OUTWETC THEMA DIASTASE PAPOID PAPAIN PEPSIN PANCREATIN MO Dushman MUTLULUN TABLET "CAROID CHARCOAL AND CHAS. ROOME PARMELE CO. NEW YORK. CAROL The Alienist and neurologist '3 I THE ftlienigt and If eupologi§t A QUARTERLY JOURNAL ■ OF Scientific, Clinical and Forensic Psychiatry and Neurology. Intended especially to subserve the wants of the General (Practitioner of J&edicine. "Quantam ego quidem video motus morbosi fere omnes a motibus in systemate nervorum Ita pendent u morbi fere omn es quodammodo Nervosi dici queant."—Cullen's Nosoloty: Book II,, p. 181—Edinburgk Ed. 178 0 VOLUME XVIII. Published and Edited by C. H. HUGHES, M. D., And an associate corps of collaborators. DAVID S. BOOTH, M. D., BUSINESS MANAGER. ST. LOUIS: Press of Huglies i~ Company. 1897. CONTRIBUTORS AND COLLABORATORS. VOLUME XVIII. HARRIET C. B. ALEXANDER, Chicago. MARTIN W. BARR, Elwyn, Pa. SIR FREDERICK BATEMAN, England. CLARK BELL, Esq., New York. DAVID S. BOOTH, St. Louis. SUSANNA P. BOYLE, Toronto, Canada. SANGER BROWN. Chicago. W. S. CHRISTOPHER, Chicago. S. V. CLEVENGER, Chicago. F. X. DERCUM, Philadelphia. F. GENERAL!, Italy. ARR1GO G1ANNONE, Italy. C. C. HERSMAN, Pittsburg. WM. HIRSCH, New York. ALEX. L. HODGDON, Baltimore. WILLIAM LEE HOWARD, Baltimore. C. H. HUGHES, St. Louis. JAS. G. KIERNAN, Chicago. BEVERLEY O. KINNEAR, New York. Buffalo. Chicago. Chicago. WILLIAM C. KRAUSS, SYDNEY KUH, HAROLD N. MOVER, JOHN PUNTON, Kansas City. J. H. WALLACE RHE1N, Philadelphia. HALDOR SNe've', St. Paul. J. SOURY, France. H. P. STEARNS, Hartford. EUGENIO TANZI, Florence, Italy. J. NELSON TEETER, Utica, N. Y. G. VASSALE, Italy. INDEX TO VOLUME XVIII. ORIGINAL CONTRIBUTIONS. Analgesia of the Ulnar Nerve in the Insane 10 Cyclone Neuroses 52 Defense of Modern Psychiatry 48 Encephalitic and Late Epilepsy 168 Hygiene of Degeneracy 359 Imperative Conceptions 43 Insane Confessions 560 Insane Hereditary. Insane and Con- Sanguine Marriages. Etc 1 Interaction of Somatic and Psychic Disorder 28 Neurasthenia 491 Neurasthenia Essentialis and Neuras- thenia Symptomatica 465 Neurological Progress in America 263 On Intemperance, Con-Sanguine Mar- riages, and Educational Over- Pressure, as Factors in the Gene- sis of Nerve Disease and Degen- eration of the Race 122 On the Effects of Extirpation of the Parathyroid Glands „ 57 Preputial Reflex Epileptiform Convul- sions, with Report of a Case 119 President's Annual Address 477 Psychical Hermaphroditism. A Few Notes on Sexual Perversion, with Two Clinical Cases of Sexual In- version Ill , Psychoses of Old Age 180 Report of a Case of Brain Syphilis He- roically Treated with Mercury, Followed by a Mercurial Neuritis and Recovery 22 Suicide 502 Syphilis of the Central Nervous Sys- tem 510 The Action of the Nervous System over the Nutritive Processes, in Health and Disease 538 The Auto-Toxic Origin of Epilepsy 203 The Case of Sturgeon Young, A Ques- tion of Hypnotic Injury and Death 153 The Civic Duties and Responsibilities of the Physician to his Community, State and Nation 404 Tic Convulsif Replacing Supra-Orbital Neuralgia 397 The Limits of Psychology 340 The Medico-Legal Aspect of Eroto- Choreic Insanities 414 The Occipital Lobe and Mental Vision.. 399 The Significance of "Degeneration" to the General Practitioner 547 The Stigmata of Degeneration 62 What is Meningitis? 132 Tremor and Tremor-like Movements in Chorea 496 237251 iv Index. SELECTIONS. NEURO-THERAPY— A Case of Cerebro-Spinal Meningitis Complicating Gonorrhoea Treated by Antikamnia 216 Are You in Pain? 576 Antikamnia and the Neuroses 67 Auto-Intoxication and Fig Syrup 68 Consciousness in Epilepsy 213 Division of the Cervical Sympathetic in Cases of Exophthalmic Goitre ... 67 Effect of the X-Ray on the Central Nervous System 212 Hyoscyamine for Paralysis Agitans 419 Injections of Osmic Acid for Neuralgia 214 Insomnia 68 Intestinal Antiseptics in Insanity 213 In What Cases of Insanity is Thyroid Extract Useful? 419 Neuropathic Heart 214 Saline Subcutaneous Transfusion in the Insane 214 Tabes Dorsalis 67 The Anti-rheumatic Action of Salicylate of Strontium 69 The Fleschig Method and Hydrocyanides in Epilepsy 576 Therapeutic Value of Mercury and Ar- senic 215 The Treatment of Atony of the Small Intestine in Neurasthenics 212 Thyroid Extract in Menopause Mental Disorder 579 Thyroid Gland in Insanity 577 Unusual Efforts of the Bromides 67 PSYCHIATRY— Bed Treatment of Melanaholia 581 Committee on Diseases of the Mind and Nervous Diseases 424 Etiology of General Paralysis of the Insane 580 Malingering by an Insane Hypochon- driac 582 Mental Therapeutics 69 Neuropathic Heredity and Aicoholism, and Vice Versa 216 Prevention of Insanity: The Duty of Psychiatry and the State 226 Specific Treatment for Active Forms of Insanity 582 Steps Toward Insanity 579 Syphilitic Melancholia 423 The Case of Spurgeon Young—Death Due to Hypnotism by Unskilled Amateurs 421 NEUROSURGERY— Some General Principles that should Govern Operations for Otitic Brain Disease 584 Surgery in Exophthalmic Goitre 585 CLINICAL PSYCHIATRY— A Case of Cerebral Abscess Situated at the Posterior Part of the External Capsule 71 Another Idiot Savant 73 Communicated Insanity 70 The Relations of Aicoholism to Insanity 69 Index. V PSYCHO-THERAPY— Early Treatment of the Insane 73 Danger of Home Detention of the Insane 227 Hyoscin Hydrobromin in the Treatment of Insanity 74 CLINICAL NEUROLOGY— A Case Showing the Nature of Perfor- ating Necrosis of the Spinal Cord.. 78 Aetiologies of Epilepsy 594 An Enormous Dose without Death 80 Aphasia in Polyglots 75 Birth-Palsy 431 Brain Tolerance to Traumatism 75 Cardiac Neurosis of Sexual Origin 588 Classification of Epilepsy 75 Choked Disc and Prognosis 597 Constipation in the Insane 432 Emotion Dyspepsia 430 Etiology of Graves' Disease 589 Fissure of Rolando 592 Hereditary Hydrocephalus 59"2 Hysteria: A Favorable Prognosis Not Always Safe 228 Hysteria and Epilepsy 596 Hysteric P^sis 591 Increase of Insanity and Consumption Among the Negro Population of the South Since the War 428 Influence of Tobacco on the Nervous System 587 lodothyrine in Myxoedema and Goitre 593 Kerosene in Aicoholism 228 Mental Fatigue and Exercise 77 Mental State of the Nurse and Health of the Nursling 590 Neurasthenia - 426 Neurasthenia and General Nutrition ... 431 Partial Rupture of the Spinal Cord without Fracture of the Spine 586 Pseudo-spastic Paresis with Tremor after Trauma 586 Stigmata of Degeneration 76 Tactile Amnesia 589 The Genitalia and General Nutrition.. 590 The Nervous Manifestations of Syphilis 587 The Symptomatology and Pathology of Exophthalmic Goitre 79 Thymus Gland in Exophthalmic Goitre 593 Tic Doloroux 590 Weather Neuroses 77 Untoward Effects of Trional 432 NEURO-DIAGNOSIS— Hysteria Diagnosis 440 Roentgen Ray Locates Bullets Through the Skull 81 NEUROPHYSIOLOGY— Heart and Thyroid Innervation 599 Influence of the Vagus on the Secretion the Urine 81 The So-Called Convulsion Centre and Centre for Locomotion in the Re- gion of the Pons 597 NEURONYMY— Neuronymic Progress in America 439 vi Index. NEUROPATHOLOGY— # Epilepsy—Autopsy 433 Neurasthenia as a Toxic Neurosis 231 Pathogenesis of Syringomyelia 601 Pathology of Bulbo-Spinal Atropho- Spastic Paralyses 437 The Pathology of Aphasia 434 Trauma, Tabes and Multiple Sclerosis.. 600 ED J 7 A Big Meeting 444 According to Holy Writ 94 A Critique on a Crooked Idea 605 A New Materia Medica by Dr. Frank P. Foster 90 American Medico-Psychological Asso- ciation 251 American Public Health Association 246 Among the Neurological Treatises 92 Aphasia Medico-Legally Considered ... 239 A Physician in the Cabinet 98 Asexualization for Crime 447 Association of Assistant Physicians of Hospitals for the Insane 249 Atrophine Versus Quinine Tinnitus 250 A Study in Morbid Egoism 240 A Tough Citizen 91 Bi-Lateral Psychomotor Myosynchrony 245 Change of Address 240 Change of Name 92 Charles VI 247 Congres International de Medecine 251 Des Attitudes Anormales, Spontanees ou Provoquees, Dans le Tabes Dorsal Sans Arthropathies 95 NEURIATRY— Nervous Functions of the Suprarenal Capsules 230 The Pupils in Paresis 229 The Traumatic Neuroses in their Medi- co-Legal Relations 228 4LS. Dr. Frank Parsons Norbury 84 Dr. Frank Wilfred Page 100 Dr. John B. Hamilton 89 Dr. John H. Callender 91 Dr. P. M. Wise 89 Dr. P. O. Hooper Re-Elected 85 Dr. William F. Drewry 100 Duchenne and Neurology 610 Female Escort for Insane Women 249 Gayety and Gloom 246 Gimlette 448 Hereditary Neuropathy and Crime 91 Higher Medical Education 232 Hobart A. Hare 238 Illinois Eastern Hospital for Insane 247 International Medical Congress * 250 Kleptomania and the Case of Mrs. Castle: 236 Lord Roberts' "Forty-one Years in India" 617 Medico-Legal Society 101 Medico-Psychological Association 444 Medico-Psychological Association of Great Britain and Ireland 84 Index. .vii Medico-Psychological Association of Great Britain and Ireland 246 Meeting of the American Medical Pub- lishers' Association 247 Meeting of the Missouri State Medical Association 248 Mimic Locomotor Ataxias 89 Mississippi Valley Medical Association 448 Modern Greek as the Language of Science 84 National Confederation of State Med- ical Examining and Licensing Boards 238 Neuriatry and Psychiatry 87 New Pathological Department 238 Notice to Subscribers and News Agents 95 Our Mutual Interests 83 Over the Hookah 92 Physical Rest Versus Gymnastics after Study 247 Poetic Therapy 245 Program of the Section on Neurology and Medical Jurisprudence of the American Medical Association 233 Psychiatry and Neurology at Moscow 611 Psychalia or Mentalia 603 Schlatter Dead 445 Section on Neurology and Medical Jur- isprudence! 