4, v F5“ "'1: 4 ‘3.4. . ‘vi-34.1!‘ . . 4 . . . .. . 4 .4 . . 4 4 . . . . . . 4 .. in. Y7: .4. 3 JUN.)- u ... .4.44)4 4 |. Iran; .|.. ‘I I 12. 444% U “4%? . w. > 4 .4 I . aw . hhhX 4 flwmlméwi . . 4 4 WWW? m4 “6.855.,” 4 . .. 4 . 4. . 4 »444P .\l\.n\>-V HA4.‘ . ixlHJ - 4 . . 4 . . H . 4 4 . . . 4 . . . 4 . 4 n‘ l :4. . . w \ 4 . 4 4 . 4 4 _ 4 4 . 4 . _ . . 4 4 4 . . 4 . nvvbfl ,.. .3 4 _ . . 4 . . 4 4 . . 4 . 4 4 4 . 4 2L5.» Lina >- 4 P . 4 4 . . 4 . . . #4.... . “4 .mfiw‘rmffivf . 4 . . . . 4 ._...4.. . lira“)? F.41..4 4 . 4 . 44 .. .. . .. .4 4 4 4 4 44 . 4 4 . 4 4. .4.4 .. 44 . . 4 .44».&¥ZA~,5FL&ILI¢K:#AM51...‘! 433) "v ...\4.l 4 4 n unun. .1... . .. A. .- 73144. Tlikiix. ~ \».1 4 . ~4.....n.4a-\1. . .. “54.1.44 (4 44,114: .4 .4 . 4.4,...“ . 2.4V“.- I :. will 4.41:(.4|4 . uwfiwm K. .phu 166 4 University of Michigan — BUHR 2 2 2 O .5 .1- O 9 3 _ ‘I'll! llllv‘bylflll'll'llllli .. \ k T! . V A | > . lllll'ilivlllnlllllf »1..4..raIl;L.4._r|{.x4_:.,u4_4Lv fifim . , . . 4§§44..4.4..4.. 4.. v . .431. 4 4 . 4 . . 4 4 :1. . ‘44.3% {5R MEDICAL LIBRARY “44%,” LIIIJIJPJLLILILLIIJHJLHLU a." EE-55:55:5-=55:- IIU‘U‘IIll'l.l'§'ll,ll"0‘l WW h. "lllllllllllllllllllll - l a .- n a {- =l b'n‘ctnb'a'lu'n‘nu'un - c‘- n’q'oii I- 0 ‘iii "ma'immnmw ' I “ ifiifi’ifii'ii'flflifififi'ii'ifl" illilllllmmi‘lfil a. mmimmimwmwm THE ALIENIST @ONEUROLOGIST A QUARTERLY jour-nuy ......op.... SCIENTIFIC, CLINICAL AND FORENSIC Psychiatry p and Neurology. Intended especially to subserve the wants of the General @mctitz'oner of Medicine. “Quantum ego quidem video motus morbosi fere omnes a motibus in systemate nervorum ita pendent. ut morbi fere omnes quodammodo fnervosi dici queant.”—Cullm’s Nosology: Book II., p. 181-Edz‘nburgh Ed. 1780. b VOLUME IV. —EDITED BY- C. H. HUGHES, M. D., And an associate corps of collaborators. sn LOUIS, MO.: EV. E. CARRERAS, STEAM PRINTER, PUBLISHER AND BINDER. 1883. PRE S S UP Ev. E. Cameras, Steam Printer, Publisher and Binder, s'r. Lutrxs, MU. A. BIANCHI, M. D., ' CONTRIBUTORS TO VOLUME IV. GEORGE M. BEARD, A. M., M. D. New York. ALBERT N. BLODGE'I‘T, 1;. D., oston, Mass. D. R. BROWER, M. D., 'r. n. CROTHERS, M. ‘D., Hartford, Conn. s. DANILLO, M. D., St. Petersburg, Russia. OECILIA DEAN, M. D., Baltimore, Md. PLINY EARLE, M. D., ' Northampton, M ass. J. J. ELWELL, M. D., ' Cleveland, O. PROF. GOLGI, Italy. WILLIAM A. HAMMOND, M. D., Ne w York City. C. H. HUGHES, M. D., St: MOI JA S. G. KIERNAN, M. D., Chicago, Ill. M. J. MADIGAN, M. D., EDWARD C. MANN, M. D., New York City. JAMES H. MCBRIDE. M. D., Milwaukee. Wisconsin. Italy. Chicago, 111. Brooklyn, N. Y. ALLAN MCLAN E HAMILTON, M. D., New York City. WM. JULIUS MIOKLE, M. D., M. R. C.P., London. E. M. NELSON, M. D., - St. Louis, Mo. A. H. OHM ANN-DUMESNIL, A.M., M.D. St. Louis, Mo. D. V. PARANT, M. D., France. RALPH S. PARSONS, M. D., Near Sing Sing, N. Y. LUIGI M. PETE-ONE, M. D., Italy. IRA RUSSELL, M. D.. Winchendon, Mass. G. SEPPILLI, M. D., Italy. EDWARD O. SPITZKA, M. D., New York City. P. It. 'I‘HOMBS, M. D., Pueblo, 001. A. VAN DERVEER, M. D., Albany, N. Y , H. WARDNER, M. D., Anna, Ill. P. M. WISE, M. D., Willard, N. Y. JOSEPH WORKM AN, M. D., Toronto, Canada 23-3-886- IV ' INDEX. INDEX To VOLUME IV. QRIGINAL CONTRIBUTIONS. 1 ‘age. Bibliography, report on ................... .. 655 Bilateral secondary descending scle- rosis and atrophy, mainly of pons varolii and medulla oblongata; slight difi'use myelitis .................. .. 1 Cerebral syphilis manifested by iso- lated involvement of the trigeminal nerve; persistent conjunctivitis and facial anaesthesia ........................ .. 58 Clinical phenomena and therapeutics of delirium tremens ..................... .. 9] Contribution to the question of the mental status of Guiteau and the history of his trial ...... ............... .. 201 Continuation of the study of the min- ute anatomy of the central organs of the nervous system. ..................... .. 383 Concealed insanity-As illustrated by the case of Mark Gray. .. . 461 Curability of insanity; new observa- tions .............................. ......... .. Experience of an opium eater during the withdrawal of the drug ........... .. Extract from report on diseases of old age. ............................................. .. Female diseases among the insane .... .. 113 Folie a deux—-its forensic aspects ..... .. 285 Guiteau.--A case of alleged moral insanity ....... ............................ .. 193 Guiteau.-A case of alleged moral in- sanity ........................................ 621 Guiteau, mental status 543 Guiteau, in re.-—Rep1y to J. J. Elwell, . D., .... ....................... .. 417 Handwriting in relation to pathology, changes in .................................. .. 566 Pa‘. 9. lm portance of a knowledge of insanity by general practitioners of medicine. 276 Influence of age upon the mind and body in relation to mental derange- ment ........................................... .. 220 Insanity from quinine ...................... .. 608 Management of chronic inebriates and insane drunkards ........................ .. Maniaco-uraemic delirium in renal aifections .................................... .. 439 Minor treatment ofinsane patients .... .. 675 Myxoedema—pachydermic cachexia... 14 N euratrophia.——The cause of inebriety 5 a clinical study ............................ .. 104 Othaematoma ................................. .. 687 Pathogeny or hallucinations in refer- ence to a case of voluntary psycho- sensory hallucination ................. .. Progress of psychiatry and neurology. 70 Reciprocal insanity ......................... .. 591 Reflections on the development, move- ments and transmission of mind .... .. 291 Rights of the insane ....................... .. 183 Sexual perversion, case of ............... .. 87 Simulation of insanity by the insane... 355 Some new experiments in muscle reading (thought reading.) .......... .. 175 Studies on the minute anatomy of the central organs of the nervous system. 236 Syphilis in its relations to progressive paresis ............. . .. ..................... .. 450 Syphilitic Gumma of the brain, case of. 190 Therapeutic value of cephalic and spinal electrizations ...................... .. 77 Traumatism in relation to insanity..... 646 Trifacial neuralgia, report of cases of.. 611 INDEX. v SELECTIONS. ‘ Page. _ Page. ANATOMY AND PHYSIOLOGY.—— (gaLINICAL 1P€YgHIAT1RY-_—C0fntlfl1l1ed. ' ........................ .. 488 emngea Were“ 0515 0 t e 99m‘ _ ‘étffiéi’i-aifcfiii-liti‘iir ....................... .. 486 we Gummy, abstract 911 ---------- -- 13:» Electrmphysiology of human nerves_ 489 Mental symptoms and ear disease ...... .. 697 MOl'fll .lIlS&I1.1l3y—-What 18 1t e - . - . . . - . - u u form bgdy ______ ________________________ 489 Moral “insanity ................... 311 Nerve endings in the epidermis ....... .. 489 Nonfaretlc forms of syphlhtlc 111' Optic nerve ..................................... .. 487 83111135’ ----------------- n; --------------------- -- 3 6 Rapidity of nerve force............... 490 Path019sypfathet0s1s‘, Schptz onghe, 138 Reflexes in childhood 490 “Phoblas’ and ihe“b<>hwlmlels- 473 Structure of the spinal cord. 487 P9,“ scfll'latinal insanity. ------------ ---- ~ Terminations of olfactory nerves ...... .. 707 Pummy 19011019211119 --------------------- -- ' ‘ P , Puerperal insanity. .......................... .. 511 CEREBRO HYSIOLOGX'“ _ Pulse among the insane ................. .. 474 Posterior lobes of the braln and the Restraint ................... ................. .. 3111 Seat of intellectualit¥¢~y~y~ - --------- -- ‘332 Senile progressive paresis ................ .. 138 Retreating foreheads and intellect 521 Sfenger on cel-ebralafl‘ectigns of Sight Suavitor in modo, etc ...................... .. 322 in general paralysis .................... .. 308 CLINICAL NEUROL0GY_._ Sudden recoveries from amnesia 697 Act of rotation ........................... 140 S5’ stematized .a1c.0h01i.c insanity """" " 138 Arsenical paralysis, cases of. .......... .. 315 Qr‘?ml_)el:atm"i.m l‘nrsa;.llt§i """""""""" '- Arthropathies in progressive paresis. 485 T1_cm?'n0n(f) P9"? “ilftzlon'z "" --- " (8 Bulbar lesions in ataxia ................. .. 701 , ,lansltory .mor_fi0m ‘'3 Pmsmmg" 6‘) Functions of the phrenic nerve _______ u 140 lransitory insanity ........................ .. 699 Hereditary transmission of artificially FORENSIC PSYCHIATRY.- produced lesions .......................... -- 32 Il Processo Guiteau ..... ..- ............... .. 129' Localized cortical atrophy, secondary NEUROTHERAPY._ to an extremity amputation .......... .. 483 A , f t, 706 . ‘ ' . .. 0‘ . - - a 0:10.10... . . . . e - s - . . . e e ~ . a. Myxoedema, case oi ........................ .. 139 AO'J“? .c‘mt‘ily mfnéguf-fla """"""" -- ,1 Note on the action of continued cup Ai1mint1_strat1%i£ho (‘c 312a 44o rents, studied from a physiological A tefa 10.118 0 e 001' m p OSP ‘mus stand-point .............. ............. .. 312 polspnmg """ """""" ". """"""" " 140 Paralytic dysphagia from typhoid .... .. 701 Amz‘mlla muscalla 1“ negatlve 1)’ PB- 48] Progressive total hemiatrophy __________ u 699 ixmtti’llfiatu'z .................................... .. 702 Reflex palmar emeses ____________________ n 321 r‘lIly. Ill 11 8 .......... .2 ...... .._ ........ ..: .... .. Sexual perversion ........................... .. 485 uipslcum enemata 1“ 09mm PUISOB- F6 Transient albuminuria as it Occurs Palm 0 11169,‘ ...... . ....... .... iél ticularly in children, andadolescents 023$)“ 1's“ P '1 911111991“ 014 ------- -- 481 in apparent health ........................ .. 484 'l‘rophoneurosis of the skin in tahetics. 484 ‘ Variola and vaccination in insanitym. 482 CLINICAL Psxoruarmn- Chronic iodoform psychoses ............ .. 311 Delusions and executive ability ....... .. 698 Early progressive paresis ................. .. 695 Eye lesions of progressive paresis. 474 Folie avec conscience .... ................ .. 137 Gout and insanity ........................ .. 309 Hemiatrophy of the face in a mono- mamac ........................................ .. 698 Insanity in a child ............................ .. 311 Insane from fear .............................. .. 696 Insanity and Addison’s disease .......... .. 475 Locomotor ataxia terminating in pro- gressive paresis......... ................... .. 696 Cure of a case of “rebellious neural- gia ............................................ .. Diabetes insipidus and central nerve lesion’. ......................................... .. 479 Excitation of Vascular nerve-centers. 477 Ether douche or lavcment tor local pain ............................................ .. 703 Gold bromide in epilepsy ................ .. 482 llydrobrolnic acid as a bromide sub- stitute ........................................ .. 705 Hyoscyainia in psychiatry ............... .. 478 Indian hemp in epilepsy .................. .. 482 Nerve stretching ......................... .. 707 Nerve stretching and temperature...... 481 Nerve suture and transplantation .... .. 704 Nicotine in tetanus ............ .......... .. 482 Paraldehyde.......... ......................... .. 704 v1 ' ~ INDEX. SELECTIONS. Page. ‘ ' ' Page. NEUROTHERAPY—CODfinued. Nnunornnmrr-Continued. Paraldehyde ................................... .. 705 Succus conii in chorea ..................... .. 706 Paraldehyde as an hypnotic ............. .. 707 Therapeutic use of the magnet ........ .. 479 Poisoning, case of .......................... .. 479 'l‘herapeutic value of nitro-glycerine. 480 Silver in locomotor ataxia ................ .. 480 Tonga, in neuralgia of the face ....... .. 482 Spinal lesions in ergotism ................. .. 705 Treatment of Meniéré’s disease ........ .. 706 . EDITORIALS. ALIENIS'I‘AND NEUROLOGIST ............. .. 714 “ Many are called, but few are chosen.” 494 Annales Medico-Psycholgiques ....... .. 500 Memory of Baron Munchausen re- Announcements ............................ .. 501 vived ........................................... .. 326 Aphasia and insanity ....................... .. 149 Medical management of hospitals for As others see us. (Louisville Med.News) 328 the insane, political changes in .... .. 715 Association of American Medical Edi- Michigan law as to wills .................. .. 711 tors ................................ ....... .. 329 Misconceptions of moral insanity .... .. 146 As others see us .............................. .. 492 Moral character in insanity ............. .. 714 Brass poisoning and insanity ......... .. 152 More light on Guiteau’s ancestry ..... .. 148 Center for the salivary secretion ....... .. 331 Narrow view of insanity ................. .. 151 Commendable religious journal 325 New Antipyretic Kairn ................... .. 501 Cortical sensory discharging lesions. 494 New England Medical Monthly ...... 501 Correction ...................................... .. 297 Other channels of audition .............. .. 498 Cotoin ...................... .. 331 Personal ‘liberty and jury trials for Coupling of irresponsibility with in- insanity ...................................... .. 495 sanity .......................................... .. 151 Persistent double consciousness ....... .. 151 Cure of a case oi epiiepsia . ......... .. . 152 Plea of insanity brought into disrepute 325 Dr. L. S McMurty ......................... .. 715 Power of vicarious nerve function .... .. 145 Gazetteer men ...... ..‘.., .................... .. 151 Premeditation as legal evidence of in- General functional neuratrophia ....... .. 330 sanity ....................... ........... 712 Good periodical discontinued .......... .. 152 Psychical effects of nerve stretching... 711 Gospel ot fatness, Dr. Clouston’s........ 500 Government’s tribute to the medical profession .................................. .. 147 Guiteau mania ............................. .. . 497 Guiteau verdict...... ........ ............. .. 713 Hammond prize .............................. .. 331 Higher education of medical men .... .. 330 Honor to whom honor is due ........ .. . 147 How the jealous public protect the insane ........................ ..- ...... ..... .. 3'29 Hypnotism ..................................... .. 496 insanity in hysterical women ........ .. 499 Intimidation and compassion in the cure of insanity ............................ .. 708 Journalistic ..................................... .. 324 Judicial psychology of the Guiteautrial 141 Kalaemia 'vs. Uremia... . 151 Kleptomania ..................... . . . ......... .. 330 Large brain ..................................... .. 151 Letters of the insane ..................... .. 327 London Medical Times and Gazette .... .. 498 Low temperature in insanity ........... .. 14S Lunatics at large, Dr. Curwen .......... .. 150 Malaria in skin diseases; a correction. 150 Public prejudice against the plea of insanity ...................................... .. 145 Recent insane asylum investigations“.- 491 Reign of the “ Ines ” in therapy ....... .. 323 Rep y to Dr. Elwell................ . 501 Rights of the insane ........................ .. 1413 Rights of the insane in Illinois ........ .. 709 ‘- Sane Lunatics.” ............................ .. 71! Sensitive cardiac nerves ...... ......... .. 500 Simulation of insanity....... .. . 496 Society for the protection of 152 Speciaiisni in medicine ........ .. . ...... .. 331 Stevens, Dr. Chas. W .................... .. 742 Style of men who read the ALIENIST AND NEUROLOGIST ...................... .. 324 Term imperative conception 33l- 'l‘hirty-seventh annual meeting of the Association of American Medical Superintendents .......................... .. 354 To the friends of the A LIENIST AND NEUROLOGIST ............................... .. 715 Trephining in a syphilitic ................ .. 499 'l‘ri-State Medical Society ................ .. 329 Yearning for higher medical education 149 INDEX. ' Vll HOSPITAL NOTES. Page. Page. A retired American superintendent..... 343 State Homoeopathic Asylum for the Central Lunatic Asylum (for colored Insane, Middletown, New York .... .. 725 insane), at Richmond, Virginia ..... .. 725. State Hospital for the Insane at Wes- Cincinnati Sanitarium ..................... .. 722 ton. West Virginia ........ ............. .. 721 Dakota Hospital ‘for the Insane, at State Hospital for the Insane, Warren, Yankfon ..................................... .. 729 Pa .............................................. .. 515 Dixmont, Pa, Hospital for the in- State Insane Asylum, Agusta. Maine. 727 sane ......... .. . ............................... .. 514 State Insane Asylum.at Cleveland. O. 723 Eastern Lunatic Asylum. at Williams- State Insane Hospital, at Tuscaloosa, burgh, Virginia“... ...................... .. 717 Alabama ................................ ..'..:. 724 Eastern Michigan Asylum .............. .. 334 State Insane Asylum, Jackson, LOlllSl- Eastern North Carolina insane Asy- ' ana ............................................. .. 716 lum .......................................... .. 724 State Insane Asylum, Stockton, Cali- First Minnesota Hospital for Insane, fornia .......................................... .. at St.Peter ................................... .. 722 State Insane Asylum, at Athens, Ohio. 719 Government Hospital for the Insane, State Lunatic Asylum, N0. 2, St. Washington, D. C ................ ..... .. 728 . Joseph, Missouri ......................... .. 719 Hospital for the Insane, Topeka. Kas.. 514 State Lunatic Asylum, Jackson, Mis- Illinois Eastern Hospital for the In- sissippi .................................... .. 720 sane, at Kankakee ......................... .. 716 State Lunatic Asylum. Trenton, New Indiana Hospital ........................... .. 514 Jersey ....................................... .. 727 Missouri State Lunatic Asylum ....... .. 342 State Lunatic Asylum, Columbus, S. C. 717 North Carolina Insane Asylum ..... .. . 718 State Lunatic Asylum, at Little Rock, State Asylum for the Insane, at 'l‘ope- , Arkansas .............. ................... .. 718 ka, Kansas ..... .., ......................... .. 728 “ The Retreat,” Hartford, Conn ....... .. 514 Second Minnesota Hospital for In— Western Lunatic Asylum,at Staunton, sane, at Rochester. ....................... .. 721 Virginia ...................................... .. 5 REVIEWS. American Journal of Neurology and psychiatry ............................. .. 351 American nervousness, Herbert Spen- cer ............................................. .. 351 Burr’s index to medical subjects ....... .. 171 Character and hallucinations of Joan of Arc ...... ........................... ..35l—_540 Clinical lectu‘res upon epilepsy ......... .. 169 Compensazioni Funzionali Della. Cor- texcia (,erebrale ............................ .. 730 Continental Magazine ..... ............. .. 739 Crime of suicide, and how to prevent its increase by legislation and other- wi e...‘ ....................................... .. 34S Disease of the Scythians, and certain analogous conditions .................... .. 16S Diseases of the nervous system.... ..... .. 539 Dr. Mann’s book on insanity ............ .. 73S ' Giornal de neuropathologia ........... .. . 166 Greisinger’s mental pathology and therapeutics ................ ............. .. 170 Hartford C'ouramf ...... .................. .. 170 Hand-book of medical electricity .... .. 540 Higher education of medical men, and its influence on the profession and the public ................................. .. 347 (How to avoid insanity ..................... .. 539 Insanity; its causes and prevention. 736 Insanity, its classification, diagnosis and treatment .... .. . ...................... .- 523 Insanity; its causes and prevention... 538 Introduction a L’Etude De’Electro- 'tonus des nerfs moteurs et sensitifs ehezl’homme ...................... .... .. 539 La psychiatric. la ncuropatologie e la scienze affini ............................... .. 540- Lecture on artistic anatomy and the sciences useful to the artist ...... 351 Luys ...... ................................... 527 ltledico-Legal Society of New York.. 169 M edico-Legal relations of insanity, etc. 352 Medico-Legal Journal ..................... .. 540 Medical education and regulation of practice of medicine in the United States and Canada ....................... .. 739 Naso-antral catarrh, and its treatment. 351 VIII INDEX. REVIEWS-Continued. ,/ Page. N ervousness .............. .............. .. 165 Order of disorder in mental diseases... 163 Physician’s daily record .................. .. ' 740 Proceedings of the Association of med- ical officers of American institutions for idiotic and feeble-minded persons 343 Reports of the insane hospital for the year 1881 ............................ ...... .. 153 tights of the insane, and their enforce- ment ............................................ .. 349 Scrofula and its gland diseases ......... .. 351 Shoemaker’s oleates ......................... .. 170 Sympathic diseases of the eye .......... .. 349 . Page. Sulla compensazioni Funzionali de] la corteccia cerebrale ........................ .. 537 ‘Transactions of the Colorado State Medical Society ........................... ._ 345 Truth and removal .... ................ .. 350 Treatise on insanity in its medical rela- tions ........................................... .. 531 Ueber die Summirung von lteizen in den sensiblen N r rven des Menschen. 540 Walsh’s physicians’ combined call- book and tablet .......................... .. 171 What shall we do for the drunloaroH Female Diseases Among the Insane. 115 the forms most frequently associated with insanity and by this means judge of their gravity and probable influence on mental disease already existent. Here, as elsewhere, on this subject, exact researches are wanting. Tuke1 says briefly that sexual anomalies exist in ten out of a hundred women. Kraft-Ebing found six cases of genital lesions out of nineteen; eight being normal, and in five the con- dition being unknown. Skeene,2 after the examination of one hundred and ninety-two insane women, found that but twenty-seven menstruated regularily and that utero- ovarian disease was frequent among the insane. After extended biographical researches, I can find no other contributions to the frequency of sexual diseases among the female insane. Autopsy reports are not pre- cise and differ among themselves. Veiser3 in ten autop- sies of the female insane (seven melancholiacs and three maniacs) found uterine and ovarian disease in seven cases. j. C. Howard4 found that out of one hundred and twenty-seven autopsies, there existed uterine and ovarian disease in twenty-four cases among which were uterine fibroids seven cases; cancer, two cases; large ligamental cysts, three cases; ovarian tumors, four cases; ovarian cysts, four cases. Hergt,5 on the other hand, has found that two-thirds of the cases coming under his observation, presented sexual anomalies. He has very properly included retroversions etc., but gives no details as to the type of mental disease or age of the patient. In the clinic of Mier- zejewski,6 I have examined forty-two insane women and three hysterics from nineteen to sixty years old with the following results: six, past the climacteric (aged forty-four to sixty-two years) presented no other change than senile uterine atrophy. Thirty-five of the remainder presented various types of sexual anomaly. L. Mayer has found that out of one thousand and twenty-five gynaecological Psychological Medicine. Archives of Medicine. February, 1880. Wuertemburger Correspondenzblatt. No. XL., 1860. Journal of Mental Science, 1872. Zeitschrift fur Psychiatric. Band XXVII. Biblioteka Medesinokaia. No. V., 1881. I 16 S. Danillo. cases, ninety were associated with mental alienation. My researches are in marked contrast with those of other authors, particularly Skene and Tuke. As to the result of the autopsies by Howard, Keiser and Hergt, it must be remarked that, even without taking into account the fact of their differing results, these can have but a very relative value, since the functional and slighter pathological changes must necessarily escape observation. Since the deductions from my own observations already cited must be made with some reserve from the limited number, I have resolved to augment this in order to make generalizations which would tend to define the question more clearly. In each case there was taken, the age of the patient; type of mental disease; physiological state of the female (virgin or not, births and miscarriages), form of sexual anomaly. The diagnosis was always made by touch and the speculum. The patients numbered one hundred and fifty-five; my researches in toto would there- fore cover about two hundred cases. The patients’ ages were between fifteen and seventy-five years. The meno~ pause had occurred in patients aged from forty-two to seventy-five years; sixty in all. One hundred and forty were still menstruating; of these, thirty-one were virgins, forty-one non parturient non virgins, sixty-eight mothers, of whom thirty-eight were primipara and thirty multipara. Of those who had reached the menopause, two were vir- gins, four non parturient non virgins, forty-four mothers (nine having had from eight to twelve children.) The vtypes of mental disease were: idiocy, one case; epileptic insanity, fifteen; hysterical. insanity, fifteen; progressive paresis, fourteen; chronic mania, thirty-one; chronic alco- holic insanity, two; secondary dementia, ten; melancholia, twenty-five ; melancholic furor of puerperal origin, five; acute mania, eighteen; acute puerperal mania, eight. The types of insanity in the patients past the menopause were: terminal dementia, twenty-eight; chronic mania, nine; progressive paresis, ten; chronic alcoholic mania, three; melancholia, ten. Female Diseases Among the [maze 117 Of these two hundred cases, one hundred and thirty- one presented diverse lesions of the sexualv apparatus. In the cases whose physiological functions were in full activity, the sexual anomalies presented were: Endo- metritis, with chronic metritis of the fundus, forty cases; twenty-eight being accompanied with cervical metritis and endometritis; twelve with some degree of ulceration. Chronic metritis diffuse of the fundus and neck existed in eight cases, and of the body only in four cases. Men- strual disorders in general (suppression or retardation) existed in eighty cases. These figures, however, are not exact, and have but a relative value. Uterine anomalies of position were found in forty-four cases; associated with endometritis in thirty-eight cases; and, still further, com- plicated with metritis in twenty cases. Six out of eleven cases of alterations of uterine position were associated with para, endo, and metritis; the others with chronic oophoritis. Perineal metritis of puerperal origin was found in four cases of puerperal insanity; four cases of vulvitis and seven of vaginitis were found, One case of puer- peral insanity was complicated by a large ovarian cyst. One case of acute mania had a large uterine fibroid. A urethral caruncle was found in one case of acute mania. Ovarian hyperaesthesia was found in eight cases (two of the right, two of the left). There were, beside the cases of senile uterine atrophy already noted, found in the menopause patients, six cases of chronic diffuse metritis; three cases of long standing perineal rupture and nine cases of senile endometritis. Sexual anomalies of the female insane are not much affected by the type of insanity. Out of forty cases of melancholia, five of puerperal origin, thirty-two presented different types of female disease. Out of forty cases of chronic mania, thirty-four were complicated by sexual disorders of the same type as those of the melancholiacs. The maniacs and progressive paretics presented about the same ratio. Out of thirty-eight cases of dementia on the other hand, but twelve were complicated by sexual I I 8 S. Danillo. disease; but of these thirty-eight, ten had passed the menopause. Ten out of eleven hysterical cases presented diverse sexual anomalies Of the one hundred and forty menstruating females, one hundred and twenty presented sexual anomalies. Of the sixty menopause patients, eighteen only did so. Insanity, before the menopause, eighty-four per cent. of the women present sexual anom- alies. While of those who have passed the menopause, but twenty-eight per cent present these. The menopause therefore exerts an influence. The result of my researches may be summed up as follows: The complication of insanity by sexual anom- alies is very frequent during the persistance of physio- logical functions. After the menopause such complica- tions are rare. Pregnancy and delivery exert an influence in the production of these anomalies and on their relation to the menopause. If the fact be admitted that there is an intimate rela- tion between the sexual nervous system and the central nervous system in the female, it will be readily seen that all irritation which radiates from the sexual organs may react strongly on an already affected brain. Here is found a very vivid illustration of the saying of Mauper- tius that infinitesimal causes frequently repeated, lead to important results. *On the Pathogeny of Hallucinations in Reference to a Case of Voluntary Psycho-Sensory Hallucinations in an Alienated Person?" By D. V. PARANT, M. D., PHYSICIAN TO THE ASYLUM OF TOULOUSE. {Translated by A. H. OHMANN-DUMESNIL, A. M., M. D., St. Louis] ' HE question of the nature and origin of hallucinations I is not yet completely solved. After the researches -»of Baillarger, of Brierre de Boismont, of Michéa, and of others; after the discussions held in the Medico-Psycho- logical Society; after the recent works of Drs. Despinej’ and Régisj; who have again called attention to this sub- ject, it will doubtless not seem out of order to make known a case which I have observed, and which, on account of its interesting details, seems to me to have a real importance in regard to this point. But first of all, .and in order to draw suitable conclusions from the case, ‘the state of the question must be briefly set before us. Numerous theories, which it is unnecessary to enumer- .ate, have been given on the origin of hallucinations. It is sufficient to remember that all have for a common object 'to determine the part which is played by the intelligence and that by sensation, in the production of the morbid phenomenon. And it is a fact that it is impossible to search elsewhere than in the abnormal modifications of the intellectual or sensory functions for the starting point .of hallucinations. Among all these theories, but two have any great weight. The most recent is due to M. Luys and M. .Ritti, who have skillfully maintained it. According to *From the Annalee Medico-Psychologiques, May, 1882. fDr. Desplne, Theorie Physiologique de l’Hallucination. (Annalee Medico- i'fsychologiques, Nov., 1881 ) , ,1 Dr. Regis, Des Hallucinations Uuilaterales. (L’Encephale, March, 1881.) 120 D. I/. Parant. them, hallucination is a purely reflex phenomenon, an act of cerebral automatism. They start out from the principle that the ganglia, centers of perception of the sensory organs, have certain powers in respect to the function of different organs. In the normal state, these powers are only evoked by the influence of external agents; in the morbid state, on the contrary, they acquire a complete spontaneity, and the false sensation is but the result of the abnormal action of the central ganglia. This explanation, which excludes all direct interven- tion of theintellectual element, has certainly the merit of being simple and easily understood. But it is open to‘ several objections, and, as we will prove further on by the case we will cite, it has particularly the fault of not being applicable to all cases of hallucinations. The other theory, the oldest and most generally accepted is that of Baillarger, and maintaining that the point of origin of hallucination is, and can only be, the intelligence. The imagination acting upon the brain, its organ, gives to the centers of perception a mode of acting analogous to that which they receive in presence of an impression really perceived by the organs of sense. But here present themselves, several secondary ques- tions which demand solution: How is the morbid phen- omenon produced? Does the intelligence always act independently of an abnormal modification of the sensory system? What is, in all cases, the share of the organs of sense? M. Baillarger has not taken up the study of these- different questions; he confined himself to establishing a fact, viz., the certain and primary intervention of the intel- ligence. The researches of Drs. Despine and Régis, which confirm the facts acquired by Baillarger, also complete them by determining the share which appertains to the senses and the intelligence. Basing himself upon cases of unilateral hallucinations, Dr. Régis admits that a hallucination may have for real origin a pathological modification of the sensory organ in The Pathegeny 0f Hallucinations. 121 which it is localized. “But,” says he, “the hallucination becomes really such only when the intelligence steps in.” And the reason that he gives for this is, that if it was not thus we could not explain why the same sensory lesions do not always give rise to hallucinations, still more, to the same hallucinations. Despite a case he quoted of a hallucinated person cured of his mental disease, at the same time as of a disease of the car, this argument does not appear decisive to us; for if the same sensory lesions do not always give rise to hallucinations, it is because there is not an absolute relation, that of cause and effect between the one and the other, and it is simply a coincidence. It is possible (and we believe'this is often the case) that an hallucination may be localized in a. certain organ of sense, on account of a former peripheral or central lesion of that organ. But it often happens that the organ in which the hallucination is localized is sound. The false sensation must arise somewhere else. The coincidence was none the less important to note, and, in this respect, the paper of M. Régis is of considerable interest. In the memoir of Dr. Despine, we find facts of the the greatest importance. These are relative to hallucina- tions of sight, which became double under the influence of an artificial strabismus, whereas they were single where the eyes were normal in position. Analogous to these are the cases communicated to the Société de Biologie, at its meeting of Dec., 17, 1881,. by M. Féré, concerning certain hallucination of vision in hysterical persons. M. Féré has proven that in these hallucinations, the object is really seen as a real object, and that it is seen with both eyes according to ordinary physiological laws. ‘Indeed, if a prism be placed before the eyes of the patients, these women immediately see two images, and the false image is placed in accordance with physical laws. There is in these facts the evident proof, first, that in dure hallucination there is a sensory and an intellectual ‘122 D. V‘. Parant. element; second, that, to ‘localize _ itself in a certain sense, the hallucination employs the aid of the organs of that sense; third, that the hallucination localizes itself when the organ is perfectly normal and consequently that .it is outside of the sense itself that we must look for the origin of the morbid phenomenon. Another conclusion to be drawn, is that M. Baillarger has well characterized hallucinations in denominating them “psycho-sensorial ” It remains to establish that the point of departure of hallucinations is really in the intelligence. We find irre~ futable truth of this in cases of voluntary hallucinations, similar to the one we will relate. To impress its full value to our observation, we must first exclude two species of voluntary hallucinations which are pretty common but very different from that which occupies our attention and which, not being properly hallucinations, cannot be taken into account. In the first place, there are persons particularly gifted (artists, musicians, painters) capable of so concentrating the faculties of the mind, that they succeed in mentally representing images, conceiving sounds, as if they saw or heard them in reality. Brierre de Boismont has studied cases of this kind in detail, and he makes this the start- ing-point of his theory of hallucinations, which, according to him, consist above all of a mental representation more or less vivid and clear. But the persons of whom he speaks are not really hallucinated, and only exercise in an extraordinary manner, their memory and imagina- tion. In the second place, there are patients capable of experiencing, what M. Baillarger has termed psychic hal- lucinations and that Michéa calls false hallucinations. Although in this latter case, the phenomenon is more really morbid than the preceding, the manner in which the individuals explain the impressions they experience, ‘ shows clearly that they are not true hallucinations. They have, they say, the power of hearing the language of one .soul to another, the language of thought; they hear The Pathogeny of Hallucinations. 123 internal voices; they believe themselves endowed with a sixth sense. The majority of the individuals who comprise the first group, are of sound mind and understand the nature of their impressions. In the second group can be little else but alienated persons who believe in the reality of what they imagine. The one and the other have in common the power, and at will, of easily passing into an imaginary world. The part played by their mental facul- ties, in this operation, is easily understood and it is evident that the intelligence only is concerned. But as these are not true hallucinated persons, they cannot aid in proving the intellectual origin of hallucinations. Qutside of these two groups of individuals, capable of having voluntary, false hallucinations, there are also others who can also voluntarily have real hallucinations, such as M. Baillarger calls psycho-sensorial, and in which the sensitive morbid impression is, without doubt, exteriorized. Michéa has no doubt of this, and others have with him asserted this. M. Baillarger, on the contrary, seems to think that in all cases of voluntary hallucinations, there can only be psychic hallucinations. Our case seems, in this respect, absolutely convincing; it is as follows: Miss X., aged thirty-eight was confided to my care in 1877; she had been ill for several years. She is attacked by a mental disease characterized chiefly by delirium of persecutions and by hallucinations. Since I have observed her, this delirium of persecution with hal- lucinations has always been most manifest; it consists in Miss X. believing herself to be the constant object of criminal attempts upon her person, from which she seeks to escape by a thousand different ways; at one time she remains motionless for hours against a wall, the legs tightly closed; at other times she wishes to sew her skirts and dresses. At night she accumulates bed-cloth- ing. The women who approach her are men who have designs upon her virtue. Men are naturally held in greater suspicion; a few, whom Miss X. names, have 124 D. V. Parant. gotten into her bed at night; she has felt and touched them, and details their attempts against which she pro- tests. Miss X. has, besides, hypochondriacal ideas. She often believes her intestines to be stopped up, and is ceaseless in her demands for purgatives. Every moment she com- plains of ailments which are purely imaginary. The hallucinations are numerous and almost incessant; she ex- periences all those which torment the most ill of alienated persons; revelations, menaces, suggestions, future or distant voices coming either from buildings or caverns which she believes exist under the house she occupies and in which she hears the groans ‘of unhappy victims, the members of herfamily, etc. What she writes, like what she says, shows the multiplicity of her delirious ideas. The follow- ing are two interesting extracts: October, 1877. Since the ninth of this month, I have been frequently told, at the extremity of the walk, the reason of my sojourn here, as well as of my companions. We are all subjects of the bulls of St. Thomas, according to which the State affords temporary imprisonment; my time, they say, is one hundred and six days. It is added that it ought not to have been imposed upon me as a great example, having preceded them; but the people of the city had to be satisfied. Consult upon this the code on the different articles of examples, bulls, police regu- lations and one hundred days and more. May, 1879. I certify that a sensible diminution of the menses having persistently declared itself since Sept 2, 1878, that of this month really makes me fear a great coagulation in my bowels, and perhaps an accident lead- ing to pregnancy. To destroy this act of suffering, I should have remedies reserved by the civil laws, to which I am entitled. Here I am deprived of the inviolability of my residence. For the laughter and conversations in the panels, I am all open. The short extracts depict well the mental state of Miss X. But it is not only as a persecuted and halluci- nated alienated thatI wish to show her; in this she resembles many other persons. What constitutes an The Patnogeny of Hallucz'naz‘zons. I25 interesting peculiarity of her hallucinations, what distin- guishes her from the mass of alienated, is that Miss X. spontaneously excites some of her morbid sensations, as we shall see. She has complaints or requests to make; she comes to us to make them known. Generally, the answers she receives do not satisfy her. Then she goes to a locality which she prefers, either near the course of a streamlet, under a wall or near a window with closed blinds, more rarely behind a door. She strikes several small blows to attract the attention of invisible interlocutors; after wait- ing a few moments, she is informed that they are there, and the conversation begins. “Major,” says she, (she is most frequently engaged with majors), “I have asked such and such a thing and I have been answered such and such a thing. What do you think of it?” A pause, during which she listens; she speaks again, becomes silent, recommences; and after this performance has lasted several minutes, she comes and tells us that the informa- tion she has received does not agree with my words and that We ought to let her free to act otherwise than we permit. At other times she consults her majors because she is told to take food which does not suit her; to work or obtain something which is disagreeable to her. Sometimes, whilst peacefully sitting among other per- sons, if anything displeasing to her occurs, she suddenly rises, goes to the center of the garden or near the wall, calls in a loud voice, listens, speaks and comes back seating herself, saying that the majors disapprove of what occurred. No one about her mistakes that which she experiences, and it is impossible, for the patient, to doubt of the reality of these pretended conversations which she has caused. She is undoubtedly in good faith, as her attitude shows. Here is an extract from vone of her let- ters, proving her sincerity: “Yesterday, towards ten o’clock in the morning, gz'm'ng news of myself 1n one of the conchas (sea-shells) of the yard, I heard the major observe that the first substitute 126 D. V. Parant. is slow or powerless to obtain my release. I sent at the to]? of my voice this question to the grating;:._..-"Do the officers refuse an escort, or the prefect his 'fufHderIingSP Then the major answered and informed me that": it would require two sergeants of the sword and not assessments. At twelve a fife sounded at the gate of the walk, but did not approach that one which I was knocking to show my presence. * * * Here is the maul with which I have struck nine times the neighboring gate of the town-office, where Majors Pezeux(?) and De Kers(?) are to hear my demand in order to obtain my release, indefinitely deferred, as soon as possible; it is at eight, twelve and two that I make my demands.” To establish beyond doubt that it was with true vol- untary hallucinations that we were concerned, that is, with psycho-sensory and not with psychic hallucinations, we observed the patient with the greatest care, and this is what we found: The voices which she hears in the conversations which she starts, belong to several different persons; ordinarily she designates two majors, as we have seen, under the fantastic names of Pezeux and Kers. The one has a graver voice than the other. When she does not interrogate them directly to obtain advice from them, she leaves them at times; then their voices are confused, like a murmer, and their speech only becomes clear when she speaks to them. At times, when interro- gated, they do not answer immediately; they commence to converse in a low voice, as if to prepare a concerted answer. Then the patient does not hear what they say to each other. In the beginning, she only heard them behind a wall, behind the blinds of a room, and she had had to go and speak to them where they happened to be. This is yet, ordinarily, the case; sometimes she can hear them murmer, speak in a low voice near her where she may be; and she need not move in order to question them. The patient very positively asserts that she hears with her ears, and not mentally nor by the aid of any extraordinary sense. It is very evident that this hallucinated patient presents very clearly the power of having at her will false auditory The Pathogeny of Hallucinations. I27 sensations, and of making herself answered by voices she believes she hears in sentences complete enough to con- stitute an entire conversation. She believes in the reality of what she hears, and does not admit that she is hallu- cinated. She differs a great deal from the other alienated, who are only passive in the presence of the morbid phenomenon, and who do not hold coherent conversations with their invisible interlocutors, or, at the least, do not provoke them and do not seek after them. She plays an active part, and takes the lead, evidently, in the produc- tion of some of her delirious ideas. These provoked hallucinations, and willed by her, are evidently produced under the following conditions: The patient unconsciously formulates to herself what she desires or wishes. In this frame of mind, she questions her majors, who give her answers in accordance with the preconceived ideas. The answers, previously prepared, shape themselves as soon as the question has been made, and, as a consequence of the morbid conditions, become a true hallucination. In all that has been produced, there is certainly a primordial intellectual operation, a manifest influence of the imagination or the placing in activity of the centers of perception. If, in spite of the clearness of the fact, it were neces- sary to demonstrate that the sensory system only acted after the intelligence, the proof should be found in the nature and variety of the answers, of the words heard by the patient. The abnormal vibrations of the sensory system are of themselves impotent to produce such a diversity, and can only originate among false sensations, uniform sounds, or confused sounds, or at most few words, and indefinitely spoken. This is generally the case with most hallucinated in whom a menace, an insult, a short phrase or one or two words often repeated constitute the hallucination. We will not disguise the fact that there is here a combination of operations and modifications difficult to follow. We could, doubtless, in order to explain them, employ the ‘128 D. V. Parant. formulas given by Dr. Despine in the work we have mentioned. We could say with him that the centrifugal nervous activity has carried on the cerebral excitation, creator of the idea, first to the sensitive ganglion, where this idea has been made sensible, and then to the external organ of sense, which has been impressed as if by an extraneous object. But this centrifugal nervous activity is as yet but a hypothesis. We prefer to limit ourselves to a recital of the fact, where range is incontestable, that is, the existence of psycho-sensory hallucinations, volun- tarily produced by the person hearing them, and in which the imagination, the thought, has elaborated the elements of the morbid sensation before it has become real and sensory, and before it has “exteriorized” itself. Depending upon this acquired truth, we are led to recognize that it is not possible to see in voluntary hallucinations the result of a simple automatism, or the bringing into play of the reflex properties of the cerebral cell. From which it follows that the theory of automa~ tism is imperfect, as not being applicable to all cases. On the other hand, we find there a complete confirmation of the conclusions of M. Baillarger, that hallucinations produce themselves from within without; that is to say, are conceived by the intelligence before being localized in this or that organ. We will make but one reservation to these conclusions, and it refers really more to a word than to a thing. M. Baillarger, speaking of the conditions necessary to produce hallucinations, says ‘that there must be “the involuntary action of the memory and of the imagination.” Would it not be more exact to say the “unconscious action?” In our case, we see a patient who has hallucinations excited and willed by herself, but who has no conscious- ness that she wills them. She spontaneously transforms into hallucinations that which is but the expression of her thought and of her will, but who does not account to herself that she thus has hallucinations. She voluntarily T/ze Paz‘lzogeny of Hallucinations. 129 rexercises her mental :faculties, but this exercise is entirely 'unconscious. The conclusions to be drawn from this note, and the .case which forms its subject may be summed up in the .following manner: The senses, diseased or sound, have, .each one in its own regard, a certain share of action in 'the production of true hallucinations. There are cases of voluntary psycho-sensory hallucin- .ations in the insane, which, in their production, demonstrate without doubt the primary original influence of the intel- .ligence. SELECTIONS. FORENSIC PSYCHIATRY. lL PRocEsso GUITEAU. Notes by Prof. Arrigo Tam- -assia (Revz'sz‘a Sperz'menz‘ale clz' Frenz'alrz'a e di lllea’z'ez'na Legale, Reggio Emilia, Italy, Anno VIIL, Fasciolo lII., :I882).——The Trial of Guiteau, by Professor Tamassia.——— The so-called human justice, but more particularly that (‘of America, will never more have the opportunity of becoming overheated by that swaggering vehemence .-of a few months back, which it exhibited towards that most offensive intrusion-the forensic medicine of mental .alienations. The hangman from New York has elegantly I-truncated its every apprehension and silenced every clamor. “Over the cadaver of Guiteau, now are silent the ignoble potentates of the ‘streets, the unblushing presumptions of American legists, the inhuman fiscalism of certain doctors, gifted with opportune knowledge and hungry brains, who Ihave made of this trial one of the most shameful pages of modern judicial history. These parties and persons of ‘the same order, who dreaded the flooding of America with the piteous doctrines of Europe, can now breathe "tranquilly and console themselves with the malign com- placency of having escaped a grave peril, and now that there is no further danger, they may boast of having 'icordially applauded and assented to the capital punish- ment of Guiteau, thus displaying a symbol of their .~sympathy for his illustrious victim. Silence now reigns, I 30 Selections. and, perhaps, those who with so much frenzy called for the blood of the culprit, have forgotten their heroic efforts- of those days. But that science which, in the name of right and truth, contended so manfully against the pop- ular fury for the life of the assassin, does not surrender to- the victory of violence. It calls for new light on that tragedy, and it appeals no longer to the voluble responses- of citizen magistrates or of the political press, but to the minds and the hearts of honest men; to the authority of those enlightened ones, whose solitary judgment is by far more precious and decisive than the quasi automatic unanimities of many deliberating assemblies. Behold now‘. many of our colleagues who have taken, as experts, a less part in this memorable trial, are to the front with relations and new informations, intent on presenting the psychological problem to the tribunal of history and of science. Some pessimists may tell them these posthumous protests are but the whinings of discomfited personal ambition; that they are but bestirring themselves to raise again a wave now dead by scarifying, after having failed to demolish, the respectability of a judgment so solemnly pronounced. Some, too, of those jurists with placid stomachs, who made merry over the responses of the accused, and in their cross-examinations diverted them- selves by casting nets to entangle the experts with riddles and charades, may continue still to laugh at every severe objection which may now be made to the commotions excited by them in the audience. The whole of this- surpassingly good trial may now dine with comfort; “write as you will,” say they, “but your Guiteau will not be resusciated, and your ink will certainly not obliterate the mark of infamy with which we have branded him.” We concede, with all good grace, these consolations to these gentlemen. But it is not to them that the protests of science must be directed ; they would believe they perform a loyal duty by rehearsing with unabated enthusiasm their great deeds, even though the problem of the mental state of the accused should, by new studies and new documents, be established by the very highest grade of evidence. Our protests are, on the contrary, destined for that portion of the public who, not sharing in the theatric emotions of a State trial, and not bending to the tumult- uous despotism of party politics, are able to distinguish where science commences, and where sophistry and ignor- ance obscure. It is from this sane part of public opinion, Selections. I 31 from the response of men of true science, that we are to expect the service of inducing a salutary reaction in the public mass by well convincing it that the most arduous problems of science must not be brutally solved by the passions of the street, the suggestions of the interests of the moment, or the instinctive perception of the ordinary sense of the vulgar crowd. And we of the Revista, who endeavor ever to hold high the rights of science, cannot remain inert in the presence of these publications, which review and analyze all the phases of this strange case. We treasure up all the materials which our confréres of America are sending to us, and we have studied to draw from them a faithful history, which we shall offer to the judgment of our readers. To us it is not a question bedaubed with politics as it was in America; it is a question abstractly scientific. Its echo and its example will not, we trust, be without effect on that fraction of our public, and of our magistracy, who, not being American, will regard with less evil eye the fact of the gallows and the galley have not been adopted with any certain liberality as the fittest expedients for practically defining, in certain intricate cases, the prob- lem of responsibility. In the meantime, our readers shall see the biographic records of Guiteau hereafter; the trial, the expert researches, the autopsy and our impressions. Remarhs hy the T ranslator.—-“ To see ourselves as others see us,” the Scottish poet said, “would from many a blunder free us.” But who, at such a cost, would choose to shun the danger? Were we sure that the view taken of our words and acts by others would, at all times, and in all circumstances, be clear and free from prejudice or misconception, then might we, with better trust, defer to the opinions of our neighbors or friends. Professor Tamassia, in the preceding very eloquent preface to his thesis on the case of Guiteau, has, with more than an ordinary degree of frankness, indicated to the American people, but more especially to the members of the legal and medical professions, his estimation of their moral and intellectual attributes. Regarding, as we do, everything coming from the pen of this illustrious Italian, as well meriting serious consideration and sober criticism, we feel it to be our duty, alike towards him and our own fellow- countrymen, to offer a few observations on the more salient, and, perhaps, we might not unjustifiably say, the less generous passage of his preface. I 32 Selections. We might, in due order, begin with his first words, in which he bespeaks the contempt of his readers for “the so-called human justice, and more particularly the American,” but we deem it better to give antecedence to a subsequent passage, to which, as a member of the specialty of alienism, and “particolarimente l’Americana,” did we not object, we should have good reason to feel that we have been very indifferent to the good fame and professional competency of our confréres. “Sul cadaver di Guiteau,” writes Prof. Tamassia, “tacciono ora quelle ignobili prepotenze della piazza, quelle spudorate prosunzioni dei legulei Americani, quell inumano fiscalismo di certi medici a coscienza opportunista ed a cervello digiuno, etc." Now, as to the ignoble potentates of the market squares or the public streets, we do not feel called upon to shed much ink or many tears. We believe that between our American roughs and the Italian fittfanti there is no very wide intellectual or moral difference. Indeed, considering the fact that the population of our American cities so largely consists of the outsweepings of the nations of Europe, it would be more than marvellous that our “ignoble street potentates” should have left behind them all their faults and follies, all their ignorance and long inherited mental inertia; so let them pass, and so, too, do we pray let pass the “shameless presumptions of American lawyers,” for, poor things, their morality, as everybody well knows, is a thing of pure conventionality, their function is that of reluctant lingual gladiators, and they are as like their brethren of the old world as two black sheep are like each other. But now we come to something that stings more deeply, something that wounds so lethally that we cannot avoid crying out in the dying words of the professor's illustrious countryman, tu quoque Brute.’ We are not sufficiently master of idiomatic Italian to have felt justified in rendering into English Vulgate the words “inumano fiscalismo; we might be unjust to the writer did we interpret his words by our common phrase, “the reckless love of gold,” and perhaps even more so, should we turn them into the classic American, "worship of the almighty dollar.” These terms, however, would be more intelligible to our readers than the two polysyllables of Prof. Tam- assia, but they would be so repugnant to professional decorum, and so insulting to the medical profession of America, that we would rather fail in exact translation Selections. I 3 3 than believe that they expressed the deliberate conviction of the author. Again, we must instance the harsh expression, “coscienza opporz‘nnista.” Whether we have incorrectly softened these words by the English “oppor- tune knowledge” we do not feel certain; they certainly, without any detectable perversion, might be rendered opportune conscience, or in our Anglo-Saxon every-day tongue, convenient conscience, and this commodity would, we think, better harmonize with the Professor’s “ceroello cligizmo,” for a starved or fasting brain would better con- sort with a convenient conscience than with opportune- that is ready to order—knowledge. But soften it or disguise it as we may, and as the warmest admirer of the distinguished Italian medico-legal jurist might feel constrained to do, we find it impossible to withhold our disapproval of the language of Prof. Tam- assia towards the medical experts who testified to their belief in the sanity of Guiteau. We are all liable to error; we neither say they were in error, or the contrary; nor whether their testimony was Well founded or ill founded. We have known several of them for many years, and have learned from year to year to esteem them more and more, and we cannot, even from a far off foreign land, bear to see their well-deserved good fame sarcas- tically assailed. Three or four years ago, when the distinguished Tam- burini closed his introduction to the report of the com- mission of experts, who were appointed to examine the Would-be assassin of King Humbert, he used the following language: “Noi per altro albiamo la coscienza di avere in tutto e per tutto adiempieto al nostro dovere.” We never, for a moment, doubted the sincerity of that highly accomplished alienist, and even had we believed that the I finding of the commission as to the mental condition of Passanante was erroneous, we would not have been tempted to insinuate that their decision was tainted by the inhuman fiscalism of hungerea’ brains, or the plasticity of accommodating consciences. Prof. Tamassia never, so far as we are aware, wrote a line in censure or even in mild criticism of that finding; and yet we honestly believe that between the cases of Passanante and Guiteau there were so many features of resemblance as to constitute a parallelism which might have prescribed to any prudent Italian censor the expediency of eschewing, not alone all verbal severity, but still more, all sarcastic allusions to the I 34 Selections. action of his foreign brethren. Indeed, we confess our- selves unable to evade the conclusion that Tamassia’s rhetorical gun is a double-barreled weapon, or, if single, it was either double shotted or crooked enough to carry round a corner. Neither our time nor the space at our command permits us to enter on the demonstration of the parallelism between the mental characteristics and the crimes of Passanante and Guiteau; nor do we feel at all disposed to retort on our esteemed confrere by instituting a comparison between the manifestations of public senti- ment or popular denunciation, which were alike displayed in Italy and America, in connection with the two assassins. Right heartily could we sympathize with the illustrious Tamburini when he felt himself constrained in alluding to the difficulties encountered by the Passanante commis- sioners, to use the following language: “ There certainly was not preserved to the experts, that calm and serene surrounding which is necessary to those who should judge impartially, according to science and conscience(?); on the contrary, pressure was brought to bear on us from all quarters, that we should, with all speed, complete our task; the newspapers and the par liament, in which the voice of a minister styled us a Psy- chiatric Academy, vied with each other in pressure on the magistrates and ourselves. Yet surely, if there ever was to experts a position of the most grave responsibility, ' both before the tribunal of justice and in the face of the entire nation, this was one; and if ever there was a case in which it was important to analyze and accurately to weigh every fact, to sever appearances from realities, exter- nals from inmost psychological mechanism, this was one." We content ourselves with the citation of this one passage from the eloquent preface of Prof. Tamburini, which is in truth almost throughout a continuous lament over the flagrant indecency of both the general public and (which is still worse) of the public officials, in their relations with the prosecution of Passanante. With all becoming deference to the eminent Prof. Tamassia, we now venture to say, that if the trial of Guiteau has been as -he has characterized it: “ one of the most shameful pages in modern judicial history,” it has the honor of not stand- ing alone; and if Prof. Tamassia has seen, in the exhibi- tion of popular passion evoked on this side of the Atlan- tic by the crime of Guiteau, anything more scandalous than has been (faithfully, we doubt not,) recorded by Selections.‘ I 35 his worthy friend Tamburini,‘ in connection with the case .of Passanante, we can merely say that the atmosphere of Italy is less clear than we have heretofore believed it to be. We would now ask, whether, had the Passanante commission found the offender insane, the Italian street potentates would have bowed deferentially to their decis- ion? “Fortunately,” wrote Prof. Tamburini, “the judg- ment (whose?) was such as to tranquillize completely the public conscience, and to expose the wrong of the sus- pectors and distrusters of psychiatry, who suddenly, as if by magic, ceased to clamor.” After all, human nature is as like itself in Italy as it is in America. CLINICAL PSYCHIATRY. ABSTRACT ON MENINGEAL TUBERCULOSIS on THE CERE‘ IBRAL CONVEXITY. By W. Julius Mickle, M. D. Medical Times and Gazette, London, April 15, I882.—The cases are reported partly for the medico-legal interest. The principal points in the first case were briefly these: In a patient with advanced pulmonary phthisis we find life somewhat abbreviated by the oncoming of cerebral symptoms due to extensive meningeal tuberculosis of the convexity of the brain, with incipient inflammation. And we particularly note the short duration of any cerebral symptoms, and their slight and ambiguous character, notwithstanding the considerable lesion of the brain. There is no reason why death might not have been brought about in a similar way early in the course of the case; and it is evident, therefore, that under certain contin- gencies, such as may, and will, every now and then occur in practice, cases of this kind lead to more or less obscurity as to the manner vand cause of death, and to possible medico-legal enigmas. The patient, a soldier, aged 41; formerly maniacal, latterly somewhat demented; the subject of chronic pul- monary phthisis, and of occasional attacks of bronchitis and of diarrhoea; became bedridden eleven days before death. Four days before death he was feeble, emaciated, and his pulse rather slow. Thus he remained until the day before death, when cerebral symptoms were. first noticed. For on this day he was mentally dull, apathetic, drowsy; paid but little attention to his surroundings, or I 36 S elections.» to questions put, or to his comforts, wants or inconven—- iences; when addressed, was slow to understand, and: brief, or even irrelevant, in his replies. Swallowing was‘ slow and difficult, and some hiccough was noted. Tern; perature, 98°. No perceptible spas-m or paralysis. From.‘ fraction of minute to fraction of minute the pulse rate" varied from 78 to 96; and the respiration, 26 per minute, was of a modified Cheynes-Stokes’ character. On some occasions there was only an ascending and descending; respiratory rhythm; but at others, a distinct apnoeal period,.. though only a brief one, was added. In the latter event, the respiratory period consisted of five or six respirations- gradually increasing in fullness and loudness, and it alter- nated with a recurrent pause in breathing, which com- pleted the respiratory cycle. At first, the pulse was» rather slower during the respiratory period; subsequently, not. Later on, the respiration was more regular; but, still later, it reassumed the Cheynes-Stokes’ form. Left hand and feet, oedematous. Urine, non-albuminous. At the necropsy, the meningeal veins were turgid over the posterior upper aspect of the cerebrum. Numerous minute whitish tubercular granulations existed in the pia- mater over the upper and external surfaces, or the con- vexity, of both cerebral hemispheres. These were more numerous over the right hemisphere, where also, at points, the granulations had coalesced into larger nodules, which,.. while adherent to the pia-mater, were partly embedded in the cerebral gray cortex, the surface of which was left eroded at these points on removal of the meninges. The right second and third frontal, posterio-parietal and supra-- marginal gyri were those mainly thus affected. Brain flabby; slightly wasted. Turbid serosity in lateral ven- tricles; and some softening of fornix and corpus callosum.~ Phthysis pulmonalis; bronchial lymphatics tubercular; slight tuberculosis of kidneys, and tubercular ulceration of the small intestine; old pleuritic, perisplenitic and peri-- renal adhesions. The mental symptoms supervening on the meningeal tuberculosis were not distinctive. The expiratory condi--- tion was an exaggeration of that sometimes occurring in meningitis of the base. Here the so-called cortical motor" zone was somewhat affected, and yet without decided. motor symptoms being observed. The supposed cortical. visual centers were considerably affected, but without- prominent visual symptoms. Selections. I 3 7' The second case was that of a soldier, aged 31 ; hallu- cinations of hearing and of touch; listlessness, failure of memory, and of attention, and slight depression existed.~ Pulmonary tuberculosis, onyxitis, and finally, slight pleurisy, preceded death. For two or three days before decease he had “ pain all over,” and on the last day of life was slightly delirious and loquacious. Necropsy-Moderately firm, whitish granulations over the posterior part of right angular gyrus; yellowish nodules-- just above middle of right ascending parietal gyrus, partly embedded in the gray cortex, some being buried in the fissure of Rolando, and all appearing together as an irreg- ular mass formed by the fusion of several nodules, which were caseous internally, and connected by firm fibroid tissue. On the under surface of the right occipital lobe the membranes were the seat of numerous, almost confluent, dirty-whitish granulations, which were more or less caseous, and formed an irregular layer, beneath which the convo- lutions were softened, pulpy, and of dull-red hue. Scat- tered granulations were seen on the under surface of the right temporo-sphenoidal lobe; similar granulations also existed over the posterior half of the external surface of this lobe, and a state of gray cortex, such as is just de- scribed.—Tuberculosis of lungs and pleura; recent pleurisy on right side. Old plueritic and perihepatitic adhersions- on Caseous abdominal glands. Yellow tubercle of spleen, and of left kidney. Here the tuberculosis was of the convexity and pos- terior base of right cerebral hemisphere, limited to the distribution of certain arteries. Mental symptoms due to tuberculosis were of short duration, and motor absent. Here also, with early and long-continued auditory and tactile hallucinations, tuberculosis finally befell part of the supposed right cortical auditory center, and parts adjoin- ing the supposed right tactile center; while the right angular gyrus and part of the right (so-called) cortical motor zone also suffered, but without the production of obvious visual or motor symptoms. FoLIE AVEC CoNsc1ENcE.—Under this title Dr. Cotard (Arc/zines a’e Nenrologie, September, 1882) discusses a form of insanity which “is characterized by the fact that the patient reflects on the sensorial and psychical troubles of ' which he is the victim, and who, after analyzing them, recognizes their morbid nature.” It is an affection of slow growth found in hereditary cases, manifesting, as a. I 38 Selections. rule, Morel’s signs of degeneracy. The cases cited by Cotard are really cases of persons dominated by imperative conceptions, the erroneous nature of which they recog- nize; but mingled with these are cases reported by himself, in which the patient, already insane, fears to become so, but does not recognize his already existing insanity. Two progressive paretics had ideas of suicide and morbid fears. One case of the same psychosis had a dim memory of his expansive delirium. During a remis- sion, his folie avec conscience is, as a rule, simply the presence of imperative conceptions in persons hereditarily degenerated. The metaphysical mania, or griibelsacht of the Germans, would find a place here, and the various morbid fears mentioned in the july number of the ALIENIST AND NEURoLocIsT. - Psychologically, Dr. Cotard’s view is rather redundant and tends to complicate psychiatry. Imperative or dom- inant conceptions, or morbid fears, occurring in the insane would sufficiently express this condition. ScHUTz ON THE PATHOLOGY OF ATHETosIs (Prager Med. l/Voch., I882, Nos. 3 and 4) relates a case of athetosis of the fingers in a man whose right extremities had become gradually paralyzed. At the necropsy, he found softening of the left optic thalamus and also of the head of the caudate nucleus. The internal capsule was involved, especially at the junction of the middle and anterior thirds. The posterior part was intact. In a second case there were general convulsions, followed by feebleness of the left half of the body. Later on, there were involun- tary spasmodic movements of the hand and foot. He ultimately recovered. Schutz thinks that in this case there was an inflammatory focus in the right hemisphere, which, perhaps, involved the same parts as in the first case. SYSTEMATIZED ALconoLic INSANITY.——DI‘. Parrel (Annales Medzco Psychologiques, July, 1882) describes a case of chronic alcoholic insanity, which, like many of such cases, is accompanied by systematized ‘delusions of marital infidelity. The patient acting on these delusions attempted to kill his wife and threatened her supposed paramours. Like many of the cases of secondary monomania, the case terminated in progressive paresis. SENILE PROGRESSIVE PAREsIs.--A form of progressive paresis occurring in old age has been discussed by Seppilli .and Riva, and its pathology outlined. To the clinical Selections. I 39 history of the subject, Dr. Rey (Annales Medico Psycho- logigues) contributes a case: A man seventy years old was attacked by progressive general mental enfeeblement which occurred earlier than is usual in progressive paresis, NEUROLOGY. A CASE OF MYX(EDEM_A was reported by A. McLane Hamilton, M. D., at the Dec. 7th Meeting of the New York Academy of Medicine, of which the following is an abstract: _ The patient was seen by him in September, I882. She looked anaemic and badly nourished. The tissues were swollen and doughy to the touch. The special senses were impaired and she was morose and inclined to seek solitude. The swelling was greatest in the face, though pretty generally diffused. The skin was the color of white wax, and shiney like the surface of morocco. Her hair was thin and dark. Her temperature subnormal, and the thyroid gland had disappeared. Her pulse indi- cated a condition of increased arterial tension. She had numbness of the hands and feet, and complained of a metallic taste in the mouth. Her gait was clumsy like that of the general paretic, though improving by exercise. The tendon-reflex was greatly exaggerated. There were marked indications of mental failure. The urine, on examination, contained sugar and earthy phosphates, but no albumen or casts, specific gravity I022. The oedema pitted slightly after prolonged pressure, though the tissues quickly returned to the general elevation. The author accepts Hadden’s theory of the origin of myxoedema, that the deposit of mucin depends upon lym- phatic obstruction and that the mental symptoms are due to the condition of the brain produced by lesions of the sympathetic system. Dr. Hamilton believes the trophic changes to be due to disturbance in the lateral and pos- terior columns of the cord. It probably depends upon a lesion primarily of the bulb, with secondary extension to the postero-lateral columns of the spinal cord and the spinal sympathetic ganglia. Cases with muscular atrophy and deep tissue- changes are rare, and when so found probably indicate degeneration of the multipolar cells in the anterior horns. Renal disease is not the cause of the malady, but the result. 14o Selections. THE ACT OF RoTATIoN,—-Dr. Bechterew (St. Petersbnr~ g'er Med. Wochenschrift) arrives at the conclusion that not only injury to the middle and posterior cerebellar‘ crus, and deep injufy to the medulla oblongata, produce rotation, but that lesion of the inner part of the crus cerebri in its whole course, from the thalamus to the pons can generate it. When the inner part of the crus cerebri is injured, the rotation is about the inner side, while a lesion of the external layer of the crus cerebri causes rotation about the side of the injury. The rotation about the long axis is produced through a lesion of those fibres which go from the cerebellum through the upper part of the crus cerebri to the corpora quadrigemina.—-Chicago .Med. Review, Aug. 18th. FUNcTIoNs on THE PnRENic NERVE-—MM. Henocque and Eloy’s experiments on animals show that afier removal of the roots of the phrenic nerve, the immediate consequences were—Ist. Extensive contraction for some moments of the inspiratory muscles; 2, the cessation of diaphragmatic contractions on the side operated upon; and 3rd, a very feeble respiratory movement of the thoracic wall on the same side, caused by the action of the inferior intercostal and the accessory elevators. Now-- one degeneration has been observed in some cases at the end of a fortnight or more; respiration of the side operated upon recommenced afterwards, but was feeble in comparison with the healthy side; in some cases there resulted difficulty in phonation.-Medical Press. Cin. Lan. and Clinic. NEURO-THERAPY. ALTERATIONS OF THE CoRD IN PHOSPHOROUS PoIsoNING. Danillo’s researches.—-I. In acute poisoning, the central nervous system contains deposits of pigment of haemic origin. This has heretofore not been noted. 2. Large doses of phosphorous give rise to a central myelitis along the whole length of the cord, with the formation of extravasation and pigment. Smaller and repeated doses give rise to a diffused myelitis, affecting‘ the gray and the white matter. EDITORIAL. The Judicial Psychology of the Guiteau Trial. a-—When a simple-minded colored divine, despite the verifi- cations of astronomy to the contrary, declares that “the sun do move,” even though the unscientific assertion carries conviction to an unlettered congregation of sable hearers, no great harm is thereby done to science; or even when a great church hurls its anathemas against the heretical teachings of the science of the universe and compels a Galileo to recant, truth is simply but moment- arily “crushed to earth to rise again,” for the world does move despite the opposition of either church or state, and opposition from both is but little less futile in the long run than the antipathy of the faithful jaspers, who read the scriptures literally, to the disparagement of true science. And even when the learned judiciary, whose province it is to interpret rather than to make pathological laws, as it likewise is its province to determine what muni- .cipal laws are, and not to inahe them, formulates a judicial psychology not sustained in the laws of morbid mental movement, sound psychiatry may be thereby set back a quarter of a century or so before the courts; but the truths of psychiatry remain the same as though no judicial fiat had sought to make them what they are not, and they will ultimately appear uppermost, despite judicial decision that they are What they are not. To ignore motives and resistless impulses of mind deranged, does not and will not obliterate them as facts from the phenomena of mental disease. To declare that “the true test of criminal responsibility where insanity is interposed, is whether the accused had sufficient use of his reason to understand the nature of the act with which he is charged, and that it was wrong to commit it,” unless this phraseology is liberally interpreted to mean something more than wrong in the abstract, does not change the fact that many insane persons, while having sufficien use of their reason to know what is morally and legally wrong, nevertheless feel by reason of their changed mental condition, that the particular acts they may be impelled to do are either impulsions that ought not to be, or cannot be resisted, or that it is not wrong for them 142 Editorial. to do them. Acts which to them would appear. wrong to every other person are self-justified. In a lunatic asylum, “Atlas,” groaning under the weight of the world, recog- nizes the folly of his fellow lunatic, who imagines his- belly full of snakes. If the insane would only reason like sane people, or. see without distortion the code, moral and civil, such_a test as was laid down by judge Cox in the Guiteau trial would be simple enough, but unfortunately for his judicial psychology, the psychology of clinical psychiatry refutes- the “ only safe rule,” the one test of criminal responsibility he has prescribed in that historic trial, namely, “whether the prisoner possessed the mental capacity at the time the act was committed to know it was wrong.” If only those lunatics are ‘to be exempt from the consequences of crime, who are so insane that they do not know what they are doing, and that the act is wrong in the abstract, then the number of insane criminals, or who would be criminals, in our asylums might be greatly diminished by applying Judge Cox’s test to their responsibility. The judiciary of this country will always be liable _to error so long as it continues to mahe, instead of trying simply to interpret, the laws of morbid mental movement, and to apply the same test of responsibility to the sane and the insane. The right and wrong test of responsibility has a more tenacious hold upon the judiciary of America than upon that of any other enlightened country, though it has not always been adhered to, stronger than in France, Germany or Russia even. The English judiciary has by no means consistently adhered to this mediaeval test, having succes- sively adopted and rejected it in different historic trials; having relinquished it in the famous trial of Hadfield, in the year 1800, reaffirmed it in that of Bellingham, twelve years later; again abandoned it in the trial of Martin, in 1831; and, three years later, reaffirmed it in another great state trial, only to be again virtually disre- garded in the recent trial of Roderick Maclean for attempting (on March 2d, 1882) the life of her Majesty the Queen, as the following interrogatories of the Lord Chief justice on that trial show: First question by the Lord Chief ]ustice.—“ Do you think he knew what he was about?” Second question by his Lordship-“Do you think he knew he was doing wrong?” Editorial. I 4 3 Third question ‘by his Lordship-“Do you thinh that if he did hnoio he could have helped it .? The right and wrong test was not prominent in this ‘trial, but if the medical witness had testified that Maclean knew his act was wrong but resistless, the court, in view of his history of previous insanity and late incarceration as a lunatic, would have accepted the morbid irresistibility, criterion probably, as the third question of the Lord Chief Justice foreshadowed, and so will the courts generally when the insanity is undoubted. Why not then make the test in all cases such as will embrace any form of real mental disease,' and be consistent? As Chief Justice Blackburn has said, “we cannot fail to see that there are cases where the person is clearly not responsible, yet knows right from wrong.” The only inquiry that would be just to the insane person would be as to the existence of the disease, and its influence upon the act of crime, and the possibility of resisting it. To assume rational criminal intent, if knowl- edge of wrong exists, is not fair where disease is inter- posed in extenuation by the defense. The inquiry should be, how has disease distorted the normal relationship of the man to the crime and surroundings, and if courts persist in defining how alone mental disease can absolve from responsibility, they should be careful to be compre— hensive enough to include those forms of insanity which are characterized by morbid impulsions of the mind, as well as those in which deranged perceptions are prominent. When the judiciary shall substitute mental pathology for metaphysical conception of morbid mental action in regard to questions of insanity, it will only charge that to con- stitute insane irresponsibility the mind must be so affected by disease of the brain as to distort its natural relationship to crime, rendering it truly incapable of resisting crime, either by overpowering morbid impulse or delusive conceptions of the legal or moral character of crime, or of the necessity or duty of committing it. The Rights of the Illsane.—The present age, under the pressure of sensational journalism, and the misuse of‘ the habeas corpus, is likely to do as much harm to the insane as was inflicted upon them in the days of dungeons, stripes and chains, before Bicétre was reformed, and the iniquities of old “Bedlam” were exposed and suppressed. It is no charity to release from asylum custody every harm- less-appearing lunatic who asserts his sanity, or who may O :144 Editorial. have a friend or two who is unwilling to believe him insane. Not a day passes ‘in the history of the world without the public being startled with preventable tragedies, having for their heroes or heroines some one or more of the supposed harmless class of insane persons, who have either been taken out of asylums on habeas corpus, or have kept themselves out of them by an appearance of .sanity or of harmless insanity. The Hadfields, the Mac- leans, the Lawrences (not to mention the Passanantes and ~Guiteaus), who make kings and queens and presidents their mark; as well as the Grays, who walk into theatres and make targets of its distinguished actors; the Remshaws, who quit their work to shoot asylum superintendents; the Freemans who attend to their business in day time and sacrifice their children at night; the moral monstrosities, sweet-appearing on the witness stand, who break away from asylum restraint by aid of sympathetic courts only to make otherwise happy homes hells on earth, the insane self-destructions innumerable, and the murderers of the innocent, unsuspecting and helpless which might be averted, ‘will continue so long as public attention continues to strain its vision to detect a possibly sane person in our asylums, and overlooks the great and increasing number of incipient and harmless lunatics at large. Lunatics at large are uncertain, however harmless they may appear, and actually are under the regulated surveillance of a well-ordered asylum management. Their liberty should generally be allowed them under judicious surveillance, .even though they appear safe to be at large, and it is not always a question of safety alone. We owe the harmless lunatic a duty to save him from perpetual lunacy if we can. To leave him wholly to himself, even though he hurts no one, is not always kind. Such a course endangers incurable chronicity, and this is cruelty to him. If we were to become insane, and could judge after insanity as before, we would wish to be speedily cured whether we might be harmless or not. Recovery would not be likely to be promoted by leaving us wholly to our insane devices, even though the unrestrained liberty might ‘be sweet to us, and harmlessly exercised as to others. What a world of woe to mankind and wrong to these victims of disease will be averted when the true nature of insanity and its curative needs shall be publicly under- .stood. The public duty of the hour is to rightly under- .stand and rightly manage the insane. Editorial. 145 Public Prejudice Against the'Plea of Insanity is daily verified in injustice done to the actually insane. Cases like the following are quite often seen in the public prints. We made satisfactory personal examina- tions of the person referred to below, and testified to her insanity on the first trial: NEVADA, Mo., November 17. In the murder case of the State against Mrs. Mary Harper, brought to this County on a change of venue, the prosecution this afternoon entered a nolle prosequi and the prisoner was discharged. In October, 1881, in Henry County, Mrs. Harper killed her little step-son, aged about six years, by cutting his throat with a butcher-knife in a most savage and brutal manner. The case caused great excitement at the time, and a long and tedious trial was held in the Henry County Circuit Court. * * * The result was a hungjury. Another trial was had at the next term of the Henry County Circuit Court, with the same result, after which the case was brought here on a change of venue. * * * Over forty witnesses and medical experts were summoned and in attendance, consequently a considerable sensation was created when this afternoon the Prosecuting Attorney from Hem'y County announced that the case would not be pros- ecuted further. Mrs. Harper, for several months past, has been confined in the asylum at Fulton, and was brought from there to the trial at this place. Her hus- band, the father of the murdered child, believes her insane and has used his influence to secure her acquittal. She attempted to commit suicide while in the Henry County Jail about a year ago. * * * Various opinions prevail in the community regarding her sanity, and some severe criticisms are passed on the Henry County Prosecuting Attorney for his action in dismissing the case. Dr. Smith, of the Fulton Asylum, and all the medical experts, testified to her insanity. She was placed into the asylum at Fulton by order of the Supreme Court. Thus it is with the inconsistent public. Ever eager to get them out of, or prevent them from being sent to, the asylums, but always ready to hang them for the results of their disease. This unfortunate woman tried to kill her own suckling babe, her mother and herself, under the delusive impul- sion of morbid auditory hallucinations, which commanded the bloody, unnatural deed. Like most lunatics of her class,"she felt that she “had to do it; they all had to go.” The Power of Vicarious Nerve Function to which we have before referred in these pages, and which we have elsewhere maintained (Amer. four. of Insanity, October, 1875), must be invoked to harmonize the dis- crepant views of Ferrier, Brown-Séquard and others, with 146 Edema. reference to cerebral localization. Goltz has demonstrated, by carefully conducted experimentation on the inferior animals, the capability of life for twelve months after ablation of three-fourths of the cerebral cortex. His con- clusion was that the doctrine of special motor areas is untenable, whereas he should have concluded that the. motor areas of Ferrier are not the only centers of motor impulse under all circumstances. Gradual ablation, as well as slow obliteration by dis ease, permits of active development of motor function in latent or secondary motor areas. Dr. J. C. Dalton, referring to these experiments of Goltz and others, and observing the impossibility of permanently paralyzing a single muscle of the body by the destruction of any part of the cerebral cortex, dis- credits the idea of exclusive special sense areas. This is undoubtedly correct, but the special sense areas in the normal condition of the brain undoubtedly do exist, not- withstanding their boundaries may be somewhat extended by the assumption, under certain circumstances of morbid invasion or physiological experimentation, of vicarious function. Alexandrine La Bross, sans cerehelli, existed and moved about before Flouren’s or Vulpian’s slicing experi- ments on fowls demonstrated that the power of movement thus abridged was capable of being slowly regained; and , P. P. Gage walked about for years after, though minus a large part of an anterior lobe of one hemisphere, with power of speech and thought, verifying the vicarious function of the hemispheres of the cerebrum. There are vicarious centers undoubtedly demonstrable, as the substitute channels of nerve force conduction are proveable. Misconceptions of Moral Insanity, Prichard’s Definition.—— “Moral insanity or madness consists in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses, without any remarkable disorder or defect of the intellect and knowing and reasoning faculties, and particularly without any insane delusion.”—- [Art on Moral Insanity, p. 19, Bell’s Library.] “ ‘this form of mental derangement has been described as consisting in a morbid perversion of the feelings, affections and active powers, without any illusion or erroneous conviction impressed upon the understanding; it sometimes coexists with an apparently unimpaired state of the intellectual faculties.”—-[Ibid.,p. 20.] - Editorial. 147 In one sense, indeed, their intellectual faculties may be termed unsound; they think and act under the influence of strongly excited feeling, and persons accounted sane are, under such circumstances, proverbially liable to error both in judgment and conduct. Conclusions of the reasons alone out of harmony with the natural character and surroundings of an individual may have disease for their basis, according to the theo- retical conceptions of some of our worthy confreres in psychiatry, while the morbid aversions, antipathies, fears andv feelings are not to be recognized as founded in disease unless the reason is also deranged. This is clearly a theoretical objection to moral insanity in which the reasoners ignore their own reason as the morally insane do. Moral insanity cannot exist they say because they will not permit it to be. Honor to Whom Honor is Due.—At the late‘ Jubilee Celebration of the Medical Faculty of McGill ~University there was present one gentleman who graduated from that institution forty-seven years ago, Dr. Joseph Workman, for the last generation and up to some four or five years ago, Medical Superintendent of the Asylum for the Insane, at Toronto. At the meeting of the Medico- Chirurgical Society of Montreal, on October 8th, the following resolution was passed in honor of his presence: “That the members of the Medico-Ohirurgical Society of Montreal, in session this evening cannot allow‘the opportunity to pass of expressing to you the pleasure your visit to the city has been to them. They feel that to you the Medical Societies of Canada owe much. Your zeal and ability have always been liberally expended in promoting their welfare, and they desire to express the hope that you may be still spared for many years to give them the benefit your wisdom and counsel.” We are sure that the profession of this city, and especially the members of the Toronto Medical Society, at whose deliberations he for two years presided, and the constant sight of whose venerable form has been an encouragement to some and a reproach to many, will eagerly join with us in a heartfelt echo of the sentiments expressed above by the Medico-Chirbrgical Society of Montreal. ' The Government’s Tribute to the Medical Profession.