a repe- tition of the last attempt 1 made to kill my wife and child; 1 want to see them, but I dare not." Had this man been .out of reach of surgical help, would his suicide have been a crime? Psychological science and a sound theology which is ever based on truth would answer, no. While the smaller calibered theologians would say, yes; because the decalogue says, "Thou shalt not 'kill.'" But it also says, "thou shalt not steal;" yet who would not do both in defense of his life or of the lives of loved ones dependent on him. "Self-preservation is the first law of nature." There is presented a handsome enough array of theological and medical critics to adorn a logical shooting gallery, but their shots, as 1 say, are all wide of the mark. I do not advocate suicide. I would not myself attempt it. Never thought of it in my life as a personal remedy, but there are many circumstances under which men apparently ought to die, either by their own or other hands, and the world would be better for their departure. Such circumstances have been, are now, and are yet to come. It is less an evil for some men to die than to live and The Neurotic Salvage of Suicide. 107 what matters it to the world whether they take themselves away from the earth they encumber or are removed? The world is bettered by their going. The moral question is with themselves, their consciences and their God. Suicide is not the remedy that 1 approve for most of the evils which suicide averts from the race. There are others— asexualization, for instance, and those the state employs, incarceration, reformation and execution. But the fact exists that suicide, horrible and shocking to our sensibilities as suicide is, has not proved so harmful to the race, because it has more largely pruned out the unfit to live and propo- gate their unfit and fateful kind. ''To take up arms against a sea of troubles" in faith and heroism, facing every adversity, as did Job of Bible story, finally triumphing without retreat in suicide, is the brave, manly and commendable part, while to seek cow- ardly refuge in self-destruction fr^m the ordinary ills of life, is despicable. Personally, to the individual I should say, never despair; What though skies are darkened now, And storms adverse draw nigh: Hold bravely up, do not despair, The darkest ciouds pass by, to those who persistently fight on, battling manfully and ever hoping, ever trusting, ever fighting on and never saying die. Nevertheless many despair and destroy them- selves because of the weakness of their organisms: some, weakened by vices that would give to their posterity a greater weakness of organism, react more painfully to their environments. When such destroy themselves and when the criminally and viciously endowed do likewise, the world profits in having no race of weaklings left after them to repeat their sad experience. By the timely suicide of such persons race degeneracy in their line is arrested and race decadence postponed in the cutting off of the individual. Among the viciously dowered criminal class there are millions in the world who had better not have been born so far as we can judge from the teachings of hereditary criminology. Regarding them we discuss a mental condition based on vicious organic endowment, not a sentimental theory. Of 108 C. H. Hughes. the demise of such we might sing as sang the untutored miners over the bier of their dead "pardner," "With rapture we delight to see "The cuss removed." A slight variation in the words from what the saintly Watts intended, but physiologically true, when we divest the sub- ject of suiciding criminals of all sentiment and view it in the clear light of scientific truth. While it is individual cruelty to favor taking the life of the criminally or the insanely endowed and heartless to gloat over their suicide, it is nevertheless as good for the race that they go away as it would have been had they never been born. Gentlemen of the Clergy and critics of my own cloth, this is the sum of my offending. The evil or good effect of suicide is not of our making. It grows out of the laws of nature, reproduction and hereditary transmission. I do not advocate suicide as a remedy, but I say the weaklings, mental and moral, the criminal and the vicious, who commit suicide do often unawares and without intending, pay a debt to nature and confer a benefit on mankind. The world is better for their taking off, for it is cumbered with one less at least and possibly many more of their kind. We approve the warrior's sacrifice of life for his country, enshrine his brow in laurel and engrave his patri- otism on bronze and marble; why not approve the suicide who dies that none of his kind may come after him, if he be greatly degenerate, mentally or morally? The good grain grows best when the tares are taken from the field. "Is suicide a Sin" is not my theme in the crookedly criticised essay in the October ALIENIST. Suicide in the individual is very often a sin, dastardly, viciously, venge- fully or insanely designed, a cowardly retreat under fire in the battle of life, a wrong to one's dependencies and a mistaken or wicked escape from difficulties, a desper- ate, despairing and devilish substitute for manly resolution, reformation or courage. Yet the timely suicide of the moral imbeciles and mental defectives who commit it, has proved a blessing to a world they have often so ignominiously and The Neurotic Salvage of Suicide. 109 selfishly left. For the "one more unfortunate" the world has often been saved a progeny of woe burdened creatures like themselves. The very thought of suicide is often an unhealthy thought and from my standpoint of life and duty ought never to be entertained, yet that does not alter the fact that the average weak and foolish suicide who takes himself out of the way and gives place to a better man or woman with the hope of a more stable and courageous progeny to stand more nobly in line of life's battles with- out thought of desertion or retreat, confers a benefit on the earnest, duty-doing working world, whose "sea of troubles" he "takes up arms against" by the craven coward's weapon of self-destruction. So that one may see individual evil in self-slaughter and yet discern the general good that comes of it. The race marches on to its destiny less encumbered because of those degenerates and cowards and otherwise unfit to survive who thus take themselves out of the ranks of life's conflict. ADDENDUM. It would not be difficult for the student of psychopathic and neuriatric heredity to select from the following cases abstracted from the work of Sollier, together with those recorded on p. 216, et seq., vol. xviii of the ALIENIST AND NEUROLOGIST, several hundred instances where timely sui- cide or death in other forms might have saved the world much neuropathic misery and the race great psychopathetic harm from which good alienists and neurologists devoutly pray that mankind may be delivered. 1. Terr—, 6 years, symptomatic idiocy. Father alcoholic. 2. Nesiing—, 6 years, complete idiocy. Two maternal uncles, alco- holics. 3. LangI—, 12 years, idiopathic epilepsy. Brother alcoholic. 4. Mo—, 9 years, symptomatic idiocy, epilepsy. Father alcoholic. 5. Miel—, 16 years, idiopathic epilepsy. Father alcoholic. 6. (Same subject), Mother alcoholic. 7. Mesni—,15 years, alcoholic, idiopathic epilepsy. Sister alcoholic. 8. Pi]—, 13 years, epileptic idiot. Father alcoholic. 9. Richoll—, 20 years, epileptic. Paternal uncle, alcoholic. 10. Jean—, 13 years, complete idiot. Father alcoholic. 110 C. H. Hughes. 11. Sol—, 4 years, idiot. Father alcoholic. 12. Joussel—, 12 years, imbecility. Father alcoholic. 13. Lebr—, 11 years, epilepsy, mental debility. Father alcoholic. 14. Luc—, 12 years, epilepsy, mental debility. Father alcoholic. 15. Gra—, 16 years, pachydermic cachexia. Father alcoholic. 16. Mig—, 13 years, epilepsy, right hemiplegia. Father alcoholic. 17. Jui—, 9 years, imbecility, instability. Father alcoholic. 18. Lorr—, 5 years, complete idiot. Paternal grandfather alcoholic. 19. Lelon—, 8 years, epilepsy, imbecility. Father alcoholic. 20. Rivan—,15 years, imbecility, infantile hemiplegy. Father alcoholic. 21. Chatil—, 16 years, imbecility. Father alcoholic. 22. Moquer—, 11 years, complete idiocy. Father alcoholic. 23. Gouri—, 13 years, imbecility and perverted instincts. Father alcoholic. 24. Rem—, 10 years, instability and perverted instincts. Father alcoholic. 25. Rolin—, 13 years, imbecility. Alcoholic mother. 26. Simonn—, 17 years, epileptic. Alcoholic mother. 27. Waecht—, 14 years, complete idiot. Father alcoholic. 28. Gros—, 30 years, epilepsy, idiocy. Father alcoholic. 29. Jourd—, 47 years, alcoholic aud epileptic. 30. Lepell—, 16 years, idiopathic epilepsy and imbecility. Father alcoholic. 31. Legan—, 45 years, alcoholic, late epilepsy. 32. Mor—, 14 years, complete idiot. Paternal uncle alcoholic. 33. Sirconl—, 41 years, alcoholic and epileptic. 34. Cann—, 20 years, idiopathic epilepsy. Alcoholic mother. 35. Schad—, 15 years, idiopathic epilepsy. 36. Ender—, 5 years, alcoholic imbecile. 37. Blanch—, 3 years, complete idiot. Father alcoholic. 38. Boissi—, 3 years, complete idiot. Father alcoholic. 39. Crepi—, 14 years, symptomatic idiocy. Father alcoholic. 40. Caba—, 6 years, imbecility and right hemiplegia. Father alcoholic. 41. Cont—, 8 years, complete idiot. Father alcoholic. 42. Dufo—, 8 years, complete idiocy and epilepsy. Alcoholic father. 43. Duv—, 15 years, imbecility, goitre. Father alcoholic. 44. Dupu—, 7 years, half idiot. Father alcoholic. 45. Hans—, 8 years, complete idiot. Father alcoholic. 46. Rossi—, 14 years, complete idiot. Father alcoholic. 47. Detr—, 28 years, epilepsy and dementia. Brother alcoholic. 48. Maill—, 28 years, idiopathic epilepsy. Father alcoholic. 49. Rec—, 13 years, idiocy and epilepsy. Father alcoholic. 50. Debar—, 30 years, alcoholic and epileptic. 51. Dorl—, 41 years, alcoholic and epileptic. 52. Gach—, 17 years, alcoholic and epileptic. 53. Cart—, 15 years, mental instability. Father alcoholic. 54. Monat—, 4 years, epilepsy and complete idiocy. Father alcoholic. The Neurotic Salvage of Suicide. Ill 55. Pig—, 7 years, imbecility. Alcoholic mother. 56. Laumail—, 7 years, imbecility, epilepsy. Maternal grandfather alcoholic. 57. Jon—, 5 years, complete idiocy. Maternal grandfather alcoholic. 58. Spor—, 14 years, imbecility. Maternal grandfather alcoholic. 59. Bril—, 13 years, hereditary epilepsy. Maternal grandfather alcoholic. 60. Montag—, 15 years, congenital imbecility. Paternal grandfather alcoholic. 61. Mur—, 15 years, epilepsy and imbecility. Maternal grandfather alcoholic. 62. Bign—, 4 years, complete idiocy. Paternal grandfather alcoholic. 63. (Same subject). Maternal grandfather alcoholic. 64. Cont—, 8 years, idiotic. Maternal grandfather alcoholic. 65. Adel—,10 years, completely idiotic. Maternal grandfather alcoholic. 66. Bland—, 14 years, idiopathic epilepsy and imbecility. Father alcoholic. 67. Bennet—, 14 years, imbecility. Paternal grandfather alcoholic. 68. Card—, 12 years, imbecility and perverted instincts. Paternal grandfather alcoholic. 69. Chreti—, 5 years, instability and imbecility. Paternal grandfather alcoholic. 70. Dufourm—, 10 years, imbecility. Maternal grandfather alcoholic. 71. Echas—, 14 years, imbecility and cerebral atrophy. Paternal great grandfather alcoholic. 72. (Same subject). Maternal grandmother alcoholic. 73. Saint-Arn—, 6 years, completely idiotic. Maternal great grand- father alcoholic. 74. Trep—, 15 months, idiotic hydrocephalus. Paternal grandfather alcoholic. 75. Bond—, 13 years, idiopathic epilepsy. Paternal grandmother alcoholic. 76. Maisonh—, 14 years, epilepsy, hemiplegy. Maternal grandfather alcoholic, 77. Dam—, 10 years, epilepsy, hemiplegy and imbecility. Maternal grandfather alcoholic. 78. Duch6—, 18 years, chronic epilepsy. Maternal grandfather alcoholic. 79. Tall—, 10 years, completely idiotic. Maternal grandfather alcoholic. 80. Chop—, 15 years, idiopathic epilepsy. Maternal grandfather alcoholic. 81. Berang—, 16 years, complete congenital idiocy. Paternal grand- father alcoholic. 82. Moncont—, 7 years, epileptic symptoms, idiotic. Maternal grand- father alcoholic. 83. Breg—, 17 years, epilepsy. Maternal grandfather alcoholic. 112 C. H. Hughes. 84. Lou—, 13 years, idiopathic epilepsy. Paternal grandfather alco- holic and a suicide. 85. Ducon—, 11 years, completely idiotic. Maternal grandfather alcoholic. 86. Gene—, 7 years, completely idiot. Maternal grandfather alcoholic. 87. Brunch—, 9 years, idiopathic and epileptic. Paternal grandfather alcoholic. 88. Palad—, 39 years, idiopathic epilepsy. Maternal grandfather alcoholic. 89. Bau—, 9 years, idiotic. Maternal grandfather alcoholic. 90. Guit—, 7 years, idiotic. Maternal great grandfather alcoholic. 91. (Same subject). Paternal grandmother alcoholic. 92. Vath—, 7 years, completely idiotic. Maternal grandfather alcoholic. 93. Pige—, 4 years, complete idiot. Paternal grandfather alcoholic. 94. Ranv—, 10 years, imbecility. Paternal grandfather alcoholic. 95. Ren—, 5 years, complete idiot. Paternal grandfather alcoholic. 96. Farg—, 13 years, cerebral atrophy, athetosis and debility. Maternal grandfather alcoholic. 97. Gir—,7 years, completely idiotic. Paternal grandfather alcoholic. 98. (Same subject). Maternal grandfather alcoholic. 99. Guit—, 7 years, idiotic. Eather alcoholic. Foundling. 100. Gren—, 9 years, complete idiocy. Maternal grandfather alcoholic. 101. Larei—, 11 years, marked imbecility. Paternal grandfather alcoholic. 102. Mett—, 16 years, imbecility, epilepsy. Paternal grandfather alcoholic. 103. Mor—, 16 years, mental debility and chorea. Father alcoholic. 104. Math—, 10 years, symptomatic epilepsy. Maternal grandfather. 105. (Same subject). Father alcoholic. 106. Mavr—, 7 years, imbecility and epilepsy. Paternal grandfather alcoholic. 107. Mitt— 10 yrs., epilepsy and mental debility. Father alcoholic. 108. Rolin— 13 yrs., imbecility and epileptic vertigo. Maternal grandfather atcoholic. 109. Lefevr— 9 yrs., Idiotic. Maternal grandfather and grandmother alcoholic. 110. Pinc— 14 yrs., mental debility. Paternal grandfather alcoholic. 111. Reul— 11 yrs., epilepsy and mental debility. Paternal grand- father alcoholic. 112. Neclai— 13 yrs., idiocy and symptomatic epilepsy. Father alcoholic. 113. Nerri— 12 yrs., epilepsy. Paternal grandfather alcoholic. 114. Verl— 14 yrs., epilepsy. Maternal grandfather alcoholic. 115. Wiln—14 yrs., infantile cerebral hemiplegy. Maternal grand- father alcoholic. 116. Gran— 9 yrs., imbecility. Father alcoholic. 117. Laril—16 yrs., epileptic hysteria. Maternal grandfather alcoholic. TheJNeurotic Salvage of Suicide. 113 118. Jan—7 yrs., complete idiocy, microcepalous. Father alcoholic. 119. Mor— 16 yri., epileptic. Father alcoholic. 120. Terr— 5 yrs., complete idiocy. Maternal grandfather alcoholic. 121. Brugn— 11 yrs., idiopathic epilepsy. Paternal grandfather alcoholic. 122. Bonj— 16 yrs., epileptic. Father alcoholic. 123. Corb—16 yrs., backward, perverted instincts. Father alcoholic. 124. Crep— 10 yrs., idiopathic epilepsy. Maternal grandfather alco- holic. 125. Berg—16 yrs., epileptic. Maternal grandfather alcoholic. 126. Misb— 6 yrs., complete idiot. Maternal grandfather and grand- mother alcoholic. 127. Dav.— 7 yrs., mental instability and imbecility. Paternal grand- father and great-uncle alcoholic. 12S. Gard— 17 yrs., epilepsy. Father alcoholic. 129. Hach— 17 yrs., epilepsy and imbecility. Maternal grandfather alcoholic. 130. Hel— 18 yrs., epilepsy, and hemiplegy. Maternal grandfather alcoholic. 131. Laud— 13 yrs., imbecility. Paternal grandfather alcoholic. 132. Mico—10 yrs., symptomatic epilepsy. Paternal great-grandfather alcoholic. 133. (Same subject). Maternal great-grandfather alcoholic. 134. Mich—16 yrs., epilepsy. Maternal grandfather alcoholic. 135. Munhov— 16 yrs., half epileptic. Paternal grandfather alcoholic. 136. Mor—5 yrs., completely idiotic. Paternal grandfather alcoholic. 137. Brissel—Imbecility and cerebral hemiplegy. Maternal grandfather alcoholic. 138. Horn— 11 yrs., complete idiot. Maternal grandmother alcoholic. 139. Piqu—16 years, imbecility, foolish childishness. Paternal grand- father alcoholic. 140. Richall— 20 yrs., epileptic. Maternal grandfather alcoholic. 141. Vallert— 20 yrs., chronic epilepsy. Paternal grandfather alco- holic. 142. Gauth— 9 yrs., complete idiot. Maternal great-grandfather alcoholic. 143. Peroch— 47 yrs., late epilepsy. Father alcoholic. 144. Bio— 9 yrs., symptomatic epilepsy. Maternal gseat-grandfather alcoholic. 145. Mond—5 yrs., idiotic. Paternal grandfather alcoholic. 146. (Same subject). Maternal grandfather alcoholic. 147. Eng.— 3 yrs., symptomatic idiocy. Paternal grandfather alco- holic. 148. Bertram— 15 yrs., alcoholic epilepsy. 149. Bill—32 yrs., epilepsy. Father alcoholic. 150. Charpeut—10 yrs., idiotic. Maternal grandfather alcoholic. 151. Duv—8 yrs., epilepsy, idiotic. Maternal grandfather alcoholic. 114 C. H. Hughes. 152. Par—9 yrs., epilepsy, idiotic. Maternal grandfather alcoholic. 153. Lecl— 24 yrs., epilepsy. Fatter alcoholic. 154. Lem—15 yrs., epilepsy, imoecil'.ty. Paternal uncle alcoholic. 155. Mor— 3 yrs., convulsions, idiotic. Father alcoholic. 156. Mora—3 yrs., idiotic, epilepsy. Paternal grandfather alcoholic. 157. Nial— 17 yrs., idiotic, Paternal grandfather alcoholic. 158. Ygon— 18 yrs., mental instability. Paternal grandfather alcoholic. 159. Blanc— 18 yrs., epilepsy, infantile hemiplegy. Paternal grand- father alcoholic. 160. Cheder—33 yrs., idiopathic epilepsy. Father alcoholic. 161. Bar— 18 yrs., mental debility. Maternal grandfather alcoholic. 162. Gregoi— 20 yrs., epilepsy. Maternal grandfather alcoholic. 163. Georg—16yrs., epilepsy. Maternal grandfather and grand- uncle alcoholic. 164. Joli—31 yrs., epilepsy. Maternal grandfather alcoholic. 165. Mor—46 yrs., Partial epilepsy. Maternal grandfather. 166. Mall—35 yrs., epilepsy. Maternal grandfather alcoholic. 167. Lebe— 11 yrs., epilepsy and loss of intellect. Maternal grand- father alcoholic. 168. Gantr— 12 yrs., microcephalous. Maternal grandfather alcoholic. 169. Meel—7 yrs., epilepsy and loss of intellect. Paternal grand- father alcoholic. 170. (Same subject). Maternal grandfather alcoholic. 171. Klei—9 yrs., epilepsy. Paternal grandfather alcoholic. 172. Bress—9 yrs., idiotic. Paternal grandfather alcoholic. 173. Rich— 12 yrs., idiotic. Maternal great grandfather alcoholic. 174. Rosenmay— 10 yrs., epileptic. Paternal grandfather alcoholic. 175. Espinas—idiotic, epilepsy. Maternal grandfather alcoholic. 176. Herg—7 yrs., epilepsy, idiotic. Paternal grandfather alcoholic. 177. Lemail—8 yrs., epilepsy. Maternal grandfather alcoholic. 178. Mall—4 yrs., idiotic. Paternal grandfather alcoholic. 179. Pill—8 yrs., epilepsy and idiotic, Maternal grandfather alcoholic. 180. Semai— 7 yrs., imbecility, right hemiplegia. Maternal grand- father alcoholic. 181. Corb— 7 yrs., idiotic. Maternal great grandfather alcoholic. 182. Taber— 6 yrs., epilepsy. Maternal grandfather alcoholic. 183. Dum— 7 yrs., imbecility. Maternal grandfather alcoholic. 184. Darte— 12 yrs., Maternal grandfather alcoholic. 185. Duv— 15 yrs., imbecility, goitre. Maternal great aunt alcoholic. 186. Lucr— 11 yrs., idiotic, epilepsy. Maternal grandfather alcoholic. 187. Richa— 15 yrs,, epilepsy and imbecility. Father alcoholic. Foundling. 188 Sin—7 yrs., idiotic, epilepsy and blind. Father alcoholic. Foundling. 189. Wath—7 yrs., complete idiot. Paternal grandmother alcoholic. 190. (Same subject). Maternal grandmother alcoholic. The Neurotic Salvage of Suicide. 115 191. Tourn— 5 yrs,, idiopathic epilepsy. Father alcohoiic. 192. Arp—17 yrs., idiopathic epilepsy. Maternal grandfather and grand-uncle alcoholic. 193. Ger— 15 yrs., idiopathic epilepsy. Maternal grandfathes alcoholic. 194. Bru— 17 yrs., epilepsy, imbecility and strabismus Father alco- holic. Foundling. 195. Boutr— 8 yrs., mental debility and epilepsy. Maternal grand- father alcoholic. 196. Rauv— 11 yrs,, imbecility. Paternal grandfather alcoholic. 197. (Same subjcct). Maternal grandfather alcoholic. 198. Guin—5 yrs., marked imbecility. Paternal grandfather alcoholic. 199. Bout— 15 yrs., idiopathic epilepsy. Maternal grandfather alcoholic. 200. Dubu—13 yrs., epilepsy. Maternal grandfather alcoholic. 201. Guerr—36 yrs., epilepsy. Father alcoholic. Bastard. 202. Carl— 15 yrs., mental instability. Maternal grandfather alcoholic. 203. Monat—4 yrs., complete idiocy, epilepsy. Maternal grand- father alcoholic. 204. Al—17 yrs., mental instability. Maternal grandfather alcoholicr 205. Sauln—9 yrs., imbecility and strabismus. Maternal grandfathe. alcoholic. 206. Charret— 3 yrs., complete idiot. Maternal grandfather alcoholic. 207. Mitt—10 yrs., imbecility and epilepsy. Father and three uncles alcoholic. 208. Weiss— 7 yrs., wholly idiotic. Father alcoholic. 209. Demitt— 16 yrs., idiopathic epilepsy. Father and three uncles alcoholic. NOTE. To such as may regard this and any preceding paper as too radical, I may quote as a germane matter of reference from "Some Points on Lunacy Practice, etc.," by 'J. E. Shaw, M. B., Ed., in the Bristol Medico- Chirurgical Journal of December, 1897, the same being an abstract of the presidential address before the Bristol Medico-Chirurgical Society. "A recent issue of the Journal of the American Medical /Association has a long argument in support of its proposition to kill all idiots. Urquhart at Montreal said that in Scotland in former days all male epileptics were castrated, in order to pre- vent the propagation of the heredity; Sir J. Crichton Browne quotes the advice of the New York Medico-Legal Society to the effect that suicide should be recommended to those more or less insane." Cerebral Syphilis with Wide Spread Involv- ment of the Cranial Nerves. By GEORGE J. PRESTON. M. D. Professor of Nervous Diseases, College of Physicians and Surgeons, Baltimore. IN considering the diagnostic symptoms of cerebral syphilis great weight should be attached to the fact that the lesion is frequently very widespread and that multiple lesions are common. The size of the gummatous masses in the pia for example may be large or small, and the lep- tomeningitis may be confined to a comparatively limited area at the base of the brain or may involve a greater part of both basal and vertical meninges. In addition to the affection of the meninges, syphilis may involve the brain either as a gumma of the brain substance with symptoms of tumor, as circumscribed or diffuse syphilitic encephalitis or as cerebral sclerosis. More important and far more com- mon is syphilitic arteritis which plays such a very promi- nent part in the production of hemorrhage, thrombosis and embolism. The following case is interesting in that it shows how manifold may be the symptoms of syphilis of the brain. The patient E. W. colored, aged 37, presented himself recently at the clinic for Nervous Diseases of the City Hospital. His family and early personal history is unimportant except that he was, as he expressed it, "scrof- ulous" as a child. Ten years ago he had a chancre fol- lowed by distinct secondary manifestations. He was treated thoroughly according to his statement, and continued in perfect health until about three years ago. Sometime, probably in '65, he was suddenly taken sick, the chief symptom being very severe pain in his head. He was [116] Cerebral Syphilis. 117 confined to bed for a month and attended by a physician. This attack left him with some suppurative disease of his left eye which gradually destroyed the sight and the eye was enucleated about a year after. Between one and two years after the attack described above, he had a sudden paralysis of right arm and leg and right side of the face. He was walking on the pavement outside his house when he suddenly fell and was unable to get up without assist- ance. There was no loss of consciousness. From his description there must have been a moderate degree of aphasia. He now presents the following rather remarkable array of symptoms; a right hemiplegia involving the face on the same side. This paralysis, according to the history, was for a time absolute. He can now walk with some dif- ficulty and can use his arm a little. The tongue when pro- truded deviates to the right side. The dynamometer shows grasp of right hand 75, left 130. The patellar tendon or reflex on the right side is greatly exaggerated and there is ankle clonus on this side. The left tendon reflex shows little if any exaggeration and no ankle clonus is present on this side. If the left or non-paralyzed tendon be struck with the percussion hammer there is a movement of abduction of the right or paralyzed leg, the abductor associate reflex. This form of association reflex, it may be said in passing, is not uncommon. The right leg is about half an inch smaller than the left and the same difference exists between the right and left arms. There is no aphasia but his articula- tion is difficult. The movements of his tongue are good and he experiences no trouble in swallowing. General sensibility is unimpaired except around the left eye and temple. Here there is loss of tactile and pain sense; tem- perature sense remaining normal. Taste is lost on left side of tongue, and for this reason he chews on the right or paralyzed side, though with some difficulty, since he has but imperfect control over the right buccinator and the movements of the tongue to the right, are performed with difficulty. Careful testing would seem to show that the sense of smell was absent on the left side. With the right nostril closed he was not able to perceive the odor of vale- 118 George J. Preston. rian. Examination of the hearing shows nervous deafness in the left ear. Dr. H. H. Friedenwald reports; vision for distance good at 3 feet. Right eye removed for some sup- purative disease. Hemianopsia on right side involving entire side, the lower periphery encroaching on left field. The line of vision runs directly through the fixation point. -The pupil reacts about equally whether light is thrown on the right or the left side. There is no disturbance of the muscular sense and the electric reactions show no qualitative changes. There is a slight quantitative diminution on the right side. There are no sphincter disturbances and no trophic manifestations other than the slight atrophy on the right side from non -use. It is remarkable that the nerve which is so frequently paralyzed in syphilitic nasal disease, the motor occuli has in this instance apparently escaped; nor is there any evi- dence of paralysis of the fourth or sixth nerves. To sum up the symptoms, there is a right hemiplegia and right hemianopsia presumably from central disease, with involvment of the right facial nerve, left olfactory nerve, the left auditory nerve, the left trifacial and the left glosso-pharyngeal. The explanation of this case would seem to be a gum- matous leptomengitis, irregular and extensive in outline but mainly on.the left side. Following this was a thrombosis of the left middle cerebral artery, accounting for the right hemi- plegia. The hemianopsia is either due to involvement of the optic tract or to disease of the cuneous lobe of the left side. It was noted that the pupil reacted equally whether the light was thrown on the right or the left side. Now according to Wernicke this would indicate that the lesion was back of the corpora quadrigemina or in the cuneous. The rule laid down by Wernicke is that when the pupil contracts when light is thrown on either the diseased or the normal side then the lesion is posterior to the corpora quadrigemina. When however contraction of the pupil occurs only when the light strikes the sound side of the retina no Cerebral Syphilis. .119 contraction following the light stimulation of the blind side then the lesion is somewhere between the chiasm and the corpora quadrigemina. It must be said that the observ- ations of Henschen and others, cast considerable doubt upon the accuracy of this symptom. The patient has begun to improve under anti-syphilitic treatment and it is quite pos- sible that the symptoms due to peripheral nerve involve- ment may partly or entirely clear up. The Virile or Bulbo-Cavernous Reflex.* By PROF. C. H. HUGHES, M. D. Honorary Member British Medico-Psychological Society: President Section on Neurology, American Medical Association; President of Faculty and Professor of Neurology and Psychiatry, Barnes Medical College, St. Louis. U. S. A.; President of Section on Nervous Diseases, First Pan-American Medical Congress, etc., etc. AT a session of the Societe de Biologie, on May 3rd, 1890, M. Onanoff proposed to designate under the name of bulbo-cavernous reflex, the smart contraction of the ischio- and bulbo-cavernous muscles (erector penis and accelerator urinae) which mechanical excitation of the glans produces in the normal man. Clinical researches which he has carried on with regard to this phenomenon have permitted him to establish some considerations of real value as to to prognosis and diagnosis of certain nervous diseases. For his examination he proceeded in the following man- ner: The index finger of the left hand being placed upon the region of the bulb of the urethra, the right hand rapidly rubs the dorsal surface of the glans with the edge of a piece of paper, or again lightly pinches the mucous mem- brane. In these conditions the index finger applied upon the region of the bulb perceives a more or less intense twitch which is in relation with the contraction of the ischio- and bulbo-cavernous muscles. Here are the results M. Onanoff furnished by study of this new sign: In sixty-two adult subjects regarded as healthy, or at least exempt from all appreciable neuropathy, the bulbo- cavernous reflex has never been absent. •Presented by the author in abstract to the International Medical Congress at Moscow The Virile or Bulbo-Cavernous Reflex. 121 In aged persons who had lost their virility, on the con- trary, the reflex in question is abolished or scarcely percept- ible. In three cases of common hemiplegia, where the genital . functions were not influenced by the disease, the reflex was normal and without exaggeration. In two cases of transverse myelitis, situated at the level of the superior lumbar region, the reflex was manifestly exaggerated. In these two cases the erection took place without the knowledge of the patient. In progressive locomotor ataxia it is to be remarked first that as a general rule the urinary troubles appear to have no influence on the bulbo-cavernous reflex. On the other hand, when the reflex exists in these patients, they have preserved intact or exaggerated their sexual function, while when it is abolished they never have complete erections. Nevertheless, it may occur that certain tabetic patients have seen their genital function diminish although they have preserved their reflex. But then the impotence will be transient and the return of the function is the rule under the influence of treatment (suspension). On the contrary, with that same diminution of the gen- ital reflex, we may see that the impotence will be lasting and the treatment ineffectual. It results that in this category of diseases the presence or the absence of this sign is very important for the prog- nosis of genital trouble. M. Onanoff adds that it appears to him to be prudent to speak with some reserve by reason of the small number (thirty-four) of his observations on ataxics. In the last place, the same sign may aid in the diagnosis of certain cases of impotence of such difficult path- ogeny as we observe in urinary, hemorrhoidal and divers neuropathic patients. In all these cases, in fact, the bulbo- cavernous reflex is never wanting, and it is habitual that the genital functions re-appear under the influence of the treatment of the principal disease. The author cites in this respect an instructive fact. In diabetis mellitus, with loss of patellar reflex and abolition of genital functions, the bulbo- cavernous reflex persisted although feeble. Now when the 122 C. H. Hughes. diabetes improved, for some time under the influence of treatment, the bulbo-cavernous reflex became alike stronger at the same time that the patient remarked the awakening of his genital functions. In nine cases of neurasthenia with complete or partial loss of the genital functions, the bulbo-cavernous reflex was absent in no case. It is not without interest to determine that the reflex does not depend on the sensitiveness of the mucous mem- brane of the glans. In fact, an exaggerated bulbo-cavernous reflex was noted in some tabetics in whom this sensibility was greatly impaired. But then the voluptuous sensation was wanting in the patients although the erection was com- plete and persistent. M. Onanoff gave the following resume: 1st. There exists in man in the normal state a reflex which may be called "bulbo-cavernous." 2nd. In cases of troubles of the genital function, (a) the presence of this reflex will indicate a dynamic origin and will permit a favorable prognosis; (b) the absence of this reflex will be the sign of an organic lesion and will involve a grave prognosis.—La Tribune Medi- cale, May 8, 1890. In January, 1891, not then familiar with the fact of^M. Onanoff's valuable discovery, though an abstract thereof appeared in my journal, the ALIENIST AND NEUROLOGIST, for October, 1890, from the May number of La Tribune Medi- cale, 1 said:—* In a perfectly healthy individual, whose spinal cord is entirely normal, especially in its genito-spinal center, placed supine on a couch without head-rest, nude about the loins, the sheath of the penis made tense by clasping the foreskin with the left index finger and thumb at about the place of the fraenum and pulling it firmly toward the umbilicus, plac- ing the middle, ring and little finger low down upon the dorsum of the virile organ, the dorsum or sides of the penis, near the perineal extremity, then sharply percussed, a quick and very sensible reflex motor response or retraction of the •Alienist and Neurologist. The Virile or Bulbo-Cavernous Reflex. 123 bulbo-cavernous portion will be felt to result from this sud- den percussional impression, like that which follows, though less pronounced, in the testicles, after sensory irritation of the inner aspects of the thighs and known as the cremasteric reflex, with this difference only, the cremasteric reflex is a sudden upward movement of the testicle of the side irritated while the virile reflex is a sudden downward jerk. While this reflex, like all reflexes with which I am familiar, is away from the irritating afferent impression, it is in marked contrast with the patellar tendon phenomenon in being away from the heart instead of toward it, as so many reflex movements are. It differs frr>m the ordinary penile erection and must not be mistaken for it (for it cannot properly be called an erection) in this respect, too, viz., that it is down- ward and not upward and proceeds always from a peripheral and external irritation; whereas, erections more often pro- ceed from direct central (cerebral) impression proceeding downward and outward. Its action corresponds to the oesophageal reflex, or reflex for swallowing. I repeat what I said in my first communication; "some skill in palpation—a sort of tactus eruditus—is necessary in examining for this sign, the characteristic jerking back of the bulbous urethra within the sheath of the penis being felt only when carefully sought for. It is not ordinarily to be seen." 1 have found the sign absent in cases like the follow- ing: Pupils unequal, patellar reflex exaggerated and other evidences of sclerose en plaques, with history of syphilis and acknowledged feeble virility, and diagnosis by a competent ophthalmologist of optic atrophy. I believe it will be found to be quite generally absent when there is optic atrophy, unequal pupils and other evidences of cerebral sclerosis, or multiple cerebro-spinal disease of this nature. I have found this sign absent in the status epilepticus, but not necessarily modified in hemiplegia and have seen it exaggerated in cere- bral paraplegia. From my earlier records, in which this reflex was either impaired or absent permanently or periodically, I have noted 124 C. H. Hughes. in my first communication on this subject that the first three were middle aged; of these the first was a married brewer and gave a history of syphilis; erections feeble; white atrophy of retina, unequal pupils—left hand larger than right; vision obscure in both eyes; cerebro-spinal sclerosis (multiple and lateral); reflex absent. The second gave a history of former syphilis, though at time of observation he was in good flesh and general health excellent; miller and merchant; lives in country; impotent —seldom has erections, but at times has good erections and completes the sexual act; reflex greatly impaired when examined. The third was impotent; virile reflex always absent. Had no erections. The next two were children under twelve years of age; of these the first was an epileptic country boy; the second, also a country boy, had epilepsia gravior. Reflex scarcely perceptible on repeated examinations since the first test. The next was that of a civil engineer, single, aged about 28, with nocturnal epilepsia from excessive masturba- tion; reflex absent. Additional experience since the discovery of this impor- tant diagnostic sign only confirms the conviction uttered in my first paper, viz., should receive further consideration at the hands of neurological clinicians, for it appears worthy a place in clinical neurology with Westphal's paradoxical con- tractions, Erb's reaction of degeneration, or any of the hitherto recognized diagnostic reflexes, or clonuses. 1 have found an analogous reflex to this phenomenon in healthy females. It may be elicited in normally vigorous persons when that condition of the organ is present that we find coexis- tent with a desire for coitus, when the sexual act is about to commence and shortly after coitus, if the sexual desire has not been gratified to satiety. It can be evoked during priapism and during penile relaxation, if power for a second coitus remains in the organ. In order to secure the attention this sign deserves at the hands of physiological scientists and clinicians, I fee The Virile or Bulbo-Cavernous Reflex. 125 justified in repeating what I have said before on the subject, viz.: We are on the verge of further most important discov- ery in the direction of physiological and pathological reflex phenomena and on the verge of an enlarged comprehension of their value in diagnosis and prognosis. I believe that every part of the body supplied by an afferent (sensory) nerve communicating with a center, whether cerebral, spinal or ganglionic, capable of an efferent or motor response, will be found susceptible under appropriate stimuli (electrical, mechanical or special), in normal or pathological state, responsive in some way and that this plus or minus respon- siveness is yet to have far more remarkable value in clin- ical estimation than is now accorded it or dreamed of in medical minds. For instance, in our clinical investigations, we take into consideration such purely physical reflexes (in addition to the cardiac and visceral movements) as the palpebral, pupillary, naso-pharyngeal, visceral, cremasteric, anal and the tendon reflexes of the lower and upper extrem- ities, normal and abnormal and the clonuses which are of the nature of reflex phenomena prolonged into rhythmical movements. Many of these are more or less influenced by condi- tions of psychical inhibition. Then we have in disease often to consider the state of the psycho-physical reflexes, as the involuntary shedding of tears, unintentional or causeless weeping, involuntary and unsuppressible laughter, shouting, involuntary exclama- tions of various kinds, as of fear* disgust, joy, etc., and sudden involuntary and unrestrainable psycho-motor responses of various kinds, virile erections under erotic psychical impressions. These latter are downward influences, reflex responses from psychical excitation through peripheral impressions transmitted through sight or other senses, or originating altogether in ideational center. Then we have psychical responses to psychical peripheral impressions, such as the sudden mental states and expressions following physical impressions, like the immediate outcry of periph- eral pain—the true nature of a reflex phenomenon wher- 126 C. H. Hughes. ever we find it, being a peripheral impression transformed into an immediate, or almost immediate, motor response or expression. If we take into consideration how much of our power for regional diagnosis has been aided within the past few years by what we already know of these reflexes, espe- cially of the knee-jerk, Achilles reflex, the foot clonus, the anal, vesical, cremasteric and virile, how much more may we not hope for with confidence, if we but persevere in our search for unknown manifestations of these phenomena? 1 have already elicited in certain moribund states, an oral reflex, as heretofore announced and a physiological anal reflex and have confidence even before its announce- ment, not knowing it was new, much that Rosolimo asserts concerning the reflex of the anal sphincters, this latter reflex serving as an especially valuable differentiating test where sexual failure is to be early distinguished from com- mencing vesical or rectal paralysis. The following clinical records appeared in my paper: Case 1—Mr. J. H., aged 23, single, locomotive fireman, first presented for treatment July 11, 1891, with the follow- ing history: Three years ago, in alighting from his loco- motive running at the rate of fifteen miles an hour, he sprained his back, but it did not give him much trouble at that time. About three weeks ago, while perspiring freely, he "caught cold" and the perspiration suddenly stopped— from this patient refers present trouble, though he had an attack of la grippe in February and about the latter part of April he noticed impairment of right leg. Four years before he had indulged in sexual intercourse to excess—upon one occasion had connection seven times in twenty-four hours. He has had no inclination for sexual intercourse lately; thinks he has had sexual desire but a half-dozen times during the past two years. Bowels constipated, for which he resorts frequently to purgatives. Had an attack of vertigo to-day and fell to floor while in the act of yawning. Pulse (sitting) 66; upon slight exertion (walking about the room) pulse increases to 78. Right knee-jerk abnormal; R. quadriceps The Virile or Bulbo-Cavernous Reflex. 