442 Selected Good Advice 451 Southern Surgical and Gynecological Association 102 Tennessee Centennial and International Exposition, Nashville, Tenn 247 The American Electro-Therapeutic As- sociation... 102 The American Journal of Insanity 444 The American Medical Association Semi- centennial 450 The Barnes Medical College and the Cleveland Medical Journal 84 To Castrate the Crippled in Mind 451 The Change in the Presidency of the State Commission in Lunacy 96 The First Medical Degree in New Eng- land 610 The Foreign Cult in American Medi- cint 488 The Functions of the Neuron 93 The Loud Bill 90 The Management of the Journal of Nervous and Mental Disease 92 Teach Medical History 94 The Medical Staff of the Illinois Hos- pital for Insane 247 The Medico-Legal Journal 99 The Philadelphia Neurological Society 445 The Physician as a Citizen 248 The Physicians of Santa Clara County, Cal 95 The Relationship of Pedology to Neu- rology 83 Therapeutic Skepticism 604 The Rights of the Insane in State Hos- pitals 242 The Second Pan-American Medical Congress 86 The Section on Neurology and Medical Jurisprudence 452 The Semi-Centennial Meeting of the American Medical Association 245 The Southern Surgical and Gynecolog- ical Association 90 viii Index. The Training School for Nurses 444 The True Criteria of Insanity 86 The Unreliability of Borax 92 The Value of a Knowledge of Neurology 100 To the Members of the Medical Profes- sion 88 Toxic Neuriatry 248 A Practical Treatise on Medical Diag- nosis 105 About Children 626 Architecture of the Brain, Illustrated 104 A Treatise on Appendicitis 105 Clinical Lessons on Nervous Diseases.. 258 Clouston on Mental Diseases 257 Contrare Geschlechtsgefuchl(Sexual In- version) 104 Diseases of the Ear, Nose and Throat and their Accessory Cavities 258 Disorders About Children 626 Eye Strain in Health and Disease 458 Genius and Degeneration 104 Hysteria and Certain Allied Conditions 455 La Nouvelle Iconographie de la Salpe- triére entre dans sa dixieme annee d'existence 256 Manual of Medical Jurisprudence 625 Tri-State Medical Society 237 Twelfth International Medical Congress, Moscow 452 Typhoidous States 235 University for the State of Missouri ... 249 We Acknowledge an Invitation 445 William W. Ireland's Early Honors 445 Manual of Static Electricity in X-Ray and Therapeutic Uses 256 Merrell's Digest of Materia Medica and Pharmacy 257 Neural Terms, International and Na- tional 460 Over the Hookah; the Tales of a Talk- ative Doctor 103 Physician's Visiting List 105 Sajous' Annual 626 Sexual Disorders of Male and Female.. 621 Text-Book of Mental Diseases 459 The July Monist 459 The Leading Article 255 The Menopause 460 The Non-Heredity of Inebriety 103 Traumatic Injuries of the Brain and Its Membranes 625 REVIEWS. THE Alienist and Neurologist. VOL. XVIII. ST. LOUIS, JANUARY, 1897. No. .1 ORIGINAL CONTRIBUTIONS. INSANE HEREDITY. INSANE AND CON- SANGUINE MARRIAGES, ETC.* By H. P. STEARNS, Superintendent of the Hartford Retreat Tor the Insane. Hartford. Conn. THERE have been eighty-seven admissions during the past year. Seven of these were of persons who had formerly been in the Retreat. On examination I find that twenty-eight of these eighty-seven persons were reported to have had some relative who had been insane; that' is thirty-five per cent, of the whole number. In seeking for information in relation to heredity relating to insanity I have examined the records of 870 persons, all of them ad- mitted to the Retreat during the last ten years. Of these 193 were known to have had an inheritance of insanity, either direct or indirect. 1 h ave thought it might be of in- *Report to the Board of Directors. April, 1896. [i] 2 H. P. Steams. terest to exhibit by means of a table in what form and de gree this heredity appeared, and herewith subjoin one: « AuntsJ si e « 0 < C c i .other. randfal rother ncie or ncles a i 0 oubtfut £ C c m Je c O 5 ca Melancholia, 17 16 11 5 2 47 7 Mania, 11 20 2 3 18 9 3 62 7 Delusional, 6 1 4 1 3 4 2 20 Dementia, : i 1 2 4 1 16 5 Epochal, 3 4 1 6 5 2 18 4 Sexual, 2 1 2 "i "i 1 15 Toxic, 5 3 1 47 Neuropathic, "3 "i 1 i 2 1 Other Forms. 3 3 17 6 Total, 46 50 10 9 41 35 12 230 45 Total numbers, 870; total heredities, 193; unknown. 230; doubtful, 45; parents of known and reported heredities, 22+; parents of doubtful, 5+: parents of unknown, 26+. From this table it appears that there was an inheritance of insanity in some degree in 22+ per cent, of the num- ber. It also appears that heredity may, and often does, become a most important factor in the causation of insanity; but how great its importance may be in this respect does not appear from the above statistics, nor indeed from the statis- tics of other institutions for the insane. These are neces- sarily of a very imperfect character. We are nearly always obliged to depend upon persons who attended the patients when they were admitted for information in this respect, and unless they are intimately acquainted with the family history they are unable to give it with accuracy. In many cases when attended by relatives, it is not easy to obtain the family history in this respect, as it is not unfrequently regarded as important to conceal the fact of the existence of insanity in the family. Still, imperfect as they are, they may serve as a basis for some consideration relating to the subject of heredity; for while we understand little relating Insane Heredity. 3 to the essential nature of heredity, we do know something about its phenomena. Heredity may be defined as that peculiar quality or prop- erty of organisms which enables them to transmit their es- sential characters to their descendants. Its action appears to be universal and covers all forms of life, whether vege- table, animal, or human. Its roots reach down into the very elements of all living structures, and it appears to be one of the essentials of life itself. It passes beyond the bounds of healthy functions into morbid conditions of both mind and body. But the modus operandi of this marvelous process—this universal biological law—has always hitherto remained, and perhaps still does remain, a sealed book. By what process or method this influence may extend over several generations, manifesting itself in some particular form or disease in one or more persons, and in no others; affecting one member of the family and not another of the same family; how a peculiar character, such as the color of an eye, the hair, the skin; the size and form of the mouth, the teeth, the lips; the contour of the chin, the cheek, the nose, the hand, the foot; the mental and moral characteris- tics, and even peculiar movements of the hands and body, may all appear in one or more individuals in a generation and in no others, these physiological processes have, 1 say, remained a mystery while observers have been obliged to occupy themselves with the study merely of certain phe- nomena and characters in organism which we say are due to hereditary influences. Within comparatively few years, however, the study of this subject has received a new impetus. It now relates not so much to the character of the results as it does to the intricate and delicate arrangements which nature has provided for securing these far-reaching results. This part of the subject, however, is too complicated and abstruse, and the terms used in its description are too technical to be introduced in a report of this kind. My present purpose has to do with another phase of the subject, viz.: that re- lating to mental disorders. In a condition of ordinary health the thought process 4 H. P. Stearns. occurs automatically except during the hours of sleep, and even then it may eventuate in what we call dreams, the character of which the person has a sort of subconscious realization. Its activity, however, during dreams is not sub- ject to the will of the individual. During our waking hours the impressions received upon the end organs of the five senses, and from the revival of the stored-up experiences of the past, give rise to mental activities which express themselves in the form of speech or motion, if they eventu- ate in outward manifestations at all. But it is frequently the case that these thought activities do not pass from the brain and discharge themselves in any form of outward manifestation. They can be arrested and examined by the