—At last a grateful (I) Congress awards its honorarium to the consulting surgeons and medical attend— ants of President Garfield, and thus attests its exalted 148 Editorial. appreciation of the professional fidelity and skill which sustained and prolonged the life of the late lamented executive for so many long weeks in comparative comfort beyond all reasonable expectation, under so mortal a wound, and the measure of its gratitude is exhibited in the sum of five thousand dollars awarded to each of the distinguished consultants for about nine weeks of service in which their time and talents were at the command of the nation, and they were debarred from making any important surgical engagements elsewhere. A grief stricken nation generously gives the bereaved family a quarter of a million, to which Congress adds the remain- ing salary of the President’s unexpired term, and gener- ously donates to his chief physicians five thousand dollars apiece, while his medical nurses get nearly an equal pecuniary recognition, and the regular medical attendant .is awarded sixty-five hundred dollars! Noble Nation! Magnanimous Congress! Generous Committee! Low Temperature in Insanity-We take the following from the Detroit Lancet for January, being a part of Dr. Kiernan’s address on Insanity: In the case of a man tried for murder in Canada, Dr. H. Howard cited low temperature as a corroboratory evidence of insanity. Ulrich has reported a case of progressive parcels in which there was a temperature of 91.3 F., and a case of melancholia in which the temperature was 83.4 F. Tilling reports a case of primary monomania in which there was a temper- ature of 89.6 F.; one of melancholia attonita in which there was a temperature of 82.4 F., and two cases of progressive parcels in which the temperature was 83.3 F. and 81.5 F., respectively. Bechterew reports one case of senile dementia in which the temperature was 87.8 F. ; two cases of progressive parcels in which the temperature was 93.2 F. and 86.9 F. Ireland reports a case in which the temperature was 82 F. Lowenhardt reports two cases of insanity in which the temperature was, at various times, 87.5 F., 89.6 F. and 90.5 F. Mendenhall has reported a case of dementia in which the temperature was 90.5 F. Zenker has reported nine cases of insanity in which the temperature fell easily; in three cases as low as 90.6 F. As a corroborative symptom of the existence of nervous disease, this question of low temperature may be of value. Any sugges- tion on this topic, however, would be as yet premature. More Light on‘ Guiteau’s Ancestry.—We have good authority for the statement that a large part of the people of the town of Freeport, 111., where the father of Chas. J. Guiteau resided, believed his father was insane, but it was the interest of the officials of the bank with which Guiteau, Sr., was connected to deny it. The Editorial. ' I49 paternal grandmother is said also to have had attacks of melancholia, and descended from a hypocondriacal father, and had an ancestry of peculiar people. A grave mistake was made in pronouncing Guiteau a sane man, and the history of his trial only serves to show how difficult a question to decide that of sanity is, when only an incomplete life history is studied, and conclusions are biased by the pressure of popular opinion and the patriotic feeling. Since the hanging of Mrs. Surratt, the Government has made no greater blunder than the execution of Guiteau. If Mrs. Surratt Were alive to-day, no charge of treason would stand against her. When posterity passes on Guiteau, he will be adjudged insane. The Yearning for Higher Medical Education has promise of ultimate gratification in the following aspirations after fame of the Joplin College, though the beginning is “petit.” Behold the announcement: COLLEGE or Pnvsiouixs AND SURGEONS, Gents: Please send price list of Doctors and Druggists Names by states, as I want to mail several thousand Annual Catalogues lo the Profession all over the U. S. A.and canady. I am starting an embriotic Pioneer-Medical College and I must, of necessity, noise it around the world to make it pay me. An early reply will greatly oblige, Yours Respectfully, etc., J. C. PETIT, M. D.. Dean We take pleasure in helping to noise this “emhriotzc pioneer” Medical College around the world, knowing the cosmopolitan as-pirations of its projectors. Great enterprises have often very small beginnings. We feel confident, however, that the foplin emhriotic will not be easily discouraged, notwithstanding the State Board of our neighboring State of Illinois cruelly proposes embryotomy for its alumni. But such is fate when the head is larger than the pelvic brim. Let the foplin embriotic thrive. Such institutions make fast gradum schools with ante gradum capacities in their faculty chairs tolerable. Let the embryotics come forth, there will probably be enough post-gradi to com- plete their incubation. Aphasia and Insanity.—-Dr. Rousseau (Annales Medico Psychologiques, November, 1882) comes to the following conclusions respecting aphasia and insanity: In general, insanity and aphasia are rarely associated, and the analysis of them then varies according to which of I 50 Editorial. the ‘affections was primarily developed, for in one case there may be simple coincidence where in the other it may be necessary to admit that there is an antagonism. The lesion that produces aphasia may leave the intelligence intact, but more frequently it is enfeebled without being destroyed. Aphasiacs may become insane, but this can only exceptionally happen since they are somewhat cut off from relations with the outside word. The insane do not so frequently give evidence of amnesic aphasia, although they fall, under the common law, relative to the ataxic form. Applied to progressive paresis, these opinions seem somewhat too positive-K. ' Malaria in Skin Diseaes—a Correction-Dr. L. P. Yandell refers to a paragraph which has lately appeared in the [Michigan Medical News and other journals, as follows: “What I have contended for, and what I have reiter- ated, is simply this: Malaria is Z/ze clzz'ef source of acute skin disease. Scrofula is z‘lze c/zz'ef source of chronic skin disease. The more inveterate cases of skin disease are often due to the coexistence of these two things. The specific exanthems, of course, are not included here, but I contend that their progress and termination are often largely influenced by the presence of malaria or struma. ] do not claim that malaria and struma are the sale causes of the dermatoses. Indeed, many of the derinatoses may exist z'rza’epena’em’ly of malaria or sz‘mrma, and most fre- quently some exciting cause is necessary to develop the cutaneous eruption. Dr. Curwen on Lunatics at Large. “A great deal has been said latterly about the personal liberty of the insane, but those who are so specially urgent on this matter, forget that every member of the community has his personal liberty, and also his life, involved by the fact of so many irresponsible persons being at large, so that from the President of the United States down to the humblest member of the community, no one can tell when his life may be threatened or his property be destroyed by some one for whom his family or pretended friends may interpose this plea of personal liberty. No man has a right to personal liberty where that liberty may imperil the life or property of another.”——[Address before Alumni Association, Med. Dept., University of Penn, Jan I9th, I882J Editorial. I 5 I Kalaemia. vs. Uremia.-—Fult_z and Ritter (London Med. Rec., Jan., 1882) have reached the conclusion, after numerous experiments and observations, such as the injection of solutions of potassium salts, and the examin- ation of animals that have died from uremic poisoning (so-called), and finding an excess of potassa, the injection of urea giving negative results, that the so-called phenomena of urea poisoning are really due to the acclamation of potassa salts in the blood. They use the term “potassaemia,” but “kalaemia” is more euphoneous, if the ureic pathology should be supplanted by subse- quent confirmations. . T0 Gazetteer Men who persistently importune us to subscribe for directories containing the names of leading physicians, we have only to say we have no need of their goods. We can generally find the names of most of the eminent men who do not take the ALIENIsT AND NEUROLOGIST among the recommendations of the proprie- tary medicines asking our daily attention. The Narrow View of Insanity applied to Guiteau has lately been applied very unjustly to some of the patients in the New York City Lunatic Asylum, and patients with hallucinations of hearing and delusions of persecution have been declared only eccentric and not insane or dangerous. Yet those who know lunatics well will always give such a wide birth if they are at large. Mark Gray has also been set at liberty to shoot at Booth again, may be! The Coupling of Irresponsibility with Insanity causes contests over its recognition in any but its most marked and undoubted forms in medico-legal cases, and leads to the non-recognition of its obscurer phases. A court-room, with capital crime or a will in contest is the last place in the world in which to make a correct and satisfactory diagnosis of insanity. Persistent Double Consciousness-Fiddle X., of Bordeaux, is probably the most remarkable case of double consciousness on record. For twenty-five out of every thirty days, during the past twenty-three years (on the authority of Dr. Azam), she does not remember what she has done during the other five. Her age is thirty- nine years. A Large Brain.—-Sixty-two and a-half ounces of brain belonged to a late Leadvilie, Colorado, gambler, who I 5 2 Editorial. betrayed no greater excess of greatness than belonged to the Louisville, Ky., baker, who died some years ago, with a brain larger than Webster’s, Cuvier’s or Aber- crombie’s. The Society for the Protection of the Insane will meet in Philadelphia on the 25th of this month. That body has discussed the right of the insane to liberty. We hope they will consider the paramount right of these unfortunates to judicious surveillance and restraint in order that their Welfare, as well as that of the community, may be subserved. The insane should be protected against themselves even though they be not violent, and rescued from impending chronicity, even though they might harm. no one if unrestrained. Brass Poisoning and Insanity.-It has been observed by Binswanger (Neurologz'selzes Cem’miélaz‘t, March 15, 1882) that seventy-five out of one hundred brass founders suffer from a species of fever. One patient, aged twenty-seven, while suffering from the initial stages of this fever, was attacked by a species of melancholia, with frenzy and hallucinations-K. A Good Periodical Discontinued.——We shall greatly miss from our exchange table the Well conducted and richly instructive Archives of Dermatology, whose ex- istence has ceased with the completion of the eighth volume. The Cure of a. Case of Epilepsia in consequence of excision of a diseased knee (Arthritis and Anchylosis) is reported in the Jan. 6th number of the P112]. Med. and Surg. Reporter. . REVIEWS. REPORTS OF THE INSANE HOSPITALS FOR THE YEAR 1881. 1. Report of the Pennsylvania Hospital for the Insane for the Year 1881- By Thomas s. Kirkbride, M. n. 2. Twenty-Sixth Annual Report of the Trustees of the State Lunatic Hospital at Northampton, Mass, for the year ending September 30th, 1881. Pliny Earle, M. D., Superintendent. 3. Forty-Ninth Annual Report of the Trustees of the State Lunatic Hos- pital at Worcester, for the year ending September 30th, 1881. John G.‘ Park, M. D., Superintendent. 4. Sixty-Ninth Annual Report of the Trustees of the McLean Asylum, 1881. Edward Cowles, M. D., Superintendent. 5. Forty-Third Annual Report of the Superintendent of the Boston Lunatic Hospital, for the year ending April 30th, 1882. 'l‘. W. Fisher, M. D., Superintendent. 6. Fourth Annual Report of the Trustees of the Danvers Lunatic Hospital, for the year ending September 30th, 1881. Wm. B. Goldsmith, M. D., Superintendent. 7. Forty-Ninth Annual Report of the Managers of the State Lunatic Asylum, Utica, N. Y., for the year 1881. John P. Gray,Superintendent. 8. Eleventh Annual Report of the State Homeoepathic Asylum for the Insane, at Middletown, N. Y. 1881. Selden H. Talcott, A. M., M. D., Superintendent. 9. Twenty-Seventh Annual Report of the Board of Trustees and Oflicers- of the Cleveland Asylum for the Insane, for the fiscal year 1881. James Strong, M. D., Superintendent. I 54 Reviews. 10. Forty-Third Annual Report of the Board of Trustees and Oficers of of the Columbia Asylum for the Insane, for the year 1881. H. C. Rutter, M. D., Superintendent. In looking over our file of insane hospital reports, we found so many had collected, that it would be impossible to any more than mention a small portion of them. We therefore proceeded to pick out those in the ' above, almost at random, promising ourselves that we would, in a later number, look into as many more as possible. We very well remember a time in our early studies of insanity, when these reports seemed as dry reading as the market quotations in the news- papers. How our elders could pore and even gloat over them, quite passed our comprehension. As time went on, however, and our connection with the topics presented became more near and personal, we too began to take a lively interest in them, until to-day we look as eagerly for a new report, as the average of mankind for the last number of Harper’s. The casual reader who takes up an insane hospital report, must be struck with its curious make-up. Here is a mixture of all kinds of things-—pathol~ 'ogy, piggeries, cow-yards, convolutions. ventilation, ventricles, radishes, restraint, morals, mowing. We begin with the number of cures and usually end with the number of night-gowns, which the institution has recorded, as its work for the year. W e learn how many cabbages have been raised on one page, and on the next, perhaps, find a table of deaths. Why, it might be asked, do we have this varied bill of tare? To answer this question we must step into the superintendent’s place and say that we have tried to write down the doings of a year, as accurately, yet as briefly as possible. This is, we must allow, again assuming our own position, a very proper answer; but can the same result be arrived at in any other way? It must be remembered in the first place, that the report must, in most cases, con form, to a certain extent, to the law which requires the enumeration of these various business details. Then second, that the Trustees are interested in the business management of the hospital and desire to make a good showing in this direction. Then third, there is the public which wants both a clear business account of details, but desires besides, some popular instruction on the subject of insanity, as well as medical details concern- ing the patients. . These wants are somewhat exacting, yet the conscien- tious superintendent remembers further the claims of science, and endeavors more or less briefly, to satisfy them also. It will be seen then, how much literary labor he is put to, to com pile his report, which may seem little to the World, but is a mountain to him. We can imagine even Napoleon himself would have been staggered had he been obliged to write an annual report of his campaigns with as much detail as is required of the insane hospital superintendent. The report exemplifies what the superintendent himself is expected to be. Popularly he is supposed to be the physician ministering to his patients and making studies into insanity and cerebral pathology. Prac- tically, he is doctor, farmer, engineer, cook, steward, carpenter, plumber, financial correspondent, seamstress and, perhaps, clerk of the Trustees, chaplain, lecturer and father to patients and employees. When we regard the very remarkable combination of qualities which go to make up the Reviews. I 5 5 ideal superintendent, we see that few men can be equal to the requirements demanded. What wonder, when we have found the right man, that we cannot expect much from him in the way of a scientific knowledge of the morbid anatomy of the brain in insanity i If he does his required work well, we can ask no more. Sometimes we get impatient and wonder if a super- intendent’s duties could not be so arranged as to give him more time for scientific work. but after a careful investigation of every system practiced, we are reluctantly led to believe, that first and foremost, the superintendent to do entire justice to his patients, medically, must superintend everything, for there is no detail. however trivial that does not have a bearing on the medical management of the hospital. If in an individual case the super- intendent has the taste, ability and education to go into pathology, so much the better. Bye and bye our standard of medical education will be higher, the superintendent will enter on his duties with the desired knowl- edge of cerebral pathology which in the past he did not possess, and he will then be able to superintend this branch also. With a higher standard of medical education the public will learn to expect more scientific acquire- ments in the medical officers of insane hospitals, and we doubt not that a larger staff of assistants and improved methods of management will be ready at hand when the time is ripe for them. We see, then, that the report presents a very good chronicle or history of hospital management. But cannot some of the details be omitted from the printed report? Cannot they be presented at a trustees’ meeting, and then silently filed away? With the greatest respect for the worthy super- intendent, we should be so much relieved if he would omit the history of the old sewer, or the new asparagus bed, or the root cellar. It is such a disappointment when we see a nicely printed page without the usual tables, and expect some ripe utterances concerning insanity, to find instead a long account of draining the meadow down by the old garden gate. Whisper it gently into the manager’s ear, but give us-the public-some glimpses into your grand experiences. Open a few pages of your clinical observa- tions and detail to us some of the remarkable psychological phenomena which daily pass before your eyes. No man has a better chance to study character than the hospital superintendent, for he sees human nature in all its nakedness, with the mask of decorum and social respect thrown off. He has only to record his observations to give us the most valuable infor- mation. And it is in this respect that we find him. like other American medical men, defective. It is an exertion for him to write with exactness and precision. He often rattles off many pages of loosely worded English. but it is difficult for him to sit down and accurately put his observations into writing. After all, however, we should be thankful for insane hospital reports, for they contain very much of value that would otherwise be lost. Only through their pages many a superintendent makes himself known as a writer. In times past, our superintendents have rarely published much in either general or special journals, but every year now witnesses an improvement in this respect. 1. This report, which is Dr. Kirkbride’s forty-first, as usual, contains much of interest. The kind and worthy doctor is one of the few remaining I 56 Reviews. of that generation of superintendents, now nearly passed away, who had something to say, and could say it, too. His work stands as a most fitting monument to his painstaking efforts to ameliorate the condition of the insane. Each one of his reports gives us the results of his matured j udg- ment; and, collectively, these reports will be of scientific value for many years to come. He has shown us that the two sexes can be satisfactorily treated entirely separate from each other, but we doubt not that he would have been equally successful with the two sexes in one building. Another successful plan of treatment he has demonstrated is that of daily evening amusements for patients, and to this he lovingly refers in the report before us. For thirteen years, every evening during nine months of the year, some form of amusement has been provided for the patients, and two years ago such a system of amusement was made a permanent regulation. The variety of entertainments oifered embraces stereoscopic exhibitions (the hospital owns an immense collection of photographic pictures), lectures, concerts, gymnastic exercises, exhibitions of various kinds, social parties, etc. All these things make a very pleasant change for the patients, and any one who has visited Dr. Kirkbride’s must have been struck by the degree of perfection to which the amusement system has been brought. It is to our mind, however. an open question whether so much amusement is a necessity. A recent writer, in the Journal of Mental Science, has argued that such a method of hospital life is not well fitted to prepare the patient for a return to the ordinary duties of life. The whole force of the institu- tion should be towards work rather than amusements alone. It should not be forgotten, however, that Dr. Kirkbride has labored to introduce useful occupation among his patients. Out of 3,825 patients admitted since the institution opened, 3,825 have been restored to their friends, or upwards of forty-five per cent., which. to say the least, is a very good showing. During the last year, 209 patients have been admitted, and 57 discharged cured, or, we will say, about twenty- eight per cent. The latter, it will be seen, shows a great falling ofl‘ from the total percentage of cures for the forty-one years. Among the tables, No. VlIL, which gives the supposed causes ot insanity, is of interest. We learn that out of the total number of 8,480‘ cases, ill health was the cause of 1577; intemperance in 828; fright in 73— a surprisingly large number, it seems to us; use of opium in 33-a very small number, we should say; use of tobacco in 17-—a large proportion relatively to opium. In 3,298, or nearly two-fifths, the cause was unascer- tained, which only shows us how unreliable such tables must of necessity be with our present imperfect methods of collecting statistics, and how impossible it is to make use of them for the purpose of making deductions without exercising great care. 2. In the footsteps, or perhaps more properly, in the same rank with Dr. Kirkbride, the nestor of American insane hospital superintendents, Dr. Earle, must be placed. He, perhaps as much as anyone of our distin- guished superintendents, has done his share in endeavoring to infuse into reports, a spirit of scientific accuracy. His labors in regard to the curabil- ity of insanity and hospital statistics have given him a world-wide Reviews. I 57 reputation. He may not be strictly right in all vhis deductions, but he has thrown considerable light into obscure nooks and crannies and knocked down a good many men of straw. His dignified, accurate, terse, and telling manner of stating and recording his investigations, has not only stimulated others to more careful work, but has also served as a useful corrective of the slouchy, careless, hap-hazard style of writing, so much in vogue in hospital reports. Like Dr. Kirkbride, Dr. Earle is an ardent believer in entertainment, and we find that during the year, the patients assembled for either worship, instruction, entertainment or amusement, 329 days of the year. About ‘Hone-half of the patients attend these meetings and often they do not last for a longer time than half an hour, we have been told. Twenty persons were discharged as recovered during the year, 120 persons having been admitted, or nearly 17 per cent. In the “Studies relative to the Curability of Insanity,” which again from the essay portion of the report, Dr. Earle states that his conclusions are becoming each year more generally accepted, both by superintendents, the medical profession and laymen. At the four State hospitals in Massa- chusetts, during the year, 1092 persons were admitted and 283 persons dis- charged recovered. or a percentage of 25 91. The three older hospitals, Worcester, Taunton and Northampton admitted 521 persons during the year, and discharged recovered, 118 persons or a percentage of 22.64. Of the 118 persons discharged, 55 had been previously discharged, thus bring- ing down the actual gain in the number of recovered persons in the com- munity to 63, or 12.09 per cent, Of these, 55 persons. readmitted after previous recovery, had been discharged altogether 115 times. The public had been told of 115 recoveries of those 55 persons, hence if recoveries and not persons be enumerated, the three hospitals issued 118, but they took back 115, leaving therefore an'actual gain of only three persons in the community. Such figures as these may well startle us, but the question is, it Dr, Earle draws an entirely correct inference, at how long intervals were these persons readmitted? Were they able to go out and resume the ordinary duties of life? Surely, a person getting apparently well and able to bear the strain of his usual life must have been well enough to count as a legitimate cure. As we look at the matter, we should go still further than Dr. Earle, and ascertain exactly how long it was between discharge and readmission and then divide up the persons into real and apparent cures, according to a standard of length of time of apparent mental health. Dr. Earle, like other superintendents, must give annual statistics; now, supposing one of his twenty cures of persons of this year is admitted immediately at the beginning of next year, how is he going to correct the false showing that he has just made? He cannot change the statistics of this year, which counts him as arecovery; neither if he gets well next year, can he help putting him down again as a recovery, and so each year the same person may make a recovery, and in a few years make a good many. We grant that it is a great step forward to make this person recover less often than formerly, but the principle of allowing him to recover over and over again, which seems to- us after, all the correct one, still remains true. In the future, we think that the length of time the person remains I 5 8 ' Reviews. Well,wil1, as we said before, determine the validity of a recovery, rather thanthe number of times. 3. Dr. John G. Park, superintendent of the hospital, states that the re- coveries have been 21.68 per cent. on the admissions. Fourteen of the 54 recoveries were of persons who had been inmates of the hospital before, and 12 had been discharged recovered; one had recovered 9 times; one 6 times; one 4 times; two 3 times ; l twice and 6 once each ; one had been discharged improved and one not improved. Dr. Park says “although it may be a question, upon which there may be an honest difference of opin- ion, whether each case which recovers may not be fairly called a cure, even if the patient has a second attack within a few months or a year, there can ' be no doubt that the public has been hitherto widely misled as to the meaning of the word “recovery” as used in the hospital reports and as to the permanency of cures from insanity. Not a small number of patients who were discharged recovered in the earlier reports of this hospital have many times since become a burden to the public or private purse by rea- son of a return of their malady.” Dr. Park finds that of 94 patients discharged previous to 1840, 3 men and 5 Women who remained well after their discharge are still living ; 26 men and 14 women remained well as long as they lived ; 24 men and 21 women became again insane and of this number 7 committed suicide and 10 have been inmates of other hospitals. The criminal insane in the hospitals are alluded to and the opinion is expressed that “not a lunatic hospital in the state is a fit place for the safe custody of the criminal class.” 4. Dr. Cowles, acting on a plan the opposite of Dr. Kirkbride’s of separation of the sexes, has introduced into his male wards some female at- tendants. He has chosen women of matronly, discreet and amiable quali- fications and placed them (one each) in charge of the ordinary housekeep- ing in two wards. Each one is assisted by one or more ward-maids. She presides at the table and acts as if she was the mistress of the house A male head attendant has the general care of the wards and direct charge of the patients. There are now four women thus employed, whose duties require their presence day and night in the wards, and so far it seems as if there were no reason why female nurses may not be associated with insane men with great benefit to them. The results have been better than expected. The wards are more home-like, and both the patients and attendants are better behaved. We trust that Dr. Cowler will be successful in his experiment, for ordinary attendants are quite apt to acquire rough manners and naturally often lack the refinement that their patients possess and without which the latter are liable to suffer. It will be no easy matter, however, to find the right women, for at the best, the nature of the duties is difiicult, and women with the right mental and moral qualities, will often lack the phys- ical. 5. This old hospital is always interesting to read about, as its reports show to some extent the progress that has been made in the treatment of insanity. It is an old, dingy, prison-like building, erected at a time when the menagerie plan of caring for lunatics was in vogue. While improved Reviews. ' I 59 plans have been gradually introduced, and the lunatic is made very com- fortable here, the stone floors and thick walls carry us back to the days of the insane man’s Nero. In 1837, patients were taken from the Worces- ter Hospital and placed at the Boston Almshouse, in cells or in wooden cages on wheels for convenience in giving them an airing! (We can imagine Pinel and Connolly writhing in agony in their graves, when they read these words!) In 1839, however, this asylum was completed and these patients removed to it, where under the care of Drs. Butler and Sted- man they were treated like sick persons. Afttrwards extensions were made to each wing, containing twenty cells each, but these were abolished by Dr. Walker, who was the first superintendent in the State to give up the cell plan of treatment. ' Since 1853, the necessity for more room at the asylum has existed. The noisy, destructive, violent and filthy patients have been treated in the lower wards of the main building, much to the disadvantage of the quiet class. And it seems rather a reflection on the city of Boston that while she has done so much for many classes of her poor and affiicted, she has neglected‘ her insane and still continues them in this narrow, contracted old building, where, Dr, Fisher says, “ a single bad case may disturb the whole wing, keeping patients awake, whose recovery depends on their ability to sleep.” The herding together of all sorts and kinds of patients gives rise to much confusion and real injury. Boston may suppose, in her innocence, that she did her whole duty by her insane, when she helped to build the Dan- vers palace and squandered hundreds of thousands of dollars on the most ‘foolishly situated and lavishly finished institution within the borders of Massachusetts, but let anyone read Dr. Fisher’s report and they will be led to believe that there is still to-day a crying necessity for a new hospital for her insane. To be sure, $60,000.00 has been appropriated for new dining- rooms and indirect steam-heating and ventilation and some minorimprove- ments, but after all, the same radical defects in the building itself must still continue. ~ At the end of the report there are some well recorded post-mortem notes of six cases of general paralysis by Dr. W. W. Gannelt, the patholo- gist. _ 6. The fortunes of the Danvers Hospital have been somewhat varied, we should judge, from what we have read in its annual reports, and the last year seems to have been no exception to this rule. With its present _ able superintendent, however, we now look confidently forward to some permanent progress. As a new institution, much disorder and chaos was to be expected, and this state of affairs was unfortunately heightened by the bad situation and extravagent and yet faulty constitution of the build- ing. Built for paupers, it was yet in its finish and general arrangement quite unfitted for the care of this class. It was badly and inconveniently arranged and poorly equipped, when opened. It seemed about as well adapted to its purpose as would be the elegant cabins of a new ocean steamer for the transportation of emigrants, and it was not much easier to manage, than would such a steamer be with its helm in the bows and its wheel-house in the hold. However, after much trial and tribulation, and a general over-turning, upheaving and May cleaning, a happier future .160 Reviews. may be looked forward to, and the Danvers Hospital will undoubtedly ‘stake the lead as the great pauper institution of Massachusetts. The Trustees say that the report again shows that the hospital is not self-supporting. We should say not, as it entered on its last year with a debt of over $23,000.00, which is not likely to be improved as Dr. Gold- smith says. The only possible way to make this hospital self-supporting, ‘it would seem, would be to convert several of the wards into large dormi- tories, thereby crowding together a much larger number of patients and reducing the per capita cost of maintenance. A Board of twelve consulting physicians, eminent in their profession, has been appointed, who make monthly visits and favor the management with much good advice. we doubt not. The Trustees call attention to the necessity of removing the criminal insane from the State hospitals and treating them in separate institutions. Dr. Goldsmith says that a large number of feeble, helpless and demen- ted old people are sent to the hospital, a part of whom might be treated at home. The admission of so many of this class accounts in part for the large number of deaths, 94 or 8 5-10 per cent. of the whole number treated, There were also 23 deaths from general paresis, or nearly a fourth of the Whole number, ' There were 39 autopsies, but We miss the report of the pathologist, Dr. G. G. Putnam. 7. There were admitted into this hospital, 212 men and 190 women. There were discharged, recovered, 128-54 improved. 158 unimproved and .51 died. The percentage of recoveries was 31.76. The average of recoveries since the opening of the hospital in 1843, has been 36.47 per cent. The managers report what has been done to insure protection from fire, and then state that the accounts have been kept in a satisfactory manner. They close with a eulogy of the superintendent and his assistants. The usual essay of the superintendent is omitted, which makes the report rather dry reading. The large accumulation of chronic insanity received during the first year, is due to some specific cause. That cause, is apparently the general distrust in asylums and asylum management engendered by the sensationalism of the press and individual notoriety- seekers and purturbators, in recent years. The committal of these cases to the asylum now indicates, first, an increased confidence in asylums; and second, that many of this unfortunate class have been retained at home until their care and custody became a burden which could no longer be borne, and the asylum was sought as a last retreat. This explanation may be true of New York, but the same preponderance of chronic admis- sions is found in States where the asylum purtiu'bator is not abroad, and we should therefore feel obliged to look further for acomplete explana- tion. We should say that insanity in its early stages often is not recog- nized, and even when it is, in many cases the friends, from ignorance. do not understand the necessity of early treatment, and keep the patient at home until he gets completely unmanageable. Then, too, even ';in this enlightened age, many persons are ashamed to have it known that insanity exists in their own families. The practical criterion among the laboring Reviews. I6I and lower classes for seeking the asylums, is usually, that the insane per- son cannot be controlled, or supported. 8. The Trustees of this hospital rejoice and are exceedingly glad at the result obtained, and the Superintendent also joins in hearty congratu- lations. And well they may rejoice, for they have discharged 50 per cent. of their patients cured, though we do not understand how they make their estimate. Apparently, they have beaten Dr. Kirkbride, Dr. Gray and all the noble army of able superintendents. Under the heading of ‘ ‘ The Labor Question” we are treated to a variety of old fashioned observations, jcouched in the most generous and even grandiloquent flow of language. We find that “gentle motion causes the blood to take on a more active circulation,” a fact not entirely unheard of in the annals of physiology. We find further that “sunlight stimulates a ruddy glow in the cheek (does it not also gently redden the nose?) and plantsa healthful brown upon the hands and arms; and the spring-time breezes, laden with life from the eternal hill-tops bear to the lungs their inspiring freight of invigorating oxygen and their welcome burden of disease antagonizing osone.” If this is not poetry we should like to know what it is. Why is it not possible to write a whole report in song, instead of occasionally exploding in this unexpected manner? We really hope that here after the allopathic superintendent, struggling under his heavy load of pills and boluses, will be stimulated to emulate his homoeopathic brother, and at least record a few post-mortems in appropriate nursery rhyme. “Absolute quiet and freedom from every form of exiting exercise are sometimes the most important means with which to tone down to a normal level a hyperaemic and over-stimulated brain!” What? Is this homoeopathy? Is this similia similibus curamtur? Should we not treat hyperaemic brains by violent exercise and powerful exertion‘? Absolute quiet and freedom from every form of exercise can only be suited to cases of great depression. Let us stir up and goad on to furor the violent maniac, and overpower the unfortunate melancholiac by every means known to homoeopathy, even starvation being justifiable in such a case. Than will good, honest old Hahnemann be forever the savior of all mankind. Our friend will excuse us if we have caught his poetic style. We very much regret to see him quoting Drs. Chapin,Kirkbride, Gray, Griesinger,Buckni1l and Tuke, and some of the other false advocates of rational medicine. In the “conclusion” we have revealed to us a new fact in physical science which we venture to assert is not even equalled by the comet. A last the discovery has been made of the law of crystallization of the “phys- ical aspects” of an insane asylum. We find these crystals “are comely and shapely proportions.” We shall now look for a general falling to pieces of insane asylums, and as the cold weather approaches shall expect to see these “comely and shapely proportions” strolling oil in various directions “Growing experience leads to show more and more conclusively the wealth of resources that abides in homoeopathy as a practical means for curing the insane.” Just what these resources are we do not know, in fact, not the slightest mention is made of them. We should like to know some- thing about these “practical means” whereby 50 perjcent. of the patients 162 Reviews. are cured. And instead of several pages of trite observations about the‘ “labor question,” written to slow music, it would have been much more serviceable to the ignorant medical public to have had the exact “practical means” abiding in homoeopathy stated in so many words. Perhaps the opinion of the homoeopath Worcester* (who by the way seems to be an admirer of the Middletown H ospital managers) will be en- dorsed that "there are two or three agents employed by the old school whose use you will do well to bear in mind, both for your patients’ sake- and because you will not want to see your patient pass into another physician‘s hunds.”j' Charming principles these, if they are homoeopathic, but we hope the “old school” will avoid them. Ghloral hydrate is there recommended in doses of 20 or 30 grains and bromide of potash in 10 grain doses! Perhaps also, if they follow the advice of Worcester, if a patient lP-QS- to escape, they use bellod. stramon; or desires to be alone, calc. carb. cuprum and ignat; or dreads being alone, crimicif.,lycop., sulphur; or weeps, bellad., ignat., kali brom., nati. vum., pulsat., platina, sefia, sulphur. At any rate, in the next report we shall regard it as an unpardonable offence if some demonstration is not made whereby we may at least faintly discern some difference between “old school” methods of treatment and so- called homoeopathie “practical means.” 9. The number of patients at this hospital at the end of the year was. 622. The percentage of recoveries was 33.6 and of deaths 4.28. In both cases a favorable showing. Among the deaths it is strange not to find one from general paralysis, especially, when we remember that at the Danvers Asylum one from sixteen of the deaths last year were from this cause. The special subject of discussion in this report is on “epilepsy and some of its varieties.” N othnagle, Echeverria and others are quoted with the idea of throwing light on some of the obscure forms of epilepsy. Several cases are then cited which are illustrative of epilepsy of the non- convulsive type, which are characterized by mental rather than by bodily symptoms. These cases are all interesting, and worthy of report, did space permit. They show how much danger may, in some cases, be associated with the concealed or larvated form of epilepsy and semi-popular discus- sion of the subject will do no harm. In considering provision for the insane and epileptic in Ohio, it is stated that there are about 2,500 ineurables and 600 epileptics to be pro- vided for, and this can best and most economically be done by erecting supplementary buildings to the existing hospitals. A large proportion of epileptlcs are insane and can be treated in common with the ordinary insane. It is our opinion too, that supplementary buildings will, inthe future, be the most available means for providing for the constantly increasing number of the chronic insane. 10. This report is the most bulky one coming to us, for the reason that every cent expended at the asylum, during the year, is accounted for in the financial portion. The publication of so many items seems a little unnecessary and must add very much to the cost of the report, but perhaps- the good people of Ohio are fond of financial details; we are not. *Insanity and its Treatment. p. 274. iltalics are the reviewer’s. Reviews. 163 There were 930 patients in the asylum at the date of the report. The percentage of recoveries was 48.33, and of deaths, 5.31. We find two deaths, only, fi'om general paralysis, out of a total of 65. The superintendent of this asylum also considers the subject of more extended asylum accommodation and argues especially for a separate hos- pital for insane epileptics, contrary to the opinion of his brother superin- tendent at the Cleveland Asylum. He gives a rather dramatic picture of the epileptic, with the “piercing cry, frothing mouth, clenched teeth, bleeding tongue, horrible contortions, turgid face,” etc., when seized with a convulsion. The effect on the mind of the healthy individual is bad enough, but still worse, in his opinion, on the insane person. _ The advantage of a separate institution for the care of the epileptic insane he thinks would be: l.-—-'l‘he withdrawel of a turbulant and trou- blesome class from the general hospitals for the insane. 2.-—Cheaper buildings. 3.—Diminished cost of maintainance. 4.-Better care in such an institution. We are ourselves rather inclined to think that he goes too far on the side of separation. Dr. Jolly, of Strasburg, comes nearer the mark when he says* that, on the whole. insane epileptics can best be treated in insane asylums. Epileptics who demand temporary hospital care, should be pro- vided for in special divisions of general hospitals. Combined with these, there should be out-patient’s departments. Cases of long duration will require special buildings or separate divisions in existing institutions. In Berlin, the Charité Hospital has an epileptic department with 30 beds, and the ‘,Bicetre in Paris has 80 beds for males, and the Salpetriere, 137 beds for females. : The epileptic insane can here have special wards to themselves in ordinary hospitals, or a supplementary building on the hospital grounds, as Dr. Strong suggests. It must not be forgotten that many insane epileptics have no perceptible convulsion, and many present- entirely different forms of insanity which can be most conveniently classified with the ordinary insane, presenting similar forms. It must not be forgotten furthermore, that the epileptic in a convulsion may also aifect- his brother or sister epileptic, who may have a very slight degree of epilepsy, or who is in his or her convalescent stage of the disease. THE ORDER or DISORDER IN MENTAL Drsnasn, by O. Evarts, Super- intendent of the Cincinnati Sanitarium, is a well-written paper, like all of the author’s contributions to the literature of psychological medicine, in which the attempt is made, but not successfully, we think, to evolve an unvarying law for the commencement and progress of cerebral disease involving the mind. The author’s initial proposition is that “knowledge of disorder presup- poses knowledge of order in mental as in other diseases,” and upon this the converse proposition, that knowledge of order presupposes knowledge of the methods of disorder is predicated, but, in our judgment, not proved. To know the order in which a structure, animal or otherwise, is built up, by no means assures as how it will come to pieces. *Arehiv fur Psychiatric und Nervenkrankheiten. Vol. Kill, 22. Heft. 164 Reviews. Construction and disintegration, though opposite processes do not proceed in complementary order, z‘. a, the one does not always begin where the other ends. As in the fall of a building, the destructive disintegration may begin in the chimney top or gable ends from some adverse winds or other external force applied to them, or in the foundation from inherent defect existing from the beginning of the structure. Despite all attempts to define, theoretically, how mental disorder must originate and proceed on the basis of how mental order is organized and progresses, the clinically observable fact is that mental aberration begins sometimes at one and sometimes at another point in the cerebrum, some- times touching first the perceptive, at others first implicating the reflective faculties, but more often the former than the latter if memory be a regis- tered impression of external or internal occurrences, and be a part of the perceptive life. The perceptive faculties and the senses, even in the order of nature, undoubtedly fail before the reflective powers give way. The old man ceases to see. hear or taste aright before he begins to think, and these perceptive failures first deceive and mislead his reflective faculties. In the physiological progression of mental life, from infancy through youth and manhood, to final dotage and senile imbecility, the last change of all, ‘is just what we so often see in what the author terms the develop- ment of mental disorder, not an involution beginning with the intellectual failure, but a progressive degradation, in which, “sans teeth, sans eyes,” the “last scene of all ” is “sans everything.” Dementia is the usual termination of insanity of long standing. It is most rare for insanity to begin with total loss of mind. so that we cannot concur with the author, notwithstanding the pleasure his very philos- ophical treatise has given us, that if his propositions are true (and we are not disposed to gainsay them) relative to the order of mental evolution, that mental disorder ends where mental evolution begins. That these aphor- isms are true, sometimes, may be conceded. That they are the rule cannot be demonstrated by observation, however tenaciously they may be held, as the theoretical base of progressive and retrograde mental movements. The author thinks that the order of mental disorder should be (and this is the rock upon which so many good men stumble) : " First, disorder of imagination or ideation; second, disorder of feeling ; third, disorder of memory; fourth and last, disorder of consciousness.” But, unfortunately, the order of disorder is more erratic and disorderly than the Doctor thinks it should be. Consciousness and memory are often the first to fail, as in epileptoid automatism, apoplexia and aphasia, and sometimes the feelings give way, as in melancholia and conscious morbid impulses, in a manner at variance with the patient’s reason. As might be expected, a mental philosopher holding such theoretical views of how insanity ought to proceed could not acquiesce in the existence of such well known forms of mental aberration embraced under the generic term “affective insanity,” such as moral and emotional insanity They are contrary to his view of what ought to be “ the order of nature,” and, of course, cannot exist (in his mind). He has provided no place for them. They are not because theoretically they cannot be. Moral and emotional insanity are in this view philosophical Reviews. 16 5 misconceptions, whereas the believers in these forms of insanity see them as clinical facts. “All philosophy,” according to Dr. Evarts, "which makes a generic distinction between morals and intelligence, imagination and reason, judgment and will, requires revision.” The mind is all and only reason, according to him. Of course, according to this philosophy, facts must be shaped if received, to meet the mental image of what insanity should be. ' We thank Dr. Evarts for the entertainment the reading of hisinteresting paper has given us, and for the strength he has added to our convictions that mental disease is a law unto itself, sometimes attacking the leaves and branches, sometimes the bark and the root of the tree of mental life, some- times destroying by vitiating conditions of sap or seed, sometimes destroy- ing by causes touching the top and from without. The paper may be read in the Cincinnati Lancet and Clinic for October 21st, 1882, and will set the thoughtful to thinking, and will repay perusal. N ERvoUsNnss. By Dr. Paul Julius Mobius, Leipzig, 1882.—In the preface to this work the author says: "As little as health and disease are divided from each other by a charm, just so little can the individual path- ological conditions of the nervous system be sharply distinguished from each other (bounded). He then gives a schematic drawing showing the relation of the most important general neuroses to each other and to nervousness (vide p. 7). Then proceeds to define these various disorders. Says (p. 18), “It is often difficult to discriminate between healthy stupidity and ‘pathological imbe- cility. In conclusion, he defines neurasthenia as follows: “ N eurasthenia is that form of nervousness whose appearances all possess the character ' of irritable weakness without the commingling of the features of other neuroses.” Causes of Nervousness.—Refers to the influence of heredity. Gives tables showing influence of heredity on the propagation of various nervous diseases (epilepsy, hysteria, etc.). Draws attention to the influence of age on the development of nervous disease (p. 45). Says puberty is a dangerous period for those inclined to nervousness. Says by far the larger number of cases of nervousness take place at the period of perfect physical ripeness (p. 53. appendix to this chapter). . School.-—" Of all the detrimental influences which react upon humanity during youth, and which may give rise to or encourage the development of nervousness, there is none so important as too early or too intense intellectual work” (p. 56). . Sea:.—“ The question whether nervousness and analogous conditions occur with greater or less frequency with men or with women is not to be answered with certainty” (p. 74). Race and Climata-There are no statistics bearing with certainty on this subject. ' Civilization.—“ The more civilized a people become, the greater the number of ‘head-workers." and consequently the more asymmetrical the employment of the head will become in comparison with the remainder of the body” (p. 83). 166 Reviews. Class.——“ If we except women, we can make two great divisions: Call- ings necessitating‘head-work,’ and such as demands. more particularly, ‘muscle-work ’ ” (p. 91). The Causes of Disease in a More Narrow Sense.-Mental Causes : “ Under this category, mental ‘ overtaxation’ belongs at the head.” Causes which A feet the Body: “Overtaxation of bodily function. Under this head belongs night vigils and intemperate sexual indulgence ” (p. 96). The Phenomenon of Nervowsness.—“ As in all neuroses, weakness of Will is a principal characteristic, and this also holds true in nervousness.” One of the first appearances is the impossibility of directing the atten- tion for any considerable length of time in one direction. Furthermore, the absence of individual calculation exhibits itself in this, that these patients become the playthings of their moods. Now comes weakness of memory closely related to “rapid fatigue,” which takes place on mental exertion. In many cases, the patient is easily excited, morbid intensity and anger are frequently observed. Indifference to those things which were formerly highly esteemed. Over-sensitiveness is the usual cause of melancholy depression. Rarer is anxiety without cause. Characteristic of nervous weakness is helplessness. Very frequent is morbid fear. Fear of t‘ thunder-storms ” among adults is frequently met with. Another form of fear is “place fear,” characterized by dread of lonely places, etc. (p. 109). Fear of being alone. “ fear of disease ” (p. 110), is not hypochondria, which is a continual consciousness of disease. “Compulsory ideas,” those which appear to one affected by them as alien, and which stand opposed to his healthy consciousness (p. 113). A particular form of the “compulsory ideas ” is the “grubbing mania” (p. 114), characterized by a. continuous querry after the how and why of everything. ' “Hallucinations of memory.” Quite as important as frequent are hallucinations of the senses; they occur not only with the insane, but also with the healthy. It is rare to find the nervous enjoying good sleep; most of them suffer from pronounced insomnia (l). 119). Again. others suffer from unnatural somnolence. Here and there nervous persons are to be found who suffer from somnambulism. An artificial somnambulism or hypnotism is also spoken of. . Dr. Mobius is one of the oldest of German neurologists. The appear- ance of this work is a sign of the increasing interest in this subject in scientific Germany, where there is now a larger literature of this nervous- ness and nerve exhaustion than in all the rest of the world put together. This work ofDr. Mobius is written in a very pleasant and interesting style, and contains many original and valuable suggestions that thoughtful persons everywhere should carefully consider. It deals philosophically and ably with one of the great problems of the present and future. GIORNALE DE NEUROPATHOLOGIA.—\V€ have received the initial num- ber of a new publication (8vo.. pp. 64). published at Naples. Prof. Francesco Vizioli is the general manager, and Drs. Raifaele and Antonio Vizioli the editors. In the programme, written by Francesco Vizioli, the necessity of such a puplication is insisted upon. He believes in the sentiments Reviews. 167 “enunciated by Erb in a discourse delivered at the opening of the Polyclinic at Leipzig, in which he contends that a division into psychopathology and neuropathology will have to be made, which, if it exist not in fact, still shows itselt plainly throughout the domain of nervous and mental diseases. Another illustrious German, Benedikt, has pointed out the progress of the division of labor and how it is a necessary consequence of the progress of medical science. It is on these words of Erb and Benedikt ‘that is based the whole programme of this publication. The name Giornale di Neuropathologia has been given to it to indicate its essentially clinical character, its object being the study of the nervous system from a clinical point of view. The question of cerebral localization and cortical excitability are reviewed at some length, and a resume of experiments given to determine ‘the question. The conclusion arrived at is that these experiments are confirmatory of the idea that electric stimuli reveal a function of the motor area and not of the other parts of the nerve centers. To sum up, it is asked that clinical phenomena, physiological observation and experimental data be all brought to bear upon this mooted question in order to bar- monize all these various facts in such a manner as to be of real value and benefit. The object of this journal, it is further stated. is to present papers and other subject matter on nervous diseases, and intended to subserve the interests of the general practitioner; for that reason, psychiatry will not the considered at all. One of the reasons given for this decision is that it is necessary on account of the large amount of material contributed to each branch. Under the head of “Original Articles,” will be embraced all that concerns neuropathology in its broadest sense. .In this will be included clinical observations, experimental researches and experiments in all the branches of medicine that can serve ,to illustrate nervous diseases. Under the head of “ Resume of Articles ‘ ublished in Italy and Abroad,” will be included normal and pathological anatomy, normal and patho- logical physiology, therapeutics and clinical notes. psychiatry and legal medicine. Particular attention will be paid to the Italian advances made in neurology and neuropathology. The “Analytical Reviews” will make special mention of articles which cannot be reproduced, and whose principal points. physiological, histological, pathological, etc., which may have a bearing upon the study of nervous diseases. will be given. The “ Synthetical Reviews” will contain short abstracts derived from various sources, unaccompanied by any commentaries. In the “Review of Scientific Societies " will be included the reports, facts and conclusions bearing upon the subject, and not included in the two former sub-divisions. The “Biography” will deal with reviews of domestic and foreign works. The “ Bibliographical Index” will include not only books and pam- phlets donated, but articles in journals and recent editions of works, or such as are difficult to obtain. 168 Reviews. “Varieties and Notices ” and “Scientific Correspondence” sufficiently explain themselves, and form the two last subdivisions. This journal deserves success, and will undoubtedly achieve it, from the fact that it will devote itself to a branch of medicine which is of imme- diate benefit to, and now demanded by, the general practitioner. It has received high praise from its Italian contemporaries, and deservediy so. Its editors have been identified with the subject of nervous and mental diseases for many years, and have had excellent opportunities for observa- tion, and a long apprenticeship to journalism will fit them for this under- ' taking-[Ohmann-Dumesnil.] THE DISEASE OF THE SCYTHIANS, AND CERTAIN ANALOGOUS Cosm- TIONS is the title given by Dr. Hammond to a monograph read before the American Neurological Association, June 23d, 1882, in which he records his observations of some “ mujerados,” or “womaned,” impotent men whom he found among the Pueblo Indians, similar to the unsexed anandrii or mares described by Hippocrates and referred to by Herodotus as having existed among the Scythians, and which Nysten has discussed in the Dictionaire de Medicine under the caption of Maladie de Scythes, as resulting, as Hippocrates conjectured, :from inordinate horseback riding, contrary to the belief of Herodotus and the Scythians themselves that the gods were at fault. The difference between the mujerados and the mares consists chiefly in the fact that the deprivation of verility is, in the former, intentionally produced by enforced masturbation and constant horseback riding “for a specific purpose in the saturnalia or orgies, in which these Indians indulge,” among which, Dr. H. states, is pederasty. The genitalia become atrophied, and the instincts and proclivities undergo a corresponding change, etc. The author shows that the essential point in the “disease of the Scythians ’ is that they act like women in consequence of impotency, whereas the cases of perverted sexual instinct described by Krafft-Ebing and others are not easily embraced within the .scope of his memoir. He classes the mujerados among the mentally alienated, yet the reasons for the classification do not appear quite plain since “the mvjerado," as the author states, “is an essential person in the saternalia or orgies in which these I ndians, like the ancient Greek s, Egyptians or other nations indulge ;” a mere “ passive agent in the pederastric cere.. monies which form so important a part in the performances,” made a mujerado by the tribe to which he belongs, “held in some sort of honor and need not work unless he chooses,” “no disgrace attaching to his position, the condition being one which is forced upon him by the power of tradition, custom and public opinion, and which, recognizing the impos- ibility of escape, he assumes, probably with reluctance in the first instance, but eventually with entire complaisance and assent.” A change of deportment, in a savage, brought about by adequate external cause, and in conformity to a tribal usage and a changed physical condition, which render certain physical functions impossible, must be regarded as rational in character, however much that change may be at variance with the proprieties and customs of civilization. Reviews. 169 The old chief who, by unmistakable signs and perfect equanimity, ad- mitted to having committed pederasty on one of these mujerados might not have been a reliable “Injun ” since the others “ avoided all reference to the subject and confessed the most complete ignorance of the matter when he questioned them directly thereon.” Insanity may begin in the head or in the testes, i. e., its exciting cause. A mujerado with a neuropathic diathesis might become a lunatic, and a lunatic might believe himself to be a mujerado. . CLINICAL LECTURES UPON EPILEPsY.*—This is a collection of lectures delivered at the St. Anne Asylum, which has already appeared in the Progres Medical. The first chapter calls attention to the fact that the crimes committed by epileptics exhibited,as a rule, a remarkably brutal and purposeless character. Epilepsy is, in Mr. Magnan’s opinion, an affection of markedly hereditary origin. Sometimes not only the tendencies but the disease itself is directly inherited. Fright and moral causes have been sometimes seen in the etiology of epilepsy, but in the majority of cases, these as Mr. Magnan says called into action the disease already in embryo. The epileptics in the majority of Mr. M agnan’s cases exhibit a marked change of character just prior to the attack. This has been observed as far back as the time of Paul Zacchius, who from it drew the well-known conclusions (Quest. Med. Leg., Frankfort, 1688) that epileptics were irresponsible for some time before and after an attack. The usual sensorial and intellectual auras are detailed at length. He- is inclined to believe that an aura starting from a cicatrix afi'ordsindications for surgical interference. He is inclined to believe, like Sommer (Archie fuer Psyehiatrie, Band V. and VI.) and Griesinger (Jour. Mental Diseases),- that mental disturbances, consequent upon epilepsy, may manifest them- selves in four ways: As pro-epileptic phenomena; as equivalent of the epilepsy; as post epileptic phenomena; or as intervallory phenomena. He also claims that insanities occur in epileptics without any connection with the epilepsy. He has never seen progressive paresis result in an epileptic. The reviewer has seen one case (Journal of Nervous and Mental Disease, April, 1878). he is inclined to believe that transitory mania is allied to epilepsy. The cases reported do not tend to corroborate this view. He is inclined to believe that epilepsy may be cured. He places great reliance on the bromides, but says nothing of the peculiar psychical results which Stork, Bannister, Jewell, Spitzka and the reviewer have observed as the consequence of their use in insane epileptics. To the use of ergot in this afi'ection he makes no allusion. Spitzka claims that ergot produces a number of minor discharges, which take the place of, and thus prevent,- the great epileptic discharge and its consequence. The book is interest- ingly written, and the cases cited clearly reported-K. MEDICO-LEGAL SOCIETY on NEW Yomn-The annual meeting of the Society was held on the 6th of December, the President, Mr. Clark Bell, . in the Chair. There was a very large attendance. Dr. 0. W. Mytel of Detroit, Mich., had an interesting paper entitled: “ What is expert testimony, and who are‘ it By M. V. Magnan, M. D. , Paris, De Paliage and Lecroisnier, 1882. I 70 Reviews. experts .9 ” Dr. E. Sanders, of New York, had a paper on “ The coroner sys- tem. Should it be abolished .9 ” At the election of officers for the ensuing year, the following officers were elected: President, Clark Bell, Esq.; 1st. Vice-President, A. O. Dor- emus, M. D. :, 2d Vice-President, Hor. D. C. Calvin; Secretary, Leicester P. Holme, Esq.; Assistant Secretary, Gilbert R. Hawes, Esq.; Treasurer, Jacob Shrady, Esq.; Librarian, R, S. Guernsey, Esq.; Curator and Path- ologist, Andrew H. Smith, M. D.; Corresponding Secretary, Morris Ellinger; Chemist, Prof. C. A. Doremus; Trustees, E. H. M. Sell, M. D. and B. A. Willis, Esq.; Two members of Permanent Commission, Hon. A. G. Hull and M. H. Henry, M. D. Large accessions to the Library were announced, and fifteen new members were elected. After the meeting, a banquet was given at the Hotel Brunswick, at which over one hundred gentlemen sat down; Mr, Clark Bell presided. Speeches were made by Dr. Nitgel, Gov. Stewart, L. Woodford, Judges Amore Calvin and Church, of Penn; Fethian, of N. Y.; Drs. Layn, Andrew H. Brutle, M. H. Henry and F. R. Sturgis; Hon. B. A. Willis, Morris Ellinger and many others. THE HARTFORD COURANT, of Nov. 29th, contains an interesting account of a meeting for the promotion of practical temperance, held the evening previous at Allyn Hall in that city, at which three specially forcible addresses, eloquent in facts and figures, which must tell for temperance, were deliv- ered by Drs. James Campbell, H. P. Stearns and John S. Butler. If the temperance cause ever wins, it will be through temperate measures, based on the disclosures of scientific observation, and none know better than observant and experienced alienists, like Drs. Stearns and Butler, the fatal potency of alcohol for harm, impossible to the organic basis of man’s moral, mental and physical constitution. When the invective of the rostrum is substituted by the careful cal- culations of science, and the destructive ravages of the demon of strong drink are seen by all, as they are now revealed to the few in race degen- eracy irreparable, then will temperance become the voluntary law of man‘s being. He will be unto himself a law of prohibition. SHoEMAKER’s OLEATES are not unctious substances designed for lubri- cating purposes in connection with one of the useful trades, as one of our friends conjectured, but favorite forms of prescriptions employed by our dermatological friend, Dr. John V. Shoemaker, whose interesting and instructive monograph on the “Oleates and Oleo-Palmiiates in Skin Dis- eases” is before us through courtesy of the Doctor. The monograph is from advance sheets of transactions of the Pennsyl- Vania State Medical Society, and worthy of careful perusal by all interested in dermatological therapeutics. GnErsINGER’s MENTAL PATHOLOGY AND THERAPEUTICS -—The issue of Wood’s Library for 1882, reproduced from the translation made by Drs. Lockhart, Robertson and Rutherford for the New Sydenham Society. in 1867. was first published in 1845. When these facts are considered, it is remarkable that our reviewer found so little in it that is objectionable. Reviews. I 7 I BuRR’s INDEX TO MEDICAL SUBJECTS is an improvement on any index rerum we have ever seen, and will give satisfaction to any who may wish a ready index reference to subjects desirable to refer to, in journals, text- books, etc. Manufactured and sold by the J. B. Burr Publishing (30., Hart- ford, Conn. THE YoU'rHs’ CoMPANIoN is the best paper of its kind among our exchanges. It is an excellent paper for hospitals and asylums for the non demented insane, its contents being always entertaining and unobjection- able WALsH’s PHYsICIAN’s COMBINED CALL-BOOK AND TABLET, like his virus “ takes well,” and should be in the hands of every practitioner. geeks, Monographs, Etd, (Received. Pathological Anatomy, Pathology and Physical Diagnosis. A Series of Clinical Reports, Comprising the Principal Diseases of the Human Body. By J. A. Jeancon, M. D. Progress Publishing C0,, Cincinnati, 0. The price is one dollar per vnumber and those we have seen are well worth the money. Burr’s Index to Medical Subjects. Adapted to the special use of phy- sicians and surgeons. An “index for future information or future use. All words and names are indexed by the first two letters, with nearly three hundred combinations cut in thumb holes in the edges of the leaves. Con- venient, saves time, labor, money and vexation. So valuable, that we heartily commend it. Manufactured and sold by the J. B. Burr ‘Publishing Company, Hartford, Conn. Die allgemeine 'Elektrisation des menchslichen Koerpers. By Sig- mund Theodor Stein. Verlag von Wilhelm Knapp, Halle am S. Lecons Cliniques surL’ Epilepsie. By M. V. Magnan, of Paris. Contribuzioni Allo Studio Sperimentale Dell’ Ipnotismo. By A. Tam- burini and G. Seppilli. Notes on Twelve Cases of Brain Tumor, Chiefly with Reference to Diagnosis. By Charles K. Mills, M. D., Neurologist to the Philadelphia Hospital, Lecturer on Medical Diseases, and Electro-Therapeutics in the University of Pennsylvania. Reprinted from the Archives of Medicine, Vol. viii., N o. 1, August, 1882. Comparative Vital Movement of the White and Colored Races in the United States. By S. S. Herrick, M. D., Secretary of the State Board of Health, Louisiana. Read before the American Public Health Association, Savannah, Ga., November 30, 1881. The Responsibility of Criminal Lunatics. By S. S. Herrick, M. D., Secretary Board of Health, State of Louisiana. Some Points on the Administration of Anaesthetics. By George H. Rohe, M. D., Professor of Hygiene and Clinical Dermatology, College of Physicians and Surgeons, Baltimore. Clinical Observations on Inflammation of the Mastoid Cells. By Edward C. Harwood, M. D., Member New York County Medical Society ; of New Yerk Neurological Society ; of American Medical Association etc. A paper read before the North-Western Medical and Surgical Society of New York, with a Report of the Discussion by Members of the Society Reprint from the Virginia Medical Monthly, Richmond, 187 7. Some Observations on the Therapeutic use of Alcohol. By Alfred K. Hills, M. D. Reprinted from the New York Medical Times, for August and September, 1882. Books, Monographs, Eta, Received. 173 Report of a Case of Pistol-Shot Wound of the Second and Third Cer- vical Vertebrw, Considered in its Medico-Legal Aspects.--Attempted Suicide-Death. By Edward C. Harwood, M. D. Reprinted from the Bulletin of the Medico-Legal Society of New York, Vol. iv., No. 5, March, 1882. The Therapeutic Action of Potassium Chlorate. By John V. Scho- maker, A. M., M. D., Philadelphia, Pa. From advance sheets of Trans- actions of the American Association. The Treatment of Syphilis with Subcutaneous Sublimate Injections. By John V. Schomaker, A. M., M. D., Physician to the American Hospital for Skin Diseases, etc. From advancesheets of Transactions of the Amer- ican Medical Association. The paper may some day appear in the transac- Statement of facts in connection with the quarterly Report of the Treasurer of the Medico-Legal Society of New York. Prepared for presen- tation at the meeting of Sept. 6th, 1882. By Ed. C. Harwood, M. D. Phlegmasia Alba Dolens. By P. V'. Schenck, M. D., Resident Sur- geon of Female Hospital, St. Louis. Read before the State Medical Asso- ciation. Reprint from the St. Louis Courier of Medicine. August, 1882. The Use of Hot-Water Injections in Uterine Disease. By P. V. Schenck, M. D., Surgeon to Female Hospital, St. Louis. Reprinted from the American Journal of Obstetrics and Diseases of Women and Children. Vol. xv., No. iv., October, 1882. Use of the Ecraseur for Curing Deep-Seated Fistula in Anno. By J. M. F. Gaston, M. D., of Campinas, Brazil. Extracted from the American Journal of the Medical Sciences for July, 1881. Menstrual Amblyopia. By M. F. Coomes, M. D., Prof. of Physiology, Ophthalmology and Otology, in Kentucky School of Medicine, Louisville Reprinted from the Medical Herald, October, 1882. Some Thoughts on Phthisis, with Special Reference to the Value of Laryngeal Symptoms in Diagnosis. By M. F. Cooms, M. D., Louisville Ky. Reprinted from the Archives of Laryngology, Vol. iii, No 3, July, 1882. Reflections on Criminal Lunacy, with Remarks on the Case of Guiteau. By Charles K. Mills, M. D., Lecturer on Mental Disease and Electro-Thera- peutics in the University of Pennsylvania. Reprinted from the Trans- actions of the Pennsylvania State Medical Society for 1882. Hall's Journal of Health, for November, 1882. E. H. Gibbs, A. M., M. D., Editor. Proceedings of the Seventh Annual Session of the Southern Illinois Medical Association. Annual Report of the Barony Parochial Asylum, for the Year 1881. Annual Report of the Government Hospital for the Insane for 1882. Biennial Report of the Vermont Asylum for the Insane. Twenty-second Annual Report of the State Lunatic Hospital at Harris- burg, Pa., for the Year Ending September 30th,'l882. Report of the Board of Trustees of the Arkansas State Lunatic Asylum, Little Rock, Ark., January, 1883. I74 Books, Monographs, Eta, Received. The Sanitary News, Vol. ii, No. 6, Hamilton, 0. Twenty-second Annual Announcement of the Bellevue Hospital Med~ ical College, 1882-1888. Thirty-ninth Annual Report of the State Lunatic Asylum, Utica, N. Y. 1881. Reports of the Lunatic Asylum of Georgia. Annual Report of the Superintendent of the Cleveland Asylum for the Insane. Report of the Vermont Asylum for the Insane, for two years ending July 81st, 1882. ' Report of the Medical Superintendent of the New York City Lunatic Asylum, Blackwell’s Island, New York. Fifth Annual Report of the Danvers Lunatic Hospital. Thirty-fourth Annual Report of the Indiana Hospital for the Insane. Extract from Third Biennial Report of Board of Trustees of the State Charitable Institutions of the State of Kansas. Relating to the Manage- ment of the State Asylum for the Insane, at Topeka, Kansas, for the Biennial Period ending June 30, 1882. The St. Joseph Medical Herald for January, 1383, Vol. i, No. 1. Edited by J. L. Geiger, M. D. and F. C. Hoyt, M. D., St. Joseph, Mo. Fifteenth Annual Report of the Inspector of Prisons and Public Char- ities on the Asylums for the Insane and Idiots of the Province of Ontario, 1882. Conjoint Session of North Carolina Board of Health and Medical Society of North Carolina, held in Concord, May 10th, 1882. ' Third Biennial Report of the Board of Trustees of State Charitable Institutions of the State of Kansas, for the Biennial Period ending June 30, 1882. Biennial Report of the Alabama Insane Hospital, at Tuskaloosa, for the Years ending 30th September, 1881 and 1882. Twenty-seventh Annual Report of the State Lunatic Hospital at N orth- ampton. Twenty-third Annual Report of the Longview Asylum, Carthage, 0., to the Governor of the State of Ohio, THE ALlENlST NEUROLOGIST. Vol. IV. OCTOBER, 1883. NO. 4. ORIGINAL CONTRIBUTIONS AND PREFERRED TRANSLATIONS. The Mental Status. of Guiteau--A Re- View. By JAMES H. MCBRIDE, M. D., Superintendent of the Hospital for the Insane, at Milwaukee, Wisconsin. IN the April (1883) issue of this JOURNAL, there appear- ed an article on the mental status of Guiteau, written by Dr. J. J. Elwell, a member of the Cleveland Bar. It will be the aim in the following brief review of the doc- tor’s article, to show wherein it appears to the writer that he errs, both in his argument and conclusions. The doc- tor treats of Guiteau’s mental status under five separate paragraph headings, and in this review I shall consider his propositions in the order in which he has arranged them. It is of course quite impracticable to quote the doc- tor fully; and in order that no injustice may be done him, all who read this review are recommended to first read carefully the excellently written article by Dr. Elwell. It is proper that I should preface this article with an apology for making such frequent references to myself. Having been one of that army of experts who so long besieged the court room during the Guiteau trial, it has been found quite impracticable to write upon the subject of the prisoner's insanity without making those frequent references to personal experience, which, if possible, I would gladly avoid. 544 . jarnes H McBride. First. “A person cannot be torn insane.”—-Dur- ing the past year this statement has been cried aloud from the housetops of psychological discussion with almost wearisome reiteration, and yet it is doubtful if there is any reason why the air should be so frequently rent in proclaiming an indisputable fact. It is unques- tionably true that no person is born insane; and it is also true, though apparently forgotten, that no person is born sane. At birth a human being is but a mass of human possibilities, determined and limited by his inherited or- ganization. No person can be called sane or insane, until hev has developed mind in some degree, and at birth a person has no mind, because the organ of it is quite undeveloped. “ There are no positive indications of the hereditary tendency to insanity being present in the Guiteau family.” It is really strange how men differ. If the Guiteau family did not exhibit a predisposition to insanity-properly attributable to inheritance-then the meaning of the term inheritance is narrowed to limits that are ‘quite insignifi- cant. When we consider the number of cases of insanity occurring among the uncles, aunts and cousins of Guiteau; when further we consider his mother was for eighteen months previous to his birth sick and helpless from some form of brain affection; that of her two subsequent chil- dren one died of quick consumption in infancy, and the other was deformed and died soon after birth; when we consider the mental weakness of the father, that the assassin’s only sister was insane some years ago, and has recently been declared insane by an Illinois jury, the wonder is not why Guiteau became insane, but how by any possible chance or accident a sound organization could come of such a union of mental and physical weak— ness and disease. During the trial of Guiteau, I saw much of his sister, Mrs. Scoville, and it was my opinion, as expressed at the time, that she was insane. John W.. Guiteau was barely an improved edition of his brother, and I certainly never saw so strange a mixture of sanity The Mental Status of Guiteau. 545 and folly as he exhibited. He was frantic, even unreason- able, in his efforts to save his brother, yet he retailed to every chance questioner the plans and secrets of the defense, and was a continual hindrance to Mr. Scoville. He said to me on one occasion that if he knew his father was insane, rather than have the fact proven, he would see his brother hung. There was a striking similarity of the mental traits of Guiteau and his father, with an exaggeration in the son of theieccentricities of the parent. Guiteau was a crooked limb of a tree that had few straight fibres in it, and because he was a little more degenerate in organization than his father, the cycle of his existence was briefer, and mental disorder came at an earlier period of life. Considering the eccentricities of the Guiteaus, the numer- ous cases of insanity occurring in the family, and in par- ticular the weaknesses of the assassin’s parents, We would naturally expect that mental disease and degeneracy would occur among their descendants; to expect sound organizations to come from such a source would be to :seek for pure water to flow from a poisoned fountain. That the law of inheritance may help to explain the mental characteristics and life of Guiteau, it is not neces- sary that insanity should have been transmitted to him by a. direct and unbroken line of descent. Family degeneracy may come from many and distant sources, from states of mal-organization in one generation that .are not easily named,‘ but which when further devel- oped in succeeding generations exhibit themselves in various states of disease, and in innumerable ‘forms of mental and physical deterioration. The offspring of par- ents who are merely of weak organizations may in one instance be consumptive; in another, cancerous; in another, epileptic, and in another, perhaps, insane; all, however, owing their diseased and degenarate organizations to a tendency to family deterioration. When a medical man finds that a number of near relations are afflicted with insanity or consumption, or any other disease that is known to be hereditary, he 546 fame: H. McBride. is' justified by every rule of logic, and all medical experience, in concluding that a disease affecting so large a number of persons who are related, *must have had its origin in peculiarities of constitution of ancestors. Insanity occurring in three brothers and three sisters and in certain of their children, and consumption occurring in other members of the same family, did not, probably, occur because of the special circumstances of life of each indi- vidual independent of any form of inheritance. Every med- ical man who considers such a family history will properly conclude, that the disease thus occurring has been derived by descent in some form-the expression in diseased des~ cendants of conditions of degeneracy existing in ancestors. ltis an unquestionable fact, that insanity and other diseases may have their origin in conditions of ancestral life, and organizations; although, in those ancestors these conditions may not develop actual disease, they may be .exhibited in forms of disease and degeneracy only in descendants. A large proportion of the insanity that occurs is due to direct and positive transmissal of the insane temperament, and another proportion is attribu- table to the inheritance of organizations that are simply weak and degenerate. This second proportion is as much due to inheritance as the first, and it is not to be ignored because disease in the ancestors was’ not fully developed and active. If all the insanity existing at the present day could be swept away, and with it all the hereditary tendency thereto,‘ insanity would continue to occur, and a proportion of it would be attributable to a form of inheritance. That is to say, insanity so occurring would be attributable to the transmission, from the previous generation, of conditions of organi- zations favorable to degeneracy. Guiteau, it is plain to me, owed his insanity not necessarily t‘o his insane father, nor to his diseased mother; but to a distinct and positive and common tendency in the Guiteau family to mental and physical degeneracy. If evidences of family degeneracy ever justified the conclusion that The Mental Status of Guz'teau. 547 there is hereditary predisposition, this conclusion is surely justified by' the history of the Guiteau family, in two generations of which there were many individuals who were either defective, consumptive or insane. That Guiteau’s alleged good health was inconsis- tent with the existence of insanity in his case is a claim that is not well founded, as every-day experience with insane persons shows. Insane people are frequently physically diseased, indepedent of brain disease, but they may also be physically sound. There is now a man in this institution who has been insane for about twenty years, and who has no discoverable disease of any organ, and who has never been seriously ill in his life, so far as it is known. In this institution of over three hundred inmates, there are a number of persons who enjoy excellent health aside from their mental disease, and it is not probable that the proportion of those who enjoy good general health is greater here than in similar insti- tutions. In relation to the autopsy, it is not probable that there will soon, if ever, be a unaminity of opinion regard- ing the significance of its revelations. Yet it would seem that those who insist that insanity is always a symptom of a pathological state, should be slow to cast aside as worthless the evidences of disease revealed in the exami- nation of Guiteau’s brain. Here was a man who was believed to be insane by his own relatives; who years previously had been declared insane by an intelligent and experienced physician who had abundant opportunity for observing his mental condition; who was also consid- ered insane by a number of persons who had seen him at various times; who was regarded as insane by a num- ber of medical gentlemen who had made insanity a special study. This man is .executed and his brain is examined by microscopists, who are disinterested and scientific gentlemen, and they discover evidences of dif- fuse chronic disease. All this, and much more, has appeared to me to be strong evidence of this man’s 548 james H. McBride. insanity, and yet some of those who have written in sup- port of the idea of Guiteau’s sanity have tripped over these matters with a jaunty air that is quite discourag- ing to one who is disposed to regard them in soberness. The careless ease with which such facts have beentossed aside, in the discussion of this subject, is shown by the reference in the article of Dr. Elwell, to the evidence of disease as reported in the examination of Guiteau’s brain. It seems to me, however, there is here a failure to interpret correctly the meaning of the pathological appearances in this case. As an architect can with the same materials construct buildings of various shapes, according as hefits those materials together, so the con- clusion at which one may come from a consideration of certain facts-will depend upon the way in which he regards those facts, upon his manner of fitting them to each other. If we accept it as a truth needingno quali- fication, that serious ,brain disease may exist without producing insanity, then of course the demonstration of the existence of disease in the brain of Guiteau is of little value in determining his mental condition. But to stop with such a statement is to consider the subject quite imperfectly. It is not sufficient to say, that because men have been known to remain in a state of sanity with serious disease of the brain, that, therefore the existence of dzfi’nse e/zronie disease is without special signification. In our study of this question we should take into consideration certain distinguishing features of the morbid conditions, which we attempt to compare. The trunk of a tree may be struck by lightning, and a large portion of it be destroyed, and yet, the part remaining uninjured ‘may take on the function of the part that has been destroyed, and the tree continue to grow, and to present the appearance of health. If, how- ever, the tree is attacked with a ‘form of decay that dif- fuses itself throughout its structure, its growth may be so seriously impaired that it will wither and die, and yet, the most careful examination may be necessary to dis- T he Mental Status of Guiteau. 549 cover the disease that destroyed its life. A man may have a large abscess of his liver, and yet wholly recover from it, and the function of the organ after- wards be properly performed. If, however, his liver be attacked with cirrhosis, though a -microscope be neces- sary to detect the morbid growth of connective tissue, yet we know that the disease will slowly but certainly strangle the little liver cells, and finally destroy the function of the organ. A bullet, or even a crowbar, may pass through the brain, and yet, after: the imme- diate effects have been recovered from, the mind will remain in the normal condition; a large abscess may form in the brain, destroy tissue, and yet- the person recover without any observable loss of brain'function. Experience teaches us that these things do occur, and our knowledge of physiology and pathology would lead us to conclude that they might occur, even without the lessons of experience. There is, however, a different and special significance in those forms of cerebral disease which are diffused and chronic, which are not localized and isolated in centers of healthy tissue, but in minute masses and microscopic colonies of degen- eracy, are found scattered in various regions of the brain.. When we discover evidences of this form of disease, we are justified in concluding that this wide-spread and serious impairment of nutrition implies a like serious im- pairment of function. The function is not only lost in those parts destroyed by disease, but the undiseased por- tions of the organ, through contributing to the main- tenance of a morbid process, lose to some degree in vigor of function. In the case of Guiteau’s brain, we are informed that in all parts of the organ examined by the microscope (more in some parts than in others) the nerve tissue was seriously diseased, the blood-vessels were diffusely and chronically degenerated, and other evidences of cerebral degeneration were discovered. Our knowledge of the pathology of insanity justifies 5 50 fame: H. McBride. the conclusion that the existence of diffuse and long- standing brain disease, such as was shown to have existed in this case, has a special significance, and ‘it seems to me that the reasonable and inevitable conclusion from the examination of Guiteau’s brain must be that the character and extent of disease shown to exist, was wholly inconsistent with mental health; that it compels us to conclude, that there could not have been in his case anything short of long-standing and serious mental derangement. This opinion is not expressed hastily, but after careful and impartial study of the case during life, and of the reports of the post-mortem examination; and in the light, dim though it may be, of nine years of patient investigation, which I have devoted to the microscopic pathology of the brain in insanity. Second. No one, perhaps, has claimed that a motive- less crime is necessarily an evidence of insanity. There is, however, much evidence of insanity in Guiteau’s reason- ing regarding the consequences to himself of the shooting of the president. ‘ His whole scheme of taking part in the presidential campaign, with a view to subsequent political reward, was conceived in insanity and grew to its absurd and colossal extravagance through the continual help of progressive disease. A man without even medium talent who has attempted to speak in public a hundred times and always failed, proclaims himself a political orator and asks for assignments to speak in a presidential campaign; to the prospective president from whom he would expect reward, he hands a copy of a wandering, empty and incoherent speech, which of itself would destroy all possibility of political preferment. He attempts to deliver this speech to a colored audience in the Bowery, but quits before he has completed it, because, as he said, he “didn’t like the crowd.” He subsequently claimed, and doubtless sincerely, that this speech elected Garfield president. Then he is seen in Washington seeking an appointment to a foreign mission as a reward for his imaginary political services- T he Mental Status of Guz'teau. . 