127 clonus marked up to origin of muscles—a slight tap below right patella (not sufficient to produce patellar reflex) will cause quadriceps muscle to vibrate. Right knee response below normal, left knee-jerk impaired, no quadriceps clonus, Right gastrocnemius reflex normal; right plantar and solar reflexes exaggerated and clonus follows reflex excitation; plantar surface of right foot hyper-aesthetic. Flexion of right foot incomplete one-half, rotation impaired one-half, flexion and extension impaired about one-half. While sitting he can only lift right leg and thigh about three-fourths as compared to left. Has head and backache. No spinal ten- derness, tender over crest of right ilium and beneath ribs of right side. Aesthesiometric tests of finger-tips give normal results. Numbness of left great toe, but no abnormal aesthesio- metric sign. Has slight right scrotal hernia; has phimosis. Case 2—Mr. Chas. E. H., 21, occupation, farmer; single; applied at my office for treatment August 15, 1891, and gave the following history: About a year ago he slept on the damp ground for five successive nights, each morn- ing he felt stiff and head was sore. As the effect of this he was sick in bed with a fever for a week or more, legs were paralyzed, bowels, constipated and urine retained— was catheterized several times. He was attended by two local physicians. Says he suffered severe pain during first three weeks of illness and was troubled with erections. Patient's present condition is as follows: Pulse 90 (patient sitting) and full, temperature 100 Fah., appetite and diges- tion good and sleeps well; no erections at present. Some pain in lumbar and sacral regions. Crosses right leg over the left with difficulty, cannot lift leg without assistance of hands, cannot stand alone. Patellar tendon reflex is absent, virile reflex present, but impaired, cremasteric reflex normal and has abdominal reflex. Has never had syphilis or any zymotic disease. Since this singular reflex sign was first discovered by me independently, but not published, prior to M. Onanoff, l have discovered another and a better method of eliciting it. When the patient is lieing supine and the reflex 128 C. H. Hughes. re-enforced, with legs drawn up, and by engaging his atten- tion in conversation, preferably on some erotic subject for psychical re-enforcement, the foreskin is held between the thumb and fore-finger at its orifice, beyond or about over, the meatus urinarus, and stretched or pulled steadily upward with considerable force so as to be a little dis- agreeable to the individual, if necessary, the penis will then retract backwards and downwards and the character- istic reflex will be elicited in normal or exaggerated response or fail, thus telling you whether your patient's virility is impaired, intensified or in abeyance to some morbid state of the spinal center of the cord presiding over this genital reflex or whether old age has destroyed this reflex. The medico-legal significance of this sign in qnestions of rape or paternity or sexual capacity in any direction is at once apparent, and it should be more diligently studied than it has been. Finding it in the healthy, it should be practiced till the tactus eruditus essential to eliciting it where it possibly exists, is fully acquired. It must be practiced often to be plainly felt, for it is far oftener felt than seen and is best felt when sought after the manner of M. Onanoff, viz., with the tactile sense of a trained index finger or thumb or both placed on the dorsum of the virile member. I conclude this brochure with two'communications from our lamented confrere, M. Brown-Sequard. One of them, ajpersonal note written in English, for the distinguished savant was once an American citizen, the other, an edito- rial critique in VArchives de Physiologie, which, next to the work of the laboratory that made him immortal, he most highly prized of all his scientific treasures. NICE, March 16, '91. DEAR DOCTOR HUGHES—Please excuse this bad writing. I am kept in bed by phlebitis. I am sorry you are not to come to Europe this year, but I hope you will come bye and bye and that I will then be in a state of health allowing me to have the pleasure of seeing you. The Virile or Bulbo- Cavernous Reflex. 129 I read with great interest your paper on a Virile Reflex. Unfortunately the facts you certainly discovered have been previously discovered and published by Dr. Onanoff, who communicated them at a meeting of the Biological Society, of which I am the president. He made that communication on the 3rd of May last. I send you the number of the Proceedings of the Society containing Dr. Onanoff's paper. You and he agree perfectly on every point. In an article of the next number of The Arckives de Physiologie (April number), I give a short account of the facts you found, not knowing of the publication made in Paris. A great deal more is to be discovered as regards reflexes than is supposed, and if you look out, you will most likely find absolutely new facts. Believe me, dear Dr. Hughes, Yours faithfully, (Signed) M. BROWN-SEQUARD. Nous recevons d'un medecin tres distingue de Saint- Louis (Missouri, Etats-Unis), le Dr. C. H. Hughes, direc- teur d'une importante revue—THE ALIENIST AND NEU- ROLOGIST—un travail qui a pacu dans le numero de jan- vier dernier de ce recueil et qui a pour objet de signaler un nouveau reflexe dont l' absence peut de la valeur comme diagnostic dans des cas de certaines affections de la moelle epiniere. 1l s'agit d'une contraction du bulbo-caverneux, sous l'influence d'une irritation de la surface dorsale du penis. L'auteur cite des cas assez nombreux ou il a vu manquer ce reflexe, qu'il crovait avoir decouvert. Deja cependant le 3 mai 1890, le De. Onanoff avait communique a la Societe de biologie (voy. Comptes rendus, p. 215), untravail don- nant les resultats obtemus par lui sur un grand nombre de malades et d'individus en bonne sante, etablissant l'exist- ence a l'etat normal d'un reflexe ischio et bulbo-caverneux, sous l'influence d'une irritation de la surface dorsale du gland. II est evident, d'apres ces publications, qu'um reflexe, meritant d'etre connu, existe dans les organes genitaux males. MM. Hughes et Onanoff sont d'accord a montrer 130 C. H. Hughes. dans quelles circonstances on constate l'ansence ou l'exag- eration de ce reflexe. Nous nous bornerons a ajouter que Ie travail de M. Onanoff est institule: "Du reflexe bulbo- caverneux" et qui celui du De. Hughes porte le titre de "Note sur Ie reflexe viril."—Archives de Physiologie, numero du April, 1891. Another important clinical and diagnostic fact has come under my observation on several occasions in connection with the eliciting of the virile reflex sign, viz., when the organ is siezed, the patient recumbent, the foreskin stretched fur- cibly upward towards the umbilicus and vigorously tapped on the dorsum penis in cases of spinal irritation and myelas- thenia, the lower extremities are thrown into violent reflex agitation, the quadraceps extensor femoris muscle contract- ing and the contractile effect extending to the adductor muscles of the thigh and the extensor tibial muscles. This phenomenon appears in these cases when this virile reflex sign is even feeble, and partial impotency and sexual neu- rasthenia exists. This phenomenon is found also to coexist with the presence of the cremasteric reflex. This matter however will be made the subject of a future communication. The knee phenomenon in these cases is sometimes comparatively feeble. SELECTIONS. NEURIATRY. CARDIAC NEUROSES.—At a recent meeting of the Italian Medical Society, a report of which is published in the Independance medicale for November 3rd, and abstracted in the New York Medical Journal for November, ultimo, Dr. Silva is reported as having made a special study of parox- ysmal tachycardia and bradycardia. The former, he said, was developed especially at maturity, without distinction as to sex, under the influence of great emotion or from exces- sive mental and physical exertion. It was manifested by sudden attacks, vertigo, buzzing in the ears, and contrac- tions of the neck and of the epigastrium. The heart beats were accelerated, and the number sometimes reached two hundred and fifty and even three hundred pulsations. If the thoracic region was examined at the time of an attack, an undulatory trembling would be perceived near the car- diac region, and auscultation would reveal a foetal rhythm of the beats. The cardiac sounds were so accelerated that it was scarcely possible to distinguish the different periods. Sometimes, however, a systolic souffle could be perceived, which disappeared after the attack. The pulse was small and the face pale. In addition to the vertigo, there were delirium, insomnia and oliguria, but there was no fever. Mydriasis or myosis of the eyes was observed. It was not possible, said Dr. Silva, to determine the certain cause of these attacks, which manifested themselves without any apparent cause and lasted from a few minutes to several hours. They became grave when they exceeded the latter duration and terminated then in death during an asystolic attack. More frequently the attack was terminated [131] 132 Selections. suddenly at the end of a few hours by polyuria and profuse sweating, when the patient recovered. Attacks of tachycardia might follow each other at intervals of a few days, or there might be very long respites. The diagnosis, said Dr. Silva, was established by the abruptness of the paroxysms, which were not accompanied by sounds of organic lesions of the heart. This abruptness of the symptoms, which broke out and disappeared suddenly without leaving behind them any alteration in the general health, was also a guide to the clinician in distinguishing tachycardia from the true endocarditis; and in angina pectoris arhythmia, which was generally absent in tachycardia, was present. Regarding the pathogeny of this affection, Dr. Silva said that many theories had been advanced. According to certain authors, it was an excitation of the great sympathetic; according to others, it was, on the contrary, an ephemeral paralysis of the pneumogastric nerve which caused the attack. Debove and Courtois-Suffit thought it was a bulbar neurosis; Frantzel thought it was an undiscovered lesion of the myo- cardium. The speaker thought that the beginning of the attack depended upon the pneumogastric nerve, and that later this attack was kept up by the poisons produced by the excessive work of the heart. Regarding bradycardia, or the slow pulse of Charcot, the author continued, this syndrome was manifested especially in old persons. The patient was attacked suddenly with malaise, the face became pale, and he fell to the ground in a condition of trembling and profuse sweating. The pulse slackened and did not reach more than from seven to ten beats. Soon the patient recovered consciousness himself, and all the alarming symptoms disappeared at the end of a few minutes. The attacks might break out without any apparent cause or after emotion, anger, etc. The patient might succumb after the first attack. More frequeutly the attacks occurred every two weeks or every month; in the interval the patient, who might live many years, was very well. Dr. Silva stated that the diagnosis of bradycardia was very easy and the prognosis very grave. Selections. 133 Charcot and Caracretti had thought it was a circulatory or functional anatomical lesion of innervation, but Dr. Silva thought, on the contrary, that bradycardia depended some- times upon a lesion of the centre of the pneumogastric nerve, sometimes upon arterio-sclerosis, and at other times upon a lesion of the myocardium. The two affections, he thought, should be treated in the same way—that is, with hydrotherapy, electricity, thoracic massage, and climatic treatment. EPILEPSY AND AUTO-INTOXICATION.—Dr. C. Agos- tini has followed up the researches of Voisin and Mirto, who have shown (Journal of Medical Science, July, 1897) that the urine of epileptics possesses a special toxicity (and those of a number of other observers have demonstrated that true epi- leptic fits can be produced as the result of auto-intoxication by abnormal products developed in the gastro-intestinal canal), and has made an investigation into the composition and toxicity of the gastric fluid and urine in epileptic insanity at various periods in relation to fits. He finds that in the inter- vals between the fits the gastric juice is in most cases normal as far as can be recognized by mere chemical analysis with, however, a tendency to hyperacidity and especially excess of hydrochloric acid. For a short time previous to a fit and for some time afterwards, there are changes indicating a condition of transitory dyspepsia. An epileptic convulsion in proportion to its duration and intensity greatly disturbs the whole digestive functions of the stomach, increasing the secretion of hydrochloric acid and mucus, favoring the devel- opment of abnormal fermentation products leading to the appearance of biliary acids, lowering the peptic action and diminishing the sensibility, motility and absorbing power of the organ. In the intervals between the fits the toxicity of the gastric juice (tested upon rabbits) is not necessarily greater than in healthy individuals provided the patient is not suffering from chronic gastric catarrh. In the prodromal period in relation to a convulsive seizure, and especialy in those cases in which there is chronic gastric catarrh, the stomach wash displays energetic and constant toxic properties. 134 Selections. After a convulsion this toxicity is still further increased. Attacks of petit mal increase the gastro-toxic power in a similar manner. The toxic principles appear to be of the nature of leucomaines and are probably the same as those that are found in the gastric fluid of dyspeptics in general. Examination of the urine shows that in the intervals between the fits the tissue metabolism of epileptics is below normal as evidenced by the elimination of azotised substances (urea, uric acid and creatinin) phosphoric acid and chlorides. The excretion of azotised products is further diminished in the prodromal period. After a violent motor fit there is an increase in the density and acidity of the urine and in the elimination of all the ordinary products of tissue change except .chlorides. None of the abnormal con- stituents of the urine that may appear after a fit do so regularly or constantly. The urine of epileptics has always a greater toxicity than that of the normal individual. This toxicity is increased in that period immediateiy preceding a fit. After a convulsion the urine is hyper-toxic and remains so for more than twenty-four hours. The toxicity is always pro- portionate to the gravity of the gastro-intestinal disturbance associated with the fits. It is probably the products that have the general reaction of leucomaines. The administra- tion of bromides distinctly diminishes the toxicity of the urine. Agostini maintains that in a large proportion of epi- leptics the fits are preceded by marked symptoms of gastric catarrh. In the intervals between the fits the catarrh in most cases disappears, but in many it persists, becoming aggravated about the time of the fits. In those patients who have chronic gastric catarrh the epileptic phenomena are more frequent and more severe. He believes that this chronic or transitory gastric catarrh is accompanied'by putre- factive changes in the contents of the stomach and intestines and the formation of toxic substances which become absorbed and tend to accumulate in the blood giving rise to the malaise,headache and furring of the tongue which precedes the occurrence of a fit and finally determining the convulsion or series of convulsions. He has found that all measures tend- Selections. 135 ing to the elimination of such toxic products or to the pre- vention of their formation, diminish the frequency of the fits or altogether prevent them. He further believes that the pro- cess of oxidation is usually deficient in epileptics. Hence leucomaines absorbed from the intestinal canal are not com- pletely oxidized as in healthy persons. He also thinks it is probable that in epileptics on account of the morbid func- tioning of the nervous system, excretory processes take place with abnormal slowness so that there is a tendency to the retention in the system of products of reduction that ought to be eliminated. He fully recognizes that idiopathic epilepsy is essentially a cerebral disease and would look upon it as the result of a "polymorphic degenerate state," the most constant and most pathognomonic feature of which is the existence of "somatic and functional asymmetry." He rejects the view of Chaslin and others, according to which epilepsy is due to a special brain sclerosis. But while admitting the existence of a cerebral abnormality that predisposes to epilepsy and often actually determines it, he contends that it is logically and experimentally proved that in many cases the determining cause of the repetition of the fits is auto-intoxication. The irritation occasioned by the toxic agents produces either hyper excitability of the psycho-motor centres or exhaustion of their inhibitory power permitting the tumultuous action of the lower automatic centres. These toxic agents need not have epileptigenetic properties. They act simply by increasing the vulnerability of the imperfect and unstable nervous system of the epileptic. Since auto-intoxication plays so important a part in the production of epileptic fits, Agostini advocates the endeavor as far as possible to remove the factors of such intoxication. In the first place, correct gastro-intestinal catarrh when it is present, and endeavor to remove toxic substances that may have formed in the alimentary tract. As the best means of attaining this object, he recommends repeated washing out of the stomach with salt water, especially when fits are anticipated and before the occurrence of a crisis. He also advises the use of purgatives, saline enemas, diuretics (especially lactose) and the abundant administration of milk 136 Selections. along with salol or naphthol as intestestinal antiseptics. In the second place—endeavor to increase the activity of pro- cesses of oxidation and of normal tissue changes in general. These objects, he thinks, are best secured by the use of small doses of alcohol, careful hygiene, fresh air and mod- erate muscular exercise. With regard to diet he does not agree with Haig that epileptics should become vegetarians. He has found that a purely vegetable diet gives even worse results as regards the fits than a purely meat diet, a cir- cumstance which he attributes to the fact that vegetable albumen putrefies more readily than animal albumen. He recommends a milk diet with plenty of milk. Lastly, we should endeavor to diminish the reflex activity of the corti- cal nerve centers, which in epileptics are in such unstable equilibrium. He believes that the only really effective drug for this purpose is potassium bromide. He recommends that it should be given in somewhat smaller doses than those generally used, and that it should be combined with salol. Its efficacy is increased by the antitoxic therapeutic meas- ure already mentioned. If gastric catarrh appears the administration of bromides should be suspended and the attention directed to the removal of the catarrh. CLASSIFICATION OF EPILEPTICS.—So little is known of the etiology of epilepsy that it is not possible, in the iight of present knowledge, to make a satisfactory clas- sification of its forms. The terms grand mal, petit mal, psychic and Jacksonian are largeiy symptomatic designa- tions, and bear little relation to causative factors. A classification based strictly on etiology is not possible, but none will deny that such a classification would be more scientific and valuable. The classification here offered is not held to be perfect or even satisfactory, but is used as a working basis for future improvement; 1, genito-neuropathic; 2. post-paralytic; 3, traumatic; 4, hystero-epilepsy; 5, hereditary; 6, imbecilic; 7, acquired; 8, senile.—Dr. Fred- erick Peterson, Third Annual Report of Craig Colony of Epileptics. PSYCHIC ANESTHESIA.—Dr. Charles W. Bun, of Phil- adelphia, remarks that, at the November, 1896, meeting of Selections. 137 the Philadelphia Neurological Society (Journal of Nervous and Mental Disease, May, 1897), he reported the case of a woman who, suffering from mind blindness, was also unable to recognize objects by touch, though tactile sense was normal. He suggested the name tactile amnesia for the condition, maintaining that it was analogous to amnesic aphasia. At the time the report was made he had seen but one other case, and in both there were other symp- toms. Soon after a gentleman came to him complaining of the same trouble unaccompanied by other symptoms, con- fined to one arm and due, as will appear, to an entirely different cause. His history is as follows: B. C, 24 years old; single; family •and personal history negative. When about 10 years old he was accidentally struck on the side of the head by an axe-handle with such force as to throw him into a river, on the bank of which he was standing. At first he was thought to have been drowned, but exami- nation of the head showed a simple depressed fracture of the right parietal bone over the motor area. He remained in a state of alternate coma and delirium for about three weeks. On recovering normal consciousness he found him- self partially paralyzed on the left side, including the face, and completely anesthetic upon the same side. The palsy and anesthesia entirely passed away in a few months, sen- sation returning before motion. He was supposed to have recovered completely until, on putting his left hand in his coat-pocket for the first time after his illness, he discovered he could not tell what he had in his grasp, though he had the sense of touch. Little attention was paid to this symp- tom at the time, and he was told it would soon pass away. It has not. Examination.—He is a spare but fairly healthy- looking young man. He is scholarly and thoughtful but neurotic, supersensitive and morbid. The left leg, arm, and face are slightly smaller than the right. There is no palsy of either side, but he uses the left hand a little awkwardly. Gait and station are normal. The knee-jerks are equal and a little exaggerated. There is no depression nor pain on pressure at the seat of the alleged fracture. Pressure on the vertex over an area about as large as a one-cent 138 Selections. piece causes mental confusion, a condition of dreaminess, and if continued, light hypnotic sleep. With the eyes shut he recognizes well variations in the positions of the hands or arms. Tactile sense is normal on both sides. On the entire left side, even on the finger-tips, he fails to localize touch. He is absolutely unable to recognize any object put in his left hand, but knows he is grasping something. His grasp is good and remains good when the eyes are shut, there being no muscular relaxation even after several minutes. In the right hand there is no sensory trouble. On both sides temperature and pain sense are normal, and he can distinguish dull from sharp. There is no difficulty with speech, vision, hearing, taste, or smell. The urine is nor- mal. Examination of the thoracic and abdominal viscera is negative. Dr. M. W. Zimmerman examined the eyes and reports, "Right eye: The media are clear and the fundus is normal. The field is difficult to take, the eye easily wandering in any direction without any apparent reason or object. On the temporal side the red field extends beyond the blue. Left eye: The media are clear and the fundus is normal. Fixation is less difficult. The red field extends beyond the blue in the larger part of the circumference. There is practically no contraction of the field for white in either eye. The fields were taken several times on different days and were constant. The pupils are equal and react well to light and with accommodation." To sum up, we have a man who for some years, ever since a serious injury to the head causing a temporary hemianesthesia and hemiaplegia, has lost the ability to rec- ognize objects by touch in the left hand, though simple tactile sense and the so-called muscle sense are preserved, and who has also a partial reversal of the fields of vision, is neurotic and susceptible to hypnotism. Simple as the symptomatology of the case is, there is much in it that is at present inexplicable. It contains problems of as much interest to the physiological psycholo- gist as to the neurologist. It differs—and this is of impor- tance—from similar cases in the loss of the ability to loca- Selections. 13 lize sensation, and I cannot bat believe that this inability stands in close causal relation to our patient's loss of the power of recognizing objects by touch. Touch cognition is in reality a very complex process. To do it accurately tactile and sometimes pain and temperature sense, muscle sense and power of localizing, must be normal. We have much to learn concerning all these. Muscle sense certainly depends upon the afferent impulses from the joints, the muscles, and though in much less degree, the skin. The means by which we localize a touch on finger or toe, as happening at any one point, the psychologists have not yet settled for us, and how we group the many sensations from an object into one whole is absolutely unknown. In my other case the difficulty lay in interpreting the sensa- tions felt, because of the loss of the stored up tactile images, the patient having in other words no sensory tac- tile recollections with which to compare her recent sensa- tions. Hence the name tactile amnesia. But in this pres- ent case, as said before, there is another element. The patient cannot localize, and it is easy to understand that if, for example, while holding a key, he cannot tell what fingers the sensations come from or even refers some to the upper arm he can have no proper conception of the form of the key, cannot tell that is a key. It would seem as if there was here a contradiction in the statements of the patient. If he knows the positions of the fingers and can feel touch, such knowledge should aid him in recog- nizing the object grasped. Yet he says he cannot. Although at the mercy of his veracity, Dr. Burr believes him. Since the trouble seems to depend in this case upon the loss of the localizing sense, and we have no means of knowing whether he has tactile amnesia or not, it will probably be wiser to call it by the broader and less defin- itive term psychic anesthesia. What central lesion has caused the symptom and where it is situated cannot be determined. It is most probable that he had a fracture of the parietal bone with slight injury to the motor cortex and the neighboring sensory region. The injury could not have been severe or the 140 Selections. hemiplegia and hemianesthesia would not have been so transient and the recovery so complete. But it is not proven that his present trouble depends upon the same lesion. Parietal fracture with hemiplegia and temporary anesthesia is very frequent. Psychic anesthesia is very rare. Dr. Burr is inclined to believe that in this man the con- dition is hysterical. He is hysterical in temperament, has partial reversal of the visual fields,and is susceptible to hypno- tism. Dr.Burr thinks the physical injury has acted to suggest the symptom, which in many regards is like the"systematized anesthesia" not infrequent in hysteria. This does not explain very much, but further we cannot go. BREMER'S BLOOD TEST OF DIABETES.—In a com- munication to the New York Medical Journal of December 11th, 1897, Dr. L. Bremer reviews this subject and his critics as shown in the following extracts:— There were two factors shown in the method published in this journal, causing uncertainty and divergence of results in the hands of experimenters not entirely familiar with the details of haematological researches: 1. The indef- inite chemical composition of the reagent recommended and described by me, an eosin-methylene-blue compound, rather difficult of preparation. 2. The insufficient exactness of the process recommended for hardening the blood film. I have succeeded in doing away with these objection- able features and I have devised a method which even per- sons of limited experience or none at all in haematological work will be able to execute. Briefly stated, the mode of procedure is as follows: Prepare two sets of blood speci- mens, one of diabetic, the other of non-diabetic blood, the films to be spread in rather thick layers on cover-glass slips or slides. The latter are preferable for naked-eye demonstration, because they are more easily handled. Place the two sets, say eight or ten of each, in a heating oven, the tray on which they rest to be at least six inches above the bottom of the apparatus. By means of a good- sized gas flame run the temperature up to 135° C. (this being the heat optimum) within from eight to ten minutes. Selections. 141 After cooling, place two slides, one with a diabetic, the other with a non-diabetic blood film, back to back, in a one per-cent. aqueous solution of any of the stains above named for from two to five minutes. Then rinse thoroughly in distilled or filtered water and dry. It will be found that Congo red and methyl blue have not stained the diabetic blood, or on prolonged exposure have stained it feebly, whereas the non-diabetic blood film has assumed the red or blue stain respectively. Biebrich scarlet has the oppo- site effect; it stains the diabetic but not the non-diabetic blood, unless the specimens remain too long in the reagent. The solutions ought to be freshly prepared, old ones losing the differential staining capacities. I have discarded the eosin-methylene-blue compound for practical naked-eye demonstrations, and the hard- ening of the blood film by means of boiling ether and alcohol has likewise been abandoned. The color reagents now employed by me are Congo red, methyl blue (not methylene blue), and Biebrich scarlet. The hardening of the blood film and the fixation of the haemoglobin or the erythrocytes are now effected by heat exclusively. The reliability and positiveness of my tests were dem- onstrated before the Societe medicale des hopitaux (Paris) by Dr. P. Marie, physician in chief of the hopital Bicetre, and Dr. Jean le Goff (P. Marie et J. le Goff, Bull, et mem. de la Soc. mid. des hdp. de Paris, No. 16, p. 626) . Again, in a monograph on the subject, Sur certaines riactions chro- matiques du sang, Le Goff describes my methods and tes- tifies to the exact reproduction of my results. Lepine and Lyonnet (Lyon mSdical, June 7, 1896) affirm likewise the correctness of my observations, but maintain that leu- cjemic blood gives the same reaction as diabetic blood. This is true only of the eosin-methylene-blue compound, when the alkalinity of the reagent, by the predominance of the methylene blue, is excessive. With a more neutral combination the difference is easily established. When the reagents mentioned above for naked-eye demonstration are employed, the difference of the stains is as marked as when any other non-diabetic blood is used for check specimens. 142 Selections. I do not think that, as is maintained by the same observ- ers, the differential reaction is a mere matter of a different degree of acidity and alkalinity of the blood, but hold that a peculiar change of the haemoglobin of the diabetic eryth- rocytes is at the bottom of the phenomenon. What the nature of the change is, 1 do not know. Le Goff also repudiates the theory advanced by Lepine and Lyonnet. The experiments of V. Patella and A. Mori (Reazioni cro- matiche del sangue dei diabetici, Gazetta degli ospedali e delle cliniche, November 15, 1896) yielded negative results, because these investigators did not strictly adhere to the directions laid down by me. PLEASURE WITHOUT OTHER SENSATIONS.—While exploring the sensations of various parts of the body about a year ago, I chanced to notice a phenomenon of which I find no mention in the various physiologies and psychol- ogies. 1 submit the brief statement in the hope of learning if any one has previously made a similar observation, or if the fact, which I have repeatedly observed, can be confirmed by physicians who have the opportunity of testing large numbers of patients. The observation may be summed up as follows: Whereas the surface of the glans penis is moderatively sensitive to the pointed end of a toothpick and responds strongly to the point of a pin, the mucous mem- brane around the orifice of the urethra is absolutely lacking in sensations to touch in either case, although strong pres- sure with the point of a pin will cause pain. There is, however, another sensation aroused by the application of any object to this mucous membrane—namely, that of pleasure—which increases directly with the degree of erec- tion. The confirmation of this observation would establish the hitherto unrecognized fact of the separate existence of pleasure as an independent sensation, a fact of con- siderable importance in the psychology of feeling.—Scrip- ture, in New York Medical Journal. THE BECHTEREW TREATMENT OF EPILEPSY.—Eight cases of epilepsy treated for a period of six weeks with a Selections. 143 mixture of bromide of potassium, codein, and adonis ver- nalis, are reported by De Cesare (Rif Med., August 13, 1897). The medicine is given twice daily. In four cases there was complete suspension of the fits; in three other cases the fits were replaced by infrequent attacks of ver- tigo, and in the last case there were four attacks of vertigo and two convulsions. In each case the attacks were very much reduced in frequency; no bad results were observed. The digestion was not impaired, the pulse was fuller, the temperature normal, diuresis increased, sleep uninterrupted and calm, and the mental condition unchanged. The author believes the results were due to the combination of drugs, and not to the bromide alone.—Drs. Mistle and Greggs, Abstract, Canadian Practitioner. [The true test of value is in leaving out the Bromide of Potassium.—Ed.] THE SO-CALLED BRYSON'S SYMPTOM NOT A SIGN OF EXOPHTHALMIC GOITER.—Dr. Hugh T. Patrick, of Chicago, maintains that the Bryson symptom in exophthal- mic goitre is of no significance, showing by a study of forty cases that diminished chest expansion sometimes found in this disease is not pathognomonic, but is simply an expres- sion of the general myelasthenia which he claims is always present therein. [We knew this long ago and did not suppose any one had seriously regarded this as a real symptom.—Ed.] ARTHROPATHY AND SYRINGOMYELIA.-Kienbock showed a female, aged thirty-three, at the Medical Club, with much swelling on the extensor side of the elbow preventing vol- untary movement, although passive movement was normal. The skin was healthy and unchanged, except at one spot, where a cicatrix was present, as the result of a burn; on the fingers a few sores and scars were still to be seen. Subjectively she complained of a feeling of cold all over the left arm, in respect of which it was noticed as an important fact in the case that it was dissociated with the paralysis of sensation, which extended to the pectoralis and supra-scapularis. The application of heat to the patient over these parts gave no pain. 144 Selections. The external appearance of the patient conveyed the impression of arthritis deformans, while the other symptoms left no doubt of the disease being of a neuropathic charac- ter. The distinction between tabes and syringomyelia is not difficult when we reflect on the present phenomena of dis- sociated sensation-paralysis, exalted reflex, clonus, and the absence of all other signs of tabes, which left syringomyelia as the only alternative. Examined by the Roentgen rays few changes could be observed; the bones seemed a little thicker than usual, but no calcareous deposit could be detected in the joints. Another important fact in the case was the absence of any unilateral muscular atrophy. In the discussion, Schleisinger said the most important symptom to his mind was the absent trophic disturbance, this being an early phenomenon in syringomyelia.—Vienna Cor. Med. Press and Circular. LOCOMOTOR ATAXIA— Landon Carter Gray, of New York, stated that a study of seventy-seven cases of loco- motor ataxia recorded in his case books had led to one con- clusion—that in every instance the symptoms had been improved by treatment, and in a few the improvement had been startling. In most of them it had been satisfactory. In his opinion, rest was the most important part of the treatment, for every muscular movement involved a strain on the diseased parts. In the severer cases the patient should be in bed for weeks, whereas in the milder ones a few hours a day in bed might be sufficient. The amount of rest required varied greatly with different individuals. What- ever might be the rationale, it was certain that antisyphil- itic treatment would often have a most startling effect on the progress of the case.—Universal Med. Jour. THE ELEVATOR AS A CAUSE OF NERVOUS DISEASE.— It is asserted by reputable medical men that some of the increase in the number of cases of brain fever and nervous disorders is due, in no insignificant degree, to the extension of the elevator system. Most people feel a sensation as if they were falling when going down in a rapidly moving "lift," and the constant repetition of this seemingly slight Selections. 145 dizziness induces chronic headache, or other nerve disorders, and even leads to brain fever in some instances. Those who habitually ride up and down six or eight stories two or three times a day almost inevitably become a prey to some form of nervous trouble.—Coll. and Clin. Record. PERSPIRATION-NEURASTHENIA.—Dr. Peyer {Med. Times and Hosp. Gaz.) reports the case of a man thirty years of age who, during the last four years, had perspired profusely in the day, and, during the last month, also in the night. So profuse was the perspiration that he was obliged to change his clothes several times during the night. He had become very emaciated. Many drugs were tried, but with- out any benefit. As the patient confessed to having mas- turbated for many years, the diagnosis of sexual neuras- thenia was made. He was treated with sounds and the psychrophore, and after six weeks of this treatment the perspiration ceased and the patient was completely cured.— Cincinnati Lancet-Clinic. NERVOUS VOMITING.—Dr. Alfred Meisi (Centralblatt fur die Gesammte Therapie, 1897)reviews the diagnostic points, summing up the therapy as follows: 1. For the general neurosis, change in surroundings, country air, sojourn in an institution, rest, hydrotherapy, and general faradization. 2. Diet of solids administered in small quantities. If intol- erance is severe, then rectal enemata for a few days. The stomach-tube also may be used, and milk to three ounces inserted several times daily. In mild cases one-sixth of a .grain of menthol with a grain and a half of sodium bicar- bonate after meals, or suppositories of one-third of a grain of extract of belladonna and half a grain of codeine are useful. If there is hysterical hypersecretion, bismuth prep- arations with alkalies in large doses are useful. Cold appli- cations, as ice-bag or ether spray, may assist the action of the drugs. Suggestion is to be made use of, either as to the effect of drugs, or that food which is introduced through the stomach-tube cannot be vomited, or a fast for twenty- four hours may be ordered, and then liquids in teaspoonful doses at short intervals given. After cessation of the vom- 146 Selections. iting roborant medication, iron and arsenic, best as arsenical mineral waters, and strengthening feeding are necessary to prevent relapse.—American Journal of Medical Sciences. BLOOD TREATMENT OF DISEASE.—Whatever we may regard as the antecedent neurotic and metabolic change of gangrene, the reconstruction of the blood is indicated in all efforts at treatment. An interesting paper by Dr. C. S. Eld- ridge, of Chicago, thus discusses the subject of supplied blood versus gangrene:— "During the next week there chanced to come under my observation the only case of gangrene of the scrotum that I had ever seen. It had resulted from subcutaneous ligature of the pampiniform plexus of veins for the cure of varicocele in an anaemic subject. The gangrene appeared at the bot- tom of the scrotum a few days after the operation, and spread rapidly. In spite of all efforts to check its progress the lower half of the scrotum rotted away, exposing the testes, upon which gangrenous spots speedily put in an appearance. Red streaks extending from the scrotum upwards and outwards along either groin indicated that the progress of death was going on along the tissues in the direction of the cords, the left one being the more marked. The areolar tissue beneath the inflamed tracts rapidly rotted away, so that the finger could readily be passed its full length in the direction of the inguinal canal on either side. The patient's temperature ranged from 101 l/i to 103 degs., his pulse seldom going below 120, and death was rapidly approaching. Strenuous efforts were made to check the progress of the spreading gangrene, but to no purpose. The necrotic surfaces were frequently and thoroughly dressed with various antiseptic preparations, such as charcoal, quin- ine and iodoform, after being carefully cleansed with some- times bichloride solution, sometimes carbolized water, and sometimes a weak solution of bromine. In spite, however, of continuous and faithful attention to the decaying parts as well as careful treatment of the patient's general condition by the exhibition of appropriate internal remedies, the gan- grene spread rapidly and the room became so offensive with Selections. 147 the odor of death as to be nauseating to those in attend- ance upon the case, and the exhibition of Piatt's chlorides and other atmospheric disinfectants seemed to be utterly powerless to control the terrible odor. "After at least two-thirds of the scrotum had been rotted away and the patient's life completely despaired of, it occurred to me to try the efficacy of local feeding as a last resort; the appearance of the granulating surfaces in the few places where they could be observed between the large patches of gangrene upon the surfaces of the testes, point- ing to the fact that the tissues were certainly badly starved, they were so pale and anaemic and fragile in their nature. "Accordingly the man was placed under an anaesthetic. Much of the dead tissue was removed with the aid of tissue forceps and scissors, some of it however clinging so closely to the decaying surfaces as to render the removal of all the patches of gangrene impossible. Iodoform gauze was then soaked in bovinine, each testis was wrapped in a separate strip of it, pieces of it were tucked well up into the groin under the line taken by the rapidly spreading disease, then a large piece of it was wrapped around the entire scrotum and spread over the outer surfaces of the groins. While memory lasts 1 can never forget the extreme surprise as well as satisfaction at the result of the first treatment. The odor immediately disappeared from the room, the fever of the patient subsided, his pulse lowered, and he was per- ceptibly better in every way, his restlessness and thirst rapidly disappearing, and he became for the first time com- fortable. Bovinine was poured over the surfaces of the gauze once in two hours, but the dressings were not removed for twenty-four hours, although previously they had been changed every two or three hours in order to stay the progress of the disease if possible. When the dressings were removed at the expiration of twenty-four hours, there was no odor whatever to the wound, and although the patches of gangrene were not entirely gone the granulations were of a healthier type. The bovinine dressings were of a healthier type. The bovinine dressings were again applied, this time without the anaesthetic, and were kept in 148 Selections. position this time for forty-eight hours, saturating the gauze every two hours by pouring bovinine over its outer surface as had been previously done. When the dressings were removed the gangrene had almost entirely disappeared, the exposed surfaces had taken on a healthy appearance, and the case was evidently rescued. The bovinine dressings were continued until the case was entirely recovered. So much of the scrotum had sloughed away, however, that as the wound healed it left the testes exposed in two-thirds of their extent." NEUROTHERAPY. ANTIKAMNIA.—It is gratifying to note foreign appre- ciation of American pharmaceutical products of therapeutic merit such as Antikamnia, concerning which The Edinburgh Medical Journal, Scotland, says: "In doses of three to ten grains, it appears to act as a speedy and effective antipy- retic and analgesic," and The Medical Annual, London, Eng; "Our attention was first called to this analgesic by an American physician whom we saw in consultation regard- ing one of his patients who suffered from locomotor ataxia. He told us that nothing had relieved the lightning pains so well as antikamnia, which at that time was practically unknown in England. We have since used it repeatedly for the purpose of removing pain, with most satisfactory results. The average dose is only five grains, which may be repeated without fear of unpleasant symptoms." PSYCHIATRY. THE SKOPTZIES—The Skoptzies, religious castrators in Russia, are possibly the most famous of the people of this description. The Russian government has condemned members of this heresy to hard labor in Siberia, but has been unable to extinguish the sect. Pelican, Privy Counsel of the govern- ment, has exhaustively considered this subject. Articles have appeared in Le Progris Midical, December, 1876, and there is an account in the St. Louis Clinical Record, 1877- 78. The name Skoptzy means "the castrated," and they Selections. 