personality; be approved or disapproved; be analyzed or modified, and formed into new combinations which commend themselves more or less fully to the personality and thus become opinions and beliefs; or they can be disapproved and rejected. Such is a brief word in the physiological action of that portion of the brain, the function of which relates to sensa- tion, preception, and thought, when it is in a state of nor- mal and conscious activity. But when by reason of unfavorable influences and experiences, such as over-exertion, long-continued anxiety, uncertainty, and worry, ill health; or from the effects of poisons acting upon its delicate structure, such as foul air, alcohol, opium, and the products of disorganized tissues of the system which have not been eliminated from it; or again from the influence of unfavorable inheritances; these physi- ological activities of the brain become deranged and changed in character so that the actions and reactions are no longer normal, the effects are manifested in states of mind which are termed insanity. In other words that condition of mind which we term insanity arises from or consists in the mor- bid and disordered activities of certain portions of the brain and general nervous system. Now when the brain has once become deranged in its normal action or has passed through the storm of excite- ment attending an attack of mania, or the profoundly Insane Heredity. 5 depressed condition usual in melancholia and other forms of insanity, its cell structures do not readily return to a state of healthy function. On the contrary, there is likely to remain for a long time a super-sensitive condition of it, and more or less of probability that from the experiences of uncertainty, trouble, and disappointment, there will again occur a disorder of mental function. Habit of action in the normal condition becomes a sort of second nature to most persons—much more does a habit of action which has been established in a disordered state of the brain tend to become permanent, or liable to return again if recovered from. Now it is this acquired or inherited tendency of the brain towards unstable and morbid action that is likely to be transmitted to succeeding generations. Indeed, 1 think it may be claimed without fear of dispute that this condition of the brain when it has once eventuated in insanity is more likely to be transmitted than almost any other morbid tendency. It should be added in this connection that it is not nec- essary that the peculiar condition in the parent should have eventuated in actual insanity to insure its doing so in the offspring. It is not unfrequently observed that qualities of mental action in one parent which have been regarded as nothing more than eccentricities or peculiarities—sometimes eventuating in periods of depression and a morbid irritability —when crossed with certain characteristics in the other parent, the nature of which may not be known—not un- frequently develop into one of actual insanity in succeeding generations. Again, a tendency towards some one diathesis or form of disease in one generation may assume in a succeeding gen- eration a different form of disease or diathesis. For instance, a consumptive or rheumatic parent may have child- ren who are quite free from tendencies towards these par- ticular forms of disease and yet inherit a brain of such an unstable organization that it has attacks of insanity; or vice versa, a parent who has been effected with an attack of insanity may have children with a consumptive or scrof- ulous tendency. 6 H. P. Stearm. On the other hand, if one of the parents has a vigorous constitution and a nervous system unusually robust, and is endowed with a tendency to longevity, these qualities may prove sufficiently potent to overbalance any weakness and tendencies toward disease in the other parent and the off- spring may be healthy, though in some degree affected by the infirmities of the weaker parent. Some persons and fam- ilies also seem to be endowed with unusual ability in trans- mitting healthy characteristics of race and nationality, and this may prove an important factor towards eliminating ten- dencies to disease on the other side of the house. In these two characters or qualities, which we may assume exist to some extent in all healthy persons, there is contained a power of incalculable value to the human race—indeed, one essential to its continued existence—that is a tendency on one side to overcome weakness and disease on the other which might otherwise continue to increase, especially under the influence of unfavorable environments. From these considerations the danger from consanguin- eous marriages becomes apparent. Statistics relating to this subject, however, appear at first view to point in opposite directions. For example, the ancient Egyptians, the Per- sians, and Syrians and many othernations were accustomed to contract consanguineous marriages in all degrees of rela- tionship. The Seleucidae and Lagidae followed this prac- tice during long periods, and both these races were remark- able for their vigorous and healthy physical constitutions and great power of endurance. On the other hand, the tables of statistics compiled by Dr. Bemis and others present abundant evidence going to demonstrate that among some families living in more recent times intermarriages result very disastrously. The children are not unfrequently deaf-mutes or idiots, scrofulous, phthis- ical, insane, or deficient, both in body and mind to some extent. Again, experiments with interbreeding cattle, possessing certain strains of blood, seem to prove that this may be continued for several generations without apparent unfavor- able results, and possibly with good results in some direc- Insane Heredity. 7 tions. I formerly had a flock of India pigeons which inter- bred apparently without deterioration for many years. They remained healthy, strong, and very prolific. The same is true in reference to some families of rodents. On the other hand, there is much evidence that this can- not be practised with other classes of animals without unfavorable results. This is markedly the case with swine, dogs, hens, etc. It is necessary to often introduce new strains of blood to prevent rapid deterioration. The question now arises as to how we can reconcile these two classes of results which seem to be so opposite in their character. It appears to be evident that the mere fact of consanguinity is not of itself sufficient to explain the degenerative characters which are found to exist in some cases where it has been a factor. We have found its presence in numerous instances among different families of man and various classes of animals without apparent unfav- orable results. Therefore, when they do appear we must look for the cause in some other direction. We have de- fined heredity as that peculiar property of organisms which enables them to transmit their essential characters to their descendants. This peculiar function must therefore cover the transmission of bad as well as good characteristics, unhealthy as well as healthy conditions of the system ;and if there existed no tendencies towards disease, and no imper- fections, mental or physical, none could be transmitted. In other words, if both parents were in a state of perfect health, no deleterious results would follow in-and-in breed- ing, and it could be practiced indefinitely without harm to offspring. But in the present state of our civilization it is safe to conclude that there are no persons in absolute per- fect health, either of body or mind, and the same is true, though in a less degree, among other orders of animals. Different orders of animals, however, differ in this respect as much as different families of man. As a rule, cattle, rodents, and many classes of birds are healthy, while swine, hens, dogs, and sheep are subject to frequent at- tacks of disease; and it seems to be true that very largely as different orders of all animals, man included, are brought 8 H. P. Steams. out from a state of nature and subjected to the conditions pertaining to a state of what we call civilization, do they become effected with disordered conditions. We have not yet learned how to avoid these unfavorable results to either men or animals, and it appears that as the artificial re- straints and exactions of life become increased and intensi- fied, especially in the great cities, the various forms of dis- ordered function and disease multiply. In this way we see how much more danger there is that a morbid heredity will increase. Like tends to beget like, and if two persons with a tendency towards the same con- stitutional diathesis or disease marry, the tendency towards this disease becomes double in the offspring. In case only one parent has a morbid tendency, the influence of the other, if healthy and strong, may be sufficient to overcome and eliminate it in the offspring. Now persons and animals of the same family necessarily inherit the same tendencies toward health and disease to a greater or less extent, according to the degree of consan- guinity. Persons with no blood relationship are much less likely to have like tendencies. Indeed, they are likely to have characters which would have a counteracting influence upon such unfavorable tendencies in others. We readily, therefore, perceive the danger of unfavorable results from marriages among blood relations, not because of the mere fact of relationship, but because of the proba- bility of increasing characters and tendencies towards any special forms of disease which may exist in both parties. The question arises whether a person who has passed through an attack of insanity should contract marriage. It would not be easy to formulate a rule which would cover all cases and never be set aside; but in view of the fact that when one has once been insane he will ever after- wards be in great danger of another attack, it is of the greatest importance that all parties concerned should have a full understanding in relation to this feature of the case. The practice, more generally pursued, of keeping the fact that a person has had such an experience concealed, especi- ally when the party is a female, cannot be too strongly Insane Heredity. 