55I He had not even one friend anywhere, was ignorant, penniless, ragged, bareheaded and without shoes, wander- ing about the streets of Washington, asking strangers to recommend him for the position of mmister to Austria. Then his contemplated visit to Europe after the shooting, his expected triumphant return and welcome by the nation, a reward for his crime, and an immortality as a nation's de- liverer. All this, we are told, was seriously entertained by a sane man, but to me it would seem to be the plans and con- duct, possible only to a person who was positively insane. In regard to the question of immorality it would seem that very much depends upon what men mean by immorality. When Dr. Beard says that all insane people are immoral, he doubtless has a different standard of morality from Dr. Elwell, who says that insane persons are not generally immoral, for it can hardly be that phenomena, which are every day being carefully studied by physicians, would be so differently interpreted. While it is probably not true that all insane persons are immoral, yet it is true that conduct which is regarded in sane persons as immoral, and certainly which is a viola- I tion of that which we regard as the moral law, is not only observed (as a symptom) in insanity, but it may be an early symptom of the disorder. A minister of the gospel stole books and surgical instruments, though he continued to perform the duties of his profession. Other evidences of insanity soon appeared, his thefts at the same time becoming more frequent, with finally no attempt at concealment. The pilfering was evidently the first symp- tom of the attack of insanity, which, after having lasted several months, ended in recovery. Another minister, as the earliest observed symptom of insanity, becomes intox- icated and at various times commits gross immoralities. A gentleman of wealth, during the development of general paresis, and as the first indication of the disorder, stole silverware and other articles that attracted his attention by their brightness. That the most tender, kind and affectionate persons 552 ‘ janzes H. McBride. become in consequence of insanity suspicious, unkind, cruel and even murderous; that they become untruthful, "treacherous and grossly immoral all this is well known~ and finds illustrations in every insane asylum in the world. The moral perversion of general paresis, puerperal mania and other forms of insanity has been widely observed, and the literature of the profession abounds with illustrations. We would, indeed, expect that a loss of the moral sense would necessarily result from insanity, because it is one of the latest and highest acquisitions of the race in the course of its development, and in accordance with the law of retrograde degeneration it would be one of the first to fail. Third. That novamount of deliberation is inconsistent with. insanity is a statement which is supported by an abundance of testimony. The insane man may be hasty, rash, impetuous and abandoned 'to some controlling idea that hurries him without reflection to the ‘commission of a crime; but he may also be calm, shrewd and delib- crate, and plan with all possible skill and foresight. The following is a forcible illustration of deliberation in the commission of a crime by an insane person, and which was hardly excelled by the much talked of deliberation of Guiteau: Mrs. Josephine A. Willner was for a number of years a resident of Milwaukee, and during that time was a patient of Dr. G——-, a prominent physician of the city. In 1874, her husband having died, she removed to Geneva, Ohio, where she continued to reside. For a year or two previous to her leaving Milwaukee, her acquaintances observed that she acted very strangely and by some was regarded as an insane person. After having lived in Geneva for some months, she wrote to Dr. G—, demanding that he quit poisoning the air, as this conduct on his part was injuring her health, and demanding also that he quit interfering with her affairs in Geneva, through atmospheric influences. Finally, to avenge her imaginary The Mental Status of Guiteau. 553; wrongs, she decided upon a plan of action and proceeded to carry it into execution with all the care and deliberation .conceivable. With “excellent judgment and care” she selected a pistol, carried it home and attempted to shoot with it at a target. It did not act to suit her, however, and she also states that she did not like the appearance of it, as “it had a rough, unladylike handle, and that she wanted a better-looking pistol.” She exchanged it for another pistol, and with this she practised shooting at a target in her back yard during the period of four weeks. She then started for Milwaukee, distant seven hundred miles. She changed cars at Chicago, and during the ride to‘ Milwaukee, of one hundred miles, was noticed to be quietly reading a book. At Milwaukee she took a car- riage, drove to the residence of Dr. G—, called him to the door and shot him dead. As she had not been satis- fied with one or two chance shots at a sapling, she did not need to shoot but once, and sent the bullet to a. vital spot. She says that she purchased the pistol and practised with it, with the distinct intention of going to Milwaukee and killing Dr. G—. She was found insane, and is now held in this institution by order of the court, There is not now, nor has there ever been since the time of the homicide, any reason to doubt her insanity. Fourth. It is not probable that Guiteau was the originator of the plea of insanity in his case. Not that it would be inconsistent with the existence of mental disorder, but from my acquaintance with him I do not believe that such a plan of escape would have occurred to his weak and chaotic mind. That an insane person may plead insanity as an excuse for crime, findsv an illustration in a case now in this institution. Mrs. Crocker, ' a lady who had been well educated and who had studied law, had resided in Milwaukee for many years, but had latterly been a resident_ of Washington City. Because of certain differences between herself and her stepmother, she came from Washington to Milwaukee, appointed an interview with that lady at the office of a lawyer, and, ‘554 fame: H. McBfide. without any immediate provocation, shot at her step- mother. When the case was called for trial, she put in the plea of insanity, claiming that she did the shooting in obedience to a command received at night from the .spirit of her dead father. She insisted that at the time of the shooting she was insane, exhibited much interest in the trial, and suggested to the attorneys questions to be put to experts. Being put upon the stand, she claimed under oath that she was insane at the time of the shooting, and underwent a long examination without ariy apparent inconsistency or contradiction in state- ment. She was acquitted on the ground of transitory mania, and was set at liberty. She was soon after arrested for another offense, and upon trial, being ‘declared insane, was committed to this institution, where she now is. She was undoubtedly insane at the time .she attempted to shoot her stepmother, the insanity having existed for a number of years previous to that time. She states that the plea of insanity at the time of the first trial was false, that she did not entertain the delusion which she claimed to have entertained, and that she only entered the plea to escape punishment- There is no doubt in my mind that her statement is true, and that her claim that she was influenced to commit the deed through the commands of her father’s spirit, was entirely false. Such a delusion would not be in keeping with her other mental symptoms; it is totally _ unlike those she is kown to entertain, and a belief in the communication with spirits is one which she is now, and always has been, prompt to ridicule. She is shrewd and intelligent, but entertains many wild and extravagant ambitions which remind one of Guiteau, though, intellect- ually, she is far his superior. On Thanksgiving Day (Nov., 1881), Guiteau said to me in the presence of another physician, that he had never read any works on insanity or on the jurisprudence of insanity. When I asked him the general question, if he had read works on the subject of insanity, he replied T he Mental Status of Guz'teau. 555 that he “supposed he had and thought he knew some- thing about it,” and was evidently anxious to impress me with the idea that he was acquainted with the literature of the subject. When, however, I mentioned the names of the various prominent authors on insanity, he said that he was not acquainted with what they have written. He admitted his ignorance of this subject with evident reluct- ance, and as I pressed him with questions regarding his knowledge of works on the subject of insanity, he became excited and impatient, and dismissed the subject with his favorite phrase: “I know nothing about it, and I care nothing about it.” That he had a scrappy knowledge of the cases of Sickles, McFarland, Freeman and Coles- Hiscock, is probably true, for a person could not read law, even in the superficial way in which he read it (and certainly he could not read the daily papers), without being informed somewhat regarding these cases. There is no evidence with which I am acquainted, however, that he understood their legal and scientific bearings; he sim- ply may have known the plea in each case and the resultof the trial, and this is knowledge which many an insane man might acquire. Fifth. Notwithstanding the medical talent which arrayed itself on the side of Guiteau’s sanity, it does not necessarily follow that he was therefore a sane man. In matters of science neither majorities nor minorities are to be considered, but opinions are to be valued according as they harmonize with experience and scientific knowledge. On the question of Guiteau’s sanity we know the doctors were divided, unequal though it was. After as careful an examination as I could give to the mental condition of Guiteau, I believe that he was an insane man at the time he shot the president, and that he had been insane for many years. From my observation of him, it appeared to me, that prominent mental characteristic of the man was that of congenital defect of organization, and to this had been added mental degeneracy. F556 fames H. McBride. I am aware that he was regarded by some as a man of talent; yet to me his positive and serious lack of sense and judgment was the first thing that impressed me, and the more I studied him the more was I impressed with the belief that, mentally, he was by nature and disease weak and degraded. He had a certain amount of super- ficial cunning, as persons of a certain grade of mental defect have—he would occasionally say a smart thing or make a witty sally, but the imbecile “court fools” of old could do this and they were laughed at by royalty. "Guiteau was one of the class of persons whom we meet in asylums and out of them, who though congenitally men- ‘ tally defective, are cunning, restless and wayward, occupied for a time with strange and impossible schemes, who are interested in everything by turns and nothing long, pursue senseless and impossible ambitions for a time and then tire of them one by one, like a boy with his tops and hoops and marbles, and devote their senseless enthusiasm to some other chimera. The peculiar memory which Guiteau exhibited, appeared to some to be inconsistent either with insanity or congenital defect. It may be con- fidently stated, however, that his memory was one which persons who are congenitally mentally defective may pos~ .sess. There'was not an incident of his life which was too trivial for his microscopic recollection; his memory was .stored with the petty incidents of an existence that was pitiably dwarfed and inferior in all its possibilities. It was the memory of a savage of an inferior mind, taking account of the trifling events of a life that was itself trifling, because it was that of ‘an inferior organization working out its own poor and mean salvation. It was a memory which sensible people do not have, which in fact they cannot afford to have, for it would be like filling the ‘valuable space of a warehouse with the garbage and rubbish of the street. Superior minds'remember prominent incidents or gen- eral principles, but‘rth-ey do ‘not stop to treasure the trifling and trivial occurrences of each day. Guiteau, with The Mental Status of Guiteau. 557 all his Indian-like memory, was doubtless quite incapable of I committing to memory a page of printed matter or of com- prehending general principles of law, or indeed principles of anything. He was as superficial as he was quick; his mind was wandering, restless, and his ideas on all sub- jects quite chaotic, and the mind he possessed was but the miniature of sense and sanity. During repeated interviews with him, I questioned him on the subject of the history of this country and of Europe, the history of political parties, and also regarding his knowledge of the history and principles of the Chris- tian religion. When asked the ‘general question he would assert in his egotistic way his familiarity with a subject, but upon further questioning it would appear that he was ignorant of it. He was, in brief, an ignorant man, because he was incapable of acquiring‘ knowledge, and because his mind was dwarfed by nature and hopelessly disordered by disease. In concluding this paper there are two considerations suggested by this discussion which may be briefly alluded to here. Space will not permit of the elaboration of an argument sustaining these propositions, and I will con- tent myself with a hasty statement of my conclusions concerning them. “The only line that science can draw upon the definite knowledge as yet acquired of the human con- stitution, is that which defines insanity to be a positive pathological state, a physical disease which forms the underlying basis and cause of all the complex mental phenomena by which chiefly its existence as disease is popularly recognized.”—Am. four. of insanity, ]an., 1882, p. 306 and 307. Our accepted definitions of insanity are based upon the assumption that the disorder is always the product of disease; that however badly organized one’s brain may be, he cannot be technically insane except his brain is diseased. It is R. W. Mackey, I believe, who says that 5 58 james H. McBride. definitions are less exact as human knowledge progresses. As man advances in knowledge and in his ability to comprehend laws that are more and more general, he learns that nature nowhere in all her infinite varieties makes sudden leaps nor draws sharp lines of distinction; and, therefore, his definitions which artificially separate and abruptly limit and demarcate, do gradually and in- evitably lose their value. Mr. Curdle was applauded for his definition of the dramatic unities as “a sort of a general oneness,” a specimen of word-jugglery equally applicable to the universe or a housefly. Bichat, was it not, defined life as the “totality of those processes by which death is resisted.” In this definition, it was thought he expressed a great truth of nature, yet he taught men nothing by it; he simply turned an intellectual hand- spring and came down in his own tracks. Let anyone read the thousand definitions of insanity that have from time to time expressed men’s knowledge of morbid mental states, and he will observe that the meaning of the term insanity has been continually chang- ing, and he will observe also that the boundary-lines of the disorder have, as expressed in definitions, become more extended and more indistinct. Compare the technical insanity of the time of Coke or of Hale, with the tech- nical insanity of the present day, and behold the change! Definitions are indeed fascinating things, and in a measure useful, but they are continually misused. They are but expressions of a temporary phase of knowledge,- they are at best but rude approximations to the truth, and are destined to endless change and re-arrangement. It is doubtful if the present definitions of insanity, which assumed that the disorder is the expression of disease, are consistent with medical experience, or with the teach- ings of modern science. It will doubtless be considered quite unorthodox to detract from this time-honored dic- turn of alienists; we all have a fondness for it from long association, it being the bottle from which the new- comer in the nursery of psychological science is first fed. The Mental Status of Gnz'teau. 559 It should not be forgotten, however, that error is of all things positive, and contented with herself. Science-that ‘embodiment of knowledge—has come, in part at least, through doubting that which was regarded as unques- tionable, and through consequent change and reconstitution 'of human knowledge. To question the correctness of accepted theories may be a means to progress; scepti- cism, therefore, in matters of science is to a degree desir- able, and it is this day helping to turn the wheels of human progress. It is admitted that the force called mind, if not pro- duced, is at least made manifest through the agency of the brain cells, and it is also admitted that‘through dis- ease of these cells, or certain clusters of them, mental disorder may result. Many, however, who accept these .as just conclusions, deny that through an originally faulty arrangement and association of these same cells, there could result mental disorder. To the minds of some there appears to attach to the word “disease,” a sort of magic by which nature accomplishes very strange results, and results too, which she cannot imitate by any con- dition or process that is not essentially morbid. It is true, however, that there are conditions of mental iunsoundness which are not produced by disease, but which are due to malorganization of brain; and if we ‘observe the conduct of those who are unsound from defect of brain organization and those who are unsound from brain disease, we find that distinctions which we attempt to draw are quite ‘unwarranted. An idiot boy who has seen his father kill a sheep, concludes that he will imitate him, and kills his little brother; but no one would believe it just to punish the idiot. Please remember that this idiot’s brain is not dis- eased and he reasons too, but because of inborn twists of organization he reasons badly, and acts badly. A mother, who when mentally sound is kind, tender and affectionate, has an attack of melancholia, and during the continuance of the disorder, kills her three children; 560 jaines H McBride. but no one, perhaps, would believe it just to punish her ' for conduct which was the result of disease of the brain. Then disease cannot be the only test in such cases, for surely the idiot’s mind is not less unsound in every sense of the word, than the mind of the mother. Keeping this in mind, let us go a few steps further, and consider a person who is not an idiot, and yet whose brain is badly and imperfectly organized. This man, in consequence of his defect, reasons badly about everything, he is incapable of applying himself except in a profitless and paroxysmal way which only emphasizes his degenerate state, and his life is utterly worthless and aimless, though it is the best that he can make it. Finally, in a time of political excitement, he conceives the idea that he will do a patriotic act by killing the ruler of a great nation. He reasons so badly that he believes that in place of being shut up as a lunatic, he will be considered the great man which he conceives himself to be; that he will be hailed as a deliverer, and rewarded for his act. 50 he kills the president, and he is so unreasonable as to suppose that if he can only conceal himself for a few days, the public, which without understanding his patriotic motives may at first feel disposed to punish him, will after having had time for reflection, conclude that his act was a meritorious one. Now all this reasoning, if such it can be called, is the work of a disordered mind, and his thoughts run in this channel because the only existence of which his poor dwarfed nature is capable, forces his thoughts so to run. Though he be several grades higher in organization than the idiot who killed his brother, he certainly is several grades lower in organi- zation than any man who can properly be called sane; and if we fail to recognize this slighter degree of defect, it is probably the fault of our methods, certainly not the fault of him who is defective. Therefore, if we have in our possession a poor old definition, the requirements of which are that this man shall be hung, the question is whether we shall execute the man or the definition. The Mental Status of Guiteau. 561 Reason would seem to suggest, that we should save the man_from judicial murder and hang our definition, which, though it may have done well in its time, is old and useless. It would seem, therefore, that the distinction which our definition of insanity attempts to make is one which can- not properly be made; it is a definition which does not define, and no amount of metaphysical gymnastics which may be performed about it will conceal its conspicuous imperfections. The weakness of this definition may be made more apparent by a further consideration. In studying the methods by which nature- works out the problems of or- ganic life, we find that without invoking the aid of disease, she yet departs in many instances from her general rules of work, and produces every possible degree of defect and deformity. She gnarls and twists a tree and causes it to grow crooked, yet the tree is not diseased; she bends the bones of a human limb; she constructs a defective heart; she makes defective muscles for the eye, yet in neither case is there disease. We find, also, that in the construction of that most complicated of organs, the brain, that nature’s architecture is sometimes faulty, and that there is every degree of structural defect in cerebral organization. The most serious defect in brain organization is called idiocy; a less serious, imbecility; and a less serious still, has not been named or classi- fied. The subjects of this slighter degree of defect are left to drift about the world at the mercy of their sense- less vagaries, to curse society with their useless and annoying liberty; and when following the evil but resist- less impulses of a bad organization, they kill some one, then we rise up in virtuous indignation and choke them to death. The question occurs then, does it necessarily follow that before a person can be considered insane, there must be a change of mental character produced by disease ; may not insane beliefs and conduct be the natural product 562 jar/res H. McBride. of a bad mental organization? One man may entertain a false belief because his brain is in a morbid state ;‘ he arrives at his conclusions not from choice and correct reasoning, but because of the action of a diseased brain. Another may entertain a precisely similar belief, because there are wanting in his brain certain parts essential to proper reasoning, or because of a bad arrangement of existing parts. He, therefore, arrives at his conclusion not from choice, nor because of a morbid process, but because - of the chance suggestions, the wayward and imperfect logic of a defective mind. If in the first instance, there is insanity in consequence of disease, why is there not insanity in the second case resulting from oad organization? A human brain may, in fact, be so badly organized, that in its evolution there is not only defect of mind but disordered mental action; so badly organized, indeed, that deranged action may be its only form of activity. ' If nature inacertain case organizes not only a bad brain, but certain other parts of the system, which determine the preparation and assimilation of nutritive material, so that the nutrition of the brain fails to be what it ought--so that the individual thinks imperfectly and incoherently-surely the individual cannot be consid- ered responsible for his conduct which results from his defective organization. While, therefore, it may be allowable in the two cases mentioned, to make a distinc- tion in names and to say that one is insane and the other is an imbecile or something else, so far as their responsi- bility is concerned there would surely be no difference. The true test in each case should be the reasonableness or the unreasonableness of the belief considered in con- nection with the condition and life-history of the individual. One entertains the belief in consequence of disease, and in the presence of his belief he is helpless; the other entertains the belief in consequence of malorganization, and so, in the presence of his belief, he too is helpless. ' In the view here taken, therefore, insanity is not The Mental Status of Guz'teau. 563 necessarily and always a symptom of disease; it may be so, and it may also be an indication of a badly organized brain. In the case of Guiteau the difficulty of reconciling his mental characteristics with that iron-bound require- ment that one must have changed through disease from his normal self before he can be considered insane, was a difficulty that was serious with certain gentlemen. They could not see that he had “changed,” and, therefore, they could not‘ consider him “technically” an insane man. If Guiteau, however, with all his wild and strange delusions, and his utter unreason was not, “technically” insane, then it is only the worse for the technicality. Bellingham, an insane man,- killed Prime Minister Percival, but he was hung because he happened to know enough to be able to distinguish “right from wrong.” He was not, according to the accepted ideas of the time, “technically,” an insane man; and, therefore, because he could not be handsomely fitted with a definition, he was taken out and executed. “’ When science cannot speak definitely and with authority, it is her duty to be silent.”—A1nerz'ean journal of Insanity, January, 1882, page 306. The scientific man is entitled to give definite and positive opinions, if he but remembers that his most cherished laws and highest principles must in the inevita- ble progression of human thought be subject to cease- less change and rearrangement. As nature in the pro- cession of the seasons forever renews, unfolds and advances in her forms of life, so must the laws and prin- ciples of science in the evolution of human knowledge be forever modified and revised. The scientific man, while he uses every fact for its full worth, knows that the time will come when it will be laid aside as an outworn gar- ment of the mind, and its place be taken by ‘those that, having a higher and a better meaning, answer to new and advanced conditions of development. Therefore, 'every fact or principle is to be used for a time, its enduring parts assimilated in human knowledge, and then its 564 janzes H McBride. identity will be lost in facts and principles that are higher. The scientific man, for the sake of being authoritative and definite, does not cling to‘ the remains of principles that human thought has outgrown, neither does he des- pair because in his intellectual advancement the horizon of human thought stretches wider and wider about him. Being himself in intelligent harmony with nature’s law of progress, he gladly welcomes this rapid growth of knowledge and this perpetual rearrangement of the forms of thought as the prophecy and promise of an unlimited development, and of which the science of the present time is but the first faint rays of the coming day. To the man of science human knowledge is always readjusting itself to the ever-renewing conditions of mental progress; to him each principle is but a temporary formulation of human knowledge, each fact is but an outpost beyond which there looms a vast and untrodden region of higher facts which forever multiply as he advances, and yet forever lure him on. The medical expert may be positive in his opinions, in so far as positiveness is warranted by facts, if he bears in mind the necessity for this occasional revision of his beliefs and definitions in order that ' they may harmonize with the inevitable progress of science. There is, however, on the part of psychological expert witnesses, a tendency to an unwarranted positiveness of statement. The temptation for the psychological expert to be positive in his statements is great; for then he can more easily sustain himself as a witness, and he is less liable to be entangled by questions that are sug- gested when doubts are expressed. Hence the expert witness in cases of insanity is usually positive, and excep- tionally admits having a doubt. It is a fact, however, that in quite a proportion of cases upon whose mental condition experts are required to give an opinion, the insanity, if it exist, is not fully developed-it is in the formative stage. The Mental Status of Guiteau. 565 Indeed it is in these obscure cases that the services of experts are most needed-—these cases that occupy the doubtful region between sanity and insanity. Yet it is, perhaps, just to say that experts in their testimony seldom appear to have discovered these cases; every case is placed clearly upon one side of the line or upon the other, and the transition period would appear to have no existence. In reading much of expert testimony one would suppose that in developing insanity nature departed from her wise rule of passing from one extreme to another by imperceptible gradations, and that she passed from sanity to insanity, not over a debatable region, but by a sudden boun'd. Definitions are hence unconsciously framed, so that doubtful cases are excluded and the defini- tions themselves tend to support the experts in an unwar- ranted positiveness. The harm of being uncompromisingly positive is, how- ever, witnessed by a thousand errors that such positive- ness has bred in the past, and by a thousand crimes committed in the name of unquestioned beliefs. The stake and the thumbscrew were positive, and they were the natural products of faiths that would not submit to be questioned, and which silenced the consciences of those, who working towards mental freedom, were inclined to listen to the whisperings of doubt. Yet all experience teaches us that it is right to doubt, and that an honest doubt has as much right to its existence as has an honest conviction. The law tells us that the reasonable doubt of one I man can outweigh the positive convictions of eleven men and any array of evidence; nor does the law say that this doubt should be concealed, butrather that it should be expressed. If the psychological expert entertains an honest doubt he will only entertain it as the result of intelligent reasoning. Pray, why should he not, like a brave man, give expression to that doubt, and bravely also give his reasons for entertaining it? Changes in Handwriting in Relation to Pathology. In review of the works of the following authors, 'viz: Ma'roé,~ Poincare, Charcot, Buchwald, Erlenmeyer, Vogt, Swortzofi‘, Grasset, Ireland and Durand. 1863-1882. By A. BIANCHI, M. D., ltaly.* HE study of the alterations observed in the hand- writing of different individuals, is useful in the diagnosis of some maladies which have their origin in alterations in the nervous centres, and may guide us in their diagnosis and treatment. Varied as the diverse cus- toms of the peoples, stand the written signs in their form and their groupings, to denote the different degrees of the civilization of man, and following them up from the cunei- form and hieratic characters of the ancient Asiatics and ‘Africans to the sculptured signs of the Indians and the Mexicans, from the written words of the Thibetans and the Chinese, numberless as the ideas and objects, to the forms of the alphabet of our times, we see that, along with the development of civilization, there is to be observed a gradual and progressive perfectionment of the written speech. This has led to the endowment of man with the power of presenting, by means of a few letters, so many combinations as, by their varied groupings, suffice to repre- sent the names of the various objects he may desire to indicate, and to evolve his own ideas. But, if the study of the various and progressive im- provements of written language is important in ethnology and anthropology, it may well have some importance for the physician who must occupy himself solely in the alter- ations, psychical and mechanical, which may be met with in the actual mode of writing of different individuals, *Translated by Joseph Workman, M. D., Toronto, Canada, from I! Pisani - Gazetta Sicula. Palermo, 1882 - Changes in Handwriting. 567 especially in certain morbid movements. All the obser- vations hitherto made relate to the common English characters, and only a few have been accomplished, in Germany, in the Dutch characters, which are, however, pretty near those of the- English; only a few have been obtained in the Semitic, Arabian and Indian. We are not at present aware of any study of this sort made by our‘ physicians in the diseases of China and japan, though it would certainly be important to see whether, with these people, who for every idea have a distinct written sign, the diseases of the nervous system always effect the same . alterations in their written language, as are observed among us. However, limiting ourselves to the simple observation of facts made by the physicians of those countries in' which written words consist in the union of the letters of the alphabet, we must make a few distinctions in order to- render the subject more clear. A 1st. Physiology of Writing.—When we examine the method of writing, it is seen that every people traces the characters with the right hand, whether from pre- ponderance of structure, result of habit, or education; it is observed that, whilst the Asiatics write from above downwards, and from left to right, the Semites and the Arians trace their writings in lines one below the other; but the former from right to left, and the latter from left to right, the one presenting the centripetal and the other the centrifugal course. The psychicho-mechanical act of writing is, according to the majority of physiologists, executed by a reflex mechanism, similar to that of oral speech, with the sole difference that the acting muscles are those of the hand, on which the reflex act, and that the sensation comes, for the most part, through the organs of sight, although the auditive sense also takes a notable part. Hence, in order to learn to write, it is necessary, not only that the pupil shall see the signs, but also that, being heard, he should understand what is intended to be expressed. 568 A. Bianc/zi. An optic impression is therefore requisite for learning to write, and for the awakening of the activities of the motor cells which are in relation with the muscles of the hand; and those cells vare probably located in a given centre, which, according to some, is one and the same with the centre of oral language, but according to others it is quite different. The former authors base their asser- tions on numerous pathological cases, in which both the written and the spoken language were lesioned at the same time; the latter, on the other hand, rely upon cases equally numerous, in which the spoken language was lesioned and the written not affected, or vice versa, and upon the apti- tude shown, for example, by deaf mutes (individuals in whom vocal impressions awaken no reflex action on the centre of speech), to learn to write and to converse by different movements of the hands. The opponents of these authors adduce, as an example, individuals born blind, who, although they have never received a visive impression, can yet learn to write, under a patient system of education; they are habituated to receive the tactile impression of the ‘various letters of the alphabet, and to join them in such a manner as to compose the diverse words expressing the objects touched by them, the ideas which they adopt, or the words heard by them. (A diagram is here presented for the purpose of more clearly representing the author’s “scheme of the probable mechanism of language,” the eye and the ear being the receivers of impressions. From the eye the impression is transmitted to the “visive nucleus of the optic thalamus, thence to the related cortical cells, then down to the corpus striatum, which acts on the medulla, so as to put into motion the muscles of the fingers. As to the aural impressions, they are figured as going into the auditive nucleus of the optic thalmus, thence to the cortical cells, and thence down to the bulb, which excites the vocal muscles, ‘or to the medulla, which puts into motion the muscles of the hand. Having thus, to his own satisfaction, disposed of the navigation of sights and sounds, the author proceeds): Changes in Handwriting. 569 “Furthermore, instead of auditive and visive sensations, there may be intellective currents, which, carried to the medullary centre, may give place to motions of the fingers for writing. The results of the impressions which may be transmuted into written language are therefore three,- the visive, the auditive and the intellective. The tactile may supply the part of the visive, in exceptional cases, after long habit; the intellective are indispensable to good, regular and sensible writing. The collocation in the cere- brum of a centre for the co-ordination of the motions necessary for writing, is a reasonable thing. Woroschiloff believes that this centre is in the medulla, near its cer- vical swelling, because he saw that, in a dog, here was the centre for the associate motions of the fore and hind limbs. But, in order to explain well the mechan- ism of writing, we cannot bring to our aid the experi- ment of comparative physiology, as this is powerless in presence of this phenomenon, which is the exclusive faculty of man, and hence man alone can be the special study relative to the psychical mechanism of writing. It is not, then, comparative physiology, but truly the physiology of man, or better, the exact clinical study of cases of central lesions, with alterations of written language, which can throw sufficient light on this phenomenon, and instead of hypotheses, more or less reasonable, may sub- stitute a theory safely founded on an unassailable basis. But as yet this is difficult, since the patients met with in clinics and hospitals are mostly ignorant of writing; and, ’ therefore, whilst we are able to recognize the varied series of alterations in spoken language, we cannot, with equal security and frequency, study those produced in written language by central lesions. That the difficulties of observation are great, is a fact proved by the limited bibliography which, up to the present, the subject exhibits; and it is exactly for this reason that we have been induced to press it on the attention of physicians, in order that, from multiplied observations, truth may emerge. Attempts have been made, and are 5 70 A. Buz'anehi. still made, but hitherto the result has been certainly only little encouraging to him who would occupy himself on the alterations of written language, unless he starts with the conviction that only by persevering and daily fatigue he may reach a fortunate result. In this way the legal expert has so far succeeded, that from macroscopia and microscopic study of various writings he is enabled to dis- tinguish alterations introduced into them, artificially, from those made by the original writer. I need not say how much psychiatry may be benefited by the study of the psychical composition of the writings of the insane, enabling us at such times to judge, from the simple exam- ination of them, as to the intellective lesion which has fallen on a given individual, and to form a prognosis sufficiently secure. In the meantime, from the divers observations of physiologists, it may be concluded that writing, a most complicate muscular art, is a truly marvelous thing. For the purpose, first of all, the instrument with which the written signs are to be made, must be firmly fixed by the flexors of the first three digits; next, the whole hand has to join in the action of the flexor and the interosseous muscles, and finally a regular precise motion must be required of the hand itself. This motion, among the Arians, proceeds from left to right, by means of the extending of the wrist and forearm, and a rotation and abduction of the arm. By 'this mechanism a right line only can be traced, and it is requisite, in order to effect the writing, that, during the tracing of this line, the pen shall describe a series of right and curved lines and points, by alternate con- ‘ tractions of the flexor and extensor muscles. Buckhardt has, with a miographic apparatus, explored the three groups of muscles which are in operation in writing. They are the interosseous and the long exten- sors and flexors. He saw that the interosseous can hold ' the, pen and trace the letters; that the long extensors aid them in the more extended motions, and maintain Changes in Handwriting. 571 the semiflexions of the hand; and that finally, the long flexors, with the muscles of the hypothenar eminence, are the antagonists of the interosseous, and act only in the fixing of the hand and the formation of the letters which are prolonged below the horizontal line on which the others are traced. But, according to the individuals, there are modifications of this mode of action, and we see some using one muscular group in preference to another. Hence, the act of writing presents a tonic action (fixation of the hand and the pen), and a clonic motion (formation of the letters). In order that the writing shall be normal, there must be regularity in the transmission of the psychical impressions, a uniform dis- tribution of the nervous excitations in the muscular groups, and precision in the relation of these muscles. In conclusion, the formation of a written letter sup- poses that the motions of the fingers and of the hand, together with the psychical excitation, form in the brain a figurative impression, which, being often received by the memory, diminishes, each time a little, the time necessary for the production of an action which finally becomes unconscious. ' But it is certain that the mode of tracing characters, so varied according to different peoples and different tissues, must not have as cause any specific conformation of the brain, but must rather be the result of primitive habits and external causes observed in every people, and which, ' by inheritance‘ and education are transmitted, and after- wards necessarily retained. It is thence a fact well known, that all peoples, with the exception of some Orientals (Mussulmans, Buddhists, Semites), trace their characters from left to right, and centrifugally as regards the axis of the body, and all write with the right hand. This fact, ' explained by some as depending on hereditary transmission, education, and also the more precocious development of the left hemisphere of the brain, is yet involved in darkness. I ’ 2nd. Classzfication.-—Erlenmeyer has recently divided 5 72 A. Bianchi. alterations in writing into mechanical and psychical. He distinguishes the former as ataxic and tremulous ,' the second, as conscious and unconscious; and the psychical alterations he designates by the term disgrammatographia. The ataxic writing, like the ataxic gait, is characterized by excessive exaggerations of the movements necessary for the formation of single letters; therefore the ascend- ing lines are within their limits, whilst the descending are grosser and longer than necessary, the curves are angular and large, the form of the letters is irregular, the words are not in a right line. In short, this is the sort of writing which is observed in children who are learning to write, and in which uncertainity and irregularity pre- dominate. The tremulous writing presents, instead, an undulating contour of ascending and descending tracts, so that the vertical lines and the curves are converted into finely serpiginous or broken lines; this‘ is the writing we have seen, in the last periods of life, in the phy- siological state, and in it weariness and tremor predomi- nate. To these two varieties of writing should be added the so-called reverse chirography, which is also called litho- graphic, spectral and letter-copy. This is the left-hand writing observed in some patients; it may be produced by sound persons; it consists in tracing the letters from right towards left, with the upward slope to this side, so that in order to read it, we have to hold the sheet before a mirror, whilst looking in, or to turn the paper over and read by transparency. This sort of writing, which Erlenmeyer considers as pathological, but Buchwald and Vogt as the normal writing of the left hand, has only of late been the object of special obser4 vation. In fact Buchwald described it in 1878, as present in three right hemiplegics, and he ranked it at first among the varieties of aphasia, but he was finally led to the conviction that it obtains also in the healthy, and especially in children. Erlenmeyer, of Coblentz, in 1879, as has been said, believed the lithographic form to be Changes in Handwriting. 5 73 only pathological, but Vogt admits it as a normal fact. The studies of this sort of writing since 1880 have been few; we know of only the memoir of Ireland, who oscillates as to its pathological importance; and of that of Durand, who regards the reverse writing as normal, and only sometimes to require for its development special cerebral lesions. _ A curious fact has enabled us to learn that the reversed writing, as a pathological phenomenon, has been found in some manuscripts. In the Codes Atlantz'eus, of Leonardo da Vinci, preserved in the Ambrosiana di Mil- ano, all the writing is of the left hand, reverse sort; and though it has been believed that Leonardo adopted this form, in order to prevent his writings being read by the importunate, it seems, on the contrary, that it was simply the consequence of a paralysis in the right hand, which also impeded him in painting. This is revealed by a diary which was found in the national library of Naples, in which it is recorded that one De Beatis, who, in 1517, followed the Cardinal of Aragon in his travels through Germany, Flanders and France, visited Leonardo in the vicinity of Ambroise, in a villa given to him by Francis the First, and he observed that he could no longer expect valuable paintings from Leonardo, because his right hand was paralyzed. It was therefore but the necessary consequence of writing with the left hand that obliged Leonardo to execute the reversed form of writ- ing. We have lastly the agraphia, which consists in the traces made by the diseased, merely of right, straight, undulating, or circular lines, instead of the customary letters. This agraphia may be quite complete, the patient being unable to trace any letter. True paragraphia consists in writing ungrammatically, whilst the patient is aware of his errors. In this it differs from another sort, that observed in general paralysis, in which the person is ignorant of his errors. Patients under this disease always leave out some necessary elements of 5 74 A. Bianehi. language, and letters, syllables, or whole words may be passed over unheeded; the writing may also exhibit the mechanical alterations above described, especially the tremulousness. The alterations in writing may then be physiological or pathological: we shall speak of the former before call- ing the attention of the reader to the latter. 3rd. Physiological alz‘erations in writing-It is natural that the handwriting of a child who is commencing to write, should be different from that of a practiced pen- ' man. This diversity is observed, not only in the mode of formation of the various letters, but also in the group- ing of them, and in their disposition. Hence, we see that the vertical lines are rather prolonged, or they are exag- gerated; the curved lines are replaced by pieced ones, or by acute angles; the transverse lines are wanting, or they are too much extended, and finally, all the writing shows trembling and uncertain turnings. This obtains as respects the formation of letters and words; but when we come to the disposal of them, according to the rules of syntax, we see numerous errors, whether proceeding from the suppresion, or the addition, of let- ters in various words, or from neglected or mistaken punctuation. Finally, there may be observed in individ- uals who are beginning to write, errors in the construction of phrases or propositions, or errors (and not rare) in the exchange of one word for another. All these phenomena, which may be called the physiological errors of writing, go on, more or less slowly vanishing, accord- ing to the greater or less aptitude of the individual to learn, and in the well-instructed adult we find they .have totally disappeared; but in the adult who has not sufficient capacity, or but little practice in writing, they remain.-—Towards the decline of life, the writing, ‘for the most part, tends to resume the primitive form, which was observed in early youth at school; it becomes tremulous and irregular, with frequent mistakes in syntax, and the exchanging of one word for another is here Changes in Handwriting. 575 specially accentuated. Physiologically then, the writing may present to us alterations in the mechanical execution alone, or in its psychical elaboration. In analyzing the different parts of a writing, we see that it presents vertical lines of various lengths, united to curved lines variously disposed, and that by the union of these right and curved lines, all the several words are formed, composed from the alphabet used by us. Although it is the habit of the Latin people to write from left' to right, yet there may be cases (and this is observed, as has before been said, in children and in inexpert persons), in which, when the paper has not been ruled, the words are disposed in a line variously oblique, or from above downwards, instead of in a right line across. This fact is observed even in persons who write Well, when they are obliged to write in the dark, and it is more frequent than is commonly believed. ' In our common use, the writing has a leaning from left to right, from below upwards; but, this is not constantly followed, in various individuals, because it depends on the varying mode of obliquity of the paper Written on, and the different habits of the writers; so that we may see some writings quite vertical, and others, though more rarely, with the slope from right to left. The lines traced have, for the most part, neat turns, but frequently they present to the naked eye some irregularities, depending either on a little cutting off, or on an irregular distribution of the ink; hence, we some- times see that the letters preserve the thick and the slender lines, according to the established rules, or some- times they all present, instead, a uniform coloring, without any increase on one side more than on the other. Next, as respects their distribution, it is known that the letters forming a word should be either united or collected side by side, and that between word and word a certain space should be left. This also may be found 5 76 A. Bianchi. physiologically neglected, and there may be seen too, often extensive areas between words, or even between letters in the same word, and some words may be united without any intervening space. Lastly, the letters, instead of being kept of equal dimensions and heights, may be seen irregular,—extraord- inarily elongated, or sweepingly rounded, or one more, and another less elevated. These are the mechanical alterations which may be found in the writing of the sane man, and which it is important for us to know, for the successive studies which we shall report on the writing of the diseased man. The psychical errors depending, in the sane, for the most part, on ignorance of the established rules of good Writing, are still more numerous in the insane, and con- sist in errors of orthography, grammar and syntax. Of these errors, the appreciation of which is easy of accom- plishment by the man in a state of sanity, and well instructed, we shall merely intimate the name. summarising, we shall say, that, taking as a type the writing of the instructed adult man, we see that the child and the aged man are two physiological termini, which have, as to the writing, much pathological relation. In fact we have centres which preside over the psychical function of writing, but do not yet act in a complete manner, and therefore, have need of perfectionment; whilst in old age the centres themselves and their paths of conduction are lesed and wearied, and are no longer fitted either to respond with sufficient energy to external stimuli, or to send back the sensations received, unless with ever-increasing difficulty. We have then two different modes of behavior of the centres presiding over writing; in the child, an action of them progressively increasing, but in the aged, their progressive enfeeblement. We shall see that these two facts are frequently met with in pathology, in various central lesions, some of which are capable of altering the Changes in Handwriting‘. 577 writing, but of having a progressive amelioration, whilst others bring only successive and continuous diminutions of the intellectual power that presides’ over writing. 4th. Pathological alterations of writing. Ataxia writ- ing-The ataxic writing, which, as has been ‘said, is observed in children who are learning to write, is found in pathology in cases of central or peripheral lesions of the nervous system, which impair the coordination of the motions of the different muscles that accomplish the act of writing. It is observed also, in cases of convalescence from grave maladies, as typhus, and especially in cases of sclerosis of the posterior cervical columns, and diseases of the cerebellum. Charcot says he could not assign special characters to the writing of patients under dis- seminate sclerosis, because he first saw them with the disease far advanced, and then the writing was reduced to disconnected marks, without the possibility of nor- mal arrangement. However, in one case of this scle- rosis, though the patient presented writing almost unintelligible and ataxic, after treatment with the nitrate of silver she was able to write in a much more reg- 11118.1‘ way. 5 The ataxic writing is sometimes also observed after fatigues, and in poisonings by alcohol or chloral. In these cases, however, it is purely functional, and it ceases with the cessation of the causes that had provoked it. In the cramp of writers ataxic writing is very usual, and it is conjoined with the tremulous and paralytic types. T remulous writing-The tremulous handwriting, which ' is especially presented in paralysis agitans, may really be of great aid in the diagnosis of this incipient mal- adv; in fact we may, with a lens, see, in the writing of these patients, parts very accentuated and large and tremulous, which finally we can observe with the naked eye, as in the case observed by Charcot in the Sal- petriere. This writing is further observed in disseminate sclerosis and general paralysis; and here it may be 5 78 A. Bianchi. noted that Erlenmeyer himself is not able to judge of the difference between the tremulous writing of incipi- ent paralysis agitans and incipient general paralysis. This writing is momentarily found also in the sane, in cases of severe cold or of poisoning by alcohol, mor- phine, nicotine and chloral. But it is to be observed, in this relation, that in alcoholism the patient writes atax- ically when he is in the period of excitement, through the influence of ingested alcohol, and on the contrary, he‘ writes tremulously when this influence has passed off. It is also seen that in these cases a little-alcohol can for some time give sufficient force to the muscles to write without tremor or ataxia. Agraphia-Writing reduced to mere broken and irreg- ular lines is observed in the last stages of paralysis agitans and disseminate sclerosis. There are some cases in which the handwriting of these patients has been reduced solely to lines irregularly disposed. The same fact is observed in cerebral lesions which cause right hemiplegia, and are capable of bringing alterations of the writing in the most varied manner, and of thus presenting both the tremulous and the ataxic writing, and that of difficult execution as well as complete agraphia, and psychical alterations as well as material. Hence agraphia, which is the complete impossibility (material or psychical) of tracing written signs, may orig- inate either from paralysis of the muscles which serve in writing, or from destruction of the cerebral centre or cen- tres that preside over the execution of writing. Agraphia and difficultied writing are, for the most part, united to aphasia, though there have sometimes been cases in which the aphasic was able to write, or the agraphic to speak. In aphasia there may be not only disturbance of the speech,” but also of the other manifestations of thought, as writing, imitation, drawing, music, etc., and yet the intelli- gence in some cases remains sound, but in others it is changed-In aphasic diseases there is observed not only the common phenomenology of the patients being inept Changes in Handwriting. 57 9 to express in words the image presented by external signs (logoplegia), but also the other, of integrity of the intel- ligence, and of the visive and auditive organs, conjoined, with impossibility of comprehending the written or articu- late signs, just as if they were those of another language, unknown to the patient. The conventional written or articulate signs do not then awake any recollection of the image, in the mind of the patient, who ignores the relation that exists between the word spoken or written and the object it should indicate, and he has thus lost the remem- brance of the symbol which gives to thought determinate and precise form,—the internal language,—presenting thus verbal amnesia. Inv these cases there is deafness to words and blindness to writing, yet the patient hears the noises and has perfect sight, but the sounds do not awaken any recollection, and ‘the written signs do not summon any image in his brain. If, however, we present to the patient the object named, or written, he recognizes it, because the notion-of it has not passed away. Aphasia then comprehends not only alteration of the passage from the idea to the expression of it, but also the loss of transmission of conventional sounds from outside to the brain. The cerebral lesions that give place to this aphasia are ,diverse; thus, while lesion of the centre for the formation of words ( 3rd frontal or the insula) maintains in the patient the motion of the object and of its uses, but not of its name, lesion of the apparatus of transmission, conjoined with integrity of. the centre for the formation of words (lesion of the centrum ovale under the 3rd frontal) gives to the patient the notion and the name of the object, but does not‘permit him to give to it the appropriate name; hence he often changes it for another, though knowingly. Further, a partial lesion of the visual centre (piega curva), or a‘destruction of the paths of transmission between this centre and that for the formation of words, will allow, in the patient, the notion and the visual image ofv letters, but 580 I A. Bianchi. he will be unable .to give the true name to the 'letter which he sees. Finally, a partial lesion of the auditive centre (superior spheno temporal convolution), or a destruc- tion of the path of transmission between this centre and A that for the formation of words, will carry in the sound produced by the pronunciation, and he will understand it, but it will not make him lay hold of the relation between the sound and the word which it represents. Many cases, however, favorable, and many adverse, have been marshaled to uphold or to deny these diverse localizations, and the cerebral lesions capable of giving origin to such disturb- ances of written and spoken language. Lithographic writing-Among these aphasic disturb- ances, mutable in diverse diseases, in a curious way, and strangely conflicting with one another, a special position ought to be given to the lithographic writing, which, as we have before said, has been specially studied by Buchwald, in 1878. He, we repeat, in 1878, observed vin three hemiplegics, a special lesion in the handwriting, which he called spectral, or reflex, because the patients, writing with the left hand, carried the words from right to left, so that it was necessary to turn the paper over, or hold it before a mirror, or by means of transparency, to read it. He attributes this mode of writing to a variety of aphasia, from the perplexity of written language; but on the other hand he was aware that it was not present in all cases of right hemiplegia with aphasia, but only in grave cases. Further, he observed even in the sound, and especially in children, some who wrote better from right to left than from left to right, when they were caused to write with the left hand. He considered this writing as a pathological thing corresponding to a special cerebral disease; but Vogt, in 1880, believed, on the contrary, that this writing is normal when it is done with the left hand. Swortzoff ‘has made merely a short allusion to this special writing, and has erroneously attrib- uted its first observance to Erlenmeyer. Finally, if we except a few other authors who have mentioned this mode Changes in Handwriting. 581 of handwriting, we reach the end of 1881 without seeing any new work on it. At this time Durand occupied him- self in an analysis of the works above cited, and he has made an ample contribution to the clinical importance of this writing, which he proposes to call lithographic, or the letter-copying form, because lithographers write thus on the lithographing stones, and merchants obtain a similar form when they take copy of letters written with a particu- lar sort of ink. The conclusions of this author are in accord’ with the opinions expressed by others; and though he thinks that the ligthographic handwriting is the normal writing of the left-hand, he does not deny that it may sometimes be due to lesions of the encephalic central organ. _ The experiments made, in order to be able to see what muscles were more or less used in writing, were restricted to those accomplished by a localized interrupted current, in each of them, on sound persons. It was afterwards pathologically seen that there is a difference between the vertical and the lateral tremor, because the former is due solely to a lesion of the musculo-spiral group of the several muscles. It was seen, in analyzing the psychical fact of writing, that the image of the form of the letters and the words is received by the brain along with the impression of the motions necessary for the formation of the letters, and that by little and little there is established a quasi solidarity between these two facts; in fine, by exercise and use we may virtually see the figure of the word before tracing it on the paper with the hand, and in the person writing, this image is united to the remembrance of the muscular contractions whose co-ordination reproduces the figure determined at pleasure of the will. Thus, in the child, we see that he attentively fixes the model, in order to impress the image on his brain, and to constrain the muscles of his hand to follow the given direc- tion; sometimes, instead, he does no more than pass with the ink over lines (letters) traced in pale color on the 582 A. Bianclzi. paper, and thus he obtains that the unconscious impres- sion of the motions executed by the hand, is imprinted on the brain along with the image given by the sight, and by many times repeating the same impressions of images and muscular motions associated with the image, it happens at length that they obtain such close association that, in the adult, it is impossible to distinguish the two phases of the phenomenon. But the same impressions are always pro- duced, and their imprint is preserved in the memory, becoming finally so profound that the practiced man succeeds in writing with the eyes shut, as well as with them open, presenting at such times, only some disorder in the distribution of the words, in the horizontal lines, and the punctuation. Experiment therefore tells us that, for the act of writing, we require the impression of the image of the words and the disposition of the words, and further, the impression of the motions necessary for their forma- tion. This last fact seems to have its seat in the left hemisphere prevalently, but a little in the right also, for it cannot be admitted that the binocular impression transmitted from the eyes, and producing equal images on the hemi- spheres, calls forth only on the left the muscular contractions necessary for the external impression of the image. In a hemiplegia of the right side itwill therefore happen that the image, not calling forth, on the left hemisphere, any centrifugal motion in the muscles of the right hand, will oblige the extensor cellular groups in the sound right hemisphere to write from the left, because of the preserved remembrance of the muscular combinations associated with the image of the word. Hence there will be an identical centrifugal motion and the reversed lithographic writing. The same contractions preside over this writing as over common writing, and it is as symmetrical, as respects the axis of the body, as the other. In‘ reality, if experiment- ally, the eyes of an individual "be bandaged, and he is made to write with each hand, we shall see that he almost always writes reversed with the left hand, and with a little practice it will succeed that the two writings, being Changes in Handwriting. 583 superimposed, are exactly equal. If, instead, the individual writes with the left in the common mode, there is a cen- trifugal form on one side and a centripetal on the other, but the muscular groups which enter into action are antagonists, and they give an insupportable contraction. According to these experiments, repeated by Vogt and Durand, the centrifugal writing is the normal of both hands Dr. Ireland advances the hypothesis, that the image, or the impression, or the change in the cerebral texture, by which the image is produced, is formed in the mind of the lithographic writer, reversed, like the negative of a photograph, or if the usual centre forms a double image, the right and left, they are in opposite directions in the two hemispheres. We might then believe that the image of the left, having, from disease, disappeared, the reversed one of the right remains, and is capable of tracing the characters from right to left, and in the centrifugal direc- tion, because it is easier. Further, in those who write with the left, and not reversed, it may be that there is a greater facility in copying the image of the right side of the brain. ’ The experiment that has most aided this study, has been that made on children in the German and American schools. Ireland informs us that in a school of one hun- dred pupils of both sexes, only_ five were found, who, in writing with the left hand, gave the lithographic form, and these were all who used the left hand instead of the right. It was observed that they seemed unaware that they were doing anything abnormal, and they wrote fast and better than the other pupils. In another school of one hundred and thirty-four individuals, only three, in the same condition, wrote reversed. Vogt, in experimenting on many hundreds of persons, saw that the ordinary writing was done well with the right hand and the eyes shut, and almost as well as with them open, in 98 per cent., if the person wrote often and at different times, but if performed with the left hand, 584 v A. Bianchi. in the same conditions, it approached to that with the eyes open in 16 per cent. On the other hand, the reversed writing, done with the right hand, and the eyes closed, did not resemble that made with the eyes open, and frequently it could not be read, whilst if done with the left hand, .it resembled more that done with the eyes open in 92 ‘per cent. From these experiments it seems that the reversed writing is the writing of the left hand, and all the more so since it becomes very difficult if it is desired to execute it with the right. Durand observed besides that among intelligent per- sons, or those who write much, they are seen to do the writing with the left almost as well as with the right hand, and they cannot write reversed, because in them the image of the word is so fixed in the memory that they cannot conceive it in another way, and they con- strain the muscles without knowing it, to trace the image as they have it in the brain. But in persons of little intelligence, and who seldom write, there is an aptitude to write with the left hand in both ways, and the reversed letters are better formed than those carried from left to right. The study of the diseases in which this mode of writing is observed, is but recent, and the cases are there- fore few which have been reported by authors. Buchwald » relates, among others, three observations, one of a man of forty-five years, with hemiplegia on the right side, combined with aphasia; he wrote with the left hand cen- trifugally, tracing the letters and numbers well, excepting the 8. By long education he was enabled to write some phrases centripetally with the left hand. After six months the lesions of speech disappeared, but the tendency to lithographicwriting continued. However, the cases may be divided into two groups;—those with perfect intelli- gence, right hemiplegia and slight aphasia, and those in which all the morbid phenomna are very accentuated. Buchwald observed that, the hemiplegics, or the slightly aphasic, did not present the lithographic writing; _ Changes in Handwriting. 585 Swortzoff observed the same, but Vogt tells us of a Swiss who, during twenty years, wrote in the non-reversed way with the left hand, the right being paralyzed. Among the grave cases Swortzoff places that of a florist: of thirty-three years, who was struck with logoplegia, from blindness to speech, with right hemiplegia and con- tracture. Having improved, she re-acquired, in some degree, the faculty of speaking, and of writing, with the right hand, her own name reversed; but her memory of words had disappeared; she could not read, but could write pretty well with her left hand, in the lithrographic form, though readily mistaking one word for another. Durand has a case of a man of thirty-five years, aphasic in a slight degree, from syphilis; by little and little he saw his right arm paralyzed; he wrote with the» left easily, and in the lithographic way, but he wrote in the normal form, with the same hand badly and with difficulty. ‘ . Ireland relates the case of a girl of seven years, paralytic and imbecile, hemiplegia on the right, from birth, quasi aphasic, epileptic and active, but timorous. After eighteen months of education, she learned to write, but in the lithographic way, as has been seen in the example reported further back.- The same author states the case- of another girl of fourteen years, imbecile, but more intelligent than the other; she used the left hand, and wrote well reversed, better than in the normal way. Ireland relates the following additional cases: That of Millard, who, in an imbecile boy of twelve years, who learned to read, observed that the writing done with the left hand, required the paper to be reversed, in order to read it. Next, that of Nibar, who observed a man who wrote well with both sides, tracing with the left hand the letters in ‘the lithographic form. From these few cases‘we may conclude, with reason, that the reverse structure, although it is the physiological of the left hand, yet it obtains more specially in cases of lesion, of the left hemisphere, and in aphasia, because then the 5 86 A. Bz'anc/zi. normal writing of the left is liberated by external cir- cumstances, by education, by remembrance of the figures traced from the right, and by the influence, of the sight and the will, leaving thus only the remembrance of the impressions of the muscular motions, united to that of the impression of image. This writing is therefore due, on the one side, to aphasia, and on the other, it is a thing purely physiological, and it would be only accidental to see an organ re-acquire its normal func- tions under the influence of a pathological part. Wrz'z‘ing of the de1nenz‘ed.—Finally, it seems useful to say, in a little space, how profitable it may be to the physician to examine the writing, when it is presented in a case of real or supposed mental alienation. Without in the least invading the field of the medico-legist, it is only for the diagnosis of the clinical form of the intellec- tive lesion that we think these principal points should be placed in assemblage. Here are observed all the so-called disgrammato-graphias, conscious and unconscious, in union with the diverse mechanical alterations of writing corre- sponding to the various lesions of the peripheral nerves, and of the encephalic and medullary mass. Thus, in maniacs, the handwriting runs rapidly and boldly, but slowly and hesitatingly in melancholics, who have brief and incomplete thoughts, whilst those of maniacs are prolix, incoherent and oft-repeated. Simple dementia presents want of association in the ideas, repetition of the same words and phrases, omission of words or of parts of the phrase, and numerous ortho- graphic errors. In general paralysis, in addition to these facts of demenitia, there is the true tremulous writing, .and in the last stage of the disease the true handwriting disappears to give place to marks and lines unintelligible to us, but with which the patients believe they are able to communicate and express their ideas. ’ In monomania there are observed written signs, cor- responding to the variety of the psychical alterations. The attentive observation of these signs is of great Changes in Handwriting. 587 importance, as a diagnostic and prognostic element, since from their disappearance we may infer recovery or a diminution of the intellective lesion. In mania, the writing is always tremulous and irregular, with extensive tracts difficult to be read, sometimes quite illegible, and with oft-repeated lacunae; when this writ- ing resumes, or tends to resume, its habitual form, we may with security promise an early recovery. In maniacal excitation and monornania, the writing is often full of capital letters, in the beginning, the middle and the end of words, and the words themselves are often underscored, in order to draw the attention of the reader to an idea or a phrase. These two characters of the handwriting of these insane persons are useful in ‘ diagnosis and prognosis, because from them a certain return of the malady may often be predicted. From the study, then, of the writing of the insane, not only may we know the exalted or depressed forms of the malady, but we may also, from them predict its early arrival, and our prognosis will be easy. Thus, in patients with general paralysis, when as yet all the symptoms are silent, and the writing presents neither, tremor nor irregularity, nor forgetting of words or letters, nor repetition of phrases, or omissions of entire parts of the discourse, there may be found in the writings of these persons phrases which show a weakening of the reason, a hesitancy, risky projects, and a different form in the letters. It is, however, a fact that the intelligence has not altogether disappeared in cases of abnormal writing in the insane; rather, indeed, it may still yet exist, when speech and writing are abolished. [Either this looks close akin to mystery, or I have failed to render correctly the author’s language, or the printer's devil has been indulging in barbarous vivisection. -TRANSLATOR.] Prognosis.—When we find that we have in hand .a patient who can write, it is highly useful to get him to 588 ' A. Bianchi. trace some characters in the commencement of his case, that we may see whether they are altered; this may be of great assistance in the prognosis of a nervous disease. If, for example, in chronic alcoholism we see that, after treatment with strychnine, the writing resumes its neat turns, and is no longer tremulous, we may be quite sure of a favorable prognosis; but if we see it remain sta- tionary, or the tremor in the lines increase, we may securely anticipate a malady quite incurable. The same may be said as regards the prognosis of incipient, or advanced general paralysis, and paralysis which has for its cause a syphilitic process. In the latter case the prognosis is more easy when we see, in the progress of the specific treatment, the writing slowly becoming more regular, and finally reaching a point of real improvement, characterized by the return of the handwriting to its normal form. This fact is realized in cases of amendment in mental diseases, when we see disappearing the special signs described by us, which characterize the different forms of alteration in the writing of demerits. It will therefore be useful to examine the writing of these persons, that we _may be able to judge when a probable recurrence of their primitive mental malady may happen. T reatrnent-Erlenmeyer speaks of the benefit from gal- vanization of the brain in general paralysis. He saw that under the use of the current there was an amendment in "the psychical and mechanical alterations in the writing, and besides, that it was executed with greater rapidity. But similar effects were not always obtained in the altera- tions in the writing resulting from general paralysis. On the other hand, in cases of paralysis from syphilitic lesion, successive amelioration and absolute recovery may be obtained from. the specific treatment. And in cases of acoholic tremitus, under therapeutic measures and appro-. priate diet, the tremulous character of the handwriting may be made to disappear. In the forms of dementia the treatment will proceed with profit to the patient, when we shall see, even before Changes in Handwriting. 589 the disappearance of the phnenomena of the malady, the writing return to its ordinary forms, and the disgrammato- graphia altogether, or partly, disappear. But the therapeutic criterion should be deduced from the probable seat of the disease. Thus, in cases in which, whilst the formation of ideas and their perception are yet unimpaired, the writing is difficult, because of lesion purely mechanical of the right limb; galvanization of this mem- ber, and the employment of those means which may restore to it force and coordination of the motions, will be use- ful. If the lesion is of the senses only, as for example, loss of vision, we may by a well-directed method, teach the patient to write in the dark, and this will be so much the easierthe better the patient has before been instructed, and if he had before enjoyed the faculty of sight. 0n the contrary, in cases of central lesion which has I destroyed in part the cellular mass, or the means of trans- mission for written language only, treatment will be of little use; but if the lesion is on one side alone, we may hope, by a special education, to be able to make amends for it. Cerebral galvanization, as Erlenmeyer employed it, may, according to him, be useful. Every sort of treat- ment for restoration of the writing will be useless in cases of complete destruction of the centres assigned for written . language, and of the means of transmission. 5. Conelusions.-—We may, from the exposition of facts, just now completed, draw, with sufficient safety, some conclusions, provided we content ourselves with the study of the clinical part only, omitting altogether the physio- logical investigation: 1st. The study of the mechanical and psychical altera- tions of writing merits special attention, ‘and may be of great utility in diagnosis, prognosis and therapeutic direc- tion. 2nd. The reversed writing, it seems, may in future be studied with real advantage. Up to the present time it may I be said that it is observed in many cases of right hemi- plegia and idiocy. 590 A. Bianelzi. 3rd. In mental diseases, especially, attentive examina- tion of the psychical and mechanical alterations of the writing, may notably clear up the diagnosis of the disease. 4th. In prognosis, whether relative to an improvement or a relapse, examination of the handwriting may afford notable aid. 5th. The best treatment in cases of mechanical alter- ation of the writing is galvanization of the brain, good intellectual exercise, and a well-directed education of the hand. 6th. The specific treatment, in cases of altered writing, from syphilitic cerebral lesions, and that of strychnine in those from chronic alcoholism, give the most benefit. Reciprocal Insanity.* By RALPH S. PARSONS, M. D., near Sing Sing, N. Y. HEN friends of the insane are advised to place the patient under special care, away from home, the question is sometimes asked, whether association with other insane patients may not be in itself injurious; whether insanity may not be in some way a contagious disease, so that even sane persons who are in constant association with the insane are on this account liable themselves to become insane. The answer is that as a rule, insanity is not contagious; ‘that insane patients do not often adopt the delusions of their insane associates, but on the contrary recognize them as delusions no less clearly than any other persons would; and further, that attendants in charge of the insane do not show any greater liability to insanity than persons who are engaged in ordinary occupations. When insane patients do adopt the delusions of their associates, as is sometimes the case, they usually accept the false beliefs on testimony precisely as false beliefs are accepted by many sane persons. Hence, the adoption of these ‘delusions in such cases is not a symptom of insanity, save in so far as it denotes the existence of an already impaired intellect; nor do the adopted delusions materi- ally affect the mental condition of the patient, or the probabilities of recovery. To a certain extent and in various ways, an insane patient may sometimes be bene- fited by being judiciously associated with other insane patients. On the other hand, annoyances may arise from such association which are injurious, precisely as any other annoyance would be injurious, and not at all on account of the contagiousness of the disease to the influence of which they are exposed. *Norm-Read before the American Neurological Association, June 22nd, 1883. 592 Ralph 5. Parsons. In some cases and under certain conditions, however, two or more persons do sometimes exert. an adverse reciprocal influence upon each other, tending to the pro- duction of insanity in each, or to its development in‘ succession from one to another. Insanities may arise reciprocally in various ways, as: First.—From identical causes acting at the same time and under similar circumstances onindividuals of like susceptibilities, who are in close sympathy and intimately associated. The mental disturbance excited in each im- mediately reacting upon, and increasing the mental disturbance of the others. Second-From insane delusions being entertained by one of two or more predisposed persons, in intimate relation with each other; and the deluded person acting as a cause of the development of similar, or identical insanity in the others; and mutual reactions taking place. Third-Through emotional influences; as when one subject of a convulsive form of nervous disease, or of a form of insanity characterized by emotional disturbance, is intimately associated with persons of similar tempera- ment and susceptibility. ' The following cases will serve to illustrate these insanities : In the spring of 1865, twin sisters, about nineteen years of age, were admitted to the New York City Lunatic Asylum as patients, in a state of acute mania. The manifestations of insanity were so nearly alike in the two as to be practically identical. The language, appearance and actions of the sisters were the same. They were so similar in person that it was difficult to distinguish the one from the other. They had always been together, and had become insane at the same time, under the influence of the same causes on similar physical and men- tal organizations. It is quite possible, and even probable, that either of the young women would have become insane under the same influences, if she had had no sis- ter, or if she had been a long time separated from her Reciprocal Insanity. 593 sister. There can be little doubt, however, that the beginnings of insanity in each were stimulated by the disturbed mental state of the other. It was quite evident that in the result they were mutual causes of mental dis- turbance. Only a few weeks ago, all the members of a whole family, including a father, mother and several children, residing in the interior of this State, were reported to have become insane at the same time, through ,the influ- ence of fear; the mental disturbance of each reacting upon the others as a cause. ’ The following case is narrated at length, in order to present a more complete picture of the disease than a brief abstract would have'done: On the 7th of May, 1870, a woman named Margaret C v , was admitted to the New York City Lunatic Asylum, as a patient. No positive evidences of insanity, either in appearance, conduct, or conversation were observed at the time of her admission. She made the statement that a certain man wished to marry her younger sister Julia; that her sister did not wish to marry the young man, and that he had procured her commitment to the Asylum, because she had reproached him for pressing his attentions on Julia. On the 9th of May, Julia visited her sister at the Asylum, and corroborated her statement in every particular. Julia was evidently insane; but it was then thought that Margaret’s notions were founded entirely on the testimony of julia regarding her own troubles; and hence, that her beliefs could not properly be considered as insane delusions. She was allowed to leave the Asylum in company with her sister Julia. On the 9th day of July following, both Margaret and Julia were admitted to the Asylum as insane. The statements made by these sisters were identical in every particular. The delusive ideas, however, all had regard ' i to the younger sister. During their examination at the time of admission, and indeed on all other occasions when both patients were together, they talked with 594 Ralph 5. Parsons. great volubility and earnestness. One of them would begin a statement of their troubles; after a few moments the other would take up the thread of the narrative, as though by a sort of common consent, and after con- tinuing a few moments the story would again be taken up by the first, and so on, until the close of the interviews. In their ideas and feelings, each seemed to be the counterpart of the other. They had the idea that a certain teacher in one of the public schools was enamored with Julia; that in fact, there was an understanding between the gentleman and Julia, that they were to be married, although he had never spoken to either of the sisters, nor had any communication in writing ever passed between them. He, on his part, as they said, looked and acted out that he would marry Julia; but in what these looks and actions consisted they were not able to explain. On their part Julia had chosen the gentleman for her future husband, and this seemed to them a satisfactory and definite settle- ment of the question. The statement that she had chosen the gentleman was often repeated in explanation, or as a proof of the engagement; and they seemed to think that Julia’s choice having been once made, the acquiescence of the_gentleman would be a matter of course. Still they repudiated the idea that the engage- ment was in any sense compulsory on his part. On the contrary, although Julia was willing and even anxious to marry the man of her choice, she would scorn to accept him save as a willing suitor. She would rather remain unmarried through her whole life. All the trouble of the sisters 'lhad arisen from this engagement. Their father and mother did not understand them. When on one or two occasions they spoke about the engagement in the presence of their parents, both the father and the mother remonstrated with them for enter- taining such foolish notions. They never afterwards mentioned the subject in their presence. Still they felt assured that their parents knew all about the affair, quite Reciprocal Insanity. 595 as well as they themselves did. Their parents, they said, had other and more ambitious views. They wished Julia to marry the son of a wealthy builder, who lived in the neighborhood. They never said anything about their ambitious wishes, but acted out what they thought; they treated their daughters coldly and sometimes did not give them enough to eat. So too, the builder’s son pressed his suit, by his looks and by his actions, with great persistence. This was their greatest annoyance. Julia, who was the less demonstrative and the less ener- getic of the two, simply expressed her displeasure to her sister in mild terms of indignation. Margaret, however, went to the young man and bitterly reproached him for his cruel conduct. Not only that, but she attempted to break the windows of his house with a stick. Through the connivance of their parents and the builder’s son other people also annoyed the sisters. Tradespeople would charge them more for articles they wished to buy, than they charged other people. Such was the history given of themselves, by these two "patients at the time of their admission on the 9th of july. Although the impres- sion was at first gained that the delusive ideas originated with Julia and were simply accepted as true by Marga- ret, through faith in julia’s statements, a further inquiry served to remove this impression. On the contrary, it became a serious question, whether the delusions had not really originated with Margaret, and afterwards been adopted by Julia. There was no evidence to show, how- ever, that the delusions had originated with the one rather than with the other. Since it seemed evident that the influence of each was but to fix the delusions of the other, they were placed in separate wards at the asylum. Julia was quiet and made no especial complaint. She was allowed to leave the asylum on the the 13th of July, in care of her father, with the understanding that she was to engage in some occupation away from home, and that when, after a little time, Margaret should be allowed to leave they were 596 Ralph .5. Parsons. to live apart. Margaret was irritable and abusive in lan- guage. She was indignant that she'should be separated from her sister, and complained that Julia was abused and starved, although she had no evidence of any kind on the subject. When .told that Julia had been allowed to leave the asylum, she would give no credit to the statement, but expressed the belief that she had been choked. Margaret was allowed to leave the asylum in care of her father, on the 18th of July, and was advised to live apart from her sister. On the 12th of Febuary, 1873, Margaret and Julia were again admitted to the asylum, as patients. Their delusions were essentially the same as before. On the second day after their readmission, the following note was made at the time of the morning visit, both the sisters talking alternately, as above mentioned. The notes are recorded under julia’s history, and as though she only had made the statement, since each said the same things in regard to their troubles and used the singular pronoun in her narration. ’ The notes are as follows, viz; Says now, that at the time she was here before, she was laboring under a misunderstanding in regard to the young man named Tracy: Says, Tracy did wish to marry her, but did not persecute her, as she formerly ' supposed. Has since learned that her parents were her persecutors, in connection with the Devlins. Did not know of this until two weeks ago. Now knows that her parents wished her to marry john Devlin. Found this out by the way in which her parents and other people acted and treatedher,—had herself chosen to marry first one and then another gentleman; but obstructions were placed in the way. Sometimes the priests acted instead of her parents, and prevented her marriage with the persons she had chosen. Means were taken to prevent them ‘from making the acquaintance of Julia. Has never spoken with any of these men. The men acted to her that they would not be allowed to speak Reciprocal Insanity. 597 with her, until they were allowed by her parents. The parents acted that they wished her to marry Devlin, but never spoke on the subject. Devlin was in the habit of following her about, and she used to do the best she could to avoid him. Did not think until two weeks ago that her parents annoyed her on account of Devlin. Thinks now that if she would return home her parents might let her marry whomsoever she chose, but is deter- mined never to return home, on account of the ill-treat- ment to which she has been subjected. Her parents, she is persuaded, would be willing to have her marry some othenman than Devlin, if they could make the selection; but she objects to any man of their choosing, and now entertains very strong antipathies against her parents on account of their persecutions. Her parents interfered with her by their actions, and without seeing her, or speaking to her. Found this out entirely by the results, by reason- ing from what she considered to be the facts. Went in company with her sister to Devlin’s house, and tried to break the windows with a stick, on account of his actions. Her parents had ‘chosen Devlin for her, but she does not want him. Has insulted him publicly and privately, but he will not notice her insults. Hates him because he is so little. Does not care for his riches, but wishes to marry the man of her choice. Wishes to remain here until Devlin and her parents are willing to let ‘her alone. Her parents have injured her for two years, but she did not know it was they who injured her, until recently. Went with her sister to judge Bixby, and made a complaint against Devlin, when she was arrested and sent here. Did not live apart from her sister after leaving the asylum, as she had promised. The sisters ‘were allowed to leave the asylum in care of their father, on the 27th_ of Febuary. On the 27th of March, they were again admitted, having been arrested and sent to the work-house, and from thence to the asylum. Their mental condition was the same in all respects, as before. About one month afterwards, 598 Ralph S. Parsons. however, Margaret for a few weeks entertained ideas in regard to herself, which heretofore, she had enter- tained only in regard to Julia. She too had chosen a husband for herself. Said that when she was ready the man she had chosen would be compelled to marry her. Julia was allowed to leave the asylum, in care of herself, on the 21st of April. She was so undemonstra- tive when not in Margaret’s company that there seemed to be little liability of her getting into trouble when apart from her sister. Margaret, however, was at times exceed- ingly vehement in her expressions. She at times threat- ened to take vengeance on her supposed persecutors. At about this time she began to entertain a strong antipathy against Dr. H., one of the assistant physicians at the asylum, saying that he also was one of her persecutors. She had previously chosen him as her future husband. She afterwards became quiet and orderly, and was allowed to leave the asylum. julia had proposed that she would go to Philadelphia, where she had formerly re- sided, while Margaret should remain in New York, and they were advised to carry this project into effect. The following letter, postmarked at Philadelphia, was subsequently received from Julia: “DR. PARsoNs:—I understand that Dr. H. has spied and watched me to this city, and what a cheek he had and what mean principles, for he has seen plainly and publicly in New York City, that I was true to another gentleman, for when I left the city, how dare he follow me? He certainly must have a singular appetite for me when he watches me, and I false to him and true to another. Why it was like following me from Egypt’s fire to the north pole. It was ill-bred and impolite in him to dare it. But I suppose he did not care, through his impudence. I do not thank any one to spy or watch me, and I true to another. Therefore, Dr. Parsons, stop him immediately, because I am not true to him and never shall be. How dare he watch me coming to this city? Besides I was always true to this gentleman, even while I was over there, but I thought it was he who put Reciprocal Insanity. 