149 call themselves the "White Doves." They arose about 1757 from the Khlish or flagellants. Paul I. caused Sseli- wanow, the true founder, to return from Siberia, and after seeing him had him confined in an insane asylum. After an interview, Alexander I. transferred him to a hospital. Later the Councillor of State, Jelansky, converted by Sselianow, set the man free, and soon the Skoptzies were all through Russia and even at the Court. The principal argument of these people is the nonconformity of orthodox believers, especially the priests, to the doctrines professed, and they contrast the lax morals of these persons with the chaste lives, the abstinence from liquor, and the continual fasts of the "White Doves." For the purpose of convinc- ing novices of the Scriptural foundation of their rites and belief they are referred to Matthew xix, 12: "and there be eunuchs which have made themselves for the kingdom of Heaven's sake," etc.; and Mark ix., 43-47; Luke xxiii., 29; "blessed are the barren," etc., and others of this nature. As to the operation itself, pain is represented as voluntary martyrdom, and persecution as the struggle of the spirit of darkness with that of light. They got persons to join the order by monetary offers. Another method was to take into service young boys, who soon became lost to soci- ety, and lied with effrontery.—From Gould and Pyle's Curiosities of Medicine. AN EXAMPLE OF FATAL PSYCHIC SHOCK.—The importance of the vagus nerve in its relations to the cranial and thoracic viscera is constantly presenting in the phenom- ena of life. Instantaneous death through its influence is often afforded in sudden mortuary records and every grade and degree of influence present in the chronicles of daily life. A remarkably tragic case of this kind, recalling too the recent Luetgert trial at Chicago, where the plea of sud- den disappearance was put in defense, the defendant claim- ing that murder was not committed, occurred at Gibraltar in 1841. James Baxwell, a respectable merchant there, was charged with the murder of his daughter, Elezia. The girl was missing, and in a cave near her father's house some 150 Selections. of her hair and clothing were found stained with blood. Witnesses testified to hearing the father say angrily that he would rather see her dead than to see her married to a certain man who had asked her for her hand. Wild shrieks, as of a woman in mortal agony, were heard on a certain day by other witnesses issuing from the cave where the clothing was found. And, to clinch the case, nobody had ever seen the girl since that day. Baxwell was convicted and sent to the scaffold. Just as he was about to be launched into eternity the girl's lover, William Katt, cried out to stop the execution, as the girl was still alive. He had married her and kept her in hiding ever since, and had fabricated the evidence in the case, including the cries of mortal pain for the vindictive purpose of hanging her father. The black cap was removed from Baxwell's face, but he was derfd. The excitement of the ordeal had killed him. THE INSANE IN ENGLAND.—In a paper read before the British Medico-Psychological Association, Dr. H. Rayner shows that substantially the same defects exist in the Brit- ish provision for the insane as is the case in many states of the Union. 1. The defect in the provision of treatment (Journal of Mental Science, July, 1897) in the earliest stages of disorder is utter and complete. 2. The defect in dealing with the improved or occupation class is very great indeed. 3. The helpless workhouse class are massed in too great numbers and too much isolated from their friends. 4. The responsibility for treatment is not sufficiently and clearly delegated, where the insane are treated in large masses. 5. The number of medical attendants is too limited. GERMAN LAW ON INEBRIETY.—The new code, the sixth paragraph, which will come into operation in Germany in 1900, enacts compulsory treatment of habitual drunk- ards. Among the persons liable to be interdicted, the inter- diction involving being placed under a curator, who will be empowered to place the individual anywhere for treatment until discharged from curatorship by the court, inebriates are specifically mentioned. The exact description is, "he who in consequence of inebriety cannot provide for his Selections. 151 affairs, or brings himself or his family into the danger of need, or endangersjthe safety of others," * * * This meas- ure was first advocated in 1863 at a meeting at Hanover, presided over by Judge Naumann, of Hameln.—British Med. Journal. N EURO-SURGERY. LUMBAR PUNCTURE.—Thiele (Deut. med. Woch.) relates his experience in v. Leyden's clinic as to the value of this procedure, says the British Medical Journal. The material includes thirty-two cases with sixty punctures. There was no unpleasant after-effect, and this was chiefly to be ascribed to the fact that the puncture was practiced with the patient on his side, and that only one case of cerebral tumor was thus treated. There were three cases of epidemic meningi- tis, two of which were fatal. There was no room for doubt as to the diagnosis in these two cases, but in the third case, which recovered, there was considerable difficulty. Here at any rate an earlier diagnosis was made possible. The meningococcus was found in the fluid, and was also culti- vated from it. There were seven cases of tuberculous men- ingitis, all fatal. Lumbar puncture was here often of diag- nostic value. Only twice was the tubercle bacillus found, but the fluid presented in general characteristic appearances. It was clear or only slightly opalescent, contained an increased amount of albumen, and was more or less rich in cells. A table is appended giving the details of these cases. In four cases the diagnosis of serous meningitis (Quincke) was made. Here lumbar puncture was useful in the diag- nosis. The nature of a case of hemorrhagic pachymeningitis was made certain by this procedure. In the remaining cases lumbar puncture did not assist the diagnosis, and it had no clear therapeutic effect. These cases included apoplexy, cerebral tumor, uremia, cerebral syphilis, etc. In one case there were symptoms of a spastic bulbar palsy, and after death thrombosis of the basilar artery was found. A pres- sure of two hundred and twenty was present at the com- mencement of the puncture, and of fifty at the end. The 152 Selections. fluid was clear, and measured forty c. cm. In another case of spastic paralysis in all four extremities, in which the condition of the head made- a chronic hydrocephalus probable, six punctures were practiced. From six to twenty c. cm. of clear fluid were drawn off. The spasm appeared to be less, but any permanent improvement was doubtful. In two cases of chlerosis with cerebral symptoms spinal puncture was also practiced. The patients improved, but it could not be said with certainty that the improvement was due to the puncture. The author concludes that spinal puncture is a valuable extension of our means of diagnosis, and that some therapeutic value is probable in cases of serous and sero- purulent meningitis, as well as in the cerebral disturbances of chlorosis.—Medical Review. CLINICAL NEUROLOGY. NATURE OF THE ALTERATIONS IN THE SPINAL CORD IN TABES.—Darkschewitch (Moscow Congress, IVien hlin. Rundschau, Dec. 12) considers that the present status of our knowledge conflicts with the assumption that tabes is due to a primary affection of the cord. He attributes it to a preced- ing affection of the peripheral nervous system of apparently varying character and varying localization. The alterations in the posterior column appears as the consequence of at least two morbid processes, a polyneuritis and a pachy- meningitis in the ramification region of the posterior spinal artery. The affection of the lateral ventricles is apparently only the result of a polyneuritis.—Journal of American Med- ical Association. NEUROPATHOLOGY. THE MORBID HISTOLOGY OF EPILEPTIC IDIOCY AND EPILEPTIC IMBECILITY.—As a result of histologic studies, Andriezen (British Medical Journal) has found in cases of epileptic idiocy and epileptic imbecility, a diffuse sclerosis or overgrowth of the neuroglia fiber cells in the brain substance and a co-extensive change in the nerve cells. The latter Selections. 153 was of two kinds. 1. Defective development (fewness and slenderness) of protoplasmic processes. 2. Increase in amount and diffusion of pigment throughout the cell body, especially its basal part, and a displacement of the nucleus toward the apex of the cell. Later changes were a gradual destruction and atrophy of the nerve-cell processes, conse- quent on or co-extensive with the further overgrowth of the glia (sclerosis), until whole groups or islands of cells might be so destroyed. There is thus a common pathogenic basis for epileptic idiocy and epileptic imbecility, and for focal epilepsy occurring in the child, namely, anomalies of growth and nutrition impressed upon the growing nerve cell as well as upon the neuroglia cell, and affecting predominantly this or that area of the brain, frequently in territories corres- ponding to a particular vascular distribution. In cases of epilepsy supervening in adult life, after the brain cells had attained complete development, the changes found were, as regards the nerve cells, only of the second kind. But in addition these very frequently exhibited intranuclear vacuo- lation of the cortical cells also. The significance of the changes especially associated with the epileptic neurosis (more particularly when occurring congenitally or in early life, and therefore entailing also a more or less obvious degree of mental impairment) is still more striking when it is remembered that in the brains of non-epileptic idiots and imbeciles similar lesions are generally absent, and the con- volutionary forms may be, and often are, plump and well formed, though inclined to simplicity of arrangement. These are to be looked on as general arrests of development, not complicated of course with the epileptic neurosis. In the brains of non-epileptic imbeciles, sclerosis and microgyria are both conspicuous by their absence. When the epileptic neurosis is present, however, this process also is present, and the other changes detailed are also present in varying degrees. It is in the combination of these two classes of pathologic changes that lesions are to be found, the surest indication, the seal as it were, of epileptic idiocy or epileptic imbecility in the brain.—Jour. Am. Med. Assoc. 154 Selections. NEUROPHYSIOLOGY. LESIONS OF THE SPINAL CORD IN CASES OF AMPUTATION OF THE FINGERS.—The necropsy of a recent case has strikingly confirmed the modern assertion that the section of a nerve determines lesions at a distance, in the nerve's originating center. In this case, described and illustrated in the Presse Mid., the lesions in the spinal cord corresponded in every particular and almost exclu- sively to the innervation of the parts amputated. An inter- esting feature of the case was that the amputation was congenital. The woman was sixty, and a cancer was loca- ted in the cervix uteri.—Jour. Am. Med. Assoc. Has the Cellular nucleus independent exis- tence?—The Boston Medical and Surgical Journal notes the interesting presentation and discussion of this subject at the Moscow Congress as follows: A very interesting paper was contributed to the Moscow Congress by Profes- sor Loukianoff, director of the Institute of Experimental Medicine in St. Petersburg, on "Inanition of the Cellular Nucleus." Notwithstanding the great advances made recently in the science of cellular morphology, he called attention to the fact that there still remain important prob- lems awaiting solution, such, for instance, as the conditions of life surrounding the cellular nucleus. The nucleus is undoubtedly the most important element of the cell, but we know very little as to its functions of nutrition and growth. To investigate certain vital func- tions of the neucleus, he had made experiments touching upon the changes produced in the nucleus when the organ- ism is placed in a condition of inanition. The results of these experiments tend to prove beyond a doubt that the nucleus is endowed with an independent existence. Dr. Loudon had investigated the influence of starvation of bacteria (an analogous problem). He found that bacteria subjected to starvation diminish rapidly to fifty per cent. of their former mass. After this period of diminution, a con- dition of equilibrium is established, when the bacteria show Selections. 155 no changes. In this they differ from the multicellular organism. Along with these experiments, others were con- ducted on the cellular necleus itself. Whilst investigating the changes produced in the pancreas of the guinea-pigs subjected to starvation, Brunner observed, that while the cell loses ten per cent. of its substance, the loss of the nucleus amounts only to three per cent. We are therefore justified in thinking, that the nucleus suffers less from lack of nutrition than the cellular substance, and although a part of the cell, it does not lose its autonomy. The cell again consists of various elements, the most important of which is the necleolus. . . Madame Dovranovitch, experimenting on changes pro- duced in a starving organism, found, that while the cellular tissue lost forty per cent. of its mass, the nucleus lost twenty-five and four-tenths per cent., and the nucleolus forty-three and five-tenths per cent. Dr. Laraveitch, experimenting in Loukianoff's labora- tory on guinea-pigs, found, that while the body in general loses thirty-five per cent., the loss of the nucleus of the hepatic cell is only twenty-five per cent. of its mass. All these experiments go to prove the fact, that while the cell, the nucleous and the nucleolus lead an existence in com- mon, it is nevertheless variable in each. Loukianoff described his own experiments concerning the change produced in the cell and its nucleus by various forms of starvation. Twenty animals (white mice, as they seem the least influenced by change in food) were sub- divided into six groups; some were deprived of both food and drink, three were fed on tallow, three on egg-albumen, three on peptones and three on oats; thus some animals were subjected to absolute starvation, some fed exclusively on fat, others on nitrogenous food, and others on albumen. The experimentation investigated the changes in the longi- tudinal and transverse diameters of the hepatic cell. The number of these measurements (about 2,000) are sufficient to draw more or less definite conclusions from. The cellular nucleus diminishes from fasting, but this diminution is not 156 Selections. related directly to the changes which take place in the organism. While suffering as much as the organism from complete starvation, the nucleus presents changes different from those found in the organism in cases of partial starvation, as expressed in the predominance of nitrogrenous, albuminous or fatty food. The biological autonomy of the nucleus is also evidenced from another fact: the one or the other kind of inanition influences the formation of double nuclei, but this division of the nucleus into two parts does not run parallel with the changes of nutrition, as experienced by the nucleus, nor does it have anything in common with the alteration observed in the organism. All these facts point to an independent existence of the nucleus. Of this existence we know but little, and there is here a little desirable field for careful study and research. NON-DECUSSATING PYRAMIDS.—Among three interest- ing cases reported last May to the American Neurological Society by Dr. Philip Zenner, of Cincinnati, is the following: Male, age thirty-three. Chief symptoms: Jacksonian attacks in the left side of the face, paresis of the left arm and leg, left facial paralysis. Tenderness to percussion over left side of skull. Post-mortem, large tumor in left hemisphere pressing upon left central convolutions. The symptoms were on the left side of the body. Sections of the medulla revealed an absence of the crossing of the pyramids. EDITORIAL. [All Unsigned Editorials are Written by the Editor^ The Field of the Alienist and Neurologist for 1898.—The ALIENIST AND NEUROLOGIST, now entering the nineteenth year of its history, is an independent journal of advanced and advancing neurology and psychology, neu- riatry and psychiatry. It constantly aims at the proper presentation of neurology applied, not only to disease specially involving the nervous system, but to the nervous system as it is involved in disease in general and diseases of the organs and viscera (a very important consideration for the physician), and to neurological considerations in sur- gery. In short, it is a journal of nervous and mental diseases in particular and a periodical treatise upon the neuriatric aspects of all disease. It is therefore indispensable to the general practitioner, the special practitioner in neurology and the specialist in every department of practical medicine. It seeks to correctly interrogate and properly interpret the nervous system in all the phenomena of morbid processes and thus to aid the physician whether confined exclusively to the specialties. of psychiatry and neuriatry or broadening his efforts to the whole organism. It assists the physician in every condition of disease to treat the whole man and if it may be said to have a medical creed, it is that the patient should be understood in all his neural relations and receive consideration all over, wherever his omnipresent nervous mechanism reaches and influences him, rather than in the location or organ particularly involved and demanding special attention. This, indeed, since the ALIENIST AND NEUR- OLOGIST was founded has come to be one of the distinctive features of clinical and therapeutic medicine, and the phy- sician or surgeon who takes most complete account of the nervous system in its multiform relations to the patient's disease processes, will have the best results for his intelli- gent insight and study. The practice of the art preventive and the art restorative, is largely neurological in the best and most successful medical endeavor. [157] 158 Editorial. The nervous system is a dominant element in conditions and results. This fact is becoming more and more demon- strable as neuriatry and neuro-physiology advance and the doctor of medicine takes just account of their importance. Therefore the ALIENIST AND NEUROLOGIST should be on every table, as it it now on so many of the tables, of those who aspire to the highest success in the practice of medicine or to make the best impression before courts and juries where the problems of man diseased, especially in his cerebro-spinal axis, are under judicial investigation. The Practice of Medicine is a matter of diag- nostic and technical skill, knowledge of remedies and judg- ment, or of experiences, discernment, resources and how to use them. Success or failure is mainly in the individual doctor, plus or minus the patient's full or reluctant acqui- escence in the treatment, and favorable or unfavorable con- ditions within and about the patient, that is, a good or bad constitution and habits of the patient and hygienic or unhygienic environments. Many matters make the issue, but the judgment, skill and personal mentality or individuality of the physician, all other things being equal, constitute the chief factors in the result, whether it be favorable or otherwise. To be possessed of the paraphernalia of practice does not make one a physician any more than to own a machine shop makes one a machinist. The surgeon's knife unskill- fully used may kill when it ought to have cured. The assassin and the surgeon may wield the same blade. A chest of tools does not make a mechanic nor an electric battery an electrician. A well balanced judgment, a well regulated and resourceful brain, make the physician. You may stuff an incompetent brain" with knowledge, that is, crowd his memory with facts and point out a skillful way for it to use them, and yet if that brain lack trained and spontaneous judgment it will fail. A knowledge of military tactics is useful, but it takes a military mind to employ them aright. A great General may even sometimes win a battle with inadequate resources. Strategy is an element of success in all great military movements, but a poor Gen- eral will meet with defeat with the best resources at com- mand. It is the same with the success or failure of the physician. There are some good sectarian practitioners in medicine, as compared with some of the regulars in their localities, because their judgments and personnel are better and they handle their limited resources more strategically than those Editotial. 159 physicians about them with all the resources of the world's materia, medica at their command. They look about them, add to their resources from regular medicine, make up their deficiencies in therapeutic resource, and try to equal the best regular practice; while some of the regulars about them are slothful and self-satisfied and not determined to grow, and some of the latter may be deficient in good med- ical judgment and broad powers of observation. In every professional calling, given an equal amount of knowledge of that calling, it is judgment chiefly that makes the successful man; judgment to use his professional knowl- edge aright and to prompt hitn to seek to enlarge his knowl- edge and improve in the right use of it with his advancing years and enhanced opportunities for increasing his store of resourceful information in his profession. Enlighten the People.—The Texas Medical News of November last has a timely and proper editorial on the necessity of enlightening the people on medical topics through the secular press and thus counteracting the misleading and designing quacks and fakes, who wrongly mould popular opinion on matters medical to the detriment of the profes- sion's interests and the people's welfare. The profession has been too derelict in the matter. The little fellows in the profession who could not properly construct a sentence and who are not sufficiently posted in the literature and resources of their profession to write or stand intelligent criticism, get behind the code and say they do not wish to advertise themselves and denounce with an assumed holy horror those who, when called upon by the press, do give the people the true light. The advertising denounced by the code is very properly denounced, as the ordinary resort of empirics and charlatans; it is the laudatory call- ing attention to special skill in particular diseases after the manner of quacks. But it is the duty of the profession to properly enlighten the public on all health matters without indelicate boasting or undue ostentation, but in a dignified and scientific manner. This is due from the profession to the public, due from it to humanity and the cause of legi- timate medicine. If light fell in the secular press on the public from right sources, certain states in this glorious union would be having legal exceptions in medical practice regulations, made in favor of osteopathy and all the foolish and fatal medicine fads of the day to the chagrin and dishonor of legitimate medi- cine. "Mostly fools" is what Carlyle would have said of the practical common sense of the medical profession in 160 Editorial. regard to the care of its interests. Its numerous societies seldom discuss and agree upon matters of vital interest to medical men as a class and the profession as a body, as other organizations do, and its great code of medical etiquette and morals is distorted by the designing men in the ranks of the profession so as to suppress ambition and darken public counsel, while quacks and charlatans thrive and flourish in the unimpeded glare of pseudo science, criminal misrepresentation and calumny of the medical profession. The Damage of Daily Drink.—That we may not by our total abstinence friends be misunderstood in one of our editorials in the last issue of the ALIENIST AND NEUROL- OGIST, we make by way of addendum, the following remarks on a subject that never loses interest to science and human- ity. If mankind in general knew what advanced pathology teaches the widely observant physician of the effects of daily alcoholic potations on the human organism, the use of alcohol and its principal compounds, natural or artificial, as a habitual daily beverage, would be shunned as a viper is avoided. Daily potations of strong drink persevered in, except in most exceptional moderation, will ultimately under- mine the strongest constitutions as insidiously as the wiles of Delilah conquered the mighty Samson. Tri-daily pota- tions of strong drink are stitches in the shroud and nails in the coffin of the drinker, by which the garment of life's span is prematurely finished and the funeral casket that transports us to the end of earth is prematurely ready for us. Alcohol thus indulged in and not physiologically counter- acted by an exceptional organism endowed with unusual power of resistance, makes morbid changes in the brain, its blood vessels, its coverings and its substance, as well as in the heart and other organs of the body. Wine is a physi- ological mocker and whosoever is deceived thereby is not wise. The morbid changes in the chronically alcoholized brain are well set forth in the recent treatise of Dr. W. Bevin Lewis on mental diseases. "The vessels dipping into the cortex, or outer layers of the brain, from the pia mater (or undercovering of this organ) are of under size, coarse and frequentiy tortuous and their coats are in advanced stages of atheromatous (earthy deposit) and fatty change." "The nuclei of the adventitial sheath are somewhat num- erous, are freely proliferating (projecting out) or their pro- toplasm is in a state of fatty disintegration," or breaking down. Editorial. 161 The most prominent feature of chronic alcoholism, how- ever, is the abundant increase of the scavenger cells of the surface of the brain lying immediately beneath its mem- braneous covering. Beneath the inner covering of the brain (the pia mater, as it is called, or pia) and pressing into the brain surface, pathologists often find a vast quantity of what they have called Amyloid bodies. Proliferating nuclei appear along the walls of the blood vessels giving them a peculiar spinous appearance. The parivascular spaces, or spaces around the biood-vessels, which carry the lymph-like brain fluid to cushion the vessels, is often found unduly distended with lymphoid elements. The motor cells of the fifth layer of the brain cortex, or rind of the brain, undergo a fatty change, become degener- ate, break down and are absorbed, hence the chronic alco- holic paralysis of old drunkards and the temporary and acute paralysis from the great blood pressure of acute intoxication upon these same centers in the brain. The saying, "he is paralyzed," joculously applied to a man who is very drunk, has more scientific accuracy than was intended by the orig- inator of the expression. The blood-vessels of the brain are the first to feel the effects of alcoholic intemperance. They become enormously and unequally distended and the brain suffers from blood pressure symptoms. Locomotion, perception and ideation are at first embarrassed and finally .permanently impaired or destroyed. "We are struck," says the author previously quoted, "by the large number of extremely coarse dilated vessels which afford us evidence also of grave structural change." Neither does the spinal cord escape, for throughout its whole extent we find increased vascularity. The change in the vessels of the spinal cord is like that which has long been recognized in chronic Bright's disease, says Bevan Lewis. "Through the medium of the blood vascular system, alcohol, by its ready absorption and permeability, is rapidly conveyed to the most distant parts of the organism, estab- lishing wide-spread constitutional disturbances; whilst through the peculiar selective capacity of the nervous centres for this poison, it thereupon expends its primary and most potent influence. Although in all cases the nervous centres bear the chief brunt of its attack, it by no means follows that the subjects of chronic alcoholism suffer in the same way. In one, the gastric (stomach); in a second, the hepatic (liver); in a third, the renal (kidneys) and cardiac (heart) 162 Editorial. symptoms may come to the front; whilst in others, the nervous centres express the special virulence of the agent in their direction. Undoubtedly a neurotic heritage plays a foremost part in thus predisposing to more exclusive deter- mination of the morbid agency upon the higher nervous centres, just as these subjects predisposed to renal degen- eration will, on the establishment of alcoholism, display the usual cardio-vascular (heart and blood-vessels) changes of chronic Bright's disease." The general effect of alcoholic excess is depravity of nutrition and impairment of the nutritional fluids and func- tions, the digestion becomes disordered, the excretory func- tions become deranged and the nerves exhausted or de- stroyed. The higher centers of the brain break down in delirium tremens, insanity, dementia or paralysis, or lesser degrees of mental impairment—a paresis, or lesser paralysis, of speech or motion and aphasia, or speech forgetfulness, and memory failure in general, sets in and thus science confirms the truth of all observation that wine is a mocker and who- soever is deceived thereby is not wise and to him who tar- rieth long thereat or imbibeth oft, its organic consequences are physical ruin and dissolution. This temple of the human soul in which a god might dwell and angels Walk about, can by the unwisdom of the alcoholic habit become transformed into a dwelling place of fiends and furies, can by the dis- eases it engenders be made the dwelling-place of misery and woe of mind and body as the testimony of our advanc- ing civilization with the human wrecks in its dreadful wake, distorted, crippled, dethroned and dead, fearfully prove. Besides the mental and physical destruction revealed by science in the pathway of alcohol as its immediate effects, she points with pitying finger to woes innumerable in the aftermath of its devastating violence which the hand of municipal and individual charity gathers into the hospitals for the insane, the homes for the feeble-minded, the colonies for epileptics, the alms houses and penitentiaries of the land. She points the transgressor with warning hand to the mentally and nervously maimed of the children and chil- dren's children of the drunkard. Alas that one should put an enemy in his mouth not only to steal away his own brains but to rob an unerring heritage of that normal mentality which is or should be the inherent right of the innocent and unfit posterity for the battle of life. The testimony of science say: Be cautious! beware! "For in the last it biteth like a serpent." It poisons the blood, the heart, the brain and the nerves. It Editorial. 163 distorts, depraves, degenerates the organism. It destroys the delicate mechanism of the mind's display and polutes the fountain source of the soul's manifestation. It burns out the machinery of the mind with fire infernal and where a spark of divinity might dwell it leaves but the cinders and ashes of a once brightly glowing and glorious mentality. Its poisoned fangs are like unto those of the stealthy adder in the cradle. Through its baleful influences the unborn come into lives of misery, neurotically and mentally maimed, unfitted for normal life and fortunate if they fill graves untimely; while hurt and helpless womanhood mourns and dies in the mists and blasts of the world's tardy awakening to the destructive effects of the drink habit. Eye Strain in Health and Disease,with spe- cial reference to the Amelioration or Cure of Chronic Nerv- ous Derangements Without the Aid of Drugs, by Ambrose L. Ranney, A.M., M.D., is the pretentious title of a late work by an over zealous opthalmo-neurologist, which has been reviewed in our pages, and in which the author has suc- ceeded in losing sight, like our gynaecologist friends of pre- ceding decades, of preneural conditions. It is a psychologi- cal peculiarity of the medical enthusiast, when he takes a special theme for his subject, to ignore antecedent and col- lateral bearings and descant too exclusively in apparent sequences as though they were exclusive consequences to the exclusion of predetermining neural states. Ambrose Ranney proves too much and yet his subject is worthy of considerate attention from all prudent minded neurologists. American Medico-Psychological Association. —The American Medico-Psychological Association meets in St. Louis, May 10th-13th, 1898. This distinguished body of American Alienists will be given a royal welcome. The Unadvised Renewal of Prescriptions at the pleasure of patient or on the advice of the pharmacist is a great evil. It wrongs the doctor and the patient; the doctor, by keeping his patients from consulting him, and the patient by keeping the latter from the skilled medical aid he may need. When patients and druggists decide the question of repetition of prescriptions and the doses of same, they become practically doctors and being without the necessary medical education, they often gravely err against the interests and welfare, comfort and recovery of the patient. 164 Editorial. Dr. Outten's Book.—Dr. Warren B. Outten, Chief Surgeon of the Missouri Pacific Railway, has written a new book: "Man's Inherited Martyrdom—A Fitful Study of Degen- eration." The work is of great interest and is sure of a favorable reception. It will be published as a serial in the Tri-State Medical Journal and Practitioner, of St. Louis, beginning with the March issue and continuing until finished. Medical Expert Testimony.—A paper by Clark Bell, Esq., on the proposed reform in the law of expert testimony in New York State, includes quotations from the remarks of the Hon. John W. Goff on the subject at the last December dinner of the Medico-Legal Society, criticises the present system and certain legal notions, and proposes the following: Section 1.—When in any civil or criminal proceeding it appears that the testimony of skilled experts may aid in determining any issues of fact, any justice of the court in which such proceeding is pending may upon the application of either party and and after reasonable notice and hearing, appoint one or more skilled experts and make such reason- able examinations and tests in relation to the person, thing or subject matter involved, as either party may request. Section 2.—Such expert may be examined as a witness at the trial by either party, or at the court, and shall receive for his service and for his attendance at court a reasonable sum, to be fixed by the court and paid by the party mak- ing the application and be taxed in his costs if he recover. Regarding Advertisements in the ALIENIST AND NEUROLOGIST.—Having suggested the value of an ad. in the ALIENIST AND NEUROLOGIST to a proprietary friend we received the following reply: "Regarding our placing an ad. in 'THE ALIENIST AND NEUROLOGIST' would state that while we have the great- est esteem for your excellent journal, the class of physi- cians amongst which it circulates are so eminently scientific that they have but little opportunity to use proprietary remedies." Concerning the above we have to say, that the ALIEN- IST AND NEUROLOGIST has certainly one of the best and most discriminating list of patrons who know and employ good proprietary medicines and who are so situated at the head of large hospitals and with extensive practices, as to prefer such agencies as facilitate prescribing, and among them are such proprietary preparations of known reliability Editorial. 165 and excellence as find place in our pages and to which the reader is referred. We will not knowingly admit a medicine or appliance to our advertising pages which has no special merit. Pro- prietary preparations for internal use, besides being of guar- anteed purity and accuracy of composition, should possess the virtue of palatability and acceptability to the stomach, and with abbreviated name, save the physician the labor of detail in prescribing, the latter being an important consid- eration with the busy doctor. The true proprietary medi- cine man is a real adjunct to the medical man in his ardu- ous work. This again is confirmed by the excellent array of specialties offered to the profession in the advertising pages of the ALIENIST AND NEUROLOGIST, a periodical which has the whole medical profession for its field with subscribers and contributors from Russia and Finland to the tropics and over all intervening territory East and West. We give our friend thanks for the compliment he pays us and the assurances that we can do without his "ad." better than he can do without our pages; but we forbear speak- ing further. Dietary Cranks.—Our esteemed and level-headed cotemporary thus discusses a subject of much importance in its neuro-therapeutic aspects, as well as those of dietetics. While there are some excellent features about the Battle Creek Sanitarium's peculiar dietary for certain patients specially prescribed, acting as an "advent" of surprise and rest to certain gormandized gastric mechanisms needing a sort of digestive rest cure, it is about. as well adapted to the majority of stomachs belonging to neuratrophics needing extra good nutrition as the second advent doctrines of the mana- gers of that institution are fitted for the soul sustenance of the average Christian. Dr. Kellogg's dietary is restful, like all the environments of Battle Creek to the over-gorged gourmand, but not very filling. But let Dr. Upson speak. He goes through Drs. Kellogg's and Saulbury's exclusive dietary doctrine like a dose of Epsom: According to the daily prints Dr. Kellogg, of Battle Creek, Michigan, recently delivered a lecture before a large audience in the Y. M. C. A. Hall of this city. Among other things he is said to have urged abstention from meat as an article of diet on sanitary grounds. The comparative method is espe- cially favorable in the study of fads and crank systems. Saulsbury and Kellogg added together furnish a plentiful 166 Editorial. dietary, subtracted the one from the other they reduce them- selves to the absurdity of annihilation. Exclusive systems of diet result from the application of observation on disease to the regulation of the body in health. It is only necessary to change the disease which is on view to get an entirely new set of requirements. There is no doubt of the efficacy of raw meat, dry bread, and hot water, exclusively, in the very common acid-dyspeptic states. Plethoric individuals with the irritated kidneys and neuralgic twinges of the uric-acid condition fly with joy to the grains and nuts of Battle Creek. A sect has lately arisen which, if we are informed aright, largely discounts the very moderate restrictions of the two schemes mentioned above. It has evolved a theory which is truly ponderous in the way in which rt tramples down the joys of the table. The Ralston Club has solved the mystery of arterio-sclerosis. Their logic is simple. The arteries calcify; the lime-salts cause calcification; all foods except fruits and all natural waters contain limesalts; ergo: eat nothing but fruit, drink nothing but distilled water. They apparently assume that with this one mighty brain - throb they have solved the problem of life, and that they have, left men no shadow of an excuse for dying under two hundred years of age. The monkey, the nearest of kin to the hairy progenitor of man, is appealed to as a touching instance of plain living (we wish we could add high thinking, but though the apostles of Ralston may believe it they do not expressly say so). The monkey, they tell us, eats only fruits, and never drinks water with his meals. Presumably the reason why he fails of the double century mark in respect of age is because he does not drink dis- tilled water. The Ralstonites pause in their consideration of the ani- mal kingdom with the monkey. This is unfortunate. The raven, for instance, lives to be one hundred years old. He lives on carrion. The next army of cranks may be encour- aged to follow his example. The fruit-eating craze is possibly the most degenerate of the many recent fads. The fruit-eating and pot-bellied natives of the tropics and their next lower relatives, the apes, are truly inspiring objects of imitation by civilized man; not even their outdoor and arboreal lives save them from the consequences of a meager and irritating regimen. It is truly pitiful to see the army of neurasthenics, dyspep- tics, rheumatics, starving their tissues and acidulating their blood at the beck of a few, to put it charitably, hare- brained enthusiasts. It is fair to suppose that a troop of rickety children will later rise up and call them anything Editorial. 167 but blessed, a fate from which the ape saves himself by abundant potations of river water. The fact with regard to fruit is, that although it contains little nourishment it agrees well with many people endowed with a vigorous gastric mucosa and fairly alkaline blood. To them it brings looseness and joy. In many dyspeptic states, it is the first food-stuff to disagree, and to the ill- nourished neurasthenic it is a miserable substitute for the better tissue-builders. An appeal to the facts of evolution gives little comfort to the cranks of one dietary idea. Primitive man has as hunter and herdsman thriven on an animal dietary. Nuts and fruits have served his turn as well, and encouraged him to the cultivation of the cereals. There is no evidence to show that the people of any nation have become longer - lived or shorter-lived on account of an exclusively vegetable dietary, or that any association of cranks has increased the longevity of its members by any exclusive system whatever. Breitang's Tympanoscope is a new electric auro- scope devised by Dr. Max Breitung, of Coburg, and illustrated and described in Deutsche Medizinal Zeitung fur den 6 January, 1898. It promises to be of diagnostic utility not only to our confreres, the aurists, but to psychiatrists and neuriatrists. Through it aural inspection may be similarly serviceable with ophthalmoscopic examination in determining intra- cranial diagnostic matters. You cannot see through the brain with it, but it reveals the aural mechanism and tym- panic conditions better than previous appliances and hence has its added value to the cerebro-diagnostician. Ernest Hart Dead.—Ernest Hart, editor of the British Medical Journal, is dead. Mr. Hart had been conspicuous for his devotion to social and sanitary progress in London. He established a society for the abatement of smoke, and instituted cheap concerts for the poor. As chairman of the parliamentary bills committee of the British Medical Association, he took an active part in pro- moting a better organization of the medical departments of the British army and navy. Among sanitary investigations he especially inquired into the various epidemics due to the pollution of milk, and devised a series of regulations for safeguarding the milk supply of towns. 168 Editorial. After investigating the conditions of the Irish peasantry, in Galway, Donegal and Mayo, he published in the Fort- nightly Review proposals favoring the creation of a peasant proprietary and for reclaiming waste lands. These were adopted by the government. He was the author of numer- ous works. Brain Desuetude— Speaking at Selkirk on Dec. 8th, 1897, Sir James Crichton-Browne (The Lancet) dwelt on the dangers to health involved in indolence and disuse of the brain. The medical profession, he said, adapting itself to the needs of the time, had felt it incumbent upon it dur- ing the last decade to insist mainly on the evils of misuse of the brain, on the excessive strain not seldom imposed on it in these days in the fierce struggle of the race to be rich, and more especially on the overpressure imposed on it in the name of education when in an immature state; but they were not less keenly alive to the correlative evils of the disuse of the brain. Elderly persons who gave up business and professional men who laid aside their avoca- tions without having other interests or pursuits to which to turn were in many cases plunged in despondency or hurried into premature dotage. He did not know any surer way of inducing premature mental decay than for a man of active habits to retire and do nothing when just past the zenith of life, and, on the other hand, he did not know any surer way of enjoying a green old age than to keep on working at something till the close. It had been said that one of the rewards of philosophy was length of days, and a strik- ing list might be presented of men distinguished for their intellectual labors which they had never laid aside, who had far exceeded the alloted span of human life. Galileo lived to seventy-eight, Newton to eighty-five, Franklin to eighty- five, Buffon to eighty, Farraday to seventy-six, and Brew- ster to eighty-four years. Sir James Crichton-Browne drew special attention to the great age generally attained by English judges. They were, he said, men who could never fall into routine, but were called upon, as long as they held office, for mental effort in considering and deciding on the new points and cases which were constantly submitted to them. For the most part, they had at one period of their lives .undergone some overstrain in the active practice of an exacting profession, and yet they lived to a ripe old age, and were, he believed—notwithstanding the jokes and jibes of hungry aspirants at the bar—more exempt from dotage than any other class of the community. The sustained Editorial. 