9 censured. If after a full explanation, and the other party has consulted friends and obtained professional information as to the future prospects, he or she chooses to go forward and consummate marriage, it is in some respects a matter of their own concern. It would be so entirely in many cases if no children were to be born of such marriages, who would always live under the shadow of an impending danger from the beginning. The right of persons to inflict the state with children having such an inheritance, is very doubtful. If, however, the female is past the period of child-bearing, the objections to marriage, so far as they relate to children, would be nil. But when there is reason to anticipate a family, persons contracting marriage assume a responsibility which few physicians should be willing to advise. In case the insanity has been the development of an inheritance and has existed in either immediate or remote direct ancestors, the risk becomes greater. If on the other hand, the attack can be attributed to some accidental experience or physical disorder, and the other party has a vigorous constitution and good inheritance, the danger be- comes much less. In such cases there exists a reasonable probability that the stronger and more stable qualities of nerve tissue will triumph over and eliminate the weaker ones. It is true that there always exists a tendency in weak and partially diseased organisms, under favorable con- ditions, to return to a state of health, and if not, to die. ANALGESIA OF THE ULNAR NERVE IN THE INSANE.* By DR. ARRIGO GIANNONE. CROM the time when Biernacki first called attention to * the fact that in tabes there was very frequently anal- gesia of the ulnar nerve where it lies in the humero-cubital canal, a fact which, according to his researches in twenty individuals affected with tabes dorsalis, was verified in seventy per cent, of the cases, there have been many other observations made, the greater part of which tend to the conclusion that in some forms of mental disease this symptom may be of diagnostic importance. Cramer, on studying fifty-one paralytics, found that thirty-nine of them, that is about seventy-six per cent., presented an absolute analgesia of both sides, and seven had it on one side only, so that in all there were forty-six cases or about ninety per cent. In non-paralytics on the other hand there was marked reaction to pain in seventy-nine of the cases, so that from the very different behavior of the two classes investigated, he deduced the, fact that this analgesia might serve as a point in differential diagnosis. Otto Snell l3) followed Biernacki and Cramer and studied over one hundred insane, of whom twenty-five were paralytics and the other seventy-five had been selected from epileptics and other forms of chronic disease "in which we would naturally expect to find the greatest alterations in sensibility." He gives for the paralytics these results: * Translated from the Julv Revista di Patologia nervosa e mentale by Dr. Susanna P. Boyle. Toronto. Professor of Pathology and of Histology. Ontario Medical College for Women; Physician to Giri's Home, Toronto. [10] Analgesia of the Ulnar Nerve. 11 Ulnar symptom normal in four per cent, of cases, weak in forty per cent., lacking in fifty-six per cent. In non- paralytics it was normal in thirty-three per cent., weak in fifty-two per cent, and absent in fifteen per cent. Besides this Snell gives in a table the results obtained by him in the various diseases examined: Normal. Weak. Absent. Epileptics 22 5 or 23% 11 or 50% 6 or 27% Idiots S 1 "20" 4 "80" Primary Dementia 7 2 "29" 2 29" 3 "42" Secondary Dementia 7 6 "86" 1 "14" Senile Dementia 2 2 "100" Paranoiacs 21 6 "29" 13 "62" 2 Stuporous 6 2 "33" 4 "67" From these results we may conclude with Cramer that, compared with other forms of mental alienation, ulnar analgesia is most frequent in progressive paralysis. Orschansky (4) has published a series of researches carried out by him in Mendel's polyclinic, on sane individ- uals, on twenty cases of tabes, and on many individuals with other diseases. He arrives at the following conclusions: "Analgesia of the ulnar nerve is not at all characteristic of tabes, as in many diseases which are not nervous in origin the pain reaction is altogether absent, while, on the con- trary, in a certain number of cases of tabes it is neither lessened nor absent." Boedeker and Falkenberg, (s) from results arrived at by them very different from those reached by Cramer and Snell, conclude that the ulnar reaction is not typical of progressive paralysis nor can it be adopted as a means of differential diagnosis. In fact they obtained this anal- gesia, in the investigation of one hundred paralytic men and twenty-five women, in respectively fifty-eight per cent, and fifty-six per cent, of the cases while in two hundred psychopathic men and one hundred women there were respectively thirty-nine per cent, and thirty-three per cent. Hillenberg (6) attaches great importance to this symp- tom as a criterion of differential diagnosis, and obtained from sixty paralytics the following results: Forty-three had complete unilateral analgesia, seven had diminished 12 Dr. Arrigo Giannone. dolorific reaction and five had unilateral analgesia with diminished reaction on the other side, in all fifty-five or 91.6 per cent. On the other hand in the psychopathic patients 83.4 per cent, of the cases presented a normal ulnar * reaction. In epileptics on whom he made separate researches he found the analgesia in 76.9 per cent, of the cases in men and 70.07 per cent, in women or an average of 75.4 per cent, of all cases. The researches of Gobel (7) give the following results: In fifty-four cases, forty-seven presented total analgesia or 87.3 per cent., two had analgesia on one side, i. e., 3.5 per cent, and five reacted normally or 9.2 per cent.; in women also affected with paralytic dementia, 81.9 per cent, gave the pain reaction, in 13.6 per cent, there was total anal- gesia and in 4.5 per cent, unilateral analgesia, a result altogether opposed to those previously obtained. Obregia '8) observes that analgesia is very frequent in progressive paralysis (88 per cent.). Hess (9) brings statistics to prove that "analgesia of the ulnar nerve is one essential peculiarity of paralysis particularly of men"; in thirty cases, he found total analgesia in twenty-two, unilateral in one; in all, twenty-three had analgesia of the nerve; of the remaining seven, five felt pain and two had doubtful sensation, hence we have these proportions, 76.6 per cent, with analgesia and 16.6 per cent, without. In women the following results were obtained in twelve paralytics: disappearance on both sides in five cases, on one side only in one (50 percent.), normal in four and weak in two (50 per cent.). Taking together these two sets of statistics we find that analgesia was present in 69 per cent, of the cases. Hey has compiled a summary of all the cases hitherto studied and taken the average, and finds that in four hundred and seventeen cases of tabes and paralysis, 66.9 per cent, had analgesia; in three hundred and fifty-four paralytics it was present in 70 per cent. According to sex, the ulnar symptom was absent in 73.7 per cent, of two hundred and thirty-two men, and in Analgesia of the Ulnar Nerve. 