599 us there, and persecuted me. I found out since what an impudent, dirty, ill-bred, know-nothing my wicked parents had for me. None but an impudent wretch wants me against my wishes. Stop him quick, for he shall never come within my door, nor none but whom I am true to publicly. I never intend to accept of Dr. H., nor do I ever mean to change to him. I am already pleased. and satisfied, and Dr. H. knows it. Therefore, he had no business to follow nor spy me, coming here. I should rather die. I was surprised, for I never thought about him in the least. I never expected any one to’ spy me here, but the gentleman I was true to, and left the city for. Stop watching me immediately, or I shall write more scandalous. “JULIA C.” About a month afterwards, another letter written in the same strain was received. This letter was mailed in. New York City. It was subsequently ascertained, that. the young woman remained only a few weeks in Philadel- phia. During the latter months of the year, Margaret wrote several letters to Dr. K., who had been formerly assistant physician at the asylum on Blackwell’s Island. She complained that Dr. K., Dr. H. and certain other" parties, came to the city, and annoyed them by their inter-- ference and importunities. She threatened to shoot them unless .these indignities were stopped. On the sixth of January, 1874, the sisters were again admitted to the asylum. Margaret acknowledged having- written the threatening letter to Dr. K. She averred that Dr. K., Dr. H., Mr. Tracy and Mr. Devlin had followed them to Philadelphia; also that Dr. H., had procured her‘ commitment to the asylum, for the purpose of compelling her to marry him. Julia made statements that were’ nearly identical. They were placed in different wards. Julia was quiet and agreeable in conversation. She urged that'she was now enlightened, knew that she got into trouble on account of her notions, and promised in future to avoid the expression of her peculiar ideas, so as to prevent further trouble. She very often urged the plea. that she had been enlightened, and hence should be dis- charged. 600 Ralph 5. Parsons. Margaret was irritable, and abusive in language. On seeing the physicians of the asylum, she would often become greatly excited, upbraiding them on account of the indignities she had suffered, and on account of her unjust detention. At times she would expose her person in the presence of the physicians, in a defiant manner, intimating that since she was kept here for an improper object, she might as well show that she knew what the intentions were regarding her. She did not appear to expose her person through any impulse to commit an indecent act, but rather through a sort of bravado, and to express her defiance. Her animosity was expressed more especially towards Dr. H. They left the asylum in care of their father on the 9th of May, 1874. ' Nothing further was heard from either Margaret or Julia, after the date above mentioned ‘until January, 1875, when, on the 16th, 17th and 20th, of the month, Julia wrote long letters to the resident physician of the asy- lum, complaining of her persecutors, and asking him to stop them. One of the letters reads as follows, viz: “Saturday, January 16th, 1875. “DR. PARSONS :—-K. is the most treacherous rascal that ever existed, and hanging is too good for him, through the wicked advantage he is taking of me through my parents being wicked. My wicked father has me beat and starved to death, because I would not destroy my future happiness by accepting of K., to accommodate him; and what a mean brute K. is to accept of me under the circumstance that I liked another, but accepted of him because it pleased my wicked parents. K. is a murder- ous ruffian. Doctor, I have written three or four shocking letters to the Commissioners, about K., and the murderer would not stop, through my parents hating me and through their trying to starve me to death. How dare my wicked parents be opposing any one I choose, to get me to marry Dr. K. They know right well that K. dare not come face to face to me; that I would have him arrested instantly and imprisoned for life’. Through all the gross, insulting letters I have written to him, and through the letters the Commissioners have received from me about Reciprocal Insanity. 601 him, K. should not dare to watch me, after such shock- ing insults, except to murder me, either this way or that way. But the ruffian knows that I cannot get work, and my wicked father is asking of the parish priests and of his neighbors for charity, and I am starving with them ' during the last-four or five weeks. Since I would not accept him, he wants me starved to death for spite, the rowdy, for he is a rowdyish professor when he dare. take advantage of me through my parents being my greatest enemies. What does my father mean by choosing a rake like K. for me? It is because I hate K., and like another, and since it is so that he used me cruel all my lifetime he also wants my future life to be unhappy. I would rather beg than spend my future life with such an unmerci- ful infidel as K. is; even if he would not murder me. I could not enjoy such an unmerciful, unprincipled slop. “Doctor, don’t you remember what you told Mr. Cole- man on the 17th of last March, about the terrible letters I had written to him? How dare he expect me, after all those fearful letters, as you called them? “Doctor, please do go and stop the murderer, immedi- ately, because my wicked parents are very cross and stubborn to me through him, and I am living on bread and tea and cold water, by them, through K. opposing the gentleman I have chosen and am true to. How dare K. be trying to pull and drag me to him against my wishes, from the gentleman I like? Hanging is too good for him. It would be a charity for you to stop him quick. “ Doctor, please excuse this writing, because if my wicked father saw me writing it, he would kill me, he is so guilty. Respectfully. “JULIA C.” The whole letter (with the exception of the postscript) is given, for the purpose of showing the general current of thought, more clearly than extracts would do. The other letters are similar in character. One of them also contains a tirade against Sal Devlin, “the low wretch of a wanton widow, who aided her outlawed robber of a father in his persecutions.” It is pertinent to mention that Julia had seen neither Dr. K. nor Dr. H. for a long time previous to the writ- ing of these letters, the former being in Europe and the latter in Virginia. 602 Ralph 5. Parsons. At the date of admission in 1870, Julia’s age was stated to be twenty-four years and Margaret’s age twenty- six. Whenlast admitted, Margaret said she was forty 'years of age, and that her age as formerly given was incorrect. She did not appear as old as forty years, but is probably more‘than two years older than Julia. Both Margaret and Julia were in what would gener-- ally be called good health, although each lacked the bodily vigor and elasticity of mind that result from per- fect physical health. They were rather thin in flesh, and had an appearance of physical depression or weariness, such as might arise from overwork, too great confine- ment, or trouble. No very marked hereditary influences could be traced. A cousin, however, was said to be insane. Their parents who are well advanced in years, are in a fair state of health. Their father appeared to be a man of good judgment and fair intellectual capacity, but the mental powers of their mother were of a low order, although she had never manifested any symptom of insanity, or even of what might properly be called imbecility. No especial peculiarities in the natural characteristics of either of the patients were observed, or could be ascertained. Margaret, however, was rather inclined to be irritable and aggressive, while Julia was of a milder temperament, and more easily influenced and controlled. No objective cause, or causes of their insanity could be ascertained, other than their associations, or rather lack of associations, and their habits of life. Up to the period of their first admission to the asylum, they had always lived at home, with their parents. They were industrious women, and occupied their time in the munufacture of men’s clothing, for wholesale dealers, one of them operating on the sewing machine and the other fitting and finishing the work. Through this divi- sion of labor, each finally came to consider the aid of the other, in the light ofa necessity. Neither of them thought she could work apart from her sister. They Reciprocal Insanity. 603. were always together. They never visited, they had no friendship with other women. Their only acquaintance with men was in a purely business way. Each was all-in-all to the other——companion, fellow-worker, friend. They did not even associate with their parents, but in all that related to their plans, or to their feelings, they were strangers to them, as to all the world beside. Thus in the midst of a great city, they lived a sort of dual hermitage. They were occupied with the same work; they conversed about the same things, for they conversed only with each other. They finally came to think and feel almost as though they had been one per- son, instead of two. And this mutual influence had been .so gradual that it is difficult to judge which was the leading factor in the development of their belief, their feelings and their aspirations. If Margaret was the more positive and aggressive in temperament, Julia, on the other hand, had more of imagination and spontaneity. After a careful study of their history and characteristics, the conclusion was reached that their delusive ideas had been of very gradual growth, taking their rise, first in an undue activity of the imagination, then in the indulgence ‘of unfounded hopes and aspirations, then in the conviction that these hopes would one day be realized, and as a final result the notion that some one had interfered to prevent the realization of their beliefs. Their delusions finally became of such a character that there were unmis- takable indications of the existence of insanity. Through- out the whole of this process the change in mental state in each appears to have progressed pari passu with the change in the mental state of the other; or, in other words, under the influence of mutual reactions and of causes common to both, they became insane at the same time. The following points in connection with these cases are especially noteworthy: The efficient causes of their insanity seem clearly to have been moral instead of physical. Neither of the 604 Ralph 5. Parsons. patients had ever complained of serious illness of any kind. They had sufficient exercise, both at home and in the open air. They were not overworked, and they had a sufficient supply of nutritious food, at least until troubles arose by reason of their insanity. These moral ,_ causes acted at the same time on similar temperaments, and not unnaturally produced similar results in each case. In‘ saying that the causes of their insanity were mental, as contra-distinguished from physical, it is not meant that no changes had taken place in the brain as the cause of the insanity; but simply that the molecular change in cerebral structure, which. was the immediate cause of disordered mental activity, was itself brought about by moral instead of physical causes. None of their relations were known ever to have been insane, with the exception of one cousin. But still, although there had been no insanity in the direct line of ascendents, as far as could be learned, there can be little doubt, that they were really predisposed ‘to insanity. Indeed, it is doubtful whether moral causes ever produce insanity unless a predisposition exists. Their mother was a woman of limited mental capacity. The mental faculties of the daughters were of a higher order than those of the mother, but yet they undoubtedly inherited from her an instability of cerebral organization that amounted to a real predisposition to insanity. The exciting causes of the insanity of the two sisters would seem to have depended chiefly on their habits, and on their mutual influence. Since they associated only with each other, their notions were not corrected by a comparison with the views of other people. Hence, the first beginnings of extravagance in their ideas were unchecked. They continued to indulge in their unfounded notions, until what was at first a mere wish or hope, finally became, through force of habit, a firm belief. Not only did they lose the benefit of a comparison of their beliefs with those of other people, but each acqui- esced in, and thus confirmed the beliefs of the other. Reciprocal Insanity. 605 Hence, hereditary predisposition, lack of occasion for properly exercising the faculty of comparison, and thus correcting their false judgment, and a mutual confirmation of their false beliefs, finally eventuated in delusions, which are characteristic’ evidence of - insanity. If the last factor mentioned, that is, their mutual influence, had been wanting, it is not at all certain that either of the sisters would have become insane. On the contrary, it is not unlikely that both‘ would have escaped the disease. ‘ Cases not unfrequently happen in‘ which the insanity of one member of a family becomes an immediate excit- ing cause of the insanity of another member. The simple fact that one member has become insane is in itself pre- sumptive evidence, that other members of the family inherit the insane diathesis; and hence, that they are in danger of becoming deranged, through association with their insane relative. The following history, transcribed . from the Records of the New York City Lunatic Asylum, and furnished through the courtesy of Dr. T. M. Franklin, the Medical Superintendent, is similar to the preceding in all essential respects: Three sisters, Mary K., Catharine K. and Anna Theresa K., respectively forty, thirty-seven and thirty-five years of age, were admitted to the New York City Lunatic Asylum, as patients, on the 21st of August, 1877- These three sisters had lived together for many years, support- ing themselves, principally by sewing. They appear to have been feeble-minded, credulous, impressionable peo- ple, over whom their imaginations had more control than the exercise ‘of their reason. They heard the vague statement that a relative had died, leaving them a large amount of wealth, and they conjectured that it was some one on their mother’s side of the family. Talking this over among themselves, they persuaded each other that it was actually the case, and that they were in reality heiresses to a large estate. They then began to 606 Ralph 5. Parsons. fear that people were laying obstacles in the way of their ascertaining the locality of this fortune. Finally, ‘they feared that every one was trying to cheat them cut of their inheritance. This fear occupied their minds night and day, and the delusion of immense wealth, of which they were wrongfully deprived, became the center about which all their thoughts revolved. The little intelligence they naturally possessed, became impaired, "their vague suspicions extended to every one about them, and a morbid dread took possession of their lives. ‘The strangeness of their actions excited remark, and they were several times dispossessed by landlords, without any given reasons. They were said to have become abusive ‘on several occasions. The suspicions of their neighbors were aroused, so that they were arrested, when they were found to be insane, and sent to the asylum. After some months they were all discharged, in care of a relative, as improved. The following cases are instances of the reciprocal influence of emotional states in the causation of insanity: A. B., a subject of chorea, had attended a small private school, for one or more years, associating freely with the other pupils. One of her schoolmates, C. D., .a girl of especially unstable, nervous organization, became insane, the symptoms partaking of the nature of delirium, of hysterical insanity, and of epileptic insanity. It was diagnosed as a case of choreic insanity. E. F,. a cousin of C. D., attended the same school, having her seat next to A. B. During the early part of the illness of her cousin, C. D., she often remained with her as a com- panion for several hours, or a day. A few weeks after the commencement of her cousin's illness E. F. suffered a similar attack, the symptoms being equally severe and differing mainly in the fact that motor symptoms of chorea were manifested in the latter case. It was not ascertained that either of the girls had practiced self- abuse. A lady in affluent circumstances, suffered an attack Reciprocal Insanity. , 607 of insanity, with emotional disturbances. After a time her daughter, who was making a visit to the mother, was suddenly attacked with a similar form of insanity, without any other evident exciting cause, than the influ- ' ence of the mother’s emotional state. Among the inferences which may be deduced from these and similar cases, are the following, to wit: First-That, although under ordinary circumstances the contagion ‘of insanity does not extend from one person to another, the influence of the insane on persons inheriting similar faults of constitution, or a known pre- disposition to a similar form of insanity, should be avoided as dangerous. ' ' Second-That the conditions favoring contagion are most likely to occur among blood relations, who are inti- mately associated. T hird.—-That emotional forms of insanity are especially liable to extend from one child to another; and also III-5. lesser degree among women. \ Fourth-That when two or more persons thus become insane, through similarity of predisposition, sympathy and intimacy of association, they usually exert an adverse recip- rocal influence upon each other, both as cause and effect of their insanity. ‘ Fifth-That the contagion of insanity under the influ- ence of sympathy, predisposition and intimate association, is most likely to occur during the inception and develop- ing period ‘of the disease; and that this liability ought to be taken into consideration, among other reasons, in deter- mining the question whether it is advisable to treat insane patients at their own homes, during the early stages of their insanity. Insanity from Quinine. By JAs. G. KIERNAN, M. D., Chicago, 111. IN 1881 I reported* the following cases of insanity re- sulting from the use of quinine: ' CASE I.—T. P., American, single; grandfather, uncle and brother died insane. Patient had, however, been in very good health up to about three months before admis- sion, which occurred during the year 1874, when he was attacked by headache, for which, on the supposition of its being malarial, three grains of quinine were prescribed three times a day. After taking‘ three doses of this, the patient was seized by a violent attack of lypemaniac frenzy, with marked hallucinations of hearing of a depress- ing type, and considerable dimness of vision. These phe— nomena persisted for three months, as the quinine‘ was continued, and the patient treated with morphia subcu- taneously. On admission to the asylum, which was at length rendered necessary, the patient was in the con- dition already described, and was placed under chloral and hyoscyamus as a hypnotic, and conium to quiet motor excitement. Under this treatment the patient was in fit condition to be discharged within six weeks after admis- sion. He manifested, a day previous to discharge, some slight evidences of malaria, whereupon quinine was admin- istered, which had the effect of bringing on a fresh attack of lypemaniac frenzy, with the same symptoms as -previ- ously. The quinine was stopped, and the same treatment as before resorted) to, when the symptoms disappeared. The patient was discharged, fully recovered, four months after admission, but returned within a year in the same mental condition, from the same cause, to recover and relapse under the same circumstances. 1* Journal of Nervous and Mental Disease, 1881. insanity from Quinine. 609 CAsE II.-—P. ]., Irish, aet. thirty, married, brother in- sane, sister epileptic, uncle afflicted with shaking palsy, was admitted to the New York City Asylum in a condition of extreme dementia, being able to utter but few words, and being very neglectful about himself and his surroundings. He had been in relatively good health up to about three weeks prior to admission, when he was attacked by a slight chill, for which he was given ten\ grains of quinine; in three hours after he sank into the condition in which he was on admission, but from which he recovered after three months’ treatment in the asylum. In 1875 he was ad- mitted in precisely the same mental condition from the same cause; was treated much the same, and had' ap- parently fully recovered, when, manifesting some evidences of malarial infection, an assistant physician, who was ignorant of his history, ordered him five grains of quinine, which had the effect of producingia relapse, the patient returning to much the same mental condition as he was on admission. He, however, at length fully recovered. To these cases I am now able to add a third case: CASE III.—R. B., aet. thirty-eight, has a sister epileptic ; a maternal grandmother and a maternal aunt died from “rush of blood to the head.” The patient resembles the maternal side of the house in appearance and disposition. He has never been able to take even a small quantity of beer for fear of it affecting his head. Having recently come into a malarious district in Chicago, he was attacked by fever of a quotidian type. Upon the advice of a fel- low workman, he purchased and took 9i of quinine sul- phate at a dose. In an hour thereafter he was violent and destructive, smashing ‘furniture purposelessly. His friends called me at this stage. There was a wild, purpose- less violence, but 'no delusion or hallucination present. He was very incoherent and hilarious. This condition disap- peared in two hours, he having meanwhile been given a hypodermic of conine, which controlled his move- ments. A sdcond dose of the quinine led to exactly the same results, and its aetiological influence was therefore 61o fas. G. Kiernan. clear. Since disuse of the quinine there have been no further psychical phenomena. I have been able to find but one case in literature, that of Dr. Delafield,* who has reported a case of trans- itory fury due to quinine. Such cases as these are likely to become of medico- legal importance. I have heard of three instances in which the use of quinine has been alleged as an excuse for certain escapades seemingly the result of intoxication. In one case, that of a Catholic clergyman, the man had suffered from vertigo, but was not addicted to the use of alcoholic beverages. The second case was that of a Washington lawyer, who, however, had been clearly insane and an inebriate previous to the use of quinine. The third case was that of a Presbyterian minister, of unblemished character and an abstainer on principle, who suddenly became violent, angry and destructive after taking five two-grain quinine pills. This violence lasted less than an hour, and the man was himself again. As these cases and others are becoming newspaper topics, it is exceedingly probable that some criminal may, as was said to have been Sergeant Mason’s intention, plead the use of quinine as an excuse for crime. From the cases reported, it would seem that the administra- tion of quinine might test the validity of this claim. It will, however, be obvious that quinine can act only as an exciting cause, and that, at the time of the sec- ond administration, some of the predisposing causes might have ceased action. A fairer test would be the character of the insanity alleged to have been produced; since, from the nature of -the cases cited, it is clear that a deliberate crime would be inconsistent with any of them. ‘New York Medical Journal, October, 1882, p. 406. Report of Cases of Trifacial Neuralgia. TREATED BY REMOVAL OF MECKEL’S GANGLION; ALSO BY THE SUCCESSFUL INTERNAL ADMINISTRA- TION OF ACONITIA. By A. VAN DERVEER, M. D., Albany, N. Y., Professor of Principles and Pra ciice of Surgery and Clinical Surgery, Albany Medical College; Member British Medical Association; Attending Surgeon Albany Hospital; Consulting Surgeon St. Peter’s Hospital, etc., etc. THE causes that produce such dreadful suffering as neuralgia are so very different that medical treatment, or rather, the use of medicine, alone, is not always able to afford relief; and yet it is well known to all of us that there are certain conditions, due to the weak and enfeebled state of the system, that may be reached in this manner. And then again it may be stated as a positive truth that in some cases actual surgical interference becomes neces- sary. The cases I am about to report will, I am sure, substantiate the statements I have just made. In this I do not know that I present anything especially new or original, and yet it seems to me the cases are worthy to go on record as illustrating the good resulting from operative surgery when medicine has failed to afford that relief sought by suffering humanity. Mr. S., aged fifty-eight, came under my observation May, 1870. He gave the history of having suffered for over ten years from severe neuralgic pains about the right side of face, along the alveolar process, upper jaw and right side of tongue; also in the track of the inferior dental nerve. In the preceding five years Dr. Detmold, of New York, as well as the late Dr. Alden March, of this city, had =53 Portion of this paper was read at the meeting of the American Surgical Asso- ciation, held at Cincinnati, May and June, 1883. 612 A. Van Derueer. each operated twice by loosening the attachment of the check from the alveolar processes, affording a few months’ relief each time to the patient. I did the same operation with equally good effect; but in September, I870, the pain returned with as much earnestness as ever. I now made use of a very thorough treatment of iron, arsenic, Brown- Sequard neuralgic pills, injections of chloroform, and every remedy known to me, but with no especial benefit. March, 1871, I made a section of the infra-orbital nerve, which resulted in affording great comfort to the patient, and for two years he remained quite free from pain. It then returned, more especially along the course of the inferior dental, and I suggested the removal of Meckel’s ganglion, but his health was such that neither he nor his friends thought it safe. The old gentleman has lived on however, and though yet in great pain for months at a time, he will improve occasionally, and is alive at the present time. Between the time of having Mr. S. under treatment and the care of the following case, I was so impressed with an ~ operation I saw Dr. Thorndike, of Boston, perform on an exceedingly feeble gentleman, aged sixty-five, consisting in the removal of the infra-orbital nerve‘with Meckel’s ganglion, in a case of long standing trifacial neuralgia, right side of face, that I determined to try it with my next similar patient. I would state here that I have since been informed by Dr. W. G. Wheeler, of Boston, that this patient remained well for two years; that the pain then returned in the left side of the face, and, after suffering a long time, he entered the Massachusetts General Hospital, had another operation like the former, and' died a few days afterward from exhaustion. Miss B., aged forty, first consulted me July, 1875, giving the following history: For three or four years previous she had suffered from neuralgic pains in right side of the face, differing as to length of time and degree of severity. Her general health up to this time had been good. No serious sickness, and family history clear. Passed the menopause T rifaeial Neuralgia. 6 I 3 about two years before. Since that time she had had little relief from pain unless under the influence of medicine. All her teeth had been removed (one or two at a time) from right side upper jaw, and some from the lower jaw that side, with but little, if any, relief resulting. Had taken medicines almost constantly. For the previous six months she had had no remission of pain, though taking large doses of morphine, chloral and bromides. Was at times stupid from effect of these drugs, and yet complaining of pain. Countenance sallow, pale, and features expressive of great torture. Unable to do any work, or read or become interested in anything. The pain would start in the upper jaw, extend over the face, pass down, around and through the lower, to chin and along right side of tongue, also penetrating the temporal region, leaving a heat or inflam- mation in the mouth, very severe. At times she would be unable to take a drink without having the pain aggravated for hours. Was thoroughly miserable, and despaired of ever getting help. An examin- ation of urine showed kidneys to be in a healthy state. Was unable to give a satisfactory reason for development of original trouble, except that she had for the most part of her life been confined indoors as seamstress or forewoman in a large store, getting little outdoor exercise or fresh air. I gave her large doses precip. carb. iron; also Brown- Sequard neuralgic pills, but with no apparent benefit. Gave hypodermic injections chloroform with a few moments’ respite from pain, but the inflammation following was very severe. Also gave morphine in the same manner, but so little good followed that she readily consented to an operation. On September 5, I875, assisted by Drs. W. H. Bailey, N. L. Snow, Lewis Balch and F. C. Curtis, and my two medical students, ether being given, I proceeded to re-‘ move the infra-orbital nerve and Meckel’s ganglion in the following manner: Making an incision from the inner angle of the eye, down to the bone, along the nose, for a distance of little more than an inch; then another 614 A. Van Der'oeer. incision, similar in length, at right angles, under the infra- orbital ridge, raising the flap and periosteum, I exposed enough of the anterior wall of the antrum to admit the application of a good-sized trephine, removing a button of bone, so that the upper edge, opening, exposed the infra- orbital nerve and its canal. Lifting the nerve from its bed by means of a bone chisel, grooved director and probe, I followed it until the posterior wall of antrum was reached, where, by means of a smaller trephine, another button of bone was removed, and the spheno-palatine fossa reached. The ganglion was now lifted from its bed, and, with curved scissors, the nerve and it were severed and removed. This was followed by a sharp hmmorrhage, at first somewhat alarming, but controlled by portions of sponge, firmly applied, to which a silk ligature had been tied. The wound in the face was then closed by inter- rupted sutures, a drainage tube, with ligature from sponge, being placed in most dependent point. The patient rallied nicely from the anaesthetics, and was immediately relieved from all pain. There was considerable trouble in remov- ing the sponge, and the parts suppurated quite a good deal, but ultimately healed kindly. From that time on she has been in perfect health, increasing in flesh, attend- ing fully to her work, and a more grateful patient I have never seen. Mrs. T., widow, aged thirty-seven, no children. Ex- cellent family history. When two and a half years old she suffered from perforating ulcer of the right eye, resulting in the loss of sight and the partial flattening of the cornea. At about the age of fourteen she began to wear a simple cover, she and her people thinking it im- proved her appearance. This she continued to wear for seventeen years. During this time she did, in addition to her ordinary school work, a great deal of fancy needle- work, such as embroidery. Always felt very proud of the ‘sight in her left well eye; could see fine print at a greater distance than could many of her friends. During the lat- ter part of the period of wearing the cover, she occasionally T rifaeial Neuralgia. 6 I 5 ‘noticed that a strong light would give the eye a tired feeling, followed by a slight pain at times, and then she would remove the cover for a little while. The ball did not shrink in any way perceptibly until some time after marriage. After the cover had been out for a short time, it would give, for a few minutes, a slightly increased pain on re- introducing it. Six years before my seeing her, when in her usual health, she caught a bad cold by being out in the chilly night-air, and then the eye began to pain her - severely. The spasms of pain 'would be only fouror five daily, at first, confined mostly to the eye-ball, and com- pelling her to leave the cover out most of the time; but there was really no rest for any length of time. She now consulted the late Dr. Robertson, of this city, who ad- vised very positively to let him rerriove the eye at once, believing it would stop the spasms of pain, and prevent any injury occurring to the well‘ eye. This she most de- cidedly declined to have done, and contented herself by using a soothing eye-wash. _ . I During the fall of 1877 ‘and winter of 1878 the pain was yet confined to the eye; but in the spring of 1878- it began to extend out over the cheek, down along the lower jaw and right side of tongue, and back over the temporal region. For the next two or three years she consulted a'number of physicians, both at home and in New York, some of whom advised the removal of the eye, some an operation on the nerve, and some thought no" operation would do any good. All gave her a thor- ough course of medicine, which she tried faithfully; also, the use of electricity, and many outward applications, no permanent good resulting. She would be better, but the pain would always come on, more or less severe, just be- fore heir menstruation. She was referred to me by my friend, Dr. D. H. Cook, of this city, in the spring of 1881. I advised her to'see Dr. Merrill, of this city, and learn, as near as possible, how much the eye had to do with the-trifacial neuralgia, and whether its removal was not 3616 A.“ Van Deroeer. now the best treatment. She saw Dr. Merrill, who advised‘ the removal of the stump, as the eye had now shrunken to quite an extent, but again she positively refused. The Doctor fitted her with another cover, but no marked ben- Lefit resulted. She could wear the cover but very little. I now gave her a very earnest and careful treatment with quinine, iron, Brow'n-Sequard neuralgic pills, arsenic and aconitia, but with only slight improvement. The acon- itia was Merck’s make, and never given in more than one-eightieth of a grain doses, three and four times daily, which would produce marked physiological effects, such as dryness of the throat and tingling of the fingers. The spasms of pain were agonizing to witness, re- turning every one, two or three minutes. At last she :got no rest even with large doses of morphine, by stomach or hypodermic injection. I also tried chloroform by the latter method. Her life was becoming a burden to herself, and one of intense sorrow to her friends. She got no rest during nearly the whole month of July. August 2, 1881, I consented to remove Meckel’s ganglion, though feeling ‘firmly convinced that the proper thing to do was the removal of the eye. The operation was done in the same manner as described in the previous case, assisted by Drs. .Snow,_Merrill and Warden, and my medical students. For a few days after she suffered occasional spasms of pain, but on the sixth day she was entirely free from it, and slept for the first time a quiet, restful sleep. She remained in. a com- fortable condition, improving in general health, not taking any medicine until the last week in November, 1881, when the pain returned along the course of the inferior dental nerve, the spasms being very intense, and coming on so rapidly as to prevent any rest. I tried faithfully aconitia (Merck’s), but with little, if any, good resulting. Again she could not bear it in larger than one-eightieth grain doses three to four times daily. On January 2nd, I trephined the lower jaw, and removed, as I thought thoroughly, a section of the inferior dental nerve, giving her almost immediate relief. From this time on she remained in excellent health, T rifaeial Neuralg'ia. 61 7 gaining in flesh and strength, feeling very happy, but grad- ually losing the sight in her left eye, until the last week in December, 1882, when she suddenly had a spasm of pain along the lower jaw and outer portion of the tem- poral region. This was followed, next day, by two or three spasms; then, the next week, she had five or six daily; then the pain came on as of old, except over the cheek. She was now very much discouraged, and refused all medicines. Her sufferings became so great, especially along the course of the inferior dental nerve, that, at the urgent request of her family, she finally consented to the removal of the eye, which was done by Dr. Merrill, April 3, 1883. After this operation the pain lasted for ten days, then ceased, and since she has been very comfortable. Occasionally she feels a weak sensation about the face, peculiar and difficult to describe, especially just previous to her menstruation. She says her face feels as if it would fall to pieces. At the present time it is difficult to believe so many operations have been performed about her face, so perfect has been the healing process. In considering this case, I am strongly impressed that the diseased eye was the cause of the reflex irritation. The next case coming under my observation was that of Mr. H. N. Farmer, aged sixty-eight, married; referred to me by Dr. J. J. Buckbee, of Fonda, N. Y. He was admitted into the Albany Hospital March 20, 1882. About thirty years before, while working with some machine, he received a severe blow from a stake, just over the left Malar bone. This he thought to be simply a bruise, and it did soon pass away. A few years after he had a number of ulcerated teeth on the same side. About fourteen years ago he noticed a dull, heavy sensation in his forehead, on the left side, and this was followed, in a short time, by sharp, darting pains, just under the eye, which could be started by merely touching the part. He dreaded wiping his face with towel or handkerchief, as it would result in spasms of pain. The pains would begin with a jerk, sometimes starting at the angle of the nose, 618 A. Van Derr/eer. and again near the eye. Later it would come on of itself, and was more' severe in cold weather. About ten years ago he began to be treated, and received no relief. Five weeks before he entered the hospital, I saw him first with Dr. Buckbee, and advised a thorough course of treatment with aconitia, it never having been used with him; which was tried, beginning with one-hundredth grain four times daily, increasing until one-twentieth grain was given as often, but no benefit whatever resulted, patient noticing only slightly the physiological effect of the drug. Merck’s make was used. Why the aconitia was tolerated in such large doses, and producing no more toxic effect, I am unable to explain. It was prepared by the same druggist I am in the habit of getting it from, and he cannot offer any explanation. Mr. N., like Miss B., had had one tooth after another removed, no relief being afforded by it, March 21, I882, assisted by Drs. Snow, Ward, Hailes, Mosher, Wood, Kennedy and Schofield, I did the same operation as in the last two cases, and with immediate relief. After recovering from the anaesthetic, he did not have a single spasm of pain. It was pleasant to witness his surprise and comfort. So rapid was his recovery, that he left the Albany Hospital six days after the operation, with the parts nearly healed. Dr. Buckbee has since in- formed me that the wound was entirely healed in a few days, and that he has been free from all pain since. His only regret was that he had not had the operation done many years sooner. When we contrast the treatment of the cases of Miss B. and Mr. F. with that of Mr. S., we can come to but one conclusion,-—that the removal of the ganglion and nerve is really the only true operation to do, and that the manner of making the incision in the natural curves and folds of the skin, leaves so little cicatrix as not to deter any patient. In doing the operation, a good direct or reflected light is necessary. As regards the danger from ham- orrhage, I am sure it is possible to avoid it entirely. T rifaeial Neuralgia. 619 By taking out a good-sized button from the posterior wall of j! lllllllllllllllllll llllllllllllllllllllllllllll ll llllllllll'llll'l in, I, , Hllllll’ l__——:_—-_ l~:.——_: the antrum, and watching carefully, the internal maxillary artery can be seen pulsating, and thus avoided, while a most excellent view of the ganglion can be obtained. As with all operations upon the nerves, I am convinced the operation needs to be done very thor- oughly; if not, failure is likely to result, as it will, in cases where the pathological lesion is still more central and the cause not peri- pheral. In lifting the infra-orbital nerve from its bony canal, I found, in my last operation, the instrument here shown figured of great service, as by its use the operator is not so likely to tear or separate the nerve-some- thing very important to avoid, for, by keep- ing the nerve in its continuity, he has a sure and safe guide to and along the ganglion. That aconitia is of service in treatment I think the following cases very well illustrate: Mr. B., aged forty, merchant, good family history of health, consulted me in June, 1880, for severe neuralgia in right side of face, hav- ing come on a year previous, after exposure in a long ride, to ,cold. For six months the pain had been almost constant, much as in the history given by Mr. N. Had been under med- ical treatment, with very little benefit. Was not anaemic, and of good habits. I gave him in solution one one-hundredth grain of Merck’s aconitia three or four times daily for four weeks, when he reported himself well. One year after there was no return of the pain. In taking the medicine four times daily he felt only slightly the physical effect. November 8th, 1880, I was requested by my friend, Dr. T. D. Case, to see Miss K., aged ourteen, excellent family history, who had been 620 A. Van Deroeer. suffering severely for two years from trifacial neuralgia, right side of face. In that time she had been mostly under the care of a specialist, who had been trying to cure her by the use of prisms and the wearing of glasses, but with little, if any, permanent good. Under the use of aconitia, as in the former case, she made a most excel- lent recovery, as I am informed by Dr. C. Mrs. L., aged thirty-three, married, no children, first con- sulted me about two years ago. Had suffered for a number of years from trifacial neuralgia, right side of face, which was liable to be brought on by over-exertion, or any mental strain or excitement. The attacks would last from twenty- four to thirty-six hours, and the suffering be intense. By use of good tonics and the aconitia in one-eightieth grain doses, given when the attack was coming on, every three hours until four doses were taken, she has quite recovered. Other cases I might mention convince me that in aconitia (not always relying upon Merck’s make) we have a most excellent remedy for treating this very formidable disease or train of symptoms. [SECOND PAPER] GUITEAU.—A Case of Alleged Moral Insanity. A RE/OINDER, B Y j. ]. EL WELL, T0 REPL Y on E. C. SPITZKA, D., N. Y., Professor of Medical Jurisprudence and of the Anatomy and Physiology of the- Nervous System in the New York Post-Graduate Medical School ; Physician to the Department of Nervous and Mental Diseases of the Metropolitan Throat Hospital; President of New York Neurological Society; Member of the American Neurological Associa- tion: W. and S. Tuke Prize Essayist; William A. ‘ Hammond Prize Esssyist, Etc. 'Ut Sementemfeceris, ita et metes.-A rude due, a rude ainer. 'HEN my article on Guiteau was printed I had no- thought of appearing again so soon, or at all, on this or on any other subject. I am compelled to do so by a bitter and unprovoked personal attack by a writer whose name I mentioned but once in my paper, and then with perfect respect. When a doctor administers to you a. good round dose of Wormwood, gall and brimstone, in a mixture of Hammond’s nitro-glycerine, it is about time for the patient to .call his family together, and see to it that his house, is set in order; for there is something‘ serious, real or imaginary, the matter. If the doctor is particularly smart-knows every thing, as in my case, and is never for a moment troubled with a doubt on any subject, however complex or completely hid to others- then the emergency is the greater. Hashish may also have been in the dose—for it was fearful——and should the 622 Elie/ell. next page or two seem a little wild, it must be attributed to the medicine. On opening the last ALIENIST, I saw, or thought I saw standing before me, a vast pyramid, with the base towards the heavens, and the apex-lost in the sands of an all-comprehensive, “etc.” This colossal pile was covered from top to bottom with eulogistic hieroglyphics, inscrip- tions, titles, badges, records of the most marvelous exploits in psychiatry, neurology, and in fact in all departments of science, outnumbering the deeds of the most noted Pharaoh. High on the broad base of this lofty monument stood the figure of what seemed to my heated imagina- tion, the, Prophet of Truth, wrapped in the comfortable robes of perfect assurance and self-satisfaction, proclaim- ing in a loud voice, “It is the duty of those who know the truth to correct error!” What I saw, I have since learned‘ was the apotheosis of a “ Scientific Alienist.” (This sounds like “shallow rhetoric without reason,” babbling over the cobble-stones of a disturbed and unsanctified temper. Per- mit me, however, to try again with my hook baited with a little fish from the prolific, rhetorical pond of this great prophet; and if no better luck attends the effort, I will at once come down from the .‘dangerous and cloudy region of metaphor, to the solid terra firrna of facts, figures, and common sense.) A “scientific” gladiator appears upon the scene, stripped to the loins, with twisted hair and painted.body, and comes bounding into the arena of dis- cussion and. strife, “like a prognathous African, howling and yelling in ignorant glee, with arrow an spear, to hew off” my “head, and drag the mutilated symbol home in triumph.” (This is much better “rhetoric ”——nothing “shallow” 'here—-“ symbol” is good, but “hewing off heads with arrow and spear,” is about perfect.) I now see the folly and shallowness of such sentences in my poor little article as these: An impartial discussion of the matter is not to be expected, until a sufficient time has passed to allow the sediment of popular indignation and professional zeal to fall to the bottom. Truth will then reveal herself, and not till then, for she shuns excitement and prejudice. Guiteau-A Rey'oinder. 62 3 ' neurologist ; ’ Mind. sound and unsound, with many-sided and ever-changing phenom— one. has escaped - the ' grasp offllanguage, and no satisfactory definition, has ever been formulated of these terms. No standard of measurement or court of appeals has been erected by which the issue of sanity or insan- ity can be measured or decided. Each case is sui generic, and encompassed by its peculiar difliculties, and must be judged by its own characteristic phases for which no precedent can be found. An examination of mental questions, therefore, is much like a voyage of discovery on an unknown sea, without chart, beacon-lights or headland. I promise, if I get through safely with this job, to avoid hereafter all vain efforts of the like shallow rhetoric; for I will take no more risks of having my “head hewed off with arrow and spear, and the muti- lated symbol dragged home in triumph ”——or of having it kicked off by a rhombo-cephalous mule. All this uproar and fury is over an unpretentious paper of mine, prepared in response to an invitation of the editor to write something for his JOURNAL, and almost forgotten, which has,ito my great surprise attracted much more attention for and against, than its merits deserve. It pretends to speak for nobody but the writer, and to give his views in the briefest possible manner.- He makes no_ pretention to being.“a scientific alienist,” or “a practical ’ but he does claim to have taken for many years, a deep interest in all psychological, physiological and kindred subjects-keeping well abreast, as he thinks, of the best and latest thought on these important ques- tions, in his studies and reading-now and then writing a magazine article,’ without contributing specially to the literature of the subjects involved. He holds with Dr. Dalton, that some things have been settled in the past. . One would think that a great light had suddenly burst over the field of psychological and neurological science, and that the fathers knew and did but little. ‘He is conserv- ative, and holds to the old landmarks. Dr. Dalton in his Cartri'ght lectures says : However much we may pride ourselves on the advance made during our time, we may be sure that by far the greater part of our actual knowl- edge is a legacy from the past. It " has been winnowed in successive generations from error and imperfections, which always accompany its 624 ’ Elwelt. first acquisition; and it is probable that‘many of our own discoveries will require a similar depleting treatment in the future. This corresponds with what Dr. Hack Tuke said in his address to the Medico-Psychological Association in Lon- don, “that progress in this direction had been principally made by clearing away former errors, rather than by devel- oping new treatment.” ' Confessing, then, our utter ignorance of the mysteries of brain action and of the brain itself-which Prof. Hamilton, of Aberdeen, in one of his Morrison lectures on insanity, says, “is the most complex of all organs”—let us hold fast to the old creed, that the brain is simply an organ attuned by immaterial and immortal forces. Judge then of my astonishment, and indignation as well, to find myself unmercifully and personally assailed in a great JOURNAL, and charged with having been “ guilty of manufacturing facts,” “misquoting others,” “misquot- ing testimony,” “omitting essential facts,” “ using sophis- try of speech” and “shallow rhetoric without reason,” of “being a mere echo,” who “has not even elementary knowledge of medicine,” and as having “quoted himself as authority ” for what I said, and “ ought to be disbarred,”- etc. Having exhausted his own stock of English epithets, he calls out a German doctor, to denounce me in Dutch; which he proceeds to do in the following “scientific” style, on account of my North American Review paper, which he says is an illustration of “ glanzende Unwissenheit.” It is no relief to me that I find Mr. Blain charged with having denied what he had before stated as a fact; and that half a dozen government witnesses-—“to call matters by their right names-told a falsehood.” If this is not a case where the stern old rule, “an eye for an eye-a tooth for a tooth” is in order. I see no use for the rule. The language applied to Mr. Blain, and to the witnesses and to myself, is shocking, and such language as one gentleman never applies to another. He seems to be an old offender. I find in the New York Record (p. 687, vol. xx.) this language: “It is difficult to feel great Guiteau-A Rey'oinder. 62 5 sympathy for a witness who is so inconsiderately aggres- sive as Dr. Spitzka. He made the surprising statement that whoever took a different ground from himself was either incompetent or dishonest.” The defence, with the subpoena of the goverment in its hands, could find in all this country but one professional medical witness who would go upon the witness stand, and under the rules of evidence swear squarely to the insanity of Guiteau. That solitary witness was Dr. Spitzka. He even boasts of the fact. “The only opinion given by a physician called in as an expert witness, that Guiteau was insane, was my own”! Four of the distinguished experts who swore to the contrary “ are convicted as liars and ignorami out of their own mouths,” and the balance of the thirteen able gentlemen who believed Guiteau sane, and said so, “ to call matters by their right names-told a falsehood.” Some lied, the others told a falsehood. I am wholly unconscious-in the article aforesaid-of having misstated, misrepresented, manufactured or sup- pressed any material thing whatever; and have done nothing of the kind, as I will attempt to show. In my paper, I took it for granted that so intelligent a constit- uency as I was addressing through the ALIENIST, knew al the elementary facts of the Guiteau case, and that they were just as familiar with the evidence bearing upon its main points, as myself; for such evidence has been printed and published, as the London Lancet says: ad nauseane. My paper was necessarily very brief, covering only eight pages. I said, “the writer proposes, as briefly as practic- able, to group the salient points of this remarkable case, which, as he understands them, establishes the proposi- tion of the entire sanity and consequent responsibility of this homicide, on the 2nd of July, 1881.” These propo- sitions are given as briefly as possible, with my reasons 'therefor. I said, “the exigencies and limitations of journalism demand brevity.” I had no desire or right to occupy valuable pages, to which others had better claim than I. It would be as impossible to misrepresent or 626 . f. j. Elwell. suppress the main points of testimony in this world-wide case known and read of all men, as to misrepresent or suppress the alphabet or the multiplication table. Nor had I any object to do so. I took no special interest in it, only as a leading one. Had I been an inconsid- erate rampant witness somewhere, and then and there have made a fool of myself, then I might have been glad to have seen the evidence of my folly suppressed. It so happened that in the number of the ALIENIST in which my little eight-page article appeared, and immedi- ately following it, there was printed an eighteen-page paper of a very pretentious and exhaustive character, from the pen of Dr. E. C. Spitzka, M. D., etc., etc., on the very question I had discussed, from the opposite stand-point- that of Guiteau’s insanity. On reading that article-though full of errors of fact, and bad in spirit-it never occurred to me that I ought to return to the field and abuse him for differing with me; yet, I had good grounds for doing so, for he floundered fearfully through the muck and mire of his own testimony, when on the stand-exposing himself at every point to ridicule and criticism. In this article he says: “ Guiteau exhibited indications of theomania, Qnern- lantenwahnsinn-erotomania or simple megalomania.” In this article he says: “I made what was considered then and there as the hit of the day.” “ There was laughter and applause.” He was undoubtedly very smart while on the witness stand, or we should not have “the hit of the day” and “laughter and applause.” He prints it himself, and it must have been so. (It is in another paper given hereafter, that 'he says, “Command me as to any scientific advice that you may need. Ihave received more than two hun- dred letters of commendation,” etc.—Letter to Scoville.) I had presented my reasons for Guiteau’s sanity in eight pages, Dr. Spitzka had given his reasons for believing him insane in eighteen. There the matter should have rested so far as we are concerned-at least until others had been heard. Now for the main specific charges. Guiteau—A Rejoinder. 627 First.—“ One naturally wonders why Dr. Elwell should take so much trouble to sustain the justice of Guiteau’s sentence, by endeavoring to prove his sanity, when he already stands committed to the doctrine that if Guiteau was insane, then there would have been the greater rea- son for punishing him.” Let us see if I stand committed to the doctrine that the really insane should be punished. I do not. In the North American Review paper, to which my critic refers as the foundation for this charge, I use language not easily misunderstood. Here it is: That no confusion of ideas may arise-no misapprehension of the points at issue-and that the field of discussion may be properly circum- scribed and defined, and no words wasted, let it be said at the outset, and distinctly understood, that there can be no dispute as to the entire irre- sponsibility of that class of insane criminals coming within the famous rule of the English judges-those not knowing the difference between right and wrong. A person utterly unconscious of the distinction between good and evil, justice and injustice, right and wrong, at the time of hommitting the offence, by the common consent and judgment of mankind, is not responsible for his act-Not influenced by fear or favor, by punishment in this life or in another, without forethought or calcu- lation for the future; he is completely wanting in every element of character and faculty of mind necessary to fix responsibility for personal conduct or accountability to human tribunals. That is the record where “Dr. Elwell stands com- mitted to the doctrine that if Guiteau was insane there would have been the greater reason for punishing him,” if anywhere. No. To these stricken and desolate lives, and to their unfortunate families, Dr. Elwell would extend all the patience and all the skill of a great profession-the resources of the nation and the sweet and beautiful char- ities of a gracious Christianity. I do stand committed in the North American, as fol- lows: . 0n the other hand, to the punishment of that large class of alleged insane, thrown to the surface as the emergency requires, for whom the defense of irresponsibility is so constantly interposed in courts of justice-composed .of the weak-minded, the evil-minded, those more or less disordered in mind. but still know right from. wrong, the “odd” and the “singular” people; and, lately have been added to these, the eccentric; and still later (see London Lancet), “ those of bad memory,” have been made to swell the list. This is the class whose position as to 628 j. ]. Elie/ell. e responsibility is here under discussion; and these are the persons who are spoken of in this article as the insane, and not those who come under the rule of the English judges. (See North American Review, for January, 1882. This language is plain, and correctly defines my posi- tion on the question of responsibility of the insane; and there is not the least excuse for the man who has misrepre- sented me. It is, however, a fair sample of his entire article. Second.—“ Dr. Elwell’s paper chiefly consists of a pero- ration, laudatory of the government experts, and a foot- note, referring to his own medical jurisprudence as authority in moral insanity.” That is what the “President of the New York Neurological Society” says my paper “chiefly consists of.” (By the way, Dr. Seguin, of New York, who is responsible for what he utters, says this “President” was not fairly elected to the position he claims to occupy. See report of election in Medical Record.) Again, “Dr. Elwell, with all his prejudices, devoted twenty- ' one pages to moral insanity in the treatise to which he refers as an ‘authoritative’ one.” In another place,-—“ he could have found better authority than that which he cites.” Again: “He has ultimately tahen the stand himself as an authority on moral insanity.” Now for the “foot-note” upon which this slander is based. The “President” did not print the note, for that would have carried the cure with the poison. Here it is : Nora-For a more fall discussion of‘ the subject of Moral Insanity, see chap. xxix., page 400. 4th edition of the writer’s work on Medical Jurisprudence; also his article in the North American Review, for January. 1832, on the Moral Responsibility of the Insane. As everybody sees, it is not a reference to whatI have written elsewhere, as authority, but “for a more full discussion of the subject of moral insanity,”——because I could not say all I wanted to, in the little space afforded me in the ALIENIST. The note is written in plain language ——there is no room for a mistake. When full discus- sion means the same as full authority, then, and not till then, will it be true that I ever referred to my own medical jurisprudence as “authority.” The only one Guiteau-A Rejoinder. 629 who has egotistically referred to himself is the distinguished president, on page 432 of his article. Here is the “peroration,” as he calls it, which, with the foot-note, forms the “chief portion” of my article, to answer which requires twenty-two pages, and as many notes. Law and medicine never confronted each other in a court of justice or elsewhere with an issue so momentous, witnessed by the intelligent peo- ple of two continents as excited spectators; never did law make greater demands upon the resources of medicine; such requisitions were never more fully and promptly met, by so many and so able representative men of the profession; never was testimony given under weightier and more solemn circumstances; and finally, never has a great profession been so triumphantly vindicated from the clamor, general distrust and odium into which medical expert testimony had fallen-when insanity was interposed as a defense for crime—and completely lifted out of that quagmire of sen- timentality, fatalism, “moral monstrosity.” and wickedness, called moral or emotional insanity, into which it had fallen. I stand by the “peroration,” and the foot-note is a standing condemnation of Dr. Spitzka’s assertion that “Dr. Elwell quoted himself as authority for what he said.” It is Dr. Spitzka who egotistically quotes himself as aforesaid, and who says of himself, “It is the ‘duty of those who know the truth to correct error,” and “Com- mand me as to any scientific advice that you may need. I have received more than two hundred letters of com- mendation, and I made what was considered then and there the hit of the day. Applause and laughter.” Thir .-—-“Dr. Elwell is a mere echo of Dr. Ordro- noux’s attack on moral insanity.” That may be. It is always well to echo truth, whatever may be its source, and I consider it an honor to follow so safe, wise and conservative a ‘ leader as the gentleman named, and simply refer to it as another misstatement of fact. It so happened that my chapter on moral insanity, to which my critic refers, was written in I859, and the article referred to as that of Dr. Ordronoux’s in 1873. It is quite possible that Dr. Ordronoux_wrote on the subject before I did, though I am not aware of the fact.‘ On the appearance of my book, Dr. Ordronoux wrote in the New York journal of Medicine, as follows: 6 38 j. j. Elwell. But in justice to a great subject upon which it descants most lumin- ously, because most briefly-the subject of all subjects in medical juris- prudence-in justice to ‘the overwhelming importance which must everywhere, and in all places, attach to the phenomena of mental disease, and the legal conditions flowing out of them, we venture to pause and . utter a few words over the chapter on Insanity. At the outset we may say that any intelligent man may talk flippantly enough on the above topic, up to a certain point, because common observation" of functional derange- ments in the brain, as manifested in intoxication and somnambulism, are of every day occurrence, and to the inexperienced eye simulate forms of chronic, organic disturbance. Inasmuch also as the causa causans of insan~ ity is in most instances as completely hid from the physician as from the layman, each meets on equal terms in the deep, dark mine of mental pathology. Beyond a certain point medical knowledge avails nothing- up to a certain point it avails much. When the physician has reached his ultimo Thule he can see no better than the layman who has followed him, and this conviction of the inability of penetrating the mental constitution beyond its most superficial operations, gives every man the right to have “his say” up to those pillars of ‘Hercules beyond which lies the psychical Atlantis. Hence, as Prof. Elwell tells us, “ Countless volumes having been written by the ablest minds of the medical profession upon the great subject; quarterly and monthly periodicals having been established expressly for its discussion and elucidation; some of the ablest thinkers in medicine having made it for a lifetime a speciality, . . . . the pop- ular mind and general reader come very naturally to conclude that the whole subject is well understood.” But when either lawyer or physician comes to investigate and apply rules of law to any individual case he finds, lamentabile dictu—“ That notwithstanding all that has been accomplished by the accumulation of facts, and the enunciation and discussion of theories upon the subject of insanity, especially during the last century, the Whole question is still sub judice.” ' With names and classifications the author tells us that courts have nothing to do, and were courts more prone to remember this they would most assuredly reject the equivocal name of moral insanity from their adjudications. And in this connection we cannot help saying that if there be among all the chapters in this truly valuable book, one which we par- ticularly consider as the keystone of all the rest-and whose ho nest, frank, and conservative tone will do more to beget a true medico-legal union before the courts, where now we so often have a complete antagonism of the two professions, it is the chapter on “ The Position of the Courts upon Insanity.” Who does the President of the New York Neurological Society echo? He is a weak echo of a .class of modern crazy German pagans, who are trying, with what help they can get in America, from such "scientific alienists” as he, to break down all the safeguards of our Chris- tian civilization, by destroying if possible all grounds for l Guz'z‘eau-A ‘Rejoz'nder. 63 I human responsibility-putting forth the cold vagaries of agnosticism and nihilistic utilitarianism-accepting nothing beyond the reach of uncertain human experiment and his own fallible reason—reconciling the irreconcilable factors of life and human existence; while all that he really does is to start at every turn he makes, or step he takes, mysteries that are, have been, and always will be, fat/zom- Zess. He solves at once phenomena which, in the present state of science, are absolutely beyond the realm of legit- imate inquiry. He sees no difficulty whatever in under- standing the chemico-molecular action of the brain. He penetrates boldly into the sacred dark chamber where thought is born (throws up the curtain), handles it, hands it over to the nurse, and is then on the lookout for more “advanced thought.” Had Dr. Spitzka been present when God said “Let us make man,” he would have responded to the “us;” and, while he would hardly have undertaken the main work of creation, he would have made valuable suggestions. Conscience and consciousness, he would have left out in man, as troublesome factors- in his system and plan of the universe. With him brain and mind are coexistent and coévil-the death of the material terminates the mental. Depravity and crime are synonymous with disease and circumstance. These are some of the theories dangerous to society, started or revived mainly in Germany,‘ of which Dr. Spitzka is “only the echo.” By the side of all this, I wish to place on record the. refreshing and spring-like words of the great physiologist Dr. Carpenter, of London: “I deem it just as absurd and illogical to affirm that there is no place for a God in nature, originating, directing, and controlling its forces by his will, as it would be to assert there is no place in man’s body for his conscious mind.” The truth is, little as we know of mind or spirit out of the body and independent of matter, our exact knowl- edge of the essence of mind, in its connection with the hu- man brain, is almost as limited, humiliating as the thought 632 i V j. ]. Elwell. may be. Of the existence of mind or pure thought out- side of matter there can be no doubt, as seen in the Creator “originating, directing, and controlling its forces by his will.” We can only know God by his manifes- tations through mind and matter, and that is about all we know of mind-its manifestations. - Here is what the London Lancet thinks of these mat- ters: (page 695, vol. i., 1882.) ‘ The plea of insanity ought to be called the plea of irresponsibility, so completely is the idea of disease being subordinated to the hypothesis of unaccountability. It cannot be doubted that the public safety and-in a very grave and practical sense-public morals, also, are endangered by the humanitarian spirit of the times, to which a materialistic philosophy lends especial force, and which tends to regard _man as a mere instrument in the hands of his physical destiny—a machine wound up and, set to work out a particular class of actions, and obey a certain series of impulses- and which strive to find excuses for his wrong-doing accordingly. It is a humiliating, and so far as the repute of the profession may be affected, a disgusting fact, that in almost every recent case of murder, some medical person has come forward with the suggestion that the prisoner is insane. Again, the Lancet says: Lefroy was not insane, and Guiteau is not insane. The only insanity accruing to the latter case is that which those who support ‘the plea of insanity may themselves impart to it. The posi- tion of the matter in regard to this question is becoming one of exceed- ing gravity, and it will soon need to be very seriously discussed. (Page 1012, vol.ii., 1881. Fozm‘li.——“ Speaking of the medical testimony for the " defence, he says: ‘Dr. Spitzka’—-'this is the only mention made of Dr. Spitzka’s name in my article—‘ the defend- ant’s chief and most important witness says, ‘he found his skin was in a healthy condition; found his appearance perfect; his eyes perfectly healthy.’ ” “No change of habits or life.” “Dr. Elwell actually uses quotation marks falsely, giving the impression that'those words were used by the witness in a certain order, whereas the fact‘ is, noth— ing was actually said as represented in Dr. Elwell’s manufactured quotation.” He is “at an utter loss to find anything in his testimony to compare with the words ‘no change in the habits or thoughts,’ which Dr. Elwell pretends to cite from it.” Dr. Elwell does not pretend to cite from Dr. Spitzka’s testimony, the words “no change in Guiteau-A Refoinder. 63 3 Q. the habits of life or thought,” and does not attribute them to him, as no one knows better than Dr. Spitzka himself. On the opposite page he had read, not a half-minute before, precisely the same in substance; the same words condensed, quoted from Dr. Hughes. Here they .are: This JOURNAL has laid down the following rule, which is undoubtedly correct: “If no change in the habits of thought, feeling and action takes place, then it is Inot insanity. The true test of insanity, therefore, is this comparison of the individual with his former self, taken in connection with disease of the brain.” By this fair rule let Guiteau be judged. The president, essayist, etc., that he might make a point on me, sees nothing but “quotation marks actually used,” losing sight altogether of the thing quoted. He can’t find the words in all his testimony. Certainly there ‘were quotation marks, not for him, but for the ALIENIsT, and they ‘were right before his eyes when he -wrote. There is no chance here for mistake. As for the “manu- factured quotation;” “he found his skin was in a healthy condition; found his appearance perfect ; his head perfectly 'healthyf’ they can be found in the journal of Insanity, page 339, January and April, 1881, precisely as I have used them. Not having the three thousand pages of the official evidence before me, I relied upon it as I found it in the ALIENIST, journal of Insanity, and other journals. It is, however, ‘substantially correct, as I find it in the official record. “I did not examinehim" for any ordinary physical complaint at all,” says the Witness, “and there- fore found no evidence of it.” Again; “externally I found the head in quite a healthy condition, a little eruption on ‘the skin, but nothing that you would call disease.” Did I try to represent Guiteau any healthier than he was? Did I not frankly admit the syphilitic “taint”? ' I thought and said that Guiteau displayed able gen- 'eralship in many respects during the trial. In this I also “misrepresented and suppressed facts.” In reply I will ‘quote from the Medical Record, the words of its editor. (Page 65, December 10, I881): ' 634 ' j. j. Elwell. Guiteau displayed a wonderful acuteness in appreciating the legal bearing of the questions put to him, and in evading answers that would criminate him. He clung to. his theory of inspiration with a tenacity which might raise the suspicion that he appreciated its legal value. Upon the general public the prisoner’s quickness of mind and extreme adroitness made the most impression. Though mercilessly cross-exam- ined, no inconsistency or incoherence was brought out. To the medical mind the fact that some confession of remorse and regret was made, as well as the undoubted mental suffering of the witness during the cross- examination, will perhaps have the most weight. Fz'ft/z.—-“ Probably Dr. Elwell may be induced to give the grounds on which he makes such statements as the following: ‘First, there is no positive indication of this hereditary tendency in the family of the Guiteaus; and no one thought of having him shut up in a lunatic asylum.’ ” I have done so once, so far as space would allow, and can again; What if Dr. Rice did, at one time when Guiteau had been raising the devil aglittle more than usual, advise his commitment to an asylum? Not one of his family or friends thought of acting upon the suggestion. This was in 1875; yet in I876, Scoville tried to have him go in partnership with him in the practice of law. Does this look as if so sharp a man as his brother-in-law thought him a fit subject for the asylum? Why did not Scoville take the Witness stand, as did Reed, his associate counsel, and try and save Guiteau’s life, if he believed he had ever been insane? Who more" competent to speak on this question of hereditary insanitythan Scoville? Yet he is dumb. Guiteau said he had never seen Dr. Rice but. two or three times in his life, which was probably true. Dr. Rice says, “there was no delusion, no hallucination, no- illusion.” It seems from the evidence, that Dr. Rice did not think best to make out a certificate of lunacy. - Dr. Rice swore positively that Guiteau’s father was not insane. So did his brother and sister. No'effort, I repeat, was ever made by anybody to confine him except for fraud. Nobody pretends the mother was insane. N0 ancestor- was insane. Insanity does not often descend from uncles, aunts' and cousins. The Medical Record says: “It is worthy of note that despite his eccentricities, the uniform Guiteau-A Rejoz'na’er. 63 5 I story of his life is that nobody thought him insane.” (Page 65, October 22, I881.) Guiteau had, without doubt, an ancestral “taint” of .S‘pz'tzha insanity, but this kind of insanity Dr. Barker calls “wickedness,” and the “taint” is from his father the devil. Again the Record says: “But neither morbid egotism nor consequent delusions, necessarily stamp the individual as a lunatic. The degree of the one, the irrationality of the other, as well as accompanying facts, must be considered. Guiteau’s egotism was great but not phenomenal; his delusions were contemptible, but not entirely without data. Add to this that his feelings, though brutal; were not uncontrollable; that he was more vicious than passionate; more coherent than incoherentzin his language or writing, and we get the fiction of a man who is vain, brutish, weak-minded and offensive, eccentric-hat not insane. The testimony of those who have known him most in mature years, viz., his wife, his brother, Noyes and others, shows that they saw in him something disagreeable and eccentric. He was indeed suspected of insanity by Mr. Scoville, but it may be that this was largely because he was such a nuisance.” —-Mea’z'eal Record, page 630, December 3, I881. Sixth-“If Dr. Elwell, notwithstanding his very frank and undoubtedly snhjeotz'oely correct admission, that an examination of mental questions is much like a voyage of discovery on an unknown sea, without chart beacon-lights or headland,” etc. Let me remind the reader that when I wrote this, nautical psychology was not so well under- stood and defined as now, and consequently more unsafe and uncertain. Capt. Spitzka’s great and complete chart was not yet on the market, and I had to do the best I could without it. On his new map I find every crooked channel made straight, every rock, sunken danger and reef marked with buoys of empty barrels,—every creek, bay and inlet, flagged. All is now clear, safe sailing, day and night. The chart is dotted all over with beacon-lights. In fact there is no darkness on what before was a foggy and ' dangerous coast. This chart is called “Insanity, its 6 36 j. ]. Elwell. Classification, Diagnosis and Treatment, by E. C. Spitzka, M. D., New York.” I ‘can only, I am sorry to say, for want of space, make room for part of his “classification;” ‘to Wit: GRoUP I.—Sub-group A. of ‘group 1; lst class of sub-group A. of group 1; division 1 of class 1 of sub-group A. of group I.—Order A. of division 1 of 1st class, of sub-group A. of group I.—-Sub-order A. of order A. of division 1 of 1st class of sub-group A. of group I.—-Genus 1 of sub-order A. of order’A. of division 1 of class 1 of sub-group A., of group I.—-Genus2 of sub-order A. of divisionl of class 1, of sub-group A. of group I.—Genus 3 of sub-order A. of division 1, of 1st class of sub-group A. of group I.—Genus 4 of sub-order A. of division 1 of class 1 of sub- group A. of group I.—Sub-order B. of order A. of division 1 of class 1 of sub-group A. of group I.—-Genus 5 of sub-order B. of order A. of division 1 of class 1 of sub-group A. of group I.—-Genus 6 of sub-order B. of order A. of division 1 of sub-group A. of group I.—Genus 7 of sub-order B. of order A. of divisionl oiI class 1 of sub-group A. of group I.—-Order B. of division 1 of sub-group A. of group I.—Genus 8 of order B. of division 1 of sub-group A. of group I.—Genus 9 of order B. of division 1 of class 1 of sub-group A. of group I.—-Division 2 of class 1 of sub-group A. of group I.—Genus 10 of division 2 of class 1 of sub-group A. of group I,-—Genus l1 (Hebephmania) of division 2 of class 1 of sub-group A. of group I.—-Second class of sub-group A. of group I.—Genus 12 of second class of sub-group A. of group I.—- Genus 13 of second class of division 2, of class 1 of sub-group A. of group I.—Genus 14 of class 2 of division 2 of class 1 of snub-group A. of group I.—-Genus 15 of class 2, of division 2 of class 1 of sub-group A. of group I.—Sub-group B. of group I.—Class 3 of sub-group B. of group I.—Division 1 of class3 of sub-group B. of group I.—Division 2 of class 3 of sub-group B. of group I.—Genus 17 of division 2 of class 3 of sub-group B. of group I.—Genus 18 of division 2 of class 3 of sub-group B. of group I.—Class 4 of sub-group B. of group I.— Genus 19 of class 4 of sub-group B. of group I.—Genus 20 of class 4 of sub-group B. of group I.—-Genus 21 of class 4 of sub-group B. of group I.—-Genus 22 of class 4 of sub-group B. of group I. contains all other insanities of groups not enumerated in the foregoing sub-groups, divisions, subdivisions, orders, sub-orders, classes and sub-classes, and 21 Genera. It contains “failure of logical inhibitory power, mania raisonant, moral insanity of some types,” not all. I would humbly suggest that a 23 Genus might be added to class 4 of sub-group B. of group I., to include the few left of the human family not covered by the 22 Genera of group I., and those. corralled in group II. ; who are supposed to have still left, a little common sense. It would be much the smallest list in the catalogue. Guiteau—A Rejoinder. 6 3 7 Then comes group II., with a shot-gun full of insani- ties, in which he puts hysterical insanity under neonoinania. This group H., if possible is more complex and endless in its nomenclature than group I. I have given group I. complete, for the benefit of the psychological mariner; and if in trying to follow it he finds himself in a fog so dense, that that off Newfoundland is bright daylight by the side of it, it is not my fault. After his great feat at classification, diagnosis and treatment of the insane, and success as a Witness, essayist, professor, president, critic, etc., Dr. Spitzka should have another title, that of professor of universal knowledge. He is the psychological clearing-house of America. He is fully competent to fill the chair which Haller, in Gottingen, occupied a hundred “years ago, as professor of anatomy, history, physiology, surgery, obstetrics and medical jurisprudence, combined with the duty of writing at the same time one review a week, and summing up at ‘the same time all medical knowledge in his Bibliotheca. These duties Would not apparently, from the amount he seems to know, interfere withhis other professorships, presidencies, essays, etc. Dedicate this crazy nomenclature and this insane book to the Moon, and the effort is complete. Forsa‘rt said, “Good heavens, young gentlemen, let us have less science, and more art!” Seoenth.—“ Dr. Elwell may thumb the jury trial records from one end to another of the twenty-seven hundred pages, without finding testimony given by a single wit— ness, or a clause in the speeches of the defense, to justify his strange misrepresentation, and equally will he search in vain among the numerous pamphlets written by those , who maintain that the assassin was insane, for the statement that Guiteau was a case of moral insanity and nothing else.” This raises the whole issue as to the existence of moral insanity, and nothing else. Dr. Spitzka dare ,not stake his case on pure moral insanity. Why not stand squarely up to the doctrine as held by Prichard and Ray, and not leave its defense to a few sincere and’ honorable 638 j. j. Elwell. . believers in it like Dr. Hughes and others, who stand up manfully and ably to the defense of what they believe to be true? Dr. Spitzka seeks to take all the advantage of the principle of moral insanity without having to use the term by which this condition of mania is best known. I use the expression “moral insanity” in its general sense, just as he used it in his testimony when he said, “I would have concluded that he suffered from moral imoeoility, or moral monstrosity. I did not use the expression moral insanity; out what others call moral insan'izfy, I call moral monstrosity; ” and what Dr. Spitzka calls moral imbecility and moral monstrosity, others call moral insanizjy. What then is the difference, if any, between what I call, in the case, alleged moral V insanity, and what he calls moral monstrosity? He says the terms are used thus interchangeably. Dr. Spitzka calls Guiteau’s case a pure case of ' moral imbecility or moral monstrosity, and it is what others call moral insanity. He does not say what he means by the terms “moral imbecility ” and “moral monstrosity,” only that what he so calls, others call moral insanity. He does not say in his testimony that Guiteau had what he called moral im- becility or moral monstrosity, “and nothing else.” But he does say that where he uses those terms others use moralinsanity. I have used the term “alleged moral insanity,” and it was used correctly, according to his own definition of moral imbecility or moral monstrosity, which hesays means ‘moral insanity as others use it. Dr. Spitzka, and his class of alienists, believe as one of them testified, that one-fifth of the human family are insane in a greater or less degree, and that in one group alone, to say nothing about the other groups, there are twenty-two genera. In one of these genera he places some kinds of moral insanity, the other kinds he scatters elsewhere; but nowhere in his book is he as liberal as , when on the stand, for then what others called moral insanity he called moral imbecility and moral monstrosity. There is no getting away from this position. Guiteau-A Rejoz'na’er. 639. Moral insanity, as defined and understood by the best class of alienists who use the term, at whose head stands the editor of the ALIENIST, there’is nothing particularly objectionable. Dr. Hughes, instead of making every fifth person insane, thinks that ‘about one in a thousand is found in that category; and when on the stand he is always conservative. Dr. Hughes says: It _is not contended that a person affected with derangement in his 7 affective life, in order to be designated as morally insane, should be more free from errors of judgment and of the understanding, than an average number of sane people are liable to be under excitement. Understamlings are not all alike. Errors of judgment are common to the rational mind. To err is a human attribute of mentality, and it is obviously illogical and irrational to expect that before we should permit or acquiesce in the use of the term “moral insanity” or “afi'ective insanity,” describing that form of mental aberration, with which we are all familiar, that we should demand of the individual so affected, that he should be sounder in his reasoning powers than the average rational mind. Misconceptions of judgment, and misconceptions of fact are common to sane people. Mis- taken conceptions are not uncommon to rational minds, and it is not to be expected that there should be nothing of that’ kind before we should recog- nize the existence of a state of disease—call it “moral insanity” or “ affective insanity,” “ reasoning mania” or whatever term we may choose to invent-.—it is not to he expected that with such a form of aberration we should gauge the mind of the afi‘ected individual by a more rigid standard than that by which we would measure the average rational mind. That is what I should argue in a case of that kind. Of course I know that there are gentlemen who would differ as to the propriety of the term, and knowing the theoretical basis upon which those differences are made, I should make no quarrel with them or enter any objection to their designating it by some other appellation. Nevertheless, the fact of mental disease still remains, in my humble opinion. Again he says : In the vast majority of changes in the moral character, the intellect either becomes abeyant—and in such a sense may be considered to have undergone a change-to have become subservient and acquiescent, and evidences a predominance of the aberrant moral over the intellectual character; or the intellect becomes also specially implicated and delu- sions accompany the effective change which we call moral insanity. There is no obscurity here. ‘Again, he says: We recognize the fact that there is a form of insanity, which displays itself especially in disordered impulse, feeling propensity or passion with whatever of intellectual implication may be apparent. I call it moral insanity as the most descriptive term. .640 j. j. Elwell. And again : It matters little what becomes of the name, though we think it a good one as descriptive of the characteristic features of some forms of effective insanity, so long as nomenclature is based on the prominent symptomatology rather than upon the distinctive pathological features of insanity. » This is clear enough. We can understand just what he ‘means by the term moral insanity; and as he teaches and testifies on the subject, no danger can arise to the community. So of J. Workman, M. D., of Toronto, and others. Such writers I place on my list of the noted “thirteen,” who are trying to lift the profession out of the disgrace brought upon it by just such wit- nesses and writers as Dr. 'Spitzka. Dr. J. S. Jewell, a noted alienist, says: Whether all insane are morally irresponsible, has bien and ought to be questioned, especially when opinions vary so widely as to what are the phenomena to be included under the term sanity. There is. however, a general criterion for determining the fact of moral insanity, and it is that a person to be considered irresponsible for his actions, must be unable to distinguish the difference between the right and wrong of an act. 'l‘hat insanity often involves practically complete irresponsibility there can be no real question. That on the other hand, the plea of insanity is often falsely made and successfully urged as a defense against the extreme penalties of the law for some flagrant crime, when there is no real ground for such a plea is notorious. That the public sentiment has become justly inflamed against the insanity dodge is plain to all. I suppose those witnesses in the Guiteau case, who said that science knew no such insanity as moral insanity, simply mean that science only recognized insanity based upon disease of the substance of the brain and tangible symptomatology, and not as Dr. Hammond says in his» .new book, “on an emotion.” I do not see how human tribunals are -to fix responsibility to law, if they cannot cast an anchor on something more substantial than an emotion ‘or an indefinite term like moral insanity, when used to cover wickedness. There must be disease, or real imbecility-not “moral” imbecility-just simple imbecility, or disease, if there is irresponsibility. This the courts can lay hold of, and always do, gladly. Guiteau—A Rey'oz'nder. 64 I Dr. Spitzka claims also that all the alienists of Europe agree with him on the question of moral imbecility or moral monstrosity. He says: “in Italy, as in fact almost generally throughout Europe, the writer is unable to find a single alienist who opposes this doctrine of moral insanity.” Here he uses the term, but don’t tell us what he means by it, so he must mean moral imbecility or moral monstrosity. What is European and Italian opinion on the question of moral insanity? ' ' Dr. Bonfigli, of Ferrara, who is good authority, talks very differently. He has Written a book on moral insan- ity, and in it is found a review of the declared opinions of forty-six eminent alienistic writers on the subject of moral insanity. He says, seven of these forty-six hold to the doctrine of absolute, pure and distinct, moral insanity. Of these, three are French, three German and one English. Seventeen of these- forty-six hold to moral insanity conditionally-not as a distinct, pure mental disease. They connect it with more or less intellectual insanity. Of these seventeen, seven are French, six Ger- man, three Italian and one English. Twenty-two, he says, deny the doctrine of moral insanity in toto. Dr. I. Work- man, of Toronto, late Superintendent of Toronto Asylum for the Insane, etc., in commenting on this statement of Dr. Bonfigli, says: “ Had Dr. Bonfigli been more versed in the literature of English and American alienism, he could have much augmented the numbers assigned to the latter two countries; and, undoubtedly, the classes of conditional advocates and of utter iepndiatoi/s would have had almost exclusive admission to his catalogue. He, however, introduces into his book a report of a discussion on moral insanity which took place at the annual conven- tion of Medical Superintendents of Asylums, in New York, in the year 1863. I had the pleasure of being present and taking part in the discussion, which was conducted in the most courteous ‘manner. Dr. McFarland gave it as his conviction, that “in all the cases‘of so~called moral insanity, a real intellectual disorder was present.” 642 j. j. Elwell. He was followed by the other members in rotation, including the distinguished and very long experienced Dr. Kirkbride, the President of the association and the veri- table Nestor of the fraternity, numbering in all present, some forty representatives of the United States and Cana- dian asylums. ‘Of all this assemblage, only two or three declared their belief in the actuality of moral insanity, and even these declined to define it as a distinct and _independent form of disease.” \ This seems to be about the position of the question in Europe and America; and yet Dr. Spitzka “ is unable to find a single alienist who opposes this doctrine of moral insanity in Italy or in fact generally!” Eig/zt/a-Dr. Spitzka says: “ To have an insane ances- tor will hereafter have to be considered rather an advan- tage than otherwise.” No, not an advantage-yet the physiological and pathological fact remains true and is not to be laughed down, that the wonderful living forces of nature, which push the infant to adolescence and holds the man perpendicular on his feet for threescore years and ten, against the constant powers of gravity, is the _ ever-watchful enemy of disease, and the constant conser- vator of health and life. So imperative are nature’s demands in this regard, and her efforts in the direction of health, if she fails, she often proclaims sterility. If she can encyst a ragged bullet, and thus save life, who dare limit her power? It does not follow that because the ois eon- ser-oatrix natzaw, and the ois medioatrix natnroe at once summon their occult but myriad forces to encyst a bullet, or repair a fractured femur; that it “will hereafter‘have to be considered rather an advantage” to be shot or to have a broken leg. It is high time that the foolish and danger- ous 'dqptrine of once insane always insane—that because insanity haisonce been developed in a familya cloud ever after rests :on that family from generation to generation; that that family and all its collateral branches in every direction are “tainted,” and that this taint is liable to break out at the most unexpected times, in the most Guiteau-14 Rejoz'nder. ' 64 3 unlocked-for quarter-be discarded and denounced. The theory is false, and the doctrine is dangerous to society. Nz'nth.