169 brain-friction in their case kept that organ bright and polished. These facts, he thought, ought to inspire us with some doubt as to the wisdom of the compulsory retirement and pension regime under which we lived. He had known sev- eral cases of mental disease induced solely by enforced idle- ness in men turned out of the public service, and more par- ticularly the army, in conformity with a fixed rule, while still in the prime of life and capable of useful work. On entering the public service a man had to ascend by grad- uated steps of increasing work and responsibility. Was it not possible to arrange graduated steps of diminishing work and responsibility by which he might descend on leaving it? Much waste and wretchedness might thus be saved. The physiological notion of life was not cruel overpressure at the beginning, penal servitude in the middle, and silly superannuation at the end, but the timely, continuous, orderly, well-balanced exercise of all the functions and fac- ulties with which the being is endowed. Touch Paralysis.—The Cleveland Journal of Medicine calls attention to this new subject in the following abstracts from two other leading medical periodicals, one English, the other American. In the British Medical Journal of September 25th, 1897, Dr. R. T. Williamson of London writes on "Touch Paralysis" or the inability to recognize the nature of objects by tactile sense. This term is of course not applied to cases in which organic tactile anesthesia exists. In all such cases failure to recognize objects placed in the hand is readily explained, this failure depending upon conditions either peripheral or central. There are, however, cases of cerebral disease in which, while tactile sensibility remains unchanged, objects touched or held when the eyes are closed are not recognized. The following are cases of the kind: A woman aged twenty-six, with syphilitic history, had a number of epileptoid seizures, characterized by numbness and twitching of the left thumb followed by unconscious- ness. There was later much headache, with double optic neuritis and other symptoms of cerebral involvement. The hand-grasps were about normal and though all forms of sensation in both hands were undiminished it was found that, with closed eyes, she could form no conception of the nature of objects grasped by the left. In the second case, a female patient of twenty-seven years with marked cardiac failure (dilated left ventricle), 170 Editorial. had suffered from an attack of right-sided hemiplegia of sudden onset, from which she had recovered almost com- pletely, a very slight impairment of hand-grasp remaining. In this case as in the former the touch-sense and all other forms of sensibility remained acute, but a similar disability was observed. Another instance of this nature is fully reported in the University Medical Maganne of October, 1897, by Dr. Charles W. Burr of Philadelphia. The patient aged twenty-four, of neurotic temperament, was, when ten years old, struck vio- lently over the right motor area with an ax-handle, and sustained a simple depressed fracture of the right parietal bone. On the return of consciousness right hemiparesis with hemianesthesia was noted, from which in the course of a few months he made a complete recovery. On putting his left hand in his pocket for the first time after his illness he found that though he distinctly felt the object in his grasp he could not form any idea of what it was. On examination tactile and other forms of sensibility were nor- mal on both sides, but on the left side, while feeling a touch as acutely as on the other he failed to localize it. The position of the left arm and hand could always be rightly judged with closed eyes, showing that "muscle- sense" was unimpaired. We have observed similar cases but considering them a variety of tactile anaesthesia did not specially note. We think them worthy of special record. There are more of them to be found and they seem to show how varied are the differentiations of neural function shown by disease beyond the power of the laboratory to demonstrate. Substitution and Renewals of Prescriptions.— Substitution in prescriptions, is the basest of crimes, whether the prescription be a proprietary medicine or an extemporized compound. Proprietary medicines are often specifically pre- scribed because of the assured excellence of their formulae or the superior and certain quality of their ingredients and when ordered by the physician the law should place the unscrupulous substitutor on the same plane as the capital criminal whose liberty or life is forfeited for his crime, because a substituted drug may destroy life by permitting disease to go on which the true prescription might have saved. The druggist is not a doctor and can not take the place of the doctor by substituting something he may think just as good. The law should make it exceedingly unhealthy for him to attempt such a perfidious practice. The same is Editorial. 171 true of unauthorized renewals of the doctor's prescriptions. When unauthorized repetitions are made the pharmacist and the patient become, for the nonce, medical men and, not having educated medical judgments, make mistakes, of course, that make misery and fatality often times, in lieu of extending relief. The physician alone is the proper judge of the quantity and duration of his treatment. The prescribing druggist who refills prescriptions robs the profession of its exclusive rights in this regard and the patient of his deserts. A Medical Man in the Cabinet.—The sanitary welfare of the people demands a national bureau of public health with a physician as its chief in the President's Cab- inet. Sanitation is the salvation of a nation. Health in peace as in war makes enterprise and prosperity possible to a people. Moral degeneracy follows physical, in a people. Hereditary physique and morals go together. Caesar and Napoleon worked wonders with the world; Napoleon and Caesar, epileptic, failed, and Napoleon's change of char- acter followed his "epileptic change." Russia's unjust fame as the most tyrannous of nations came from the excesses of the mad filiacide monarch Ivan, The Terrible. A mad English monarch, George the Third, made two peoples out of one which the coming centuries must tell how much is weal and how much woe for the Anglo-Saxon race. The evil to nations from neuropathic degeneracy revealed to us in the historic past in the lives of Nero hereditarily tainted with epilepsy and insanity, the acquired degeneracy of Commodus and Heliogabalus warn us in the woe and misery of their subjects against indifference to sanitary states of mind in absolute rules and teach us the lesson that when the people make the rulers from among themselves, they should be first mindful of the health of the people from whom the ruler, the legislator, the judiciary and the army and navy, are selected. Healthy people make and execute whole laws and pro- mote happiness and prosperity. The Psychical Salvage and the Sin of Suicide.— A clergyman's influence depends much on his conformity in argument to the Christian precept of charity. But certain cleric critics have in unchristian spirit hurled harsh epithets at us. They have called us "pagan and worse than pagan" and classed us with Ingersoll whose agnostic icono- clasm and crippled logic concerning things sacred, we do not in the main approve. Neither do we approve his defense of suicide in general as a virtue. Suicide is often a sin. 172 Editorial. Viewing suicide in its scientific aspects and noting its effects on mankind, is a different thing from discussing it as a vice or virtue. Abstractly speaking there is seldom virtue in it on the part of the individual, because better resources and nobler remedies might be found in most instances. . The moral merits or demerits of suicide belong to another sphere of work and another cloth than ours. But from all that we have observed in our field of research, we have learned that the world is better off in certain instances for a certain sort of men having been removed from earth either by their own or others' effort; we have seen such instances and whatever you may think of the right or wrong, the crime or virtue, of suicide, so have you, gentle reader. The International Medical Congress at Mos- cow.—Dr. A. Rovinsky, writing to the Boston Medical and Sutgical Journal, says: Whatever the results, practical and otherwise, of the International Medical Congress recently held at Moscow, it is as yet too premature to judge; one thing, however, is certain; it has uncovered a terra incognita before the eyes of the scientific world; it has shown that the "Barbarians of the North" have pro- gressed in medical and allied sciences by gigantic strides to a position not very far from that occupied by the other European nations. The Russian has proved himself to be not only an apt pupil, but also a careful and conscientious independent investigator. The difficulties of the Russian tongue have served as a great obstacle in the way of intro- ducing the world of science to the vast accumulation of scientific labor and original research, of which the Con- gresses caught but a glimpse from the papers read by the Russians and from visiting the medical institutions of Mos- cow and other cities. There are fields of labor—as that of the so-called "zemstvo" physicians—which are peculiarly adapted to the canditions of life in Russia, and which can- not possibly be comprehended, and therefore appreciated by a foreigner: in these an enormous amount of work is done by thousands of quiet, unobtrusive practitioners, especially in the line of public hygiene, of which there is a truly lamentable lack in a great many parts of the empire, and which, in view of the ignorance of the population, it takes more than ordinary courage to establish. As far as can be judged, the Congress—with the exception of some inevitable occurrences of an unpleasant nature—turned out to be a success. The great number of physicians, among whom shone not a few stars of the first magnitude, the abundance of papers presented, and the Editorial. 173 importance of the subjects discussed—all prove conclusively that the medical world has accepted the invitation of Russia to the Congress most willingly; although it is not to be denied, that curiosity to see the "Russian bear" in his lair prompted not a few in responding to the call. What they saw in Moscow (or to be more explicit, what was shown to them of Moscow) was certainly a pleasant disappointment. I understand that the Executive Committee of the Conven- tion, notwithstanning a great many obstacles in their way (of which the foreigners need not necessarily be cognizant) have discharged their duties to the satisfaction of all, and it was certainly due partly to their efforts that the great num- bers of foreigners left Moscow with a greater, so to say, scientific baggage, than they brought with them. Add to this the proverbial Russian hospitality, that seemed to even excel itself on the occasion, the unique features of Moscow —with its Kremlin, on one side, reminding one of some Asiatic city; and its hospitals, libraries, scientific collections, its great university, on the other hand—and you will readily perceive that the impression left on the minds of the for- eigners by Russia and its representative scientists will be lasting and favorable. When the impressionable nature of the Russian and his almost fanatical love for science (a trait of character readily noticed by the keen Virchow) no one can foretell what a powerful impetus in the direction of scientific investigation the Congress has given to Russian science. At the same time nothing could so elevate the standing of Russian culture beyond thfi confines of the empire. Not by any means the last party to profit by the "feast of science" is the Russian government. Constantly holding in check the embryonic public opinion of the land, the Russian government has always striven to create for itself a favorable public opinion in Europe (the utility of such a policy does not concern us here), sometimes at the expense of a great deal of energy, as by subsidizing certain parts of the press in Europe, keeping a whole system of spies, etc. It requires no fertile mind to comprehend, that having taken a most active participation in the preparations for the Congress, and having extended unbounded hospi- tality to the foreigners (for if the Russian government does do things, it does not do them by halves), the Czar him- self taking an almost direct interest in the proceedings, the government has won over to its side hundreds of intelligent staunch supporters, who will carry with them pleasant remembrances into all the corners of the habitable globe. This is by no means of small importance. We all remember 174 Editorial. the flutter of excitement and the adverse criticism toward the Russian liberals, created by the sensational reports of Rev. DeWitt Talmage's visit to St. Petersburg and his inter- view with the Czar, who not only allowed him to enter his most august presence, but actually permitted him to taste of his cuisine and to pat his children! As if to strengthen the political misalliance between France and Russia, the next Medical Congress has chosen Paris as its place of meeting. But strange to say, as com- pared with the Germans, both quantitatively and qualita- tively, the French were insufficiently represented in Mos- cow. Besides, the Methodical Germans had their commit- tees all prearranged long before the opening of the Con- gress, the Frenchmen were rather slow in doing so; hence, very probably, the great difference in the respective repre- sentations. Of the many famous men present no two attracted as much attention as the great master Rudolf Virchow and the founder of the modern school of criminology, Cesare Lom- broso. The venerable old teacher, who counted among those present many a gray-haired pupil (Virchow is seventy-six years old) of his, called out quite a pathetic protest, when he intimated in his opening speech that this may be the last medical congress he is able to attend. Of his several addresses that in the Section of General Path- ology on the "Role of the Vessels and of the Parenchyma in Inflammation," seems to be the most notable one. A deputation from the women physicians of Russia thanked him for his efforts in behalf of the medical educa- tion of women; in 1893, when the women were not admit- ted to the University, Professor Virchow was the first to open his lecture-rooms and laboratories to them. In reply he said, that the woman brings into her scientific work an idealism and the purity of her soul. He also expressed his delight at the opening of the medical school for women in St. Petersburg. Prof. C. Lombroso, whose appearance was hailed with delight, as he has quite a number of appreciative ad- mirers among the Russians, delivered, among others, a notable address on the "Latest Requisitions of Psychi- atry." An unassuming servant to medicine, psychiatry has invaded so many departments of knowledge, that no other branch of science can be compared to it. She has given a new and more perfect classification of hysteria, she has elucidated many points regarding epilepsy, revealed the eti- ology of pellagra, alcoholism, egotism, discovered a whole series of degenerative processes in cretinism, goitre and Editorial. 175 myxedema, at the same time giving us means to either foresee or to cure these degenerations. She has explained the nature of the phenomena of epidemic fanaticism. She has succeeded in proving that a great many of the so- called criminals are in reality sick men who, instead of being punished, must be subjected to medical treatment. Guided by clinical experimentalism, the progressive alienists came to the conclusion that they must study rather the patient than the disease, that they must find in the patient's physical and functional disturbances as much as they look for in psychical alterations. Fortified by their first successful efforts the alienists continued in the same direction, hoping to discover certain characteristic traits, that would aid them in distinguishing the sane from the insane. Without as yet finding these, they nevertheless established a new method of investigation in the domains of psychiatry and crime. They have concluded, that against the a priori investigation of the crime, we must put the direct analytical examination of the criminal himself, and of the conditions of life surrounding him; guided by this idea, our system of punishment must be such as to act rather less severely, but the law must strive to set aside the con- ditions creating the criminal. In the domain of psychology she has first of all shown the parallelism between the phenomena of ideation so far beyond and above our control, on the one hand, and the phenomena of perception, so easily verified, on the other hand. We all know the perseverance of very strong and very prolonged impressions, that are left even after the subject causing them, has disappeared. This law of perse- verance is found to be uppermost in the mental sphere of the insane; thus one patient who became insane because of fright caused by an explosion of powder, continued to imagine himself in the midst of flames. Such and a great many other facts assist us in comprehending the mechanism of thinking. In the cortical strata of the brain in which thought is formed there takes place a movement, analogous to that said by the physiologists to take place in the end- fibres of the sensory nerves. Psychiatry thus leads us further than pathological anatomy. Thought presents in reality the diminished image of the subject, -an image called out by sensation. But while in the condition of waking, thanks to the predomi- nance of brighter perceptions, this image is so pale, that we are unable to determine its nature. Only when these perception phenomena disappear, as in sleep, in the hallu- cination of the monomaniac or of the hypnotized subject, 176 Editorial. does the idea become what it was, that is, an image. But it is while studying hypnotism and hysteria, that the secrets of psychical phenomena are revealed to us, because knowl- edge of these mental conditions enables us to understand the secret with the aid of experimental investigation. Facts prove that thought is connected with the law of molecular motion of the cortical brain matter. Professor Lombroso paid a flying visit to Count Leo Tolstoi, whom he considers one of the greatest minds of the century, and does not at all agree with Dr. M. Nordau in classing him among the great degenerates. Unfortu- nately, one of the count's sons was just then passing through a severe typhoid, and the doctor's stay had to be shortened. In the Section of Gynecology and Obstetrics, Professor Sneguireff, of Moscow, delivered the Chairman's Address, in the course of which he pointed to the picture of Raphael's Sistine Madonna as a perfect type of healthy and beautiful womanhood, for which science and art must strive. "Take care that the cradle of humanity is healthy, because health is beauty, beauty is truth, and truth is happiness. The peace of the future and happiness on earth consist in the knowledge of preserving one's strength, given by nature, and in developing the harmony founded on mutual love and respect. Not only may the woman enjoy the rights that we enjoy, but she must have more rights and less duties." By the number of important papers under discussion the Section on Hygiene was one of the most interesting. Prof. V. Vaughan, of Ann Arbor, Mich., read a very able paper on the examination of drinking-water, and Professor Novy, of the same University, on the necessity of instruction in the elementary schools in the measures for combating infec- tious diseases. To organize the work of public hygiene, Dr. Burgertern recommmends in his paper the systematic spreading of popularly written treatises on the subject by the aid of some official method; the instruction in hygiene by competent teachers in all the schools of the land; the establishment of chairs to institutes of hygiene in connec- tion with every medical school so as to prepare a sufficient number of specialists in public hygiene; a special sum to be designated by the central government for the purpose of instructing the people in hygiene. Among other addresses in the same Section was one on "Alcoholism in its Relation to Public Hygiene." Dr. Grig- orjeff, of St. Petersburg, brought forward some interesting statistics concerning the State monopoly of the sale of alcohol in Russia; in general it has tended to diminish the Editorial. 177 evil. Dr. Yarosheffsky, of Samara, discussed the special hospitals for alcoholics. He and Dr. Korovin have among other things called the attention of those present to the fact, that among those battling against the great evil in the civilized communities, the physicians are not to be found; although they could do much more than the various prohi- bition societies, whose utility is after all a matter of fiction rather than of reality; alcoholism is to be considered as a sort of an epidemic disease and treated accordingly. A most brilliant address was delivered by the famous neuro-pathologist, Krafft-Ebbing, on the "Etiology of Pro- gressive Paralysis." It was a skilful analysis of the con- dition of modern civilized life, done by the hand of a mas- ter. He pointed out that the modern man has paid dearly for the great progress in trade, manufacture, agriculture and for the innumerable inventions. The intensity of the mod- ern life is still more enhanced by the political activity, the great diversity of opinions, the struggle for existence, not only among individuals, but among classes and nations; the nervous system is thus in a condition of never-ceasing excitation, increased by the abuse of the various nervines, as tobacco, tea, coffee, alcohol. The physical degeneration of the great masses of people segregated in the large man- ufacturing centres is the true reflection of their miserable conditions of life, and appears as rachitis, scrofulosis, tuber- culosis, etc. The female is not surrounded by any more favorable circumstances. Such conditions form certainly a very fertile soil for the development of various nervous disorders, among which progressive paralysis occupies a preeminent place. The ever spreading curse of syphilis is probably the most important etiological factor in the causa- tion of the disease; he would, however, not commit himself to considering syphilis as a sine qua non in the etiology of progressive paralysis. If he were to state the etiological factors of the disease he would say: "civilization and syphilization." Another hardly less interesting and important address was that by Prof. 1. JWetchnikoff on "The Plague." The interest in the paper was heightened by the fact, that the author applied the comparatively new method of serum- therapy in the treatment of the disease, which up to lately was considered only as a subject of historical interest and not of medical importance; but its recent appearance in India and in Hong Kong has attracted the attention of the scientific world. Recent investigation of the plague has enabled us to diagnosticate the disease early and to check its spread in time, and so perfected has the method become 178 Editorial. that even a student is now able to diagnosticate a case of the plague. The Pope's Physician.—battle & Co. claim that he commends and uses Bromidia. They send us the fol- lowing very flattering excerpt: "l have given your Bromidia with success as a remedy for Insomnia, especially where produced by excessive study or mental work." DR. LUIGI SALUCCI, Physician to the Holy Apostolic Palaces, The Vatican, Rome. September 1, 1897. Battle & Co. with reference to the above, say: "We enclose you an article which evidently comes from The Pope's Physician. We hope you will give it a good place somewhere in your journal. It is short and if you could place it on the bottom of some regular reading page we would take it as a great favor." Now if Battle & Co. can secure the Pope's benediction on Bromidia, we will take a dose ourselves to attest our faith in drugs. Coming Round.—A paper read before the American Association of Obstetricians and Gynecologists concludes that in oophorectomy "a portion of healthy ovary should be allowed to remain whenever possible." Thanks! For when "Ginnycology" passes into the hands of the lady "ginny- cologists" and they extend their field to testectomy, we may be able to point with "saving grace" to this precedent for the salvation of our own orchids, when orchotomy shall become the surgical therapeutics, in the hands of the gentler sex medical, for orchitis, orchalgia, lumbago, sciatica, facial neuralgia and all mascular vagaries, morbid impulsions and ailments of man's cerebro-spinal and ganglionic and peripheral nervous systems, in short, when, with orchectomy in one hand, ovarectomy in the other, surgical therapy shall be directed by our long suffering and vengeful sisters in the profession. Dr. B. Sherwood Dunn, Neurology and all mas- culinity thank you for your plea for a little of the healthy ovary to be left in the pelvis. It may yet be the salvation of the imperilled testes, trembling below the belt, just on the outside of the fatal precincts of normal oophorectomy. In the January North American Review, Prof. Cesare Lombroso tells "Why Homicide Has Increased in the United States." He suggests the establishment of colonies Editorial. 179 for the incorrigible, the multiplication of reformatories mod- eled after the Elmira institution, and the rigorous combating of the saloon influence. The Degradation of Military Medical Men both in the British and American armies and navies should be resented by the profession of both countries. What is an army's efficiency without proper sanitation and provision against preventable and for curable ills and for the many medical and surgical emergencies of the service? and what spirited medical man will forego the opportunities of honor and advance in rank of the other departments to take a degraded place on the medical staff, to be spurned and out- ranked by epauletted subordinates and subalterns as mere servile attendants? The average educated and well-trained medical man in these days of high scientific requirements is the peer of most, and the superior of many, army officers in knowledge of the essentials of an army's welfare. The medical director is, or should be, in value in a campaign next to the com- manding officer of an army corps, and the same relative value extends down to the brigade or batallion. The medi- cal staff may save from or consign an army corps to disaster; may permit or prevent pestilance; may select or fail to select sanitary supplies, equipment or encampments; may burden a marching army with or release it of invalids; may anticipate or neglect, remove or overlook, sanitary difficulties that stand in the way of victory. If anywhere brains and knowledge, ambition and skill, should be encouraged, it is in the medical corps of the army. These qualities and incentives to the most efficient service are as essential as with the artillery, the maneuvers of the cavalry or the management of the infantry. The engineer corps should not outrank the medi- cal. The efficiency of the medical department should be looked to with more zeal and more solicitude on the part of field officers and men than even the commissary or quarter- master's departments, for well men can forage for them- selves and will not ordinarily suffer for clothing if they are started out right on a campaign. Napoleon's Waterloo began at Moscow and Sadona. If he could have kept his army well on that fatal march he might have mastered the world. More and better medical management of that fatal invasion might have made the maneuvers of retreat less imperative and disastrous. If Napoleon's own health had been better cared for after that 180 Editorial. retreat he might not have failed or risked his fate at Water- loo. In this connection we are pleased to note that the pro- fession of Great Britain'is protesting against the contemptible manner in which medical officers of the British army are treated by their brother officers. Army medical men must have adequate rank, respect and promotion, else men who are the most capable and who could fill any place in the service with ability and honor, will ignore the medical department to the great loss of military efficiency. High minded men make an army, as they make a state, in every department of its service. The Last Slap at the Expert Witness.—The Chicago Medical Recorder says: Experts are having a hard time now. Some can get no pay for their testimony, others are accused of ignorance, and others again of venality^ but it was reserved for a St. Louis judge to recognize a ' pro- fessor" of phrenology as an expert in insanity. He testified that the defendant in a murder trial was insane, and, upon being questioned as to the reasons for his conclusion, said that his opinion was based solely upon a phrenological examination made by passing his hands over the man's head. Medico-Psychological Association Announce- ment.—At a meeting of the Committee of Arrangements in St. Louis, Mo., on January 12th, 1898, it was decided that the 54th Annual Meeting of the American Medico- Psychological Association will be held at the Southern Hotel. Said Association will convene May 10th, 1898, and will con- tinue May 11th, 12th and 13th. The aforesaid Hotel has agreed to give a discount of 50 cents per day on all rooms of $3.50 and upwards, and to all ladies accompanying mem- bers a rate of $2.50 per day in any room regardless of the regular rate. The Committee has under advisement the social fea- tures of the meeting to be announced later. Any informa- tion desired will be cheerfully furnished by the Chairman of said Committee, Dr. C. R. Woodson, Superintendent State Lunatic Asylum No. 2, St. Joseph, Mo. You are cordially solicited to attend with lady members of your family and contribute to the success of the coming meeting. We would suggest that you communicate directly with Editorial. 18J the Southern Hotel for the accommodations desired and it will insure rooms in readiness upon your arrival. Respectfully, C. R. WOODSON, Chairman, C. B. BURR, J. F. ROBINSON, J. T. COOMBS, C. H. HUGHES, E. C. RUNGE, Committee. NOTES. tt^"No commission allowed agents or dealers on renewal subscriptions."^Jt Sousa's Debut was as a violinist before an audience of insane people and attendants at the "St. Elizabeth," the United States Government Hospital for the Insane at Washington City. His age was then eleven years. Dr. E. L. Melius, pathologist to the Westborough, Mass., hospital, resigned last September to accept a similar position at the Johns Hopkins Hospital at Baltimore. The Westborough Hospital has begun making an examination of the blood of each patient admitted, with a view to tab- ulation of results. Some interesting phenomena have already been observed, which, if verified later, will be given to the public. New Medical Journal.—In January, 1898, the Phil- adelphia Publishing Company, incorporated under the laws of Pennsylvania, began the publication of a weekly medical journal, called 77te Philadelphia Medical Journal. The company has a capital of $30,000, in shares of $10 par value, full paid and non-assessable. The management of the company is entrusted to a board of trustees, in which are representatives of leading medical schools. The edito- rial management has been entrusted to Dr. George M. Gould. The price of subscription is $3 per annum. Psychiatry and Neuriatry in France.—Among other subjects the coming French Congress of Alienists and Neurologists will next year discuss psychic disturbances following operations, arteritis in neuro-pathology, and mania transitoria in its neural and medico-legal aspects. 182 Editorial. Eleventh International Congress of Hygiene and Demography will convene at Madrid, April tenth, proximo, and remain in session till the close of April seven- teen. Following is the announcement of the secretary gen- eral. We wish this important assembly the success it so richly merits. Neuviéme Congrés international d'Hygiéne et de Démog- raphie dont la célebration aura lieu â Madrid du 10 au 17 Avril 1898, sous le patronage de S. M. le Roi Alfonse XIII et de S. M. la Reine Régente. Dans la séanee de cloture du VlII Congrès, célebré a Budapest (1894), a ville de Madrid fut designée comme lieu de réunion du Congrès suivant. Le Gouvernement de S. M. se propose de remplir dig- nement l'engagement alors contracté. Le Patronat Royal lui donne son auguste protection; et le bon vouloir, dont se trouvent animés quiconques s'occupent en Espagne de l'interessante étude de l'Hygiène et de la Démographie, en assure le succès. Les travaux de propagande et d'organisa- tion, a la charge d'un Comite général presidé par Son Excellence M. le Ministre de l'Interieur, sont très avancés. Les Programmes et Reglements du Congres et de l'Exposi- tion y annexée, déjà imprimés en quatre langues, com- mencent a circuler et se distribuent partout; a liste des fêtes, receptions et excursions scientifiques ou expansives, est en preparation; les dispositions nécessaires a effectuer dans le Palais de l'Industrie et des Arts, cédé par le Min- istre de Fomento (Agriculture, Commerce et Travaux publics) comme local, ou doivent avoir lieu, la célebration des séances du Congrès, ainsi que l'installation de l'Exposition-annexée, sont également a l'étude; on prévoit, en fin, la présence en Espagne de gran nombre de personnalités étrangeres, dis- tinguées dans les sciences, et tout porte a croire que la réussite de la réunion du IX Congres International d'Hygiene et de Démographie ne restera pas au dessous des succes précédents. Le Congres et l'Exposition auront lieu du 10 au 17 Avril de l'année prochaine 1898. Veuillez me permettre M. au nom du Comité général de Propagande et d'Organisation de vous prier de contribuer a lui donner gain de cause, tout en daignant accepter son invitation. Madrid 10 Juin 1897. Le Secrétaire général, DR. AMALIO GlMENO. Hospital Construction, etc.—The February, 1898, issue of the Albany Medical Annals will be an extra number Editorial. 183. upon subjects pertaining to hospitals—their construction and administration, including the following articles appropriately illustrated: "A Description of Hospital Buildings on the Pavilion Plan," by Albert Van der Veer, M. D., Attending Surgeon, Albany Hospital; "The Construction of Hospitals;" by P. M. Wise, M. D., President N. Y. State Commission in Lunacy: "The Warming and Ventilation of Hospitals," by Fred P. Smith, Heating Engineer for N. Y. State Archi- tect and Capitol Commissioners, Albany, N. Y.; "The Plumb- ing of Hospitals," by Wm. Paul Gerhard, C. E., Consult- ing Engineer for Sanitary Works, New York; "Hospital Equipment," by C. Irving Fisher, M. D., Superintendent, The Presbyterian Hospital, New York; "The Medical Ser- vice of Hospitals," by Henry M. Hurd, M. D., Medical Superintendent, The Johns Hopkins Hospital, Baltimore,—all written by well-known men of expert experience on the subjects treated. A variety of practical topics of interest to all engaged in the management of hospitals, also not elsewhere to be found, will be presented in this number, The price of this number of the Annals to non-subscribers will be twenty-five cents, post-paid. All orders should be addressed, Albany Medical Annals, Albany, N. Y. Insanity in Pennsylvania.—The number of insane in all classes of institutions in Pennsylvania on September 30th, 1886, was 9,473. The National Pure Food Congress, to assemble in Washington, D. C, March tenth, should be heartily en- couraged by the profession, commonwealths and people. Its success means health and life to thousands and death to dangerous drug and drink adulteration, dastardly deception in foods and commercial rottenness. The beginning of the end is coming to a nation when it long permits this method of insidious assassination of body and morals to continue. Save America from this secret foe of health, business hon- esty and commercial rectitude. REVIEWS, BOOK NOTICES, ETC HUGH WYNNE, Free Quaker,* is a literary character story and revo- lutionary historical novel of high rank by a man of eminence in medicine, whose merits as a writer are only equaled by his well-earned fame as a physician. It may be said of this last and best production of our talented author and colleague in neurological medicine, as was facetiousiy said of friend Hammond, author of "Robert Severne," etc., etc., "he writes fiction well." Every physician should read "Hugh Wynne" for the just tribute the author pays to the skill and virtue of that patriot statesman physician, the great Rush, with his delicate clean cut face under a full wig, to whose great professional skill and high civic virtue, the author has erected an imperish- able memorial in which, however, appears no line of fiction. Every patriot will enjoy this book for its historic records of daring, suffering devotion to duty of our patriotic sires of '76 and for the light it especially throws on the field and camp character of Washington and other patriots of his time; on the causes of Arnold's downfall; on the home and political life of the followers of Penn, and for its historic data. The book which has reached its thirty-six thousandth edition will also find a welcome place, not only in the hearts of every descendant of those patriot sires who mingled in the fray when souls were tried and an invinc- ible nation was born to freedom, but descendants of both Whig and Tory will read it with true Anglo-Saxon pride. The sorrowful glory of that dread- ful camp-ground, Valley Forge, of Lexington, the fateful Brandywine, the historic records of "Williams, Marion and Morgan," "the thrash- ing Torleton got at Cowpens" and "of the fight at Guilford," Greene, los- ing fights and winning strategic victories "probably more by luck than genius," the boy Lafayette, the Comte de Rochambau and the Duc de Lauzan, De Grass and Duponceau "much overworked," and so many other fields and events of the time of America's conception and natal throes, are so well told that the student of American history must needs possess himself of the book for its merits of style and fact and for its moral, political and personal character lessons. The story of Arnold's treason and the noble Andre's capture are neatly woven into the romance of Hugh Wynne and Darthea. •By S. Welr Mitchell, M.D., LL.D., Philadelphia. 