13 43.7 per cent, of seventy-one women. Amongst those who were neither paralytics nor epilep- tics he found that the ulnar reaction was absent in 16 per cent., uncertain in 82 per cent, and normal in 82 per cent. In women these percentages were respectively 9 per cent., 2 per cent, and 89 per cent. From such facts the author concludes that the symptom to which Biernacki has called our attention has a certain value; but it would possess a great diagnostic importance if we knew to what to attribute the analgesia of non-para- lytics. In male epileptics Hess found this analgesia in 8.69 per cent, of the cases, while in women he could not find it at all. He discovered besides that the pain reaction was absent for six to twelve hours after a convulsive attack; after this time the reaction appeared again and only in the case of one woman did the analgesia remain for about thirty-six hours, the normal reaction returning after forty- eight hours. Hess attaches great importance to this in the diagnosis of the epileptic psychosis. Finally, there appeared but a short time ago an article by Sambo, 110) who, while investigating analgesia of the peroneal nerve in cases of tabes, found that analgesia of the ulnar was present in eleven out of fifteen cases, with- out there being any relation between the disappearance of this reaction and the disturbances of sensibility. As will be seen the results obtained do not agree very well. Some authors maintain that the disappearance of the ulnar reaction is a point of great diagnostic value, while others deny it any such importance and, like Boedeker, Falkenberg and Orchansky, affirm that ulnar analgesia is not characteristic of either tabes or paralytic dementia. And we find the average in progressive paralysis oscillating between a maximum of 91.6 per cent. (Hillenberg) to one of 56 per cent. (Snell-Boedeker) in regard to analgesia; while in other mental diseases we find the average for non-analgesics to vary between 82 per cent. (Hess) and 53 per cent. (Snell). It must be noted, however, that in his 91.6 per cent. Hillenberg includes, besides the bilateral 14 Dr. Arrigo Giannone. cases, those in which the symptom was presented only on one side and those in which the pain reaction was some- what diminished, which the other authors have not done. They have made an average of itself for this last class or else have included them in the normal (Hess). If we take this fact into consideration and subtract from Hillenberg's figures those cases having a weak reaction, we obtain for this author a percentage of 80 having true analgesia. My researches on this subject have been chiefly made among the insane, not neglecting, however, any cases of tabes which have occurred this year in the Sante Spirito Hospital, and those met with in the neuro-pathological clinic. The insane cases which 1 have studied number two hundred and fifty-seven, thus divided; paralytic dementia forty-seven, of whom thirty-nine were men and eight women; the others were afflicted with various mental dis- orders but were mainly epileptics, idiots, alcoholics, para- noics and cases of dementia; of these one hundred and seventy-three were men and thirty-seven women. The method used in the researches did not differ at all from that indicated by Biernacki in his article; the patient was made to flex the fore-arm on the arm, and there the nerve-trunk was pressed on with moderate force by the second finger while the thumb rested on the front of the epicondyle of the humerus. In normal individuals the fol- lowing symptoms are called forth by this pressure: 1st. A contraction of the muscles innervated by the ulnar. 2d. A pain more or less acute, but very characteristic, and one which can with difficulty be borne without some reaction on the part of the patient. 3d. A manifestation of this pain consisting in a change of countenance, flexion of the arm, or exclamation of pain. Now, of these signs, in my researches, only one has been constant and unmistakable, and that is the contrac- tion of all the muscles supplied by the ulnar nerve, a con- traction which cannot escape the finger of the hand which holds flexed the fore-arm of the patient. Analgesia of the Ulnar Nerve. 15 On the other hand the external manifestations, such as changes in the face and exclamations are entirely want- ing in certain mental states in which the patient succeeds in mastering every sensation reaching him from the outside world, and it has often been my lot to see, especially in paranoics and some idiots, the face remain tranquil and impassive, revealing no trace whatever of suffering while the arm was strongly flexed, and the shoulder quickly drawn upward and backward. And so much the more must we take into consideration this manifestation, in as much as the face changes may be so slight and fleeting as to be almost gone unless the countenance is most attentively watched, especially when the physician has not yet had much prac- tice in such studies. Another fact to which Boedeker and Falkenberg called attention in their article is the following: often examining patients with intervening spaces of time the ulnar symptom was found to vary. It has also happened to me in more than one case that a person in whom we had perhaps found analgesia at the first examination, on being exam- ined again after some length of time presented the characteristic reaction. The above named authors in order to explain this, have considered it to be due to the strength exerted by the observer, which may vary quantitatively from day to day. But I would add these hypotheses: 1st. Want of practice in research, by means of which, at first, a weak reaction may excape the observer. 2d. The nature of the anatomical lesions of the ulnar nerve, on which 1 shall dwell briefly before closing. 3d. The condition of the patient, especially that of his nervous system at the time of examination. Having premised these considerations 1 shall now give the results of my observations on forty-seven cases of paralytic dementia. In thirty-nine men we found: Analgesia of both sides 21 "one side only 2 Weak pain reaction 10 Normal"" 6 Total, 39 16 Dr. Arrigo Giannone. The percentage would stand thus: ( absent in 59 Tts (the Greek journal of New York) and the patriotic Professor Leotsakos started the fight in the American periodicals, but the true apostle, the ardent and zealous defender of our true and his- torical pronunciation and language in the New World, is the distinguished American physician and Hellenist, Dr. Achilles Rose. This learned and indefatigable Philhellene, who has promoted a better knowledge of living Greek by his writings and lectures, who by his arguments, which could not be contradicted, has upheld the true Greek pronunciation, has at the same time undertaken the herculean work of advocating Greek as the interna- tional language of science. We deem it our duty to make known to the Greek public the profound and scholarly lecture published in the New York Medical Journal, which lecture gives a study of the historical evolution of the Greek language and the various phases through which it has passed. This lecture was delivered recently in New York before a numerous and select gathering, was loudly applauded, and after having appeared in print was highly appreciated by American scholars.—N. Y. Med. Jour. Medico-Psychological Association of Great Britain and Ireland.—The last general meeting was held at the rooms of the Association, 11 Chandos Street, Cavendish Square, on Thursday, November 19th, under the Presidency of Dr. Julius Mickle. Editorial. 85 The following papers were presented: Dr. Mercier, "To examine the alleged exceptions to the Rule of Secrecy, and to move a resolution;" Dr. C. H. Bond, "Further points in the relation of Diabetes to Insanity." The President, Dr. Mickle, had suggested the following subjects for the Essay for the Bronze Medal and Prize of Ten Guineas, which is open to all Assistant Medical Officers of Asylums, though candidates were at liberty to present an essay on any other subject if they preferred to do so; (1) "Heredity in relation to Insanity;" (2) "The rdU of Syphilis in the production of Mental Disease;" (3) "A contribution to the Study of Microscopical Change of the Nervous System in Mental Disease." The members dined together after the meeting at the Cafe Royal, Regent Street, at 6:30 p. m. Dr. P. O. Hooper Re-electtd— The Board of Charitable Institutions of Arkansas has elected Dr. P. O. Hooper to the position of superintendent of the Insane Asylum of that State at Little Rock, made vacant by the resignation of Dr. J. J. Robertson. Dr. Hooper resigned this position four years ago, after holding it for eight years, and was succeeded by Dr. Robertson. This is a good appointment and a proper recognition of clinical familiarity with the insane in the selection of the Medical head of a hospital for the insane. In selecting such a man the Board has recognized its obligation to the insane of the State, who are entitled to experienced medical min- istrations, and to the people of the State whose taxes pay for cures and the best care of these unfortunates. Dr. Hooper was born in Arkansas in 1833, and received his literary education in Little Rock and Nashville, Tenn. He graduated from the Jefferson Medical College, at Phila- delphia, in 1856, practicing his profession in Little Rock without interruption, save the