-—“ It evidently did not suit Dr. Elwell’s purpose to quote the official report of the Microscopical Com- mittee,” etc. - I did not refer to the microscopical test, because the- best medical authorities place no reliance thereon as a test of insanity. Even Dr. Ray says: “It will scarcely be claimed, at the present day at least, that structural changes found after death from any disease, are the prim- ary cause of the disturbance manifested during life.” Who knows what structural change takes place under the strange alchemy of death in the microscopical tissues of thought? Take the report of Dr. Shakespeare, et. al.-—- what does it amount to? There is not even a hint in it, much less an' assertion, that Guiteau was insane, as the result of their microscopical investigations. Dr. Savage, editor of the journal of JVlentaZ Science, says of the microscopical appearances of a section from the frontal convex of Guiteau’s brain: I should say there is‘ ‘nothing that I have seen which is not com- patible with mental health. It is true there are changes about the vessels and their walls, but these and similar changes are commonly’ found in bodies of persons dying or being killed when past middle age. There are no marked general changes in the nerve-cells, and I can only repeat that the specimen examined would not have any weight with me in causing me to reconsider my judgment on the sanity of the assassin. That is what one competent to speak on the question of the microscopical appearance of Guiteau’s brain thinks. The editor of the Medical Record, says: The facts seem to be. that while there was some chronic disease in and about the blood-vessels, there was nothing indicative of any form of insanity; while on the other hand, much more serious changes are not infrequently found in the brains of persons who had been perfectly sane. Account must be made also of the fact that Guiteau had been suf- fering from malarial poisoning, and that he suffered death from strangula- tion. Guiteau’s insanity, if it existed, was confessedly chgehic; therefore all acute changes found would have no weight in estimating their aetiolog- ical hearings on the alleged mental disease. The severest form of vascular disease was apparently the corpora striata, a place where physical troubles would not be excited, while it is well known that the disease did not dis- turb any function known to pertain to those ganglia. The view that the 644 j. j. E/tt'e.’ . changes found were all significant or characteristic of commencing general paresis, is unfounded, and quite unworthy of serious discussion. The same remark must be made regarding Dr. Godding’s surprising statement, that the arachnoid opacity was indicative of mental disease. There have been some rather labored attempts to prove the brain atypical. The con- volutional development, however, as we are told, though deficient in some parts, was compensated for by fuller adjacent gyri. So far as the eye and some rough measurement could tell, the two hemispheres showed no asymmetry. The fundamental fact in the present case for the determination of atypy, viz., the comparative weight of the two hemispheres being absent, it would not be allowable, nor in accordance with scientific honesty to make positive statements regarding the matter. The futile and decidedly ezv-part‘e attempt to show pathological cranial asymmetry hardly needs com- ment. In fact, Guiteau’s mental condition must be decided by a study of his words and actions when alive. If these did not prove him a lunatic and irresponsible, the postmortem findings will not help the case. H TeaZ/a-Not wishing to be again charged with sup- pressing,” I ought to include “ a gem of purest ray serene,” brought to light by my muck-rake. It was written nine days after his brilliant appearance on the stand. Here it is ; 130 E. 50TH Sr., December 22,1881. MY DEAR Sm: I have written Reed some important points on Hamilton, whom you may also ask if he wrote or inspired an editorial in the Philadelphia Eng. Bulletin. I feel morally sure he did. ' Introduce that cast by all means. I suppose the sculptor will have to swear to its identity 86 give his experience. Leave out phrcnology. The skull shape of the cast is reliable; the face part “ was smoothed out because G. smiled,” at is not as reliable. It is possible that 1 had the right 85 left sides mixed up on the stand. It is the left side which shows defective innervation (tongue 85 face), while the right half of skull is smaller, but the chief anomaly is the posterior face 6c crest. ' Ask Hamilton whether Broca does not call such skulls abnormal, whether Meynert in his last article on the subject does not do s0,,and attach the greatest weight to skull anomalies. I sent Reed a paper of mine; marked the authorities cited in the foot-note; you need only read over to see their importance on cross-ex. . I trust you recognize the importance of the points Dr. Kiernan gave you, &. the further necessity of asking questions exactly in such an order that the “ bad ” four are convicted as liars and ignorami out of their own mouths. Command me as to any scientific advice that you may need, not involving a trip to Washington. I have received more than two hundred letters of congratulation and commendation, three anonymous threats, and two letters from lunatics. bend copy of my evidence if you can. With regards, GEo. SoowLLE, EsQ. SPITZKA. Guiteau-A Rejoinder. 645 There are other things in this menagerie, called a reply, which I would like to exhibit, had I not already exceeded my limits. For instance : A Dr. Spitzka is extravagantly laudatory of the “Con- tinental Courts,” as contrasted with those of England and America. The rule of responsibility, as found in the criminal code of Germany, is substantially the same as the knowledge of right and wrong in England and America. Here it is: ' i There is no criminal act when the actor, at the time of the offense, is in a state of unconsciousness or morbid disturbance of the mind. through which the free determination of his will is excluded. "(Es giht fein illerhredyen, menu 5111f Seitbeé fllergebené, bic il3er= ion in einem befinnungslnfen ober fnnitigen franfhaften geiiiigen Suiiunbe tit, moburd) bet freie fiBille heeintr'cicbtigt iii." - Dr. Spitzka ought to learn from all this, that reckless and headlong abuse of one who has never intentionally laid a straw in his way, or said an unkind word of him, is not prudent. The saying of Napoleon, “ L’audace, l’audace, toujours l’audace,” may do for a warrior, but is not a safe maxim for a president, censor, essayist, etc., and that blows can be given as well as taken. - And now I take my leave of him forever, with the benediction of my Uncle Toby, when he- held the fly between his fingers, before letting it go. [This and the former article are from a strictly medical stand-point. Possibly I may sometime speak to the intel- ligent readers of the ALIENIST, from the legal stand-point, that they may see how lawyers, judges and law journals look at the case] Cleveland, Sept. I‘, ‘I883. Traumatism in Relation to Insanity. By D. R. BROWER, M. D., Professor of_Mental and Nervous Disease, Women’s Medical College, Chicago, Ill. URET,* in his discussion of cerebral traumatisms, comes to the following conclusions, which have an intimate relation to the subject of this paper: First.—When a localized lesion‘ is produced by the traumatic action of the cephalo-rachidian fluid, in any region whatever of the myelencephalon, it is revealed by certain signs in relation to the part’s function. ' Seoona’Q-Jn the first period of the phenomena of shock, the signs differ according to the intensity of the lesion produced. If the destruction of the wounded part (center or conductor) is complete, there is ‘a loss of func- tion-a paralysis. If the lesion is light and non-destruc- tive, and consists in a light shock, there is, or will be, by mechanicalirritation, exaltation of function. ' Third-4n the second or period of congestive and in- flammatory reaction, if the destruction of the part is com- plete, exaltation of function, followed by paralysis, may be observed, finally succeeded by paralysis. Fonrt/z.-'—In all periods, phenomena of diffusion of symp- toms (epileptiform attacks, psychic phenomena, etc.) may be observed. ' From these conclusions it will be obvious that the immediate effects of traumatism are not the only ones to be dreaded, and that slight traumatisms may produce very serious results. Fiirstnerj‘ and Azain’sI results, in a gen- eral way, corroborate Duret. The literature of trauma- tism in relation to insanity is by no means meager. The earliest American alienist, Benjamin Rush,§ reports * Etudes Experimentales et Cliniques'sur les Traumatismes Cerehraux, p. 137. i Allgemeine Zeitschrift fuer Psychiatric, Band xxxviii. . 1 Archives Générales de Medecine, February and March, 1881. § Medical Inquiries and Observations, p. ‘28. T traumatism in Relation to Insanity. 647 the case of a young man, who died in the Pennsylva- nia Hospital in 1809, who became deranged in conse- quence of a contusion on his head, by a fall from a horse, in his fifteenth year. A Mr. died'insane, in the same place, from a'brain injury, caused by his be- ing thrown out of his chair some years before insanity became manifest. He says that cerebral injuries are slower, in showing themselves than are the results of traumatism elsewhere. Esquirol* says that falls on the head, even during infancy, predispose to insanity, and sometimes excite it. A three-year old fell on .its head, and from that time suffered from cephalalgia, which be- came more marked at puberty, resulting in insanity at seventeen. Crichton Browne}L has reported psychic phenomena, varying from idiocy to senile demen- tia, which resulted, from traumatism. Griesingeri says that traumatism may set up insanity immediately; but in other .cases it. does not'appear for, sometimes, years ‘after the original injury. The traumatism sets up an acquired predisposition, without detectable cerebral lesion. Schlager,§ after a study of forty-nine cases, found that, in twenty-one of these, the injury was followed by an» immediate loss of consciousness, in sixteen by simple‘ mental confusion and wandering of the ‘thoughts; in sixteen by dull pain in the head. In nineteen cases, insanity commenced within a year after the accident; the other cases in from four to ten years. The patients, -as a rule, manifested, from the time of the injury, a tendency‘ to cerebral congestion, after the ingestion of a small amount of alcohol or mental excitement. In several cases ocular hyperaesthesia and amblyopia made _- its appearance. There appeared, in fifteen cases, sco_ tomic dots, which exercised an influence on the psychi- cal phenomena. The patient often experienced tinnitus aurium. In eighteen cases dullness of hearing resulted. * Maladies Mentales. 1‘ West ‘Riding Asylum Reports, Volume II. 1 Mental Pathology and Therapeutics. § Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien, XIII, 1857. 648 D. R. Brawler. In three, hallucinations of smell and pupillary changes. The character and disposition changed. In twenty cases great irascibility and angry, passionate manner, even to' violent, passionate outbursts, was remarked. Sometimes there occurred over-estimation of self, prodigality, rest- lessness and disquietude. In fourteen cases, loss of memory, and mental confusion was present. Fourteen attempted suicide. The prognosis in all cases was bad. Seven became paretic dements. Marcé* says that, in the greater number of cases of cerebral traumatism, the psychosis. assumes an illy defined form, offering irregular alternations of stupor, agitation and imperfect lucidity, without systematized delusions; but recovery is never complete, and the patient becomes progressively de- merited. Skaei” says that: Fz'rsz‘,--Traumatic insanity is gen- erally characterized, at the commencement, by maniacal excitement, varying in intensity and character. Second, ——The excitement is succeeded by a chronic condition, often lasting several years, when the patient is suspicious, irritable and dangerous to others. T/zz'rrL-In many such cases distinct homicidal impulses exist. F0urZ/z,——The characteristic delusions of this type of insanity are those of pride, self-esteem and suspicion, true melan- cholia being but rarely present. Fz'ft/z,-This form of insanity is rarely recovered from, and has a tendency to pass into dementia, and terminate fatally, by brain disease. LuysI agrees with Schlager. Dickson§ believes, like .Schlager and Luys, that traumatism may cause both a predisposition to and insanity itself. Krafft-Ebingil classi- fies insanity from traumatism as it is: Fz'rsz‘,——The direct consequence of the accident. Second,—-Manifested later, the prodromus of disordered motor and sensory phenom- * Maladies Mentales. 1‘ Cited by Tuke, Psychological Medicine. 1 Maladies Mentales. § Medicine in Relation to Mind. || Lehrbuch der Psychiatric. Tt’ilttflttZZlSflt in Relation to Insanity. 649 'ena, and change of character. ‘Third-Preceded by a latent susceptibility, the result of the accident, which may be called an acquired predisposition, which requires but a slight exciting cause to develop into insanity. Calmeil,* Voisin]L and Laséguei report cases in which traumatism in infancy produced epilepsy at puberty, fol- lowed by paretic dementia in middle life. Blandford§ agrees with Krafft-Ebing and Skae that insanity may be due to traumatism, and that this may cause a predisposi- tion to insanity. HammondIl is of like opinion, and reports several corroborative cases. Furstnerm< and Verityj'T entertain similar views. Kiernanjti after analyzing forty-five cases, comes to the following conclusions: First,-—That traumatism'produces certain psychoses. Second-—That the majority of these are unaccompanied by epilepsy. Third-That a large pro- portion are accompanied by depressing delusions. Fourth, —That the majority of the latter are unattended by any hereditary taint. Fifth-—That, with certain modifications, Krafft-Ebing’s views are correct. Sixth-—That injuries re- ceived before the age of forty are more potential in the production of insanity than those received subsequently. Seventh-—That slight injuries are as much to be dreaded as grave injuries. Eighth-He finds that the percentage ofv insanity, due to traumatism (ten per cent.) given by Schlager, was greater than that found by himself (two per cent). ZVinth,—-That certain cases of insanity, due to traumatism, have Well-marked, systematized delusions. Tenth,—That in all cases of insanity due to traumatism, a guarded I prognosis should be given. Spitzka§§ expresses his concurrence with these views of Kiernan. * La Paralysis (hez les Aliénes. 1- Paralysie Genérale des Aliénes. I Cited by Voisin. § Insanity and Its Treatment. || Treatise on Insanity. " Allgemeine Zeitschrift fuer Psychiatrie, Band xxxviii. H- American Journal of Neurology and Psychiatry, may, 1882. It Journal of Nervous and Mental Disease, July, 1881. §§ Insanity: Its Diagnosis, Classification and Treatment. 6 50 D. R. Brower. Bucknill and Tuke* believe that, while there is some truth in Skae’s views, exceptions are very numerous. Macleodj' reports a case in which the physical symptoms resembled paretic dementia, 'but, in its initial symptoms, corroborated Skae’s views. McGeeI has reported a case of periodical insanity due to traumatism. Molliére§ reports a very similar case. Cases are reported by Mickle,|] Schiile,** Austinj‘i and Emminghausii which corroborate Kiernan’s views. It may be accepted, in a general way, that traumatism produces a predisposition to insanity; and that the psychoses caused by traumatism are, as a rule, of a chronic type. The following three cases recently came under my own observation: I , ‘ CASE I.—Capt. , aet. twenty-three, was Wounded in the right parietal region, in one of the .early campaigns in Virginia; he was rendered insensible for a short time, but speedily recovered after being carried to the hospital. Examination showed a contused wound of the scalp, without any involvement of the bone. In a few days he returned to his command, apparently well. Prior to the beginning of the war, he was the junior partner of a prominent law firm in New York, remarkable for his steady and regular habits, his industry and mental bril- liancy. Impelled by patriotism, he gave up his chances for preferment there, and entered the army as a private. The qualities which so distinguished him in New York, rapidly advanced him to a captaincy. Shortly after the injury he began to have headache and to pass sleepless nights. About four years afterwards a change was manifest in his emotions, in that he became irritable, resentful, quarrelsome and dissolute. The attacks 1* Psychological Medicine. 1‘ Psychological Medicine. 1 Mississippi Medical Monthly, April, 1883. § Lyon Médlcale, April 3, 1881. H General Paralysis. . *’*- Handbuch der Geisteskraukheiten. ‘H’ General Paralysis. II Allgemeine Psychopathologie. T ranmatism in Relation to Insanity. 65 I of ‘cephalalgia became more severe, and were accompanied by dipsomania. He had a wife and two children. Prior to this condi- tion, he always manifested‘ for them the warmest attach- ment; but now, during the paroxysmal attacks, he treated them brutally, and yet, during the interval, his old love continuously showed itself. These abnormal states became more frequent and violent, and finally his wife, not under- standing their pathology, lost her patience, and became‘ _divorced, thus cutting him loose from his only balance- wheel. He then left this country and went to France, where he became an active member of the Commune. Here, as elsewhere, he was a leader. His outrages were conspicu- ous, and furnished abundant occupation for his irregular explosions of nerve'force. At the close of the Commune, ‘he escaped from France, and was last heard of in the South African diamond fields, having escaped from jail after conviction of attempted murder and mail robbery. This case has in it the evidences of logical perversion, which form the basis of systematized delusions; and, in all probability, the disorder in vaso-motor action will result in paretic dementia. The immorality displayed by _the patient was, it is obvious, of pathological origin. His affinity for the Commune was of the same nature as that which led so many of the insane to join that movement (which decreased the number of hereditary lunatics by killing off so many of them). CASE II.--]. K., aet. thirty-nine, Irish father of unsta- ble mental equilibrium. *- Paternal uncle, three paternal cousins and a brother insane. He was a quiet, orderly youth. Entered the army early in the civil war, and was struck on the head several times, resulting in a cicatrix over the junction of the right coronal and sagittal suture. He remained unconscious for twenty-four hours. On his return home, he was found to have undergone a change of character; was quarrelsome and subject to fits of un- governable fury. His family manifested fear of him, and 52 D. R. Bmwer. he conceived the delusion that they wished to poison him. About this time he had one attack of grand mal. He believed that other people wished to poison him, and car- ried about him various roots and camphor as antidotes; and frequently took doses of sweet oil. These delusions of conspiracy and suspicion increased, and he carried a knife and pistol ‘for self-defence. ‘The Catholic Church and its priesthood, of which he had been a devout member, were regarded by him as active agents in persecuting him. In 1870 he left home, and traveled to and fro to avoid persecution, but found this impossible. He had frequent attacks of pm‘: mal and epileptiform neuralgia. He had attacks of transitory furor, which led ‘him to attack his wife, who regarded him as insane, but was deterred from action by the publicity attendant on the disgraceful trial by jury system, of the lunacy laws of Illinois. He finally shot and killed his wife, under the delusion that one of his persecutors had attempted to enter his room. He was suddenly awakened by his wife arising, supposed her one of his enemies, and killed her. On finding that he had killed his wife, he attempted to commit suicide. A small bottle of whiskey, smelling strongly of camphor, was found‘ in the room. His wife and himself had been on very good terms. Dr. H. M. Lyman and myself were called as experts, and testified to the man’s insanity. The prosecution en- deavored to account for all his irregularities by attributing them to the effects of whiskey; and in corroboration of this view, the small bottle of whiskey, half empty, played an important part. The judge instructed that, if the in— sanity was the result of inebriety, it was no defence,— which resulted in the following verdict: “We, the jury, find the defendant guilty in the manner and form charged in the indictment, and fix his punishment at death by hanging. We, the jury, also find the defendant insane at the present time.” The judge granted a motion for a new trial, but K. relieved the case of any further legal relations by committing suicide the day after. There was found T rauinatisin in Relation to Insanity. ' 65 3 among his effects a note, written the first day of the trial, which showed that his failure to sooner commit suicide was altogether due to a want of opportunity. It will be obvious that, in this case, there were sys- tematized delusions of persecution. The epilepsy was an epiphenomenon. The suicide was an expression of the man’s love for his wife, and not in itself necessarily an in- sane act, although an evidence of insanity. A sane man, killing his Wife under a mistake, might have committed suicide in like manner. CASE III.—J. V., aet. fifty, had a paternal grandmother, two of his paternal uncles and two paternal cousins died insane. He manifested such mental impairment at the age of puberty as to earn for himself the sobriquet of “silly” and “crazy” among his companions. He grew up, however, to be a man of seeming ordinary mental capacity, with industrious and frugal habits, raising a large family and accumulating considerable property for one in his station. - When forty-two years old, while at work on the rail- road track, he was struck by a passing locomotive; his left arm fractured, and his head injured sufficiently to pro- duce cerebral concussion, followed by loss of conscious- ness, which continued for several days. After recovery he complained of severe and frequent cephalal‘gia, had restless nights, and gave evidence of a change in emotional con- dition, by irritability, fits of crying and dislike for soci- ety. One year after this injury he sustained another. A staircase he was assisting in erecting fell, and, striking him on the head, knocked him senseless. After this second accident his mental perturbation was more manifest; he neglected his work, squandered' his property till he became penniless, and manifested de- lusions. He thought himself possessed ,of great wealth, boasted of being the third son of God, wandered about his neighborhood hatless, coatless and barefooted in mid- winter. He was ardently devoted to his wife; he told several persons that she was too good for this world; 654 D. R. _Brower. that he was the third son of God, and must send her to heaven; accordingly, in June, 1878, in a public place, in the presence of several persons, without warning or evidence of passion or excitement, he shot her. She died immediately. ' The plea in defense was insanity. Dr. H. M. Lyman‘ and myself served as experts. With this history before us, and with the evidence of neurotic disturbance shown by pupillary inequality, well~marked nystagmus, fibrillary twitchings /of the muscles of the face, back, thorax and lower extremities, the evidence of the jail attendants that he slept scarcely at all, ate but little, and only such things as were brought from without, believing the jail food to be poisoned, we had no hesitation in say- ing that he was insane at the time of the homicide, and at the time of the trial. After this opinion was rendered, E. P. Weber, Esq., the prosecuting attorney, abandoned the case, and the jury returned alverdict of insanity without leaving their seats. This case was an impure one. The man was, at starting, a primary monomaniac; but that the traumatism exercised a decided influence in changing somewhat the type of the psychosis is sufficiently evident from the history. The termination of the case was paretic de- mentia, but the intervening phenomena were such as have been already ascribed to traumatism. The ques- tion of treatment naturally occurs. Would trephining be of service? It is doubtful. As has been shown, trauma- tism ‘produces deep-seated, impalpable change, and on this the trephine could exert no influence- Trephining in cases of depressed fracture would relieve one source of irritation, and would therefore be justifiable. Mickie"< has proposed, in cases of traumatism, to use kalium iodide, rest and local cephalic applications of cold water. From an a priori stand-point,‘ these would seem likely to be ‘of value during the period between the receipt of "the injury and the inception of the psychical symptoms. * American Psychological Journal, April, 1883. Report on Bibliography. PRESENTED To THE THIR TY-NINTH ANNUAL MEETING OF SUPERINTENDENTS OF AMERICAN HOSPITALS FOR THE INSANE, AT NEWPORT, RHODE ISLAND, JUNE, 1883. HE present year has seen many works on psychiatry issued into existence. In England, Tuke has con- tributed a valuable historical work, to the literature of this subject. In France, Luys, Bra, Ball, Bonnet and Voisin have written systematic works on insanity. Billod has collected his scattered contributions into two large volumes; Magnan has produced an interesting volume on Epilepsy; Mairet, one on Melancholic Dementia; Castaing, a small work on Chronic Mania; Mobit and Durantel, small works on Recurrent Mania; Le Grand du Saulle, an extended and valuable treatise on Hysteria; Rougier, a small essay on Melancholia, from locomotor ataxia; Régis, a small work on Progressive Paresis in the Female; Bourneville, one on Idiocy, Hysteria and Epi- lepsy; Descourtis, one on the Divisibility of Mental Operations; Ribot, a work on Psychical Heredity, and one on Diseases of the Memory; Paris, an essay on Ambitious Delusions; Lelorrain, one on The Insane from a Penal Point-of View; Broquére, one on Apoplecti- ‘form and Epileptiform Attacks in Progressive Paresis; Roux, one on Ethyl Bromide in Epilepsy and Mania. In Germany a new edition of Krafit-Ehing’s Lehrhuch, has appeared, and a work by Arndt. Mendel’s work on Mania, is a contribution of decided value. In Italy, Ver- ga’s work on the Classification of Insanity, looms up prominently. In the United States and Canada, alienists have been very active in the production of works. Griesinger has been reproduced, unaltered from the Syd- enham Society translation in an American edition. Drs. 656 Report on Bz'élz'ogmpky. W. A. Hammond, E. C. Spitzka and E. C. Mann have published ‘systematic works on Insanity; while Drs. H. P. Stearns and E. C. Spitzka have discussed the [Etiology of Insanity. The first deals with the general aetiology; the second with the somatic only. In Canada, Dr. Howard has published a small work on the “Philosophy of Insan- ity, Crime and Responsibility.” Dr. Worcester (a homoe- opathist) has also written on Insanity in general. No less than five new journals devotedto Psychiatry, have appeared. Of these, two are American, one is German, one Italian and one Russian. It will be obvious from these, that the tide of periodical psychiatrical literature is growing in vol- ume, and to chronicle even the titles of the same is no mean task. A bibliography is always a matter of perhaps equal fatigue to the reader and writer. SPECIAL PS YCHOSES. The contributions to the special psychoses are by no means few. Drs. G. Alder Blumer,1 P. M. Vll'ise2 C. Shaw,3 Charcot,‘ Raggis and Sterz,6 have reported cases of sexual perversion, corroborating the views expressed by Westphal, Krafft-Ebing and others, that this type of mental alienation occurs in hereditarily defective indi- viduals, and ischaracterized by the fact that the male is attracted by the male, and ma versa. Transitory insanity has been analyzed by Brush,7 Lowenfeld,8 Lombroso,9 Burns,“ Kiernan,11 Engelhorn,12 Spitzka”v and .Delafield,“ whose reported cases confirm the views of Krafft-Ebing and Schwartzer. EPILEPTIC INSANITY, in its varied phases, American J curnal of Insanity, July, 1882. Alienist and Neurologist, January, 1883. Archives de Neurologie, Tome IV. , 1882. Journal of Nervous and Mental Disease, April, 1883. Annali Universali di Medicina y Chirurgia, 1882. J ahrbuecher fuer Psychiatric, Band III. American Journal of Insanity, July, 1882. N eurologisches Centralbl att. Archivia di Psichiatria, Fasc I. , 1883. Rocky Mountain Medical Review, March , 1882. Detroit Lancet, March, 1883. Centralblatt fner N ervenheilkunde, 1882. American J c urnal of Neurology and Psychiatry, 1882. New York Medical J ougnal, October,‘ 1882. rifififigcomqmgmeovww Rejoort on Bihliography. ' a 657 has been discussed by Kiernan,1 Kerlin,2 Respaut,3 Bourne- ville,‘ jehn,5 I Spitzka,6 Hughes,1r Russell,8 Kuhn,9 Lent,1o ' F iirstner,11 Vallée,l2 Pelman and Mdli,13 Eotkin“ whose cases .support the views of Falret and Samt. PROGRESSIVE PAREsIs has been the subject of papers by Hughes,15 Ken- .ner,16 Zacher," Magnan,I8 Obersteiner,19 Snell,20 Fabre de Parel,21 Lamaestre,22 Baillarger,23 Frigerio," Regis,25 Lange,26 Rely,27 Mickle,28 Foville,” Taguetf’o Mendel,31 Culléréf”2 I La- fitte,33 Stenger,“ Tuttle,35 Goldsmith,36 Broquére,37 Schiilef'8 Howard,39 Camuset,“0 Berger,“1 Seppilli,‘2 Wigglesworth,43 Chicago Medical Review, February, 1882. Alienist and Neurologist, July, 1882. Alienist and Neurologist, January, 1882. Archives de Neurologie, Tome IV. , 1882. Neurologisches Centralblatt, No. 3, 1882. American Journal of Neurology and Psychiatry, 1882. Alienist and Neurologist, July, 1882. Medical Times and Gazette, January, 7-21, 1882. Berliner klinische Wochenschrift, No. 17, 1882. American Journal of Neurology and. Psychiatry, 1882. Berliner klinische Wochenschrift, July 10, 1882. L’ Union Medicale du Canada, January, 1882. . Allgemeine Zeitschrift fuer Psychiatric, Band XXXIX. 14. Medizinkoje Obosrenje, July, 1882. 15. Chicago Medical Review, April 16, 1882. 16. Cincinnati Lancet and Clinic, March 5, 1883. . Archiv fuer Psychiatric, Band XIII. 18. Journal deZMédecine et de Chirurgie, January, 1882. 19. Monatshel'te fuer praktische Dermatologie, No. 11, i882. ‘20; Zeitschrift fuer Psychiatric, Band XXXVIII. 21.‘ Annalee Medico-Psychologiques, July, 1882. 22. Ibid. _ 23. 11nd, January, March, 1883. '24. Archivio per la Malattie N ervoso, F. I. to II. , 1883. '25. L’Encephale, No. l, 1883. 26. Hospitals Tidende, May 19, 1883. 27. Annalee Medico-Psychologiques, N o 1, 1883. 28 Journal of Mental Science, July, 1883. 29. Annalee Medico-Psychologiques, Tome VIII, 1882. 30. Ibid. 31 Neurologisches Centralblatt, February, 1882. 32 Annalee Medico-Psychologiques, March 1882. 33. Ibid. 34. ' Archiv fuer Psychiatric, Band. XIII. as Boston Medical and Surgical Journal, December 28, 1882. 36. Archives of Medicine, August, 1883. 37. These de Paris, 1883. 38 39 40 41 42 43 pap-1H iiiwr-loeoootlcaoimoawt-a cc’_! .0...- . Berliner klinische Woohenschrift, July 10, 1882. Journal of Neurology and Psychiatry, February, 1883. . Annalee Medico-Psychologiques, January, 1883. Neurologisches Centralblatt,.October, 1882. Revista Sperimentale di Erenlatria, Anno IX. , ~li‘aslc I. Journal of Mental Science, January, 658 Report on Bibliography. Oebeke,1 Spitzka,” C. K. Mills,3 McFarland and Kiernan.‘ Baillarger and Frigerio discuss the question‘ whether there be not paralytic insanities of different aetiology, prognosis, and clinical course. Seppilli discusses at length the ques- tion of progressive paresis in the female, and disproves Neumann’s assertion that this psychosis does not occur among females. He is of opinionpthat the climacteric is not without influence in the production of this psychosis in the female. Mendel has recently discussed at length melancholia, in the same clear analytical way which gave his study of mania so much interest. He defines melancholia as a functional cerebral disease, attended by morbid psychical phenomena, which has for its basis a morbid excitability of the sensitive side of the mind. In the typical melan- cholia, there are three sta'ges,—-a stage of depression, in which the patient although depressed, has not lost the power of appreciating his relations to his surroundings; a stage of melancholia, in which this power is lost, and _ the patient has delusions or hallucinations of a moral or physical nature; a stage of decline. Besides this typical form there is: First, The so-called “mild melancholia” of the Americans; the “reasoning melancholia” of the French, which lacks the melancholic stage. Second, The melancholia attonita. Third, The melancholia periodica. Morse has also discussed the same subject, and Kier- nan: has briefly confirmed Mendel. Moral Insanity,—that morbid entity which has been claimed to be unknown to science, seems to have had much attention directed to it dur- ing the past year. It has been discussed by Hughesf’ Gas- quet,6 Manley,7 Andrusski,8 Magnan,9 Hollander,10 Work- Allgemeine Zeitschrlft fuer Psychiatric, Band XXXIX. , 1882. American Journal of Neurology and Psychiatry, August, 1883. J ournal of Nervous and Mental Disease, July, 1883. Alienist and Neurologist, July, 1883. ' Alienist and Neurologist, January, 1882. Journal of Mental Science, April, 1882. Ibid, January, 1883. Wratschebnija Wedomosti, No. 27, 1882. Journal de Medecine et de Chirurgie, April, 1882. J ahrbuecher fuer Psychiatric, Band III. H ¢cb00qo>uw~oassH I'D-.0000. Report on Bihliography. 659 man,1 Lombroso2 and N. Folsom f‘ and the weight of authority during the year is in favor of the existence of the psychosis denominated by Morel, Ray, Conolly, Krafft- Ebing, Schiile, Tuke and Crichton-Browne, moral insanity. On the other hand the New York Medical Society, at its 1882 meeting, passed a resolution that the alienist was not justified in drawing conclusions as to sanity from moral manifestations of conduct, that department pertain- ing exclusively to law. PRIMARY MoNoMANIA has been discussed by Pasternazki,4 Burr,5 Andrusski,6 Buccola" and Spitzka,8 who confirm the conclusion of Sander that there is a congenital type of insanity dependent on cor- tical malformation rather than disease. KATATONIA first described by Kahlbaum, in 1874, whose existence was sub- sequently confirmed by the researches of Kiernan, Brosius and Hecker, has been discussed by Lafenauer,9 Kiernan10 and Hammond ;11 and their researches are fully confirm- atory of those already cited. ' REASONING MANIA has been discussed by Hammond and Chase,13 and its relations to primary monomania seem clearly demonstrated. HEBEPHRENIA, or insanity of pubescence, has been dis- cussed by Burr,l4 who confirms pre-existing researches on the subject. He alludes to the fact that religiosity and‘ sexual ideas are often concomitant or alternate, as noted by Workman and others. In a general way his results corroborate those of Hecker and Kahlbaum. FoLIE DU DOUTE has been discussed by Ball“, and Canadian Practitioner, February, 1888. Archivia di Psichiatria, No. 1, 1882. New York Medical Journal, February, 1882. Wratsch, No. 31, 1882. American Journal of Medical Science. July, 1883. Loc cit, No. 27, 1882. Revista Sperimentale, Anno VIII. Somatic Etiology of Insanity. Orvosi Hetilap, Nos. 5 and 6, 1882. Alienist and Neurologist, October, 1882. New York Medical Journal, April 15, 1883. Journal of Nervous and Mental Disease, January, 1882. Chicago Medical Review, May 1, 1882. Physician and Surgeon, March, 1882. Eulenburg’s Real Encyclopaedie. -.-4r-a--r-i—l|-J oimpawf-lpcoooflczoiboswfi 660 Report on Bz'élz'ogmpky. -' Tamburini.l Under this title are included mysophobia, toxophobia and allied conditions. Tamburini divides it into the metaphysical type, whose intellect is affected by endless imperative metaphysical conceptions; the realistic type, in whom trivial realistic imperative conceptions affect the patient; the scrupulous type, whose morbid impulses relate to the question of conscience; the timorous type, who fear to compromise themselves by any act, however simple; the calculating type, who find themselves forced to calculate; and finally, a type in which the contact of external objects is feared. MEGALOMANIA is discussed ‘by Foville. The types of insanity occurring at certain periods, in childhood, old age, in pregnancy, during lactation, etc., have been discussed by Hughes,2 Leidesdorf,3 Gauthier,‘ Savage,5 Guermon- prez,6 Mackintosh,7 Moller,8 Kiernan,9 Cohn,10 Magnan,11 Griffin,12 Berner13 and Hammond.14 ACUTE DELIRIOUS MANIA, the typhomania of Bell, has been discussed by Géné“ and Kie‘rnan.16 _ PERIODICAL AND CIRCULAR INSANITY has attracted the attention of Koster,17 Foville,l8 I-Iaase,19 Ritti,20 Hurd,” Taguet,22 and Schafer,23 who confirm previous researches. Ohio Medical Journal, April, 1883. Alienist and Neurologist, 1882. J ahrbuecher fuer Psychiatric, 1883. These de Paris, 1883. Journal of Mental Science, July, 1883. Archives Génerales de Medecine, August, 1882. Edinburgh Medical Journal, April, 1882. Archiv fuer Psychiatric, Band XIII. Detroit Lancet, 1882. Arch-iv fuer Kinderheilkunde, Band IV. Journal de Medicine et de Chirurgie, April, 1882'. Australian Medical Journal, June, 15, 1882. Norsk Magazine of Leegevidenskabens, 3B. XII. Alienist and Neurologist, July, 1883. Revista Frenopatica Barcelonesa, November, 1882. Detroit Lancet, September, 1883. Allgemeine Zeitschriit fuer Psychiatric, Band XXXIX. Brain, July, 1882. Allgemeine Zeitschrift fuer Psychiatric, Band XXXIX'. Annalee Medico-Psychologiques, July, 188:. Journal of lnsaniiy, 1882-3. ' Annalee Medico-Psychologiques, July, 1882. Neurologisches (.‘entralhlatt, May, 1882. wwwNl-JHHHHHHHHH 9°Pr“:=E°9°:~‘?=P'r-°°l°*-‘° . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Skene. Dr. Alex. J. C., on the diagnosis and treatment of malignant dis- ease of theneck of the uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Smith, Dr. Albert H., on retroversion of the gravid uterus . . . . . . . . . . _ _ . 539 Smith, Dr. Albert H. , on a new vaginal speculum . . . . . . . . . . . . . . . . . . . . . 54.3 Smith, Dr. Eustace, on worms found in children . . . . . . . . . . . . . . . . . . . . . . 553 Smith, Dr. Eustace. on the acid dyspepsia of infants . . . . . . . . . . . . . . . . _ . 597 Smith, Dr. F. G. Case of retarded physical-development . . . . . . . . . . . . . . 728 Snelling, Dr. F. G., on relaxation of the pelvic symphyses during preg- ‘ nancy and parturition. . . . .‘ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561 Speculum, a new vaginal. By Albert H. Smith, M.D . . . . . . . . . . . . . . . . . 543 Stefit'en, Dr., on examination of the heart in its physiological and patho- logical conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524 Sterility in the female, the pathological conditions causing. By Joseph Kammerer, M D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~. . . . . . . . . . . . . . . 546 x Index. Stricture of internal os as a cause of miscarriage. By William Mar- shall, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sudden death following abortion. case of. By R. A. Cleemann, M.D. . . . Synovial apparatus of the new-born. By Dr. W. Heineke . . . . . . . . . . . - . T. Taylor, Dr. Isaac E. , on relaxation of the pelvic symphyses during preg- nancy and parturition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . Terry, Dr. C. 0., on some recently reported cases of monstrosity . . . . . . . Testa, Dr. Giuseppe. Researches on gastro-hysterotomy . . . . . . . . . . . . . . Thiesseu, Dr., on burns of the pharynx and epiglottis in children . . . . . . . Thomas, Dr. (of Leipzic), on scarlatina . . . . . . . . . . . . . . . . . . . . . - - . . . . - .- Thomas, Prof. T. G. , on chronic inversion of the uterus, and a new operation designed as a substitute for amputation . . . . . . . - . . . - . . . . . . . Thomas, Prof. T. G. The induction of premature delivery as a prophy- lactic resource in midwifery . . . . . . . . . . . . . . . . . . on induction of premature delivery in deformity of the pelvis . . . . . . . . . . “ “ “ placenta praevia . . . . . . “ “ “ aggravated uraemia. . . “ “ “ in excessive vomiting. . . " “ “ in placental apnoea. . . . . “ “ “ in commencing epithe- lioma . . . . . . . . . . . . . . . “ “ “ in'death of the child. . . . “ “ “ in threatened death of child . . . . . . . . . . . . . . . . “ “ “ in approaching death of mother . . . . . . . . - . . . “ “ “ in amniotic dropsy . . . . . . “ “ “ in previous rupture of uterus . . . . . . . . . . . . . . . 'the care of the prematurely delivered child. . . . Tobacco, use of, in pruritus of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . Temperature, normal, of children. By Mr. J. Finlayson . . . . . . . . . . . . . . Transactions of the Philadelphia Obstetrical Society . . . . . . . . . . .347, 532, Tumor, fibre-cystic, causing inversion of the uterus. By Thomas Addis Emmet, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . U. Urethra, calculus removed through, from the bladder of child. By Dr. Fleming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urethroplasty. By John H. Packard, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . Uterine catarrh, treatment of. By Joseph Kammerer, M.D. . . . , . . . . . . Uterine elevator, modification of, for treatment of retroversion and re- troflexion. By E. Noeggerath, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Uterine injections, treatment of endometritis by. By J. C. Nott, M.D . . Uterus, chronic metritis in its relation to malignant disease of. By E. Noeggerath, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .505, Uterus, concealed accidental hemorrhage of the gravid. By William Goodell, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . chronic inversion of, reduced by a caoutchouc tampon . . . . . . . . . Uterus, inversion of, from a fibre-cystic tumor situated at the fundus. By Thomas Addis Emmet, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . diagnosis and treatment of malignant disease of the neck of the. By Alex. J. C. Skene, M.D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PAGE 147 595 369 358 1 75 528 423 732 734 736 738 7 40 741 741 741 742 743 175 726 207 610 354 207 218 Ira-dew. Xi PAGE Uterus, on chronic inversion of, and a new operation designed as a sub- stitute for amputation. By Prof. T. G. Thomas . . . . . . . . . . . . . . . . . . . . 423 Uterus, on the utricular glands of. By Prof. G. Ercolini . . . . . . . . . . . . . . 121 removal of a large fibrous polypus of. By Dr. H. Hoenig . . . . . . 134 direction of the axis of, in the adult female. . . . . . . . . . . . . . . . . . . 140 new symptoms of rupture of. By Dr. M. Jolly . . . . . . . . . . . . . . . 142 Uterus, retroversion of the gravid. By Albert H. Smith, M. D . . . . . . . .. 539 V. Vagina, case of atresia of, with pregnancy. By Dr. Herzfeld . . . . . . . . . . 135 Vagina, narrowing of, for relief of prolapsus. By Mr. Norton. . . . . . . . . . 139 Vaginal speculum, a new. By Albert H. Smith, M.D . . . . . . . . . . . . . . . . . . 543 Vaginitis, lead poisoning a cause of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 operative occlusion of the, in incurable vesico-vaginal fistulae. By Prof. G. Simon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Variola, pregnancy complicated with. By Dr. Isambert . . . . . . . . . . . . . . . 550 Vulvitis, remarkable case of follicular. By B. F. Dawson, M.D.. . . .. . . 113 W. Wagner, Dr. A case of ovariotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Weis, Dr. M. J ., on a case of incarceration of the placenta . . . . . . . . . . . . . 360 Willard, Dr. De F. , on an anencephalous monster . . . . . . . . . . . . . . . . . . . . . . 534 Worms found in children. By Dr. Eustace Smith . . . . . . . . . . . . . . . . '. . . . . 553 Wrany, Dr. A., on the pathology of the navel . . . . . . . . . . . . . . . . . . . . . . . . . 151 REVIEWS AND NOTICES OF BOOKS. Brown, Buckminster. Orthopoedic surgery: . . . . . . . . . . . . . . . . . . . . . . . . . 752 Cheever, David W. Two cases of oesophagotomy . . . . . . . , . . .' . . . . . . . . . 560 Dalton, J. C. A treatise on physiology and hygiene . . . . . . . . . . . . . . . . . . 367 Erichsen, John Eric. The science and art of surgery . . . . . . . . . . . . . . . . . 559 Francois, E. Du frisson dans l’état puerperal . . . . . . . . . . . . . . . . . . . . . . . . 363 Gay, C. C. F. Puerperal eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . 557 Ringer, Sidney. A handbook of therapeutics . . . . . . . . . . . . . . . . . . . . . . . . 752 Hartshorne, Henry. A conspectus of the medical sciences . . . . . . . . . . . . 362 Hartshorne, Henry. Essentials of the principles and practice of medi— cine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Hodge, Hugh L. Foeticide, or criminal abortion . . . . . . . . . . . . . . . . . . . .. 557 Loomis, Alfred L. Lessons in physical diagnosis . . . . . . . . . . . . . . . . . . . . . . 361 Meyer, Moritz Electricity in its relations to practical medicine . . . . . . . 558 Pennsylvania Hospital Reports. Vol. II.. 1869 . . . . . . . . . . . . . . . . . . . . . . . 181 Remy, Thaddeus A. Puerperal eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . . . 567 Ringer. Sidney. A handbook of therapeutics . . . . . . . . . . . . . . . . . . . . . . . . 752 Smith, Eustace, on the wasting diseases of children . . . . . . . . . . . . . . . . . . 750 Smith, J. Lewis. A treatise on the diseases of infancy and childhood. . 177 Taylor. Isaac E., on the spontaneous and artificial delivery of the child in face presentations with the chin posteriorly . . . . . . . . . . . . . . . . . . . . . . 751 Thomas, T. Gaillard. A practical treatise on the diseases of women (2d edition) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 366 Thomas, T. G. Nine cases of ovariotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 751 Transactions of the Obstetrical Society of London. Vol X., 1868. . . . . 556 Vogel. Alfred. A practical treatise on the diseases of children . . . . . . . . . 746 Von Niemeyer, Felix. A text-book of practical medicine . . . . . . . . . . . . . . 559 Zell, T. Ellwood. Popular encyclopedia and universal dictionary, etc. . 368 THE AMERICAN JOURNAL OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. voL. 11.] FEBRUARY, 1870. [No 4. ORIGINAL COMMUNICATIONS. RELAXATION OF THE PELVIC SYMPHYSES DURING PREG- NANCY AND PARTURITION. BY FREDERICK G. SNELLING, ‘M.D. (Read before the Medical Journal Association of New York, December 8, 1869.) Mr. President and Gentlemen .'——I propose to advert briefly, this evening, to a condition not so generally recognized in this country as it might be, but which. in Italy, Germany, and France has received a merit- ed amount of attention. I allude to relaxation of the pelvic articulations during pregnancy and par- turition. This condition has been known and commented upon since the time of Hippocrates, but it is a noteworthy fact, that but few of the systematic writers on obstet- rics refer to it. Still, we find a few monographs and 37 562 Snell/ing on Relcawat'io/n of isolated allusions to it scattered through medical litera- ture by the most eminent authorities, among Whom are Winckel, in his Pathologie and Therapie des Wochen- bettes, Berlin, 1866 ; Ballochi, Manuel. di Obstet. Milan, 1859; Cazeaux, Traité Théorique et Pratique de l’Art des Accouchements, Paris, 1 867 ; various Writers in Schmidt’s Jahrbucher, Nos. 1, 8, 58, 103, and 180; Blundell, Griflith, Debout, Erichsen, Jacquemier ; Trous- seau, in his Lecons Cliniques sur le Relachement des Symphyses du Bassin; Courot, Desormeaux, Churchill, Meissner, Smellie, Stoltz, Luschka, Albini, Laborie, Cruveilhier, Ercole Galvani, Velpeau, Lenoir, and Du- bois. The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting ‘of a degree of mobility of the pelvic bones Which effectually hinders locomotion, and gives rise to - the most peculiar, distressing, and alarming sensations. It can, perhaps, be best illustrated by the following case by Dr. Duplain. The patient, Madame , Was 26 years of age, of a lymphatic temperament, married four years, and the mother of three children. The last child Was born about the middle of May, 1867, after a labor lasting twenty-two hours, and was a child of unusual size. After its birth she Was almost constantly confined to the bed, from the difficulty, and indeed impossibility of Walking, and a singular and distressing sensation, as if the abdominal viscera Were about to fall through the pelvic outlet. She also had vague pains, increased on the Female Pelvic Symphyses, etc. 563 motion, in the hips, at the symphysis pubis, and in the loins. As for the other symptoms, her appetite was good, her sleep sound, pulse normal, bowels regular, and urinary secretions healthy. The vaginal touch disclosed no malposition, or other disturbance of the uterine system. On palpation, the abdomen was supple and lax. On examining the patient in a recum- bent position, the lower limbs presented nothing abnor- mal; their sensibility was intact and movement was free and painless. But immediately upon arising, the sensation complained of returned with much severity, Walking was accomplished with difliculty, and she dragged one foot after the other, inclining herself to the right and left as the case might be. On com- pressing the pubic and sacro-iliac symphysis some pain was experienced. From the symptoms supervening upon delivery, the - physician, M. Duplain (eliminating the possibilities of disease of the spinal cord, of the pelvic viscera, lumbo- ‘abdominal neuralgia, &c.), judged it to arise from a relaxation of the pelvic symphyses. and the sequel justi~ fied the accuracy of the diagnosis. A bandage was placed about the pelvis and hips in such a manner as to compress and confine the articu- lations firmly. Walking immediately became easy; she could maintain an upright position, the pains dis- appeared, and at the end of two months, without any other treatment, the patient left oif her bandage and found herself entirely cured. This may be regarded as a typical case of uncompli- cated relaxation of the pelvic symphyses. 564 Smelling on Relaxation of ()f a similar nature was the following case occurring in the experience of the writer. Mrs. H , aged twenty-two, primipara, was safely delivered on the 14th of last August of a healthy female child, at full term. The labor was short, lasting but eleven hours; the presentation normal, and delivery was accomplished without accident. The case progressed favorably in every respect until the tenth day after confinement, when she was allowed to leave her bed. She almost immediately complained of. the great difficulty of walking, and of the singularly distressing sensation caused by motion in an upright position. I made a digital examination, expecting to find malposition of the womb. I found that there was relaxation of the anterior wall of the vagina, but the womb was high up, and not larger nor heavier than it should be at such a time. I advised rest in the recumbent position, and (the lochia having ceased) injections of alum and water, a ' pill of two grs. of the extract of gentian and one-fourth of a gr. of extract of nux-vomica, as a general tonic. At my next visit, two days afterwards, having re- mained the greater part of the time in a recumbent ‘ position, she was somewhat improved, but the improve- ment was but temporary. At a subsequent visit I found her in tears, all her symptoms and sensations having returned. They were peculiar. There were vague pains in the pelvis, no particular sense of dragging or weight, none of the train of nervous symptoms which attend uterine displacements; but her main complaint was of the impossibility of walking. She could not tell why, nor for what reason, but she simply could not do the Female Pelvic blywyyhg/ses, etc. 565 it. After dragging herself partly across the room, her sensations became so peculiar and unendm'able that she was forced to sit down at once, lest she should fall. Professor Barker, who saw the case in consultation with me, thought that it might be a case of relaxation; and I therefore examine'l her in an upright position, by grasping the symphysis pubis, from before back- ward, between the two fingers in the vagina and the thumb upon the mons veneris, and then directing the patient to balance herself first upon one leg and then upon the other. The movement of the bones was dis- tinctly felt, one upon the other, to the extent of a quarter of an inch or more. A girdle firmly applied about the hips relieved her in two months. Trousseau presents four similar cases. The pa- tients had had one or more previous labors, followed by normal recoveries. The children’s heads were not of abnormal size. The patients were either absolutely unable to walk, or could not maintain the erect posi- tion. They complained of pains in the thigh and pel- vis, or in walking they twisted the legs one over the other. Standing upon one foot was almost out of the question, when the symphysis pubis was the seat of the relaxation; and in some it caused violent pains in the groins, if the sacro-iliac symphyses were af- fected. Dr. Hodge mentions a marked case. About two months previous to the birth of the patient’s fifth child, while walking across the room, she was suddenly check- ed in her progress by the. seeming dislocation of the pubic bones, which she believed to be jointed; causing 566 Snell/ing on Relaxation of intense agony, accompanied by a sound like a pistol- shot. Leaning on something near by for support, her movement caused the bone to slip into place again, when she was enabled to take a few steps, but with great suffer- ing. These painful sensations and sounds occurred again and again, when attempting to get up or lie down, till the birth of a fine large child, which, it may be well to say, caused less pain than she had ever experienced on any previous occasion; leaving her, however, with so-called prolapse of the womb, and the innumerable distressing sensations of such disease, for eighteen months. She then became again pregnant, and enjoyed good health until two or three months before confinement, when she suffered as before, which, contrary to expectation, brought no relief. The pain in the bones seemed per- manent; numbness and stifiness were present in the left hip, which also gave way with a noise and pain when she would lift her foot. She then dragged it as if paralyzed. This continued for six months, until she was taken to Philadelphia, where she was relieved of some of her suffering; but ten months elapsed before she was sensible of a decided improvement in the condi- tion of the bones. Dr. Hodge speaks of it as a peculiar phenomenon in connection with a retroverted uterus, disappearing upon the removal of the displacement, but does not allude to the disease under consideration. Pigeolet saw a woman, who, after a diflicult instrumen- tal labor, was obliged for a long period to keep her bed, with protracted pains in the pelvis. On the fourth day of the second labor she had chilliness about the pelvis and torpor of the lower extremities. The patient was the Female Pelvic Sy/nWhg/ses, etc. 567 forced in order to ease herself to maintain a flexed and curved position in bed, any motion of the pelvic sym- physes causing dull pain and an unpleasant sensation of crawling and formication in the lower extremities. Urinating was accompanied by pain in the symphyses, and the bowels were torpid. She had no fever. After putting on a pelvic bandage the disease yielded in six weeks. Putegnat refers to two cases. One was a woman four days delivered of twins, who made a few steps in her chamber, and the next day she experienced a slight pain in the symphyses on motion, which endured for a long period. At the same time the walk was uncertain and tottering. Cupping, general baths, tonic frictions, absolute rest, and a pelvic bandage were used, and the next labor was accomplished without further untoward consequences. Another case was happily cured by compression of the pelvis. Both of these patients were healthy and robust women. Courot cites two cases. The first of them arose from an abortion. Walking was impossible, and standing painful. After wearing for four months Martin’s gir- dle, the patient was so far cured that she could undergo great fatigue. The second case involved the left sacro- iliac symphysis. Martin’s girdle was worn during preg- nancy, although throughout its pressure was annoying. She remained twenty-five days in bed and then resumed it, wearing it three months more, and was then able to leave it off. By the third pregnancy the disease was not reproduced 568 Swelling on Relaxation of The pubic symphysis in common with the sacro-iliac articulations belongs to the second class of the amphiar- throdial or mixed articulations ; those, namely, in which the surfaces are connected by fibre-cartilage, and lined by a partial synovial membrane. I here present a draw- ing, Fig. 1, after Cruveilhier, representing a section of ‘h, . ‘if.’ I 7 t . - /, . , '1 4+ . .1 f, . -/ '7 . l ‘l ‘ Ht" .',1' '1‘ Yr,.'-/ \ r . ‘ _._ sad, '1? -- ‘ gx‘éfi} L,’ _ J ._‘_\,\__\$‘ I . _’_ the pubic symphysis coinciding with the plane of the superior strait. Its articulating surfaces are oval, of large diameter obliquely below and behind, bevelled from behind forward, and from within outwards ; from which there results in front a triangular space of separa- tion, the base of which is directed forwards, and the apex backwards. The inter-articular fibre-cartilage consists of two oval- shaped plates, one covering the face of each articular surface. They vary in thickness in different subjects, and project somewhat beyond the level of the. bones, especially behind. Each is firmly attached to the bone the Female l’etm'c b’g/mphyses, etc. 569 by a number of nipple-like processes which accurately fit within corresponding depressions on the osseous surfaces. Their opposed surfaces are connected throughout the greater part of their extent by an intermediate fibrous elastic tissue called the inter-osseous ligament, Fig. 2, and by their circumference to the various ligaments surrounding the joint. An interspace is left between the two plates of cartilage at the upper and back part of the articulation, where the fibrous tissue is deficient, and the surface of the fibre-cartilage lined by epithe- lium. This space is found at all periods of life, both in the male and female, but it’ is larger in the latter, especially during pregnancy and after parturition. It is most frequently limited to the upper and back part’of the joint, but it occasionally reaches to the front, and may extend the entire length of the carti- 570 Snellz'ng on ReZa-watz'on of lages. The accompanying sketch, Fig. 3, of a vertical section of the symphysis pubis, made near its posterior surface, well displays these various points. \ FIG. 3. The extent to which the two articular surfaces are in apposition, it must be borne in mind, varies greatly in different subjects. Occasionally the two surfaces will be continuous throughout their whole extent, while again it will be found, in another subject, that the sur- faces touching one another are quite limited. ‘ The joint is further strengthened by four ligaments, named respectively, from their positions and functions, the anterior, posterior, superior, and sub-pubic ligaments. The anterior ligament consists of several superim- posed layers, which pass across the anterior surface of the articulation. _ The superficial fibres pass obliquely from one bone to the other, decussating and. forming an interlacement with the fibres of the ‘aponeurosis of the external oblique. The deep fibres pass transversely across the the Female Pelm'c Symphyses, etc. 571 symphysis, and are blended with the inter-articular fibro- cartilage. The sub-pubic ligament is a thick triangular arch of ligamentous fibres connecting together the two 3751px“. ‘l? nun; "L, ‘~.. all] “16' \ ' . /, ($13, (tum 1;. v r ., (4,29! # l u ! ’ i V. 1‘ Z’ l 013' v’ I’, / - Q '4 4 ‘ / vi: .(\.'J'I , ./r \ ¢~ '1 \ I <9 I v i x r’- m a » 3.21M ‘(é/w Lia . 4A3 \40“ H’ ‘J /*\/// '\?'%v"“{ flab "All ‘I v ‘P a /: fill.“ 'fsnlw: FIG. 4. pubic bones below, and forming the upper boundary of the pubic arch. FIG. 5. The sacro-iliac articulations, of which Figs. 4 and 5 are vertical sections, though of the same class, are more 572 Snelling 0n Relaxation of intimately linked together than the symphysis pubis. The articular surfaces are not in apposition throughout their whole extent. That portion which is continuous is posterior. The articular surfaces are sinuous, alternate- ly concave and convex, ‘and have a double obliquity so contrived that those of the right side converge with those of the left, towards the summit of the sacrum on the one hand, and towards its upper and posterior face upon the other; in such manner that a force applied perpendicularly to its superior and posterior surface would tend to force it easily into the pelvic cavity, were it not for the sinuosities of its surface and its peculiar mode of union, which is as follows: The arti- cular surfaces are “ reoelted ” throughout their whole extent with a layer of cartilage, thicker upon the sacrum than upon the ileum. The cartilage is remark- able for the roughness of its surface, which contrasts with the glistening aspect of other articular cartilages. A synovial membrane, difiicult of demonstration in the adult and aged, but quite manifest in children and in females during pregnancy, lines its cavity. The inter- osseous ligament is the most powerful of all its means of union. It is composed of a multitude of interlaced ligamentous fibres, extending horizontally from the sacrum to the ileum, almost completely filling the deep excavation between the two bones. The other periphe- ral ligaments are mere reinforcements to the strength of the joints. They are the anterior, posterior, inferior, and superior sacro-iliac. To these may, perhaps, be added an ileo-lumbar and sacro-spinal ligament, of but little moment in this connection. the Female Pet/etc Symphyses, etc. 57 3 Laborie insists, however, with regard to the pubic symphysis, that the two opposed articular surfaces have not the same conformation, but that the left is smaller and obscurely convex, after the fashion of the rudimen- tary head of a joint; and that it sinks into the opposite articular surface. Of this relation I have not been able to satisfy myself. Were it so, it would certainly tend to increase the rigidity of the articulation, but for the fact that the interposed fibre-cartilage and the bevelling of the bone-ends on all sides acts as a counterpoise. He also insists upon a peculiar hinge-like motion of the whole pelvis during labor. He thinks that upon the entrance of the foetus into the superior strait any move- ment of the bones is impossible, but as the head passes down and reaches the inferior strait, a sort of hinge- like movement is acquired, the tuberosities of the ischia being separated, and the crista ilii approximated. This, however, can hardly be considered as established. Drs. Galvagni and Golinelli experimented upon a cadaver, but were unable to demonstrate the hinge movement. They did find, however (the subject, by the way, being a woman who had died of puerperal eclampsia), that the sacrum could be moved up and down between the two ossa innominata to a sensible extent when the pelvis had been separated from the trunk and limbs. On section of the symphysis pubis, a distinct cavity with irregular walls, and of a blunt ovoid form, was found in the centre, as stated above. Many will be slow to believe that so intimate a junction, so firm an articulation, should admit of 574 Snell/ling on Relaxation of motion, but the evidence upon the point is too over- whelming to admit of question. As a concomitant of the pregnant and puerperal state, it has been maintained by numerous authors from the earliest times, including even Hippocrates. Chally held that softening of the pelvic ligaments was a con- stant and normal phenomenon during pregnancy. Jac- quemier thinks that the ligamentous union of the pelvic bones is always swollen to a third or even one- half greater volume during pregnancy. Velpeau con- curs in the view of Chailly. Lenoir asserts that there is a decided widening or increase of the pelvic diameter towards the close of gestation. Dubois acknowledges the essential mobility of the pelvic bones by comparing them to the tarsal articulations, as being designed to prevent shock to the body in an upright position. As to the moclus in qao of its production, authors vary. Stoltz insisted that the unquestionable relaxation of the pelvic symphyses which sometimes takes place is almost always of a pathological origin, and that there is no adequate reason why it should be considered as a physiological condition pertinent to the puerperal state, and designed to facilitate parturition by permitting of distention and enlargement of the pelvic canal. ' Laborie is of the opinion that the pelvic symphyses must be regarded as allowing of movement a priori, in consequence of their structure; although their motion ‘is hindered almost completely (except during preg- nancy) by the rigidity of the sacro-iliac symphyses. Luschka, in his researches on the imperfect joints of the human body, holds that the pelvic articulations are the Female Pelm'c Symphg/ses, etc. 57 5 not true symphyses, but more or less complete joints, with apposed faces, covered with cartilage, and pro- vided with ‘synovial membranes; and that in pregnancy these imperfect or half oints are greatly augmented in volume in consequence of a copious secretion of synovia (which at other times is only present in inconsiderable quantities)——the necessary consequence of which is a certain mobility of the pelvic bones. Severin Pineau made a dissection of a woman recently delivered in the presence of Ambrose Pare, and demonstrated the relax- ation to the satisfaction of the latter. Others think the inter-osseous substance acts like a piece of prepared sponge, which forces the bones apart by absorbing fluids at this period. Others again imagine it to resemble the roots of the ivy, which by insinuating its fibres between‘ the stones of a wall or building end by overturning it; others, that the car- tilages act like dry, porous wooden wedges, which force the bones apart by their swelling, or make a place for themselves by development, as in the case of polypi in the nasal fossee or frontal or maxillary sinuses. Lenoir says that a slight degree of this relaxation is due simply to serous infiltration of the pelvic ligaments resulting from the pregnant condition. Dr. Martinelli, in a paper read before the Imperial Academy of Medicine in February, 1867, maintained the following propositions, viz. :- That the different parts of the female pelvis were movable in a high degree during pregnancy and labor, and that this mobility is not fortuitous, but an indis- pensable condition of child-birth ; that the peculiar in- 57 6 Snellc'ng on Relawatz'on of sertion and arrangement of the abdominal muscles acts with a powerful leverage to bring about the movement of the pelvic bones, and that it is further favored by the smaller extent of the articulating surfaces in womanand the general ramollissement of the ligaments at the period of child-birth. Such muscles he considers the rectus abdominis and obliquus externus abdominis and the four abductors of the thigh. According to Baudeloque, however, this relaxation may actually retard labor by destroying the point d’ap- 19ml which the abdominal muscles derive from the bones of the pelvis; and perhaps, also, the unusual distress oc- casioned by the engagement of the head forces the W0- man to restrain the pains as much as possible. It will be seen further on, however, that, on the other hand, in small or osteomalacious pelves, labor may be rendered easier and a spontaneous delivery take place, which but for this relaxation would have been utterly impossible. This separation has been known by Luschka, Morgagni, and Hunter, to reach an inch and more. . Matthews Duncan (in his late work, entitled “ Re- searches in Obstetrics ”) says, that these changes in the pelvis towards the end of gestation are beauti- fully exemplified in the lower animals, in many of whom they are found to a much greater extent than in the human female; as, for instance, in the guinea pig, in whom the pubic symphysis gives to the extent of an inch or even more. i In the cow, whose pubic symphysis is ossified, there takes place a remarkable change, demonstrated by Pro- fessor Barlow, of the Veterinary College, viz.: a great the Female Pelm'c Symphyses, etc. 577 increase in volume and a relaxation of the sacro- sciatic ligaments, rendering them slack and yielding; and the sacroiliac joints, which are described in the unimpregnated animal as secured by a substance re- sembling intervertebral substance, now have the op- posing surfaces smooth and lubricated. By this means the ilii become extensively movable upon the sacrum (or mice cereal), in an antero-posterior direction. The final result of these changes is to enlarge the genital passages in the animal. Mr. Zaglass, in 1851 (Monthly Journal of Medical Science, September, 1851), demonstrated the distinct motion of the ossa innominata in an antero-posterior direction in the human subject. This softening, relaxation, or ramollissement, how~ ever, does not as yet constitute a pathological con- dition, but probably forms a part of the general pre- paration for the parturient act, taking place throughout the system of the woman, of the same nature as the marked relaxation of the vulva and vagina at term. A natural explanation, therefore, of the occurrence of separation would be that the bones in the relaxed con- dition of the ligaments are forced asunder by the im- pact of the foetal head; and Ulsamer actually thus accounts for it. But what are we to say to those cases occurring after abortion, when the child’s head can hardly have much concern in producing the rupture, and still more in those cases occurring during the seventh and eighth months of gestation, before the child has been born at all 2 As we have seen, many authors speak of a constitu- 38 578 Smelling on Relaxation of tional diathesis, or cachexia, as the principal cause of the affection; but Debout found that, out of nineteen cases, nine occurred in robust individuals. Others have accused abdominal plethora, and the pressure of an unusually enlarged and heavy uterus, as a determining cause ; and again great physical weakness or prostration. Churchill speaks of diminished firmness of the sym~ physis pubis as associated with morbid irritability of the neck of the bladder during pregnancy, which irrita- bility often spreads as far as the vulva. But as such conditions may be regarded as common in all pregnan~ cies, and as the occurrence of relaxation to the extent of actual separation between the bones is rare, they can scarcely be regarded as causes, although they may be characteristic concomitants of the disease. I think it is not forcing a conclusion to regard it as proven from what has been advanced that an uncertain, varying degree of relaxation or ramollissement does obtain in a very large number of cases, in the pregnant and puerperal condition, of a physiological and benign character, and entirely consistent with health, and that it is to the excess alone of this condition that the pathological results above described are due. The ligaments become saturated with serum and lose their firm and resilient qualities; the synovia is greatly increased and presses the bones asunder; the pelvis becomes incapable of sustaining the weight of the body, and so gradually yields to the weight above; or some slight and insignificant movement of the patient suffices to precipitate the whole train of symptoms suddenly and at once. I am convinced that more such cases the Female .Pelm'c Symphyses, etc. 57 9 occur than is generally believed. There are so many distressing sensations incident to the lying-in state, that if the affection be but slight and non-persistent it is most natural to attribute it to the puerperal con- dition, or to some uterine displacement or irritation. Women themselves are so accustomed to vague pelvic and uterine and lumbar pains, that they almost regard them as a natural heritage, and themselves assist in deceiving the physician by ascribing them to the uterine system. Although the first symptoms frequently become ap- parent only after delivery, they also often occur during pregnancy and abortion; of which Oourot and Hodge both give instances. If occurring during pregnancy, it may follow some unusual exertion, but such is by no means a necessary antecedent. In such caseiit oc- curs suddenly, and all its peculiar symptoms are at once developed, as is also the case when it occurs after deliv- ery. To determine whether separation has occurred, We may, by flexion and extension of the thigh with the hand of the physician, placed over the symphysis pubis, feel the pubic bones moving up and down under the hand, but without crepitation. The same result is perceptible on laying the hand upon the hip-bone, when that is aifected. J acquemier has caused by dragging upon the thighs a sensible sinking down of the os ileum. In one of Trousseau’s cases, the end of the fin- ger could be laid in the space between the pubic bones in the softened condition of the inter-articular fibro- cartilage, and this has often occurred in other cases. 580 Snell'ing on Relawatlon 0f Erichsen speaks of change in the form of the hip- bone taking place, and in the length of the limbs, when the relaxation was of one sacro-iliac symphysis alone. He thinks that the anterosuperior spinous pro- cess of the diseased side stands lower and flares more than the opposite side, because of the swelling of the diseased joint, by which the ilium is forced out- wards and forwards. ' The pains bear no relation to the extent of mobility of the symphyses, but in the worst cases known the patient can neither stand nor walk, and the disease is complicated with paraplegia. To recognize the mobility of the sacro-iliac symphy- sis, one should embrace the pelvis with both hands and allow the patient to walk alone or with a support. One feels at each step that the os ileum at the side on which the trunk rests plainly rises, while the other is appa- rently lower. But, as has been said before, in all these cases it is more than easy to be deceived, as the patients on being questioned are rarely able to define clearly the seat of their sufferings, and the real affection is overlooked if care be not taken to make a direct examination. How often is the uterus regarded as the source of the pain, when the lesion is precisely located in the pelvic articu- lations. As to the termination of the disease, in slight cases a few weeks is sufficient to effect a cure ; and even with- out its being recognized, indeed, it being confounded with the general condition pertaining to the lying-in state; but in some cases it may endure for many years; the Female Pelvic Symphyses, etc. 581 according to Debout, in two cases respectively for seven- teen and fifty years. The most favorable period as regards recovery is pregnancy and the puerperal state. Light cases recon- solidate of themselves during complete rest. In severe cases Martin’s girdle may be used for circular compres- sion of the pelvis. It consists of a very solid metal , ring surrounding the whole pelvis. The spring is an inch and a third broad, padded in the same manner as a truss, both branches or arms of which are directed forwards and downwards, where they are fastened firmly by a buckle. The apparatus can also be worn during preg- nancy without interfering with the enlargement of the womb and belly. In cases where Martin’s girdle, how- ever, causes discomfort or is too heavy, I would suggest the use of a strong sole-leather apparatus, properly mcztlclecl to adjust itself to the shape, and secured in the same manner as Martin’s apparatus. It will be found lighter and quite as firm, if properly constructed. By the later use of the girdle, for instance, even more _ than one year after delivery, a cure may be efiected, but it is sounder policy to have recourse to it at as early a period as the disease may be recognized. If the disease should, in spite of the wearing of the girdle, last many years, still, with it the patient has the power of walk- ing, which, without it, would be utterly impossible. Griffiths recommended cold vaginal injections, cold baths, cold douches, vesication and stimulating frictions. Rest and the recumbent position, however, are the most efiicient aids to recovery, if not carried to such an extent as to damage the general health of the patient. 582 Smelling on Relaxation of Going up and down stairs is eminently unfavorable, and it is desirable to have the patient’s apartments upon ' the first floor, if possible, so that, if her social condition be such as to enable her to avail of it, she may have carriage exercise without detriment, and in any event will not be obliged to ascend to her sleeping apartment. But this is not the only diseased condition of the pelvic articulations incident to pregnancy, nor by any means the gravest. Sappaxatixe inflammation, with its attendant dangers, frequently sets in and carries‘ off the patient in spite of all that care or skill can do, after the most protracted and agonizing suffering-and further- more (what would seem at a first glance an actual impossibility), rapt/are of the symphyses may take . place as a crowning result. The first of these, viz., suppurative inflammation, has been treated of by Hiller, Monod, Danyau, Hayn, and others. It may arise either before or after labor, as in the case of simple relaxation, and its earlier symptoms are very similar; viz., pain in the symphyses of varying degree, greatly aggravated by movement and sometimes intermittent; crawling and pricking, and occasionally numbness in the lower extremities, and tottering and uncertain gait. The gait varies according to the part affected; and in one case a woman could only walk with bent knees dragging the feet over the fioor, with- out the ability to raise them in the least. When the pubic symphysis is the point afiected, dysuria is apt to be present; and where the sacro-iliac symphyses are the seat of inflammation there is tenes- mus and pruritus, especially during defecation. On the the Female Pelm'c Symphyses, etc. 583 occurrence of suppuration the symptoms assume a gravity which should put the accoucheur on his guard. Fever, followed by rigors, sets in, the patient’s counte- nance is expressive of anxiety, the tongue becomes furred and the bowels confined, together with the other symptoms of the inflammatory condition. The case as- sumes, in fact, the aspect which is peculiar to suppura- tive inflammation in the cavity of a joint; and of course the prognosis is eminently unfavorable. Death may indeed occur before suppuration sets in, but if this oc- cur, extensive abscesses are formed in various parts. If it be the pubic symphysis which is affected, pus forms about the mons veneris, and burrows along the vagina and down into the thighs. ' If of the posterior symphy- ses, of which the right is more often affected than the left, it may cause purulent collections in five difierent places; viz., directly upon the joint, in the gluteal re- gion, in the lumbar region, in the pelvic sub-peritoneal pouch, and, lastly, near the rectum, whence it may spread to the gluteal region, to the greater trochanter, or to the horizontal ramus of the pubes. Caries of the bones may take place, and it then runs a tedious coinse, and then invariably ends in death. Anchylosis seldom takes place. The cartilages are loosened, and the soft parts infiltrated with serum, pus, and ichor. Its diagnosis is not difficult. In distinguishing be- tween it and simple relaxation, it should be borne in mind that, in consequence of the inflamed condition of the symphyses, the difliculty of walking stands in direct relation to the intensity of the pains, and that in gene- ral the patient has more control over the lower limbs, 584 Snellz'ng on Relaxation of in consequence of the bones being still held in place by the inflamed cartilages; and especially does this hold good when the inflammation is confined to one symphy- sis alone. The vaginal touch, the imposition of the hand upon the affected points during movement of the patient, and the probe after the evacuation of abscesses, will be found sufficient to establish a diagnosis. The treatment should be directed primarily against the inflammation and the collection of pus, and rest en- joined in the recumbent position. After the subsidence of the inflammation, a pelvic bandage should be worn for a lengthened period. In slight cases the affection may be so insignificant as to be confounded with the general results and in- conveniences of the lying-in state, and attract no par- ticular attention, and pass off with rest and quiet. In others it may be so severe as to call for some treatment, though generally it is not even then that its true nature is recognized, as the patient recovers after a few weeks of discomfort and confinement. But treatment should be prompt and decided even in these cases, lest there should ensue the deplorable results detailed below. The following instructive cases are published by Dr. E. Schmiedt, and are drawn from various sources. The two first are by Trousseau. ' One was a woman, forty years of age, ‘ who was seized, seven weeks before labor, with pains in the pel- vis. At the commencement of labor she was attacked with fever and an intermittent pain in the right hip joint. An abscess soon formed in the gluteal region, and by an; exploratory incision in the region of the the Female Felm'c Symphg/ses, etc. 585 right sacro-iliac symphysis several drops of greenish putrid pus were evacuated. The patient soon left the hospital, and nothing more was heard of her. The second case was that of a woman, delivered five days previously, who felt a pain in her right hip, was unable to walk, and had chills and fever. The pains extended themselves to the nates and symphysis pubis. Four months after, fluctuation was detected over both sacro- iliac symphyses, from which a large amount of pus was evacuated on opening it. After some days death en- sued, and the sectio cadaveris showed both sacro-iliac symphyses denuded of cartilage; and in the symphysis pubis, which contained pus, the cartilages were loosened. No metastatic abscess or other changes were found in any other part. Hayn relates two cases. One, a wo- man 29 years of age, had had two successful deliveries, the last one being a triple birth, and the children small. On the third day after labor, pains occurred in all three pelvic symphyses, particularly the right sacro-iliac symphysis. Pressure on either side caused pains in the corresponding symphysis as far as the pubic symphy- sis. Active movement of the extremities was impos- sible, passive motion painful. There was present, also, a severe diarrhoea. On the seventh day there appeared a swelling on the back of the right hand. By power- ful pressure upon the right side of the pelvis a rubbing or friction noise was apparent. She died on the tenth day. On examination pus was found all the sym~ physes, especially in the right one. Also, a’woman forty years of age, in the first day of her second confine- ment, after a successful delivery, was seized with pains 586 Snelling on Relaxation of in the pelvis. On the sixteenth day severer pains in the symphysis pubis occurred, radiating towards the thighs. After four days the attack passed off. Dr. Galvagni had the opportunity of observing two ‘ cases of inflammation of the right sacro-iliac symphysis, in one of which death ensued from chronic miliary tuberculosis, and in the other from metastatic metro- phlebitis. Oase 1.-—A woman, A. P., aged twenty years, who had menstruated at fifteen years, had been troubled for some years with pains in the knees and a lameness resulting therefrom, and with an inguinal hernia ‘of some stand- ing. In her nineteenth year she had married, and soon became pregnant, and in the commencement had pro- gressed very well. About the middle of the pregnancy she found herself fatigued after slight labor, and had pains in the sacrum and general malaise, and her walk soon became uncertain. _ On the 2d of December, 1.866, she was delivered of a well-formed, though somewhat thin, full-term child. On the 8th the author found her out of bed, but she complained of pains in the sacrum, and walking was difficult, and particularly painful when she rested her weight on her, right hip. One month later he found her much emaciated, without appetite, with a dry cough, and nightly perspirations, from which he inferred the occurrence of tubercu- lization, although the physical examination gave no support to the‘idea. On the right sacroiliac symphysis there existed a circumscribed painful point; the lame- ness upon the right side was very marked, and the pa- tient was obliged to support herself with a cane. the Female Pelm'c Symphyses, etc. 587 When the author saw the patient again, at the end of two months, he found her in a very critical condition, the apex of the left lung being gone, and the woman evidently in the last stage of consumption. From the vagina there flowed a yellowish green pus, which soiled her clothing. Over the right posterior symphysis there was discovered a small fluctuating swelling. Neverthe- less, the patient was sitting up out of her bed the greater part of the day. The inflammation of the symphysis was now beyond question a matter of cer- tainty. During the next week, to the astonishment of the re- lator, the abscess became dissipated, the fever alternated with rigors, shiverings, and prostration, alternating with restlessness, until, after fourteen days, on the 24th of May, 1867, the patient succumbed. On opening the thoracic cavity the right lung was found extensively adherent, containing several cavities _ of the size of a nut, and infiltrated with miliary tubercle. Tubercle also studded. the peritoneum. The whole generative apparatus was deeply injected; the Fallopian tubes indurated, the fimbriae contracted, the os uteri livid, denuded of epithelium and in a fun- goid condition. The inner surface of the cavity of the uterus was covered with a yellow caseous, adherent pus, which also filled the Fallopian tubes. In the pelvic cavity there was found on raising the peritoneal investment a sinus from three to four millimetres corresponding to the right sacro-iliac symphysis, and so great was the disorganization that the bones were only held together by the strong ileo-lumbar ligament, all 588 ' Snellz'ng on Relaxation of - other ligaments being destroyed by suppuration. Pus in moderate quantity was found beneath the perios- teum, and had denuded by its action two strips on the sacrum and ileum. These strips were nearly one centimetre wide, parallel, and extended over the three upper sacral vertebrae, which showed their bony surfaces roughened. The abscess extended itself along the hypogastric fossa, and along the pyra- midalis at the sacro-sciatic notch, and following the ischiatic nerve, terminated in the gluteal region, without having formed any perceptible external swelling. The external abscess, which had been visible during life, had become larger, and lay under the apo- neurosis of the greater dorsal muscles-the sacro-lum- baris and longissimus dorsi; it was connected by three conduits or channels piercing through . the multifidus _ spines, and connected with the diseased symphysis and both the intervertebral spaces of the sacrum. Deeper and more externally along the ileo-sacral ligament, which alone was unimpaired, there was a very small abscess extending from the symphysis. All these abscesses were lined with a pyogenic membrane. Their contents were very thick and caseous, and dis- played under the microscope pus-cells resembling those which were found in the uterus and Fallopian tubes. The cotyloid cavity and head of the thigh-bone were denuded by the action of inflammation. Oase 2.-—E. G., twenty years of age, of a delicate constitution, had suffered in youth from rachitis, the traces of which were still discernible in the form of the Femak Pelm'c Symphg/ses, etc. . 589 her bones. For many years she had been obliged to move partly by sliding herself along, and partly by aid of crutches; later she had been affected with miliaria and acute inflammatory rheumatism. Menstruation ap-, peared in the fourteenth year, returning regularly. After a normal course of pregnancy, labor set in the 28th of October, 1863. The attending physician, after accom- plishing turning, could not extend the head; so on the 29th the laboring woman was brought to the lying-in clinic with the lower portion of the dead child hanging out between her thighs, to ascertain whether the de- livery could be accomplished by craniotomy, which was successfully done. On the next day the great volume and tenderness of the uterus was remarked, and treated by blood-letting. The lochia remained normal at first; the bowels were constipated. From the 3d of No- vember there were severe pains in the hypogastrium, the abdomen swelled, the meteorismus occasioned con- siderable difficulty of breathing, the pulse rose to 120, and the heat of skin was greatly augmented. Under antiphlogistic treatment the fever had decreased again on the 9th. There was pain in the right knee and a painful ' swelling on the anterior aspect of the right forearm. On the fifteenth there appeared an abscess on the metacarpo-phalangeal joint‘ of the little finger of the left hand. On this day the patient was seized with a shaking chill lasting one hour and a half, which was repeated on the 17th to a slight extent. On the 18th there occurred severe pains in the right sacro-iliac ‘symphysis, which were increased by pressure and coughing. Quinine was administered. In the mean 590 - YSnelling on Relaxation of time the abscess remained indolent, though increasing in size. On the 22d ".he pains in the symphysis had ' become much mitigated, although the fever and meteorismus had returned ; a diarrhoea then set in, followed by pain and swelling in the right eye-ball, and sight was entirely lost. On the 30th of November there appeared on the upper lip small white blisters contain- ing pus. She died on the first of December. On post- mortem examination there were found small abscesses in both lungs, the spleen was softened, the peritonaeum unchanged, and the uterus reduced in size. On cutting into its walls, a single sac was found containing pus; under the raised peritoneal covering of the pelvis, in the region of the right posterior symphysis, a mode- rate collection of pus in the form of a small sinus. The other symphysis was sound. The joint surfaces were not exposed, because the pelvis was to be preserved whole. The first described swelling contained pus. The direct pelvic admeasure- ment was two and two-thirds inches. This paper has already reached such proportions that I feel I must refrain from touching upon the third con- dition mentioned; viz., rupture of the symphyses, of which I have the record of some eight cases. It usually occurs after a severe labor (instrumental or otherwise, as the case may be), and is caused by some dispropor- tion between the foetal head and the pelvis of the mother, or in some cases by one of the forms of mal- presentation. It generally takes place in osteo-malaceous or rachitic pelves where the conjugate diameter is great- the Female Pelvic Symphyses, etc. 591 ly shortened. It may take place in either the pubic or sacro-iliac articulation, but its favorite seat is the right sacro-iliac. It has been known to involve two sym- physes at once. Where the pubic symphysis is the seat of rupture, one of the cartilages is torn loose, leav- ing the end of the bone bare and exposed. Other causes are said to be constitutional feebleness of the mother, great size of, or ossification of, the sutures of the foetal head, severity of the pains, cranial distor- tion, and the use of instruments. When it occurs it is generally heard by the attend- ants and bystanders, and the woman is conscious of in- tense pain and a rending of the ligamentous fibres, and, as afiecting the labor, is analogous to the results of symphyseotomy. Inflammation and suppuration set in with great rapidity, and are followed by a period of great danger to the patient, often ending in death. [The subjoined remarks by Profs. Fordyce Barker and Isaac E. Taylor are from the minutes of the meeting, reported by Dr. Winslow.