'Century Co., Publishers. New York. [184] Reviews, Book Notices, Etc. 185 The psychology of the book Is in the main as near up to date as the author could make it without anachronism. The failure of the elder Wynne's mind is attributed to his "arteries being older than his body," words put in the mouth of that pioneer American Alienist, Dr. Rush. "Our great physi- cian of the Revolution," whom now all the world has learned to revere, not only told Hugh that his father was beginning to have some failure of brain because of his arteries being older than the rest of him (atheroma) but told him also that his father's mental condition as to business, "as was in such conditions rare, continued to be lucid." The opinion here expressed is somewhat at variance from present psychiatric observation. The occupation faculties whose action has become automatic by long repetition are ordinarily the last to fail in process of mental decadence, save that of the memory of names. I have seen insane lawyers plead well and lunatic physicians pre- scribe properly, mechanics handle their tools with skill, and farmers the plow, musicians play and artists paint, when too insane to do anything else cor- rectly, save perhaps to eat and perform the daily ablutions of the toilet, etc., under suggestion from a sane attendant. But the psychiatry and psychology of the Revolution were not the psychiatry or psychology of to-day. The book ends, as so many novels do, with the marriage of the hero, Hugh Wynne, and heroine, Darthea Paniston, and their passing from further notice. Cousin Arthur Wynne is disposed of rather summarily and the title to the estate of Wynsote, in Wales, "goes up in smoke," so far as Hugh's vested rights are concerned, through a woman's passionate impulse, Darthea having cast the deed into the fire. May we expect a sequel to Hugh Wynne? STUDIES IN THE PSYCHOLOGY OF SEX. Vol. I., SEXUAL INVERSION. By Haveiock Ellis. The University Press, Watford, London. This is a subject, disagreeable and revolting as are some of its details to certain delicate sensibilities, which the student of psychology—normal and morbid—cannot ignore, any more than the study of repulsive disease or the duty of dissection can be avoided. It is for the welfare of his fellow-man that the medical observer looks into the subject of homo-sexuality, finding some of its features pitiable, others abhorent, and all demanding cold, calm and careful consideration with a view to such medical resource as may be revealed bv his study in medical, moral or statutory remedy. In this spirit the author has approached and completed the study of his subject and given to the profession of perversion, that calls for professional and public consid- eration and action. The author's analysis of sexual inversion leads him to the conclusion that "the average invert, moving in ordinary society, * * * is most usually a person of average general health, though very frequently with hereditary relationships that are markedly neurotic, the subject of a congenital predis- posing abnormality," and that three influences bring into action the latent predisposition—example at school, seduction, disappointment in normal love. "In this volume," the author asserts that he is not dealing with a subject belonging to the lunatic asylum or prison, but "with individuals 186 Reviews, Book Notices, Etc. who live in freedom, some of them suffering intensely from their abnormal organization, but otherwise ordinary members of insanity," yet there are perverts who are insane and there is insanity that develops sexual per- version. But to fully comprehend the author you should read his book. If you are a psychologist you will need to consult it; if you are a psychiatrist, it will enlighten you;if you are a moralist, it will astonish you in the fact that persons of pure, as well as impure, morals, criminal and non-criminal, sane and non-insane, may be ranked among the author's cases. EMMAUS, Asylum for Epileptics and Idiots at Marthasville, Warren county, Mo., Rev. C. F. Sturm, Superintendent; and at St. Charles, Mo., Rev. J. D. Illg, Superintendent. Board of Directors—L. Haeberle, President, H. F. Knippenberg, Treasurer, G. Niebuhr, Secretary, H. Telgemeier, W. Meier, S. Kruse, G. Goebel. Fr. Reichmann, Louis Peters. Physicians— Dr. E. A. Rembe, Physician in Charge, Augusta, Mo.; Dr. W.J. Alexander, C. M., Consulting Physician, Marthasville, Mo. The existence of this worthy institution of charity towards these unfor- tunates is a rebuke to the commonwealth which has so long neglected to pro- vide for its epileptics, idiots and feeble-minded. We wish it the success and support it deserves, and hope that the state will ultimately buy this property or make suitable provision elsewhere for these helpless ones who are so worthy of the state care and consideration. RUBAIYAT OF DOC SIFERS is, in fact, what the Persian word implies—a crown of roses lovingly placed, by the poet, James Whitcomb Riley, on the brow of the old village doctor of days agone, showing in common vernacular, shaped in rhyme, the appreciation by these common people of the fidelity, the faith, wisdom, and duty well done to humanity's call, of the old-time vil- lage doctor whose like we shall never see again. For he has passed away, while in his stead reigns another type, yet none the less sincere and devoted, a soldier to the call of duty. Stories like this of "doc Sifers" are memorial of the merit and virtue of medical men which keep in remembrance better than bronze or marble. The poem will find a place in the American heart along with Longfellow's Village Blacksmith and Will Carleton's Country Doctor. The Century Co., New York, are the publishers. AN EPITOME OF THE HISTORY OF MEDICINE. By Russell Park, A.M., M.D., Professor of Surgery in the Medical Department of the University of Buf- falo, etc. Illustrated with Portraits and other Engravings. One Volumr, Royal Octavo, pages xiv-348. Extra Cloth, Beveled Edges, 52.00 net. he F. A. Davis Co., Publishers, 1914 and 1916 Cherry Street, Philadelphia; 117 W. Forty-Second Street, New York; 9 Lakeside Building, Chicago. This is the best book on the subject that has been offered to the Amer- ican medical profession since the appearance of Renourd, transiated by Comegys, of Cincinnati, on the same subject. It is a desirable and valuable treatise by a competent and entertaining writer and is worthy a prominent place in every practitioner's and medical editor's reference library. -Reviews, Book Notices, Etc. l87 STIRPlCULTURE; OR IMPROVEMENT OF OFFSPRING THROUGH WISER GENERATION. By M. L. Holbrook, M. D.. Editor of the Journal of Hygiene, author of "Hygiene of the Brain," "Advantages of Chastity," etc., etc. Published by M. L. Holbrook & Co., New York, L. N. Fowler & Co., London, 1897. A good book for the lay reader and the newly married or those who contemplate matrimony, because it will turn the minds of the people to ante-natal causes of post-natal physical and mental, degeneracy. The book is not, however, a strong book, not equal to the great philo- sophical and scientific impressions of truth in this direction made by Mauds- ley, Spencer aud others. But it is better than nothing and suited to com- mon comprehension. We are in receipt of the initial number of CURRENT THOUGHT, Cleveland, Ohio, in the form of a quarterly Journal. Heretofore the publication has been published as paper covered books, called Current Thought Library. Mr. C. Elton Blanchard, the editor of this journal, was formerly publisher of the Cleveland Medical Gazette, and is an active student of Anthropo- logical questions, being a lecturer and director of the American Institute of Anthropology. The medical profession will find much of interest in Current Thought as will any thinking man or woman. Sample copies will be sent upon request. THE MEDICO-LEGAL ASPECT OF EROTO-CHOREIC INSANITIES. By C. C. Hersman, M.D., Pittsburg, Pa., Lecturer on Mental and Nervous Dis- eases, Western Penn. University (Medical Department); Member Staff Insane Department St. Francis Hospital; Alienist South Side Hospital; Late of W. Va. Hospital for Insane, etc. A reprint from the July, 1897, number of the ALIENIST AND NEUROLOGIST. A timely and important paper. The subject should be better understood by the profession at large especially the kindred subject, Nymphomania. Anomalies and Curiosities of Medicine, being an Encyclopedic Collection of Rare and Extraordinary Cases, and of the Most Striking Instances of Abnormality in all Branches of Medicine and Surgery, Derived from an Exhaustive Research of Medical Literature from its Origin to the Present Day, abstracted, classified, annotated, and indexed by George M. Gould, A.M., M. D. and Walter L. Pyle, A.M., M. D. Forming one handsome imperial octavo volume of 968 Pages, with 295 Illustrations in the Text, and 12 Half-tone and Colored Plates. Prices: Cloth, $6.00 net; Half Morocco, $7.00 net. W. B. Saunders, publisher, 925 Walnut Street, Philadelphia. Die Bedeutung der AugenstSrungen fur die Diagnose der Him- und Riicken- marks-Krank-heiten. Fur Aertze besonders Neurologen und Ophthalmologen von Dr. Otto Schwarz, Privatdocent an der Universitat Leipzig. Berlin, 1898, Verlag Von S. Karger, Karlstrasse 15. Preis M 2,50. Index Catalogue of the Library of the Surgeon-General's Office, United States Army. Authors and Subjects, Second Series, Vol. II. 188 Reviews, Book Notices, Etc. This valuable book continues to sustain its well-merited reputation as an indispensable reference to medicine for the medical profession, reflecting great credit on the industry, zeal and public and professional spirit of the Surgeon-General's office. Systeme Nerveux Central Coupes Histologiques Photographieeo par le Dr. J. Dagonet, 1897, gr. in 8 de 12 planches tirees en phototypie cor- tonne, 3f50. The plates in this good little work by a well known author, are accu- rate and instructive and the text is clear and interesting. The plates rep- resent important centers of the cerebrum, cerebellum and spinal marrow. Criminal Abortion: Its Prevalence, Its Prevention, and Its Relation to the Medical Examiner—Based on the "Summary of the Vital Statistics of the New England States for the Year 1892," by the Six Secretaries of the New England State Boards of Health. By Dr. H. R. Storer, Pres. Med. Staff Newport Hospital, etc., Newport, R. I. Report of a Case of Intradural Spinal Tumor Extending Through the Foramen Magnum, Compressing the Extreme Upper Portion of the Cord, and Almost Completely Destroying it at the Third Cervical Segment. By J. T. Eskridge, M.D., Neurologist to St. Luke's Hospital, etc., Denver, Colorado. The Eye in Hereditary Ataxia with a Report of FourCases of Friedreich's Ataxia in One Family. By Charles W. Burr, M. D., Clinical Professor of Nervous Diseases in the Medico-Chirurgical College, Philadelphia; Profes- sor of Diseases of the Mind and Nervous System in the Philadelphia Polyclinic. The Advance in the Principles and Practice of Medicine During the Sixty Years of the Reign of Queen Victoria. By Sir Dyce Duckworth, M. D., LL. D., F. R. C. P., Physician and Lecturer on Medicine, St. Bartholomew's Hospital; Hon. Physician to H. R. H. the Prince of Wales. -'Deficient Excretion from Kidneys not Organically Diseased and Some of the Diseases Peculiar to Women," and Diseases of the Skin. By L. Duncan Buckles, A.M., M. D., Physician to the New York Skin and Cancer Hospital etc., New York. Experimental Basis of the Dietetic and Medicinal Treatment of Hyper- acidity and Gastritis. By John C. Hemmeter, M.B., M.D., Ph. D., Clinical Professor of Medicine in the Baltimore Medical College, etc., Baltimore, Md. A Contribution to the Pathogenesis and Etiology of Diabetes Mellitus. An essay to which was awarded the prize of the Medical Society of the County of New York. By Heinrich Stern, Ph. D., M. D., New York. Splitting the Kidney Capsule for the Relief of Nephralgia. By George Ben Johnston, M. D., Professor of the Practice of Surgery and Clinical Sur- gery in the Medical College of Virginia, etc., Richmond, Va. An Address by the Hawaiian Branches of the Sons of the American Rev- olution, Sons of Veterans, and Grand Army of the Republic to Their Com- patriots in America Concerning the Annexation of Hawaii. Reviews, Book Notices, Etc. 189 The Psychology of the Emotions. By T. H. Ribot, Professor of the Col- lege of France, Editor of the Revue Philosophique. The Contemporary Science Series. Imported by Charles Scribner's Sons. Some Observations on the Relationship of Pelvic Diseases to Psychic Disturbances in Women. By P. T. Vaughan, M. D., Tuscaloosa, Ala., Assistant Physician, Alabama Insane Hospital. My Recent Work in Appendicitis. Seventy Consecutive, Suppurative or Gangrenous Cases, Treated by Appendicectomy Without a Death. By Augustus Charles Bernays, of St. Louis, Mo. Value to the Public of State Medical Societies. Presidential Address^ Medical Society of Virginia, Hot Springs, September 1, 1897. By George Ben. Johnston, M. D., Richmond, Va. on the Higher Education of Women. An address delivered before the members of the University Extension Association, at Horsham, April, 1891. By Sir Dyce Duckworth, M. D., LL. D. The Relations of Diseases of the Skin to General Conditions. By L. Duncan Bulkley, A. M., M. D., etc., Physician to the New York Skin and Cancer Hospital, New York City. The Significance of Degeneration to the General Practitioner. By Haldor Sneve, Chairman Section of Nervous and Mental Diseases, Minn. State Medical Society, St. Paul, Minn. A Contribution to the Study of Spinal Syphilis. By William G. Spiller, M. D., Neurologist to the New Jersey Training School for Feeble-Minded Children, etc., Philadelphia. Hydriodic Acid and Hypophosphites. Therapeutical Indications with Clinical Data. Edited by R. W. Gardner, Pharmaceutical Chemist, New York, Fourteenth Edition. Entire Records of Medico-Surgical Practice with Auxiliary Blood Supply —"Hamatherapy"—(or otherwise) at Sound View Hospital, T. J. Biggs, M. D,, Stamford, Conn. The Hygienic, Educational and Symptomatic Treatment of Pulmonary Tuberculosis, With a Plea for Sanitoriums for the Poor, By S. A. Knopf, M.D., New York. What Constitutes an Insane Criminal, and What Status Does he Occupy? By H. E. Allison, M. D., Medical Superintendent, Matteawan State Hospital, Matteawan, N. Y. Autogenous Poisoning in Disease. By E. D. Bondurant, M. D., Pro- fessor of Nervous and Mental Diseases, Medical College of Alabama, etc., Mobile Ala. Endemic Multiple Neuritis (Beriberi). By E. D. Bondurant, M. D., Professor of Mental and Nervous Diseases, Medical College of Alabama, Mobile. 190 Reviews, Book Notices, Etc. Stone in the Kidney. By Charles R. Robins, M. D., Instructor in Obstet- rics and Demonstrator of Operative Surgery, Medical College ot Virginia. Syphilis of the Central Nervous System. By Sidney Kuh, M.D., Pro- fessor of Neurology, Post-Graduate Medical School, etc. Chicago, Ills. Preliminary Report, Clinical and Pathological, of a Case of Progressive Dementia. By Chas. K. Mills, M. D., and Mary A. Schively, M. D. The Antitoxic and Bactericidal Properties of the Serum of Horses Treated with Koch's New Tuberculin T. R. By Dr. C. Fisch, St. Louis, Mo. Sulla Morfologia e Sul valore delle parti costituenti la cellula Nervosa, (Communlcazione preventiva) pel Dott. Cesare Colucci, Coadiutore. The Standard of Medical Education. By J. M. Bodine, M. D., Dean of the Medical Department, University of Louisville Louisville, Ky. The Action of the Nervous System Over the Nutritive Processes, in Health and Disease. By Beverly O. Kinnear, M.D., New York. Erb's Primary Muscular Atrophy. By Elmore S. Pettyjohn, M. D., Medical Superintendent, Alma Sanitarium, etc., Alma, Mich. Comparative Frequency of Stone in the Bladder in the White and Negro Races. By George Ben Johnston, M. D., of Richmond, Va. Symptoms and Treatment of Hepatic Abscess, with report ef seventeen cases. By George Ben Johnston, M. D., of Richmond, Va. Contribuzione alia istologla. patologia della Cellula Nervosa in Alcune Malattie Mentali pel Dott. Cesare Colucci. coadiutore. Report of Two Cases of Syphilis, with Remarks Relative to Ptyalism. By C. Travis Drennen, M.D., of Hot Springs, Ark. A Case of Double Facial Paralysis. By Eugene G. Carpenter, M. D., Consulting Neu/ologist to Cleveland City Hospital. Neurasthenia or Neuro-sthenia; Which? and an Efficient Treatment. By Beverly O. Kinnear, M.D., New York City. A Distinguished Physician-Pharmacist—His Great Discovery, Ether- Anaesthesia. By Joseph Jacobs, Atlanta, Ga. Ein Fall von Myasthenia pseudo-paralytica gravis mit intermittirender Ophthalmoplegic, von A. Eulenburg in Berlin. Vaginal Hysterectomy; A Review of Sixty-six Consecutive Cases. By Charles Gilbert Davis, M. D., Chicago, III. The Differential Diagnosis of Neurasthenia and Its Treatment. By Elmore S. Pettyjohn, M. D., Alma, Mich. Insane Confessions, Errabund Lunatics, The Corpus Deliciti and Crime. By Jas. G. Kiernan, M.D., Chicago. Reviews, Book Notices, Etc. 191 Morbus Basedowii. Von Dr. A. Eulenburg, Geh. Med -Rath und Pro- fessor an der Universitat,-Berlin. Alcoholism in Women;—Its Cause, Consequence and Cure. By Agnes Sparks, M. D., Brooklyn. N. Y. The Prognosis and Duration of Attacks of Mental Disease By Henry R. Stedman, M. D. Boston. The Pathology of Tabes Dorsalis. A Critical Digest. By William G. Spiller M. D., Philadelphia. A Note on the Use of De Zeng's Refractometer. By S. Lewis Ziegler, M. D., Philadelphia, Pa. Suicides in New York. By Justin Herold, A. M., M. D., Ex-Coroner's Physician N. Y County. The Johns Hopkins Hospital Reports. Vol. vi. The Johns Hopkins Press, Baltimore, Md. The Exact Treatment of Malarial Fevers. By Charles D. SJagle, M. D., Portsmouth, Ohio. Ueber den gegenwartigen Stand der Behandlung der Tabes dorsalis. Von A. Eulenburg. Acquired Umbilical Hernia in Adults. By George Ben. Johnston, M. D., of Richmond, Va. Some Observations on Paresis in the Negro, by P. T. Vaughan, M.D., Tuscaloosa, Ala. A Case of Progressive Neurotic Muscular Atrophy. By Charles W. Burr, M. D. Hemiplegia (Possibly Hysteria) with Ankle Clonus. By Charles W. Burr, M. D. On Cyclone-Neuroses and Psychoses. By Dr. Ludwig Bremer, St. Louis, Mo. A Case of Tactile Amnesia and Mind Blindness. By Charles W. Burr, M. D. A Case of Psychic Anesthesia. By Charles W. Burr, M. D. The Neuroses of Gout. By L. Harrison Mettler, A. M., M. D., Chicago, lll. The Cure of Incurables. By J. H. Kellogg, M.D., Battle Creek, Mich. Medical Experience. By F. D. Haldeman, M. D., Ord, Neb. PRESS OF Hughes A company, TWENTlETH CENTURY PRiNTERS: 41S N. THiRD STREET, ST. LOUtS. MO. THE Alienist and Neurologist. VOL. XIX. ST. LOUIS, APRIL, 1898. No. 2. ORIGINAL CONTRIBUTIONS. THE MILDER FORMS OF PERIODICAL INSANITY. By DR. A. HOCHE, Private docent and First Assistant at the Psychiatric Clinic at Strassburg. HE term "periodical" does not apply to every disease that may occur repeatedly during a lifetime. We do not consider erysipelas periodical because it attacks the same person half a dozen times; we do not speak of a periodical delirium tremens if an inebriate has it the third and fourth time, but we are authorized in making the diagnosis of periodicity when we observe, e. g., a typical attack of migraine or an epileptic seizure in an individual for the first time. It is then not merely the fact of manifold repetition which constitutes the character of periodicity, but it is especially essential that the individual attacks or times of the morbid condition are repeated without external cause or still without adequate external cause, for reasons which exist in the patient's constitution. It is the problem of diagnosis, and one not incapable of solution, to obtain if possible information as to the probable periodical character of one of these disorders on its first occurrence from certain of its peculiarities. [193] 194 A. Hoche. i . - ^ Among mental disorders we find a relatively high per- centage of periodical diseases, which is considerably increased by those corresponding to the opinions of a certain kind in psychiatry, which will then be diagnosed as periodical from the clinical type of the individual attack, if perhaps only one or two have occurred in a lifetime. Very many of the patients with the milder forms of periodical mental disorder are never, or only very late in the disease, treated in a hospital for the insane; a greater part of these are never considered ill.; numerous transition forms occur between the physiological oscillations of the psychical equilibrium and the severe and gravest cases which period- ically or constantly require care from the first. In the milder forms accrue to the physician, especially the family physician, problems in diagnosis, therapy and especially in prophylaxis, which will be briefly presented in the following pages. It will be impossible to consider all the varieties and subforms described here and there, but we will have to limit ourselves to those the most common and practically important. The comprehension of the periodical mental disorders is facilitated by a glance at certain well-known periodical psy- chical oscillations, which are practically within the bounds of health*. In a large number of persons who are in no way regarded as abnormal, the psychical condition, particularly the disposition, and thus frequently the ability, is subjected to certain more or less regular changes which occur either without perceptible connection with external conditions or apparently depend, e. g., on seasons, state of the barometer, sky, etc.; these alternating changes are accordingly conscious to the subject as "ill-humor" or as a condition of "being well-disposed." In many mental workers, but especially in artistically constituted natures characterized by a fertile imagination, this irresolute state of the mental action is again reflected in the lack of uniformity of the productions, who at times are completely idle, to then again be ener- •A thoroughly physiological exampie of active periodical psychical changes with repe- tition of definite concepts, feelings, impulses, etc., is offered by animals in times of rut. The Milder Forms of Periodical Insanity. 195 getically active for longer or shorter periods; there are "periodical laborers" as well as "periodical drinkers." In the female sex, at any rate within average bounds, periodical physical processes in the body are found as a reason for oscillations of the affective equilibrium, and we are accustomed to regard the peevishness, motiveless caprice, "apprehensions," etc., of women at the time of the menses, simply as a half normal, legitimate attendant symp- tom. Affective oscillations of greater extent, which are not regarded as morbid, are well-known to occur during preg- nancy. It is usual that for a shorter or longer time during pregnancy a depressed affective condition, prone to fears and anxious thoughts, prevails; but quite often we find the form which in a certain measure is the opposite of the preceding, the women during pregnancy feel "very well," are free from the tendency to pessimism, which at other times is peculiar to them. We find this causeless oscillating character of the dis- position, with which the patients and those about become familiar as a rule, the most marked in those persons whom we characterize as "sensitive," "nervous," "labile" (dese- quilibre) according to their usual disproportionately active mode of reaction to external impressions of pleasant or unpleasant character, and a careful analysis in the majority of these cases reveals the presence of considerable nervous hereditary taint, whose only manifestation may be this peculiar psychical constitution, the readiness with which the "position" is lost. The true periodical mental disorders are developed almost exclusively on the basis of hereditary nervous dispo- sition; their chief characteristic—except all details—is their repeated occurrence of motiveless anomalies of disposition in the sense of depression or exaltation, and in face of the fact of all possible gradations, an authorized truth lies in the opinion that this constitutional lability at the verge of physi- ological oscillation differs only in degree from that which is described as "periodical mental disorder," that it not only furnishes the foundation for the development of periodical psychoses, but in a certain measure is an abortive form. 196 A. Hoche. Hence it is almost immaterial whether an apparently internal or external exciting factor is discovered as the cause of the change of disposition or whether it is apparently spontaneous; the essential in every case is that the psychi- cal curve tends to run in a waved line. It is immaterial as to the principal significance of this form of mental disorder whether the several alternating phases follow one another rapidly or slowly, whether they are of long or short duration, whether only periods of depression or only those of exaltation succeed each other, or whether these alternate; the type is of little account . with respect to the significance of the determination of the fact that in a given case a periodical mental disorder exists; the practical prognosis in particular is influenced by the sub-form of the periodical disorder. Therefore the old classification that described the cases as periodical mental disorder, which presented a sequence of either the depressed or exalted phases, and as "circular insanity" those in which both phases occurred alternately with or without an interval, can no longer be maintained. The whole group is to be called periodical mental disorder, of which the circular cases are possibly only a variety. It is also improper to separate those periodical disorders which follow or are coincident with certain physical pro- cesses, like menstruation, or possibly, from the apparently spontaneous; the latter probably depend on certain alterna- ting physical states, only we do not yet know them. As already stated hereditary conditions play a great role in the pathogenesis of periodical mental disorders. In proportion, e. g., to neurasthenia or hysteria the milder forms of the periodical psychoses as a rule depend on a higher degree of hereditary, often direct influence, and perhaps in no other psychical anomaly do we so often find homogeneous heredity, i.e., that the offspring of a periodically insane father or a periodically insane mother are subject to periodical disorders. The milder forms seem to be no less hazardous in the constitutional character of the periodical mental disorders to the following generations than the severe forms; practically The Milder Forms of Periodical Insanity. 197 they are more dangerous in that their apparently insignifi- cant symptoms are not readily regarded as a bar to mar- riage, while the severe forms, if not beginning too late in life, will exclude propogation in the majority of cases. The childhood of individuals with later periodical dis- ease may present no peculiarities; at other times we find in childhood those traits which are observed in marked hereditary taint: at first tendency to convulsions and delir- ium in slight physical disorders, in early school years, inat- tention, irritability, capriciousness, lack of uniformity in the mental ability, early masturbation, absent-mindedness in instruction. But quite often, particularly in persons later affected with the circular form a certain periodical arrest of the faculties is observed during the school years—lack of uniformity in the class, periods of stagnation, alternating with normal progress, etc. Real periodical mental disorders strictly are rare in childhood; it must not be lost sight of that the periodical disorders which in adults are characterized by a certain milder nature of the individual attacks, may be very readily overlooked in children owing to their little developed per- sonality and the physiological tendency to change of dispo- sition peculiar to this age. The occasional temporary ten- dency to isolation, of ceasing the habitual play, etc., occur- ring in nervous children may really be regarded as depres- sive phases of a periodical disorder, as well as it is prob- able that the frequent suicidal attempts of school children with strong hereditary taint occur during such a melancholic stage. Whether a connection exists between the anomalies of disposition, such as accompany repeated attacks of chorea in childhood and subsequent periodical psychical diseases is not definitely known. On the whole, all these disorders in children subsequently maintain their importance; it will rarely be possible to fore- tell a subsequent periodical psychical disorder with any certainty; the significance of all the symptoms named in children are rather that they are signals of warning which should incite prophylactic measures. On the approach of puberty the relation of the two 198 A. Hoc he. sexes diverges; in the female sex, disposed to a higher percentage of the periodical diseases, the menses, frequently the period preceding their first occurrence also, often occa- sion the first unmistakable condition of periodical psychical anomaly. It is either a quantitative intensification of the frequent menstrual anomalies of disposition above mentioned or, what is more common at puberty, temporary states of excitement with irritability, motor impulse, tendency to acts of violence or states of stuporous confusion with terrifying sense deceptions. Both the latter forms are not of bad prognosis; they may gradually disappear after recurring several times; whereas simple depressions, which are coincident with the first menstruation, in many cases are the first signs of a circular psychosis and therefore are of a really unfavorable prognosis. The menstrual psychoses are the periodical which are the earliest to be diagnosed; the menstrual type then is plainly indicated when the menses do not appear at the time they should. In girls approaching puberty it is always to be consid- ered that the menstrual type may be present in psychical anomalies ere menstruation has occurred for the first time. At puberty in the broadest sense, then until the 25th year, those periodical cases, which may be regarded as the chief group of periodical manias, most often begin in girls and women, with or without reference to the menstrual type, and in men also. The theory of mania has been considerably changed within the last two or three decades; it had been very materially restricted years ago by the separation of forms not belonging to it, and has been still further restricted recently by the generally accepted opinion that a greater, perhaps the' greatest part of pure, simple manias are only individual phases of a periodical mental disorder, and very recently Krcepelin has entirely denied the existence of mania as an independent disease entity; he thinks mania in its nature is always a periodical disease, with a proviso that The Milder Forms of Periodical Insanity. 199 the periodicity does not always need necessarily to be man- ifested in numerous recurrences. It is to be expected that the principle of this opinion based by Krcepelin on clinical material very carefully col- lected will soon prevail in spite of the strong opposition meeting it to-day from the most diverse quarters. But for the purpose of medical prognosis it is not merely the principal position of mania; a periodicity which consists merely of an attack of mania occurring in the twentieth and fiftieth year is not periodicity practically; from this point of view it is a second attack of the same disorder during a lifetime; it is more to the purpose of this descrip- tion to consider those cases periodical mania in. which the periodicity exercises a definite influence on the forma- tion of the whole existence of a personality. We now frequently find that the manias which recur but a few times and are separated by long intervals of 10, 12, 15 years and over, are always severe psychical diseases of long duration. These cases correspond to the description generally given of mania in the text-books. Those forms which frequently recur are not usually severe; they last a few weeks or months and the intensity of the maniacal excitement is less than in the former cases, so that the diagnostic rule has long been entertained to consider manias of rapid course, apparently "recovering smoothly," as probably periodical. This milder form will chiefly here occupy our attention. Three principal symptoms, which are generallly indicated at least in the mildest cases, belong to the type of mania; exalted disposition with a tendency to quickly change, flight of ideas, motor impulse. Marked clouding of consciousness, sense deceptions or fixed delusions, play no part. The beginning of the first attack may be very sudden; but usually a period of prodromal physical symptoms precede in the way of loss of appetite, poor health, etc., when these seem to suddenly disappear as soon as the real psychical symptoms of mania are manifested. As a rule these 200 A. Hochet quickly increase to that intensity attained in the individual attack. The patient seems cheerful, excited; the eyes glisten, all movements are active; they are more talkative than usual, always have an answer ready in that, in accordance with their "good feeling," a certain tendency is expressed to be- witty at others' expense, or an increased irritability and liability of the disposition. The exalted self-feeling which possesses the patients, in conjunction with increased motor impulse, is manifested in a restless activity, in the tendency to make purchases, to contrive new projects, grand schemes, to go into those which perhaps far exceed their ability, to undertake useless journeys, to engage in amours, to prefer noisy society, to commit excesses of all kinds, etc. Naturally all these things readily occasion conflicts, possibly with slight violence, to which the patient, at first perhaps amiable, genial, amusing, is almost without exception driven by his explosive irritability and tendency to rapid change of disposition. In this stage they are often considered psychically ill, but more commonly as intoxicated. This is due in part to the fact that in the milder forms of periodical mania the consciousness may be retained for a long time or constantly, and that the patients are able to explain and excuse their excesses or absurdly strange acts by an often surprising logic. But on a closer inspection the appearance of a real increase of the intellectual ability is proven to be false; in conversation the patients cannot stick to the point, they fly off about relative matters or simultaneous external percep- tions; momentary fancies direct the conversation and their "wit" as a rule is limited to the discovery of superficial relations, similarity of sound, observation or trifling weak- nesses in those about, etc. In a somewhat higher grade of the disorder the patients' external appearance is noticeable; in the female sex increased sexual desire is manifested in the tendency to dress loudly or of making advances of a physical nature to men; in others the consciousness does not suffice to resist the impulse to strange, possibly forbid- The Milder Forms of Periodical Insanity. 201 den acts. A part of the cases of so-called "kleptomania" (which do not exist as such), cases which are a constant topic of the daily press, belong to the domain of pe'riodical mania (or to the maniacal phase of circular insanity). DuVing the existence of these psychical manifestations constant attendant physical symptoms are also found; the sleep is always greatly lessened, nutrition suffers, less by lack of appetite than that the patients have no rest, no time to eat; the body weight generally falls. After some time, weeks, months at the most, the excite- ment gradually ceases; a certain feeling of illness, then also appreciation of the disease, occurs, which in conjunction with the preceding exaltation and occasional crying, may give the stage of convalescence a peculiar psychical stamp. In these mild cases, after the excitement ceases, great general weakness, psychical fatigue and irritability usually exist; but the first mild attacks may not essentially impair the psychical personality. These mild forms of periodical mania are of a special stamp when they are developed in youthful imbeciles, as is quite common, by their silly behav- ior and a certain elementary character of the increased motor impulse. 1 Transitions of the milder forms of periodical mania into the severe and gravest varieties occur by simple intensification of the only moderately pronounced symptoms, which with incoherent confusion and frenzy may last for many months, years even, and in a certain portion of the cases terminate in dementia or death. Then these are always cases, which if they only recur at long intervals, can never be treated at home. It is often found that with great frequency of recur- rence the individual attack increases in severity, while the length of the interval decreases. On the whole, pure periodical mania in its mild forms is not a very common disease, at any rate much rarer than the circular forms, also more rare than the mild states of periodical depression. The diagnosis, which in the first attack the possibility of the presence of a circular psycho- sis must be always kept in mind, depends for periodicity on 202 A. Hoc he. the generally mild character of the symptoms, the retention of consciousness and the relatively rapid, favorable course of the disorder. In the majority of cases pure periodical melancholia begins in the prime of life, in woman possibly about the climacteric; in a smaller portion it occurs earlier in life. Direct nervous hereditary taint does not seem to have the significance in this form as, e. g., in the circular forms. For the individual attack we often find an apparently exciting factor in the anamnesis, like, e. g., removal to new surroundings in a strange place, mourning for relatives, in men financial reverses, failure in business, etc.; but usually such a condition does not exist, whose character as the real cause of the disease is questionable. Of the various clinical types of states of depression which are described as melancholia (melancholia simplex, agitata, stupida) in the periodical form, we find usually only melancholia simplex and with the further attribute—levis. The disorder generally begins gradually; physical dis- comfort, loss of appetite, restless sleep without refreshing, feeling of head pressure, etc., may accompany the slowly developed depressed disposition from the first, or precede it for a time. In the mildest grades of the disease we find without any other symptoms this depressed disposition, a motiveless apathy and dejection, which often recur regularly at certain seasons (Fall and Spring preferably). The patients know no reason why they are occasionally depressed by gloomy feelings, vague presentment of an impending misfortune, why they are no longer capable <^ enjoying this or that, or they erroneously seek reasons for their depression in exter- nal events of perhaps wholly insignificant character. But this mild depression as a rule suffices to influence the person's actions; the patients retire from society, neg- lect their private correspondence and other duties, which must not be attended to at once, but are still able to asso- ciate with other people when necessary without occasioning remark and of complying in a degree with the demands of their occupation. The change in character is apparent only The Milder Forms of Periodical Insanity. 203 to those who have previously known the person intimately. Alternations of anxious depression are frequent, but a real anxiety is as little developed in this form as a delusional falsification of external conditions. The course is generally quite short; after a few weeks or months the normal condition gradually returns and the patient recognizes that his disposition has been morbidly affected in the past, a view which may disappear with each new attack. The most favorable cases continue in this mild depres- sion, coming and going periodically; at other times the attacks are of the mildness described to become succes- sively more severe at each recurrence; or finally this mild depression may be a premonitory stage of an ordinary mel- ancholia simplex levis. In this case the depression increases in intensity, the patient loses all pleasure in his business, in his family and in ordinary enjoyments; his cares, also those to which he is accustomed, depress him more than usual, his prospects seem more gloomy to him, his physical condition serious; his fear of "losing his reason" is increased by his observ- ing that his psychical processes are inhibited. This inhibition is not always objective in a brief con- versation; but the patient is painfully conscious that tasks that he had usually mastered readily, become harder and harder for him; memory of names, dates, numbers causes him considerable effort; trifling acts seem to him like insur- mountable obstacles, until he finally ceases trying to over- come the inhibition, becomes resigned and lets matters go. Also in the patient's outward appearance, in gait, speech and expression this psychical inhibition is manifested. Real delusions—delusions of sin, firmly formulated anxious fears —do not occur as a rule in this mild form of melancholia; the morbidly false color given to all the concepts by the anomaly of disposition, which refers to the ego, natur- ally affects the past and future; the patients are usually critical enough to resist the formation of delusions. In these milder cases the hours of solitude in sleepless nights (in ordinary "nervous" persons the time when the 204 A. Hoc he. "position" is the most readily lost) are when self-accusa- tions and worries assume a serious form, owing to the want of correction by daylight and those about. . The same is true of the feelings of anxiety with prae- cordial localization, but which in periodical cases rarely attain the intensity of agitated melancholia. This circumstance causes in the majority of the cases of mild periodical melancholia the consciousness to be retained, and also the danger of suicide is. not nearly so great as otherwise in melancholia. The old rule, always too little regarded, not to trust a melancholiac with respect to his ideas as to suicide any further than we can see hint, is equally applicable to periodical melancholia. Only in the mildest cases does the memory of previous attacks afford the support of appreciation of the disease on its recurrence; as a rule reference to the happy termination and appreciation of the disease present during the interval is rejected with the assertion that it is entirely different this time. Physical changes, especially loss in weight, aged appear- ance, generally accompany the mildest attacks; constipation is an almost constant attendant symptom. Except in the very mildest cases, in which the depres- sion recurs frequently, perhaps every year, the lucid inter-' vals between the two attacks usually lasts several years, so that in melancholia frequently beginning late, possibly only a limited number of individual attacks are developed. The majority of cases of these mild varieties are never treated in a hospital; a greater part of them are diagnosed neurasthenia and hysteria; it is to be admitted that the dif- ferentiation from these two neuroses may be very diffi- cult in certain cases. The diagnosis of a periodical melancholia, as well as the assumption of a functional depression, is then especially permissable in men of middle age, when a careful examina- tion excludes the presence of progressive paresis with prac- tical certainty; the points of differential diagnosis have been The Milder Forms of Periodical Insanity. 205 fully discussed in my monograph on Early Diagnosis of Pro- gressive Paresis.* We very often meet with severe forms of recurrent melancholia, but which are not differentiated from the non- periodical cases and therefore will not need to be discussed in detail here; in these cases it is very questionable whether the fact that a severe melancholia has occurred two or three times, suffices to give the disorder the charac- ter of periodicity. The third chief variety of periodical mental disorder, the most important as to frequency and practical signifi- cance, is the so-called "circular insanity." Since the first publications in regard to this disorder fifty years ago it has always attracted the greatest interest by the often strikingly sudden alternation between the apparently entirely opposite psychical conditions of melancholia and mania and by the intensity of the simultaneously rapid oscillations of the physical functions, and has also led to the presentation of numerous hypothetical explanatory efforts, which may be wholly disregarded here, as none of them seem to be based on certain facts. The clinical material described is perhaps not so abun- dant in any other form of mental disorders as in this, except progressive paresis, still without the various authors agreeing except as to the principal points in the definition. In the extremely great variety of the types of circular insanity the individual sees only a portion of the grand domain, according to his morbid material, and so the description of its course varies greatly accordingly as the patients considered are in insane hospitals, clinics or in private practice. The following description will especially take account of the forms that do not as a rule come under institutional care, which in circular insanity constitute a larger portion of the cases than in periodical mania and periodical melancholia. In no small part of these cases running their course at home is the nature of the psychical peculiarity not recog- •Dr Hoche's monograph on the "Early Diagnosis of Progressive Paresis" appeared in English in the January. 1898. number of the ALIENi5T and Neurologist.—Transiator. 206 A. Hoche. nized; the milder cases are rarely considered "ill" by their nearest friends. The mildest grade of the disorder is not separated by any sharp boundary line from the conditions of constitu- . tional lability in persons of hereditary taint mentioned in the introduction. There is found then in youth or beginning at puberty an alternating condition of the disposition and in the manner of the psychomotor manifestations. Periods of optimism with self-confidence, speculation, social tendencies and apprecia- tion of all the pleasures of this world alternating with those of a mild depression, uncertainty, anxiety, seclusion and a tendency to low spirits of a hypochondriacal color. In persons with this form, who are often peculiar as to habits, passions and views of life, this cycle of alternating phases may be repeated through the whole life without devel- oping further and even without more seriously damaging the psychical personality; also in these mildest grades the recurring similarity of the corresponding types is. generally found to be unmistakable, as well as in an accompanying change in appearance, manner, etc. At the most the phase of depression is generally con- sidered abnormal, when the physician is occasionally con- sulted as to the cause of the hypochondriacal attacks. An active therapy, baths, change of air, etc., creates perceptible change as soon as the other phase sets in. This form does not generally have a "lucid interval"; the individuals are always either "above" or "below the mark." In simple quantitive intensification of this symptom complex we then meet those circular disease types, which in France has recently been given the very needless term of "circular form of neurasthenia." Under the gradually stronger accentuation of the alter- nating phases present in those personalties, conditions are developed, which in the depression at least, cause medical advice to be sought as a rule. The patient is irresolute, uncertain, feels an unusual need of leaning on stronger characters; the world and it The Milder Forms of Periodical Insanity. 207 interests tire him; his past life seems a failure; self- reproaches also occur; sleep is insufficient, the appetite is lessened; sensitiveness to light, noise, strange faces cause complete seclusion, in which the patient is inactive, without interest, except in his own feelings and physical discomforts, a plague to his family. After weeks or months the type changes, often suddenly, during the night. The patient feels "well," capable of work; the inhi- bition of his thoughts has disappeared; with vigor he takes up his neglected work, which he now does easily and often successfully; he is now satisfied with himself and things in general, often more than that, an inordinate idea of his own ability, verging on grandiose delusions, which is the cause of his zealously taking in hand matters of other people, the community, the society, the neighbors. Fatigue is perceived neither in his work nor in the eagerly sought, plentifully enjoyed pleasures, sleep is short, but often better than in the previous phase; his appearance is improved, appetite and digestion are good. This condition lasts for a time until finally—according to the opinion of the patient and his friends owing to "overwork"—the beautiful fire is extinguished and the whole scene is totally changed by passing into the depres- sive phase. This form, which gradually induces generally an enfeeble- ment of the mental faculties and a certain blunting of the emotions, exists as a rule the whole life. It has the des- tiny, like the majority of the forms of circular mental dis- order, that the type of the recurrent attack is more contin- uous, the duration of the individual periods becomes more irregular until finally the secondary psychical changes are more prominent. The melancholiac and maniacal traits present still more by intimation in the alternating conditions of this latter form are not so perfected that an alternation between real melancholia and mania must be spoken of; these are the cases which are generally described as "circular insanity." The milder do not need institutional care, the gravest can- not remain at home at first or afterwards. 