civil war, serving faithfully as president of a board of examining surgeons in the Con- federate army until its close, attaining a reputation not only in his own but adjoining states. He may be said to have been the father of the Arkansas insane asylum, being president of its first board of trustees until 1883. when he accepted the superintendency in order to see that all his plans were carried out relative to the building, grounds and methods of treating inmates. He served in this capacity until three years ago, when he resigned, leaving it an institution, a model of its kind, and with but few rivals in any State in the Union. His resignation was received with universal regret. Dr. Hooper is also one of the physicians 86 Editorial. who helped to organize the medical department of the Arkansas Industrial University and was dean of the faculty for some time and has continued to give lectures in the college on mental and nervous diseases. He was first Vice-President and acting President of the American Medical Association that met at St. Paul, Minn., in 1883, in lieu of the venerable Dr. Atlee, of Pa., who could not attend, and is a member of the State Medical and various national societies. Arkansas has in this instance secured the right man for the right place. The Second Pan-American Medical Congress held last November in the City of Mexico, was a gratifying scientific and numerical success. We congratulate Secretary General Dr. Liceaga and his able aids, and the Mexico profession in general on the interest taken in the work, and upon the fraternal and personal hospitality extended to the profession of the United States. It was a matter of great regret to us personally that on account of illness we were unable to attend and take the part we had hoped and been solicited to take in this important medical convocation. The True Criteria of Insanity.—1. The cause and condition within the organism of all insanity is dis- ease. a. The disease of insanity always, either primarily or secondarily, directly or remotely, organically or functionally, involves the brain. b. Primarily, as in paresis, the acute mania of trau- matism, etc. Secondarily, as in post epileptic, post choreic, post febrile, post hemiplegic, insanity, etc. The latter being sometimes primary and precedent. Directly when the morbid cause developes it at once, as in toxic and traumatic forms. Remotely where ancestral influences have developed a neuropathic diathesis rather than a psychopathic, and where conjointly, disease elsewhere in the organism has by persisting pain, or other form of transmitted or reflected irritation, developed functional men- tal aberration or when the insane diathesis is so marked that slight exciting cause, insufficient in others, precipitates the psycho-cerebral disease. This is also functional insanity. Organically, as in the forms which develop concomi- tantly with cerebral changes in the neurons or Meninges of the cerebrum or other destructive changes of the brain sub- stance, ventricles, circulation or coverings, including also the cerebellum. Editorial. 87 2. The cause within the organism being disease, insanity is developed by many or most of the developing causes of disease—physical or psychical—if the cause be potent enough to greatly involve the brain. 3. As a disease, insanity is subject to the law of dis- ease in general, i. e., change from the physiological to the pathological in the functioning of the organ involved—change in its normal manifestations, i. e., change in its functional character, as well as its organic conditions. 4. Non-congenital insanity is there/ore a cerebro-psy- chic disease primarily or secondarily involving the brain to such an extent as to markedly change the normal mental character of the individual. To determine the existence of insanity in an individual, therefore, disease is to be sought for, and the standard of symptomatic comparison is the individual's former and nor- mal psychical character, and the abnormal psycho-sympto- matic display is to be compared with the previous normal, the psycho-pathologic compared with the psycho-physiologic character of the individual. Where so-called teratological states appear (which are the product of ancestral disease and also really morbid as well as abnormal) the standard of comparison should be the psychically healthy types of the family, for insanity always d splays a change of mental character different from normal psychic display and is always the manifestation of disease involving the brain and may be termed cerebro-mental disease. Neuriatry and Psychiatry.—The Archives de Neurologie for September, 1896, contains a report from the proceedings of the late Congress of Alienists and Neurologists at Nancy, of the opening address of Prof. Pitres, in which' he makes a powerful plea for the practical union of psy- chiatry and neurology, or what we offer as a better term, Neuriatry, a term which has just philological warrant for a place in the nomenclature of neurology. Our worthy contemporary, the Boston Medical and Sur- gical Journal, under caption of the Union of Neurology and Psychiatry, antedates us in the reproduction of a portion of M. Pitres' address and in approbation of the proposition to blend the two specialties in one department of research and practice. We fully concur in the proposition, and in defence thereof take the pleasure in laying before our readers a por- tion of M. Pitres' address, and our Boston contemporary's concluding reasoning thereon. 88 EdUorfal. "The moral of this," says Pitres, "is that we should not shut ourselves up in too narrow or too exclusive special- ization, and that we should do all we can to enlarge our horizon. A neurologist would have insufficient culture were he not familiar with the progress of psychiatry, and an alienist would be deprived of precious elements of informa- tion if he did not follow with an attentive and curious eye the researches made in the domain of neurology." "For these reasons," he continues, "it is indispensa- ble to complete, each by the other, the researches of the neurologists by those of the alienists. They are absolutely united. They march side by side. They have the same objects, the same tendencies, the same methods, the same ends. They ought not to be separated. Our contemporary adds, "Great discoveries in one field have never failed to extend their influence into the other. The sciences are apt to progress much more by their influ- ence upon other sciences than by discoveries in their own domain. The principles of degenerative heredity were studied by Morel in mental disease and applied by him solely to the etiology of psychopathies and neuroses, but they have been extended to all nervous diseases, and are applicable to many morbid states. On the other hand, the laboratory work in bacteriology was at first thought appli- cable only to general febrile and epidemic diseases. Later, rabies, tetanus and other affections were found to be due to infectious causes, and, finally, the influence of infection in the etiology of nervous and mental diseases has been found to be widespread, as the discussion at the Washing- ton Congress in 1894 showed." "It would, indeed, be conducive to the highest develop- ment, both to psychiatry and neurology," says the journal further, "if the teachings of this address could bear fruit, not only in France, but throughout the world." And so say we with all the emphasis of a long combined clinical experi- ence in both departments. To the Members of the Medical Profession.— Dr. Geo. M. Gould makes the following appeal: I would be pleased to have an expression from you, either personally or through some medical journal, as to the lay-publishing firms of medical journals and the profession. The request is suggested by the fact that Messrs. Wm. Wood & Co., of New York, refused to permit the editors of "The American Year-Book of Medicine and Surgery" to use in our abstracts of Medical Progress, articles and illustrations first printed in the "Medical Record" and the "American Journal of Obstetrics." 119 S. 17th Street, Philadelphia, Pa., Dec. 1896. Editorial, $t.) To which we answer as follows: Unless an article in a medical journal, or the journal publishing the same is copyrighted no other publication can be debarred from using it. Besides, the journal or publishing house refusing the ordinary liberty of abstracts is lacking in fraternal courtesy and journalistic comity, and risks being boycotted by the profession. Even though copyrighted such a course is unwise, unjust and antagnostic to the charitable and fraternal spirit of the code of ethics. Dr. P. M. Wise, formerly of Clarence, Erie County, N. Y., has been appointed state commissioner in lunacy vice Dr. Carlos F. McDonald resigned. Dr. Wise was educated in the common schools, at Clarence Academy and at the Parker Classical Institute, graduated in medicine from the Buffalo University Medical College in 1872, and entered the St. Louis City Hospital as interne, afterwards resident physician of the small-pox hospital. In 1873, he was appointed as assistant physician at the Willard Asylum for the Insane, and so remained until 1884, when, upon the resignation of Dr. Chapin, he was elected to fill the vacancy as medical superintendent. He occupied this position for six years, afterwards filling a similar position at the St. Lawrence Hospital until the present time. He was also professor of mental diseases in the Uni- versity of Vermont. The appointment is a good one for the state of New York and her insane. Dr. John B. Hamilton, of Chicago, editor of the Journal of the American Medical Association, has resigned his commission as surgeon in the U. S. Marine Hospital Service. Dr. Hamilton will now have more time to devote to his growing surgical practice and engrossing editorial work. Mimic Locomotor Ataxias.