~—1an.] REMARKS BY PROFESSOR BARKER. THIS is a subject of great importance, although barely alluded to by English Writers for the last quarter of a century. By the ancients, and through the middle ages down to the present cen- tury, it was believed that this relaxation was a normal element in parturition ; and it was this belief which suggested to Sigault the operation which was the occasion of so much excitement at the time, that of division of the symphysis pubis in cases'of dif- ficult labor. Sigault supposed that he was simply carrying out more completely the ordinary physiological process. But that his operation was based upon ignorance and misconception of the true mechanism of labor is shown by the fact that, as has 592 Barker’s Remarks on Relaxation of been demonstrated, it would require a separation of the pubic bones to the extent of at least an inch, to gain one or two lines in the antero-posterior diameter. , The paper of to-night has been very rich in reference to the foreign literature of this subject. I would say a word of the writers upon it in our own language, among whom Denman has given a, very complete exposition of the affection, with details of some cases of great interest. He relates one where it was eight years before the patient recovered sufficiently firm union of the symphyses to enable her to walk. In .the American edition of Denman, edited by Dr. Francis, there is a full note reporting a casein the practice of Dr. Wright Post of this city, and another of relaxation of the sacro-iliac sy m ph yses from the practice of Dr. Hosack. Next to Denman, Burns gives the best discussion of the subject. Ryan also speaks of it. Miller, Rigby, Ramsbotham make no mention of the matter; and Tyler Smith, Oazeaux, Churchill, and Bedford give it but a cursory allusion. It has been my fortune to see quite a number. of these cases, some of them involving points which I have not seen mentioned by any writer. The first occurred at the very beginning of my practice. Alady in the eighth month of her first pregnancy had for several days great difficulty in walking, with severe pain in the pubic bones, till one day she fell while walking across her drawing-room. She supposed that she had caught her toe in the carpet. From that time up to her confinement, she could not walk or stand. After a very careful examination, I was unable to make out the diagnosis; and none of the authorities at my command threw any lighten the question. I therefore called in consultation two quite prominent surgeons ; and one of them diagnosticated fracture of the neck of the femur; the other, fracture of the ilium or ischium. I watched the case very anxiously, naturally expecting a difficult labor, and some unto- ward result; but, to my surprise, the labor, though a first one, proved brief and easy, with no abnormal symptoms. rl‘he patient passed through the puerperal condition with nothing to excite apprehension; yet on essaying to rise it was found that she was still wholly unable to hear her weight upon her limbs. Some six weeks after confinement, I got her out of bed, and carefully attempted to make her walk. A point which struck the Female Pelctc symphyses, etc. 593 me, and which I have never seen mentioned, was that she could stand with comparative ease resting upon either one leg or the other, but could not balance herself upon both legs at once. This of course convinced me that there was no fracture of the thigh-bone, and the fact that there was no difference in her ability to rest upon the two sides showed that there could be no fracture of the ilium or ischium. Led by this to examine the symphysis pubis, I thought there seemed to be an increase of the space between the pubic bones; and also that the cartilage be- tween them seemed softer than natural. When I left the place, some four years afterwards, this patient was able to walk only with great difficulty, upon crutches. Three or four years later yet, she was much improved, though still compelled to use crutches. I am told that after the lapse of some fifteen years from that unfortunate pregnancy she has entirely recovered and walks perfectly well. In hunting up my authorities with reference to this case, happening to turn to the anatomy of the pelvis in the first part of Denman’s work, I found the key to the whole mystery. Since that time I have seen the affection in several other indi- viduals; in one of whom, the wife of one of my colleagues, it has occurred in her last three pregnancies. As I before remarked, my observations have differed in some respects from those I have found recorded. In none of the cases I have seen has the relaxa- tion of the symphyses been dependent in any degree whatever upon the process of parturition. But in all of them-and this fact may give a clew to the true pathology of the disease-the pa- tients have had pelves very broad and capacious at the superior strait; and where I have seen them before confinement, the foetal head has lain very low in the pelvic cavity during the last month of gestation. It has seemed to me that the oedema and consequent laxity of the ligamentous tissues may be due to the mechanical obstruction of the venous trunks by the pressure of the presenting part or the foetal head. Again, in most of the cases, I have noticed after confinement pendulous belly, and great difficulty or impossibility of completely evacuating the bladder, doubtless due to over-distention during pregnancy, from the same mechanical cause which produces the oedema of the ligaments and of the lower extremities. The irritability of 39 594 Raxleer’s Remarks on Relaxation of the bladder, which, according to Churchill, as quoted. by Dr. Snelling, is frequently attendant on these cases, is explainable by this retention of urine, and the mechanical pressure on the urethra. To three of the cases I have seen, I was called in consultation. Nothing is more apt to damage the reputation of a young ob- stetrician than that a patient should fail to recover rapidly after child-birth, unless the obstacle to her recovery can be made per- fectly clear. How unjustly a young man may often have to suffer from this cause may be seen from one of these three cases, which will serve as a type of all. A lady, in her third preg- nancy, engaged to attend her a young physician in whom the family felt much interest and confidence. Both of her previous confinements had been favorable, under the charge of an old physician who had recently died. This third labor proved, to all appearance, perfectly normal, and the woman seemed to be recovering well, until she attempted to get out of bed, when she found that she could not stand. A week, two weeks passed, and the attempt was again made, with the same result. She not only could not stand, but the attempt caused severe pains in the pelvic bones. The case went on to, I think, about the eighth week after confinement, the patient with this exception perfectly well, when another gentleman was called in—a man much older and of more eminence as a surgeon than as an obstetrician. He discovered in the pelvis a hard tumor the size of a hen’s egg, which he thought scybalous, as it proved to be. It was brought away by large injections, and an early cure was promised. The young man was severely blamed for neglect; but, unfortunately for his elder, the promised recovery did not take place. The sur- geon treated the patient for some five weeks, with no perceptible change in her condition, when I was called in. A careful ex- amination satisfied me that the case was one of pretty strongly marked relaxation of the symphysis pubis; but I reserved my opinion until the following day, when I insisted on seeing both the physicians together. Then, by following a hint given by Denman, taking with me a dry pelvis, I demonstrated what I believed to be the patient’s condition, and called upon the older doctor to exonerate the younger from all blame. On both days I specially noted the patient’s incapacity entirely to evacuate the bladder. After what she supposed a successful effort to do so, the Female Pelvic Symphyses, etc. 595 I drew off, on the first occasion, about four ounces and a half of urine, and on the second about four ounces. I explained that this condition of the bladder was probably due, like the ac- cumulation of scybala in the rectum, to the same cause which had produced the pubic relaxation. A binder was firmly placed about the patient’s hips, and within a few weeks all trouble with the bladder had disappeared, but it was a year or so before she could walk with comfort. Remarks by Prof. I. E. Taylor. There is an American authority my friend .Dr. Barker has omitted to name, who has made reference to the subject of re- laxation and opening of the joints in the female pelvis during gestation-—that is, Dr. Meigs. Dr. Meigs gave his full assent-Ito the occurrence; while Roederer seems to have ignored it, and asserted that the head of the child could not by any means, even if it was large, produce any influence in enlarging the capacity of the pelvis, for the simple reason that the head of the child would be more readily moulded and compressed, than the articulations of the mother’s pelvis would yield or open. His opinions, it appears, seem to have put a veto on the views that were entertained respecting the separation of the bones of the pelvis during labor. My own impression from some instances under ob- servation is, and has been, that this relaxation or softening of the pelvic joints, and especially the pubic, is only a part of that great physiological process Nature institutes for delivery in the female economy during gestation-not confining itself to the changes in the body of the uterus and cervix, or the appendages. For we know that it has been manifested in the heart, and Coulson has remarked that the larger joints of the extremities have ex- pcrienced this relaxing or softening influence. It is conceded by many of the older obstetrical authorities that the soft tissues of the symphyses become infiltrated by a serous effusion; its structure and the capsules and the surrounding parts become enlarged, tender, and painful, and soft, and move easily one upon the other, covering each other in some instances. Boyer has asserted that they (the symphyses) have been opened as much as one-half an inch, Boivin to fully one inch. Meigs has borne testimony to the same result'f‘j In one of his cases, he has seen 596 Relaxation of the Pelvic Symphyses. it produce a crushing sound in a patient whenever she walked. In one of my patients the left knee could be partially luxated during gestation. The anatomic structure of' the symphysis pubis is somewhat dif- ferent than the sacro-iliac sy mphyses,--the attachment of the ten- don of the recti muscles to the pubic rami in the fibrous sheath—the infiltration surrounding the parts, extending to the bladder, the urethra and the vulva-—creating the tenderness and sensibility and irritability of the bladder and the looseness of the joints. This mobility and looseness is so perceptible in some cases, that if the patient attempts to stand up, if the right side is affected more than the left, the right ramus of the pubis will be elevated by the recti muscle of that side-if the left, the left ramus of the pubis-—so with the sacro-iliac unions. This it is which produces the tottering or unsteady and uneven gait when trying to walk. Some patients have had arenewal of this soften- ing or ramollissernent of the symphyses in their pregnancies two or three times. I do not perceive, therefore, why these cases should not be common, equally as much in a physiological light, as the body of the uterus or its cervix, which is so much dwelt upon as a sign of pregnancy and as necessary in gestation. It is very apparent that this physiological state, as regards the uterus and its cervix, passes sometimes very rapidly, from various causes, into a pathological condition; so I conceive that the same view may be entertained regarding the symphyses of the pelvis during gestation. Dr. Meigs has not found any benefit from the treatment by the bandage. I do not partake of this opinion, as I conceive it gives comfort, and aids in the adaptation of the joints to one another, and affords infinite pressure and strength, to the solution of an earlier restoration to a normal and healthy condition,- time and nature completing the cure by the physiological trans- formation again--as We know it does in the uterus itself after delivery. Smith on the Acid Dyspepsia of Infants. 597 ON THE ACID DYSPEPSIA OF INFANTS. BY EUSTACE SMITH, M.D., Physician Extraordinary to His Majesty the King of the Belgians, Physician to the Northwest London Free Dispensary for Sick Children, 8m. A011) dyspepsia is one of the commonest digestive derangements met with in young children, and few infants can be said to escape it altogether. A trifling complaint, and readily recovered from when attended to early and judiciously treated, if neglected it becomes a most serious and obstinate disorder, which may resist all treatment, and may lead to the most extreme emacia- tion, or even to death itself. The food taken seems shortly after being swallowed to undergo an acid fermentation; sour gases are evolved, great discomfort is produced, and nutrition is seriously interfered with. The derangement is usually caused by overfeeding with farinaceous foods. It is too commonly the case that these foods are given in enormous quanti- ‘ ties-—in quantities greater than any infant with ordinary digestive power can by any possibility assimilate. The reason of this reckless feeding is, partly, the mistaken notion which so universally prevails of the digest- ibility of these foods ; partly, the eagerness with which the child himself will swallow large masses of sop; for the griping and flatulence occasioned by the presence of large masses of starchy matters in the alimentary canal will——-if not too severe—-excite a fictitious hunger which is not easily appeased. An infant of three or four months old, in whom the secretion of saliva is but lately established, or an infant of a yet earlier age, who 598 Smith on the Acid Dyspepsia of Infants. has no saliva at all, is often fed with a large table-spoon- ful of corn flour or other farinaceous powder, boiled with milk or with water, four, five, or even more times in the day.‘ The food lies undigested in the bowels, ferments, and a state of acid indigestion is set up, which does not cease with the removal by vomiting and purging of the cause which has produced it. Even a return to a simpler diet is often insufficient by itself to put an end to the derangement; plain milk and water is vomited sour and curdled, and everything taken into the stomach seems to undergo the same acid change. As this derangement is so easily excited by improper feeding, even in healthy infants, children whose strength has been ah'eady reduced by disease, and whose digest- ive power is therefore lowered in proportion to the weakness of the whole system, are still more likely to be afiected by the same cause. On this account acid dyspepsia is a not unfrequent sequel of acute disease in ‘infants, and may, after apparent convalescence from the primary disorder, lead to death by the interference with nutrition and by the exhaustion which it so often pro- duces. The diarrhoea, which is a not uncommon se- quence of some of the acute specific diseases, as scar- latina and measles, is often primarily excited by this derangement, and is too frequently a cause of death. _ Severe operations upon the child, such as that for stone _ in the bladder, may also be followed by the same com- plication, for anything which lowers the easily depress- ed general strength reduces also the digestive power and predisposes to this complaint. Children brought up by hand are especially liable to Smith on the Acid Dyspepsia of’ Infants. 599 this acid dyspepsia, for even when fed upon a suitable diet, carelessness in the administration of the food select- ed, so that the stomach is overloaded by too frequent or too copious meals, or neglect of the necessary clean- liness, so that they are allowed to take milk which by being put into a sour bottle has already begun to change, will excite‘ this indigestion. Amongst the poor of London, it is not uncommon to find a child brought for medical advice sucking at a feeding bottle, of which the intensely sour smell at once discloses the cause and suggests means for the relief of the complaint under which he is laboring. The earliest symptoms of this derangement are due to the uneasiness produced by fiatulent distention and griping pains. The infant is restless and fretful, whin- ing and crying and refusing to be pacified. Large quantities of gas are evacuated both by the mouth and by the rectum, affording at first some relief, and the child becomes quieter until a reaccumulation takes place. At night the griping is exceedingly distressing, and his sleeplessness at this time, by the discomfort it occasions to his attendants, is usually the symptom which assumes the greatest prominence in the mind of the mother, and is the chief reason for applying for advice. The infant, after lying for a time in uneasy sleep, starting, twitching, moaning, frowning, and draw- ing up the corners of his mouth, suddenly wakes up with a loud cry and is seized with a fit of violent screaming which resists all efforts to calm him. He throws himself from side to side, erks about his lower limbs, or suddenly straightening them out in a line with 600 Smith on the Acid Dyspepsia of Infants. his body, becomes for a few moments rigid as if turned into stone. .These attacks of colic are sometimes so severe as to cause great alarm; the child falling into a state of collapse, or being thrown into convulsions, which may be repeated again and again. The ravenous appetite noticed in children suifering from flatulence has already been referred to. This symptom usually disappears as the derangement becomes more marked. Vomiting comes on after a time, the appetite then fails, and the child is thirsty and feverish. Vomiting is at first excited by taking food, but may afterwards occur when no food has been lately taken, and in bad cases may be caused by a sudden movement, or even by a touch, as in wiping the mouth. The vomited matters consist at first of food and curdled milk, afterwards of clear fluid like water; the smell is usually intensely sour. The bowels at first are confined, but after a time diarrhoea comes on, the motions being either pale, frothy, and sour-smelling, or watery and fetid. There may be straining during the passage of a stool, in which case the motions may contain streaks of blood. An eruption of red strophulus, covering the body and arms of the child, is a not uncommon symptom; it may be mixed with urticaria. An infant suffering from this derangement soon becomes pale and thin. His face assumes a constant expression of fretfulness, which is increased by the furrow which appears, passing on each side from the nose, to encircle the corner of the mouth. The lower eyelid and upper lip are disposed to be livid ; the lips twitch, and the corners of the month are frequently Smith on the Acid Dyspepsia of Iaflmts. 601 drawn up, giving a peculiarly plaintive and helpless expression to the face. The fontanelle is depressed more or less deeply, according to the degree to which the strength is reduced. The eyes sometimes assume a fixed stare, while the muscles of the face twitch, and the thumbs are drawn inwards upon the palms of the hands. These nervous symptoms——well known to nurses by the name of inward fits—-are of importance, as being sometimes the forerunners of convulsions. The tongue is at first covered with white fur, through which red papillae project; afterwards it is apt to become pale and clean, or with little patches of fur scattered here and there over the dorsum. In bad cases tlfe whole body has an offensively sour smell. This smell proceeds not only from the breath, but from acidity of all the secretions; the saliva, the perspiration, and the urine being all in- tensely acid. The cutaneous secretion is, however, seldom in excess; more usually the skin is dry, and is in con- sequence harsh and rough to the feel, especially at the backs of the arms and the belly. The feet are generally cold, and the child lies with the knees drawn up to the abdomen. The coldness of the feet is no doubt one cause of the griping pains which are so constant in this derangement, for even in healthy infants abdominal pains are frequently excited by coldness of the feet, and cease when these are warmed. During the earlier periods of this disorder the complexion turns slightly yellow from time to time, the yellow tint remaining for some hours or days. Occasionally the skin becomes completely jaundiced. After the complaint has existed for some time a peculiar earthy tint is noticed of the 602 Smith on the Aciol Dyspepsia of Infants. face and whole body, which is very characteristic of chronic abdominal derangement. . If the disorder is primary, and is not soon arrested, a chronic catarrh of the stomach is often set up, the bowels becoming obstinately confined, and the vomiting continuing as a persistent condition. In other cases, again, the derangement may settle principally upon the bowels, leading to a chronic diarrhoea. The most ex- treme emaciation is often reached through these means, and it may be only after weeks, or even months, of illness that a termination, by recovery or by death, is arrived at. When the dis'order is secondary to some acute dis- ease, or follows a serious operation, the strength is usually so much reduced by the original illness that the child, weakened more and more by the vomiting and diarrhoea, and by his inability to digest any nourish- ment whatever, soon becomes exhausted. Thrush ap- pears upon the inside of the mouth, and the child sinks and dies. Pneumonia is a not uncommon.complication in the later stages of the disease, and, if the strength be much reduced, may exist without manifesting its pre- sence by any of the usual symptoms. There is no cough, and the heat of the body is not appreciably heightened, or if heightened at first the elevation of temperature soon passes off. This pneumonia usually attacks the bases of both lungs. The earlier treatment is commenced in this derange- ment the more readily will the complaint be arrested, for as the strength becomes more and more reduced, and the stomach and bowels become more and more dis- Smith on the Acid Dyspepsia of Infants. 603 ordered, treatment which in an early stage would be at once attended by improvement loses much of its efii- ~ cacy, and great difficulty is experienced in making any impression upon the disease. When the case is seen early, and the symptoms com- plained of are merely griping and flatulence, with ravenous appetite, unaccompanied by sickness or diar- rhoea, careful inquiry should at once be made into the diet and general management of the infant. It should be explained to the parents that the appetite will best be satisfied, not by increasing the quantity of farina- ceous matter and .the frequency of the meals, but by carefully adapting the food supplied, both in quality and quantity, to the digestive power of the child, so that the nourishment given may be only such as the stomach is able to digest. This may seem a simple and self-evident proposition, but it is one which is constantly forgotten. That a child will be nourished in exact pro- portion to the amount of food he swallows, and that the more solid the food the greater its nutritive power, are two articles of faith so firmly settled in the minds of many mothers that it is very difficult indeed to per- suade them to the contrary. To them wasting in an infant merely suggests a larger supply of more solid food—every cry means hunger, and must be quieted by an additional meal. It is difficult to lay down precise rules for diet in every case of this derangement. This is a matter which can be properly learned only by ex- perience. There are, however, "certain plain rules which should always be observed. Of these one of the most important is, that farinaceous food is unsuitable to an 604 Smith on the Acid Dyspepsia of Infants. infant under the age of three months. Before that age he should be restricted entirely to the breast, supposing that the secretion of milk be of proper quality and be supplied in sufficient quantity. In cases, however, where additional food has to be given on account of the insuflicient supply of breast-milk, recourse must be had to cow’s milk, or to the milk of the ass. If cow’s milk be used, it should be diluted with a third part of lime- water, in order to prevent the too firm coagulation of its casein. Even, however, when thus diluted and al- kalinized, the cow’s milk is sometimes undigested by young infants, who seem to thrive better upon the milk prepared with a very small quantity of arrowroot or baked flour. This scarcely accords with the statement made above, of the unsuitability of such foods to young infants; but an explanation of the seeming contradic- tion is found in considering the action of the farinaceous food under such conditions. The arrowroot itself pro- bably contributes little, if anything, to the nutrition of the body, but when thus intimately mixed with the cow’s milk it has a mechanical action in separating the casein into minute portions. The curd, therefore, co- agulates, not in one large clot, but in a multitude of small clots, which are more readily attacked by the di- gestive juices. It is, however, as has been said, always a risk to give farinaceous food to young infants, and the same object may be as readily efiected, and Without any danger to the child, by adding a small quantity of isinglass or common gelatine to the diluted milk in the proportion of one teaspoonful to four ounces. In older children, brought up upon artificial food, the Smith on the Acid Dyspepsia of Infants. 605 above symptoms are often complained of even although the quality of the food with which they are supplied leaves nothing to be desired. In these cases it is the quantity which is in fault: the child is supplied with food largely in excess of his wants or his powers of digestion, and the stomach and bowels revolt against the burden imposed upon them. For an infant of six months old, one, or for a very robust child two, tea- spoonfuls of farinaceous food, carefully prepared with milk, and given twice in the day, are as much starchy matter as he is able readily to digest. His other meals should be composed of milk and lime-water, orthe milk and water with isingl‘ass, as directed above. The kind of farinaceous food is of some importance. Difierent foods vary very much in the proportion of their several constituents, and the albumen, ‘gluten, salts, &c., they contain are to be considered quite as much as the starchy matter. The very best food is, perhaps, pure Wheaten flour slowly baked in an oven till it crumbles into a light grayish powder. This, pre- pared with milk, and sweetened with milk sugar, forms an admirable morning and evening meal. It may be varied occasionally with other farinaceous articles, but whatever be the food selected, the quantity mentioned must not be exceeded. ()n alteration in the diet, in accordance with the above rules, a small dose of castor- oil, or rhubarb and soda, to clear out undigested matter from the bowels, and the administration of a little bi- carbonate of soda or potash, with an aromatic to neutralize any remaining acidity and promote digestion, are all the measures that are required at this stage. 606 Smith on the Acid Dyspepsia of Infants. If the derangement have gone on to vomiting and ‘purging, with an intensely sour smell from the breath and from the ejected matters, other means must be resorted to. In this case the stomach and bowels are filled with the acid products of fermentation, and the vomiting and diarrhoea are merely the forcible efforts of the alimentary canal to expel its irritating contents. Sedatives to the stomach and astringents to the bowels are here out of place; we shall best cure the derange- ment by assisting the expulsion, and not by obstructing the exit of the fermenting food. In determining, however, the exact measures to be adopted, the state of the child’s strength is an important consideration, and this is best estimated, not by the condition of the pulse, but by the degree of depression of the fontanelle If the fontanelle is not much hollowed, a teaspoonful of ipecacuanha wine should be at once administered, and should be repeated every ten minutes until vomit- ing be produced. The acrid matters in the stomach having been thus evacuated, half a teaspoonful of castor-oil should be given after a short interval, to act gently on the bowels, and the child should be allowed nothing but a little cold thin barley-water given oc- casionally with a teaspoon. At the same time the belly should be kept covered with a hot linseed-meal or bran poultice, and the child warmly wrapped up should be kept perfectly quiet in his little cot. If the derangement have only existed a short time, the above measures will he usually successful in check- ing the symptoms, and the child will be found to retain the breast-milk, or the milk and water with which he Smith on the Acid Dyspepsia of Infants. 607 is supplied in small quantities. Any tendency to acid fermentation that may remain should be neutralized by five-grain doses of bicarbonate of soda, given three or four times a day, and the patient may be allowed to return very gradually to his ordinary diet. When, however, the derangement is of long duration, or is secondary to a severe operation or to some acute disease, the symptoms are not so easily overcome. Here the weakness, as shown by the. depressed fontanelle, will not allow very active measures to be employed, and therefore the accomplishment of our twofold object, viz., of removing already formed acid from the system, and of preventing further fermentation, requires the most careful management. Emetics are here out of the question, for the strength will not bear further reduction, and the administration of such a remedy would be attended by the greatest danger. Our first care should be to endeavor to restore the circulation to the extremities, by placing the feet as high as the knees in hot mustard and water. If the weakness be very great, the whole body may be immersed in a mustard bath as high as the neck. It is of extreme importance in such cases to restore the proper action of the skin, for it is by this means chiefly that we hope to effect the escape of acid from the system. Onbeing removed from the bath the infant should be carefully dried; a hot linseed-meal poultice is then to be applied to the belly, and the child, well wrapped in flannel, must be returned to his cot. The warmth of the sur- face must be kept up by hot bottles placed by his sides, and the feet and legs should be well rubbed at intervals 608 Smith on the Acid Dyspepsia of Infants. with the hand alone, or with a liniment composed of equal parts of compound soap liniment and the com- pound liniment of camphor. If the child can bear the motion, frictions with the same embrocation may be used to the whole body; but in cases where the weak- ness is extreme and the vomiting obstinate, violent retching may be excited by the slightest movement, so that the frictions would have to be discontinued. In such cases the feet and legs should be wrapped in hot fiannels on which some flour or mustard has been sprinkled, and the most perfect quiet should be en- ' forced. A napkin must be placed under the chin, to receive all matters ejected from the stomach, and when moistened the cloth must be immediately removed and a clean one applied in its place. If diarrhoea exist, astringents are not to be employed so long as a sour smell from the breath and evacuations indicates the continuance of fermentation in the stomach and bowels. For a child of a year old, twenty drops of caster-oil can be administered, and will be usually kept down. After its action a simple chalk mixture may be given, or a draught containing five grains of bicarbonate of soda, with three grains of nitrate of potash, in some aromatic water, three or four times in the day. Half a drop of tincture of capsicum is a valuable addition to each dose of this mixture. If there be constipation, the bowels must be open- ed by an enema containing caster-0H,‘; and be kept in regular action by the occasional administration, as required, of one or two drops of a solution of podophyllin in alcohol (a grain to the drachm), Smith on the Acid Dyspepsia of Infants. 609 or by suppositories of castile-soap placed in the rec- tum. The form of nourishment to be given in these cases is of the utmost importance. All matters capable of undergoing fermentation must of course be excluded. Even milk itself, however diluted and alkalinized, can seldom be borne, as it is usually vomited sour and curdled immediately after being taken. Woman’s milk is usually well digested, but not always. In some cases it seems to agree as little as the milk of the cow; in others, where the irritability of the stomach is very great, the mere movement of the mouth in the act of sucking may be sufficient to excite a return of the vomiting. If this be found to occur, the breast-milk should be given with a teaspoon. In cases where a return to the breast is impracticable, or is not followed by the expected improvement, a good food is whey, made fresh as required by adding prepared rennet to cow’s milk in the proportion of a teaspoonful to the pint. To two tablespoonfuls of the whey add one table- spoonful of fresh cream, and dilute with two table- spoonfuls of hot water. Of this food small quantities can be given at regular intervals, and care must be taken that it be either hot or cold, but not tepid, as liquid food given in a lukewarm state would be aptito favor a return of the vomiting. Liebig’s food for infants, carefully prepared with freely diluted cow’s milk, will often be borne; but in very bad cases it is inferior to the diet just described. In addition, the waning powers of life must be supported by five- drop doses of pale brandy, given in a teaspoonful of 40 6 1O Noeggerath on Chronic llletritis in the food every hour, or even oftener, according to the condition of the fontanelle. I 4 By such measures success is often attained even in the very worst cases of this derangement. The obsti- nate vomiting is best arrested not by sedatives, but by giving the stomach as much rest as is consistent with supporting nutrition. Of all special drugs, calomel in doses of one-eighth or one-sixth grain, laid dry on the infant’s tongue, is perhaps the one which is the most generally successful; but our chief reliance should be placed on a careful diet, and on stimulating and hot applications, so as to promote the circulation and encourage the free action of the skin. The existence of cold feet alone would be a sufficient obstacle to the success of any treatment whatever. ON CHRONIC .METRITIS IN ITS RELATION TO MALIGNANT DISEASE OF THE UTERUS. BY E. NOEGGERATH, M.D., ETC. (Continued from page 515, vol. 2, so. a.) CASE II.—Mrs. S ,thirty-nine years old, was mar- ried twenty-one years ago. During that time she had given birth to eleven full-grown children. After her tenth confinement, she first began to sufier from back- ache, fiuor albus, and other symptoms of uterine disease, not, however, severe enough to call for medical interfer- ence. Her last child was born five years ago, after a Relation to Malignant Disease of Uterus. 611 very protracted labor. She made a pretty slow recovery, and when her menses returned three months later they were so profuse that she had to be treated energetically to stop the hemorrhage. Ever since that time her former ailings increased in severity, backache, bearing- down sensations and leucorrhoea becoming so annoying, that Mrs. S. at last felt. the necessity of. applying to a prominent gynecologist in Europe for advice. She therefore consulted Prof. Scanzoni, of Wuerzburg, who expressed his opinion that she was suffering from chronic metritis, and advised her to go through a course of treatment at the mineral springs of Kissingen. It ap- peared, however, that she did not derive the least bene- fit from their use. Having returned to New York, and not feeling any better, she applied to her family physi- cian, who put her under a course of topical applications. In the early part of January, 1868, I was called in to attend Mrs. S., who, instead of finding relief from the treatment, had been growing worse during the fall and winter of 1867. Notwithstanding the intense suffering she had been undergoing occasionally, Mrs. S. looked the picture of health, being stout and robust. On in- quiring into the peculiarities of her history, I learned, besides the facts mentioned above, that her principal complaint was a very intense infra-mammary pain on the left side, which occasionally was associated with a sensation of nausea and sickness of the stomach. There existed, further, an intense headache on top of the head, which place was occasionally swollen and apparently hot and pulsating. The most severe attacks of head- ache usually followed a digital examination of the 612 Noegge-rath 0n Chronic Metritis in Womb. She also complained of very severe back-ache, and very profuse white discharges; the menses always appeared too soon, and were copious, the amount of flow having increased considerably during the last two months. An examination of the parts involved gave the following results : both lips of the uterus consider- ably enlarged in all the diameters, very tender to the touch, and indurated; not, however, hardened equally in all directions, some portions feeling more succulent than others. From the inner surface of both lips granu- lations of considerable size were observed to arise, while in some points the tissue appeared to be exulcerated. The body of the womb arose considerably above the symphysis pubis, enlarged and indurated, very tender on being touched. On examining with the speculum, it was found that the mucous membrane around the os uteri was very much congested, and covered with numer- ous granulations and deep erosions, while the rest of the vaginal covering of the neck looked rather pale and anaemic. I came to the conclusion that Mrs. S. was sufiering from chronic metritis complicated with some" affection of the cervical mucous membrane, the nature of which was not yet clearly defined. I therefore concluded to wait for future developments before deciding as to the plan of treatment. I saw the patient about once a week from the beginning of January up to the end of Febru- ary. The changes which occurred during this time were the following: The larger granulations located in the central portion of both anterior and posterior lip increased in size, coalesced, assumed a yellowish hue, ex- Relation to lllalignant Disease of Ute/rats. 61 3 tended into the depth of the normal tissue, and at last formed separate tumors of the size of a pea, covered with a smooth lining membrane. While, however, these sections began to develop, other parts of the mucous membrane around the os became excoriated, until at last they formed irregular, deep exulcerations. At the same time, fresh, soft granulations began to shoot up from within the upper sectionof the cervical canal, into which the finger could at last be easily introduced to a considerable distance. Thus I came to the conclusion that I had to deal with a new formation of tissue, which had the tendency towards rapid retrogressive metamor- phosis. ' ' By the end of February I called in the attending physician for consultation, who had not the least diffi- culty in confirming my view of the case, inasmuch as he found that the state of things had undergone consider- able alteration since his last examination in August, 1867. We therefore concluded to have the neck re- moved by an operation, which was done on the 3d of March, 1868, with the assistance of Dr. Thomas and Dr. Henschel. The neck having been slit open in two pieces by lateral incisions, both lips were removed by a pair of scissors, up to the vaginal insertion. On examining the wound, it was found that part of the centre of the pos- terior lip looked unhealthy, while the cut surface cor- responding with the anterior lip presented a normal ap- pearance. To this diseased portion we applied the heated iron thoroughly. Although the wound appeared to be very large, after 614 Noeggerath on Ulwonic JlIetritis in the operation the bleeding was so trifling that we ab- stained from cauterizing the entire surface, but applied cotton soaked in liq. ferri subsulphatis to the wound, and plugged the vagina thoroughly. An hour after- wards, however, I was summoned in haste, and found the patient in imminent danger from loss of blood, the tampon having been expelled. Another more thorough plugging of the vagina was resorted to, but the efiorts at expulsion were so intense that even this second plug could be retained with difiiculty. A few large doses of opium, however, administered per rectum, at last con- trolled the vaginal contractions. The patient made a very slow recovery, partly on account of the loss of blood, partly from the reaction which followed the operation. The microscopical examination of the tissue of both lips revealed the existence of epithelioma in an early stage of development. On the 27th of March the wound was examined, and while the anterior lip ap- peared in a very fair process of healing, the posterior one, especially that part to which the actual cautery had to be applied, showed pale fungous granulations of con- siderable size. They were touched with sulphuric acid at first once a week, and afterwards at greater intervals. During my absence in Europe the patient was under the treatment of Dr. Thomas, who made two or three other cauterizations. In the course of last winter, both anterior and pos- terior lips began to undergo a process of involution, and the latter became atrophied to such a degree that there was hardly any tissue left between the mouth of the womb and the posterior wall of the vagina. Relation to lllalignant Disease of Uterus. 615 The body of the womb was also found smaller in all its diameters. Mrs. S. went to Europe last May, partly to invigor- ate her health, and principally urged by her relatives to have the opinion of one of the leading authorities with regard to her case. Prof. Veit, of Bonn, exam- ined her last week, and pronounced her condition very satisfactory-—one year and eight months after the oper- ation. CASE III.—Mrs. H-———, thirty years old, a tall, stout, healthy woman, was first attended by me about ten years ago for a miscarriage at the third month of gestation. This, her first confinement, occurred soon after her mar- riage. She flooded considerably at that time, and made a slow recovery. Six months afterwards she had an- other abortion of about two months. She now began to suffer from symptoms of chronic metritis, and was treated and benefited by the means usually employed under these circumstances. She became pregnant again, ‘ and gave birth to a full-grown female child about eight years ago. After this childbed she had a slight attack of endometritis ; six months afterwards she had a third miscarriage. Her fourth child was carried up to the full term. During the latter months of gestation she suffered a great deal from abdominal pains, which were occasionally severe enough to threaten premature delivery. Labor was terminated by the forceps on ac. count of spasmodic pains. After this she had a fourth miscarriage. Three years ago she was delivered by for- ceps of a third living child after she had been suffering for two months from symptoms of uterine inflammation, 616 IVoeggerath on Chronic ZIIetr-itis in and when the child was born an acute attack of metro- peritonitis confined her to bed for several weeks. The last child was born two years ago, and she again suf- fered a great deal during the latter months of, this ges- tation. Her menses during most of the time had not been very profuse, but accompanied with backache and pain in the lower part of her stomach. On several oc- casions when she was examined it was found that there existed chronic parenchymatous metritis. The neck was considerably thickened, indurated, and anaemic; the mucous membrane surrounding the 0s covered with gra- nulations. Ever since the month of May, 1868, the menstrual flow began to increase in quantity with every succeeding period. During August and October the discharge became so abundant as to produce general prostration. At that time she began to suffer from in- tense headache on top of the head; she had occasional , chills, and began to lose flesh; profuse sero-mucous leu- corrhoea. Mrs. H. called on me on the 6th of January, 1869, with the view to find out what was the cause of this new train of symptoms. I therefore made a care- ful examination, and found the following condition of things: There existed the old chronic metritis; the uterus enlarged about an inch and a half over its nor- mal size; the body as well as the cervix considerably thickened and hardened, very painful on being touched. The small superficial granulating surface was trans- formed into an extensive ulceration, covering both the anterior and posterior lip. By the touch it could be further ascertained that there existed irregular tubercu- Relation to lllalignant Disease of Uterus. 617 lar elevations starting from the anterior aspect of the os uteri and spreading over the extent of most of the ante- rior lip. Near the right angle of the os there was a pretty deep irregular loss of substance, with shaggy edges; the posterior lip was covered by a very extensive highly colored granulating ulceration. The neck being exposed by the speculum, the afore-named elevations could be perceived even more distinctly; they consisted of a yellowish velvety tissue which was sprouting in all directions over the anterior lip, and within this morbid tissue there existed a deep ulcer, which was covered‘ by a grayish-white surface. Part of this newlyformed granulating matter was removed by the scissors, for the purpose of subjecting it to a microscopical examination, when it was found to be formed of elements constituting papillary epithelioma. ’ The question now arose whether amputation of the neck ought to be resorted to at once, or whether a short time could be allowed to a trial with the application of caustic remedies. Considering the fact that the dis- ease was of an evidently malignant character, the more radical proceeding would have been justified; but inas- much as the affection was in its very first stage of de- velopment, and even so little pronounced in its charac- ter as to make the diagnosis impossible without the aid of the microscope, it was deemed advisable to allow a short time for the use of caustics. . With this view I began to touch the anterior lip with monochloracetic acid, a remedy which has come into use of late for the purpose of destroying warty, condylomatous, and papillary growths. The applica- 618 Noeggerath on Chronic llletritis in tions could be made in my office, since they were not painful, and the patient was able to ride home a consid. erable distance. These were made once a week, and soon leucorrhoea, headache, and menorrhagia disap- peared. They were persevered in up-to the middle of April, when it was found that the entire anterior lip was covered by a healthy looking mucous membrane. The ulceration on the posterior lip was touched with the liquor ferri subsulphatis, and was also in a fair state of regeneration, so that the patient could be allowed to sail for Europe, with this precaution, however,——to call on a well-known gynecologist, to ‘whom I gave her a letter of introduction, in order to be under medical sur- veillance for at least twelve or eighteen months. CASE IV.-—-Mrs. S., of Brooklyn, midwife, forty-one years old, a mother of five children, has always en- joyed a pretty fair state of health. She is a tall, fleshy woman, who, according to her own assertion, had been sufiering from chronic metritis about ten years ago, after her last confinement, and been so much benefited by treatment that she felt very little uneasiness ever since that time. The menses have never been profuse, and there existed very slight leucorrhoea. In the month of June, 1867, she was suddenly taken with severe menorrhagia; after this, menstruation ceased to appear for the next five weeks, when it set in again very profusely, lasting for about three weeks. The periodical discharges of blood returned now every three weeks, and lasted for twelve days. On the 9th of March, 1869, her attending phy- Relation to Malignant Disease of Uterus. 619 sician, Dr. Stub, of Brooklyn, brought her to my office in order to have my opinion as to the cause of the hemor- rhage. On examining I found the cervix very much enlarged, and indurated throughout its tissue. On the anterior lip there existed a protruding ridge of hardened tissue running in a line with the long axis of the canal, and corresponding with it two shallow furrows, one 011 each side, which again were lined by two longitudinal elevations. From the right angle of the os uteri there protruded a number of pedunculated ‘granulations, to the size of a lentil. One of these I was taken away with the scissors and examined at once under the microscope, when it was found to be true epithelioma. The posterior lip also exhibited numerous granulations, with deep fissures intervening. The entire tissue appeared to be very much congested, and bleeding on being slightly touched. By means of the probal touch the body of the uterus could be felt above the symphysis pubis as a hard round mass, and the entire organ was found to be enlarged to such an extent that the sound could be passed four inches into its cavity. On the 12th of March, the entire neck was cut away by the scissors close up to the vaginal insertion, and the wound left open to heal by granu- lation. ~ The treatment after the operation was conducted with no ordinary amount of skill by Dr. Stub, to whose unremitting energy the control of the reaction follow- ing immediately after the operation, and of the hemor- rhages occurring at ‘a later period, are principally due. I have seen the patient at intervals of from four to 620 Noeggerath on C’hronie Metritis in six weeks, and for the last time on the 28th of Septem- ber. No trace of the epithelioma is left, the wound covered with a smooth shining membrane, but the indu- ration of the body and supra-vaginal part of the neck has not disappeared. Chronic interstitial metritis exists, without, however, giving rise to any disagreeable symptoms. The menses appear pretty regularly, and last but four or five days. CAsE V.—Mrs. Helena Faust, a dispensary patient, twenty-six years old, was healthy up to her marriage, which took place six years ago, and during that time she gave birth tosix children. She had puerperal fever, with symptoms of inflam- mation of the generative organs, after her first child. Ever since that time she began to suffer from uterine disease, and has never been entirely well. Three months later she became pregnant with her second child, during which period she sufiered a great deal from abdominal pains. After delivery of this, as well as of the third child, she had an attack of puerperal fever. When two ‘months gone with her fourth child, she was taken with severe flooding, but did not miscarry. These hemorrhages continued up to the sixth month, when the foetus came away. She was treated during that time by Dr. Schnetter, who recognized the exist- ence of a tumor invading the neck of the uterus as the cause of the bleeding. With her fifth child she reached the full term of gestation, although bleeding most of the time. During the sixth pregnancy she felt: comparatively well, but when the child was born Relation to Malignant Disease of Utemts. 621 she had another severe attack of inflammation of the uterus and appendages. This occurred about a year before I first saw the patient. Ever since this last confinement she has been suffering severely from back-ache, abdominal pains, and profuse mucous leucorrhoea. The menses appeared every two weeks, and she has been bleeding without intermission for the last ten weeks. On examining the uterus I found both body and neck hardened and greatly increased in size, the latter covered with numerous small and large outgrowths which bled on the slightest touch. On ex- amining with the speculum these excrescences were seen to be distributed all over the surface of both anterior and posterior lips, and to have very much the shape of ivy-leaves. The secretion had as yet a decidedly 11111- cous character, and the uterus, although impaired in its mobility, could not be pronounced fixed by adhesions. On November the 25th, 1866, the neck was ampu- tated with the scissors, and the hemorrhage, which was considerable, arrested by means of the actual cautery. The patient sufiered very little after the operation, and was soon out of bed. The specimen thus removed was presented to the New York Obstetrical Society, and acknowledged to be the incipient stage of a true Olark’s cauliflower excrescence, a simple hypertrophy of the vascular papillae of the neck, as yet uncomplicated with epithe- lioma. I had occasion to examine the patient two years after the operation, when the stump was found to be covered with a smooth, healthy membrane. 622 Noeggerath on Chronic llIetritis in I have thought it necessary, even at the risk of appear- ing tedious, to detail minutely the ‘cases illustrating the position which I have taken, in order to allow others to judge as to the strength of the arguments. I have further attempted to draw as careful a de- scription of the beginning symptoms of malignant dis- ease as I could possibly do. First of all, it appears that there exists no rational or subjective symptom of cancroid or cancer, and above all no pain, at the early stages. Hemorrhage is occasionally absent, even in a pretty far advanced stage of development. The mucous char- acter of the secretion is only changed at a very late date. The only outward indication of importance is a gradual loss of weight of body, which cannot be ac- counted for by copious bloody or serous discharges. With regard to physical symptoms, the most reliable guide in judging a doubtful case consists in the ever- changing aspect of the neck, where alterations in size, density, succulence, and shape may be observed to take place from day to day. The question as to the curability of cauliflower growth is so far from being settled, that one of the most recent authors on the subject, Dr. F. Kuchen- meister, a ‘very experienced and able gynecological ope- rator, declares the affection incurable. From his de- scription of cases, however, I am led to believe that I have observed and operated on my cases at an earlier period of development,—-and in three of them, which were true villous epithelioma, no relapse has taken Relation to Malignant Disease of Ute/Pas. 623 place; in two instances twenty months have passed without a recurrence of the disease, and in the case first described in this paper a careful examination of the tissue of the uterus, removed after death, showed no trace of cancroid, eight months after the opera- tion. It is of importance to perform the operation in such a manner that the stump be not covered by vaginal flaps, in order to give a chance for caustic applications. The after treatment is as important as the operation itself. The cases reported are few in number, but many when we consider the scarcity of chances we have to observe malignant disease of the uterus at the very out- set of its development; many, if we consider, as I do, that interstitial chronic metritis is an affection observed but very rarely. To admit, with Seanaoni, that chronic metritis is the most frequent disorder to which the human frame is liable, would undermine the importance of the entire question of the relationship between can- croid and chronic metritis. I hold, however, and I am firmly convinced of the fact, that the disease which I have attempted to parcel out from among other similar uterine affections does not occur by far to that extent we are expected to see it, according to the majority of writers on this subject. Without being able to give statistical data at the present time, I feel justified in stating that I have been called upon to treat it less fre- quently than any of the conditions mentioned at the beginning of this paper. During the entire year which has passed, and treating, as I am, diseases of the uterus 624 N'oeggerath 0n Chronic Mez‘c'itis in almost exclusively, I recollect to have seen only two cases of well-characterized chronic metritis, besides the three mentioned in this paper. It is a noticeable fact, that I have only seen that variety of cancer which is called epithelioma cancroid, in connection with chronic metritis. In none of those cases where I have met with true carcinoma at that early state of development, where the condition of the uterine tissue could as yet be ascertained, have I found it to develop on a neck enlarged by interstitial growth of cellular tissue. It is, however, the rule to meet with both cancroid and true cancer at such an advanced period of‘ development, that a physician must be unusually lucky who has encountered half a dozen instances of malignant disease in its early stages of development, and I believe I am right in stating I have by accident seen more of beginning cancer than the majority of my colleagues, and thusI was enabled to col- lect the facts presented this evening for the first time. I am very well aware of the difficulty of finding an explanation of the coincidence of epithelioma and inter- stitial metritis. The more so since, at the present day, the doctrine of the pathogenesis of cancer is in such a state of fermentation, that it would seem as if what little ground we felt rejoiced to have conquered a few years ago was to be carried away by the flood-tide of the numerous recent researches. I will not detain the Academy by entering into a discussion of the latest—-— in many points conflicting-investigations. Whoever feels an interest in the matter I refer to the excellent and complete analysis prepared by Dr. William T. Relation to Malignant Disease of memes. 625 Lash and published in the M20 Yorle Med. Journal, vol. ix., No. 6. I will, however, briefly state that the drift of modern pathological anatomy points strongly towards a ten- dency to merge into one both cancer and cancroid. Here is another point where clinical medicine and pathological anatomy cannot harmonize in their views. As yet we are not ready to admit that cauliflower excrescence and carcinoma uteri be one and the same affection, be it from a diagnostic or a therapeutical point of view. If my observations should be verified by others, and not be mere accidental occurrences, they would go pretty far to corroborate the views entertained by some of the most prominent advocates . of the school of Virchow, Rokitansky, and Rindfleisch ‘among the rest, who have by numerous and very careful researches ar- rived at the conclusion that the enormous masses of epithelial cells in a cancroid tumor derive their origin from the cellular tissue interspersed between the muscu- lar strata. . . I will give a short resume’ of the more important points. discussed‘ in this paper :—- 1.. There exists a disease, usually called chronic me- tritis, and for. which I propose the name : Difased In. terstitial Metmitis. - - 2. The so-called first stage of development is only seen during the puerperal state. - 3. It consists in an abnormal growth of intra-muscu- lar cellular tissue. 41 626 Rogers on Dystocia, 4. The entire uterus, both body and neck, is equably diseased. —5. It is cured occasionally by amputation of the neck, not by any other means. i 6. Pregnancy and delivery have not a beneficial ef- fect, but are apt to prove a new stimulus to the abnor- mal growth of the uterus. 7. It is a disease but rarely observed. 8. Diffused interstitial metritis has a tendency to be transformed into cancroid or simple cauliflower excres- cence. DYSTOCIA,'_FROM CAUSE PERTAINING TO THE FCETUS-A RARE IF NOT UNIQUE CASE. BY STEPHEN ROGERS, M.D., N. Y. Corresponding Member of the Berlin Obstetrical Society. THE following history, first recorded in the Transac- tions of the New York Pathological Society, and pub- lished in the Medical Recorol of August 1st, 1867, is here reproduced for ‘the double purpose of giving it a conspicuous and permanent place in obstetric literature, and as a theme for the remarks we propose to make upon it. In the journal above referred to, my friend Dr. F. C. Finnell, of this city, is reported as presenting to the Pathological Society “two interesting intra-abdo- minal tumors from the body of an infant” whose history was as follows :-—- ' from canse pertaining to Feetas. 627 A woman twenty-one years of age, about one year after her marriage, and, as she supposed, at about the eighth month of her pregnancy, was taken in labor at five o’clock in the evening. Twelve hours after, the mem- branes ruptured and the waters escaped, and three hours later the head was delivered. Beyond this point, however, there was no. progress. The physician in attendance employed all reasonable force to complete the delivery, but did not accomplish it. He then sum- moned assistance and counsel, and renewed efforts were made, but the child remained in the same position, with only the head delivered. A third assistant, with unim- paired vigor, was at this time summoned, but his efforts only resulted in bringing down the arms, and severing the head and the arms of the child from the body. Dr. Finnell was now called, and, supposing the case might be one of hydrothorax, introduced a per- forator, but found no water. He then ' introduced the hand into the uterus, and seizing the feet of the child, brought them down and tried tn deliver, but found it impossible. Supposing that ascites might be they im- peding cause, the abdomen was now perforated, but no water found. With the thought that the contents of the abdomen might be of a semi-solid, gelatinous nature, and difficult to- force out of a small opening, the abdo- minal puncture was much enlarged by the scissors, but no fluid escaped. Almost in despair, the efforts at de- livery were renewed, and after prolonged traction and hard work there was a sudden yielding, and the muti- lated body of the child was extracted. On introducing the hand into the uterus for the purpose of removing 6228 Rogers on Dystocia, the placenta, an oval-shaped mass larger than the fist was found floating about freely, and was removed. This mass proved to be one of the two tumors above men- tioned, and will be hereafter described. After remov- ing the placenta and attending to the wants of the woman, the abdomen of the foetus was laid open, ex- posing a precisely similar tumor to the one found in the cavity of the uterus. It seemed to take its origin from the peritonaeum, and had but very slight attachments. It was located in one side of the abdominal cavity, and in the opposite side there appeared a space which cor- responded in size with the tumor found in the uterus. It was therefore apparent that this uterine tumor had originally occupied this space found in the peritoneal cavity of the foetus, and, during the efforts at extrac- tion, had been squeezed out of this cavity through the - opening made by the perforator and scissors, and there- by diminishing the size of the foetal belly so much as to render delivery possible, it having been evidently impossible while the two tumors remained together in the peritoneal sac. In connection with this history, it was distinctly stated that all of the organs occupying the peritoneal cavity were sought, and found in a healthy condition. On this account, probably, the tumors were at first regarded as fatty, and as such were presented to the New York Medical Union. An inci- sion into one of them, however, corrected this impres- ~ sion, by showing that they were cystic tumors. A sec- tion of one of the tumors having been taken for more careful examination by Dr. Rogers, when they came be- fore the Pathological Society at a subsequent date, he from cause pertaining to Faetus. 629 reported them as fibre-cystic tumors of the purest variety. He stated that he had no knowledge of any pathological structure in the adult‘ at all resembling this, except fibre-cystic degeneration of the testes. He would therefore ask Dr. Finnell if the foetus was a male or female; and if the former, whether the testes were known to have been in the scrotum. Dr. Finnell replied that the child was a male, and that while he re- ceived the impression that its scrotum contained the testes, it was true that no especial examination had been made to find them. As the remains of the foetus had been buried many days before these questions'were put, it was then impossible to renew the examination. Dr. Jacobi suggested that they might be either the supra-renal capsules or enlarged peritoneal glands. Dr. Krackowizer remarked that, inasmuch as the tu- mors were so symmetrical, and both occupied the same position in the abdominal cavity of the child, itseemed probable that they were the result of an enlargement of twin organs and not of peritoneal glands ; and as the report of the case had stated that the kidneys and all the other organs of the abdomen were found healthy, the suggestion that they might be supra-renal capsules ap- peared answered negatively. Dr. Rogers then said, that his previous questions and statements had no doubt created the impression that he believed the tu- mors to be undescended foetal testes in a state offtbro- cystic degeneration, and such indeed was his belief. On motion, a committee consisting of Drs. Finnell, Krackowizer, and Rogers were appointed to examine the tumors microscopically, and report. That commit- 630 Rogers on Dystocia, tee presented the following report upon the true char- acter of those tumors, a report which we copy from the llleclical Record of September 16, 1867. REPORT OF THE COMMITTEE. The committee would first, however, beg leave to premise, that the history of the specimens as given by Dr. Finnell at the time of presenting them, having included the statement that all of the viscera of the ventral cavity were present, and in a healthy condition, and that it was a male foetus, whose testes were not sought for, nor examined, and consequently not known to be present, had, as the Society will recollect, directed the attention of some of its members to the foetal testes as the starting-point of the enormous tumors-enormous when compared to the healthy foetal gland. The absence of any report relating to the testes of the foetus was indeed the chief cause of the necessity for the formation of the committee. For with a perfectly healthy condition of the abdominal viscera of a male foetus, whose testes were not in the scrotum or canals, the existence of two exactly similar tumors, perfect duplicates of each other, occupying the two lateral regions of the cavity, and each pro- vided with similar ducts or vessels, could scarcely be accounted for in any other way than by supposing them to be diseased testes retained in the peritoneal cavity. In the absence of this important evidence the committee were forced to resort to histo- logical proofs in the formation of a conclusion as to the character of the growths. The form of the growth is that well known in pathology as fibre-cystic. The cysts are of all possible sizes, from an almost imperceptible vesicle to one the quarter of an inch in diameter, and as we believe are lined by a delicate mem— brane possessed of tesselated epithelium. At least, this is the fact with the cysts large enough for examination. On carefully dissecting the tumors, each one is found to have a duct or vessel of sufficient size to admit a common probe. The microscope shows that this duct or vessel is lined by an epithelium of the columnar variety. Tracing it deeper into the substance of the tumor, this duct is found to be an outlet from a kind of sinus extending in the direction of the long axis of the tumor for from oanse pertaining to Feet/as. 631 about half its length. This sinus has several communicating or tributary ducts leading into it from various parts of the tumor, and is precisely similarly located and provided in the two, and possesses the same variety of epithelium as the duct. Besides this duct, each tumor has a vessel of very small size, possessing all the characteristics of an artery, leading into its substance, another having the appearance of a small vein, and lined with scaly epithelium, and between these two vessels is found a nerve-branch accompanying the vessels in their distributions. Under the microscope the nuclei of the neuralemma of this nerve twig are very distinctly visible and render its nervous character unequivocal. These three are united in one pedicle or cord, and are located at a slight distance from the large duct. Now, as this is precisely the histological description of the sper- matic cord, and the epididymal portion of the spermatic duct, and of nothing else, further proof in support of the belief that these tumors are examples of fibro—cystic disease of the foetal testes does not appear necessary to the committee. Desiring,v however, to leave no point uninvestigated, the following extract from Mr. Paget’s lecture on fibre-cystic tumors will explain 'why the committee extended its microscopic examinations. He says : “ We find examples of fibrous tumors thickly beset with numerous well-defined and lined cysts. This appears to be the nature of the ‘ hydatid testis’ described by Sir Astley Cooper. The specimens that I have seen of it make me think that it is essentially a fibrous tumor in the testicle, with cyst formation in the tumor. For upon or around the tumor the seminal tubes or their remains may be traced, outspread in a thin layer, and without difficulty separable, and the substance of the tumor is a distinct mass of common fibrous tissue, with a variable num- ber of imbedded cysts, filled with pellucid, serous, or viscid con- tents.” The committee hardly expected to find any such layer of seminal tubes over this tumor,—above the size of, and very nearly the shape of half of the fully developed foetal brain,——for the foetal testis, which is about as large as a medium-sized pea, spread out to that degree could with difficulty be detected. But in the hope that it might have been differently disposed of, we commenced the microscopic examinations of various portions of the substance of the mass, and very soon found undoubted frag- 632 Rogers on Dystocia, ments of both the straight and convoluted seminal tubes, lined with their characteristic cells. The whole tumor contains vast numbers of spindle-shaped nucleated fibre-plastic cells, and exu- dation corpuscles, and in some regions much mingled with these seminal cells. These fragments of the testes seem scattered over a great part of the tumor, for we have detected them in portions taken from widely distant parts. The locality of these fragmentary portions of the testes is generally marked by a slightly yellow tinge of the substance of the tumor, and a less cystic character of the point thus tinged. These fragments are mostly located near the sources of the vessels or ducts we have described as tributary to the longitudinal sinus of the tumor, and can with great certainty be pointed out. All doubt, therefore, in the minds of the committee as to the testicular origin of the tumors has been removed. But as to the precise pathology of the tumors, the committee see difficulty in demonstrating that the disease was originally of the fibro-areola tissues of the testis or of the cell-tubes; that is, whether it was a pure fibre-cystic disease, or whether it was in part a glandular tumor of the testis. If it be in part what is known as a “ glandular proliferous cyst,” dis- tinguished by the presence throughout its substance of structure exactly similar to that of the gland upon which it is developed, it can be so only to a small degree, for large portions of the tumor are devoid of such structure. The committee therefore incline to the opinion that it is a pure fibre-cystic disease in the testes of the foetus ; and they entertain the theory that the part of the duct present in the specimen corresponds to the epididy- mis, and represents that part of the seminal duct in a straight- ened and dilated condition. This view receives the confirmation of the best authorities upon the minute anatomy of the testis and its ducts; the epididymis being, according to them, the only portion of the seminal passage lined by columnar epithelium. The longitudinal sinus represents the rete-testis in a dilated state, forming an irregular but common canal; and the tributary ducts opening into it are the diseased and dilated vasa recta of the original testis. In conclusion, the committee would add that they have been unable to obtain any information of the record of a similar case of foetal disease, and that therefore, so Plates to Dr. Rogers’ Article. ( From Photograph 5. ) FIG. 1.-—Epididymal aspect of the degenerated testicle (half natural size). A. Thread tied to the vas deferens. B. “ “ nerve. G. “ “ vein. D. “ “ artery. FIG. 2.--Convex or opposite aspect of the testicle. fi'om cause pertaining to Fcetns. 633 far as they know to the contrary, this is an unique case in patho- logical history. STEPHEN ROGERS, F. O. FINNELL, E. KRACKOWIZER, Committee. Since the date of the above report, we have con- tinued our research into the literature relative to the ' pathology of the foetus, with a view to collect all of the recorded cases resembling more or less closely the one we here give, but, as will be seen by what fol- lows, the conclusion of the committee that it is an unique case has not been changed; The most recent systematic monograph upon the sub- ject of dystocia, from causes pertaining to the foetus, of which we have any knowledge, is that by Dr. D. J oulin of Paris. This work, published in 1863, makes the fol- lowing classification of these dystociae, viz. :— First: Excessive size of the foetus without other ab- normal condition. Second: Excessive size as a result of pathological change. Third : Abnormal presentations. Fourth: Procidentia, or vicious direction of the ex- extremities. Fifth: Parasitical tumors, containing foetal remains. Sixth: Multiple adherent foetuses. Seventh : Error of locality of the foetus, such as ex- tra-uterine. Eighth: Adhesion of a part of the foetus with the uterus or its appendages. 634 Rogers on Dystocia, Ninth: Deformity. Tenth : Rupture and other lesions caused by the £02; tus. Eleventh: Tumors. Under the second class, this author alludes to the pathological changes of all the important organs and cavities except the testes. He quotes a case of disease of the kidneys, which, on account of its resemblance to the one we have related, as respects the difficul- ties it presented, and the finally successful treatment, we will concisely state. The case is quoted from the “ Z’ Union .Me'dicale” for July, 1857, and is from the pen of Dr. Ohevance. He terms the case one of hypertrophy of the kidneys. When he was called to see the case the head had been delivered, and had been nearly torn from the body by inefiectual traction in the attempt to deliver. Believing that the obstacle to delivery was ascites of the foetus, he proceeded to turn, and then punctured the abdomen; but this resulted in no benefit, and it was not till after he had opened the bellyof the foetus and removed there- from the enlarged kidneys, weighing 1,000 grammes (35 ounces), that he was able to complete the delivery (Joulin: Oas de Dystocie appartenant au Foetus, page 47 As neither what was the exact operative proce- dure in this case, nor what is generally to be done in cases of dystocia from similar causes, forms any part of the object of this report, we will refer the reader to the original report, and to text-books on operative midwifery, for any information that may be desired upon those points. Cystic degeneration of the kidneys from cause pertaining to Foetus. 635 is not a very unusual condition in the foetus. Diseases of the liver and distention of the foetal bladder are con- ditions impeding delivery less frequently met with. Disease of the foetal testis, however, appears to be exceedingly rare. As a cause of dystocia, J oulin, as we have seen, does not even mention it. Prior to‘ the occurrence of the case we herein present, we find an allusion to but a single case. That is a case referred to by our distinguished and industrious townsman, Dr. Wm. O. Roberts, in an elaborate and wonderful paper, published in the American Journal of IlIedical Sciences, in‘1840 and 1841. On the subject of “ dis- eases of the foetus,” he says, speaking of the foetal testis, “ I know of but 'two instances of their having been found diseased. One was a case of congenital hydrosarcocele, in the Edinburgh Essays, so enormous as that it had to be punctured before the delivery could be effected.”* We have made all possible effort to obtain the original report of this interesting case, but have thus far failed, even after consulting Dr. Roberts, who does not remember the source of the information upon which he wrote that statement. As the volumes of the Edinburgh Essays which we have consulted contain no such history, we think there must have been an error in the name of the work quoted from, either by the Doctor or by the authority he used. As to what particular form of disease of the testicle this was, we have no positive information, but it is quite as likely to have been * Vol. 2, New Series, 1841, p. 303. 636 Rogers on Dystocia, cystic disease as any other. But whatever it was, it was clearly the cause of the dystocia. At least the combination of the enlarged testicle and the hydrocele was. The other case alluded to by Dr. Roberts, while in some respects it is most definite, in all that particularly touches the case we are record- ing as one of dystocia, is totally devoid of any ' history. He says it “occurs on the 76th page of Soemmering’s catalogue, in the description of a large mature foetus, of which, among other diseased con- ditions, it is said, testicali in hyolaticles concersi.” Op. cit., p. 303. This may probably be accepted as a “ general statement of a case of cystic disease of the testicle, but whether the testicle had descended into the scrotum, or was still in the cavity of the belly, we have no information. It is thought a fair inference, however, that on account of the minute examination and histological knowledge required to determine the character of a tumor like that of a diseased testicle when located in the peritoneal cavity, had they been so located at that early day their testicular origin would not have been discovered. If we admit this proba- bility, it follows that the cystic disease of the foetal testis, mentioned by Soemmering, was found in the scrotum, and is unlike the case we record. But in the fact that both testicles were affected by the dis- ease, we find another similarity. In the first case we have quoted from Dr. Roberts, we do not learn if both testicles were implicated or not. On the other hand, we have no knowledge that Soemmering’s case ofiered any impediment to delivery. Nott on Laceratecl Perineenm. 637 We have also sought the original Latin record of this case, but have not as yet found it. Dr. Roberts in this case also has forgotten the source of his infor- mation. So far, therefore, as the accessible literature of disease of the foetal testis shows, the case we here re- cord seems to stand alone: especially as a cause of dys- tocia. For an excellent chapter on the subject of cystic disease of the testicle, the reader is referred to the Treatise on Disease of the Testis, by Curling. The close correspondence between the appearance of the diseased foetal testis here recorded, and the descrip- tion of the cystic disease of the testis of the adult, as given by Mr. Curling, is an additional illustration of the general pathological truth, that the foetus is liable to become the seat of morbid processes at every stage of its development, and in every tissue and every degree, giving rise to phenomena and to conditions resembling those met with in extra-uterine or adult life. CASE OF LACERATED PERINAL‘UM—-HYPER1ESTHESIA OF CICATRIX-REFLEX ACTION ON UTERUS AND NERVOUS SYSTEM. —- BY J. 0. Kerr, M.D., n. Y. I I HAVE two reasons for publishing this case :-—-1st. Because physiologically, pathologically, and practical- ly it possesses intrinsic interest. 2d. Because I am 638 Nott on Lacerated Perineenm. charged by the patient with ignorance and malprac- tice. . The subject, Madame L , a Creole of respectable family from New Orleans, for change of climate was advised by my friend, Dr. E. S. Ohaille, to come north, and while here to consult me. She arrived in this city the day before, and sent for me on 31st May, 1869. She is of very short stature, and excessively fat, weigh- ing more than 250 lbs, so much so that she had been unable to take any out-door walking exercise for several years; complexion good, age thirty-seven, neck very short, and troubled much with vertigo ; very dyspeptic, no appetite, and ate so little that it was a mystery how she retained her size; .often vomited blood, was excessively nervous, irritable, pettish, and sleepless at night. The fat had all accumulated in the last three or four years, it is presumed from her inability to take exercise. Had been married, and was delivered of her first child fourteen years before coming to New York. The child was still-born, after a very hard labor, but she came well out of her confinement. About eighteen months later she was delivered, by Professor Oenas, of a fine boy, who is still living, and now about twelve years vold. In this labor she was delivered by for- ceps, and although she could not have been in more ' skilful hands, the perinaeum was lacerated down to the sphincter ani. No operation has ever been made to relieve the laceration, which still remained to its full extent on her arrival in New York. Her first husband died after the birth of the second child, and she married again a few years afterwards, Nott on Lacerated Perinoeum. 639 but I do not remember the exact date. One prominent point in her case was the fact, that she had not men- struated for eight gears before coming north. Every month the menstrual molimen made a demonstration by the usual backache and other similar symptoms, and there was sometimes a mere speck of blood seen, a drop or two at each epoch, but nothing more. She had at no time any leucorrhoeal or watery discharge worthy of notice. This was her statement, and in making exami' nations every two or three days for more than a month, I never could detect anything but a trifling tenacious secretion from the cervix. There was no abrasion of the os, and the intravaginal portion of the cervix was small and perfectly healthy in appearance. Notwithstanding the lacerated perinaeum, there was no approach to pro lapse, but on the contrary the uterus was higher up than we usually see it in women who have borne chil- dren. This, however, was attributable perhaps to her great obesity. The axis of the uterus was normal, a- little anteverted, as in the virgin uterus, and it was atrophied from long absence of function, the sound not entering more than two inch es. The cicatricial tissue formed over the lacerated perinaeum extended upon either side about an inch, and was half an inch in width. The most novel and strik- ing feature, to my mind, in the whole case was the con- dition of the cicatrix, which was in a state of extreme hgpertesthesia, and had been so ever since the laceration took place, now twelve years. The slightest touch of the cicatrix with a sound or the finger gave great pain, and was so intolerable as almost to throw her into 640 Nott on Lacerated Perinxa/m. spasms. In making my examinations I had to be care- ful to avoid any friction on the perinaeum; and the vulva being large, and the ostium vaginae much length- ened by the laceration, I was generally able to examine the uterus without disturbing the perinaeum. The pres‘- sure of Sims’ speculum could not be borne at all, and I was compelled to use a small cylindrical one. She had been married some years the second time, and mari- tal intercourse was always exceedingly disagreeable to her. She had married by the advice of some of her friends, under the belief that it might re-establish her menstruation, and thereby restore her health. In addition to the symptoms already detailed, she was tormented with painful Uoccyoclinia—— pressure upon the point of the coccyx with the finger, defeca- tion, the pressure of a chair while sitting, the motion of rising up or sitting down,-—in short, anything that communicated motion or pressure to the coccyx, caused severe pain; she was daily annoyed with dizziness; afraid to attempt to go up or down stairs; suffered much from neuralgic pains in face, back, limbs, and was much annoyed by cramps in the legs, particularly when she walked, even about the house. So disagreeable were the effects of exercise, that she had rarely attempt- ed out-door exercise for several years before coming to New York. Madame L. was accompanied by her mother, little son, and husband. The son was reduced to a mere skeleton by the confined action of chronic intermittent fever and ozaena. Being her only child, the mother was in so much distress about him, that she would not Nott on Laeeratecl Perintenm. 64:1 submit to any treatment herself which ‘would confine her to bed, and I therefore had to postpone indefi- nitely an operation on her perinaeum, which I regarded as the chief indication in the case. I deemed it worse than useless to attempt any course of medication, as she had forv years'passed from one to another of the most intelligent physicians in New Orleans. Nothing had afiorded any relief, and the only hope I saw of benefit- ing her was by removing the sensitive cicatrix, which there was good reason to believe was the source (by re- flex action) of her amenorrhoea, complicated train of nervous symptoms, &c. The little boy in a few weeks was improving, and as both he and the mother required a cool and healthy atmosphere, they were advised to go to Newport until the hot weather had passed. She suffered so intensely from the hot weather (which was by no means exces- sive), that she sweated to a degree I have never seen equalled. She would change her linen six or eight times a day. To occupy the time, though with little hope of suc- cess, I determined to see what effect sponge tents might have in provoking the uterus to action; accordingly, about the middle of June, after passing a sound with difficulty through the cervical canal, and dilating a little, I succeeded in ‘passing a small tent up to, but not through, the internal os. The next day this was re- moved, and one was passed fairly through into the cavi- ty. No other tent was used, nor was there any further interference with the womb. Shortly after (not having noted the date, I cannot say exactly how long), about 42 642 Nott on Lacerated Perinoeam. the last of June, she had a bloody discharge for five days,-—-the first she had had for eight years ,' this dis- charge was in quantity about what is usually passed at a menstrual period; but I could not under the circum- stances decide whether it was a true menstruation, or a simple hemorrhage provoked by the sponge tents. To the latter opinion I decidedly inclined, as she had not menstruated for eight years, and the uterus had become atrophied. The sequel to the case, however, will show that I was mistaken, as she not long after this flow be- came pregnant, and never menstruated bat the one time. She left New York for Newport the first of July, and returned on the 25th of August, after an absence of nearly two months; and although it seems that she har- bored the idea, she made no allusion to a suspicion of pregnancy to me, and such an idea did not occur to me as at all probable, if possible. ' Her health had improved a good deal while at New- port from the cool bracing air, and relief from her per- spirations. She still, however, was complaining, and all her nervous symptoms, with loss of appetite, began to reappear, and if I had been aware of her pregnancy, I should have attributed her symptoms in some degree to this cause. After fighting along as I best could with her innu- merable disagreeable symptoms until October, when the weather had got cool, I proposed again the perineal operation, on which we had been waiting for 4 months. I believed that the amenorrhoea and all her morbid symptoms were to be relieved, if at all, by removing this morbidly sensitive cicatrix and restoring the peri- Nott on Lacerated Perinceum. 643 naeum to its normal state. Seeing, as I did, no other hope of relief, she readily assented, and the operation was performed on the 16th October. As the case not only presented several novel and in- teresting points, but, from the obesity of the patient, her general’bad condition, and intolerance of anaes- thetics, I anticipated a good deal of difficulty in the operation, I invited Drs. J. Marion Sims, T. Gaillard Thomas, and Wm. R. Whitehead to assist me. Ether spray was applied to the parts, and although the local anaesthesia was not complete, it so blunted the sensibil- ity that I was enabled by rapid strokes of the knife to remove the whole cicatrix in a few seconds. The parts were brought together with four silver sutures, and al- together the operation was quickly and satisfactorily done. Dr. Sims examined the case with much care and in- terest, and was struck by the extreme sensibility of the whole cicatricial surface covering the laceration. He found it very acute and abruptly confined to the cica- trix, neither the mucous membrane within, nor the skin on the outside, showing any abnormal sensibility. What was remarkable, too, after the cicatrix was dis- sected off, Dr. Sims remarked that the sensibility was gone, and that the raw surface bore rubbing with the finger much better than the cicatrix had. Dr. Sims, moreover, gave it as his opinion that the woman would never menstruate again, or have a child. The doctor’s idea was, that at the age of 37, a woman ' with an atrophied uterus, who had not menstruated for eight years, had reached her menopause. Madame L 644 Nott on Lacerateol Perinceam. repeatedly alluded to this opinion of Dr. Sims after- wards. ' .3 None of the parties present at the operation suspected pregnancy at the time, although the sequel shows that she was then about two months advanced. Even if I had suspected pregnancy, I think the oper- ation would have been justifiable, as‘ her general health demanded relief, and it was clear‘ to my mind that she could not, in her condition, carry a child to full term ;— abortion was almost certain to occur, and no one seeing her as she‘ was, sufiering. with the train of symptoms described, could imagine that she could carry the child nine months without loss of its life. - In a woman of short stature, weighing 250 pounds, with a very pendulous abdomen, how could a diagnosis of pregnancy be made at two months ? Conjoined mani- pulation was impossible, and the sound alone, by pro- ducing abortion, could determine the point. She re- quired relief from wearing, pressing symptoms, and the operation alone promised relief. I have never in the course of my life had a patient give more trouble than this one. At the operation, from her extreme obesity and nervousness, she could not lie an hour in one position-she became covered with ecchymosed spots from the pressure of her weight, and rolled about from side to side for fifteen days, as if on a gridiron. She was incessantly annoyed by cramps and could not bear anodynes. The nurse, though experi- enced in such matters, could not introduce a catheter, and I was compelled to go to her house and empty the bladder at least three times a day. .Nott on Laeerated Perincemn. 645 The sutures were taken out on the 11th, 12th, 13th and 14th days, the union was found perfect, and the operation a success.‘ ' 19th November, four weeks after the operation, I . find this note in my record: “ The case has progressed well to date, the union is solid, the soreness and morbid sensibility is no longer complained of; she is relieved of her cramps and nervous symptoms, trouble in the head, coccyodynia, etc. Digestion and appetite good, in high spirits, and says she has not felt so well for years.” About the 1st December she complained of irritabi- lity of bladder, for which I gave her extract of buchu; this disagreed with her stomach, and was withheld at the end of two days. She then complained of severe pain in the left iliac region and above it; pressure here was painful to her, but this passed off in four or five . days. 17th December, just two months after the operation, she had uterine colics during the night, and about day- light in the morning of 18th a sudden and enormous gush of water took place from the uterus, with a few blood coagula. I still could not believe in pregnancy. On touching the os it was patulous, and a sound passed in about three inches, but I could get no other informa- tionby the sound. I supposed from the quantity of water, which was at least half a gallon, that it was some form of hydrops, either of the uterus or Fallopian tube. They described the quantity of fluid as so great that I examined the bed carefully myself, and found all the indications of more fluid than usually is seen at term. 646 lVott on Lacerated Perinoeum. She continued to have pains, with a good deal of flooding, through the day. Ooagula from time to time were cast off, and about dark a foetus of four months, _ which I think had been dead probably several days or a week, though not putrid. As the coagula had been thrown away, I could not tell whether the small placenta had passed or not, and as the finger could only reach the os uteri, it was diffi- cult to decide the point. The next morning I found her feeble, with a good deal of fever, and Dr. Thomas was called in, but did not see her till the afternoon. By the time he arrived the fever had gone ofi, and she was so much better that the doctor thought no prescription necessary. On ex- amination he found the placenta projecting about an inch from the os uteri, and tried by the finger and the assistance of bearing down to remove it, but could not, and we thought on the whole it was best, in her condi- tion, to leave it until the next day. I called early in the morning and found the placenta in stat/a gao. She was feeble, and I told her to take some chocolate or milk punch, and that I would call at noon and see if I could get the placenta away. Before that time, how- ever, I received a very polite note, from Dr. Thomas, stating that he had been sent for, that Madame L——-— had. fallen out with me, and declared I should never touch her again, and saying that he was ready to do whatever was most agreeable to me in the matter. I never was so astounded and surprised in my life, for up to this moment the lady herself, the mother, and husband, were long and loud in their praises; they had Nott on Lacera-ted Perineeum. 647 no language to express their gratitude for six months’ constant attention and kindness. My first impulse was to see the poor woman out of her trouble, for her nervous system was in such a state that I hardly looked upon her as responsible for what she had done. I therefore requested Dr. Thomas to meet ‘me at the bedside, which he promptly did. It was agreed at once to remove the placenta, which I in- sisted the doctor should do. He did remove it with his accustomed readiness and skill, and I took my leave, never to see the patient again. . Dr. Thomas informs me that the lady makes three specific charges against me. 1st. I did not know she was pregnant. 