208 A. Hoche. In the majority of the cases the alternating phases in this form of circular insanity tend to a mild coutse in the individual attacks, with retained consciousness, without the formation of delusions and without the development of intense anxiety in melancholia, without flight of ideas and without frenzy in mania. We then find again those condi- tions, which we became acquainted with in the milder forms of periodical mania and the milder states of depression, which therefore need no further description. Increasing experience will probably show that the fre- quently recurring mild, brief attacks of exaltation or of depression are more closely related to true circular insanity than to the periodical forms, in which severe and long con- tinued states of mania or melancholia but rarely occur. The great multiplicity of the varieties of the circular type may now make the boundary line seem more than half voluntary. In the largest number of circular cases the disorder begins at puberty in its broadest sense with a phase of depression; then a relatively lucid interval occurs, which is followed by the exalted period, or the original depression passes at once into the maniacal excitement. In the indi- vidual cases, variations occur in the whole course, in that the intervals are wanting, may be of longer or shorter dura- tion, that the phases really alternate or after repeated recurrence of one condition the other occurs—in short it is impossible to make statements generally applicable. For the comprehension of the whole disorder the obser- vation seems of a certain significance that, e. g., in the midst of a long continued melancholiac depression it is quite often interrupted for a day by that of exaltation to again quickly disappear. In long continuance of the circular disorder these irregular intervals are generally more frequently inserted. The circular forms composed of "real mania" and "melancholia" manifest a tendency to tfte subsequent disappearance of the type, also in the individual symptoms. The several individual traits of maniacal excitement and melancholiac depression at first, at any rate, are gener- ally so exactly repeated that a detailed prognosis as to the The Milder Forms of Periodical Insanity. 209 probable course may often be given. Little, trifling prodro- mal symptoms, which are know from the first attack, like the tendency to dress peculiarly, arrange the hair oddly, etc., indicate the threatened approach of an attack not known. The psychical condition conforms in a particularly preg- nant way to the psychical oscillations; the turgor of the tissues, the brilliancy of the eyes, alternate, wrinkles in the face come and go, the carriage is languid and again elastic, apparent differences in age of 10 to 12 years are found in the appearance between one and the other phase in milder forms, and we especially find in a short time often essen- tial oscillations in the body weight. The possibilities of the course of circular insanity are not exhausted by those previously described; there is found among the cases composed of melancholia, mania, etc., those in which the depressive phase particularly does not present the mild chaiacter, but all the characteristics of a severe melancholia with active delusions of sin and intense anxiety; these cases are especially unpleasant owing to the considerable danger of suicide and under all conditions require the custody of a closed institution. A further variety, which at least renders a residence at home impossible as a rule, is characterized by the one or the other phases being replaced by different psychical condi- tions, of which stuporous confusion with numerous sense deceptions is to be especially mentioned. To go more fully into these severe forms would take us too far. The so-called "symptoms of the interval" demand special mention, not only of the circular forms, but of periodical insanity in general. In many cases of periodical melancholia, and periodical mania there are no true symptoms of the interval, this is not to be expected in the cases theoretically placed among the periodical mental disorders, in which perhaps at puberty and at the threshold of old age an attack occurs, while the greatest part of the life has been an "interval." At the most we find those netvous or psychical pecul- iarities, which must be regarded as the expression of the 210 A. Hoche. presence of hereditary nervous taint, which is then coordi- nated to the periodical insanity, not due to it. In other cases with frequently recurring states of psychical disease the intervals originally are free from abnormal psychical manifes- tations; but gradually several anomalies remain behind, like irritability, constant lability, intellectual deterioration, blunt- ing of the aesthetic and ethical feelings, manifestations which may occur after repeated attacks of mental disorder not periodical. In the circular forms the interval, if it exists, is not free as a rule from the first, and we find in part the general nervous anomalies of heredity, in part the secondary psy- chical changes mentioned, very prominent. Hence it is that circular insanity must be regarded as the gravest of the periodical mental disorders, in which usually their hereditary degenerative character is expressed. The following general diagnostic and prognostic tenets may be added to the preceding statements, of which it is to be said that they are somewhat more definite and simple than corresponds to the really complicated conditions: In any melancholic depression or maniacal excitement occuring for the first time it is possible that it is a matter of a periodical disease; this possibility is then to be espe- cially kept in mind when strong hereditary nervous influence is provable. Rapid onset of the disorder, moderate intensity of the symptoms, relatively mild course, seemingly quick recovery indicate a periodical character. The occurrence of a melancholic depression, if trifling and of short duration, as theirs/ psychical disease in youth, is especially suspicious in the sense that it may be the first phase of a circular insanity. Mild mania quickly recovering in youth, as the first psychical disease, does not belong to circular insanity in the majority of cases, but another maniacal attack may be expected later. The first illness with mild, transient melancholic depres- sion in the prime of life, or in women near the climacteric, does not indicate a circular psychosis, but renders probable simple recurrences of the melancholic phase later. The Milder Forms of Periodical Insanity. 21l The first occurence of alternating phases of exaltation and depression in the fourth and fifth decades, is a symptom, in men particularly, which must awaken the suspicion of incipient progressive paresis; the decision depends on the findings of a physical examination and the proof of a rap- idly deteriorating intellect; the same is true of states of simple depression occurring for the first time at the age mentioned. It is determined in regard to prognosis that the period- ical mental disorders in accordance with their character as manifestations of a constitutionally abnormal predisposition, are to be regarded as favorable as to the termination of the individual attack, incurable as to the whole course. In a single case, however, in the milder forms, under the influence of external conditions and proper treatment, the course may be so mild that the individual continues to be a useful member of human society. The danger of the development of conditions of secon- dary psychical enfeeblement is not very great in the peri- odical mental disorders; the intellectual ability of periodidal patients may remain essentially unaffected through the whole life, particularly in mild attacks regardless of their frequent recurrence; whereas gradual changes in character in pejus are developed, in circular cases particularly. The milder forms of periodical mental disorder rarely influence the probable duration of life. The treatment of periodical mental disorders has various indications to fulfill. The slight effect, as subsequently shown, that our ther- apeutic efforts on the whole generally have on the fully developed cases, makes prophylaxis and the earliest possible prophylaxis appear to be the first duty of medical science. This has to begin for the still unborn generation with the efforts to prevent as much as possible the marriage of nervous, hysterical and epileptic individuals, especially when both parties are abnormal. The knowledge that these efforts will rarely succeed in the question of marriage does not relieve the true "family physician" from telling the 212 A. Hoehe. interested parents of the possible consequences of the pro- jected union. . . The medical prophylaxis in childhood, which naturally must be directed to a general prevention of nervous and mental disorders, for at this age later periodical disorders cannot as a rule be predicted, meets with scarcely sur- mountable obstacles in the fact that nervous parents by their lack of stability and self-control generally have little favorable influence on their children in the way of training; the reason is not only their bad example, but especially that-the measures of training generally are not conducted from points of view as to consequences, but from the alter- nating moods of the parents. For the children of such nervously tainted families there exists, besides the neces- sity of a specially careful physical training and inurement, the indication for a close supervision of the intellectual and emotional development. For these the danger of overfatigue and exhaustion by absolute or relatively too great demands in school or by irrel- evant matters is to be kept in mind, special attention is to be given to the children's mode of reaction to pleasant or unpleasant events, which may very early show peculiarities of prognostic importance lasting through their whole life. If we cannot change naturally a morbid predisposition being expressed in the germ, there is no doubt that it is possible to practice successfully a sort of psychical gymnastics. The unlimited granting of every wish, excessive consid- eration of the expressions of childish displeasure about unfulfilled expectations and hopes; loving cultivation of motiveless peevish moods—all these common defects of training in the better and so-called "best" class, weakly support the future psychical organism at the point on which in later life the preservation of emotional equilibrium depends, namely the elastic power of resistance to adverse internal or external events. To develop the power of resist- ance as much as possible is the duty of training which is best attained by consistency, quiet and stable firmness without excessive strictness. A number of chiefly physical procedures act in like man- The Milder Forms of Periodical Insanity. 213 ner, such as cold baths in summer, cold frictions regularly in the morning, rational sports and similar measures, which have their significance in the prevention of masturbation in boys. For these it may be advantageous, from unfavorable parental influence, to have the school years passed away from home, under the regular discipline of a boarding school with its abundant mutual correctives by the older pupils; but closed educational institutions have their sexual dangers for nervously disposed individuals. . For girls of nervous families the occurrence of puberty and the beginning of menstruation renders special precau- tions essential, by whose neglect much harm is done, even by physicians. Theoretically it will be readily admitted that nervous girls at the time of the menses should be kept quiet, remain in bed from one to two days if possible; but in reality the good intention, if it exists, is often enough broken over by an approaching amusement, ball, excursion, etc. A part of the vague nervous troubles of approaching womanhood would vanish with strict regulation of the mode of life at the time of menstruation. Very definite indications—and thus we come to the real treatment—occur at this point when the signs of real peri- odical psychical anomalies of the menstrual type are mani- fested in a girl. In this case it is an unconditional demand that the time from the occurrence of the first molimina praemen- strualia until several days after the flow ceases, is Xo be spent in bed. It may be seen that girls who are extremely peevish, ill-natured, irritable, when during menstruation the daily demands on them are greater, should pass the whole time in bed with good psychical surroundings. The states of periodical menstrual excitement already mentioned demand medical treatment, besides rest in bed and hot applications to the abdomen indicated by the pres- ence of pain; the administration of bromides in doses of 4 to 5 grms. pro die, alone or in combination with opium (0,02 to 0,04, according to age and constitution 2 or 3 times a 214 A. Hoche. day) is advisable; with simultaneous severe dysmenorrhea! troubles, it is proper to give the opium in form of sup- positories. If the diagnosis of the periodical mental disorder in one of the forms above described is made the patient's whole conduct needs regulation from the point of view that the demands on the ability and power of resistance are les- sened; excesses in work, as in pleasure, particularly in alcohol, are likewise to be restricted; it is worthy of effort, as far as conditions permit, to make laws for a uniform, even pedantically regulated mode of life, as they are intelligent patients, who, conscious of their tendency to periodicity, recognize the usefulness of these aids. It cannot be expect- ed to thus keep down the severe forms of periodical mental disorders, yet it is to be hoped of the milder types that the individual attacks will occur more rarely, be of a milder character. In each attack the physician has to decide as to treat- ment at home or commitment to an institution. A general rule can be given less in periodical mental disorders than in the other psychical anomalies, for it not only depends on the special home relations, but particularly on the different degrees of intensity and the type of the disorder. Commitment to a closed institution (not to open hos- pitals, sanitariums, etc.,) during the individual attack is then indicated under all circumstances when the morbid manifestations are such that their consequences are apt to injure the individual's personal or social existence, when, e.g., in a melancholiac stage the danger of suicide exists, in a condition of maniacal excitement, that of squandering money, excesses, penal acts. In the interest of the patient the commitment to an institution is then necessary, as this is the rule, so soon as the requirements of special care in regard to nourishment, baths, rest in bed, etc., can be better fulfilled than at home. Whereas it cannot be claimed that all milder cases of peri- odical mental disorder unconditionally need the care of an insane hospital. The Milder Forms of Periodical Insanity. 215 After what has been said as to the clinical types, in subsequent recurrences the course of the individual attack may be predicted as a rule, so that early, at the beginning of the well-known prodromal symptoms its conditions may be met. It may be useful, if institution treatment does not seem necessary, to propose a change of residence to the patient. This is applicable to those mild states of man- iacal excitement of the circular form, which occur without marked motor impulse, without severe attendant physical symptoms, and in which the anomaly of the disposition is the most prominent symptom. It depends on withdrawing the patient from friction with his daily surroundings, the demands and dictates of society and of placing him in quiet, simple, clearly arranged conditions. Residence in the country, small resorts without table d'hote, without society are to be considered, which is pernicious for girls with abnormal predisposition owing to the opportunities for flirta- tion, for male patients owing to the incentives to drink to excess. The attendance of a trusty person, who pos- sesses a certain authority and in given cases is able to arrange for a commitment to an institution, is presupposed. In the home treatment of the milder maniacal conditions general regulations are essential: physical and mental quiet with the greatest possible rest in bed, lukewarm, long con- tinued baths, good nourishment; of medicines, according to recent experience large doses of bromide (even 12 grms. pro die) as well as the older opium therapy, are to be rec- ommended, as also the necessary hypnotics.' Beginning the treatment as early as possible is essential. The first prodromal signs, mentioned by the patient him- self, as this quite often occurs, or noticed by those about, furnish the indications for beginning the therapy, which under the supposition of this early institution will abort the threatened attack, but at any rate more will be attained than when the initial period is spent in hydrotherapy, etc., as frequently happens. In the melancholic phase* the visiting of watering places, etc., is decidedly inadvisable.' •See Prof. Ziehen's Diagnosis and Treatment of Melancholia, soon to appear in Eng- ish in the American Journal of Insanity. 216 A. Hoche. It is an opinion held by the laity, by which many physicians are also guided, which is strange, that a melan- choliac depression can be relieved by amusements, journeys, residence at bathing places, etc.; the result desired always fails in real melancholiacs. A melancholiac patient, whether his depression is of the form of simple repetition of the melancholiac phase or of the circular variety, needs rest and preservation of his strength, which are best secured by constantly remaining in bed. This is also applicable to simple melancholic depres- sion without delusions and without intense anxiety, at least in the beginning of the disease. The bed treatment likewise facilitates the essential surveillance in regard to the suicidal tendency, whose presence must be assumed a priori in melancholia, which danger is almost always depreciated by relatives and physicians in every apparently mild melancholic depression. It has been mentioned that the first serious signs in this respect seem to render commitment to a hospital imperative. In the treatment of the milder forms of melancholiac depression long continued lukewarm baths are proper, which directly induce sleep in many patients, but do not always take the place of hypnotics. Of medicine, bromide and opium are the most common; with the latter after the individual's personal reaction to the opiate is determined, it is improper to proceed too timidly with the doses. In alcohol we have a valuable remedy for combating anxious suspense. After all it is true of the treatment of all forms of peri- odical mental disorder, as is not strange from their constitu- tional character, that our therapy is able to exercise little influence on the general course in the severer grades of the disease. It is in part purely symptomatic and has the object especially of protecting the patient from social injury by reasonable interference. A brief discussion of the legal relations to be consid- ered in periodical mental disorders, follows. Forensically the milder cases of periodical mental disor- der may offer great difficulties, not in the sense that they The Milder Forms of Periodical Insanity. 217 would be especially inaccessible to medical estimation with sufficient knowledge and corresponding diligence, but in so far it may be difficult in present seeming insignificance of the symptoms, to convince the judge of the existence of a mental disorder. In the penal process where a delict committed at a definite time is the point at issue, in the periodical psy- choses it is chiefly a matter of determining whether the offense occurred during a period of psychical abnormality or not. In the usually little disordered intelligence of the patient the principal stress will then be laid on the fact that the existing morbid condition of the disposition in one or another sense, or impulses, which very readily induce abnormal action (mania) or possible delusions (melancholia) have influenced the action. The proof of prior similar epi- sodes in the individual's life and the periodicity of the manifestations will enlighten the judge. On the whole the difficulties in the penal process are less than those in the civil question as to the disfranchise- ment of periodical insane. The matter is simplest in the circular cases with very short or wanting intervals; here as soon as the disorder has attained the grade that the patient is no longer able to look after his own interests, presumably does not have the ability to act legally, permanent disfranchisement is proper. It is different in the circular cases with long intervals, and in simple periodical mania and melancholia which occur without essential psychical changes during the interval. In the course of years the patients oscillate back and forth between conditions of complete or relative ability to dispose of property and those in which a testimentary capacity seems impossible. A permanent disfranchisement would not be authorized or the lucid intervals would be successfully contested by the party concerned. In fact there is nothing else in these cases than to repeatedly consider the consequences of the existing condition of the testimentary capacity. Many cases of the mildest periodical maniacal excitement or mild 218 A. Hoche. melancholic depression likewise occur without a disfran- chisement being necessary for the relatively intelligent and quiet patients. If in the interval a diminution of the intellectual facul- ties, a blunting of the feelings, a lowering of volition, grad- ually occur in the long existence of the periodical disorder, as this may be true in the milder forms, and on the degree of this psychical enfeeblement depends whether and how far the individual is deemed possessing testimentary capacity. On the whole in the milder cases of periodical mental disorder the greatest caution and diligence are advised of the medical expert in testing and judging the matter, in his own interests as well; a part of the persons who do or may resort to the press owing to fancied improper disfranchise- ment, are individuals periodically insane, for whom in the interval, it is very easy to awaken the opinion in the laity and physicians unskilled in psychiatry, that they had never needed disfranchisement. THE PHYSIOLOGICAL AND PATHOLOG- ICAL RELATIONS BETWEEN THE NOSE AND THE SEXUAL AP- PARATUS OF MAN.* By JOHN NOLAND MACKENZIE, M.D., of Baltimore. Clinical Professor of Laryngoiogy and Rninology in the Johns Hopkins Medical School and Laryngologlst to the Johns Hopkins Hospital. "Balnea, vina, Venus corrumpunt corpora nostra, Set vitam faciunt, b(alnea),v(ina),V(enus)"t Oiuoc Kal ro Aoerpd nai rj srept YUnrpcv epui) o£vrtpip> sr(/tsrgt rfy> Min> e2f 'Asdtfv.t 'HE injurious effects of undue excitation or disease of the * generative apparatus upon the organs of sight and hearing are matters of ancient recognition. That immod- erate indulgence in venery may lead to derangements of the former was familiar to Aristotle,§ and that the fathers of medicine recognized some mysterious connection between the ear and the reproductive functions is evident from the testimony of Hippocrates.il Over two centuries ago Rolfincll NOTE.—We make no apology for presenting almost in gxtgnso this classical and entertaining address from Johns Hopkins Hospital Bulletin, though not in all of the its parts strictly germane to the purpose of this journal.— Ed. 'Remarks made before the British Medical Association at Its Montreal meeting. Sep- tember. 1897. tAn oid inscription found in the Campus Florae in Rome. See Buecheler's AntholoK. Latin. Carmen. Epigraphic.. Fasc. II. p. 705, No. 1499, Teubner edition. 1897. Also Corpus Inscript. Latin, VI, 15.258, Gruter 615, 11, Orelll 4816, etc. It is attributed, however, by Seal I Ke r to a modern poet. tThe supposed Greek original. See Anthoiog. Palatin. X, 112. jAristot. Opera omnia graeco-latin. Parisils, 1854. De animallum generatlone, lib. H. cap. 7. lOpera omnia. Ed. Kuhn, Llpsiae, 1827, tom. l. p. 562. lOrdo et methodus generatlone dicatarlum partium, per anatomen, cognoscendi fabrl- cam. Jenae, 1665, part l, cap. vll, p. 32. [219] 220 John Noland Mackenzie. wrote: "Qui partibus genitalibus abutitur, et sexto praecepto vim infert, male audit," a proposition which has been fully established by the clinical experience of to-day. The intimate relationship between the genital organs and those of the throat and neck seems to have attracted the special attention of the ancients. Thus Aristotle* clearly defines the changes in the voice at puberty, and the effect of castration on its qualities.t Its harsh, irreg- ular and discordant character during the maturation of the sexual functions was furthermore affirmed to be more con- spicuous in those who attempted the early gratification of the sexual appetite. The observation that, during coitus, the voice becomes rougher and less acute, led the phonasci or voice-trainers to infibulate their pupils, or confine the penis with bands and fetters, to preclude indulgence in wantonness, X while the popular idea of the injurious effect of repeated coition upon the singing voice is reflected in the epigram of the Roman satirist: "Cantasti male, dum fututa es, Aegle, Jam cantas bene; basianda non es."? The supposed influence of sexual excitement upon the external throat is likewise apparent from the ancient nuptial •Op. clt, De animal, hlstoria. lib. vil, cap l. Choking sensations in the throat and other hysterical manifestations have from time Immemorial been regarded as signs of pregnancy. Shakespeare, in King Lear (sc. ii act iv) thus gives expression to this idea: "O, how this mother swells up towards my heart! Hysterica pauiol down, thou ciimbing sorrow, Thy element's below." tOp. cit., De animal, generatlone. lib. v, cap. 7.' U. Riolanl Anthropographiae, lib. Il, cap. 34, p. .103, Franco-furti, 1626. Riolanus quotes from the Musaeum of Aibertus Magnus the case of a giri, sent to fetch wine from a public house, who was selzed and ravished on the road, and who found in attempting to sing on her return that her volce had changed from acute to grave. See also Martial (lib. ix, Epig. ,28): "Jam paedegogo liberatus et cujus Refibulavlt turgldum faber penem." Also lib. xlv, Epig. 215: "Dic mihi. simpilcitur. comoedis, et cithaedis Fibula quid praestet? Cartus et futuant."' See also Juvenal, sat. vl, 73. The gladiators and athletes were also subjected to infibulation: "Dum ludit media, populo spectante, palaestra. Delapsa est misero fibula: verpus erat." Martial, lib. vIIl, Epig. Ixxxll. SMartial. Epig. lib. I. xcv. ad Aeglen fellatrlcem. Relations between the Nose and Sexual Organs. 221 ceremonial. Before the virgin retired on the wedding night it was customary to measure her neck with a tape and again on the following morning. If the neck showed an increase in size it was taken as a certain indication' of defloration, whilst if the two measurements were equal she was supposed to have retained her virginity. This curious test, which has also been utilized to establish the fact of adultery, has been transmitted to us in the Epithalamium of Catullus: "Non illam nutrix, oriente luce revisens, Hesterno collum poterit circumdare filo."* My attention was first attracted to the investigation of the physiological and pathological relations between the nose and the genital organs by the case of a patient in London, in 1879, who invariably suffered from coryza after sexual indulgence. Stimulated by this observation I began the study of the subject, and five years later published the results of my investigations in the American Journal of the Medical Sciences for April, 1884, in an essay entitled "Irritation of the Sexual Apparatus as an Etiological Factor in the Pro- duction of Nasal Disease." In this thesis, which was the first attempt to reduce this curious relationship to, as far as possible, a scientific basis, I advanced the series of propo- sitions which you will find embodied in the text of these remarks. Several years later there appeared in France a thesis by Arviset.t a critical review by Isch-Wallt and an excel- lent article by Joal,§ which dealt in a most interesting way with the topic under consideration. In Germany, Peyer in 11 •Epithal. Pelel et Thetldos. Ixlv. Catulll op. omn., Loud., 1882. p. 230. This phe- nomenon was variousiy attributed to the dilatation of the vessels of the neck by the semen, a portion of which, according to the Hlppocratic doctrine, fiowed down from the brain during Intercourse, and to the general agitation of the vascular system, and especially the arterial and venous trunks of the throat, during the excitement of the sexual act. tContribution a I'etude du tissu erectile des fosses nasales. These de Lyon, aout, 1887 tProgres Medical. Sept. 10 et 17. 1887. Du tlssu erectile des fosses nasales. SRevue mensuelle de laryngoiogle, d'otologle et de rhinologie, fevr. et mars, 1888- De 1'epistaxls genltale. lUeber nervos, Schnupfen u. Spelchelfluss u. den atiologlschen Zusammenhang der- selben mit Erkrankungen des Sexual apparates. Munchener Med. Wochenschrlft. Jahrgang 1889. No. 4. 222 John Noland Mackinzie. Munich, Endriss* in Goeppingen, and, in the present year, Fliess in Berlin,t have enriched its literature with their contributions. Fleiss's elaborate monograph, written in apparent ignorance of the work done by me in this special field before him, is a model of painstaking labor, and is val- uable as an independent contribution to the study of this important subject. ***** In the Ayurveda, the sacred medical classic of the ancient Hindus, a work of fabulous antiquity, the causes of common catarrh are thus tersely defined: "Uxosis concubltus, capitis dolor, fumus, putvls. frigus. Vehemens calor, retentio urinae soecumque statlm Catarrhl causae dictae sunt."t Although indulgence in venery heads the list, it is highly probable that its real influence was unrecognized, and that it is given as an etiological factor simply in accor- dance with the seemingly prevalent idea that pervades the Indian Shastras, that venery and confinement of the bowels lay at the root of most diseases. The earlier physiognomists laid great stress upon the size and form of the nose as an indication of corresponding peculiarities in the penis.§ The nose, for example, that was large and firm was looked upon as an index of a penis acceptable to women, and hence it was that the licentious Emperor Heliogabalus only admitted those who were nasuti, i. e. who possessed a certain comeliness of that feature, to the companionship of his lustful practices.II Johanna, Queen of Naples, a woman of insatiable lust, seems also to have selected, as her male companions, men with large noses, with a similar end in view.H Sterne, in Tristram Shandy, depicts with consummate humor the sup- •Ueber die blsherlgen Beobachtungen von physiotoglschen u. pathologlschen Bezie- hungen der Oberen Luftwege zu den Sexual-organen. Inaug. Diss. Wurzburg, 1892. tDle Beziehungen zwischen Nase u. weibllchen Geschlechtsorganen. Berlin. 1897, ISusrutas Ayurvedas; Id est Medicinae Systema, a venerablll D'hanvanfare demon- stratum a suo discipulo compositum. Transiated from the Sanscrit into Latin by Franciscus Hessier. Eriangen. tom. Ill, cap. xxlv, p. 44. 1850. iSee especially Ludwlg Septallus; De Naevls traclatus, sect, sect 26, p. 18, in Bonet's Labarynthl medic, extricatl, etc. Genevae, 1687. IVIde Aellus Lampridius in vita Antonll Hellogabllls. in Hist. August, etc. Bepontl. ?Guldonis Pancirolll rerum memorablllum sive deperditarum pars prior, etc. Franco- (urtl. 1646.IIb. 2. tit. 10. p. m. 176. Relations between the Nose and Sexual Organs. 223 posed sexuality of the nose in "Slawkenbergius's Tale," in which the city of Strasburg was captured by a handsome nose. Every one remembers the closing lines of that intensely amusing production: "Alas! alas! cries Slawken- bergius, making an exclamation—it is not the first, and l fear will not be the last fortress that has been either won —or lost by noses." While the efforts of those who have selected men who were nasuti for sexual purposes were doubtless often crowned with success, history, alas! records some cases of bitter disappointment. Thus Henry Salmuth* relates with great solemnity a case in point. Christian Francis Paulini in his curious workt devotes a chapter, under the caption Nasuti non semper bene vasati.t to the subject. After alluding to the prevalent impression that a large nose indicated a corresponding increase in vol- ume of the virile organ, he goes on gravely to state that he has known several "noble and pious" men in whom the rule did not hold good, and relates the following mournful tale: "Nobilissima ac venustissima Virgo, sed valde petulca, duos simul habebat procos, alterum bonae vitae, fortunat- aeque hominum, sed macilentum; alterum quadratum, et insigni naso conspicuum, hirconem, ac fruges consumere natum. Ilia, temto isto, hunc sibi elegit ob peculium, quod sperabat, magnum et conditionem strenuam. Sed egregie decepta est. Hinc domi jurgia, foris rixae et summa vir aversio, ob sterilitatem quae thorum perpetuo comitatur." it was possibly the supposed influence of an elegant and handsome nose as an incentive to illicit amours that led to the well-known custom of amputation of that organ in adulterers, "truncas inhortesto vulnere nares,"§ whilst in women detected in the actll the disfigurement thereby produced was intended as a perpetual reminder of their shame. •Ibid p. 177. tObservat. roedlco-pbysiog. Cent. I, bbs. xcvll, p. m. 141: Llpsiae, 1706. tVasatus, post-ciassical. SVirgti. Aeneid. vt. 97. (Vide Diodoms Slculus in Bibliothecae Hlstorlcae. Paris edition, 1854, tom. l, lib. l, cap. Ixxvfl (5), p. 64. On the customs and laws of the Egyptians. 224 John Noland Mackinxie. lti astrology Venus was supposed to govern the nose. $ - ik * * 4c .* The charlatans of those days pretended to establish the fact of virginity or defloration by astrological signs. Wil- liam Lilly, the celebrated English astrologer and impostor of the seventeenth century, claimed never to have made a mistake.* It was doubtless this method of imposture that inspired the line of Butler in Hudibras, "detect lost maiden- heads by sneezing, "t in the famous poem in which he smiled the pretensions of this fraternity of quacks away. The idea of some occult relationship between the nose and the virile member seems, in days gone by, to have crept even into the darkness of teratology. Thus we find Palfynt describing cases in which in place of the nose were found masses resembling the male organs of generation. To render the relationship to which I wish to call attention more intelligible it is necessary to recall the ana- tomical fact that in man, covering the whole of the inferior, the under surface of the middle, the posterior ends of the middle and superior, and, what is not sufficiently insisted upon by many writers, a portion of the septum, is a struc- ture which is essentially the anatomical analogue of the erectile tissue of the penis. Like it, this body is composed of irregular spaces, or so-called erectile cells, separated by trabecular of connective tissue containing elastic and mus- cular fibers, the latter element being not as prominent and well-marked as in the cavernous bodies of the generative organs. Under a multitude of various impressions erection of this tissue takes place, the dilatation of its cells being, in all probability, under the direct dominion of vaso-motor nerves derived through the spheno-palatine ganglion. It is the temporary dilatation of these bodies that constitutes the anatomical explanation of the stoppage of the nostrils in coryza and allied conditions, and their permanent enlarge- •Llfe and Times of William Lilly, written by himself. London, 1829. fPart Il, canto IIi, 285. Bartholinl (Anatomica Reformata, de naso: also Lond. ed., bit. ill, chap. x. p. 150) tells us that Michael Scotus pretended to be able to diagnosticate vir- ginity by touching the cartilage of the nose. tFortunus Llcetus (Jean Palfyn.) Description anatomique des parties de la femme. etc.. avec un tralte des monstres. Lelden. 1708. lib. Il, chap. .10, p. 142 and 144. Relations between the Nose and Sexual Organs. 225 ment is the distinctive feature of chronic inflammatory states of the nasal passages. This erectile area is, more- over, especially concerned in the evolution of the many "reflex" phenomena which are observed in connection with nasal affections. Indeed, the changes which it undergoes seem to lie at the foundation of nasal pathology, and fur- nish the key not only to the correct interpretation of nasal disease, but also to many obscure affections in other and remote organs of the body. For practical purposes we may consider this erectile, or contractile, area, consisting as it does, of myriad blood-vessels and blood spaces in wonder- fully exquisite correlationship, bounded on the one side by mucous membrane, and on the other by periosteum, as an important organ, certainly of respiration and probably of other physiological functions, using the term organ in its highest physiological sense. Call these bodies by whatever name we may, erectile bodies, corpora cavernosa, nasal lungs, we have a definite, peculiar anatomical arrangement of tissues endowed with specific physiological function and serving a manifest and manifold destiny in the organism. PHYSIOLOGICAL. An intimate physiological relationship exists between the sexual apparatus and the nose, and especially the intra- nasal erectile tissue: I.—(a) In a certain proportion of women whose nasal organs are healthy, engorgement of the nasal cavernous tissue occurs with unvarying regularity during the menstrual epoch, the swelling of the membrane subsiding with the cessation of the catamenial flow. - . . - (b) In some cases of irregular menstruation, in which the individual occasionally omits a menstrual period without external flow, at such times the nasal erectile bodies become swollen and turgid as in the periods when all the external evidences of menstruation are present. (c) The monthly turgescence of the nasal corpora cavernosa may be bilateral, or confined to one side, the swelling appearing at first in one side and then in the other, the alternation varying with the epoch. (d) The periodical erection may be inconsiderable and 226 lohn Noland Mackinzie. give rise to little or no inconvenience, or, on the other hand, the swollen bodies may occlude the nostril and awaken phenomena of a so-called reflex nature, such as coughing, sneezing, etc. (c) In some cases there seems to be a. direct relation- ship between this periodical engorgement of' the nasal erec- tile bodies and the phenomena referable, to the head that so often accompany the consummation of th€ menstrual act. (/) As a natural consequence of the phenomena above described, the nasal mucous membrane becomes, at such periods, more susceptible to reflex-producing impressions, and is therefore more easily influenced by mechanical, elec- trical, thermic and chemical irritation. . (g) The conditions (engorgement and increased irrita- bility of the nasal mucous membrane) indicated above, together with the phenomena that accompany them, are also found during pregnancy at periods corresponding to those of the menstrual flow. During the period of my original investigations I was unable from poverty of material, to come to any definite conclusions in regard to the behavior of the nasal apparatus during pregnancy. 1 was familiar with the fact that in some women the presence of pregnancy was proclaimed by a cold in the head. Isolated cases, too, had led me to the belief that the changes such as 1 described in my first article occurred in some women, at least, during that period at intervals corresponding to those of the menstrual flow, but at the time of publication of my essay I was not as sure of the fact as I am now. Since my work first appeared I have been so busied with other things that I have given little or no time to the subject. Several cases have, however, offered themselves to me which have con- firmed me in the belief that sometimes, at least, the phe- nomena described by me as occurring during menstruation also occur in pregnancy at periods corresponding to those of the monthly flux. Not to mention others, I have, for example, at present under my care a young pregnant mar- ried woman,, without any disease of the nasal passages, who with great regularity during the time at which her Relations between the Nose and Sexual Organs. 227 menses are due (from the 13th to the 17th of every month) suffers from acute and complete obstruction of both nostrils, intense sensitiveness of the nasal mucosa and violent par- oxysms of sneezing. These phenomena commence on the 13th, reach their acme by the 15th, and gradually subside, to disappear on the 17th of the month. During the inter- vals between the periods there is no abnormal condition of the nose present. Indeed, it was for this peculiar, dis- agreeable feature of her pregnancy that she consulted me, with a very accurate voluntary description of her symptoms. This condition of affairs has continued during three preg- nancies. If other proof were wanting of the fact that men- strual phenomena referable to the nose occur during preg- nancy, the question has been definitely settled by Fliess, who has shown that they not only occur during that period, but also during lactation. This author also reports several cases in which abortion was accidentally produced by gal- vano-caustic operations on the nose. In this connection I would call attention to the fact that Pliny* observes that the smell of a lamp which has been extinguished will often cause abortion, and that the latter ensues should the female happen to sneeze just after the sexual congress. II.—The presence of vicarious nasal menstruation. (a) It is a familiar fact that women are occasionally found in whom the menstrual function is heralded or estab- lished by a discharge of blood from the nostrils. This hem- orrhage, which may be accompanied by other phenomena referable to the nose, such as sneezing, etc., may be replaced afterwards by the uterine flow, but sometimes continues throughout the menstrual life of the individual. In the latter case, some malformation or derangement of the sexual appa- ratus seems to be, usually, though not always, responsible for the nasal flow. (b) Epistaxis also occurs, now and then, from the sup- pression of the normal flux. This was considered as a fav- orable sign by Hippocrates,t and by Celsus.t who followed closely in his footsteps. •Nat. His. lib. vll, cap. 7. top. oron. Ed. Kuhn. Llpsiae. 1827, tom. Il. p. 174. De morbls Mb. l, and Aph, Sect 5, art. 33. tDe medicina. Rotterodami, 1750, lib, Il, cap. 8. 228 John Noland Mackinzie. that this form of sexual consensus, or sympathy, has been recognized for centuries. Thus in the sixteenth century, Amatus Lusitanus* reports a case of sneezing from the sight of a pretty girl; Bonett and Thomas Bartholini.t and later, Spalpart Vanderwiel,§ relate cases of sneezing during coitus. In the last century Schurig,|| following Bartholini, and at the commencement of the present, Gruner.H give sneezing as one of the signs of pregnancy. Gruner** states that the nose becomes warm and red in the hysterical, in women at the menstrual period and in the victims of onanism. Isolated cases of sneezing at the menstrual period are found scattered here and there in older medical literature. Thus Garmanustt and Lanzonustt report cases of this kind, Delius§§ a case of sneezing following the suppression of the menses, while Petzold|||| relates one in which sneezing occurred every day during the whole of pregnancy. Paul- linilffl records a case in which the menses were brought on •Curationum medicinallum cent. Iv, cur. 4, Venet. 