—The experienced Neu- rologist meets many cases in the course of an extended practice which, once diagnosticated as probable posterior spinal sclerosis, ultimately prove to have been the result of a previous neuritis, alcoholic, rheumatic, Grippal or syphilitic, the fulgurant pains never having existed, the Argyll-Robert- son pupil never having appeared, the cincture feeling never having been a permanent symptom nor the Romberg sign, nor the true ataxic gait, though the walk is clumsy and shuffling, or in a manner ataxic. The only persistent and invariable sign in these cases being the absent patellar tendon reflex. 90 Editorial. On this subject a young and aspiring neurologist, writes us as follows: "I wish to contribute to your columns a publication on painless locomotor ataxia. I have observed two patients who have felt all symptoms of locomotor ataxia but no pains whatever, either in legs, abdomen or elsewhere. As the text-books at my command point to the pains as one of the symptoms sine qua non for a diagnosis of locomotor ataxia, I should think this is some- thing worth mentioning. What I would like to ask you is, does the profession generally know that there are cases of locomotor ataxia without pain, and is this impossible, and consequently was the diagnosis wrong, and, if so, what else could it be that would so strongly resemble locomotor ataxia, especially the incoordination?" This question we have partly answered in the begin- ning. We have seen an instance of plumbism when the knee-jerk could not be elicited and the same condition after and during the status epilepticus. The Loud Bill (H. R. 4566) ought to be defeated. Though its name is Loud with a big L, it is a covert and silent attack on the people's rights as readers. While purporting to relieve the postal department, it is really an enactment intended to embarrass the publication business, handicap the dissemination of cheap literature among the people and to promote the interests of the express companies. Look at this section for instance. SEC. 5. That publishers and others, whose publications shall be admitted as mail matter of the second class under the provisions of this Act, shall be required, before depositing such mail matter in the post-office, to separate the same into United States mail sacks or bundles by States, cities, towns and counties, as the Postmaster-General may direct. It strikes at all American asylum, hospital and other eleemosynary annual reports. The Southern Surgical and Gynecological Association held its ninth annual meeting at the Nichol- son House, Nashville, Tennessee, on November 10, 11 and 12, 1896. An interesting programme was presented. Dr. E. S. Lewis, of New Orleans presided, and delivered an entertaining and instructive address. A New Materia Medica by Dr. Frank P. Foster.—We have received from the publishers, D. Apple- ton & Co., the first volume on this subject, which will be reviewed when the second volume comes to hand. If the new Materia Medica should prove as meritor- Editorial. 91 ioas as the dicti >nary edited by the distinguished author, of which we can entertain no doubt, it will be worthy a high place in the literature of medicine. Dr. John H. Callender, a distinguished Alienist and personal friend of the editor of this journal, died at his home in Nashville, Tenn., Aug. 31, 1896. Dr. Callender came from a distinguished ancestry, his grandfather, James T. Callender was a political writer of great prominence during the administrations of Washington, Adams and Jefferson. Dr. Callender was summoned for the government as an expert witness on the question of the insanity of Guiteau, but believing with the editor of this journal that Guiteau was insane, declined to testify against him. Dr. Callender was for many years the medical super- intendent of the Tennessee Hospital for the Insane at Nashville, and was superintendent of the "Morningside Retreat" at the time of his death, had been president of the American Medico-Psychological Association, and filled the chair of psychological medicine in the Nashville Medical College. He was also chairman of the section on Physiology at the Centennial Medical Cong ess of 1876. He was a scientific and impressive teacher of psychiatry, an accom- plished physician, an eloquent speaker and a courtly gentle- man. Sincere and deep in his attachments, he was much esteemed by all who enjoyed his friendship. A Tough Citizen of Columbia, Missouri, either inherently immune to toxicity in general, or brought to that condition by self anti-toxine treatment, as he asserts, is giving test seances to the profession of Los Angeles, Cali- fornia, and at last account had injected hypodermically a quantity of sputum, containing twenty-five active baccilli taken from a far advanced consumptive. Whether the pro- cedure shall prove to be a fake, folly or fact and "Poweliza- tion" is to become a scientific, therapeutic procedure remains to be proven. Powell is the name of the audacious Colum - bia doctor now undergoing the toxine tests. Hereditary Neuropathy and Crime.—Professor Belman, of the Uuiversity of Bonn', gives the history of a notorious drunkard who was born in 1740 and died in 1800 and her heirs to the number of 834, of whom 709 have been traced from their youth. Of these 7 were convicted of murder, 76 of other crimes, 142 were professional beg- gars, 64 lived on charity, and 181 women of the family led disreputable lives. The family cost the German govern- ment for maintenance and costs in the courts, almshouses 92 Editorial. and prisons no less a sum than $1,250,000; in other words, just a fraction under $1,500 each. This transcends the fatal immoral heredity of the Jukes family of Massachusetts and the tables of vicious decadences of Morel and others. Among the Neurological Treatises creditable to American medicine there has been issued from the American press during the past year, "Nervous Diseases by American Authors," edited by Dr. F. X. Dercum; a treatise on "Nerv- ous and Mental Diseases," by Landon Carter Gray, pub- lished by Lea, Brothers & Co., and "Architecture of the Brain," by D. Wm. Fuller, of Grand Rapids, Michigan. The Management of the Journal of Nervous and Mental Disease, announces the following arrange- ment of the staff for 1897: Editors, Dr. Charles L. Dana, Dr. F. X. Dercum, Dr. Philip Coombs Knapp, Dr. M. Allen Starr, Dr. Charles K. Mills, Dr. James J. Putnam, Dr. B. Sachs; Associate Editors, Dr. Philip Meirowitz, Dr. Wm. G. Spiller; Managing Editor, Dr. Charles Henry Brown. Over the Hookah.—The Pencription thus discourses of Dr. Lydston's new literary venture: Every little while we are given a book that pretends to be a humorous work written by a funny doctor, which contains generally a lot of nasty stories which are supposed to contain a whole lot of fun. The book before us, however, is brim-full of the higher order ol wit, and we feel quite confident that it will come into the doctor's library a weicome guest, for not he alone but all his family may enjoy it. True, every word. Change of Name.—The editors of Mathews' Medical Quarterly announce that with the January issue of that publication its name will be changed to Mathews' Quarterly Journal of Rectal and Gastro-lntestinal Diseases. This is a change which has been deemed necessary for some time, as it is essential that the title of a medical journal should convey to the reader an idea of its contents, and this has not been the case with its name from the beginning. There will be no change in the policy of the journal in the least. As it will continue to be the only English publication devoted to diseases and surgery of the rectum and gastro-intestinal tract, the articles which will appear in it will be limited to these subjects. The journal will continue to be edited by Drs. J. M. Mathews and Henry E. Tuley, and published in Louisville, Ky. The Unrelibility of Borax in the treatment of Editorial. 