2d. I operated when she was pregnant. 8d. I did not know whether the placenta had or had not passed the day on which the abortion took place. The members of the profession can judge from the foregoing statement of facts how far these charges are correct. I will say in conclusion :—- 1st. There was no rational ground on which to base a belief in pregnancy ; and if I had suspected it in a sub- ject of such extreme obesity, at the end of two months, we have no means by which pregnancy can be with cer- tainty determined, unless by producing abortion. 2d. Although I would not have performed the opera- tion without a consultation, if I had been aware of pregnancy, still, I believe her case to be a strong ex- ception to the general rule forbidding it, and I would unhesitatingly have advocated the operation. All 648 Nott on LCZOé’PCZléCZ Perincea-m. medical treatment for years had failed to relieve her, her health was steadily declining, and it was better to risk abortion, or a second laceration of the perinaeum, than to risk a nine months’ pregnancy. 3d. There was very small prospect of a woman in - her condition carrying a child to full term; and if she did, it would be at great hazard to life. I therefore believe that abortion was the best thing that could have happened when it did. 4th. Dr. Paget says, in a recent lecture, that preg- nantw women bear operations well. Dr. Sims says he has repeatedly performed the perinaeal operation on pregnant women, and would not have hesitated a mo- ment in this case. 5th. From the facts that the foetus was dead at the time of’ abortion (two months after the operation), and that it was enveloped in such an extraordinary quanti- ty of water, we may infer that the death of the foetus and the abortion were the result of hydrops uteri. 6th. If this lady regains her health, her recovery must unquestionably be attributed to the sponge tents, which aroused the normal functions of the uterus, after eight long years of inactivity, and to the removal of the hyperaesthetic cicatricial tissue, which must be re- garded as the main cause of all her troubles. The patient has taken upon herself to decide points of practice when none but medical men are competent to judge. 650 Elliot on Puerperal C’ononlsions. herself from her father, her friends, and the world,_she writes a note to this man, who sends it to a lawyer, and he writes her a letter that she is guilty of attempt- ing extortion and may be committed. With this agon- izing strain upon her mind, she passes on to her confine- ment. I mention this not because of its remote but because of its direct influence. There was a hospital in Liver- pool which exhibited a remarkably low rate of mortal- ity in its lying-in wards; but it was found that they excluded primiparae. Just so surely as you exclude primiparae, and especially those who carry with them the whole burden of their shame and sorrow, the results are vitiated, and cease to exhibit the fair ratio of mor- tality for more liberal institutions. She had the ruddy, hearty, healthy, robust appear- ance not incompatible with the development of the coming trouble. She had her urine examined by the house physician; as the law in the hospital is that the urine of pregnant women should be examined once a week, especially in primiparae; and, more especially, in those in whom there is oedema of the face, or in whose urine albumen has been present or suspected, in a previous labor, or at any other time. Her urine was perfectly normal, and up to the standard. So healthy was her appearance, and she seemed so well, that the house physician did not examine it again. This is to be regretted. In private practice I follow the same law, especially in a primipara, of examining the urine as to whether it contain albumen, and the amount of this ingredient, as to its specific gravity, as to the Elliot on Puerperal C’onoulsions. 651 amount secreted by the kidneys in twenty-four hours, and as to the microscopical evidence of casts, and in doubtful cases for the amount of urea excreted. Ex- perience teaches us that frequent examinations will, if their warning voice be attended to, enable us often to ward off threatening trouble, and will disclose a ten- dency to trouble, in given cases, where one of the con- ditions may obtain and all the rest be lacking. Our patient went through her labor well, the first stage occupying thirteen hours; the second, a few hours; and the third, ten minutes. The labor was per- fectly normal, except that the head was delayed in passing the vulva, the delivery being accomplished about noon of Sunday, Dec. 26. She remained in a fav- orable condition until 7.15 RM. of, the same day, when convulsions commenced. Oonvulsions occurring after labor belong to a class of cases in which we have more hope than in those in which they antedate labor. It is an obstetric law that, when they occur during labor, we are, as a rule, to terminate the labor promptly, and place those that may follow in the category of post- partum convulsions. She had the attack, then, at this favorable time. She recovered consciousness——a favor- able symptom. She recognized the next approaching convulsion, exclaiming, “ Oh, doctor, it is coming now! ” and away she went into another. Puerperal convul- sions are not all alike. Epilepsy which has existed for a long time before rarely shows itself in labor, and, if the kidneys be free from disease, you may anticipate that the epileptic will not have a fit during parturition. Hers were not of the ordinary, or hysterical form of 652 Elliot on Puerperal Uom'valsions. convulsions, but were a severe, true eclampsia, by which term we designate convulsions that are truly epi- leptiform and distinguished by a total abrogation of consciousness. I saw this woman in several attacks, and the pheno- mena were just these: The patient, lying languidly, breathing regularly, totally unconscious, commenced to turn the head stiflly to one side—and when you see this peculiar version of‘ the head, under these conditions, you may be pretty sure that a convulsion is coming on ——the mouth open, the eyes fixed, strabismus often,-—- either divergent or convergent,—silence for a moment, and then a hissing expiratory sound, with puffs of air like a locomotive, with the face still turned to one side, the cutaneous circulation of the face congested, the eyes starting, but with the lids closed, the conjunctiva @011. gested, the face and tongue growing continuously bluer and blacker, all the limbs, which at first participate in the general rigidity, pass into violent and jerking contract- ing, clonic movements up and down; at last, as the con- vulsion goes on, the face gets blacker and blacker, the tongue is protruded, and may so far pass forward, gorged with blood and covered with froth, as to get between the teeth, and then, towards the close, the masseter muscles take on this same clonic action, and close upon the teeth, biting, perhaps, the cheeks and the protruding tongue, while blood and saliva may flow in mingled streams from the lips. This lasts for a variable length of time, with the face growing still darker and blacker, and then the convulsion ends with a deep inspiration; ——with the first thorough respiration the attack is over. Elliot on Puerperal Uon'vulsions. 653 Then follows a stage of the most profound chloroformic relaxation, stertorous inspiration, and, with checks flat- tened, breath is expelled in gusts from the mouth, lips, and flapping cheeks, all the while the dark blue color gradually disappearing from the countenance. The pulse is quickened during the whole convulsion. She may remain in this state, after the convulsion, for a considerable time, or go at once into another. Instead of this pleurothotonos, there may be emprosthotonos~ she may rise in bed, all the while being completely un- conscious, and then comes the true eclamptic attack again, or the recurrence may be ushered in by opis- thotonos. ‘From the second or third convulsion, that is, from four o’clock on Monday morning until ten last evening (Wednesday), this woman remained in a state of abso lute unconsciousness; and from Sunday evening until Monday night at nine, had, in all, nineteen convulsions, with the dangerous complication of oedema of the lung, developed on’ Tuesday morning, and yet she is going to do well. Now Dr. Pingry, the interne, had treated her well, had givemher a hot air bath, had given elaterium to act as a hydragogue on the intestines (and it is a prompt and reliable hydragogue cathartic), also chloroform, during the convulsion and a little before it, so as to an- ticipate what was coming, but without controlling it-—- all this before I saw her. A grain of elaterium in all had been given, without producing the desired evacua- tion, and then Dr. Pingry came for me. > The responsibility of such cases is very great, and no 654 Elliot on Puerperal C'onoalsions. routine treatment can be laid down, or should be uni- formly followed. We must then consider the physical character and present condition of our patient, and treat accordingly. I found a stout, sturdy, strongly-built woman of twenty, from the country, who had been de- scribed as hearty and healthy before her confinement; not one of your pale, pasty, anaemic women. I saw, when I came, that the elaterium was beginning to eva- cuate the bowels, and it soon produced full passages. There was a strong and good pulse ; and, on putting my ear to the heart, I heard the first and second sounds clearly and distinctly, with no anaemic murmur, no dis- ease of the heart, no fatty degeneration. Why this care- ful examination of the heart, you ask? Because, when considering whether you will adopt the spoliative treat- ment or not, you must determine the condition of the circulation by an examination of the heart as well as the pulses. Here, then, I found a strong and healthy heart, with good, rich blood, in a hearty young woman with convulsions which had occurred after delivery. I decided to take blood from the arm. This I do rarely and reluctantly, and only when driven to this venesec- tion by urgent'necessity. I hesitate in this matter, not alone because I deprecate in it the routine use of the lancet, but because the tendency of these cases is to anaemia and hydraemia afterwards, so that we must save the strength of our patients for the future. But, in the conditions then present, the resort to abstraction of blood was appropriate, in my opinion. Venesection is rarely performed now; so rarely that it is a very com mon thing for me to meet, in practice and in consulta- Elliot on Puerperal Conaulsions. 655 tion, physicians of high professional status and large practice, highly educated men, who have never seen any venesection at all. It was performed by Dr. Pingry, and, we watching the condition of the patient, ten ounces of blood were taken from the left median cephalic. The pulse and heart were, afterwards, in as good condition as before. The blood taken was saved, and sent to be examined as to the amount of urea it contained; the report, made without quan- titative analysis, was, that it contains a much greater quantity than should be in the blood. We had then the fact that there was present, in this blood, an unusual proportion of urea; and we know that, at the present day, we attribute much of the disturbance that occurs in albuminuria to the presence of urea in the blood. Here, then, this abnormal condition was found. The case went on. The elaterium acted. The spoli- ative treatment had been accomplished. She was watched in turn by two members of the hospital staff, for Dr. Pingry had called Dr. Sproat. And, to show you what care these women have, I may state that, from the time she had her first convulsion until she did not need further observation, she has never been left alone, but has been watched by these gentlemen, night and day, and notes of the case have been made minutely and accurately-a strong argument in favor of such establishments as these, where the poor and unfortunate of every class can receive that treat- ment and attention which it is the glory of our art to bestow. Ohloroform was afterwards tried again. I waited 656 Elliot on Puerperal Uonxulsions. to examine the albuminous urine, and saw her again at nine A. M., Monday, and regretted to find that consciousness had not returned, and that the con- vulsions still went on. In the interval, according to my advice, two ounces of blood had been taken, by wet cups, from over the kidneys. Finding her in these circumstances, I decided to give bromide of po- tassium, a remedy with effects, in quieting the nervous system, such as are recognized all over the civilized world. Besides, its effects as a diuretic are now estab- lished, and these are desirable in just such cases as this. I saw in this medicine a remedy which, I hoped, would increase the secretion from the kidneys, and which, above all, would quiet the nervous system. Accordingly it was given, thirty grains at first, next twenty, and then ten, making a drachm in all, taken within three hours. Now I lately met, in consultation, a physician of extensive practice, who, in speaking of giving medicines in convulsions, said that such a remedy could not be given, because the patient could not swallow. There are some affections in which partial paralysis of the muscles of the pharynx exists, and in which swallow- ing may not be effected; but I have never found any difficulty in eclampsia, if. given in this way: Mix the remedies with butter, and then put this little pat of butter upon the back of the tongue. If the pat pro- duces any irritation, it is swallowed at once, slipping down easily; If the patientv be so insensible to reflex action that she does not swallow, it rapidly dissolves and trickles down. Thus remedies are to be given in Elliot on Puerperal C’onoulsions. _ 657 cases such as this. She had a drachm of the bromide, therefore. I saw her again at half-past five RM. At this time there began to be a great dryness of the skin, and along with it an increase of the pulse in temperature and rate. I said to myself, the hydragogue cathartic has acted well, the kidneys are beginning to secrete, although she has taken no drink; the spoliative treat- ment has been carried far enough, yet not too far; now let me bring the action of the skin to bear, and accord- ingly ordered liq. ammoniae acetatis §vj., with 3 iij. of . sweet spirits of nitre, and then ordered an ounce an hour of the mixture, saying, we will have the efiects of the remedy during the evening, and we will also give support if necessary, by enemata containing milk, eggs, etc.; but these were found unnecessary. She could swallow, and, under the use of the remedy, began to‘ perspire. ' . I saw her again at ten RM. The convulsions had. continued; and I then recommended the use of the hydrate of chloral-—the idea now being to soothe and. quiet the nervous centres. Accordingly gr. xx. of the" hydrate were given, in two doses, under the adminis tration of which the temperature was reduced slightly. During the day, sixteen ounces of urine had been secreted, slightly less albuminous, and containing hyaline casts. - Then, at five the next morning (Tuesday), Dr. Pin- sl'y Watching her, the temperature was declared by the ' thermometer to have run up, and oedema of the lung Wag recognized. Now oedema of the lung is one of the con- 43 658 Elliot on -P/aeiperal Ooncalsions. ditions always liable ~to happen in albuminuria, from whatever cause, and may be fleeting or persistent. Such infiltration or effusion as it implies may take place into any serous cavity, as the pleura, or into the lung, just as it may into the subcutaneous cellular tissue of the face, arms, or other part. In regard to this oedema of the lung, I have seen many cases, and have known it to increase and to disappear with great rapidity-—a clinical fact of great importance. I have seen this occur in consultation with such physicians as Dr. Alonzo Clark, when it is not possible to doubt the existence of the oedema. This oedema, recognized by Dr. Pingry, placed life in the most profound peril, as the lungs, the important oxygenating centres, were being drowned, for they were fast filling up. Dr. Metcalfe happened to be in the hospital, and recom- mended the further use of elaterium, a right and proper thing to do. Accordingly, a grain more was given, in two doses, in order to drive from the lungs, and expel from the system, this poison which had accumulated in the blood. At the same time she looked as though about to die; the pulse could scarcely be felt, the number of respirations was between sixty and seventy, with tracheal rales. The case seemed hopeless; and so, from the result, we may draw another clinical maxim-—- never give up cases until they are (not thought, but) proved to be dead, a very good plan indeed. The case went on through the day, the kidneys beginning to se- crete, she taking nourishment with the stimulant which was added._ The urine became less albuminous, the kidneys were recovering, but still there was extreme Elliot on Puerperal C’onoulsions. , 659 debility with absolute loss of consciousness, yet with- out recurrence of the convulsions. I stood ready to transfuse, if necessary ; not to keep her from dying from loss of blood, because there was no danger of that, but to supply healthy blood instead of the poisoned and unoxygenated material. " When _ danger first appeared, I had requested my friend to write a note to_ Dr. Austin Flint, J r., asking him to hold himself ready, with his Roussel’s apparatus, to trans- fuse if necessary. But there would have been no use in transfusing with oedema of the lung; and it would but be bringing‘ a good remedy into discredit. But, if oedema had not arisen as a complication, and if she had gone on with steadily increasing convulsions, I would have held it to have been my duty to transfuse her. The plan was employed first at Heidelberg; and, by Roussel’s instrument, provision is made for ‘taking away the blood from a vein of one arm of a healthy in- dividual, which is then siphoned off into a vein of the patient. The blood can be seen as it passes from one' to the other, and we can watch that no bubbles of air . can go in without being seen as they pass through the glass tube of the instrument. I believe it to be the best plan yet devised. I held it in reserve, as I would in every similar case. For, in so far as the patient’s strength would permit, I would take away, through the skin, the intestines, and the kidneys, the poison that has accumu- lated in the system, and then, if necessary-supply it ‘with fresh and reliable human blood for its support, while the nervous centres are to be soothed by appro- 660 Elliot on Puerperal Con/vulsions. priate remedies. However, transfusion was not used, because it did not become necessary. a The patient struggled‘ out from the oedema of the lung, which had set in. At present there is no ‘evidence of it in the lung at all. She recognizes vevery one she knows, answers questions intelligently, is sensitive to light; her pupils dilate and contract well, although the eyes are kept pretty constantly closed. We feared some paralysis of the right side of her body, but she can now draw‘ up her arms and legs. The body, shaken and shattered by torture of mind, is coming around nicely, with the kidneys working well, and eliminating the poison from the system. ‘ Now, gentlemen, in regard to this question of the kid- neys I have, in a published work of mine, the “ Obstet- ric Clinic,” stated my conviction that, no matter what amount of albumen was excreted in a given case, or what variety of casts was found, still there is nothing in these conditions, by themselves alone, to prevent the kidneys of a pregnant woman in these conditions from returning to a perfectly healthy condition. At the same time, it becomes your duty, wherever such a special predisposition exists, to watch narrowly her urine in subsequent pregnancies. Such affections of the kidney as are indicated by these symptoms are, how- ever, more dangerous in multiparae than in primiparae. I never saw attention called to this before I stated my~ convictions. In the review of my book in The Ameri- can Journal of Medical Science, the reviewer has given the opinion that my conviction that perfect recovery of :the kidneys may follow such albuminuria, and amount Elliot on Puerperal. C’onuulsions. 661 ‘ and character of casts, should be allowed to stand for what it might clinically be worth; and presented a long list of names in opposition. My statement is true, nevertheless; and it will stand. It is already suppor- ted by other observers; and has received additional con- firmation since that time. I know it is true, because I have observed such cases with albuminuria, whose urine would gelatinize under heat and nitric acid, with casts of every kind and description, and yet have seen the pa- tients recover and remain with healthy kidneys. These conditions of the urine, occurring in pregnancy and la- bor, are as likely to be recovered from, perfectly and fully, as the same conditions of urine occurring in scar- let fever, or the exanthemata generally; or, as some- times happens, in pneumonia. Hence, you must be guarded in your prognosis when these conditions are found in a case of labor. You are not to say that this patient is the victim of a formidable form of Bright’s disease ; and that, if she do not die now, she has but a for it is not necessarily true ; because short time to live, she may pass on to perfect health. Nor can you say, when, at the autopsy, you find evidences of nephritis, that these appearances, found in the post-mortem exam,- ination, could not have been recovered from, had the patient lived. It is true, there are many appearances connected with advanced disorders of the kidney, which unfit it for performing its functions properly, but the point is this: the microscope and chemical tests show states of the kidneys, in a certain proportion of cases of eclampsia, where there is no absolutely neces- sary incapacity for performing perfectly their physio- Elliot on Puerperal Consulsions. _ 663 In a case which I saw, ten years ago, there was evi- dence of catarrh and calculi of the kidney. I was in doubt whether a largely dilated right ureter existed or not. Upon examination through the rectum, there seemed to be pain at a part of the bladder correspond- ‘ ing, as near as Prof. Van Buren and I could make out, by conjoined rectal examination, to where he experi~~ ences a great deal of pain at the probable entrance of that ureter into the bladder. His urine contained thin clouds and masses of mucus and albumen. I have told him that I would very much like to see the actual conditions of things, whether there is dilatation of that ureter and hydronephrosis, but I think that he is going to outlive me. Again, when there is but a faint trace of albumen, learn to trust the examination of no urine from a woman in the puerperal state without it has been drawn ofi with a clean catheter, after washing ‘the vulva, for the catheter may take in some discharges ‘ from the vulva which may contain albuminous fluid. Trust no examination, where your responsibility is great, unless you are positive that you have drawn ofi all, the contents of the bladder. I was consulted, only _ yesterday, as to the condition of uterine disease in an elderly woman; I touched the uterus, found the .bladder distended, said, “Let us empty the bladder,” and was handed a silver catheter,—although much pre- ferring, as you know, a male elastic catheter,-——and asked the Dr. to apply it. When he had drawn off the urine it appeared healthy. I then made an exami- nation, thinking that the bladder was empty, but found 664 Elliot on Puerperal Conuulsions. that there was more within. I then took the silver catheter and drew ofi nearly as much as before. The supernatant liquid was pure, but, at the bottom, evi- dences of catarrh of the bladder were plainly to be seen. Here, then, is an illustration of the absolute necessity for drawing ofi the urine, intended for examination, at or about the period of labor, with the precautions given you, and for the necessity of drawing off the whole urine. - Let the deep interest of the subject be my excuse for detaining you beyond the time. When you have car- ried your patient on to this stage in an attack of puerperal convulsions—-and you are to remember that they may well occur in circumstances widely different from those of the present case, even where there is the most perfect domestic harmony and felicity-then you must keep her quiet in body and mind for a length of time, must secure sleep at night, must look after her ‘nourishment, must carefully examine her urine, to ascertain whether the kidneys are doing their work. Drawing it off with the catheter for twenty-four hours is the only way to be absolutely sure; then measure the amount, to know how much is passed; and then examine the residuum with the microscope, testing it as it comes for albumen, and then making a quantita- tive analysis for the urea that is being excreted. When the amount of urea comes to the full normal standard, and all other conditions correspond, you may consider that the kidneys are doing their work. After the urine is perfectly normal, then give her a good intelligent caution for the future. In the first Elliot on Puerperal Uonoulsions- 665 place, there must be no pregnancy for some time; cer- tainly it is better to wait two years. Since the kidneys have been but lately disordered, and have been just re- stored to their normal condition, she must be instructed to wear flannel, in order to guard against any check in the performance of the functions of the skin, and subse- quent congestion of the kidney. She should live in the open air, with free exercise, and good diet, the nitro- genous elements of food being supplied I or withheld according to the way in which the kidneys do their work. She will probably need iron, for in such cases there is a tendency to hydraemia, absolute as a law. Even the most robust ‘will be apt in time to give evi- dence of chloro-anaemia: in which case direct your at tention to the venous hum in the neck, and continue treatment until assured that it is no longer there, and until all other signs of anaemia are gone. In this man- ner only will you do your patient full justice. If she become pregnant again, watch the urine with redoubled care, examining it continually, and ward off the coming trouble by proper treatment. If there be such serious disturbance that palliative measures will not suffice, then the question comes up as to when pre- mature labor is to be induced. By acting on the skin, the kidneys, the intestinal‘ mucous membrane as far as may be judicious, and with vegetables and fruits as a diet, endeavor to carry her on to a time when prema- ture labor may be induced with the hope of saving the lives of both mother and child, or perhaps to term. In conclusion, let me warn you to be careful in the use of opium where there is deficient action of the 666 Emmet on a Case of Ooa/riotomy. kidneys, and wherethere is an accumulation of urea in the blood. There are cases in which opium is treacher- ous, and in which many lives have been lost by the in- judicious use of this remedy. Besides, the'ease with which it is administered by the hypodermic syringe is a temptation towards the most dangerous way of pre- scribing it : because it at once passes beyond your con- trol ; and, again, it might be immediately absorbed by some venous radicle. In any case, there is a certainty that its absorption will be prompt ; and then, if unfavor- able symptoms follow, there is far less opportunity of overcoming them than there would have been had it been administered by the stomach, when its evil effects may be largely prevented by emesis. I speak from knowledge that what I offer you is a valuable guide to take into practice; but do not speak from any sad personal experience of my own, but with knowledge of the sad experience of others. A CASE OF OVARIOTOMY. THE PEDICLE SECURED WITH SILVER WIRE BY A NEW METHOD. BY THOS. ADDIS EMMET, M.D., Surgeon-in-Chief of the Woman‘s Hospital of the State of New York, President of the New York Obstetrical Society, etc. THE proper treatment of the pedicle after the removal of an ovarian tumor still remains a mooted question. ‘ The various means which ‘have been proposed are all The Pedicle Secured by a lVew .Method. 667 applicable to certain conditions of the pedicle, but no single method has yet been accepted as combining the advantages of each in common, and applicable to all cases. Without entering into a consideration of the merits of the question, I will simply state that for some time past my preference has been in favor of returning the stump whenever it was practicable to do so, and of closing the abdominal section. The silk ligature, in its ready application, presented many advantages over the silver wire, but I have used chiefly the metallic suture in preference, regarding its use as attended with less risk afterward. The method, as practised by Dr. Sims, of securing the pedicle by means of a series of interrup- ted silver sutures, I have used several times, and con- sidered it a great advance. I found, however, that without the pedicle was a thin one, troublesome oozing of blood frequently occurred from the tissues becoming lacerated in the tract of the sutures, as a consequence of the tension exerted in an opposite direction, as each loop in turn was twisted. October 18th, 1869, at the Woman’s Hospital, I re- moved, from a patient thirty-three years of age, a multilocular ovarian tumor, weighing forty-five pounds, which had been of some two years’ standing. ' As a large portion was nearly solid, the section had to be extended for several inches above the umbilicus before the mass could be removed. Chronic peritonitis had existed, but the adhesions were slight, except at one point, to the omentum. The left ovary was found involved with a long and rather thin pedicle. ' ‘ My'friend Dr. Sims kindly introduced the. sutures for 668 Emmet on a Case of Ooariotomy. me by his method, but unfortunately some oozing took place from the splitting of the tissues, as had been my previous experience; but after some delay it was con- trolled by the introduction of a parallel row of in- terrupted sutures, so as to secure the angles of the lace- rations. This patient, however, rapidly recovered, and was discharged cured, November 29. Realizing that this difficulty must frequently occur when the pedicle was thin and small, I resorted to a different method of applying the wire, as illustrated in the following case :— Mrs. S., aged twenty-eight, a native of New .York, was admitted to the Woman’s Hospital Nov. 25th, 1869. She had married at fifteen, and was the mother of four children. The first child was born two years and four months after marriage, and the last two years and eight months previous to admission. She had been in good health until the latter part of December, 1868, when the abdomen began to enlarge rapidly, with frequent and painful micturition, while she suffered at the same time from constant pain in the back and left inguinal region. The enlargement was so rapid, that at the end of two weeks after it was first noticed she was unable to wear any of her clothing which had previously fitted her, her appetite began to fail, and she soon became emaciated. Before the end of February the tumor had enlarged nearly, as she stated, to the size presented at the time of admission. The cata- menia, which'appeared first at the age of fifteen, and had always been regular previous to this time, became now irregular, and of shorter duration, until it ceased The Pediele Secured by a lVew .M'ethod. 669 in the following May. ".Iust‘previous to admission she had arrived from New Mexico, where her husband, an ofiicer of the army, was stationed. She was much emaciated, with oedema of the lower extremities, and scarcely yet recovered. from the fatigues of her long journey, but cheerful, and very hopeful of a favorable result from surgical interference. A large multilocular ovarian tumor filled the abdomen, extending up to the sternum, and causing the false ribs to bulge outward to a great extent. The circumference of the ‘abdomen, on a level with the umbilicus, was fifty-two and a quarter inches. The distance from the ensiform carti- lage to the umbilicus was thirteen and a half inches, and to the pubis twenty-five inches. From the left anterior superior spinal process to the umbilicus was fifteen and a quarter inches, and on the right side fifteen inches. The mobility of the tumor was but partial. (Edema of the abdominal wall, with much thickening of the tissues, existed from the pubis nearly to the umbilicus. The linea alba was well marked, with an unusual number of superficial dilated veins distributed over the abdominal surface. The whole abdomen was dull on percussion, with fluctuation, easily detected at every point, yet varying greatly in distinctness. The uterus was found high up in the pelvis, somewhat forward, but movable, and its cavity of a normal depth. The urine was carefully subjected to both a chemical and microscopi- cal examination, without detecting any deviation from a healthy condition. The heart’ and lungs were in a normal state, but the pulse was weak, and ninety-eight per minute. The tongue was clean, and the bowels 670 Emmet on a Case of ‘Ovariotomy- were regular as a habit, but the skin was dry and in- active. Her condition from the distention rendered an early operation imperative, and in fact the lesser evil, although much enfeebled after so long a journey, and unacclimated. The preparatory treatment was comé pleted in a week, and consisted of a Turkish bath every other day, with five grains of inspissated ox-gall in the form of a pill, three times a day. On the third day a dose of castor-oil was administered; and on the night previous to the operation a large enema of hot water, into which a portion of ox-gall had been dissolved, was _ thrown into the rectum, while the patient was placed on the knees and elbows. Her diet had been carefully regulated to be as nutritious as possible, in a small bulk, and consisted chiefly of strong beef-tea. Her condition improved soon in a marked degree. The oedema of the extremities was removed by rest and bandaging, and she no longer sufiered from the great distention after the thorough cleaning out of the bowels, while her skin, from the use of the Turkish baths, had become soft, and in excellent condition. Operation December 1st, 1869, at two o’clock P.M. The following gentlemen of the Consulting Board were present :——Drs. Sims, Post, Peaslee, Taylor, Barker, Cock, and Geo. T. Elliot; Drs. Perry, Swift, Brown, Winston, and Hunter of the Hospital Staff; Dr. Cas- well, of Providence; Trock, of Astoria; and N ott, Snelling, Newman, Walker, and other gentlemen in the city. An incision of some six inches was made midway between the umbilicus and pubis through the The Pedicle Secured by a JVew Method. 671' liniea alba, which was very distinct in consequence of oedema of the surrounding tissues. On reaching the Iperitonaeum it was found firmly adherent to the tumor in every direction. The main cyst, together with several others, was emptied through a common opening. By degrees the adhesions were carefully stripped off from the surface of the tumor itself, using chiefly the finger-nails for the purpose. The adhesions extended from about four inches above the pubis to the diaphragm, and from five to eight inches on either side of the median line. To facilitate their separation it was necessary to extend with scissors the abdominal section upward and to the left of the umbilicus, until it reached fourteen inches in length. Although the hand was introduced into the main sac, and an attempt made to break down into it the numerous small cysts, it was found impossible to empty but a small portion of them, and with difliculty the mass was finally removed through the extended abdominal opening. The tumor was from the left of the uterus, with a thick pedicle three inches in width. The right ovary and uterus were in a healthy condition. The ether was administered by Dr. Perry, and the case required the most careful watching, as several times during the operation the shock was so great that stimulants had to be resorted to. The tumor was removed at the end of an hour and a quarter. As the mass was held up, a clamp taken from one of Ohapman’s ice-bags was placed on the pedicle as close to the tumor as possible, when it was severed by scissors. A section of stout silver wire (No. 25) had been prepared, about eighteen inches in 67 2 ' Emmet on a Case of Ooariotomry. length, to each end of which a‘common coarse sewing needle had been soldered, after bending a portion of the wire into each eye. In the grasp of the clamp the pedicle had been spread out to its full width, and as it‘was held up, the ligature was introduced in the following manner. Below the clamp a needle was passed through the pedicle about an inch from its edge, but before its withdrawal the needle in the other hand was inserted along its course from the opposite direction. The two needles were thus drawn through, in the same manner as the shoemaker’s stitch, and at the same time the wire was tightened around the included section as much as could be done, in consequence of the proximity of the clamp. The needles were introduced again in the same manner, so as to divide the pedicle into three sections. With the ends of the wire in one hand, the pedicle was seized between the grasp of the thumb and fore-finger of the other hand, and at the instant of removing the clamp, by traction on the wire, the parts were drawn up tight together in two sections, while all bleeding from the third one was ' controlled by pressure of the thumb until the ends of the wire could be twisted. The ends of the wire were seized about an inch from the pedicle in the grasp of a pair of forceps, and carefully twisted over Sims’ shield, to a point at which the integrity of the wire was still unimpaired. The twisted portion was cut off at half an inch in length, and bent over flat along the course of the ligature, so that the end was perfectly protected at the bottom of a deep sulcus. This ligature was applied in far less time than a clamp could have been adjusted, with perfect control of all The Pediole Secured by a lVeu) rllethod. 673 bleeding, and to a pedicle which, from its size, would have been difficult of management in any other manner. So perfect was the compression, as the wire was tightened the tissues retracted from the blood-vessels, so that they projected a quarter of an inch beyond the plane of the divided surface which had been in common. Although the adhesions had been stripped off so ex- tended a surface, no oozing of blood took place after- ward, except high up in the vicinity of the ‘ spleen, where the adhesions could not be separated from the tumor with the same care, in consequence of the difficulty in bringing the parts fully in view. To the bleeding points the fluid extract of ergot was applied, but it proved valueless as a styptic, and afterward the persulp. of iron was brushed over the surfaces, but in small quantities, wishing to avoid the formation of an insoluble clot. . The external wound was closed by fifteen interrupted silver sutures, and were introduced far back from the- edges, so as to include the peritonaeum. As the oozing‘ had not entirely ceased, high up on the left side a quantity of cotton was formed into a compress, so as to press the relaxed abdominal wall, at that point, well up under the ribs ; this pressure, it being thought, would be sufficient to control all bleeding. Over the whole a. broad bandage was applied, and she was placed in bed, with artificial heat around her. Immediately before the operation she was weighed on a platform scales, and her weight, with that of her clothing and the table, ascertained. She was placed on the scales after the operation, and it was found that she had lost sixty-nine 44 67 4 Emmet on a (Jase 0f Ovariotomgl. pounds. The accuracy of this method was tested by carefully weighing the fluid and the mass taken "away, with a difference of less than two pounds, which had, doubtless been lost in the sponging. Immediately after the operation her pulse was 120 and very feeble, but reaction came on promptly. At 10 P.M., as she was restless and complaining of pain in the back, a tea- spoonful of McMunn’s elixir of opium was given by . the rectum, and she passed a comfortable night. The sutures were removed December 7th, and the union was found complete. December 9.——To this date her con- valescence had been slow, but without any interruption. Small circumscribed abscesses now formed at the entrance and exit of the abdominal sutures. Their for- mation was evidently due to ‘the diminished vitality of the tissues consequent upon the oedema and distention to which the parts had been subjected by the enormous size of the tumor. December 10th, pulse 108. Up to this time no alcoholic stimulants had been found necessary, but were now ordered. During the night of December 12th, was seized with severe cramps involv- ing the muscles of the inner part of the thigh, and afterward in the calf of the left leg and foot. Large doses of opium were found necessary to relieve her sufiering. Next morning the leg to the ankle was swollen from oedema, with an increased temperature of the parts. The limb was carefully bandaged, and in twenty-four hours she was entirely relieved. She began to recover rapidly, and in ten days the abscesses had healed. January 7th, 1870, she was discharged, having fully recovered. ' ' Harris on .Milh as a‘ Diet, (yo. 675 MILK AS A DIET DURING LACTATION. BY ROBERT P. HARRIS, M.D., PA. (Read before the Philadelphia Obstetrical Society, 1869.) FRoM a series of trials which I have very successfully made, and of which the three cases here given are re- corded as examples, I have become convinced of the great value of milk as a food for delicate mothers who desire to nurse their own children. By the term.“ deli- cate” I do not mean those actually diseased, or appa- rently inclined to tubercular or other serious organic affections, but a large class of American women in. the higher walks of life who fail as nursing mothers, either because their milk is too small in quantity or deficient in nutritive elements. Such women are generally- below their proper average in weight; have little if any color in their cheeks ; and eat but a moderate amount of food. There may not be any deficiency in the development of their mammary glands, although their mammae are usually smaller than they should be; but this is chiefly . due to the absence of adipose deposit. All such sub- jects do not bear a milk diet well ; and in such the plan must be abandoned, as the diet should not only agree with the mother, but be palatable, soas not to diminish her appetite for her ordinary diet. She should be able to eat her three meals as usual, and consume the requi- site amount of milk in addition. There are many women who have lost all their childhood’s relish for milk, just as there are sometimes young children who do the same 67 6 Harris on .Mille as a thing, and cannot be made even to try its efficacy. And there are others who are anxious for success and do make the trial faithfully, but are reluctantly obliged to discontinue the diet in consequence, not of any disrelish, but of an inability to digest it. Happily, there are also many who not only like the taste of milk, and can continue its use indefinitely, but who experience a wonderful degree of benefit from it, not only being able to nurse their infants, whom they would otherwise have to give to a wet-nurse, or raise by hand, but greatly improved in health and strength, gaining flesh, increasing in. appetite, and avoiding the ills resulting from the drain upon their system, so com- monly experienced after a few months‘ of lactation. The first case I. shall mention is that of a lady who came from New York to- put herself under my care, and was delivered. in due time of her fourth child, a boy, weighing eight pounds. She was below medium height, pale, and weighed, on an average, eighty-six pounds. After the birth of her first child, a female, her milk-failed in a few days, and a wet-nurse was called in. She nursed her second, also a girl, until it was about a month old, by which time the infant was so much wasted from the deficient quality of the lacteal secretion, that two days and nights constant care in feeding it with diluted cream and brandy every fifteen minutes, ,were required to give it the requisite strength to nurse from a healthy woman, and thus save its life. Precisely'the same result attended the attempt to nurse her third child, also a female; and in a day after it ceased to draw upon the mother her milk dried up. Diet during Lactation. 67 7 The fourth child, being a male, was a little larger than the previous children, and nursed more vigorously. When seven days old it became evident that he did not get nourishment enough, and additional feeding was resorted to for a short time. This affected his health ‘so, that he had seven green passages in twenty-four hours. I then proposed to the mother to try the efli- cacy of a milk diet for herself, which she did, taking it as a drink, in small portions, several times a day. In two days her baby was entirely well, and she began to feel, for the first time in her life, a painful distention of the breasts. She improved steadily in health, and was soon able to be up and about the house._ Her infant grew rapidly, and weighed thirteen pounds at two months, at which time she consumed two quarts of milk daily, and said that she ate in addition her full comple- ment of food. She continued to nurse this boy until he was eighteen months old, and weighed twenty-six pounds, increasing her own weight at its maximum to 105 pounds, or nineteen pounds above her ordinary ave- - rage. It is not necessary to saythat there was a marked improvement in her health over what it had been for several years. _ The second example I shall give is that of a tall, spare woman, wife of a merchant in this city, who had been dyspeptic for several years prior to her mar- riage, and whose average weight was from 106 to 112 pounds. Her infant was her first, a large boy, whose birth was followed by a considerable flooding, pro- ducing partial syncope. I commenced a milk diet in her case a few days after delivery, and with the most 678 Harris on Mlle as a Diet, ($70. 'happy results. Her breasts, from being small and flaccid, soon filled up, so that she was enabled to nurse with entire satisfaction. She took a pint of boiled milk morning and evening, and at noon a pint' of broma, made with cream. Her son grew very large and heavy, and she increased so much that by the time she com- menced to wean him her weight was 177 pounds. Being tall, and of large frame, this addition gave no appearance of grossness, but added materially to her healthful appearance and commanding presence. The third case is that of another small woman, of an equal station in life with the other two, who seldom weighed above 100 pounds. She had lost one child in consequence of failure of her milk, hand-feeding and diarrhoea ending in convulsions. Her second child is now seven months old, and, as an evidence of the effect of milk upon its mother, weighs twenty-one pounds, which is a large weight for a female child. The mother nurses without any trouble or feeling of weakness, and has increased her weight to 116 pounds. She has a better appetite for her ordinary food than she has ever ‘had, and this weight mentioned is the maximum of her life. I have used milk in a‘ variety of combinations, but think that the less farinaceous admixture it contains the better it answers the purpose for which it is de- signed. Pepper on Adipose Deposits, ~ 679 ADIPOSE DEPOSITS IN THE OMENTUM AND ABDOMINAL WALLS OF WOMEN AS A SOURCE OF ERROR IN DIAGNOSIS. BY GEORGE PEPPER, M.D., PA. (Read before the Philadelphia Obstetrical Society, 1869.) ALL authorities, who allude to this subject, agree in stating that excessive deposits of fat in the abdominal walls and omentum of women, at or about the meno- pausis, may become a source of doubt or error by simu- lating pregnancy or some abdominal tumor. But while most give this general statement, few enter into any dis- cussion of the causes or effects of such deposits, or con- firm their teachings by illustrative cases. Within the past few years three such well-marked instances of this condition have come under my observation, that I have thought them worth recording. ' CASE I.—Mrs. S , act. 50; mulatto; married, and living with her husband; the mother of several children. Had ceased menstruating a year or more before she came under my care, in the spring of 1866, for profuse metrorrhagia, which had come on without any assign- able cause, and had persisted for several months in spite of the various internal remedies employed. She was emaciated, anaemic, and very despondent; her appetite was fair, and all the other functions were performed normally. On vaginal examination the uterus was found enlarged and heavy, with its tissue unusually dense and hard; it was but slightly sensitive on pres sure, but decidedly less movable than normal. The 680 Pepper on Adipose Deposits in the Omentum uterine sound readily passed in (over 8 inches) in the normal direction, but its withdrawal was followed by increased hemorrhage. During the absence of hem- orrhage the muco~purulent discharge from the ‘ cavity of the organ was profuse. There was no lesion of the mucous membrane covering the cervix. With the exception of an astringent salt of iron, administered internally, the treatment was entirely local. The hem- orrhages were checked from the first, but the purulent discharge was very obstinate, and did not yield entirely until after several months’ treatment. She rapidly gained flesh and strength after the first few weeks, and continued to improve until, at the end of 6 months, she seemed entirely well. From this time I heard nothing of her until about 6 months afterwards, when she called on me and told me that she was 8 months advanced in pregnancy; that her mammae' were enlarged; that she had felt foetal movements, and, in fact, she stated that she presented all the symptoms experienced while. carrying her children. On palpation the abdomen was found fully as much enlarged as at full term, quite tense, and resisting. No fluctuation or solid growth could, however, be felt, and no auscultatorylphenomena were audible. On vaginal examination, the uterus was i found to occupy about its normal position, to be rather dense and heavy, but not materially enlarged, the sound entering barely 8 inches, causing no pain nor discomfort, and its withdrawal being followed by no discharge. There was no tumor nor induration felt in the pelvic cavity; but on attempting to measure the thickness of the abdominal walls by bimanual examination, they and Abdominal Walls of Women. 681 were found to be at least 8 inches in thickness in every direction in which this attempt was made. There was also increased adipose deposit in the mammae, and, to a very limited degree, over the whole body. Her diet was regulated, and her anxiety allayed by positive assu- rances that there was nothing wrong, and she has since remained entirely well. The size of her abdomen has decreased considerably, and it appears as if her anxiety in regard to her pregnancy had been the cause of the trifling disturbances she had experienced, as all her uncomfortable feelings, as well as the supposed foetal movements, passed away after she was reassured. CAsE II.—Her daughter, set. 26; married; had one child several years ago, after a fearfully diflicult labor, and has been in poor health ever since, suffering from symptoms of chronic uterine disease, for which she placed herself under my charge early in the autumn of 1867. I found much the same condition as has been described in her mother’s case, except that the menstrual discharge was scanty, while the muco-purulent uterine catarrh was much more profuse. The pelvis was slightly contracted antero-posteriorly, and its depth anteriorly decidedly increased. Her husband had contracted a chancre while away from home, which had so mutilated his penis that intercourse was almost impossible, and he himself seemed so ‘thoroughly ashamed of his condition that I believe he never even attempted coitus. Her case was more obstinate than her mother’s, but finally yielded to treatment. After leaving my hands she was employed as nurse to an infirm and aged lady, and for some months I did not hear from her. Last autumn, and Abdominal Walls of IV omen. 683 of diet. She has since diminished materially in size, so that the inconvenience is greatly relieved, while her general health continues excellent. . CASE III.--In January, 1869, was called in consulta- tion to see a woman, wt. 45; married, the mother of several children, the youngest of whom is now 8 years old. She has miscarried once since, soon after its birth. Last May she menstruated as usual, but thought that for two months before that time she had noticed some unusual symptoms low down in the abdomen. The next menstrual discharge was very scanty, a mere stain, lasting only 24 hours. After this she began to increase in size, and as her menses did not reappear she thought herself pregnant, and engaged her physician. Soon she began to feel movements in the abdomen, such as she ‘had felt with her former children. They were ill-de- fined and confused, but still of such a nature as to leave no doubt in her own mind that she had quickened. There were no sympathetic, gastric, or mammary dis- turbances, but these had been absent during her previous pregnancy. She continued to increase in size until a short time before my visit, and had become very anxious about her condition. The general health seemed excel- lent in every respect, and it was merely a dread of some impending evil that caused her to seek. medical advice. The abdomen was very large at all times, but, when occasionally distended by flatus, she sufiered' consider- able distress. The bowels were regular, but with a tendency to flatulence. The urine was voided in normal quantities and at proper intervals. ' On vaginal exam- ination the uterus was found very high up, undergoing 684 Pepper on Adipose Deposits in the Omentum senile atrophy, and apparently perfectly healthy; the sound entered in the normal direction barely two‘ inches, and caused no pain nor discharge. The pelvic cavity was cushioned with fat. The abdominal walls, enormously thickened, were soft and doughy. On abdominal pal- pation no solid mass could be felt, nor could any fluc- tuation be detected; the skin was tense, shining, and covered with old cicatrices. The abdomen was pro- minent, rounded, and changed its contour but little with change of position. She was ordered rhubarb, strychnia, and belladonna for the condition of her bowels, regulated diet, and a comfortable abdominal supporter. She passed from under my observation, but I hear is still in excellent health, though no smaller. These three cases have been the most marked exam- ples I have seen of. the condition to which I refer, al- though slighter degrees of the same deposit have from time to time presented themselves. In all three patients considerable anxiety had been caused by the phenomena described, and in two instances they firmly believed them- selves pregnant, so that one of them even had engaged her accoucheur. , The third fancied herself the victim of ovarian disease, and was beginning to fail in health, owing to "the ever-present dread this thought inspired. In the first case, the excessive deposition of fat took place at the termination of the menstrual life, and after an exhausting uterine hemorrhage had been checked; in the second, after the cure of a profuse purulent uterine and vaginal discharge; whilst in the third, after a rather unusually abrupt cessation of the cata- menia. In all, some accustomed discharge had ceased; and Abdominal Walls of Women. 685 and in all the deposition of fat took place principally in the abdominal walls, and probably in the omentum and various tissues of the abdomen and pelvis, without materially implicating other portions of the body. It appears improbable that, in any or each of these three cases, the enlargement of the abdomen could have been merely an accidental concomitant, for it so promptly fol- lowed the cessation of the habitual discharge, and con- tinued to increase so regularly for a time, and yet came to a stand-still, or diminished, without any material aid from treatment. In addition to all this, when we con- sider, in this connection, the numerous recorded instances where, after frequently repeated venesections, individuals, although debilitated and almost exsanguine, still be- came corpulent; and when we observe, almost daily, patients who, after surgical operations for the removal of diseases accompanied by profuse suppurations, be- come very fat, although they may not regain their health and strength for months, it certainly seems more than a mere coincidence, and must bear the direct relation of cause and effect. _ > The so-called “ change of life,” that subtle change by which woman is unsexed, accompanied as it is by the often sudden cessation. of an habitual hemorrhage, seems to exercise some most important modifying influence upon nutrition, either for good or evil; and is the start- ing-point of various nervous and constitutional diseases more frequently than would be accounted for by the mere age of the individual. It is difficult to explain clearly why such discharges so modify the nutrition of a part, that the economy, after their final cessation, attempts to and Abdominal Walls of Women. 687 This condition diflers essentially from the so-called “spurious pregnancies,” or “phantom tumors,” so ably described by Simpson and others,-these being proba- bly due to uterine or ovarian excitement, which induces a state of excessive nervous mobility more or less allied with the condition called hysteria. The abdominal en- largement here, instead of being due to an absolute de- ' posit or growth, appears to be entirely under the con- trol of the nervous system. The mode of causation is explained in several difierent ways, and probably cer- tain cases may be properly accounted for by some one of the theories advanced, while in other instances the va- rious causes may merely play the part of factors. The views which have the sanction of the highest authori- ties are probably the following: (a) Arching forward of the lumbar portion of the spinal column, thus causing the abdomen to protrude; (I3) relaxation, from sym- pathetic irritation, of the muscular walls of the intes- tines and their distention with flatus; and finally, a firm tonic contraction of the diaphragm, forcing the ab- dominal viscera downwards and forwards. Certain it is, whichever of these be adopted,——and the last seems to be the more probable,——that complete anaesthesia will entirely dissipate the apparent tumor, and thus render the differential diagnosis positive. Of course these fatty deposits could not be mistaken for pregnancy where a thoroughly satisfactory exami- nation had been made; but a positive opinion could scarcely be given with safety where a physical explora- tion had been refused, or was otherwise rendered im- possible, if the increase in size had been gradual, and 688 Pepper on Adipose Deposits in the Omentum accompanied by the cessation of the menses, and by the nervous phenomena already alluded to, especially if the woman have been subjected to the risks of impregna- tion. Indeed, it is often exceedingly difficult to satisfy one’s self of the true nature of the case from the mere history, for not only do the various symptoms tend to confuse, but the positive assertion of the patient is also calculated to mislead, since women who are anxious for offspring, or who dread the occurrence of preg- nancy, are naturally often led to allow their hopes or fears to bias their judgment. As before said, a positive opinion cannot safely be given save after at least a most careful external examination, when the non-existence of the ordinary mammary changes, and of any defined uterine tumor, taken in connection with the sunken um- bilicus, and the entire absence of the usual auscultatory phenomena, ought to be sufficient. While, if it be pos- sible to obtain a vaginal exploration, the want of all the so well known signs of pregnancy. will still more positively negative the supposition; for we have, in those cases occurring towards the close of sexual life, senile changes commencing, the uterus being small, light, and atrophied, the vaginal portion of the cervix par- tially absorbed, and the whole organ carried high up in the pelvic cavity from its diminished weight, or, as has been stated, from shrinking of the ligaments, while the walls of the pelvis and tissues generally are padded with fat, and the abdominal parietes enormously thick- ened from a similar deposit. When, however, this adi- pose deposit occurs after the removal of some morbid condition, as in Case 11., the uterus will often still ‘and Abdominal Walls of Women. 689 show the results of the previously existing disease, and may become variously altered in shape, size, or consist- ence. It is not, however, in the differential diagnosis of pregnancy that the most serious difliculties present themselves, but in that of ascites, ovarian disease, and abdominal tumors generally. In ovarian disease we have, in addition to the almost characteristic appear- ance of the patient, a history, very frequently, of pain or discomfort experienced in one or otherovarian region before the appearance of the abdominal tumor; and very often the patients are able to define the mass clearly, and state that it first made its appearance in some one particular portion of the lower abdomen; at- tacks of localized or general peritonitis are also quite common during its growth, and the signs of pressure are very early manifested. These symptoms, taken in connection with the absence of increased embonpoint, and the evidences of seriously impaired health, are suf- ficiently characteristic. One source of error must, how- ever, be guarded against, namely, the fluctuation, which is often very distinct in these fatty accumulations, the wave being apparently’ freely transmitted ; but, by the ordinary precaution of depressing the median line of the abdomen, not only are the vibrations of the ab- dominal walls entirely done away with, but no interfe- rence with the transmission of the fluctuation will be produced if fluid be present. On vaginal examination in such cases, we find the uterus at first generally pushed forward and to one side, while the ovarian mass can often be distinctly localized by the ‘ various means 45 690 ‘P622967’ on Adipose Deposits in the Omentum within our reach. After the mass has increased in size still further, the detection of fluctuation through the roof of the‘ vagina, if the tumor be cystic, the increased displacement of the uterus, and the pressure signs al- ready alluded to, will fully clear up the case. Still, though apparently so readily distinguished, yet when, in addition to the adipose deposit in the abdominal walls, the omentum is loaded with fat, the diagnosis becomes much more obscure; indeed, instances are on record where the abdomen was opened in the expecta- tion of finding an ovarian tumor, and the mistake only discovered when the patient had been subjected to great mental anxiety and physical danger. Fibrous tumors of the uterus, and other tumors of the abdominal cavity, have each their respective symptoms, and can scarcely be mistaken, except in those instances where many of the signs are obscured by the presence , of ascites. Here, the uniform enlargement, the bulging flanks, the fluctuation, the entire dulness on percussion except over the floating intestine, the position of this dulness varying With the patient’s posture, the descent of the vaginal cul-de-sac, and the fluctuation detected from the vagina, when taken in connection with the positive symptoms of hepatic, ' renal, or other organic disease, suffice to render a diagnosis easy. I have seen one instance of a condition in which, at first sight, the patient presented many points of resem- blance to these cases of fatty deposition. The woman had borne many children and had reached the climac- teric period; her abdomen was very large, protuberant, and pendulous; she suffered from a great “sense of and Abdominal Walls of Women. 691 weakness,” and was unable to attend to her domestic duties. On careful examination, it was found that the recti abdominales were widely separated, and the stretch- ed linea alba formed one covering of an immense hernia, which allowed most of the intestines to escape outside of the ventral parietes proper. Here the gurgling of the intestines, the drum-like tympany over the tumor, and the well-defined edges of the recti sufliciently indi- cated the nature of the condition. The condition gen- erally requires only to be detected to be cured, the morbid phenomena being most frequently caused by the apprehension of some serious disease or the belief in the existence of pregnancy; and if the patient can be con- vinced of the groundlessness of her fears, it is generally all-sufiicient. A few cases,‘ however, present themselves where a modified diet scale, a diminished amount of fat- producing food, and the use of gentle and regulated pressure are indicated. With these exceptions, I believe such cases can be left to nature, with a conviction that, when the economy has become accustomed to work at lower pressure, either that there will be no further in crease, or even a positive diminution, in the deposit of adipose tissue. 692 Mandl on the Pathology and THE PATHOLOGY AND TREATMENT OF MEMBRANOUS DYS- MENORRHCEA. ——- BY DR. F. MANDL, Vienna. (Continued from page 423, Vol. ii.) THE treatment of d’ysmenorrhxa membranacea con- tains as yet, like its science, many unanswered ques- tions; for its therapeutical part has not yet been insti- tuted, as is evident from the history of our case, where we find that a malady, affecting a forbearing patient for years, defies the earnest exertions of trusted special- ists. The English gynecologists employ an energetic me- thod of treatment during the menopause, for the pur- pose of avoiding a relapse, and of removing simulta- neously the sterility. They recommend the useof the bromide and iodide of potass. of mercury cauterizations of the uterine cavity with the nitr. of silver, injections of tincture of iod., and other alterative remedies. The German school prefers, as much as possible, an indifferent medication. Tonics, especially the prepara- ' tions of iron, are advised; also local depletions before the appearance of the menses, both for the removal of the dysmenorrhoeal attack, and for the cure‘ of the mal- ady. In order to give in a few words to our readers an outline of the treatment at the present time, we quote the words of Scaneoni, who in his work, p. 294, says: “In order to reduce the above-described hyper- trophy, and to prevent the separation and expulsion of the mucous membrane, there has been urgently rec~ ‘Treatment of lllembranous Dysmenorrhoea. 693 ommended, in addition to the before-mentioned reme- dies, especially cauterization of the inner surfacebf th_eI uterus with the solid nitr. of silver stick, and injections of astringent liquids into the uterine cavity. We have used these means for months, but we were unable to- obtain a cure, while frequently the congestive symp- toms were increased. For the present, we restrict our- selves in such cases solely to the employment of the topical antiphlogistic treatment, which, if of no use, is at any rate reliable, and does no harm.” ‘ ;Now with special regard to our patient we had to deal, as said before, with an antrooersion of the uterus, with the monthly pseudo-membranous secretions, and with an intense consecutioe disturbance of the general health, showing itself’ under the most manifold forms of hysteria, hyperoesthesia, and hystralgia. We therefore tried as much as possible to conform CD1’ treatment to these complicated indications, and, we might confess, we encountered difiiculties which we could not entirely remove. In our patient the antro- _ version was so very decided that a large portion of di- rect and reflex neuroses, as well as the disturbances of the abdominal circulation, had to be ascribed to it. We tried to lessen this forward displacement of the uterus by a suitable pessary, which it was very difficult to do; as of those instruments in use neither the intra-uterine, nor the lever, nor the hard eccentric pessaries seemed to answer the purpose. We did not dare use Martin’s in- tra-uterine regulator, of boxwood and ivory, in this case, on account of the decided relaxation, yielding, and con- tinued painfulness of the accessible uterine portions, 694 Mandl on the Pathology and Hodge’s pessary hardly improved the dislocation. The eccentric hard pessaries were not tolerated. In the same way a “ oeintm'e hypogastq'igue,” employed on a former occasion, gave no relief whatever. In order to accomplish our object, we caused a funnel-shaped ring to be made of gutta-percha, the margins of which stretch like the brim- of a hat over an eccentric air pessary which encircles the ring. Such a pessary was intro- duced airless, and then extended by a pair of elastic bel- lows, which could be connected with the pessary by a small elastic tube. The instrument having been intro- duced easily, its broadest part was pushed against the sacrum and the cervix passed into the ring without difiiculty. This instrument lessened the dislocation de- cidedly, and was also well borne by the patient. The fundus of the womb, in its desire to incline forwards, raised the cervix backwards and upwards, thus fixing that portion of the pessary inserted between the cervix and posterior vaginal wall, requiring always a certain degree of force to remove it. We used this instrument for four weeks. The position of the womb was then improved so much that it did not bend completely for- ward until twenty-four hours after the removal of the pessary. One unpleasant circumstance we could not obviate in using this instrument, viz. : the bad odor it caused after six to eight days’ use. We employed after- wards Meyer’s simple caoutchouc rings, which also could be easily introduced. These rings were well borne by the patient, and improved the position of the uterus considerably, although not quite as well as the air pes- sary. The patient continued wearing the ring while 696 Mandl on the Pathology and in the different afiections of the mucous membrane. For this purpose the chlorate was, after. November 30th, 1868, introduced every other day into the uterine cavity in the solid state, by means of the salve applicator; in consequence of which we had occasion to report several interesting data occurring in the course of the dis- ease. The introduction of a remedial agent into'the uterine cavity, of whatever kind and nature it might be, is al- ways to be considered an important interference. Therefore, before we continue in the narration of our case, it will be proper to make afe’w remwrlcs 0n the in- troduction of medicinal substances, and thus to specify more in detail the method employed byvus, as the ap- plication of medicinal agents to the uterine mucous membrane in the shape of a crayon is very well known but not yet introduced into general use, and as the suc- cess of a method frequently depends on some slight and apparently insignificant cautions. The favorite and mostly used remedy, as Well as the most liked and preferred method, is the employment of the nitr. of silver. For this purpose the porte-caustique of Lallemand, K'z'w'isch, 0 Mart, and ScanzomT is used, of which that of 070mm’ ‘is, however, the most prac- tical. There is indeed no other remedy the use of which is so convenient or less void of evil consequences, which explains its extensive use. In those cases, there- fore, Where a slightly stimulating or alterative action is desired, as in superficial erosions of the cervix, or in very slight hemorrhagefrom the uterine mucous mem- brane, or in separations of epithelium, or spongy granu- Treaanent of Jd'embranous Dysmenorrhoea. 697 lations, as after an abortion, the application of the nitr. of silver is of excellent service. As soon, however, as the action of the cautery is intended to be deeper, or a stronger haemostatic effect appears to be necessary, the nitrate remains ineffectual, because after its introduc- tion it is immediately covered with an impervious layer of chemically altered mucus. In very numerous cases where nitr. of silver is applied to the uterine mucous —membrane we often observe intense pain and occasion- ally hemorrhages, and we were inclined to ascribe their cause to the remedy itself. We have, however, become convinced that this effect is not due to the action of the lunar caustic itself, but rather to the porte-caustique con- structed in the shape of a probe, by which we cannot avoid in spite of the greatest care to touch the fundus uteri, which causes very intense pains; even the hemor- rhages are not to be ascribed so much to the caustic as to the instruments used in its application, just as we observe it occasionally after the introduction of the ordinary probe. Ever since we introduced the nitrate of silver only just beyond the inner os, to leave it there, we have seen very little pain following its use. It took at times a couple of days until the piece of caustic left inside , the womb, and the chemically altered mucus with par- ticles of nitr. of silver were expelled. Among the most important methods to employ caustic remedies in the uterine cavity we count the intrauterine injections, and they take the first rank among the caustic, haemostatic, and other therapeutical applications; the best authori~ ties either praise them as being very efiectual or call attention to the dangers following the application. 698 Mandl on the Pathology and Most of the hand-books of gynecology speak of these dangers, and prescribe certain cautious procedures to be employed in order to avoid these accidents. Thus Soanzoni throws the liquid forcibly against the fundus uteri, in order to avoid in this manner its entrance into the tubes and to secure its free discharge. This is, how- ever, a very uncertain proceeding and difficult of execu- tion, since the uterus is very apt to contract around the syringe and thus to prevent the exit of the injected liquid. Creole’ called the attention of the forty-second meet- ing of German naturalists and physicians in Dresden, in 1868, to the dangers following with the different intra- uterine treatments. Dr. Maemiel, of Dresden, mentioned on this occasion the happy results obtained by intra-uterine in Prof. C’. Bra’an’s clinic. We did, however, not perceive any confirmation of his statements after listening to a lec- ture of Prof. Bpacm delivered at his clinic. The fol- lowing is a pés’ame' of Dr. Braim’s views on this subject :——- “Prof. (7. Braun declared that intra-uterine treatments were al- ways dangerous whenever the internal os had not been previously dilated. The danger consisted in the constriction of the os inter- num around the internal canula, in consequence‘ of which the liquid could be easily passed into the tubes and the peritoneal cavity, giving rise to spasmodic pains and circumscribed peritonitis, which had often been taken for simple colic, or even to fatal peritonitis, ‘We found that the mucous membrane of the uterus would tolerate cauterization better than that of the vagina, while a drop of pure warm water injected into the tubes or the peritonaeum was fol- lowed by a very painful and violent reaction. With the greatest care which We observed when using the small intra-uterine syringe, Treatment of llfembranous Dgsmenorrhoea. 699 even two or three drops of a neutral liquid injected over the necessary amount were sufficient to produce violent reaction. Therefore Dr. Braun cannot speak favorably of intrauterine in- jections; he therefore recommends to proceed with the greatest care during the application.” Without venturing to compare our 'own experience with those who command such an extensive material of observation, we must confess that a few accidents have made us very careful in the use of intrauterine in- jections. We recollect a case that occurred under the care of Dr. Vrilcschilc ,' a solution of nitr. of silver was injected into the uterus of a patient suffering from menorrhagia, violent pains occurred after the first injec- tion, and the patient died with symptoms of intense in- flammation, and a post-mortem examination showed the existence of purulent peritonitis. In another case we injected a weak solution of tannin, on account of chronic uterine blenorrhoea, by means of a “ soude a double cou- rant.” The patient, a young healthy woman, became suddenly deathly pale, and was seized with abdominal pains; this condition lasted for ten to twelve hours, and terminated without any disastrous sequelae after a 'week’s sickness. We have made no further frequent attempts with intra-uterine injections, since we have observed on several occasions severe uterine colic after their application, and it is our general impression that ‘the young practitioner cannot be careful enough in their application, since they are followed occasionally by cellulitis, peritonitis, metritis, and endometritis. The former remarks are, however, not intended to deny all therapeutical value of this method of treat- ment. The syringe of Prof. C’. Rraun, a modification 700 Mandi 0n the Pathology and of Prcwatz’s instrument for intra-uterine injections, can be highly recommended, and has the decided advantage that the liquid is rather pressed in, drop by drop, than injected, and that with proper care a sufficient time re- mains for its discharge. In a woman who has passed through several confine- ments, whose internal orifice is sufficiently open, and the uterine mucous membrane of whom is secreting pro- fusely, we will certainly find a great tolerance for ap- plications of a mechanical nature. In cases of this kind a number of injections can be made with Prof. Brann’s syringe without producing any evil consequences. It is, however, different with flexions of a high degree, or in cases where the uterus has never been pregnant, and is as yet in the virgin condition. Under such circumstan- ces, the canula of the syringe passes through the cervix with a certain amount of resistance, the walls of the uterus, as well as the inner os, are apt to contract from the unusual irritation, and the liquid injected is easily forced against the tubes, and the accidents mentioned above are easily. produced. Sims has abandoned entirely injections into the uterine cavity, because he has violent and ‘alarming attacks of colic follow the injection of a few drops of an indifferent liquid; of late, however, he again employs them after dilating the inner os by means of sponge tents, according to Dr. Sewage, in order to permit the injected liquid to be thoroughly discharged. ' Prof. Sigmund published in the year 1853 a paper on the treatment of blenorrhoea and pyorrhoea by the ap- plication of caustic remedies to the inner walls of the 702 Mandl on the Pathology and uterus; the free evacuation of the injected liquid is to a certain degree a safeguard against its passageinto the tubes, and it has therefore a certain value under similar circumstances. Among the methods usually employed, the one advo- cated by Becheoer for the cauterization of the cervical canal we have found to be of great value for a certain number of cases. To make these caustic applications we employ Ditel’s porte-remedes, constructed by Mr. Leiter. This instru- ‘ ment consists of a canula made of hard rubber or silver, which contains a mandarin, the upper pointed end of which reaches beyond the open mouth. We have modified this instrument for gynecological purposes by giving it the shape of a uterine sound, and providing it with a protruding edge 1%- inch below the upper end. Thus we secured its passage into the cavity beyond a certain limit, thus keeping the fundus uteri from being touched by the instrument, which is very painful and gives rise to hemorrhages. The remedy to be employed is passed into the upper end of the canula in solid form, and about 2 inches in length, whereupon the instrument is introduced into the canal, and the medicated stick pushed into the uterine cavity by a forward movement of the guide contained within the canula. This method of application has several advantages: it is applicable for those cases where the remedy has to be used repeatedly; the dose of the remedy can be well defined and modified according to circumstances; it can be thoroughly applied to the mucous membrane of the uterus, because it remains in a more prolonged con- Treaanent of lllembranous Dgsmenorrhcea. 7 03 tact with the same than injected liquids, so that caustic and haemostatic remedies are made to act more intensely, and harder substances have more time to absorb liquid for their solution, for developing their resorbing and alterative influence on the mucous membrane. Every medicine which is applicable to a sensitive mucous membrane can be employed in this manner. We have use of nitr. argenti, tannin, kali chlor., perchlor. ferri, praecipit. rubr., sulph. ferri, sulph. cupri, etc. With many of these substances, such as perchlor. ferri, kali chlor., it is diflicult to transform them into a solid mass; the best means of accomplishing it is the ad- dition of glycerine, amylum, or tragacanth. The sticks from %—1 inch in length. It is certainly of impor- tance even in employing this method to ascertain before- hand the amount of irritability of the uterus. The first application contained only small doses of medicine. In ‘two cases of hemorrhage which lasted three to four years, and in which nothing but a spongy condition of the mucous membrane could be found, three applica- tions of solidified ferrum perchlorat. sufliced to stop the hemorrhage. The application of this medicine produced pains for twelve hours, which were diminished by the use of cold applications and injections; after twenty- four hours a profuse mucous secretion was established, consisting principally of iron and blood corpuscles, which lasted for four days. The next menstruation was regular and less profuse, the applications were repeated twice be- fore the expected catamenia, and each time with the same efiect. With the third application the excessive flooding had ceased. The patient, a carpenter’s wife, 7 O4 ' ' ' Mandi 0n the ‘Pathology and. has been healthy ever since. Tannin and sulph. cupri are also apt to cause severe pains, lasting occasionally for twenty-four hours, when these remedies are em- ployed in large (5 gr.) doses; these accidents could, however, always be controlled by the use of cold appli- cations and small doses of morph. By the use of tan- . nin a very obstinate uterine leucorrhoea, which had re- sisted all kinds of treatment for ten years, was perfectly cured after two weekly applications employed for six months. We mentioned above, that from the 30th November we employed in our patient a stick of kali chlor. every other day; the applications were borne very well; they caused very little pain immediately after their use; oc- casionally, however, a certain amount of pain was expe- rienced a few hours later, a plug introduced immediately afterwards was removed eight hours later, and it was vfound to be moistened, of a dark-brown color, covered with black points and streaks. These black spots were due to the influence of the kali chlor. upon the particles of blood mixed with the secretion; this admixture of blood we ascribed to the irritation produced by the in- troduction of the stick. ‘During an application imme- diately before the occurrence of menstruation we were able to verify the view just mentioned, viz. : the altera- tion of the coloring substance of the blood into a brownish or black substance by the contact with kali chlor., since we found the plug covered very exten- sively with black masses. We further ascertained this fact by experimenting with kali chlor. on blood drawn from the body. After a few injections with lukewarm Treatment of llfembran'ous Dysmenorrhoea. 705 water, part of the kali chlor. came away during the first ‘twelve hours with the water in small brittle or liquefied particles; frequently, however, the entire amount was absorbed. The first four or five applications produced no further efiect, and it was not until the sixth day the patient complained of pretty severe bearing-down pains and dysuria; when finally, twenty-four hours after the sixth application, suddenly four or five rolled-up, iso- lated yellowish-red membranous shreds, half a centim. wide, one and a half centim. thick, five or six centim. long, were discharged without being accompanied by the slightest hemorrhage. The nervous excitement was naturally very intense. The microscopical examination showed amylon corpus- cles derived from the stick. , Some of these shreds were handed to Professor Rohitansky for examination. ~ 8. Statement of Prof Roleitanslty. “The presence of starch corpuscles and other particles of a vegetable character is explained : they are derived from the mat- ter used in preparing the kali chlor. paste ;~ the membranous shreds must be considered to be of an epithelial (animal) nature; they consist of slender polygonal epithelial gells arranged in several layers. They are no doubt a production of the uterine mucous membrane regenerated after the discharge of the decidua. In view of the rare occurrence of such cases, it is of importance that I remember now to, have examined some time ago uterine discharges out of all connection ‘with conception or menstruation, which consisted of a similar epithelial formation. The con- siderable size, or rather length, of the shreds is undoubtedly ow- ing to an enlargement of the uterine cavity ; considering the ex- cessive menstrual formative impetus of the uterus in question, I am inclined to believe that this extra-menstrual formation must be 46 706 Mandl on the Pathology ‘and caused by the unusual irritation. The. pigment found upon the shreds must be explained by the effect of the kali chlor. upon small excoriations of the mucous membrane.” The occurrence of these discharges encouraged us to continue the applications, which was done; but the next application was followed again by severe pains, which lasted for two days, until a profuse mucous secretion from the uterus was established ; the secretion was of a dark yellow hue, odorless, and lasted for two days, whereupon menstruation set in- six days before it was expected. Rohitansky examined this discharge, and made the following statement :~--' 9. “I have examined the stains in the pieces of cloth sent to me. Tacre was no trace of pus, but particles which resembled those observed in the membranous shreds, distorted, broken epithelial cells; and, further, a large amount of fat in small and large globules” (the fat was derived from suppositories containing butyr. cacao). The next menstruation was copious, lasting eight days. During the first days blood coagula escaped, but no trace of a membrane could he discovered. During this ‘period 8 gr. of iod. potass. were adminis- tered daily by the mouth; the patient also took fre- quently a bath containing 1 oz. of kali caust. The pathological product, the membrane, not appearing during menstruation, encouraged us to continue this method of treatment, and we recommenced the local application two days after the cessation of the menses. The reaction following the first three introductions has already been mentioned; the fourth application again Treatment 0y“ .Membranous Dysmenorrhcea. 707 caused greater pain, restlessness, etc., after twenty-four hours, and was followed by the expulsion of a bag-like rolled/up membrane, thefundus of which was of a dark- brown coler; in addition to this, another membranous lamp was found on the tampon, introduced close to the os, a few hours after the aboveanentioned membrane had come away, the escape of which the patient no- ticed on account of previous uterine contractions. We were indeed surprised to find in these extra-menstrual excretions a newly developing decidua. As the time, eight or nine days, was too short to suppose an already regenerated uterine mucous membrane, we again re- quested Prof. Rolec'mnsk'g/ to make a thorough examina- tion of this formation, the result of which is given in the following note :—- 10. “The specimens sent me December 30th consist of two red-brownish lumps, one of which, on being unrolled, proves to be a perforated villous membrane resembling the bicorned roof of the uterine cavity; the other forms a conical membranous cap, to the roof of which is attached a grayish-white striated mu- cous mass. This latter is indeed thick mucus infiltrated with free granular detritus, on some places with a brown-yellowish pigment, and finally with free nuclei, which are in some spots largely accumulated, forming those white striee. There are also found a few epithelial cylinders without appreciable fimbriae; and finally some vegetable fibres, derived probably from linen (lint tampon). The rusty-colored membranes are, on that sur- face which is covered with mucus, more whitish, rather smooth, but still showing moist grooves in close juxtaposition. The other surface appears like a honeycomb, consisting of shallow open cells. These membranes consist of epithelial cylinders im- bibed from pigment, without appreciable fimbriae. Numerous cells contain two nuclei)’, Thus we had an exfoliation of the epithelial liningiof 708 Mandl on the Pathology and the uterus, which, if we might be allowed to account for the loss of the fimbriae by maceration, consists of the normal uterine epithelium. ' We now tried to ascertain whether, if the expulsion of an extra-menstrual membrane had taken place, we had also interfered with the menstrual proliferations; For this purpose the introduction of kali chlor. was sus- pended. On the 12th of January, however, menstrua- tion, with all the symptoms already mentioned, ensued, with an eapnlsion of several membranous shreds ,' five larger membranes which did not fit each other, a few smaller ones, as well as some blood coagula of the size of a hazel-nut, came away. On the fourth day intra- menstrual pause lasting for two days, followed by a renewed loss of blood for three days. The interval between the expulsion of the extra-menstrual membrane and the appearance of the catamenia, about ~ fourteen days, sufi‘iced to bring about the menstrual separation of a fully developed membrane; the structure was the same as on former occasions; in confirmation of which, we again quote Professor Rohitanshy, of whom I re- ceived the following lines :- 11. “ The pieces lately sent me consist of two distinct substances; first, membranous shreds: these are mucous membranes of the uterus in a state of menstrual development; the inner surface lining the uterine cavity shows the characteristic little grooves, i.e., the ostica of the prolonged uterine glands. The outer sur- face is rough, of a villous appearance. This is caused by real villous-like attachments, which, however, are not the villi of a chorion, but the detached glandular tubes or portions separated from a- layer of mucous membrane still remaining united with the uterus. There are, secondly, clotted and band-like blood coagula. There has consequently again begun the original pro- Treatment of lllembranous Dysmenorrhcea. 