1557. See also Rahn. Exercit. phys. de causis physicis mirae llllus tum in hornine, tum inter homines, tum denlque inter cetera naturae corpora sympathla, xvll, Turicl 1788. tSepulchretum. L. I, s. xx. tHlstoriarum anatomic, et medic, rarlomm. cent, v et vi, ed. Hafnlae, 1761. v, p. 184. gGynaecologla historico-medica, etc. Dresden and Lelpsic. 1730, p. 429, Observations rares de medecine etc, (quoted by Deschamps, Tratte des maladies des fosses nasales et leur sinus. Paris, 1804, p. 88.) IPhysiologlsche u, pathologlsche Zelchenlehre, etc. Jena, 1801, p. 122. ••Ibld., p. 327. Several of the older writers refer to a case of''pituitous and serous catarrh" from coltus, reported by Georg Wolfgang Wedel (see Schurig, Spermatoiogla hls- torico-medica, etc. Francofurti ad Moenum., 1720, p. 280), but I have been unable to obtain the original account of the case. John Jacob Wepfer, Observatlones medico-practlcae de affectibus capitis internls et externls, Schaphusil, 1728, obs. Ivll (see my essay. The Patho- logical Nasal Reflex, an Historical Studv. Transactions of the American Laryngological Association, 1887; also N. Y. Medical Journal, August 20th. 1887), mentions a case of hemicranla, tinnitus aurlum and vertigo associated with uterine trouble, sneezing and a nasal discharge, but few particulars are given. lt is interesting in this connection to recall the admonition of Celsus to abstain from warmth and women at the commencement of an ordinary catarrh. (Op. cit., lib. Iv. cap. 2. 3 4, "ubi allquld ejusmodi sentlmus, protinus abstinere a sole, a baineo, a veneredebemus.") Hippocrates, on the other hand, relates the following case: "Tlmocharl hleme distlllatione in nares praecipue vexato, post veneris usum cuncta ressicata sunt, lassitudo, calor et capitis gravitas successit, sudor ex capite multus manabat." Op. cit., De morbis vulgaribus. lib. v (tom. ill, p. 574). The expression "bride's cold" would seem to indicate on the part of the laity the suspicion of a causal connection between repeated sexual excitement and coryza. ftEphemerid. nat. cur. Dec. ii. An. vlll. obs. 152. tilbld., Dec. Ill, An. II, obs. 32, UAcl. nat. cur., vol. vlll, obs. 108. (FEphem. nat. cur. Dec. Ill, An. v, vl, obs. 183. See also Rahn. op. cit., p. 34. <*;Op. cit.,lcent. Iv, cap. xlvlll. Relations between the Nose and Sexual Organs. 229 (c) Hemorrhage from the nose may occur as the vica- rious representative of menstruation during pregnancy; towards the close of menstrual life as the premature or normal herald of the. menopause; or it may be observed as a recurring phenomenon after the establishment of the change of life or after the removal of the uterus or its appendages. (d) These vicarious hemorrhages are, moreover, not confined to women, but make their appearance not infre- quently in boys at or near the age of puberty, upon the full development of their sexual powers. III. —The well-known sympathy between the erectile por- tions of the generative tract and other erectile structures of the body. There is no reason why the sexual excitement that leads to congestion and erection of these organs, as for example in the case of the nipple, may not, under similar circumstances, cause engorgement of the nasal erec- tile spaces. IV. —The occasional dependence of phenomena referable to the nose during sexual excitement (such as, for example, nose bleed, stoppage of the nostrils, sneezing and other reflex acts), either from the operation of a physiological process, the erethism produced by amorous contact with the opposite sex or during the consummation of the copula- tive act. The nasal symptoms most commonly found associated with sexual excitement are sternutation, occlusion of the nasal passages (from erection of the corpora cavernosa), and epistaxis. Sneezing is sufficiently common, particularly during coitus. Quite a number of such - cases have come under my personal observation in persons in robust health and whose nasal organs were apparently free from disease. The reflex may occur before (from erotic thoughts), during, or after the consummation of the act. Many like cases have been since reported to me. Thus one physician of large practice, who became interested in the subject, found twelve cases among his clientele. It may be interesting to know 230 John Noland Mackinfie. by sternutatories, and quotes Fabricius Hildanus as having noted copious menstruation follow violent and immoderate sneezing. Sudden and complete occlusion of both nostrils some- times occurs with regularity during coitus. This phenom- enon, which may be accompanied by so-called "reflex" phenomena, such as, for example, asthmatic attacks, is doubtless due to sudden dilatation of the erectile bodies from paralysis of their vaso-motor nerves; for as Anjel* has shown, during coitus the nervous shock is dis- tributed to the whole vaso-motor system of nerves and is not confined to the erection center. Cases have also been reported in which the act of coitus was accompanied by hemorrhage from the nose (Isch-Wall, Joal.) V. —The reciprocal relationship between the genital organs and the nasal apparatus is furthermore illustrated by the occasional dependence of genito-urinary irritation upon affections of the nasal passages. Retarded sexual develop- ment, too, may possibly depend upon the co-existence of nasal defect.t Unfortunately there are no authentic cases in literature in support of this latter hypothesis, but in this connection 1 would like to call attention to the remarkable case reported by Heschel (Wiener Zeitschrift fur pract. Heilkunde, Marz 22, 1861), in which imperfectly developed genital organs were associated with absence of both olfac- tory lobes. The man was well developed, with the excep- tion of the testes, which were the size of beans and con- tained no seminal canals, and the larynx, which was of feminine dimensions. All trace of olfactory nerves was absent, as were also the trigona olfactoria and the furrow on the under surface of the anterior lobes. There was scant perforation of the cribriform plate which transmitted the nerveless processes of the dura mater. There was also an absence of nerves in the nasal mucosa. VI. —It is, finally, quite possible that irritation and con- gestion of the nasal mucous membrane precede, or are the ttArchlv fur Psych., Bd. vlll. Heft 2. •See Elsberg, Archives of Laryngology. Oct., 1883. Relations between the Nose and Sexual Organs. 231 excitants of, the olfactory impression that forms the con- necting link between the sense of smell and erethism of the reproductive organs exhibited in the lower animals and in those individuals whose amorous propensities are aroused by certain odors that emanate from the person of the oppo- site sex. Through all the centuries the season of flowers—the springtime—has been celebrated in amatory song and story as the season of love and of sexual delight. This conceit, handed down to us from the poets of antiquity, finds mod- ern expression in the glorious verse of Tennyson: "In the Spring a fuller crimson comes upon the robin's breast; In the Spring the wanton lapwing gets himself another crest; In the Spring a livelier iris changes on the burnish'd dove; In the Spring a young man's fancy lightly turns to thoughts of love." Woman, in all the ages, from the perfumed courtesan of ancient Babylon to her reflected image in the harem of the Sultan to-day, has appealed to the olfactory sense to bring man under her sexual dominion and to fire his pas- sionate desire. In the Song of Solomon, in the Aries amoris of the older writers, in the fetich worship of odor, in the picture of Richelieu surrounded by an atmosphere of dense perfume in order to stimulate his amorous feeling, is reflected the idea of the possible power of olfactory perception in awak- ening sexual thoughts. If you doubt that modern man has not forsaken this idea, read Zola,* Lombroso, Tolstoi, Nordau. Rosseau has aptly termed olfaction the sense of the imagination, and if we reflect how intimately related it is to the impressions we form of external objects, how it affects our emotions and influences our judgment, the clever definition of the French philosopher becomes all the more striking and felicitous.t •See especially a work by Leopold Bernard, Les odeurs dans les romans de Zola. Montpelller. 1889. tOf great interest is the influence which civilization exerts upon the deveiopment and Impressibility of the olfactory sense. Without enumerating, much less elaborating, the myriad conditions that conspire to produce such a result, we may safely lay down the gen- eral proposition that the physical and moral forces of civilization—the social and intellectual environment of the subject—exert a marked effect upon the olfactory faculty by inviting or encouraging disturbance of the sentient and perceptive apparatus; that the higher we 232 John Noland Mackinzie. While it is undoubtedly true that olfactory impression in man, under natural conditions, plays a subordinate part in the excitement of sexual feeling, while it may be also true that such intensification or perversion of the odor sense may indicate an abnormal condition and a reversion to the purely animal type, still the fact is incontestable that many persons are attracted sexually to each other through the sense of smell. Both history and fiction are full of such examples. In connection with this part of the subject it is inter- esting to note the extraordinary degree of nervous sympathy that may be developed through the sense of smell. IWillingeh,* for example, relates the case of a pensioner in the Hospital for the Blind in Paris, called Les quinze Vingt, who by the touch of a woman's hands and nails and their odor could infallibly assert if she were a virgin. A number of tricks were played on him and wedding rings were put on the fingers of young girls, but he was never at fault. As in the lower animals it is possible or even probable that the alternate inflation and collapse of the erectile bodies is, to some extent at least, the means by which the the grateful or ungrateful odorous particles are excluded from, or admitted to contact with, the apparatus of special sense, so in men in whom this sense is sexually excited or perverted, either normally, or from defect in the subjects themselves', the reception or rejection of the sensuous odors may be accomplished by a similar mechanism. These facts point conclusively to an intimate physio- logical association between the nasal and reproductive appa- ratus, which may be partially explicable on the theory of reflex or correlated action, partially by the bond of sym- pathy which exists between the various erectile structures ascend in the social scale, the more readily our judgments are unnaturally influenced or per- verted by Impressions derived through the sense of smell, and that the more we recede from the inferior orders, the less perfect and acute this faculty becomes, the more susceptible to irritation and the more predisposed to disease. In view, therefore, of the importance of olfaction as an avenue through which our mental Impressibility ls influenced—our Imagina- tion perverted—and in view of the relations of civilization to the sense of smell, we can readily understand why It is that this faculty is found more frequently deranged among the superior orders than in those lower down in the social scale and in the savage state. •Mlllingen. The Passions, or Mind and Matter, etc. London, 1848, p. 102. Relations between the Nose and Sexual Organs. 233 of the body. That a relationship exists by virtue of which irritation of the one reacts upon the circulation and possibly nutrition of the other, is accordingly rendered highly prob- able by the evidence of clinical observation. If this excitation be carried beyond its physiological limits there comes a time sooner or later when that which is a normal process becomes translated into a pathological state, according to a well-known law of the economy. Hence it is a priori conceivable and eminently probable, not only that stimulation of the generative organs, when carried to excess, may become an etiological factor in the production of congestion and transient inflammation of the nasal passages, and especially of their cavernous tissue, but that repeated and prolonged abuse of the function of these organs may, by constant irritative influence on the turbi- nated tissue, become the starting point of chronic changes in that structure. PATHOLOGICAL. I. —In a fair proportion of women suffering from nasal affections, the disease is greatly aggravated during the men- strual epoch or when under the influence of sexual ex- citement. II. —Cases are also met with in which congestion or inflammatory conditions of the nasal passages make their appearance only at the menstrual period, or, at least, are only sufficiently annoying at that time to call for medical attention. III. —Occasionally the discharge from a nasal catarrh will become offensive at the menstrual epoch, losing its dis- agreeable odor during the decline of the ovarian disturbance. In many cases of ozoena, the fetor is much more pro- nounced at times corresponding to those of the menstrual flow. IV. —Excessive indulgence in venery sometimes seems to have a tendency to initiate inflammation of the nasal mucous membrane, or to aggravate existing disease of that structure. There are those, for example, who suffer from coryza after a night's indulgence in venereal excesses, and 234 John Noland Mackinzie. the common catarrhal affections of the nose are undoubtedly exaggerated by repeated and unnatural coition. V. —The same is true in regard to the habit of mas- turbation. The victims of this vice in its later stages are constantly subject to nose-bleed, watery or mucous dis- charge from the nostrils, and perversion of the olfactory sense. VI. —The co-existence of uterine or ovarian disease exerts sometimes an important influence on the clinical his- tory of nasal disease. This fact has been shown in prac- tice in cases in which the nasal affection has resisted stub- bornly all treatment and in which it has only been relieved upon the recognition and appropriate treatment of the dis- ease of the generative apparatus. The recent researches of Fleiss seem to indicate that the converse of this proposition is true. The most commonly found conditions of the nasal apparatus following perverted sexual excitement, either from excessive venery or onanism, are: (1) coryza (generally of vaso-motor type), with or without reflex manifestations, such as asthma, paroxysmal sneezing, etc. (2) epistaxis, and (3) various forms of perversion of the sense of smell. In addition to these, Peyer has observed abnormal dryness of the nasal and pharyngeal mucous membrane, indicated by a feeling of dryness and burning in these regions and by complete cessation of secretion. The coryza that follows intemperate venery resembles in character that seen in the disease falsely called "hav fever," and, like it, is generally associated with more or less pronounced neurasthenia, or shall we say, localized hysteria. In other cases the nervous system is not appar- ently, involved. The predominant temperament, however, in individuals thus affected is the neurotic. While they may not necessarily in some instances belong to the so- called "nervous" or "hysterical" individual, while they may give no outward and visible sign of a deranged nervous system, there will generally be found, on careful exami- nation, a delicacy or sensitiveness of the nervous apparatus either in whole or in part. Relations between the Nose and Sexual Organs. 235 It is conceivable that this sexual coryza may be asso- ciated with almost any of the so-called reflex neuroses. In • one of my cases asthma was the central symptom. A young married woman, twenty-three years old, in otherwise appar- ently perfect health, consulted me for the relief of attacks of asthmatic breathing associated with stoppage of the nostrils. 1 could find nothing wrong at the time of consul- tation with the respiratory apparatus, and her other organs were in perfect condition. Reluctantly she confessed that every night for five years she and her husband had indulged in intemperate venery. Moderation in their sexual relations caused rapid disappearance of the symptoms, and in the nine years that have elapsed since she consulted me there has been no return of the disorder. Interesting cases of asthma of nasal origin associated with, and due to sexual excitement have also been reported by Joal and Peyer. In this connection I would recall a case of periodic vaso-motor coryza reported by me at length elsewhere,* in which the attacks invariably appeared and were most severe at the menstrual period, appearing some- times at its commencement, sometimes at its close. In the attacks coming on in the interval between the monthly periods pain was always felt in the left ovary. Residence at the seashore invariably gave relief, except during men- struation, when the attacks were as bad as when at home. The outbreak of the disease at the menstrual epoch in this case is readily explained by the physiological erection of the corpora cavernosa which occurs at that period. In this particular case the chief, and under certain circumstances the sole excitant of the paroxysm was the utero-ovarian excitement of the menstrual epoch. Nose-bleed is not infrequently the result of onanism. Years ago Du Saulsayt called attention to the fact that enormous quantities of blood can be lost from the nose from the practice of this vice, and the accuracy of his observa- •A contribution to the study of coryza vasomotoria periodica, or so-called "hay fever,'* N. Y. Med. Rec.. July 19. 1884. tComment. de rebus in med. etc., vol. xvll, p. 213. Mlchell, in Schlegel's "Sylioee selectlorum opusc. de mirabile sympathiae quae partes inter diversas corporis humanl inter- cedit." Llpsiae. 1787. (l. c. 236 John Noland Mackinxie. tion is borne out by the experience of subsequent observ- • ers. Among others, Joalt has collected several such cases and reports three of hjs own. One of his patients informed him that he masturbated to excess to provoke nose-bleed, which relieved him from violent headaches from which he suffered. Whether the hemorrhages in these cases—which by the way are not confined to the male sex*—come from simple acute distension of the intra-nasal blood-vessels, or whether definite chronic structural changes have taken place in the mucous membrane and in the vessel walls, are points which are as yet undetermined. The probability is that some intra-nasal lesion is responsible for them, for, as I have pointed out elsewhere,t the discharge from the nostrils and the perverted olfactory sense found in the later stages of onanism are often simply the outward expression of chronic nasal inflammation. The nature of the perversion of the olfactory sense in onanists will vary with the character of the nervous condi- tion produced by the vice—hyperosmia, hyposmia, parosmia and allotriosmia have all been observed in cases of immod- erate sexual excitement. The investigations of Fleiss would seem to indicate that painful, profuse and irregular menstruation may in some instances depend upon an intra-nasal cause. He cites a number of cases to show that the pain of certain forms of dysmenorrhcea may be temporarily dissipated by the application of cocaine to the nasal mucous membrane, or permanently controlled by cauterization. According to him, only the inferior turbinated body and the tuberculum septi possess a special relation to the dysmenorrhceic pains. These two localities he accordingly designates as xar* ifrxw, genital zones (Genitalstellen). If the tuberculum septum be cocainized, the hypogastric pains disappear. Cocainization of the right nostril causes disappearance of the pain on the left side of the body and vice versa. In answer to the objection that these phenomena may •See case of Lemarchind ig Trigon (girl of 16). quoted by J0*1. tl. c. Relations between the Nose and Sexual Organs. 237 be due to the general anaesthetic action of the drug, he points out the fact that cocaine absorbed into the blood does not produce a general analgesic effect, as is produced in the case, for example, of morphia. On the contrary, in small doses it acts as a stimulant. The fact that pain ceases only when the genital zones are cocainized and that it may be permanently dissipated by cauterization of this area, does away, he thinks, with the assumption that the subsidence of the pains is a part of the euphoria produced by the drug. The fact alluded to above, that in cocaini- zation of certain parts of the genital zones only individual pains disappear from the symptom complex, militates against the supposition of a simple, general narcotic effect. I cannot vouch for or deny the accuracy of the above statements, as Fliess's monograph has just come into my possession and I have had neither time nor opportunity to put them to the test. Curiously enough, the genital zones of Fleiss correspond exactly with the most sensitive por- tions of the sensitive reflex area mapped out by me in 1883.* •On Nasal Cough and the Existence of a Sensitive Reflex Area in the Nose. America, Journal of the Medical Sciences, July, 1883, The results of these experiments were first brought before the Baltimore Medical Association in the eariy part of 1883, and subse- quently before the Medico-Chlrurglcal Faculty of Maryland (April, 1883, vide Transactions) and the American Laryngologlcal Association (May, 1883 vide Transactions). The conciu- sions reached from these investigations were as foliows: "(1) That fn the nose there exists a definite, well-defined sensitive area, whose stim- ulation, elther through a iocal pathological process, or through the action of an irritant intro- duced from without. ls capable of producing an excitation which finds Its expression in a reflex act or in a series of reflected phenomena. (2) That this sensitive area corresponds in all probability with that portion of the nasal mucous membrane which covers the turbinated cqrpora cavernosa. (3) That reflex cough is produced only by stimulation of this area, and is only excep- tionally evoked when the irritant is appiied to other portions of the nasal mucous membrane. (4) That all the parts are not equally capable of generating the reflex act, the most sensitive spot belng probably represented by that portion of the membrane which ciothes the posterior extremity of the inferior turbinated body and that of the septum immediately opposite. (5) That the tendency to reflex action varies in different individuals, and is probably dependent upon the varying degree of excitability of the erectile tissue. In some the siightest touch is sufficient to excite it; in others, chronic hyperemia or hypertrophy of the cavernous bodies seems to evoke It by constant irritation of the reflex centers, as occurs in similar con- ditions of other erectile organs, as for exampie the ciitoris. (6) That this exaggerated or disordered functional activity of the area may possibly throw some light on the physioiogical destiny of the erectile bodies. Among other properties which they possess, may they not act as sentinels to guard the lower air passages and pharynx against the entrance of forelgn bodies, noxious exhalations and other injurious agents to which they might otherwise be exposed? Apart from thelr physiological interest, the practical Importance of the above facts from • diagnostic and therapeutic polnt of view is sufficientiy obvious. Thereln lies the expiana- 238 John Noland Mackinzie. I have, on innumerable occasions,* shown that phe- nomena widely different in character and anatomical sphere of operations may be produced at will by artificial stim- ulation of this area, and that they may be dissipated by local applications to, or removal of, the membrane covering the diseased surface. It is therefore not difficult to con- ceive that the phenomena referable to the uterus and ovaries during menstruation may be influenced in a similar manner. The specific relations of the two zones and the crossed action of the reflex, if such it be, are much more difficult of explanation. If such a condition of affairs exists, it is certainly a remarkable phenomenon. These observations, therefore, encourage the belief, if they do not establish the fact, that the natural stimulation of the reproductive apparatus, as in coitus, menstruation, etc., when carried beyond its normal physiological limits, or (Ion of many obscure cases of cough which heretofore have recelved no satisfactory solution, and thelr recognition is the key to thelr successful treatment." In calling attention to this area as containing the spots most sensitive to reflex-pro- ducing Impressions, 1 did not, nor do I now (as has been wrongly inferred), desire to main- tain that pathological reflexes may not originate from other portions of the nasal mucous membrane. Indeed, wherever there is a terminal nervous filament it may be possible to pro- voke sneezing, lachrymation and other reflex movements. My contention is simpiy this, that the area indicated in my original paper represents by far the most sensitive portion of the nasal cavities, and that pathoiogical reflex phenomena are in the large majority of cases related to diseased conditions of some portion of this sensitive area. That all pathological nasal reflexes arise from irritation of this particular area is a proposition which I do not, and never have maintained. The determination of these sensitive areas is of special Importance and interest in the solution of the pathoiogy of the so-called nasal reflex neuroses. Whether a special sensitiveness in certain portions of the nasal mucous membrane exists or not. the agitation of the question has led to more rational methods of procedure in the treatment of a large ciass of nasal affections, and to more conservative methods in intra-nasal surgery Before the iocation of the sensitive area or areas, the nasal tissues were destroyed with an almost ruthless recklessness that bade fair to bring intra-nasal surgery into the worst repute. (For an elaborate discussion of this whole subject see articie by the author in Wood's Refer- ence Handbook of the Medical Sciences, edited by Buck. Wm. Wood & Co., N. Y., 1887. vol. v. pp. 222-242.) •My books upon this subject may be found in the following publications: A contribu- tion to the study of coryza vaso-motorla periodica or so-called "hay fever," N. Y. Med Record, July 19, 1884. Coryza vaso-motoria periodica in the negro, with remarks on the etiology of the disease, N. Y. Med. Record, Oct. 18, 1884. Rhinitis sympathetica, essay read before Clin. Soc. of Md.; see brief abstract in Md. Med. Journal, April 11th, 1885. and In Internationales centraiblatt f. Laryngologie. etc., Sept., 1885. Observations on the origin and cure of coryza vaso-motoria periodica. Trans. Medico-Chir. Faculty of Maryland. 1885. Review of Morell Mackenzie's essay on hay fever, etc., The American Journal of the Med. Sciences. Oct. 1885. p-p. 511-528. See also discussion of the subject before the American Laryngoioglcal Association (May 14th. 1884, vide Transactions, p, 11J et. seq ) See also cases of reflex cough due to nasal polypi. Trans, of the Medico-Chirurglcal Faculty of Md., 1884, and articies in Wood's Handbook already referred to. Relations between the Nose and Sexual Organs. 239 pathological states of the sexual apparatus, as in certain diseased conditions, or as the result of their over-stimulation from venereal excess, masturbation, etc., are often the pre- disposing, and occasionally the exciting causes of nasal congestion and inflammation and perversion of the sense of olfaction. Whether this occur through reflex action, pure and simple, or as a sequel of an excitation in which several or all of the erectile structures of the body participate, the starting point of the nasal disease is, in all probability, the repeated stimulation and congestion of the turbinated erec- tile tissue of the nose. It is highly probable that this erectile area, or organ, so sensitive to reflex-producing impressions, is the correlative of certain vascular areas in the reproductive tract, and that the phenomena observed may therefore be explained by the doctrine of what we may call, for want of a better name, reflex, correlated action. In these remarks 1 have attempted no thoroughgoing exposition of the subject, but simply laid before you the results of my personal labors. These no longer represent, I am glad to say, the result of solitary observation and iso- lated experience. I have not attempted, as Fliess has done, to touch upon the biological side of the question. The study of the relations between the nose and the sexual apparatus opens up a new field of research, of pleas- ing landscape and almost boundless horizon, which bids to its exploration not only the physiologist and pathologist, but also the biologist. Above all it brings us face to face with a serious problem of life, an interesting enigma, whose sig- nificance it will be the task of the future to divine. ALCOHOLIC EPILEPSY A Wrong Theory Misapplied to the Case of Arthur Deustrow. By DR. C. H. HUGHES, St. Louis. IN the Quarterly Journal of Inebriety (Vol. xx, No. 3) appears an article* in which psychologic truth and error are blindly mingled and the author seems much mentally mixed in his psychiatry, too much confused concerning the true data of practical alienism to be the Corypheus he assumes to be on the subject of alcoholic automatism or indeed upon the subject of epilepsia in any form, to say nothing of its psychical equivalent or substitutive states, the most diffi- cult and abstruse subject in psychological medicine; one which the novice in psychiatry and the veteran in neurology alike hesitate to tackle. But there are times and places in morbid mental science, as in the realm of theological disquisition, when and where "fools rush in where angels fear to tread." The author, apparently under the dominant delusion that he is one of the distinguished denizens of the House- boat on the Styx, calls up the ghost of a medico-legal casus celebre and discusses the ignoble hero of that trial, Arthur Deustrow, in a new light, a light in which he never appeared when he walked the earth as fiendish and unprin- cipled a murderer as ever justly "felt the halter draw," with vicious fiend's "opinion of the law." In this remarkable post mortem production the Dues- trow case is considered "a good example of epileptic insan- ity." "The case shows," the author says, "the powerful influence, environment and heredity exert in certain cases." •By Dr. William Lee Howard. [240] Alcoholic Epilepsy. 241 The influence of heredity is all right enough when invoked to establish insanity. But when a man assuming to be an alienist capable of solving grave and obscure problems of mental alienation, invokes environment to prove his case, he gives himself away logically and psychologically speak- ing. The insane man is the man, of all others, who is out of harmony with his environment and acts counter to them. A statement like this is the lapsus of a novice in psychol- ogic science. "Duestrow's mother," this record goes on to state, "was the daughter of a saloon-keeper," but not a drunkard saloonkeeper or an insane saloonkeeper, which this record does not state. "This daughter," continues the record, "was in the habit of drinking (beer omitted by the record) at her father's place (home omitted in the record). His (Deus- trow's) father was also an habitual user of alcoholic drinks (beer omitted)." In short, they were beer drinking Germans —as most Germans are. As Bismarck is and von Moltke was. And as some gentlemen of die Vaderland among my acquaintance are, who could give this young man, Howard, sounder views, in spite of their beer-embarrassed brains, than was ever held by the clearest head of "all the How- ards." But this dreadful record continues. "The alcoholic (beer beverage) habit continued throughout the lives of both parents, and the son, Arthur Deustrow, was given beer to drink when an infant," and his mother was probably given beer to drink when she was carrying Arthur. This was horrible? though the record omits it. But if every boy who while a babe got a little beer or ale, or suckled breasts from mothers who were given beer or ale to make milk in the breasts, must have alcoholic epilepsy, what is to become of the German and English nations? Shade of Kaiser Wilhelm der Gross, what is to become of Deutschland und Bavaria? where an average of fifty gallons of beer per capita is drunk. "When Duestrow was 13 his father became suddenly wealthy" and Arthur "commenced a series of dissipations which continued up to the time he committed his repulsive crime." This is not strictly correct. Duestrow's series of 242 C. H. Hughes. dissipations did not begin so soon. Duestrow was much like other boys would be and are under circumstances of little restraint and gradually increased self-indulgence. As he grew older he had means allowed him for indulg- ing in the vicious life of a large city. He drank beer at times to excess, but was not a hard drinker. He indulged in immoral dissipations, went to theatres, to houses of ill- fame after he had passed puberty, to the neglect of his work at medical college. He never graduated. But he was not a violent hard drinker. He drank more beer than was good for him and did other things in the line of self-indul- gence that were not good for his morals. He was dissolute and gradually descended in the vicious indulgences of his kind. But he had never had delirium tremens or brought on himself an epileptic fit by excessive indulgence in drink or venery, and had no history of syphilis or traumatism and no epileptic record. This is a pretty rough outline sure. Rough on "the truth of history," rough on genuine honest psychiatry, if a diagnosis of epileptic insanity can be thus easily made. Now, here are the facts on this point from the sworn testimony: Duestrow had come to his house fresh from the bosom of his mistress, who had told him his wife was untrue to him and his child was a bastard. He had come in a sleigh to redeem a promise his wife had exacted of him to take her a ride. He was under the influence of drink but in no sense beastly intoxicated. He was sober enough to remember his promise and to keep it, and to remember the hour. He remembered to bring some toys to his child which he had promised the mother to get and he brought them, but he had come to the house in a bad humor because he wanted to be elsewhere, but had reason for complying with his wife's wishes about the ride. He had spoken to his child not unkindly before leaving the house. The ser- vant girl met him at the door. They had some words. She was too familiar with him and offended him so that he began striking her in the front hall. He pulled out his revolver and flourished it, threatening to shoot. The girl ran away and he did not shoot at her. The quarrel attracted Alcoholic Epilepsy. 243 the wife's attention upstairs. The wife called down, "Arthur, let the girl alone. It is my fault. Come up and strike me; you are drunk." To this the murderer responded by running upstairs, revolver in hand, exclaiming, "I'll show you who is drunk." He then assaulted his wife with his fist, saying she kept a whore-house. As his anger rose with the resistance of his wife and the excited state of his brain from alcohol, he shot her and his child. All the chambers of his revolver were not empty, but he kept some for self defense, if necessary, during or after the homocide. Here is some more of the erroneous record upon which this pseudo expert proposes to establish what he miscalls the Scientific Status of the Duestrow Case: "On the day he murdered his wife and child he was playing with the child (of whom he was very fond), when he suddenly pulled a pistol from his pocket, shot his wife, and then picked up his child and fired two bullets into the little one's brain. He walked out hatless, and was found on the street in a dazed condition. He went quietly to the police station and there made several contrary statements." "Such in rough outline," says Dr. Howard, "is a typical case of alcoholic epileptic mania." There is nothing typical in it! Before attempting to escape, and after stooping over his wife and calling "Tina, are you dead?" to make sure of his work, she making no response, Duestrow picks up his hat, conceals his revolver, which he still carries with him, and leaves the house. Does he wander aimlessly, dazed and uncertain what to do, or fall in a fit the culmination of epileptic violence or has a fit preceded the violence, or had he ever had one that any one knew of before the tragedy or since? No! No! Follow him! He goes with all his clothing on and prop- erly adjusted as quickly and as directly as he can to the nearest police station and surrenders himself, getting into a wagon going that way to expedite his going. The driver suspects nothing from his demeanor, so set and self-equi- poised is he in his voluntary determination to keep his own '244 C. H. Hughes. counsel and surrender himself safe from any immediate con- sequences of his crime. Neither epilepsy nor drink have obscured his cunning nor obliterated the consciousness and memory of the deed. What does he do now? He surren- ders himself to the officer and says: "I have shot my wife and child by accident. I went to give my wife my revolver and it went off and killed her and wounded the child. Send for my attorney, and I wish to give bail. I am wealthy; can give a million dollars security, if necessary," a boastful verity and no delusion. Shade of the mighty Caspar! Shades of Echeverria and Ray and that host of great and honest alienists who have gone to that realm where psychological error ceases from troubling, and honest psychiaters are at rest, but isn't it rough on true psychiatry to call such state of inebriate passion without element of mental obscurity, alcoholic epilepsy? . But this brilliant meteor in the firmament of psycho- logical medicine goes on. Hear him and tremble for the sandy foundations of your knowledge; ye who think you know something of the real nature of epilepsy and epileptic and epileptoid states: "An epileptic maniac, after committing a crime, when arraigned in court will admit his crime, but when, some months later, he is brought to trial he denies knowing any- thing about the crime. It is a common thing for epileptics to give some inconsistent excuses for their action; they have no accurate knowledge of what has happened, but a vague and indefinite idea and try to excuse their conduct by illogical stories." Here is a description intended to fit the writer's mis- conceptive of at least one of the cases, that of Duestrow. Duestrow not only admitted his crime at the time of the crime but explained it in the most logical, but untruthful, manner then and later in jail to me. He told me some months after the deed, as I testified at the trial, that he was drunk at the time he killed his wife and child and did not know what he was doing. But he did know what he was doing or had done, for he immediately after, told all Alcoholic Epilepsy. 245 about it, to those who had heard of the murder, and just as it had occurred and when and where, except his extenu- ating explanation that it was an accident. Had he been suddenly seized with the impulse to kill after the usual manner of epileptics, he would not have recovered so completely and so soon, so as to make the explanation of "accident." This was the most plaus- ible and most exculpative, for it promised best for his chances of subsequent escape from the legal consequences of his crime. No one witnessed the killing. He had scared away the only possible fitness; she was down stairs. The deed was done up stairs. The shots were heard. The shooting was not seen by others than the principals in the tragedy. Had he not been in a previous passion, the plea of accident had passed for more. Had he not been in a passion gradually rising to the pitch of frenzy, the plea of epilepsy might have been more plausible, though unsus- tained by previous or after paroxysms. But here is some more light thrown by this novice in neurology and amateur alienist, on epilepsy, the light of an ignis fatuus to mislead the unwary neurologic trav- eler who trustingly follows the false illumination of his pathway to knowledge: "A careful study of individuals who have had attacks of epileptic mania would show an abnormal condition of mind and morals in early life, physical timidity except when fortified by alcohol, apprehensions of all vague and indefi- nite happenings, and an existence, both mental and physi- cal, unnatural to normal human beings." A careful study of individuals who have had attacks of epilepsy may or may not show an abnormal condition of mind and morals in early life, and they are not always noted for physical timidity (1 do not know what the author means by physical timidity) except when fortified by alcohol. Shade of Julius Caesar who fell convulsed in the market place at Rome and of the epileptic Napoleon and Mohamet, what does our author mean by this and by the rest, "apprehensions of all vague and indefinite happenings, and an existence, both mental and physical, unnatural to 346 C. H. Hughes. normal beings"? Oh epilepsia procursiva of my old tom- cat who getteth a fit when thy head getteth hot under the stove, now I know why the character changeth and thou meweth. "Apprehensions of all vague and indefinite hap- penings" and hath "an existence, both mental and physical, unnatural to normal" feline beings, and so in the house-top and under my window disturbeth my peaceful slumbers. It is "the abnormal condition of thy mind and morals in early life." Tom, only for thine epilepsy and its dire ante- cedents, 1 had shot thee long ago to death! But here is one paragraph among this singular and largely Hntruthful word portraiture of epilepsy, which is nearer the truth but it does not fit Duestrow. The whole drapery of the picture as a painting of Duestrow is a mis- fit. The colors are bad, the brush is unskilfully handled and the background is scarcely a decent shadow of the truth. "in alcoholic epileptic insanity the period of anger is preceded by a calm attitude; then comes the sudden period of ferocity during which the deed is done; almost immediately subsidence of the furor, followed by partial or complete ignorance of the act." But this last paragraph contains elements of truth familiar to all psychiaters but not at all applicable to Deustrow, for his period of anger was not immediately pre- ceded by a calm attitude, nor did a sudden period of feroc- ity come on out of a calm, but developed as passion increased, and the passion passed, in the case of Duestrow, into a natural effort at escape and cunning explanation on the theory of accident with no witnesses to deny, and the act was not "followed by partial or complete ignorance of the act," but by full and complete knowledge, cunning and most natural explanation and plans for his comfort after the deed. As a case of epilepsy Duestrow was not a success. No paroxysm preceded and none followed the murder. The old irresponsible limit of Zacchias of three days before or after a paroxysm was exceeded by three years of after observa- tion and all the exciting incidents of repeated trials coupled Alcoholic Epilepsy. 247 with excessive cigarette smoking, both exciting causes of attacks in the epileptically predisposed, and yet no paroxysm is recorded, though some testimony as to a staring spell or two, while drinking at the bar, was given by one or two witnesses but not confirmed by others. Epilepsy is epilepsy whether idiopathic, traumatic, syphilitic, alcoholic or of other toxic or degenerative origin. Now let us put in juxtaposition to the preceding mis- conceptions of this disease, the true conceptions of this malady of one who, though dead, yet truly speaketh, for he was recognized in his day and is yet regarded as one who knew well whereof he spoke. Isaac Ray, on Epilepsy and its Legal Consequences, Chapter xviii, paragraph 436, el seq., writes: Epilepsy is a nervous disease characterized by par- oxysms of insensibility, unconsciousness and convulsions. These vary in severity, from that of a simple vertigo, con- tinuing for a few seconds and scarcely discernible by others, to that of a most distressful convulsive fit enduring from five minutes to some hours. They may recur twice or thrice a day for several days together, or once a week, month, or year. They sometimes occur without warning, but, as often perhaps, they are preceded by symptoms indic- ative of disturbance of the nervous functions; such as, giddiness, pain of the head, drowsiness, frightful dreams, hallucinations of sight or of hearing, vigilance, irritability of temper. The cessation of the paroxysm is followed by somnolence, pain in the head, and a sense of weakness. The recurrence of the fits is determined by whatever disturbs the general health, more especially by derangements of those organs in which the series of morbid phenomena takes its origin. Anger, fright or any strong moral emotion, is very liable to produce a paroxysm. Discussing one hundred and forty-five imbecile or demented epileptics reported by Esquirol, Ray notes that, "all but sixteen were so only immediately after the fit, and that this was also the case with three of the thirty- four who were furious," and says: This is a fact of no little importance in a medico-legal point of view, and should never be lost sight of in judicial investigations of the mental condition of epileptics. This corypheus of Psychiatry continues: The maniacal 248 C. H. Hughes. fury of these patients, is of the wildest and blindest kind which nothing can tame, the individual acting automatically, as it were, and in a state of unconsciousness. It may con- tinue for minutes, hours or days. The dementia which is the form of mental derangement to which epileptics are most liable after the fit, is characterized by intellectual stupor and moral depression, in which, however, they have sufficient energy, under some circumstances, to commit acts of violence, of which they retain only an imperfect recollec- tion when they recover. Another direct, though temporary effect of the epileptic fit, is to leave the mind in a morbidly irritable condition, in which the slightest provocation will derange it entirely. Sometimes this irritability is accom- panied by a sense of anxiety, distrust, jealousy and unfounded fear, and sometimes by great activity of the lower propensities. The mental disturbance generally follows the fit immedi- ately, but in many cases it precedes the fit and heralds its approach. And this latter fact is irrespective of the form of the disturbance, which may be fury, excitement, confusion of ideas or stupidity. The ordinary succession of events, however, is not unfrequently changed. The mental disorder which usually succeeds the fit, may occasionally precede it, in the same individual; generally proportioned to the vio- lence of the physical symptoms, but occasionally most severe when these symptoms have been least violent; and two successive fits may be attended, one by excessive mental disorder, and the other, by scarcely any. To determine exactly the mental condition of an epi- leptic at the moment of his committing a criminal act, in whom the disease has not produced habitual insanity, is often a difficult task. It may have taken place in the absence of any observer, in a fit of fury that rapidly passed away, and which perhaps, may not have followed any pre- vious paroxysm; or the accused, though subject to the disease, may not have recently suffered an attack, and may have appeared perfectly rational to those around him. The suspicion that the accused was deprived of his moral liberty when committing the criminal act, would be strengthened, if the paroxysms had been recently frequent and severe; if one had shortly preceded or succeeded the act, [etc!]. Cases of this kind should be closely scrutinized, and where the accused has been undeniably subject to epilepsy, he should have the benefit of every reasonable doubt that may arise respecting his sanity. Here are some illustrative cases: Alcoholic Epilepsy. 249 Joachim Hoewe, 29 years old, had been an epileptic since his sixth year. Since the age of puberty, the disease had become aggravated, and latterly had attacked him once in three weeks. He was long in recovering from the effects of the fits, being troubled with pain in the head and ver- tigo, and manifesting strong aversion to food, though never furious or insane. In July, 1826, after an hour's walk, he experienced a fit, and in the course of the three next days, he had several, appearing all the while to be quite uncon- scious, and refusing nourishment. On the third day he arose from his bed, and went down into the yard, where he met with a son of his brother ten years old, and a daugh- ter of a relative to whom he was attached, eleven years old. The boy asked him if he did not wish to eat. The patient made no reply, but struck at him, when the chil- dren ran off. He followed them, overtook the girl, knocked her down, and catching up a hatchet from the ground, frac- tured her skull in several places, when the neighbors rushed in and, after considerable resistance, overpowered him. He now remained quiet, till they proceeded to carry him to the magistrate, when he broke out into violent expressions of hatred against his fellow-townsmen. In prison he laid two days in a state of unconsciousness, took no nourishment and had a fit. On the third day his reason returned; he expressed some interest in his friends, complained bitterly of his sufferings, but had no recollection of what had occurred. The question having been put to the medical expert (by whom the case was. reported), whether the accused was in a responsible condition of mind when he committed the murder, it was answered in the negative, for the following reasons. Unlike real criminals, he had no definite purpose in view, and did not fly, after having com- mitted the act. The mental condition of epileptics just before and after the fit, is usually very peculiar, and for many years medical jurists have not been in the habit of considering an epileptic as deserving of punishment for any offense he might commit within three days before or after a fit. Among .the exciting causes of his fits at the time in question, and of the criminal act, the reporter mentioned the exercise and heat of the weather to which the accused had been exposed, and the inquiry of the child whether he would eat, which, on account of his morbid aversion to food, excited him, in his unconscious and irritable condition, to expend his fury on the nearest object. Two months after, he died in a fit. The following case illustrates another phasis, from the 250 C. H. Hughes. same source, of epilepsy, of great importance in a medico- legal point of view: A very sober, quiet, and industrious tradesman, aged thirty, subject to occasional fits of epilepsy, and who had lately much inclined to religious devotion, was sitting calmly reading his Bible, when a female neighbor came in to ask for a little milk. He looked wildly at her, instantly seized a knife and attacked her, and then his wife and daughter. His aim appeared to be to decapitate them, as • he commenced with each by cutting on the nape of the neck. Their cries brought assistance and he was secured before he had inflicted any fatal wound. I saw him on the following day. His countenance then presented a most hideous and ferocious aspect; the com- plexion was a dusky red, his eyes starting from their sockets, and he was continually sighing deeply, or extend- ing his jaws as if going to yawn. The pulsation of the temporal and radial arteries was full and laborious. He could make no reply to questions, although he attempted to do so; but he occasionally exclaimed, "oh dear!" He appeared to be on the very verge of apoplexy. He was depleted freely both by blood-letting and purging; his head was shaved, refrigerating lotions were applied to it, and a very low diet prescribed. On the third day his intellects were much improved, and he was quiet. He soon quite recovered, but never had the least recollection of the acts he had committed, [etc.]. Following this is the record of a doubtful case in which the doubt is cleared by the recurrence and well attested previous history of epileptic seizures. Another record by the same author gives the history of paternal alcoholism and epilepsy in proof. And here is the criterion for the prudent Alienist in court. Epilepsy in whatever form, being a paroxysmal dis- ease, its recurrence precedent or subsequent to the crime in question should be sought for and established in order to make a presumption of epileptic disease, even in its masked forms and purely psychical alternate irresponsible states or blind morbid resistless impulsions, exempting from legal con- sequences of volitional crime. But the plea of alcoholic epilepsy was not offered in the Duestrow trial. It was epileptic paranoia. PSYCHRO-AESTHESIA (COLD SENSA- TIONS), AND PSYCHRO-ALGIA (COLD PAINS.)* By CHARLES L. DANA, M.D., Visiting Physician to Bellevue Hospital; Professor of Nervous Diseases, BellevueHospital Medical College. INTRODUCTORY.—In a recently written article on the subject of paraesthesiat I have tried to show with some new emphasis the significance and relationship of this symptom. I venture to quote here some of my introduc- tory paragraphs: Paresthesia is the name given to a number of subjec- tive sensations, such as pricking, numbness, creeping sen- sations, tickling, and burning. It includes, in fact, nearly all the subjective sensations of the skin, except those of pain. It is a condition which is, therefore, extremely com- mon, and in its mildest and most trivial character is much more often experienced than pain. When these sensations fix themselves in a certain locality, following the tract of the nerve, or fastening themselves upon the hand or foot, they take on a certain clinical picture, and deserve to have the name of a disease to just the same extent that a neu- ralgia does. Paraesthesia, in almost all cases, implies simply a lower grade of irritation of the nerve fibres than occurs in neuralgia, and is a kind of ghostly simulacrum of that disease. It very often precedes or accompanies attacks of pain. There is sometimes a tingling of the teeth or burning in the face which has a shadowy likeness to a toothache or trigeminal neuralgia. In the same way, one finds paraesthesias affecting the head, causing sensations of •ReaJ before the New York Neurological Society, October 5,1897. \Text Book of Nervous Diseases, fourth edition, p. 152. [251] 252 Charles L. Dana. pressure and constriction, of burning, and general undefinable discomfort, which are entirely comparable to headaches. In conditions of neurasthenia, paraesthesias of the head are more common even than the headaches. Paraesthesia sometimes follows the course of a nerve, as when one feels numbness of the hand if the ulnar is pressed upon at the elbow, or numbness in the foot when the sciatic is pressed upon, as when the legs are crossed. There is also paraesthesia affecting one of the inter- costal nerves or one of the crural nerves. On the other hand, paraesthesia may affect all four extremities, so that they feel entirely benumbed or prickling. There is, I repeat, a very close analogy between these groups of paresthesias and neuralgias. Paraesthesia affects single cerebro-spinal nerves just as neuralgia does, or it may be more generally distributed. In the latter case it affects most the feet and hands, and it is called aero-parcesthesia. We meet then with: 1. Cephalic paraesthesias, comparable to diffuse head- aches. 2. Local paraesthesias, comparable to local neuralgias. 3. Aero-paraesthesia, involving the feet or hands or both diffusely. The cephalic paraesthesias are usually symptoms of neurasthenic or lithaemic states. Among eighty-five cases of local and acro-paraesthesiae, not symptomatic of other and organic nerve disease, I found that there were of the local forms thirty-five cases, of acro-paraesthesia fifty cases. The local paraesthesias affected the arms in eighteen cases, next the thigh and leg nerves in twenty cases, and, last, the trigeminal nerve in three cases. The following analysis of eighty-five cases of paraes- thesia occurring in my practice shows something of the cause and local development of the malady. The most fre- quent causes I find to be those concerned with occupation. Paraesthesia, in its general manifestations, may be consid- ered almost an occupation neurosis. The list of cases may be put down as follows: Occupation 15 Rheumatism 10 Alcoholism 6 Infection 6 Senility 6 Reflex irritation 2 Hysteria 3 Climacteric change 2 Various causes, such as neuras- thenic state, puerperism, etc.... 12 Among 85 cases there were 36 males and 49 females: Psychro - Aesthesia. 253 Males. Females. Total. Hands and feet, or both affected 6 6 10 11 12 10 4 12 17 18 20 4 26 Hands aione. _ Feet and legs „ General sensations Local v 14 36 49 85 The special nerves affected were: Trigeminal 4 Brachial 5 Ulnar 7 Radial 1 Crural 4 Peroneal 1 Sacral... Sciatic... Plantar.. 1 1 11 35 The commoner form of paraesthesia is simply that of a sensation of prickling numbness or of a part being asleep. A more rare form is that accompanied by sensation of heat, and here the perverted feeling verges closely upon pain. In fact, the sensation of heat is often so distressing that the patient considers it to all practical purposes a pain, although it may not correspond to the strictly technical psychological definition. Psychro-cesthesia.—Among the rarer forms of paraesthesia are those of sensations of cold (psychro-aesthesia, from 1*xpk, cold). These sensations are felt quite Japart from any actual lowering of the temperature of the body and without any objective evidences of vascular change in the affected part. Cold paraesthesias are not usually very distressing, and, although they are sometimes described as cold pains, they are not so akin to pain as are the heat sensations. The term psychro-aesthesia was first used by Pollaisson (Lyon Medical, 1887). Later it was adopted by Silvio (La Riforma medica, February 17 and 18, 1896,) and these authors have reported several cases of this kind. A case was also reported recently by Dr. L. G. Guthrie in Brain, spring and summer number, 1897. These two later articles have drawn renewed attention to this interesting symptom. A number of cases have occurred in my expe- rience, and it seemed to me that it might be worth while to report a few of them in hopes that a fuller knowledge 254 Charles L. Dana. of the aetiology and pathology of the condition might be obtained. CASE 1.—Dora C, aged fifty-three years; Ireland; washerwoman. The patient for three years had had con- stant tinnitus aurium, especially in the right ear, troubling her most at night, She had disease of both internal ears and chronic middle-ear catarrh, and both external canals were almost filled by soggy epithelial scales. Such was the report of her condition by Dr. A. M. Fanning. Her special complaint was of the cold sensation which she felt contin- uously in the forehead during all this period of three years. This annoyed her so much that she thought she could not get along without a bandage over her forehead to keep it warm. The sensation was bilateral and involved the upper part of the forehead, like a brow headache; the skin was not cold or in any way changed to the sight or touch. She had some of the ordinary paraesthesias in the hands and feet of the prickling pins-and-needles kind. She was slightly nervous and slept badly. There was no dyspepsia, and the bowels were regular. She drank a good deal of tea—five or six cups a day. Examination showed no anaesthesia in any form and no signs of organic nervous disease. Here was a case of cold paraesthesia of the forehead, associated with the ordinary paraesthesias which occur in middle-aged women who do a great deal of washing and drink a good deal of tea and, perhaps, alcohol. CASE II.—Francis L. L. aged fifty-six years; married; United States; mechanic. Family history good; no syphilis; habits temperate. His occupation compelled him to stand all day. The patient had some chronic bronchial trouble, and a year and a half ago he began to have paraesthesia of the legs below the knees. He said the trouble came on at two in the morning. Very soon after this he began to have sensations of coldness in the feet, which were always worse in the morning and lasted until the middle of the afternoon. During this time he felt as standing upon ice, and he would try by heat and rubbing to get rid of the discomfort. Toward three o'clock the cold sensations changed to burn- ing sensations, which lasted until night. He had some tremor, the pulse was rather rapid, and he showed signs of arterial sclerosis. The lungs, heart and sexual organs were normal; digestion normal, and a physical examination showed absolutely no anaesthesia to the affected parts and no change in the vascularity. The reflexes were slightly exaggerated. Psychro - Aesthesia. 255 Here, again, we have a case of cold paraesthesia asso- ciated with heat and the ordinary prickling paraesthesia, due probably to exposure, to defective venous circulation depend- ent on the man's habits of standing at his work, and prob- ably to some rheumatic influences. CASE III.—Lewis S., aged forty-two years; married; butcher by occupation. Family and previous history neg- ative. The patient was a healthy-looking man, who came to the clinic complaining of a sensation of coldness over the left thigh, especially marked on its anterior surface. This had lasted for six months, and had been gradually increasing. During the previous year he had had the same sensation in the right thigh, but this had disappeared. He denied syphilis and rheumatism. He drank, but not to excess. Examination showed absolutely no objective signs. Sensa- tion was normal as to temperature, touch, and pain. The tongue was thickly coated, and there was some history of dyspepsia. On questioning him 1 found that in his occu- pation his thigh was constantly brought into contact with the edge of a table or counter; in other words, there was constant slight trauma. Dr. George R. Elliott, who exam- ined his urine, concluded that there was a toxaemia from digestive disorder. CASE IV.—James G., aged sixty-two years; Ireland; married; occupation, clerk. The patient had suffered sev- eral years from bronchitis. For three weeks previous to being seen by me he had been suffering from some prick- ling paraesthesia of the fingers and in the lower extremities, and, at the same time, he had sensations of cold in these parts. He had dyspepsia, poor appetite and constipation. Examination showed nothing objective in the hands and feet; the knee-jerks were present; there was no loss of power in the legs, and no anaesthesia over the affected parts. The sensations of cold were not due to actual vas- cular changes, but were subjective. The patient had no signs of tabes dorsalis. CASE V.—Jeremiah H., aged forty-nine years; married; Ireland; laborer. The patient had always been a healthy man and did not drink intoxicating liquors. For four suc- cessive winters he had suffered during the whole of the cold weather from a sensation of coldness on the left leg, on the outer side just above the ankle. The affected area was sharply mapped out and measured about eight by four inches. It was not exactly painful, but gave him a great deal of annoyance and apprehension. The sensation dis- 256 Charles L. Dana. appeared as the summer weather came on. There were no other complaints. Examination showed nothing abnormal in touch, sensation or pain, nor were there any objective changes to be seen in the part affected. A careful general examination was made without discovering any signs of organic disease. The patient described his symptoms vividly, and he was shown to my class as a case of cold paraesthesia, due to some irritation of the peripheral fila- ments of the external popliteal nerves. CASE VI.—Elizabeth J., aged forty-one years; Ireland; domestic. For about a year the patient had suffered from some pains in the right ankle, together with prickling sen- sations which ran down to the toes and up to the knees. The part from the knee down also felt constantly cold, and this cold sensation was associated with paraesthesia and prickling. The patient denied ever having had rheumatism, and also denied drinking and othe-r bad habits. Her gen- eral health was good, and there were no objective symp- toms connected with the part affected. The legs and feet were not tender, nor was there any redness or swelling. The knee-jerks were present, and there was no particular weakness of the extremities. The patient complained of the coldness, but perhaps even more of the prickling and pain. CASE VII.—Mr. C. C, aged forty-four years; United States; married; occupation, business. Family history good. The patient had had syphilis twenty years before, with secondary symptoms afterward. He was a well-nourished man and apparently in good health, except for the partic- ular symptom complained of. This consisted of a sensation of intense coldness over the left hip on its lateral surface. The area was limited, and extended from the knee about two-thirds of the way up the thigh, mostly in the distri- bution of the external cutaneous nerve. He felt, he said, as though it had been painted with menthol. Warmth and exercise made it disappear for a time, but it returned. The part affected looked and felt to the touch perfectly normal. A careful examination failed to reveal any trouble with the general bodily functions. The urine, digestion, heart, and lungs were normal. The pulse was 68. A further careful examination was made for tabes, but he showed no signs of this. There was no loss of knee-jerks; no eye symptoms;, no bladder symptoms. The patient simply suffered from this continual sensation of coldness of the thigh. The foregoing cases all occurred in patients in whom it was impossible to detect any absolute signs of organic dis- Psychro- Aesthesia. 257 ease of the central or peripheral nervous system. I have under observation now at the Montefiore Home two patients, one of whom is certainly suffering from syringomyelia in an advanced stage. The other probably has syringomyelia in an early stage. In both cases the patients complain of a sensation of coldness over the upper extremities. This sen- sation is felt from the hands up to the elbows, and is simply a cold feeling not associated with pain. Both patients have some slight sensory disturbances, such as thermo and pain anaesthesia, but these are not marked. They are not accompanied with sensations of prickling or of heat, or with the ordinary paraesthesias. ! have presented the foregoing clinical data very much condensed, for the reason that 1 know that my hearers are familiar with cases of this kind, and it does not seem to me necessary to go into elaborate detail to illustrate further their character. Analysis of Symptoms.—We have apparently two classes of cold paraesthesia. In one the symptom is not definitely limited to certain areas, but involves a whole extremity or all four extremities, and is associated with other paraes- thesias or with pain, and often with evidence of vaso- motor disturbance. The other class of cold paraesthesia, psychro-aesthesia proper, is a disorder in which the sensation is quite an isolated one. The patient suffers from a feeling of cold exclusively, or almost so, having with it no prickling or numbness and not always any distinct pain, although it may amount to such. Furthermore, this form of paraes- thesia is limited to some special area, oftenest upon the thigh or buttock, but sometimes upon the calf or upon the face, and more or less closely following the distribution of a nerve. The sensation is purely dermal and superficial. The mind refers it to the external world, so that it seems like an objective sensation similar to a touch. The patient feels as though some cold object were lying upon the part. The sensation may disappear in warm weather or under exercise. 258 Charles L. Dana. In some instances it is not so much a cold sensation as a cold pain or psychro-algia, and it may be obstinate and distressing, especially in quite elderly and senile persons. Pathogeny.—The psychro-aesthesias of the first or mixed type are met with oftenest in mild forms of neuritis, such as may be caused by alcohol, or such as occurs in sciatica; they are also observed in locomotor ataxia. Among thirty- six cases carefully examined for this symptom by Dr. Joseph Frankel, he found two persons who spontaneously complained of sensations passing up and down the back like waves of cold, or affecting the legs in a similar man- ner. The symptom also occurs in the early stage of syrin- gomyelia, as noted in my two cases. Mixed psychro-aBs- thesia is thus usually due to neuritic irritation, but may indicate a lesion higher up. Yet in practically all cases it means a lesion of the peripheral sensory neurone at one part or another of its course.* The exciting causes are usually alcohol, lithaemia, expos- ure, and toxic agents that lead to nerve degeneration. The purer types of cold sensation and cold pain are found more often in men, and almost always in persons over forty years. The trouble is caused sometimes by trauma, combined with exposure and a rheumatic tendency. A neuropathic constitution favors its development. Pollaisson attributes some cases to varicose veins and to uterine disease. So far as clinical experience and reading go, the cold paraesthesia of syringomyelia is less intense and less sharply limited than those in the cases described. The patients have simply a sensation of general coldness, but not of the same sharp smarting coldness complained of by the patients whose history I have reported. The sensation is really subjective, is like that felt in diffuse neuritis, and is perhaps due to vasomotor disturbances. Pathology.—There are both special cold and special heat nerves distributed to the skin and some of the mucous membranes. The fibers carrying these thermal impulses •Dr. William H. Thomson reports a case of psychro-festhesia due to a cerebral lesion. Such cases are unique. Psychro -Aesthesia. 259 run in the cerebro-spinal nerves mingling with other sen- sory nerves. They separate again in the spinal cord, as shown in cases of syringomyelia and central-cord lesions, but apparently run very diffusedly in the brain axis and capsule, for local lesions here do not cause a differentiation of heat and cold anaesthesia. Hence (apart from psychical states) we must place the seat of the lesion in psychro- a?sthesia practically almost always in the peripheral nerves. Its presence may, however, indicate a beginning syringo- myelia or some other central cord lesion; and also, in rare cases, locomotor ataxia. Treatment.—In most cases the treatment is that of an underlying neuritis or neuritic irritation. Anti-rheumatic drugs, nux vomica, exercise, and electricity are indicated. Locally, a liniment containing a little mustard oil is useful. Warm applications and friction sometimes give relief. In very obstinate cases the question of syringomyelia should be investigated. Where there are pain and evidences of decided neuritis, as in sciatica, rest is necessary. AUTO-EROTISM: A PSYCHOLOGICAL STUDY. By HAVELOCK ELLIS, London, England. Honorary Fellow of the Chicago Academy of Medicine, Etc. BY "auto-erotism" I mean the phenomena of spontane- ous sexual emotion generated in the absence of an external stimulus proceeding, directly or indirectly, from another person. Such a definition excludes the normal sexual excitement aroused by the presence of a beloved person of the opposite sex; it also excludes the perverted sexuality associated with an attraction to a person of the same sex; it further excludes the manifold forms of erotic fetichism in which the normal focus of sexual attraction is displaced, and voluptuous emotions are only aroused by some object—hair, shoes, garments, etc.,—which to the ordinary lover are of subordinate though still indeed of consid- erable importance. The auto-erotic field remains extensive; it ranges from occasional voluptuous day-dreams, in which the subject is entirely passive, to the perpetual unashamed efforts at sexual self-manipulation witnessed among the insane. It also includes, though chiefly as curiosities, those cases in which individuals fall in love with themselves. Among auto-erotic phenomena, or on the borderland, we must further include those religious sexual manifestations for an ideal object, of which we may find evidence in the lives of saints and ecstatics. The typical form of auto- erotism is the occurrence of the sexual orgasm during sleep. I do not know if any apology is needed for the inven- tion of the term "auto-erotism."* There is no existing •Letamendi, of Madrid, has recentiy suggested "auto-erastla" to cover what is probably much the same field. In the beginning of the century Hufeland in his Mahrabiolic invented [260] Auto-Erotism. 261 word in current use to indicate the whole range of phe- nomena 1 am here concerned with. We are familiar with "masturbation," but that, strictly speaking, only covers a special and arbitrary sub-division of the field, although, it is true, the sub-division with which physicians and alienists have chiefly occupied themselves. "Self-abuse" is some- what wider, but by no means covers the whole ground, while for various reasons it is an unsatisfactory term. "Onanism" is largely used, especially in France, and some writers even include all forms of homosexual connection under this name; it may be convenient to do so from a physiological point of view, but it is a confusing and anti- quated mode of procedure, and from the psychological stand- point altogether illegitimate; "onanism" ought never to be used in this connection at all, if only on the ground that Onan's device was not auto-erotic at all. While the name that I have chosen may possibly not be the best, there should be no question as to the impor- tance of grouping all these phenomena together. It seems to me that this whole field has rarely been viewed in a scientifically sound and morally sane light simply because it has not been viewed as a whole. We have made it difficult to do this by directing our attention on the special group of auto-erotic facts—that group included under masturbation— which was most easy to observe and which in an extreme form came plainly under medical observation in insanity and allied conditions, and we have wilfully torn this group of facts away from the larger group to which it naturally belongs. The questions which have been so widely, so diversely, and—it must unfortunately be added—often so mischievously discussed, concerning the nature and evils of masturbation are not seen in their true light and proportions until we realize that masturbation is but a specialized form the term "geistige onanie" to express the filling and heating of the imagination with volup- tuous Images, without unchastity of body, and in 1844 Kaan, in his Psychopathia sexualis used but did not invent the term "onanla psychlca." Gustav Jaeger in his Enteekung der S**U, proposed "monosexual idiosyncracy" to indicate the most animal forms of masturbation taking piace without any correlative Imaginative element, a condition illustrated by cases given in Moll's Unteesuchungen uber die Libido Sexualis, Bd. I, pp. 13, et seq. But all of these terms oniy cover a portion of the field. 262 Havelock Ellis. of a tendency which in some form or in some degree normally affects not only man but all the higher animals. From a medical point of view it is often convenient to regard masturbation as an isolated fact, but we must bear in mind its relationships to understand it. In this study of auto-erotism 1 shall frequently have occasion to refer to the old entity of "masturbation" because it has been more carefully studied than any other part of the auto-erotic field, but 1 hope it will always be borne in mind that the psychological significance and even the medical diagnostic value of masturbation cannot be appreciated unless we realize that it is an artificial sub-division of a great group of natural facts. The study of auto-erotism is far from being an unim- portant or merely curious study. Yet psychologists, medi- cal and non-medical, almost without exception, treat these manifestations in a dogmatic and off-hand manner which is far from scientific. It is not surprising, therefore, that the most widely divergent opinions are expressed. Nor is it surprising that ignorant and chaotic notions among the gen- eral population should lead to the most pathetically ludi- crous results. To mention one instance known to me: A married lady who is a leader in social purity movements and an enthusiast for sexual chastity, discovered through reading some pamphlet against solitary vice that she had herself been practicising masturbation for years without knowing it. The profound anguish and hopeless despair of this woman in face of what she believed to be the moral ruin of her whole life cannot well be described. It would be easy to give further examples, though scarcely a more striking one, to show the utter confusion into which we are thrown by leaving this matter in the hands of blind leaders of the blind. Moreover, the conditions of modern civilization render auto-erotism a matter of increasing social signifi- cance. As our marriage rate declines, and as illicit sexual relationships are, in England at all events, openly discour- aged, it is absolutely inevitable that auto-erotic phenomena of one kind or another, not only among women but also among men, should increase among us both in amount and Auto-Erotism. 263 intensity. It becomes, therefore, a matter of some impor- tance, both to the moralist and the physician, to investigate the psychological nature of these phenomena, and to decide precisely what their attitude should be towards them. I do not propose here to enter into a thorough discus- sion of all the aspects of auto-erotism.* That would involve a very extensive study indeed. I wish to consider briefly certain salient points concerning auto-erotic phe- nomena, especially their prevalence, their nature, their moral, physical and other effects. 1 base my study partly on the facts and opinions which during the last twenty years have been scattered through the periodical and other medical literature of Europe and America; and partly on the expe- rience of individuals, especially of fairly normal individuals. I could wish information gained in the latter way more extensive, but unfortunately the number of normal persons whom one may question on such points with the certainty of receiving reliable answers is necessarily limited. Among animals in isolation, and sometimes in freedom —though this can less often be observed—it is well known that various forms of spontaneous solitary sexual excite- ment occur. Horses when leading a lazy life may be observed flapping the penis until some degree of emission takes place. Welsh ponies, I learn from a man who has had much experience with these animals, habitually produce erections and emissions in their stalls; they do not bring their hind quarters up during this process, and they close their eyes, which does not take place when they have con- gress with mares. The same informant observed that bulls and goats produce emissions by using their forelegs as a stimulus, bringing up their hind-quarters and bending their backs. Donkeys behave like horses, and mares rub them- selves against objects. Stags in the rutting season, when they have no partners, rub themselves against trees to pro- duce ejaculation. Sheep masturbate; as also do camels, •For instance, there is considerable difference of opinion as to how the first (usually auso-erotic) manifestation of the sexual impulse usually be^ns. whether as a local irritation or a psychic inciination to some real or Imaginary person, most authors inciining to the former alternative: see Moll. UnUesuchungen uber die Libido Sexualis, Bd. 1, p. 54. 264 Havelock Ellis. pressing themselves down against convenient objects; and elephants compress the penis between the hind legs to obtain emissions. Blumenbach observed a bear act some- what similarly on seeing other bears coupling. Mammary masturbation, remarks Fere, is found in certain female and even male animals, like the dog and the cat.* Apes are much given to masturbation, even in freedom, according to the evidence of good observers; like men they are apt at all times for coitus, and while no female apes are celebates, many of the males are obliged to lead a life of celiby.t Male monkeys use the hand in masturbation, to rub and shake the penis.% In the lower species these phenemena are by no means found in civilization alone. However common masturbation may be in Europe, it is far from being, as Mantegazza has declared it to be, one of the moral characteristics of Euro- peans. It is found among the people of every race of which we have any intimate knowledge, however natural the conditions under which men and women may live. Thus among the Nama Hottentots, among the young women at all events, Gustav Fritsch found that masturbation is so common that it is regarded as a custom of the country; no secret is made of it, and in the stories and legends of the race, it is treated as one of the most ordinary facts of life. It is so also among the Basutos, and the Kaffirs are addicted to the same habit.§ When the Spaniards first arrived at Vizcaya and the Phillippines, they found that masturbation was universal, and that it was customary for the women to use an artificial penis and other abnormal methods of sexual gratification. Among the Balinese, according to Jacobs (as quoted by Ploss and Bartels), mas- turbation is general; in the boudoir of many a Bali beauty, he adds, and certainly in every harem, may be found a wax penis to which many hours of solitude are devoted. Throughout the East, as Eram, speaking from a long medi- •Fere, ''Perversions sexuelles chez les animaux," Rev. Phil., May, 1897. tTllller, VlneHnct sexuel, 1889, p. 270. tMoll, Libido Sexualis, Bd. I, p. 76, sGreenlees, Journal of Mental Science, July. 1895. Auto-Erotism. 265 cal experience, has declared, masturbation is very prevalent, especially among young girls. In Cochin China, Lorion remarks, it is practised by both sexes, but especially by the married women.* Japanese women have probably car- ried the mechanical arts of auto-erotism to the highest degree of perfection. They use two hollow balls about the size of a pigeon's egg (sometimes one alone is used) which, as described by Joest, Christian and others,t are made of very thin leaf of brass; one is empty, the other (called the little man) contains a small heavy metal ball or else some quicksilver and sometimes also metal tongues which vibrate when set in movement, so that if the balls are held in the hand side by side there is a continual tremulous movement. The empty one is first introduced into the vagina in con- tact with the uterus, then the other; the slightest move- ment of the pelvis or thighs, or even spontaneous move- ment of the organs, causes the metal ball (or the quick- silver) to roll, and the resulting vibration produces a pro- longed voluptuous titillation, a gentle shock as from a weak electric inductive apparatus; the balls are called Rin-no- tama, and are held in the vagina by a paper tampon. The women who use these balls delight to swing themselves in a hammock or rocking chair, the delicate vibration of the balls slowly producing the highest degree of sexual excite- ment. Joest mentions that this apparatus, though well known by name to ordinary girls, is chiefly used by the more fashionable geishas, as well as by prostitutes. Its use has now spread to China, Annam and India. In China also the artificial penis—made of rosin, supple, and (like the classic instrument described by Herondas) rose-colored —is publicly sold and widely used by women. It may be noticed that among non-European races it is among women, and especially among those who are sub- jected to the excitement of a life professionally devoted to some form of pleasure, that the use of artificial instruments of auto-erotism is chiefly practised. The same is markedly •La Criminalte en Cochin Chine, 1887, p. 116. tChrlstian, art "Onanlsme." Dict. ency. des sci med, Ploss and Battels, Das Welb Moraglla, Die Onanle belm normalen Welbe. Zt.f. Criminal-Antkropologie, 1897. 266 Havelock Ellis. true in Europe. The use of an artificial penis in solitary sexual gratification may be traced down from classical times. The Lesbian women are said to have used such instruments made of ivory or gold with silken stuffs and linen. Aris- tophanes (Lysistrata, v. 109) speaks of the use by the Milesian women of a leather artificial penis, or olisbos, which he calls skutina 'epikouria. In the British museum is a vase representing a hetaira with such instruments in her hand. One of the best of Herondas' memoirs, "The Private Conversation," presents a dialogue between two ladies concerning a certain olisbos which one of them vaunts as a dream of delight, so soft and so firm, she says, far superior to a man. Through the middle ages (when from time to time the clergy reprobated the use of such instruments) to the Elizabethan age when Marston in his satires tells how Lucea scorns "Her husband's lukewarm bed, Because her pleasure being hurried; In jolting couch a glassy instrument, Doth far exceed the Paphian blandishment." Down to the present day somewhat similar appli- ances, known as dildoes and by other names, may be traced in all centers" of civilization. But throughout they appear to be largely confined to the world of prostitutes and to those women who live on the fashionable or semi- artistic verge of that world. Ignorance and delicacy com- bine with a less versatile and perverted concentration on the sexual impulse to prevent any general recourse to such highly specialized methods of solitary gratification. On the other hand, the use, or rather abuse, of the ordinary objects and implements of daily life in obtaining auto-erotic gratification, among the ordinary population in civilized modern land, has reached an extraordinary degree of extent and variety which we can only feebly estimate by the occasional resulting mischances which reach the surgeon's hands. In the last century Mirabeau in his Erot- ika Biblion gave a list of the various objects used in con- vents (which he describes as "vast theatres" of such prac- tices) to obtain solitary sexual excitement. In more recent Auto-Erotism. 267 years the following are a few of the objects found in the vagina or bladder whence they could only be removed by surgical interference:* Pencils, cotton reels, hair-pins, bod- kins, knitting needles, crochet needles, needle cases, com- passes, glass stoppers, corks, tumblers, tooth-picks, tooth- brushes, pomade pots (in a case recorded by Schroeder with a cockchafer inside, a makeshift substitute for the Japanese ri-no-tama), while in one recent English case a full-sized hen's egg was removed from the vagina of a middle-aged married woman. The age of the individuals in whom these objects have been found is usually from 17 to SO, but in a few cases they have been found in girls below 14; the large objects, naturally, are found chiefly in the vagina, and in married women. The patient usually professes profound ignorance as to how the object came there; or she explains that she accidentally sat down upon it, or (in the. case of the bladder) that she used it to produce freer urination.t Hair-pins have, above all, been found in the female bladder with special frequency; this point is worth some consideration as an illustration of the enormous frequency of this form of auto-erotism. The female urethra is not a normal center of sexual feeling, so that the introduction of an object into it can only occur by mistake or by perver- sion of sexual feeling. Moreover, for every case in which the hair-pin disappears and is lost in the bladder, from carelessness or the oblivion of the sexual spasm, there must be a vast number of cases in which the instrument is used without any such unfortunate result. There is thus great significance in the frequency with which cases of hair pin in the bladder are strewn throughout the medical liter- ature of all countries. In 1862 a German surgeon found the accident so common that he invented a special instru- •Poulet Foreign Bodies, Vol. I. tSec. e. g. Winckel, Die hrankhciten der weiblichen Harnrohre und Blase, 1885, p. 211; Ibid Uhrbuch der Fraunenhrankheiten, 1886, p. 210. GrGnfeld(Wi