709 cess of an expulsion of a menstrual decidua proper, or of a uterine mucous membrane developed into a decidua in tote, with the exception of the deepest layer retained within the uterus. ‘ “ If nothing else came away but the pieces sent me, there must be still considerable portions of the inner surface from which no membrane was separated.” >After this period we began to introduce the kali chlor. regularly every third day. We could only make the introduction four times; no further extra-menstrual membranous secretions took place; the applications were again followed by the already-mentioned copious secretion from the uterine cavity, containing the mor- phological elements described by Rolcitanslty. After the fourth application the sensitiveness of the uterus and its appendages became greater; the discharge very copious. Already, on January 29th, menstruation en- sued, the pain diminishing at the same time; it was very profuse, requiring a change of linen seven or eight times daily; in the first day expulsion of several blood coagula varying in size from a bean to that of a hazel-nut. ‘ The flow of blood weakened the patient very much, necessitating the employment of astringents. Cold injections, compresses, and acids were ordered; in this manner the bleeding was diminished, yet menstrua- tion continued till the tenth day. No membrane came away. ' The loss of blood naturally weakened the pa- tient considerably. She was in an anaemic condition, but recovered slowly. After another consultation, however, it was resolved to continue with the same treatment, as we'desired especially to prevent the for- mation of membranes, and were led to suppose that the excessive menstrual flow could be regulated by itself or 710 Mandl on the Pathology and by a modification of the treatment. After February 9th the introduction of kali chlor. was resumed, em- ploying it, acording to the reaction, daily or every two days. Its effect gave us this time more satisfaction. There was no considerable, even but a scanty, discharge. The patient improved greatly, the nervous symptoms were lessened‘, menstruation began on February 25th, only two days before the normal time, the flow being still copious but‘ not p1:ofuse,only'two or three blood coagula of the size of a pea; the bleeding; did not increase till on the fourth day, and; ceased on the ninth, without an intra-menstrual pause. ' Of membranous separations only traces of very slen- * der translucent fragments, two or three lines broad, could be discovered, which did not present the well-known structure of the decid-ua, and were recognized as flat translucent epithelial layers. Therewas no reason for discontinuing the present method of treatment. Imme- diatel'y after the cessation of the menses we resumed the introduction of the kali chlor. every other day, with the same favorable result as. in the previous month. The last applications were made daily, producing neither increased secretion nor pain. The menses appeared March 20th.. In the first days there- were but bloody spots; after the fourth day-again a copious, but, in com- parison to the last month, moderate flow; very small blood coagula; and complete. cessation on. the tenth day. The actual menstrual flow ceased on the seventh day. There were, however, in the last days two or three red- dish-colored spots visible. During menstruation iod. of sod. was administered, and kali baths temporarily 712 Mandl on the Pathology and 12. Letter of Prof. Scanzoni. “Having examined Mrs. T. at the end of July, I find that she suffers from so-called dysmenorrhoea membranacea; she is in an anaemic condition, with symptoms of a disturbance of the circulation of the abdominal and pelvic vessels (plethora abdom- inalis). The uterus was ' moderately anteverted, its volume somewhat enlarged in consequence of a hyperplasia of its walls; at the orifice I observed a superficial egg-shaped catarrhal erosion. The patient remained only two days in Wuerzburg, and not at the time of menstruation, so that I have been unable to form an opinion of the membranes discharged with the menstrual flow, yet I do not at all doubt the correctness of the diagnosis hereto- fore made. “I have never succeeded in obtaining a cure of the so-called dysmenorrhoea membranacea by means of medical treatment, and for this reason do not promise a favorable result in this case. A material advantage, however, might be attained by improving the condition of the blood, and by regulating the apparently disturbed circulation. For this purpose I also recommended the use of the waters of Kissingen, after which a ‘ cure de resins’ of several weeks would be useful. During the winter I should advise the employment of iron, with mild laxatives, in addition to the symptomatic treatment of the painful dysmenorrhoidal symptoms. “ CASTLE ZIMELBERG, OBERBAYERN, August 11th, 1868.” The patient, following the advice, went to Kissingen, where she remained for two months. In the beginning she bore the treatment very well, the catamenia was regular, without a decidual discharge. The same happened the second month with regard to the period and the decidita menstmtalis ,' the patient, however, was very much weak- ened from diarrhoea and hemorrhoidal bleeding, the nervous symptoms increased, and she returned to Vienna, where she soon recovered. Here-the next menstruation took place, with the discharge of a decidual membrane. Treatment of lllembranous Dysmenorrhcea. 713 Immediately after the cessation of the menses the kali chlor. was again introduced. The next menstrua- tion occurred without a decidual discharge; the patient recovered, and soon left for Nice, still using the kali chlor. suppositories. Dr. Rehberger informed us, December 14th, that the patient was unable to wear Meyer’s pessary any longer, which he consequently removed; no membrane came away during menstruation. The patient after- wards informed us that at the appearance of the next menses a decidual membrane was again discharged, with all the concomitant symptoms. We now close the report of the history ‘of our case, ' remarking that we, perhaps, are justified inconsidering it an improvement; that the usually monthly mem- branous discharges appeared but twice during the ten months while we had charge of the case; we might _ also consider the kali chlor. an excellent palliative in this afiection, as its local application to the uterine mu- cous membrane prevented the membranous formation, assisted, perhaps, by the improvement of the uterine dislocation. This exquisite and instructive case induced its publi- cation, and we shall now refer to the positive facts that were derived from it with regard to the knowledge of this disease. In the works quoted in the beginning of this essay, four different views may be found :-- , I. That which denies the eaistence of a decidual afea tion of the uterine mucous membrane, or reduces it to 714 Mandl on the Pathology and an even monthly recurring abortus, caused by an early destruction of the germ or foetus. . The facts reported in our cause certainly refute this theory. The absolutely necessary condition for concep- tion, cohabitation, has been excluded, beyond all doubt; during our course of treatment, the continued introduc- tion of tampons, pessaries, etc., rendered cohabitation impossible; besides, the husband of the patient was ab- sent. Yet we had decidual discharges in November and February, and extra-menstrual membranous ex- foliations in January and February. After the de- cidual discharge had ceased four months, consequent to the application of medicines, we had again, in June, the characteristic expulsion of a fully developed membrane, which was absent, however, during the two months the patient soj ourned with her husband, and reappeared during the subsequent abstinence. ' The possibility‘ of supposing an abortus lies very _ near, and consequently many tried to ascertain the true facts about it. Already Denmari refers to this circum- stance, saying: “As I have never observed this mem- brane in unmarried women, I began doubting whether it was not caused by a previous conception. But I have since obtained positive and undeniable proof that this membrane can originate without any previous co- habitation, and that the uterus of some women has the peculiarity of forming this membrane during or be- tween the period. It seems to be necessary to establish the truth of this circumstance, as otherwise the appear ance of this membrane may cause false and unjust opinions.” Treatment of lllemhranous Dysmenorrhcea. 7 '15 If the cases of decidual disease reported as having happened in girls do not exclude the above-mentioned suspicion, we quote, in proof of the assertion that de- cidual proliferations of the mucous membrane occur during menstruation even in virgins, the words of Hyrtl, who, in the tenth edition of his work on Descriptive Anatomy, page 746, says: “The formation of a de- cidua cannot be ascribed to a fecundation of the ovum alone; I found in the womb of two girls who died suddenly during menstruation, and one of whom pos- sessed a perfect hymen, the uterine mucous membrane thickened, spongy, and enlarged, in fact resembling a beginning decidua.” The recognition of the decidual aflectio-n is also of importance in a forensic point of m'ew. It might be necessary to decide in court whether a particular case was one of decidua menstrualis or preg- nancy. Such a case would offer many difiiculties in its anatomo-histological relations. According to the present state of science there is. almost no positive symptoms for differential diagnosis. . Although the decidua catamenialis is supposed to be less thick, more brittle, and of a more dirty-grayish color than the decidua gravida, this is not always the case, and, consequently, no proper symptom for difier- entiation. A decidua menstrualis can be assumedonly when there is no trace of .a chorion, reflex scrotina, am- nion, or other foetal formations. The embryonic forma- tions may, however, be absent, and yet a decidua gravi- da may be found. The cotyledons described by Mont- gomery as characteristic for the decidua gravida, are a 716 Mandl on the Pathology and positive sign for the decidua gravida; their absence, however, does not always exclude the possibility of a Hunterian membrane. Under such circumstance the physician could only be guided by an exact Ernirnng, elucidation, and a critical view of the case. It cannot be supposed that, morbid causes being pre- sent, only a single menstrual exfoliation of the mucous membrane would take place ; in most cases probably a membrane or membranous pieces are discharged nearly every month, and either the women recollect that such discharges have frequently taken place, or they can be soon expected, in spite of total abstinence from cohabi- tation. II. That theory which supposes the cause of this disease to be a considerable congestion to the ovaries or uterus, or a great disturbance of the venous circulation as an essential condition. Thus already Siebold places dysmenorrhoea mem- branacea among the so-called plethora abdominalis, and in most of the new works on gynecology decidual dis- ease of the uterine mucous membrane is described with the congestive dysmenorrhoe-as, these being found fre- quently in a congestive state, hemorrhoidal dilatations and hemorrhages, with this disease. These congestive symptoms seem, however, to be sequelae of the disloca- tions so frequently accompanying the d ysmenorrhoeal membrane. - It is known that versions always cause venous con- gestion and stasis, and it seems that a protracted dura.- tion of this disease produces uterine dislocations. Thus Oldham observed retroversion of the uterus with suchv Treatment of Membranous Dysmenorrhcea. 717 a congestion of the ovarium that, at the menstrual pe- riod, the organ could be felt through the abdominal walls, and he believes to have found in retroversion of the uterus a symptom of difierentiation from the first weeks of pregnancy. _ In our case there was a strongly anteverted uterus, neither could the ovaries be felt through the very thin abdominal walls; we also found in another case ante- version without swelling of the ovaries. This proves that dysmenorrhoea membranacea may exist with either antro- or retroversion, as well as with or without ovarian tumefaction. . III. That theory which, according to Simson, believes the process going on in decidual disease "of the uterine mucous membrane to be physiological, assuming only a hyperplastic action of the normal functions ,' for this reason, because at every menstruation the epithelium of the inner uterine surface is undoubtedly separated, forming a part of the menstrual blood. On this ac- count the great membranous epithelial proliferations were explained by an increase of the physiological ute- rine functions, which explanation seems to be the more justified as these membranous exfoliations usually occur during the catamenial period. In order to prevent a misconstruction of the expres- sion physiological process, we may remark that on one side processes occurring in an unusual manner and un- der unusual circumstances cannot be well designated as purely physiological ,' on the ' other side, no satisfac- tory explanation can be given for the symptoms accom- panying dysmenorrhoea membranacea by the designation 718 ildandl on the Pathology and ' of an intensified physiological process, or by the simple increase of vitality recurring monthly in the reproduc- tive sphere of the female genitals. According to our opinion there must be important anomalies of nutrition in order to cause the sterility, the important consecutive disturbance of local and general nutrition, and the monthly expulsion of the thickened epithelial lining of the uterine mucous mem- brane and utricular glands. We therefore incline to the IV. theory, that iriflammation is the cause the memhremou-s proliferation. Although Andral’s idea does not seem to be without all reason, to omit the word inflammation altogether from the medical no- menclature, as it is often arbitrarily used, we are not yet able to substitute another more suitable expres- sion for certain disturbances of nutrition. In the sense of those pathologists believing inflammation to be exu- dation with puriform and other changes, no starting- point can be found for this process. But if in gyne- cology only those processes having the above describ- ed results were to be called inflammation, the whole theory of chronic inflammation and infarct of the uterus had to be given up. At the present time, how- ever, the term inflammation is applied to those diseases of the uterus in which are found changes in the struc- ture. of the organ, thickening, hypertrophy, increase in the supply of blood, etc. In this sense of the term the menstrual decidual disease is especially of a chronic inflammatory character on account of the thickening proliferation, etc. Although Rhaisch, Denman, and Treatment of lll‘embranous Dgsmenorrh-oea. 719 Montgomery recognized the similarity of t the decidua gravida and menstrualis, yet they assumed an inflamma- tory cause, the decidua menstrualis being, however, till Simon, confounded with crupous and other pseudo- membranous products. These membranes, however, consist, as has been explained sufficiently, only of the epithelial covering of the uterine mucous membrane, and Theitz defines them most characteristically, in his letter N o. 6, with the words: “ Theg are pieces ‘consist- ing of the epithelial covering of the inner uterine mucous membrane and their granular prolongations. Perma- nent elements or pieces of pathological growths of tissue have not been found in the presented specimens.77 We add to the well-known menstrual exfoliations of the uterine mucous membrane the extra-menstrual epithelial separations, observed by us and examined by Dr. Rolci- tan-shy, of which no record is to be found in the medical literature,they being exactly of the same structure as the menstrual formations. They could not be derived from former menstrual periods, as we found membranes previous and subsequent to that catamenial discharge. According to our opinion, and according to the pre- sent state of medical science, a sufiicient explanation of these symptoms and products can only be found in an inflammatory process. Both anatomical _ and clinical facts agree with this oiew. If we do not take into consideration those cases in which this disease has been observed accompanied by chronic metritis, induration and ulceration of the neck to which the former could possibly have been accessory, a mucous membrane in a state of menstrual prolifera- 7 20 Mandl on the Pathology and tion cannot be distinguished from one of an inflamma- tory origin. The more or less tumefied, hyperaemic surface, the strong vascular injection around the single glands, the more profuse secretion of the latter, separa- tion of epithelium, and an easily bleeding surface streak- ed by small extravasations of blood, are characteristic for both the menstrual and inflammatory swelling of the mucous membrane. Even if the menstrual process is not identical with the inflammatory, yet we must find in the decidual disease of the uterine mucous membrane the tumefaction analogous to inflammation certainly in a still higher degree. Such is the anatomical obser- vation in post-mortem examinations in which the mu- cous membrane during menstruation was in a state of decidual proliferation, and the extra-menstrual growths can only be based upon the same anatomical facts. Under such circumstances the usual, although increas- ed menstrual congestion, does not suffice as an explana- tion, neither could a sufficient cause be found in the monthly ovulation for the extra-menstrual decidual membranes. The menstrual congestion can only increase the already present proliferous cell-formation ; the latter, by compressing the capillary system, may render difficult the return of the blood; and if the bleeding is once established, the already formed membrane becomes a foreign body, and is expelled by means of uterine con- tractions. The large epithelial proliferations show plainly an affection of the utricular glands. The longer the dis- ease lasts the larger and broader are the sequestered epithelial ducts, thus proving the enlargement of the 7 22 Mandl on the Pathology and speak of an endometritis ” in such a manner that indeed a chronic endometritis, or rather, to speak more cor- rectly, an inflammation of the utricular glands ramify- ing so deeply in the uterine tissue, or at least an inflam- mation of the matria, may be the cause of such mem- branous proliferations. If the denomination “ deoidaa mertstraalis ” is proper for this membrane as such, the name dysmeriorrhtea- memhranacea corresponds to the painful menstruation with membranous exfoliations, we might characterize our view not inaptly with the designation “ endomew'itis epithelialis.” This form of ‘fragmentary separation of epithelium is not found solitary, for we also meet with the same process in the vagina. Thus Tyler Smith, in his work on Leucorrhoea, directs attention to this kind of epithelial exfoliation, and in our patient, too, epithelial masses, connected in large shreds, were repeatedly discharged from the vagina, which, after having been placed in water, were recognized as flat translucent epithelial layers. Dr. Scheitbaaer had also examined several epithelial lumps, of the size of a hazel-nut, discharged from the vagina of another patient, which were found to be nothing but vaginal pavement epithelium. Sev~ eral authors have lately pronounced in favor of inflam- mation: see Hewit in his work on Diseases of Women, 1869, pages 55 and 332. If we now consider briefly what has been said about this disease, we come to the following conclusions :-— 1. Dysme/aorrhoea memhranacea, clecid/aa menstraalis, endometritis epithelialis is to be considered'an import- ant disease (morbus sui generis). Treatment of Jlfembranous Dysmenorrhtea. 723 2. The pathognomonic chwacter of the disease is the discharge of a formation resembling 'Hunter’s mem- brane during, and, at the latest, forty-eight hours after menstruation takes place. 3. Under certain circumstances extra-menstrual mem- branes of the same structure are discharged. 4. These membranes are of different size and forma- tion, and in typical cases their configuration resembles the lining of the womb. - 5. These membranes consist only of epithelium of the uterine mucous membrane and the prolonged and torn out utricular glands, which at first sight resemble closely the villi of the chorion. 6. Both menstrual and eatra-menstrual epithelial membranes are developed during the menopause in con- sequence of a chronic inflammation. 7. This disease produces, after a longer duration, retro- and anteoersion, congestion, and disturbances of circu- lation of the uterus, and finally considerable disturb- ances of the system in general. _ 8. Sterility is found in all women suffering from this affection. 9. The etiology is entirely unknown ; this, as well as the pathology and treatment, require farther researches- in a pathogenetic and clinical point of view. 10. The kali chlor., applied directly to ‘the uterine mucous membrane,~ seems to exercise a palliative inter- ference with the formation of the membranes. 11. A cure of the general affection can only be efiected by‘ the removal of the local symptoms. 7 24 ‘ Correspondence. CORRESPONDENCE. BY A. Jxcom, M.D. (Continued from page 532, Vol. II.) DR. J. LEDERER (Vienna) : Observations on the hereditary dis- eases of infancy._--From a practical point of view, they are: 1st, hereditary affections of the system; 2d, of single organs. The first class (syphilis, rachitis, scrofula, tuberculosis) are more easily noticed by the parents than the second, as they are more frequent and more dangerous. Their transmission from the mother is explained by intra- or extra-uteric nutrition; from the father by the semen, or by a similarity in the constituents or disposition of the blood. Thus a syphilitic father may have a syphilitic child without the mother being syphilitic, and robust and healthy parents may have scrofulous or rachitical children, provided one of them was scrofulous or rachitical when young. Of the diseases mentioned above, syphilis is the rarest, because it is mostly transmitted from the father, and even the poor will try to get cured of their syphilis. The diseased infants will fre- quently perish, because of the danger to wet-nurses employed. Internal tuberculosis is not frequent; external caseous deposits very frequent. Rachitis is a frequent occurrence, resulting from rachitis, scrofula, and tuberculosis or old age in the pa- rent. If there is scrofula or tuberculosis in the parent, there may be scrofula in one, tuberculosis in the other child. .Scrofula and rhachitis rarely in the same child. Scrofula is morefrequent than any other affection, seldom in all of the children; not unfrequently the oldest in a family are affected. Has seen no scrofula depending on syphilis of the parent. Syphilis appears earlier than any other, especially on skin and intestinal mucous membrane. Rachitis in the cranial bones is also observed in early infancy; scrofula is apt to yield early de- posits in the skin, like syphilis; tubercular granulations in the brain are rarely observed before the end of the first year. Uorrespondence. 7 25 Symptoms of chlorosis are seen long before the time of puberty in the daughters of formerly chlorotic mothers. Of the neuro- ses, spasmus glottidis may be considered as indirectly heredi- tary because of its rachitical origin ; nervous irritability is trans- mitted from hysteria. The second class contains inflammation and hypertrophy of the tonsils. Pneumonia and bronchitis are frequent in children of tuberculous parents. Chronic catarrh and atony of the intestinal tract are eminently hereditary. The transmission of faculties of the mind, of singing, etc., is ex- plained by a similar structure of the brain, the larynx, etc. The likeness of external organs in parents and children is often remarkable. Anomalies are frequently transmitted, thus macro~ cephalus and strabismus. Thus internal organs of the child are similar to those of the parents. Noller mentions arthritis deformans amongst the hereditary diseases; Seydewitz (London) some affections of the eye. Ebert asserts the identity of scrofula and tuberculosis; Stefier and Flesch protest against such identity. Jacobi and Hoppe try to prove that syphilis in the parents will not always appear in the child as syphilis, but in one of the other forms of grave disor- ders of nutrition. Schuller (Vienna): On local treatment of diphtheria.--Diph- theria and Group ought to be considered as‘ affections with marked clinical differences. Rejects the application of nitrate of silver in diphtheria, both of the pharynx and the eyelids. Has frequently found that a diphtheritic deposit disappears later when cauterized with nitrate of silver than when not in- terfered with, and that neither the reproduction nor the spread- ing of the deposit is prevented by the solid stick. Applica- tions of concentrated liquor sesquichloridi ferri exhibit no bet- ter results. Many authors consider such applications as directly injurious. Recommends strict cleanliness and tinct. opii. All the members present coincide with the above views; Cohen, Ebert, Stiebel, recommend ice and solutions of chlorate of potassa 726 Transactions of the Philadelphia as local remedies; 'Rinecher alcohol, chloracetic acid, and h yper- manganate of potassa; Baumler (London), carbolic acid. Prof. Rinecker : On encephalitis congenita interstitialis.—This affection, which has been described first by Virchow, has been found by R. in all infants who died of marasmus in the first six weeks of life, although brain symptoms were absent. The dis- ease appears to be related to physiological processes. May be that experiments made on starving young animals would yield instructive results. (T o be continued.) TRANSACTIONS ,oF THE ‘PHILADELPHIA’ OBSTETRICAL SOCIETY. -_u_-_ REPORTED BY GEORGE PEPPER, M.D., SECRETARY. MEETING OF OCTOBER 7TH, 1869. DR. F. G. SMITH, PRESIDENT, IN THE CHAIR. CASE OF DIFFICULT LABOR. DR. G. PEPPER related the history of a case of difficult labor as follows: Mrs. B-——, set. 35, of a strumous diathesis, was subject as a young. girl to frequent attacks of chronic diarrhoea; had disease of bones of left leg, and a number of chronic glan- dular abscesses; married about eighteen months ago, and mis- carried a few months afterwards, hut conceived again before menstruation had become regularly established. Dr. P. was engaged to attend her in her confinement, which was expected about the middle of July, 1869. That period having passed without any symptoms of . approaching labor, she was examined per vaginam, and the following condition found to exist: The uterus was enlarged to about the size of an eighth month preg nancy; the cervix not obliterated, but extensively softened ; the uterus apparently held its normal relation in the abdominal cav- ity, but the plane of the superior strait of the pelvis made such an acute angle with the spinal column that’ the os uteri rested above the pubic symphysis. The capacity of the pelvis rather below the normal, but not sufficiently so to warrant the induction of Obstetrical stain. 727 premature labor. She progressed favorably on the whole (though she at times suffered from marked symptoms of pressure, as oedema of feet and legs, hemorrhoids, &c.), and fell in labor Sep. 27, 1869. The first pains were feeble and irregular, and for some hours seemed to distress her but little; but as they in- creased in intensity she became almost maniacal, screaming and throwing herself about in the wildest manner. She began to vomit almost constantly, and had a number of watery stools; On vaginal examination, the os uteri was found dilated to about one inch in diameter, and soft and dilatable; it still was very high up, and directly above the symphysis pubis, so that at first it was exceedingly difficult to detect it. The foetus was alive and active, and presented in the left occipito anterior position of the vertex. The membrane ruptured early in the first stage, and the liquor amnii dribbled away slowly. The above condition lasted for about sixty hours, no change having been effected in the dilatation or in the position of the presenting portion of the child. The vagina had become hot, though not dry; the exter- nal genitals were tender and swollen. She was still excessively restless, vomiting almost constantly; pulse about 140 per minute, and feeble; belly swollen, and on the left side exquisitely sensitive. It was deemed necessary to interfere, and she was thoroughly aetherized. The os was gradually dilated by the Barnes dilator, only the largest size being needed ; and as soon as it had reached its greatest possible distention it was removed, and the Hodge long forceps applied. The application of the anterior blade was very difficult, and it was found impossible to grasp the sides of the head as accurately as desired. After the blades were in position, intermittent compression and traction was made for 1:} hour, when she was delivered of a fullsized male child, per; fectly relaxed, and evidently dead for some hours. She reacted well from the ether, the placenta was readily removed, and a most careful examination failed to show any injury from the prolonged compression of the tissues. She had some ergot given her, was drawn up in bed, and a binder applied. The pulse was about 120, and rather feeble. She was ordered beef essence, milk-punch every three hours, and hot poultices to abdomen. For the three following days she was as ill as possible; pulse 140 to 165-very quick and feeble; face pale; expression anxi- ous; tongue coated and dry ; belly very tender, and tympanitic; urine retained ; lochia scanty, and no attempt at lacteal secretion. From this date she has slowly improved until the present time. The urine still has to be drawn off three times daily; the lochia have been offensive and scanty, the belly constantly very tender and swollen, the pulse always over 130 per minute, and the 7 28 Transactions? of the Philadelphia skin intensely hot, and at times sweating. She has taken iron and quinia and morphia in very large doses; has been kept on the beef-tea and milk-punch; has had constant application of hot poultices to the abdomen and disinfectant vaginal washes. The urethra had‘ been so stretched by the position the uterus held that at first it was necessary to use a long flexible catheter. DR. PEPPER spoke of somewhat similar cases related by various authorities, and believed that the condition coincided with that called “posterior obliquity of the uterus.” He thought that the unusual inclination of the pelvis probably depended on the‘disease of the osseous system during childhood and youth. The position of the os uteri so directly above the pubic arch was entirely new to him. The finger had to be curved around the symphysis before it could be reached, and it was so high up that it was only by introducing the hand into the vagina that an accurate examination could be made. The os uteri was drawn into the centre of the superior strait a number of times, but always returned to its original position. N o postural treatment seemed to have any beneficial effect. DRs. A. H. SMITH and GoonELL remarked that they were rather inclined to question Dr. Pepper’s explanation, though, as neither of them had had an opportunity for examining the patient, no definite ground could be taken. RETARDED PHYSICAL DEVELOPMENT. DR. F. G. SMITH related the case of a young girl who had reached the age of twenty years without any further physical development than usually belongs to a child of ten or eleven years of age. The intellect, however, was mature and unusually good. .The mammary glands were rudimentary; no hair on pubis or axilla ; the form was angular; there were no sexual sensations, and menstruation had never appeared. On examination, the external genitalia resembled those of a child, but were perfectly formed. On exploring the parts, a small conical papilla was found projecting into the superior segment of the vagina, but a careful rectal and-vesical examination failed to reveal any trace of either uterus or ovaries. The mother, a very intelligent person, and the patient herself, both assured Dr. S. that small seeds of fruit frequently passed in the urine, and that on standing it occasionally deposited a greenish,'flocculent sediment, possibly faecal matter. There was, however, no escape of urine by the bowels, and even. on the most careful examination no orifice could be detected. ‘Obstetrical Society. ' I 7 29 RETENTION or PIEcEs or MEMBRANES AND PLACENTA. DR. WM. GOODELL stated that he had seen several cases where, even after the most careful manipulations, small portions of the membranes had been torn from the placenta and remained in the cavity of the uterus. The woman had generally severe after, pains, offensive and rather profuse lochia, and slight hectic irrita- tion. In one case, seen very recently, the child’s head was ex- pelled entirely. by one violent uterine contraction, the body being only prevented from being extruded by the cord, which was around the neck. After its delivery, the placenta was found inverted in the lower segment of the‘ uterus and entirely sepa- rated from the membranes. Great difficulty was experienced in removing them entire. He asked the experience of the Society in regard to the propriety of continuing efforts at extraction of portions of the membranes after all hemorrhage hadceased and the uterus contracted firmly. . DR. A. H. SMIT-H related the history of a case where, durin delivery, the membranes had been torn off at their placental at- tachment, and he was able, by rolling the protruding portion in a cloth, to, secure the expulsion of the entire mass. ‘Dr. Sfsaid that he always introduced the hand into the vagina and two fingers into the os uteri immediately after the extraction of the placenta, and believed that by thus removing clots, portions of membrane, &c., a most important step was taken towards preventing hemor- rhage, violent after-pains, and septic conditions. SUDDEN DEATH FOLLOWING ABORTION. , DR. R. A. CLEEMANN related the history of a case where abor- tion had been followed by death in a few hours. The woman was apparently healthy before the accident, lost but a very moderate amount of blood, and developed no symptoms other than those of extreme prostration and death from. syncope. No post-mor- tem examination was allowed. Several members commented on the cause of the sudden death, and related somewhat similar cases. NEW UTERINE DRESSING FORCEPS. DR. G. PEPPER exhibited to the Society a pair of long uterine dressing forceps, which allowed of the removal of the blades and the adaptation of a. pair of curved blades for carrying various therapeutic agents into the cavity of the uterus. The sound also separated, and the entire number of lpieces readily slipped into the bivalve speculum, thus enabling t em to be can tied in the vest pocket. 730 Transactions of the Philadelphia’ —MEETING NOVEMBER 4TH, 1869. DR. A. E. SMITH m THE'OHAIR. GALVANIC BOUGIE. DR. WM. GooDELL showed the Society a galvanic bougie, composed of two metals, and so arranged that when the handles were approximated a galvanic current was’ established. The instrument 'had been used by an empiric to produce abortion, and on'his trial for the crime, it had fallen into the hands of one of the court functionaries, who had given it to Dr. Goodell. Dr. G. asked if an instrument of similar construction would not be of advantage vin the treatment of certain diseases of the uterus and vagina. ' DR. G. PEPPER related the sequel of the case of Mrs. B., de- tailed at last meeting, and stated that two large pelvic abscesses had formed and discharged through thevagina, and that the patient was now convalescent. The uterus still held a position far anterior. to the normal one, and was high up in the pelvic cavity. ' DIET OF PUERPERAL WOMEN. DR. ROBERT P. HARRIS read a paper on “Milk as a Diet During Lactation.” (Printed in full in this numberof the AMER» ICAN JOURNAL or OBsrErRIcs.) DR. GOODELL spoke of the diet of. the puerperal women at the Preston Retreat, and stated that though they were not put on a milk diet, yet the dietary was very'full, and that milk entered largely into it. As a rule, the women nursed their own children, and usually had an abundant supply of nutritious milk. He also alluded to the positive effects of tea and coffee, and stated that the former had seemed to him to act as a positive stimulant to the secretion. PHYSIOLOGICAL ACTION OF TEA, COFFEE, AND MALT LIQUORS. DR. J AS. TESSON made a few remarks upon the physiological action of tea, and stated that it was usually ranked with coffee as an arrester of tissue metamorphosis, and really supplied noth- ing to the blood. DR. A.'H. SMITH spoke of :the positive effects of coffee as'an antigalactic, and he believed that unless the mother had a super-e abundant secretion of milk, it should always be forbidden to nursing women. DR. ‘G. PEPPER stated that green tea was considered by several high authorities as a positive stimulant to uterine contractions, and asked if it might not be considered a general stimulant of the- Obstetrical Society. 7 3 1 female genital system, and its action on the mammae merely a part of this exalted. vitality. DR. J AS. TESSON spoke of the effects of the malt liquors, and asked whether they'caused merely an increase of the watery ele- ments of the milk or a positive increase in the solid, nutritious constituten ts. _- I . DB. G. PEPPER answered him, and. alluded to the “ swill milk” excitement in New York several years ago, and stated that, if he remembered rightly, although the total amount of milk was greater, yet it was of a much poorer quality, though this could scarcely be considered an argument, as the food the wretched animals received was of such a character as to preclude the pos- sibility of a good rich secretion of milk. DRS. HARRIS and A. H. SMITH referred to the same thing, and stated that it was the custom, in most large milk dairies near great cities, to feed a certain amount of malt to the cattle, and that the milk was decidedly increased in amount and generally of a good quality. ‘ DEATH OF A NEW-BORN CHILD FROM HEPATIC HEMORRHAGEe DR. W. B. PAGE related the history of a case of sudden death in an apparently healthy infant, sixty hours after birth. The child had seemed strong and well. It was suddenly noticed to become pale, and the abdomen became swollen and tense. It died in a few minutes from syncope. On post-mortem examina- tion the abdominal cavity was found to contain a large amount of clotted and fluid blood, which had escaped from a laceration of peritoneal covering of the liver over the anterior edge of the right lobe. The peritonaeum was separated for some distance around the point of rupture, and no solution of continuity of the hepatic tissue or open vessel could be detected. DR. GOODELL remarked that incertain rare cases the umbilical vein, instead of passing directly into the transverse fissure of the liver and then dividing, sent off several branches before reaching that position, and it occurred to him that the case in question might have been one of a similar kind, and that, from some tem- porary distention of the abdomen or sudden change in position, one of these small vessels had been torn as it penetrated the hepatic ca sule. ' DR. G. EPPER alluded to the fact that vascular tumors had been found under the capsule of the liver in adult subjects, and thought that possibly some such condition might have existed in the present case, and the relaxed vessels surrounded by blood been readily mistakenfor a clot.~ As the specimen had not been 732 Review of Literature kept for careful examination, these remarks must be merely of the nature of hypotheses, and incapable of throwing any light on a very obscure point. d DR. W. B. PAGE' stated that' the mother had just come from ' an extremely malarious region, and that though shehad had‘ no marked chill, yet, in absence of some positive proof of decided lesion, he had considered it possibly due to the intense congestion of the liver accompanying the algid stage of a paroxysm. FATTY DEPOSITS IN THE ABDOMINAL WALLS AND OMENTUM AS A CAUSE OF ERROR IN DIAGNOSIS. Drs.-G. PEPPER read a paper on the above subject. (Printed in full in this number of the AMERICAN JOURNAL or OBSTETRICS.) - DR. GooDELL related the history of a case confirmatory of the views expressed, where a woman, after a very profuse hem- orrhage from the presence of an hydatid mole, grew stout, and had her abdomen greatly enlarged from fatty ‘deposits. He also alluded to observations on the lower animals, as where well-fed bitches, after being unsuccessfully lined by the dog, enlarge, suppose themselves with young, and, at the approach of the time corresponding with the normal termination of gestation, seek out obscure corners and yelp in a manner indicative of approaching labor. Dr. G. also spoke of the normal tendency of women to become fat, and alluded to the well-known fact that, in the ancient rites, where incremation was practised, it was found necessary to mingle the bodies of both male and female, as the male bodies alone could not be thoroughly destroyed. II. REVIEW OF LITERATURE PERT'AINING TO PREGNANCY, LABOR, AND THE PUERPEBAL STATE. I. The Ind action of Premature Delivery as a Prophylactic Resource in lllidwifiery. By T. GAILLARD THOMAS, M.D, Professor of Obstetrics and the Diseases of Women and Children, in the College of Physicians and Surgeons, New York. (New Yor Med. Journal, Feb, 1870.) . ‘THERE are certain dangers inherent to the process of partu- Pertaining to Pregnancy, (90. 733 rition which, in spite of scientific midwifery and the prophy- lactic resources of intelligent hygienic management, must for’ ever invest it with importance, and produce a certain loss of life in its performance. The most sanguine of modern obste: tricians must admit that the perils of childbirth, which have been recognized in all ages and among all people, will never disappear, but must forever endure as a fulfilment of the primal curse, “In sorrow shalt thou bring forth children.” He may turn with pride to the advances in pathology and improvements in practice which have marked the modern school of obstetrics; he may enumerate with warrantable gratification the surgical procedures that now render manageable abnormal labors with which our forefathers could not cope; he may point to a marked improvement in the statistics of the lying-in cham- ber, yet still he must feel and admit that much-very much— remains to be done. When he reflects upon the statement made by one of the most eminent living obstetricians, that in England and Wales, which contain but twenty million people, three thou- sand women die annually in childbirth, he must acknowledge that it is the duty of every obstetrician to study with the utmost devotion those influences which, exerting themselves before, during, and after delivery, accomplish this unfortunate result. As I have just now stated, a certain number of these influ— ences are unavoidable, being either inherent to the process of parturition, or developing themselves without warning in the moment of its performance. But while in some unfortunate cases no premonitory symptoms will occur'to forewarn the most watchful and intelligent practitioner of the danger which awaits the parturient act, I do not think that I assume a position which is untenable when I state that, in most instances, the most seri- ous complications of labor, both as regards mother and child, may be recognized by their peculiar premonitory signs, one, two, or even three months before the end of pregnancy, and, being recognized, may fortunately often be avoided. _ impression is, that nothing will in the future tend to diminish the mortality attendant upon parturition so markedly as the induction of premature delivery for the removal of mother, child, or both, from that condition upon the continuance of which depends the danger which menaces them. Q I . O O O O O D I U Q The practice of'inducing premature labor, unlike that of abortion, is of very recent date. Denman informs us that in the year 1756 a congress of physicians was held in London for the purpose of discussing the advantages of the procedure. It 7 31 Review of Literature 0 was approved of, and since that time its adoption has steadily though slowly extended. The following list presents the morbid states for which I should consider the operation indicated : ' ' . Deformity of the pelvis. . Placenta praevia. . Aggravated uraemia. . Excessive vomiting. . Placental apnoea. Commencing epithelioma. . Death of child and consequent septicaemia. . Threatened death‘of child. 9. Approaching death of mother. 10. Amniotic dropsy. 11. Previous rupture of uterus or performance of the caesa- rean section. 1 12. Excessive-accidental hemorrhage. 13. Previous difficulty in deliveries of large children, or of children with ossified sutures. 11. Tumors obstructing the pelvis. From this enumeration of indications for the induction of remature delivery, I have intentionally excluded a number which call for abortion, but not for the procedure which now engages our attention. I have likewise, for the purpose of avoidingprolixity and a spurious show of completeness, omitted ‘the enumeration of certain rare conditions which might call for it, but would in all probability never do so. As examples of such indications let me mention the existence of ovarian and fibroid or fibre-cystic tumors in the abdomen; the differentia- tion of an extra-uterine pregnancy from a tumor, etc., etc. The ground left untouched in the list given may be covered by two general statements: first, any condition threatening the life of mother or child after the period of viability, which could be removed by premature delivery, would call for its induction; second, any obstruction existing in the true pelvis which would allow the passage of a child that has not arrived at the full period of intra-uterine life, and would prevent the exit of one which has reached the end of the ninth month, without mutila- tion, would prove a valid indication. ' . ‘ I shall nowconsider each condition which I have enumerated, in turn, giving clinical cases as instances of a resort to the ope- ration for such indications as appear to require illustration from their novelty or the doubtfulness of their claims. Deformity 0f the Pelvz's.—-Premature delivery has been more mqgmewww Pertaining to Pregnancy, (yo. 735 frequently induced on account of this condition than any other which has been mentioned. That this should be so is a natural deduction, when it is borne in mind that in the great majority of instances it is the indication which calls for those dangerous rocedures—-craniotomy, embryotomy, and the caesarean section. Out of 300 instances in which premature delivery was resorted to in British practice, according to Dr. Tyler Smith, in an able essay in the first volume of the London Obstetrical Transactions, 273 operations were necessitated by pelvic distortion. 273 out of 300 presents a most disproportionate ratio, but the bearer must remember that these are the statistics of a past age. Every progressive obstetrician of to-day will bear me out in the asser- tion that many indications which until lately have not claimed the advantages of this operation will now do so, and make the disproportion in favor of deformity of the pelvis much less marked. It is difficult to say what degree of deformity calls for the procedure; but in general terms it may be stated that, where- ever it is estimated, or, as is far better, where it is proved that a child at full term cannot be delivered except by instrumental or manual means, premature delivery is called for. Still speak- ing generally, the normal length of the shortest diameter of the pelvis is 4 inches; between this and 3 inches is the domain of the forceps; between 3 inches and 233;, that of version ; between 2% and 2, that of craniotomy; and under 2 inches, that of the caesarean section. I shall not argue as to the propriety of pre- ferring premature delivery to the terrible risks attendant upon the ,graver of these procedures, for 'all will admit it. I take a position which will be less freely acknowledged when I state that so safe is‘the premature and artificial delivery of a child at the eighth or eighth and a half month of utero-gestation, by our present methods, that it should be preferred to delivery by the forceps at the tenthvmenstrual epoch. But under the last cir- cumstances the necessity for interference must be established, not by measurements, which do not display slight contraction ; it must have been proved by past experience with the particular patient whose case engages attention. For such a condition as that which I have depicted I have twice induced premature delivery. One of these cases will suf- fice as illustrative of my proposition: I was requested in ‘the month of March last, by Dr. Wm. B. Bibbins, to see with him Mrs. McD., an Irish woman, aged thirty six years, who had been married seven years and borne four children. She gave the follow- ing history of’ her labors. The first child, a small girl, was delivered at full term by the forceps, by Dr. Ramsey. She was in labor, she says, four 7 36~ Review of Literature days. , This .child lived for one year. The second child was a larger girl, which was delivered by forceps, and was still-born. The third Was deliv- ered by version, by Dr. Gillette, and was still-born. The fourth was de- livered by myself inconsultation with Dr. Bibbins, by version, and'was still-born. Shewas now pregnant for the fifth time, and was extremely solicitous for aliving child. "With Dr. Bibbins’s consent, I promised her that delivery should be brought on in three weeks from date, when she would be at the end of the eighth month of pregnancy. A careful exam-. ination of the ‘pelvis convinced me that it was a justo minor pelvis, but one not relatively deformed. t On the appointed day Dr‘. 'Bibbins, Mr. Hall, a student of Dr. B., and myself, met at the house of the patient, and proceeded to bring on delivery in the following manner: we placed the patient in the obstetric position, with a'tub of warm water under the edge of the bed, and for half an hour showered the os freely. At the end of that time I put in Barnes’ smallest dilator, and in an hour the ‘ us was fully dilated, and the bag of membranes presenting; no labor pains came on, and in ‘twenty-four hours We met again, and _I used the warm douche for a half hour, dilated the 0s fully with the largest dilator, and introduced a No.6 gum-elastic catheter be- tween the membranes and the uterus, up to the {'undus. In twenty-four hours we met again, and, to my surprise, found that no uterine contraction had occurred. The catheter was now removed and inserted upon the other side,- an enema of salt water was thrown into the rectum, and the largest dilator again introduced. We waited over an hour, and still there was no uterine efl'ort. Slight hemorrhage from the uterus now occurred upon removal of the dilator, and fearing for the child I proposed at once to de- liver it. Dr. Bibbins consenting, the patient was anaesthetized, and, passing the hand into the vagina, and two fingers into the uterus, I readily deliv- ered a vigorous boy, who has since done well, as has also his mother. I have met with but one other case-one, by the way, Which was coinci- dent as to. time with this one, in which it was so difficult to excite uterine contractions. Placenta Prcevia.—No one who has had experience with this form of complicated labor, will feel disposed to undervalue or cast aside any remedy which is offered for the rescue of patients presenting its premonitory symptoms. So serious are its results that, although it occurs not oftener than once in five hundred cases, which is the proportion computed as correct by some authors, it exerts a marked influence upon the statistics of obstetrics. According to the calculation of Sir James Simp- son,'based upon the analysis of three hundred and ninety-nine cases, one-third of the mothers and over one-half of the children are supposed to have been lost. The reasons for this great mor- tality are probably the following: 1. The dilatation of the cervix for the passage of the child . unavoidably exposes both mother and infant to great danger from placental detachment‘ and hemorrhage. 2. Repeated hemorrhages occurring during the ninth month ; as the os internum dilates under the influence of painless uterine Pertaining to Pregnancy, (yo. 7 37 contractions, which then occur, the woman at the time of labor is usually exsanguinated, exhausted, and depressed both physi- cally and mentally. - v ' i 3. Profuse flooding generally occurring with the commence- ment of labor, the medical attendant is oftenrnot at hand, and reaches his patient only after a serious loss of blood has oc~ curred. _ ' . ‘Fortunately, this condition is usually announced during the last months of utero-gestation by premonitory signs of reliable character, and thus we may empty the uterus before the vital forces of both mother and child are exhausted by hemorrhages, the results of repeated detachments of the placenta. My con- viction is that, in every case of declared placenta pracvia, pre- mature delivery should be induced. What objections .can be urged against it, other than that a child of less than nine months of intrauterine life does not have as good a prospect. of life as one which has arrived at full term? In the'case which we are considering, even this falls, to the ground, for an eight-months child out of the uterus, and depending upon pulmonary respiration, has a brighter prospect for life than one in that cavity depending for aeration of its blood upon a crip- pled and bleeding placenta. For the mother, how incompail‘ rably greater the safety which attends an emptied and corn,- tracted uterus! By inducing delivery during the ninth month of pregnancy, we should be dealing with a woman who is; not exhausted by repeated hemorrhages; ‘we would be in attendi- ance at the moment of cervical dilatation, and consequently the moment of danger; and we would be able by hydrostatic pressure to control hemorrhage in great degree, while at the same time dilatation of the cervix, which constitutes the period ofv maximum danger, may be rapidly accomplished. With these considerations before me, and with a certain amount of experience to support them, I cannot resist the con”- viction that, when premature delivery becomes the recognized and universal practice for placenta praevia, the statistics of Dr. Simpson will be replaced by others of a far more satisfactory kind. I have induced premature delivery for placenta praevia four-times; and, as the subject appears to me of paramount imi‘ portance, I risk the danger of wearying my audience by do» tailing all of the cases. (Space allows us to insert but one-EDS.) 'CAsE I.——Mrs. W., aged twenty-six, primipara, in good health, was sud- denly taken with hemorrhage three weeks before full term; She sent for me in great haste, but, being occupied, I was unable to go to her, and she was .seen for me by my friend Dr. Reynolds. He discovered that she had 48 738 , Review-0f Literate/re lost a few ounces of blood,- but that the flow had ceased; " Three days after? ward she was again affected in the same way, the .flow ceasingspontane- ous'ly; About a week afte‘r'this, she was taken during the night ,with'a flow, which was so, profuse, as to result in partial syncope‘ when she ens deavored 'to walk across the room. I saw her early the next morning, found .her flowing slightly, and, upon vaginal examination, succeeded in touching the edge of the placenta through the os, which was dilated to the size. of a ten-cent piece. Later in the day, Drs. Metcalfe and Reynolds saw her and agreed in the propriety of premature delivery. In accordance with this consultation, at 7 P.M. I introduced into the cervix, with considerable diffi- culty, and by the employment of some force, the smallest of Barnes’s dilators. This in twenty minutes was followed by the next larger dilator,- and in an hour. by the largest. Dilatation was rapidly accomplished, but,‘ instead of removing thelargest bag, I left it in the cervix until 10 o’clock that night. Expulsive pains coming on at that time, I removed it when the‘ head rapidly engaged, and before morning Mrs. W. was safely delivered of a liv- ing girl. vThe placenta followed rapidly, and both mother and ‘child did well. In this case, although. hemorrhage continued slightly. throughout the labor, it was never sufl‘iciently profuse to endanger ‘the lives of either mother or child. The implantation of the placenta being lateral, diminution of the flow occurred as the head advanced and made firm pressure against the bleeding surface. . at * 'X- a‘ at 96 96 Aggravated Urcemia.—-The pregnant woman is peculiarly lia- ble to a form of desquamative nephritis, which probably depends in part upon the hydraemia attendant upon utero-gestation‘, and in part- upon direct pressure of the enlarging uterus upon the kidneys and their blood-vessels. This condition, which marks its presence by albuminuria, anasarca, and the , cerebral and gas- tric symptoms ordinarily attendant‘ upon uraemia, has been appro+ priately styled puerperal nephritis. Unlike ordinary nephritis, and like that which results. from scarlatina, it is usually ulti- mately recovered from. When complicating utero-gestation, however, this form of nephritis proves the most fruitful of all the sources of convulsions, oedema of the lungs,and puerperal mania. It develops generally after the sixth month, and be- comes aggravated as the uterus continues to enlarge and exert greater pressure upon the kidneys. Sometimes, however, it does not appear till the end of the eighth month, when the danger to the patient steadily increases until the uterus has been emptied. This condition often calls for“ premature delivery, in order that the woman’s blood may not become more and more impure, as greater and greater pressure upon the kidneys occurs; that the daily increasing risk of convulsions may be avoided; and that the child; in danger from the poison accumulating in its own as ‘well as its mother’s blood, may effect aeration by some other means than the contaminated placenta. I have not space, nor do I deem it essential even if I had, to Pertaining to. Pregnancy}, (yo. 73H enter here upon the subject of statisticsas applied to" the propor. tion of women‘ affected by puerperal nephritis who escape the? evils which Ihave mentioned. It will answer my purpose, ‘in addressing a body of practical physicians, to refer merely to, a fact, which they all know as well as I,,that a large number of women, who suffer from all the symptoms of puerperal nephri-' tis, escape those results of blood-poisoning to which I have‘ drawn attention. To place before them as clearly as possible the fact that I do not advocate premature delivery merely be-I cause this complication of pregnancy exists,- I would divide all the cases of the affection into three classes : r . . . , 1. The class in which only a cloudiness of the urine develops under heat and nitric acid, and in which only slight anasarca, and nervous disturbance exist.v For this, no other interference is usually necessary than stimulation of the intestinal and cu'ta-_ neous secretions, steady and systematicexamination of the urine, andavoidance of tight clothing, nitrogenized food, and habits of luxury. _ .. ' t ' ' ' ‘ 2. The class in which _a copious deposit of albumen takes place under heat and nitric acid; anasarca to a moderate degree exists; ‘and gastric and cerebral symptoms show the influence of retained renal secretions to such an extent as to create consida erable annoyance. For this class the general management al- ready indicated should be pursued; the urine should be carefully examined every third, or fourth day during the last two months of, pregnancy, so that any increase of renal congestion might at once he recognized as an indication for interference, and the pa- tient be delivered under chloroform. ; 3. The class in which the urine treated by heat and acid un- dergoes almost complete coagulation; excessive anasarca exists; the stomach, brain, and nervous system sympathize; and ten-. dency to coma is denoted by constant desire for sleep. So long as cases of the first‘class keep within their legitimate bounds, they do not call for premature‘ delivery. Even ‘while those of the second class keep within their limits, ‘they may require it, but do not of necessity do so; but in the third class this resource will always voffer itself .as a haven of safety for both mother and child. To express this mQe concisely,I would say that the first class very rarely, the second class sometimes,- and the third class. always, calls for the induction of premature delivery. I ' For this indication I have‘ induced premature delivery three times. All the mothers-recoveredand' two of the children. One child was known to be dead‘ at the commencement of the process. _I shall give very short notesv of these cases: ' 740 Review of Literature CASE I.—Mrs. B., a multipara, aged thirty-two, had lost her father, mother, and one sister, of Bright’s disease, and in her only previous labor had suffered from convulsions caused by puerperal nephritis. She ad- vanced quite well to the seventh month, when suddenly ‘the gravest symp- toms of uraemia developed themselves. By general management she was carried to the end of the eighth month, when she could, without straining the point at all, be classified in my third group. At this time I used the warm douche at mid-day, separated the membranes by a silver catheter two hours afterward, and at 6 RM. introduced Barnes’s middle-sized dilator. At 7 P.M. this was removed, and a gum~elastic catheter introduced to the fundus uteri. This soon excited labor pains, and in three hours a large girl was born. The mother was delivered under chloroform. Both patients did well. (Space allows us to insert but one.—Ens.) Excessive Vomiting-This condition, usually existing as a morbid state before the fourth month, much more frequently demands abortion than premature delivery. Sometimes, how- ever, it continues throughout pregnancy, or, as in the subjoined case, develops toward its close. I have met with but one case which has demanded the procedure which now engages our attention. The following notes were kept for me by Dr. Sproat, house-physician of Bellevue Hospital: CASE I.—-Honors. (lurtin, an Irishwoman, married, aged about thirty-one, a domestic, was admitted to Bellevue Hospital, June 8th, 1869, and in the absence of Dr. Elliot came under the care of Dr. Thomas, who was replac- ing him. On entering the hospital she thought herself a little more than six months advanced in pregnancy, having menstruated last in December,‘ 1868. Four days before entrance the patient was attacked with vomiting, which she at first attributed to abusive treatment by her husband, although- she afterward denied it. This vomiting had continued night and day, at intervals of not more than ten minutes. After her admission to the hospital all nourishment was given by the rectum, as the stomach could retain nothing. All efforts at controlling the vomiting having failed, and the patient be- coming constantly weaker, on the evening of June 10th she was anaesthe- tized by ether, and premature delivery induced by Dr. Thomas. The os uteri was dilated manually, a single finger being first introduced, and after- ward two, which were then separated as widely as possible. The dilatation was completed by the use of Barnes’s largest dilator, and the child delivered by traction upon the feet. The whole operation was accomplished in twenty minutes. The uterus contracted well, the placenta coming away immediately. The child was alive, but survived only about four hours. The vomiting ceased on the second day after delivery, but the urine when tested gave signs of renal disease. The patient was discharged July 2d, apparently Well. I have met with no other case in which artificial delivery has been accomplished so rapidly as in this. The operation, which was performed iii" presence of Dr. Nott, of New York, Dr. "Wil- son, of Baltimore, and the house staff of Bellevue Hospital, occupied precisely twenty minutes, and was completed, without Pertaining ' ‘to Pregnancy, e0. 7 41 violence, with safety to the mother and child. It is true that the child died in four hours; but, when it is remembered that it was but six months advanced, this is not astonishing. Placental Apntea.—ln a certain number of women a fatty, calcareous, or syphilitic degeneration affects the placenta one or two months before full term, and in re eated pregnancies destroys the lives of the children. Under these circumstances, where the intra-uterine lung, the placenta, becomes decrepit and inefficient, the indication for premature delivery, which enables the child to breathe by air instead of fluid, to live like a mammal and not like a fish, is very clear. The symptoms which notify the ob=tetrician when to interfere are: enfeebled movements on the part of the child, enfeebled heart-beat,’ and approach of the time when previous infantile deaths have occurred. Commencing Epit/ieli0ma.—l)athologists now draw a broad line of distinction between the two great varieties of malignant disease which may affect the tissues of the uterus. First, we have true cancer, the removal of which is useless, because it invariably returns; and second, we have epithelioma, which, if removed in its earliest stages, may never return. Either form may develop in the pregnant uterus. If it be the latter which is discovered, it is recommended to empty the uterus and amputate its neck. I have never done this; but, to give a clinical example of its performance, I avail myself of a case presented by my colleague Prof. Jacobi, before the New York Obstetrical Society, and pub- lished in the proceedings of that body (see AM. JOURNAL OF OBSTETRICS, etc., Vol. ]. N0. 1. Page 88): . 1 Death Child and Consequent Septiecemim-JVhen a child dies in nteno during the latter months of pregnancy, it is often retained, usually without injury to the mother, until full term,’ and then expelled. So surely may we calculate upon this issue, that interference is not considered justifiable. 'In' rare cases, how-. ever, great constitutional disturbance is) set up, and a low grade of blood-poisoning demonstrates its presence. ‘I have met with but one instance of this, which I now give in illustration: ' Cass I.—N. P., a handsome young American woman, aged about twenty- five years, the mistress of a gentleman of this city, sent for me at the eighth" month of pregnancy. I found her suffering from hectic fever, which came on‘ every afternoon, and which was followed by profuse sweating, which lasted all night, saturating her night-clothes, and exhausting her excessively.‘ Upon examination I found that she carried a child in ntero, which was evidently still, and, as she positively asserted, had been so for a month. Strongly suspecting that a criminal delivery had been attempted at. the seventh month, which had failed to produce expulsion, but succeeded in de- stroying the life of the foetus, I refused to interfere, but watched the‘ case for two weeks. At the end of this time the patient was so much prostrated Pertaining to Pregnancy, (yo. 7 43 supposing the mother beyond the hope of recovery, and in such a condition that the vitality which remains to her may be legit- imately exhausted in an effort to save the life of her offspring. As examples of this condition I would enumerate the last stages of phthisis, cancer, aneurism of the aorta, Bright’s disease (not puerperal nephritis), cerebral disease, etc. In illustration I give the following: CASE I.—Mrs. 0., a multipara, weighing about two hundred pounds, forty years of age, and previously in perfect health, sent for me very hastily, in the absence from the city of Dr. Metcalfe, her ordinary attendant. I found her in great trepidation, crying, and declaring that she was sure she was going to have a fit, from the fact that she had suddenly been taken with a violent headache, vertigo, ringing in the ears, and disordered vision. The flowers which constituted the carpet pattern were, she said, rapidly revolving, so that she dared not look at them. Her pulse was full and bounding, face suffused, eyes projecting, and vessels of the neck distended. She lived very near my residence, and, obtaining a phial of her urine, I hastened home to test this and get a lancet. In twenty minutes I re- turned to her house, and found that in the short time of my absence she had had one violent convulsion. This had evidently caused the rupture of one of the vessels of the brain, for almost complete hemiplegia existed. Drs. Edward Delafield and Charles Henschel at this moment entered the room, and with their sanction I drew about a quart of blood from the arm, but Mrs. C. remained comatose and hemiplegic. No other convulsion occurred, all the symptoms pointing to serious organic lesion in the brain, and the pa- tient behaving like one in ordinary apoplexy. Dr. Metcalfe returned in for- ty-eight hours, and took charge of her, I seeing her only occasionally. On the fifth day of the attack it was evident that she was sinking rapidly, and, as the child, which was just at the seventh month of intra-uterine develop- ment, was living, it was determined to deliver it. In accordance with this decision, I easily and rapidly dilated the cervix with Barnes’s dilators, per~ formed bimanual version, and delivered a living child, which has since grown to be a large and very vigorous girl. The mother, who was completely com- atose and almost moribund at the time of the operation, died in the course of twelve hours. I neglected to state earlier in the history that the urine which I obtained on the day of the convulsion became absolutely gelatinous under heat and nitric acid. In this case, as we felt sure that a cerebral vessel was ruptured, we did not bring on labor earlier for fear of increasing the effusion. It was finally induced at the expense of the rapidly-failing strength and prospects of the mother, in the interest of the child. Amniotic Dropsy.-Sometimes the amnion, which ordinarily secretes a limited amount of fluid, takes an excessive action and distends to a dangerous degree the uterus, 'which, in consequence, interferes with‘ the physiological action of the abdominal viscera, the diaphragm, lungs, and heart. The diagnosis of this condi- tion is always obscure, but in some cases may be made by the existence of a very large and fluctuating uterus, great obscurity in sensation of foetal movements by the examiner, excessive Pertaining to Pregnancy, at. 745 the seventh month. Of the mothers, one died. Of the three children delivered still-born, two were known to be dead before the operation was performed; and the mother who died was supposed to be moribund before interference was established. One reason for the mortality of premature children is to be found in their ineflicient heat~making powers. If such a child be washed, wrapped in flannels, and treated as one at full term ordinarily is, it may die when a different plan might have saved it. Prevent a child at term from having its animal heat abstracted, and it will supply itself abundantly; but to the body of the premature child extraneous heat must be added to keep it from dying of cold. To carry out this idea practically, I do not allow a prematurely-delivered child to be washed for a week or more, and always keep it during that time in a temperature of from 90° to 95°, thus striving to let it feel as little as possible the change of locality as far as this circumstance is concerned. It is difficult to do this, unless every preparation be systemati- cally made beforehand. The plan which I follow I take the liberty of nowidisplaying to the Society. It consists in hav» ing a tin tub placed within one of larger dimensions, so that from three to four inches may everywhere intervene between‘ the walls of the two. At the upper portion of the piece of tin which holds them together a funnel is fixed, and at the lower a spigot. Into the former 1hot water is occasionally poured ; and, when re- newal is necessary, this is allowed to flow away from the latter: In the inner tub alarge sup ly of cotton or wool is placed, and in this the'child is envelope and constantly kept until all fear as to its power of generating sufficient animal heat has passed away. Within this receptacle hangs a thermometer which indi‘ cates the temperature. No difference should he made in‘ the management of the child in the hottest part of the summer. Even if the‘ thermometer ranges at 95° in the room, these pre; cautions are essential. ‘Where itiis not convenient to obtain anything else, an ordinary basket, with bottles of hot water laid in the bottom, and filled with cotton or'wool, will answer the purpose of keeping ‘the child warm. ' i ' Y I 1 But the prognosis as to the child must always be governed by its intrauterine age. Little‘ hope should? be entertained. if ‘the delivery be brought'on at or just after the seventh month; al~' most none should be indulged in before the seventh month, while a child delivered at or after the eighth month, provided its vital forces have not been depreciated by the abnormal state which has necessitated delivery, has, with proper management, almost as good a prospect of life as one arrived at full term. J ' I . .:.e;. . ‘.J a ‘in ' " ‘ n i 1, 4.- 746 Reviews and 1V ott'ees ‘of Books. 1 'The end of the eighth month, i. e.,’the ninth menstrual ‘epoch, 1s theimost favorable time'for the induction ofpremature labor. REVIEWS AND NOTICES oFsooKs.l PRACTICAL Taua'rrsn _ON THE Drsnxsns or CHILDREN. ' By ALFRED VoGEL, M.D., Prof. of Clinical Medicine in the University of ,Dorpat, Russia. Translated and edited by H. RAPHAEL, M.D., ‘etc. From the fourth ,German edition. ‘New York: D. Appleton 8t 00. 1870. pp. 603, and 6 ‘plates.’ ‘ WITHOUT feeling able, in the small place allotted to us, ‘to do full and equable justice to all the several parts of Prof. Vogel’s book, we mean to state, -however,that wev greet. its appearance in the Englishlang-uage with no small satisfaction. We consider it as both an eminently useful and scientific .book, and therefore recommend it to both. students andpractitioners with the greatest confidence. In fact, of all the text-books on the diseases of in- fancy and chiIdhQOd'Wi-th which we have become acquainted, it appears to us the‘ very one ‘which contains, in a condensed and readable form, the results of both a great number of clinical ob- servations and of anatomo-pathological facts. We do not say, however, that-the book is beyond fault and blame; we shall, in fact, have to-pointto avariety of chapters we should like to have seen differently treated. ,But-tat' the same time, we must not forget that, of all the tasks anauthor can undertake, the writing of a textbook, in modern --ltimes,,is one of the most diflicult ones. So much the worse for the large number of authors who have, for the last decennia, tried to acquire notoriety, commencing their literary career with what ought to be the last and crowning effort of a long life spent in study and observation. The time when a specialist- could pursue his course without regard to the other branches of ‘medical science and art have long passed away. To practice a specialty, without being a thorough pathologist in gen- eral, is acknowledged to be animpossibility or quackery. And certainly, to write a; text-book on a special branch of medical science or art, requires such an amount .. of knowledge in ‘the many doctrines of medical science, suchas acquaintance with path- ological anatomy, and, at the same time, such an amountof clini- ealcbservatiomthat but few and very gifted men appear to have‘ the- vocationof writing a text-book.- Such a work ought ‘to be acollection of. condensed monographs; but as a text-book is expected to have a chapter on every important or unimportant Reviews and Notices of Books. 747 subject, it requires more knowledge and more work than most men can possess or perform. We allude, for instance, to the great book of the two French masters of the pathology of childhood, Rilliet and Barthey. They have succeeded in writing a large number of monographs on subjects connected with the pathology and therapeutics of children; but they even have not been able to render their work a complete one. For there are many sub- jects for which the student or practitioner will look in vain in their three large volumes. The great difiiculty of composing a text-book explains the fact that very many illustrious men, masters in their art or specialty, have never attempted 'to condense their knowledge and the re- sults of science in that form. Therefore, such men as have the patience or the courage to write a text-book, deserve either all the credit or all the blame for their undertaking; but also all the leniency of judgment is due to whomsoever spends his best exer- tions, and risks his reputation on a dangerous field. Now, as far as Prof. Vogel’s book is concerned, we confess that the author can be satisfied with the result. The welcome extended to his work all over the world is flattering in the extreme degree to the manner in which he has availed himself of his facilities in the ob- servation of children and their diseases, and of his attainments as a clinical observer and teacher in general. ' The translator has, in the book before us, done justice to his work. There are a few points, however, to which we desire to direct his attention in his next edition. A translation ought to read like an original work. The frequent addition of German technical terms, in part intelligible to the German professional reader only, is, to say the least, superfluous. If they were of any use to the English reader, this reader would not require a translation at all. And further, it appears as if new and then the immediate intelligibility of the meaning of the author would be enhanced by not using his exact terms in every case. We speak, as an instance, of the chapter on “ abdominal typhus.” As we are more used to the sound of “ typhoid fever,” the change might have easily been made; and the differential points between “abdominal” and exanthematic typhus would have been the more prominent. Of the several parts composing the work, the introduction, and the chapter on the ailments of the new-born, are certainly good. The diseases of the digestive organs are also commendable—-in some portions excellent. There "are a few points to which we take exception, however, selecting at random a number of arti- cles, as we are unable to attend to every one. The chapter on imagination (intussusception) is, perhaps, one of the weakest in ‘748 Reviews and lVotiees of Books. the book; we venture to say that the author has not had many cases to make his observations on, else he might have improved on many a remark of Rilliet’s and Barthey’s in this respect, It is not correct, that violent pains will set in at the very beginning of the affection, nor will the patient collapse as fast as the author appears to believe indispensable. The treatment recommended by Pfeufer is certainly the proper one, as far as it goes ,' but the remarks on laparotomy (why “ gastrotomy ”?), as a last resort, are not justified by the facts. Prof. V. states that the abdominal "cavity has been successfully opened for the purpose of reducing the dislocated bowels. The facts are difi‘ierent. Although we should not hesitate to perform that operation as a last resort, we ought to state that both Gerson’s and Spencer Wells’ cases ter- minated fatally. Polypi of the rectum are not so painful as the author states. Beside the astringent or cauterizing treatment, an allusion to the external use of nux vomica and the induced current would appear indicated. “ Tgmpanitis” might have been tympanites. Amongst the tape-worms we sorely miss our old enemy, taenia mediocanellata, which is the dread and fear of all those who feed raw beef; and amongst the vermifuges, many of those which have proved more successful than otherwise in our hands. Fatty liver might have deserved a little more atten- tion, as it is not at all an uncommon affection, and its differential diagnosis from amyloid degeneration of that organ would have been interesting. - t We cannot approve of treating typhoid fever, cholera, and inter- mittent fever (the convulsive form is not mentioned) under the head of the diseases of the digestive organs.’ In this connection, leucocgthaamia has found no mention whatsoever in the whole book. Cases will occur at infancy and childhood; we have seen a well-developed casein an infant of seven months. All of these affections, together with diphtheria, belong to another class of diseases altogether. The article on the latter is shorter than need be; the author justly rejects cauterization with nitrate of silver, but lays too little stress on the necessity of local disinfec- tion, especially in the dangerous nasal variety. He praises lime water, but omits to speak of carbolic acid, which we prefer to it. The plan of treating grave symptoms under separate heads, as vomiting, diarrhoea, constipation, etc., appears highly judicious in a book which means to be practical, and the manner in which they are treated of is satisfactory. The chapter on gastromalacia, which Prof. V., like ourselves, takes to be a post-mortem change, will be found very interesting; but the treatment of fever, cone vulsions, lychen, eczema; impetigo, prurigo, and intestinal, bron» chial, and conjuncti val catarrh, under the head of dentition, appears Reviews and Notices of Books. 749 rather objectionable in our times. Nor do we believe that the chapter on the diseases of the mouth could not have been im- proved upon since the appearance of Prof. Bohn’s remarkable book on that subject. The portion of the book containing the diseases of the respi- ratory organs will be found very instructive, although now and then there will be serious discrepancies between the writer and reader. We still have that faith in the use of belladonna in the majority of cases of hooping-cough, proclaimed many a year ago in the 1V. Y. rlfedieal Monthly. But we should not like to subscribe, with anything like the serious belief of the author, to his expectation of warding ofi“ lobular pneumonia by administering small doses of calomel. His theory on [org/7292's- mus sz‘rz'clulus (“spasmus glottidis”) also appears faulty to us. We hardly remember a case (in fact only a single one) in which there was no complication with, or dependence on, craniotabes. If craniotabes was the cause of laryngismus, “it should be cured or palliated by local abstraction of blood, and by a derivative action of the bowels.” life must confess that we should just as firmly believe in any other kind of malpractice as in depletion in craniotabes. The worst feature, however, in this whole chapter, are some remarks on the treatment of croup. Prof‘. V. says that “ the prognosis in well-declared croup may be set down as fatal.” Still the twenty-two or more per cent. of recoveries after tracheot- omy are very “ discouraging.” The opinion that the operation is being given up on the continent of Europe because of this discouraging result is totally incorrect; to the contrary, the twenty-two cases saved out of a hundred “ fatal ” ones are very encouraging. And Prof. V.’s remarks on the general impropriety of operating, because of the majority of such children as were operated upon suffering from "the milder diphtheritic form,” will be palatable to but very few, if any of our readers; to us “the diphtheritic form ” is not “the milder” one. At all events, there is nothing in Prof. V.’s book, or in the modern writers in general, or in the merits of the case, that could induce us to change such views as we have expressed in the first (May, 1868) number of this journal. As natural, we might go on increasing the number of critical remarks on the book of Prof‘. V.’s. We might add, that amongst the remedies for chorea minor we miss the best of all of them- arsenic and the galvanic current; amongst those in some forms of incontinence of urine, ergot. Amongst the causes of epilepsy we look in vain for premature ossification of the sutures and fon- tanels, now uniform, then asymmetrical. 'And we might lay stress on a serious mistake, viz., that the author still insists on 7 50 Reviews and Notices of Books. claiming rhachitis as a disease of the osseous tissue only. Even the old Writers of the seventeenth century, especially Glisson, to whom he alludes, knew better, and we ought no longer to consider rhachitis as anything but a constitutionaldisease. Moreover, we might state that, in this very article on rhachitis, the author refutes his own theory concerning laryngismus, inasmuch as he connects rhachitis of the cranium and laryngismus. But, after all, we return to our above opinion, that we shall hardly find a text-book anywhere, or on anything, that would not allow of re- monstrances. This much is certain in our mind, that we do not know of a compact textbook on the diseases of children more complete, more comprehensive, more replete with practical re- marks and scientific facts, more in keeping with the develop- ment of modern medicine, and more worthy of the attention of the profession, than that which has been the subject of our re- marks. A. J. ON THE WASTING DISEASES or INFANTS AND CHILDREN. By EUSTACE SMITH, M.D., London, Member of the Royal College of’ Physicians, Physician Extraordinary to His Majesty the King of the Belgians, etc., etc. Philadelphia: Henry C. Lea. 1870. 8vo., pp. 195. BY many of our readers this book has doubtless already been read as reprinted by chapters in a supplement to the “ Medical News (f: Library” of 1869, and we venture to say that there was not one of them who did not place a high valuation on the indi- vidual chapters, containing as they did so much instruction and practical information. The first twenty-five pages of his book the author has devoted to an “Introduction” on the general signs of wasting, and the points of importance in the diagnosis and general treatment of this grave disorder. ~ Commencing with Chapter I., we find the special causes of wasting taken up in the following order: I. Simple Atrophy from Insufficient Nourishment, II. Chronic Diarrhoea, III. Chronic Vomiting, IV. Rickets, V. Congenital Syphilis, VI. Worms, VII. Chronic Tuberculosis, VIII. Chronic Pulmonary Phthisis. Each of these subjects is care‘ fully considered in regard to their complications, causes, ana- tomical characters, diagnosis, prognosis, prevention, and treat- ment. The chapters deserving of special mention are those on “Atrophy from Insufficient Nourishment; ” “Chronic Diar- rhoea,” “Chronic Vomiting,” “ Syphilis,” and “Worms.” In the former will be found sterling advice as to the food of the infant, and directions for artificial feeding, which Dr. S. enjoins Reviews and ZVotioes of Books. 7 51 should not be resorted to except from the most urgent necessity, as when the mother is unable to nurse the child and a wet-nurse cannot supply her place. Here we also find directions as to the time and method of weaning, and the treatment of the numerous ailments which often follow this important change in the infant’s life. Indeed, we cannot but think that much good would en- sue if this chapter were studied by every mother, for they would then know how to prevent much of the sickness incurred by their children, and which in very many instances arises from their total ignorance of the most trivial points as to their care. The chapters on Chronic Diarrhoea and Chronic Vomiting may be called excellent. The directions which we find for the prevention of the firstnamed disorder are such as have been found valuable in our experience, and strict attention to which is absolutely necessary before we can expect to get a mastery over the disease. We wish we could lay before our readers many important por- tions of this excellent treatise, but space will not allow us. We are therefore obliged to content ourselves with recommending to the profession this valuable book, which they will find capable of affording much reliable information for the reinvigoration of many a wasted little one. D. THE HISTORY or NINE CASES OF OVARIOTOMY. By T. GAIL- LARD THOMAS, M.D., Professor of Obstetrics and Diseases of Women and Children in the College of Physicians and Sur- geons, New York, etc. From Bellevue and Charity Hospital Reports. pp. 27. DR. THOMAS’ paper is an exceedingly excellent one in many features, and discusses a subject of great universal interest. Be- fore relating his nine cases Dr. T. gives some valuable remarks on the operation, especially in regard to the influences which tend to keep up the high rate of mortality which attends this op- eration. Among these he thinks “must be mentioned the ne- cessity for cutting into the peritonaeum, exposing this delicate and important structure for a long time, and often leaving vessels open upon its surface, or within its cavity, which pour out blood that serves as material for putrefaction. Second, the difficulty of diagnosis must not be lost sight of. It is safe to say that in no pathological condition for which surgical procedure is adopt- ed, not excepting that of internal aneurism, is this difficulty equalled.” Lastly, Dr. T. expresses it as his opinion that the mortality is greatly increased by the fact that “the operation of ovariotomy is at resent often performed by men inexperienced in the diagnosis an treatment of ovarian tumors. The statistics of some of the wiisfinfi. a... .. P... . ...... . - . . . . t . "first": , . . . w...‘ .i . . 3%. i. , . .. .. “a... v... 1 3.1.3.1... .-..v~ . . J1... v4.1.3... . . .,. . . . . Nathan...“ .» . . #1.». . . . v . l. . . r . liiiiilzwlst A. . 4.1... .wuhd .. . . . ..‘..._.~ .:.~ .. . . ..|l.lli.lilllili\% . ....l;......,. .1.- .....;.-....--. . , . x .. . . ....|U......1.......n.u. .. . .3 5.. l... . I! . . . . . . . 1. . 2. d . . . . . . 1A).. .. 4 31.": ‘v. . . . . . 1......) . 1.14.1; . . . . . . 3 . . . t . . . . . . . . . ... 2.... . . . . . J . . .. H......_..U.... .. . . .. 1.. . .. .. . . . . . . . . 3.? v 1.1.3.: . . . . ...r .. . . .. . . ZIP-Mr. . . . .fvnfinwn w... ....: .01....“ .‘h-BI . . a... MVP.” . . . . . lime...- ... d (.11.. .....i..~....~.a}. Alsace»... . 1.." ....r.. 7..., .. ... . . .. . -.I .. a ‘3v fl... tetra... up vi to . Eel... ... ..... .35.}... . r-.. .T...T:v.i~.. .1}: 11.7w. 1.1:7i-2I . . . a . l - I . . v. . . . . . . . 1...... L . . . . . . . . . . . 3». . . . . . . . . . hm‘? r... e ........ .... . . 53.... .al .21.}... J?’ .91.. . . i .r. ... . . {It . . ............ .9 a .152. . . 1...... . .|.. Ir .vll . . . . . . . . s a... . . . 1 .. nth-t;- . . . . . . 1.3.1.1., : 4"‘ .y . ~ I . 2». . . . . . . . . . . . .».{_.1...d...r>.r.». .1... . . Jun. ................. .lixi... . . . . . ‘i1... . . . . . . . .¢ f i-Afiyt: . . . .... .1. . .4....a:i.f..2 :irRIn-f. 1v 1. 1......- ‘.93... . C. .1 .l 4 . v ..... .. uiiif... tit-R. . . .'........-...».;- . .rlnrrfififlvly- ->_|¢.I1A . ‘nial-.1! I“.\I..I.AII lvvstl>’du |~. . . fits}. . . . 2.. .1‘... . ..~n........ A................v . mu... can... . 5501...... . . ani....- ..... .11.". .k .2? . 1... 1.41.. ..... |\..,-;:.n-w.... . J: . . . ..~. . .|.v-v..l>v;J||)'v-... .. ‘Chi... .. . . .. ..... ,....... .. ... ...r......... 2...... . , . . . . 5.: I. e. A... >.1 . ($1.1M. . . . . . 1 511a...)- é...“ . first... , a 5m.» . .. ...........H.....r.. . Err-4?. 5.3.22.1... 3.... .1. .. ..,_ n..,o..~r. is .f . a . . . -..-:.\...1,. . .. . .2)... .‘M . ‘nzrfltisififlrillnt. :11 . . . . . . . . . . . . . . .. . . . . . . . I. .. .v'1-.,1. . 1.1.5.2.... a". .3. .. . iiiviil. i... . 3...... . r. .........i........ .11... .... ...... .. .Z...... 1.. . . . Q. iflfiflw Mai...‘ . i .... . ... . . .. .m i '37.. fr: ./ . 3 a. 1. . T . . .fitw... x . n t f ..w...w|....n1.. .. Irv iinlllel .r. v.1, . .. ... ... is... . . v..... .'>.-....\.-..a;..i... . c3211.... . ..... a... ......“.v...%n.~....\ ....> . . . . . . . . . . 7.. tililil. . 1...: . . .. . . 1 a . . . . . . I .. .u . r .... . . . .f..n.n....u. 1.... . . . . . . T... .>. .........|.. . . . . . vztiiilb . . a. ..'.\..-......La.-..>.~.. a . . LAT... . . . . ani.-9.4»? ,w)............a mama-drier . . . . . .. . . . . . 0..\.F4.:.\P.vl v. . J.r.. . .RFJI... 1.! . . . 1 . iiulliliiii...wile I'll. . ..-;.. . . . ch. . . ._ i9... .. a... . .t. .. 3. ........ "a." . .........,. . t . tus-vii stint’ it, . . . . .. silllziilildillt . . . . . .11... {If/(“Tif- . . . . 2111i- .1 . . .. 1.. I . a . . ‘.1 ...... .twuhmflf. V4.3. .; ..|.. 1.1. . 4livviJt. . . . . .. . . . iwflmaruunun...9.3.“... . 2.9V”..- .2 . gill...’ ...........n. fills"... 1535..."... +1.“ 14.1“.- iii... ii... .2... .5... u. .m-Suhr 35.3.5»?.....,.§.\.3n.+inn. . . . . . . . .......fr.|;i . . t iiilfly... iii-3L}... 2333a..." .. . . . . a... . nnfllfamtiuwfln. . . ..... .. .3 L . . .. ti...) AHUAIL 3 . . Iii‘, . . . rift. .1... Dari}: . . ‘Iii...’ ‘vigil... . i. . . ‘.6... J.- . .. . . ......;..... .. . ......;v.r.a..:...... . . . . . .. Y . (.finfIfl/fllfi V. . . . . f»!- wflulrn. . . . I" inf-1.: . ‘f...’ . 5:1... ..... iiiievfiki . .. . .. . . . . . i. . .... . wins-bin. 31...... . . and... .......>...... . .7. . ................. .5...) . H... .1...“ P vivid-loll. . ivfitlspilsri (Plait. to ‘all. lrlvdvarirullrvlivffl . i . . . ....bh....nl.....v?wm . 1.. ... If .uffxuhulmenflv» than...‘ ilwrritltflvfvfril (r: |.r:1».. 1(1):»). ill-.2111 .533»... 3. Q . .. .1... ...¢...~.,.,....... .flnnll. in, . . . .. a . ... IJJILV . . . . . . .izoit-iifxiisv . .iiiit it}. . . (1H,“. txrhllw? . . . . Annhumnu . . .. 1:1,... .Jrw It FY'IYIIlIJI ! V I. ll». it ‘I. Ir .- frao er: lav.lv?tlln.h. ....... 3.“... .. wlfhrllnli Vi . .Kukfllhhfiét . . ufllukruv. I! . _ iii! an: - ,- rlvrlwl. ii. . t. A...‘ r. ‘in? it. v . . .. . ....,......Aa...r. In»... - .fifiQY I.‘ It! I 0' I Ii . ... t.“ . a l . 3...»... Emma... h...‘ . ltfilltvvle. If... . . . . . . . . . . Lair... 1115s.. 1...... i . . . . . 2 . .. I: Kuhn . . r . I a... b...‘ . . viii-1M1.) i.» 191/»: til it suit.‘ tihlifhviV-i”! . ....n.vur.r...r.. . 22.7.... .rH .mh-§......1..' ..... {in uan-aitavts t !n¢w...uviv|'z»r|&. .. . . . 1 r.‘ 4....- . .b... {456.1 . :17. M.; ¢/....lu LL... . . uufxsrr .v. .5...‘ l i i... an? 1Jv.. ,. e i x . . . .Lr flfiuwvfirkfiiit . use: .6. n t... :11’. lvtmrilnrwfliivriv ’ . . . . .1v.. l . . . .1 .. .....-.v \_...|i . J“?- QJv. .. 134.0, .J .41.}: A-srJ; Zulu... 1?. vi...‘ {3.1.}... {nun/u.’ it)... . i . 51:11! {5.8a var’. .. t Z 1. an .lnifilijJOifi-I It l..f.|..r-v| . . . . . . . . . n. t .: fiosvl. 1..’ ' 14.}: .11.}. .. J . . . . . . . . . . . . . . . . . . . . s t . . I "-319.03... .| . van-I J... . wan. Y. .3“ .In. .5}. 1 i.- . ht‘... .5. h’... 0 i. . ..... a... 4.. . e t 32. hr“... . . . .. 5... b. l. .2 swnhéfiznu. . 4.1.... a... . . . . . 513.3%!’ 1Jt>§¢$$ beta/)1; (it: . . . .. . I I! . . . . t : . . . . . . . in In}... Q. L... E. e 1 . f . . i .JIFIIJ a! Q's/u .... it fl . .v . . .llvrlil . . 1.. .vi. .ii... i. » val-.4": 5.41.5151“ C); vs’: II...‘ 1:. i I . hr hit-5v .9; 13!. .u!. tenure/sf i...|w..r :...s./;all)...‘ 1.. .1 e .. . . ‘I .... .1 37hr“ 1'4 .a... can... a... 9.1a»... . . . . . . I I i ill I {III ‘ .. . . , $3.5m. urn _ 255.14.... .uws-l . {65 ¥.1.5- ahwkutunknui a?» humans. whys mu...“ .0. ... . -. . .. nauisvaaihké. ha.’ 5.. . . Harm a . . . .. . _ . . r i. . s . . . . . nu...“- onunun-z ...' -_. a.” uh fir. ./ v .31.‘... ....H....I.n.)....V-.vv.. :4. 4.... . d-al.h..a.a:ri..r. waif-m... 5.1. -1-i....i..!f1.7. Q... i. . . . . . s z .u l . . adv ..... .. .. .~.,..1.... . . . wt .1... .. I. - .. .1. l flies-f... .... I)... I . but .vamriwbiflwwbwnnnwtwmnu burn-.1“. . NU.“ a... . . . . . .. am...‘ “to... a a .. er . J . f. h. s’... b .r. . . . . . . val-wind .- m (7.... a .5. p ‘W117?! wr$../....Vl..!v4o.~v1< 1.3.7’. .Hr. . s . 1. |.|'.rn..11.|~v...fi.iw..|n. .a. . . .11. .. 3. _ d,“ 1!.) ll. Marv...” fl. with iaflilitasvi. 5.. . . . . id's-nial.» . . 3TH... irvr .\ . m....m.T-{.:. . we. . . 5...... .. . T: tflfiwua .L \. I; :a 91.5%)... Mus-n . r. train. v- a. .. 6N‘. “La/KL. iLl . wfiw. LIT \ 1.0.1..‘ 1.1.1. hi... flaw-similar ".1431. its. n1» ‘QT/.5...‘ v i’... $14.3.’ ‘a i ii I . s 4.... .5 .vv . . . . . 4.14mi! rrnnlvusahnuxrm .$2.7.“muwrfinfirwl... 1245A..- . . . . ffevvslzrlrrltviisf ,...~.l.a.v..:;1.r~v..:.f.-.vt v». . . . . “2.4.3.511; . . . . . . . . . - \(PMT. an...’ rrfT-r . . . 3...... . r... an.» s. . . . .. . mun-1. ....»...... .. whit-v, . FHA.» . .. .. 1.“. . 28..., ‘v.2... I l. a. atrial... arr . . . . . ...... . 33.x . I. .... l; I 1... .1 Are-av“ A.” .... ....\:.n.........,..... . . , . . . . or... iii... , . .................._ae.e...ms . . . . . . . . .. . . ..x......w......m..rwha..iv.ww. . . . . . . . , . . .. 1. . ids... Z . . , . . . h.......w......v...........