93 epilepsy with an account of purpura borique as an incident of this form of medication for epilepsy is the subject of an article by M. Ch. Fere, Medecin de Bicetre, in hlouvelle Iconographie de la Salpetriere". This medicament is of no real service in epilepsy, shortly after it was first announced we gave it a sufficient trial to satisfy us of its unreliability. It is also objection- able because of its not being acceptable to the stomach or intestinal tract of many patients, and because of its dis- agreeable taste, bulk and an insolubility in water. The borax fad has had its day in neurotherapy. The Functions of the Neuron.—The most interest- ing subject presented at the June meeting of the American Neurological Association was that presented in president Dr. F. X. Dercum's address. On the above subject Dr. D. said: The question had arisen in his mind as to whether the neuron was not an absolutely fixed morphological element, and whether it did not possess a certain, though perhaps, limited power of movement. He found that this thought had occurred independently to three other observers, one in Germany, and two in France. Ramon Cajal, however, opposes the theory of the mobility of the neuron, and maintains that the neuroglia cells possess a great deal of mobility. He points out, for instance, that the neuroglia cells of the cortex are at times stellate, and at others much elongated. Their processes have numerous short arborescent and plumed collaterals. Two phases can he observed in them, first, a state of contraction, in which the cell-body becomes augmented while the process become shortened and the secondary branches disappear, and secondly, a state of relaxation, during which the processes of the neuroglia cells are again elongated. He further maintains that the processes of the neuroglia cells, in reality, represent an insulating or non-conducting material, and that during the period of relaxation they penetrate between the arbori- zations of the nerve-cells and their protoplasmic processes, and render difficult or impossible the passage of nerve- currents. On the other hand, when the processes of neuroglia cells are retracted, the various nerve-cell pro- cesses which they formerly separated from each other are now permitted to come into contact. It, seems, therefore, tint Ramon Cajal admits the very thing against which he contends. Take the simple example of an hysterical paralysis 94 Editorial. and see how easily it may be explained. The neurons of a certain area of the cortex, for instance, retract the terminal branches of the neuraxon to such an extent that the latter are no longer in contact, or sufficiently near to the neurons in the spinal cord which supply the muscles of the paralyzed parts. When power is suddenly re-established in hysterically palsied limbs, it simply means that the terminal branches of the cortical neuraxon, pre- viously contracted, are again extended so as to re-estab- lish the proper relations with the spinal neurons. It would be interesting to follow out the ideas here brought for- ward in their application to the various phenomena pre- sented by hysteria. Turning to hypnotism, a ready explanation is afforded for the phenomena presented, and leaving this field entirely, we can see what an enormous value this interpretation of cortical action is for normal mental phenomena, taking for example the familiar instance of sleep. According to Holy Writ.—For one to enter his tenth decade with all the faculities intact, with mental vigor unabated, and with body bowed by no burden other than the weight of years, is extraordinary. But it is well nigh marvelous that one should more than fill this measure of time, who for nearly seventy years had endured the self-ignoring life of a country doctor of the old school. Some idea of the superior quality of such a man may be gained by estimating the capacity of an intellect which could grasp and assimilate all those stupendous changes in medical science and practice which have take place within the nineteenth century; and contemplating knowledge which, ever progressing, not seldom leading, was to the end of life fully abrest the times. This man was Doctor Hiram Corson, and this is the tribute The Medical and Surgical Reporter pays him. Teach Medical History.—Under this caption the Philadelphia Polyclinic urges the teaching of medical history in our medical colleges. "The history of medicine, its developments, its errors, its trials, its triumphs, should be systematically taught by competent instructors at all our colleges. The chair of the History of Medicine should be one of the most important, and by the respect paid to it, the value of its teachings should be emphasized." The relationship of the recent discoveries of bacterio- logy of toxines, ptomains, etc., and the revival of mesmer- Editorial. 95 ism under the guise of hypnotism, and the relation of thyroid and other animal extracts to old hypotheses is referred to by the Polyclinic. We fully concur with our contemporary as to the value of such study to student and physician. The Barnes Medical College of St. Louis had such a chair most worthily filled by Professor J. S. B. Alleyne, M. D., vacated last year by his sudden death. This post is to be filled by retiring veterans in medicine instead of the usual chairs emeritus. Des Attitudes Anorwales, Spontanees ou Pro- voqu'ees, Dans le Tabes Dorsal Sans Arthropathies by Le Dr. Frenkel, de Heiden (Suisse), and Maurice Faure, Interne de la Clinique des Maladies du Systeme Nerveaux, is an interesting and valuable contribution to the new symp- tomatology of tabes dorsalis. The spontaneous hyper-extension of the knee, the extreme mobility of the vertebral articulations, the passive hyper-extension of the fingers, the extreme laxity of the external ligaments of the tibio-tarsal joint and the extreme laxity of the hip joint articulation, are well illustrated and described by the distinguished gentlemen, whose names appear above, in Le Nouvelle Iconographie de la Salpetriere for July and August, 1896. These new features in the symptomatology of tabes dorsalis are quite interesting, Dr. J. J. Putnam, of Boston, having already called attention to the laxity of the hip- joint articulation in this affection.. The Physicians of Santa "Clara County, Cal., numbering 124, have entered into a compact to not enter into any contract or agreement, or renew any existing contract or agreement, either written, verbal or implied, to render medical or surgical services to any lodge, society, association or organization. Investigation shows that medi- al compensation for lodge work averages in that county bout fifteen cents on the dollar. This is a wise move in the direction of professional protection. Respectable physicians feel a sense of degrada- tion in giving their services for fifteen cents on the dollar, and the ever-increasing spread of these charitable institu- tions is absolutely destructive to the business of other physicians. Notice to Subscribers and News Agents.—Regu- lar renewals of old subscribers to the ALIENIST AND NEUROLOGIST are not discounted to agents. A recent protest of a New York agent for foreign subscriptions com- 96 Editorial. pells us to call renewed attention to this fact. We discount to agents only for new subscriptions. The Change in the Presidency of the State Commission in Lunacy.—The retirement of Dr. Carlos F. MacDonald on September 30th from the presidency of the State Commission in Lunacy, an office which he has held since the creation of the commission in 1889, marks an important era in one of the most important and exten- sive departments of the State government. Dr. MacDonald was impelled to take this step by a due consideration to his private interests which have been seriously impaired by his attention to public duties. He has succeeded the late Dr. Choate as physician in charge of a high class sani- tarium for the treatment of select cases of mental disease at Pleasantville, Westchestej" county, and will personally conduct it, retaining an office in New York city for consul- tations. In his letter of resignation to the Governor, Dr. MacDonald says: "In taking this step I deem it due to myself to make the following brief statement in explanation thereof: The complete fulfillment of the object—State care for the depend- ent insane—which induced me to relinquish a less respon- sible and more lucrative public office to accept, at the invitation of Governor Hill, the presidency of the State Commission in Lunacy on the creation of that body in 1889, has relieved me from the moral obligation which I then assumed and which • was renewed when, in 1895, you reappointed me for another term of six years. In other words, the accomplishment within'the present year of this great reform in behalf of the dependent insane, for the consummation of which all true friends of that unfortunate class are deeply indebted to you, has left me free to avail myself of the opportunity which has come to me to retire from the cares and responsibilities of public service to which twenty-seven years of my professional life have been given in connection with the care of the insane, to the more peaceful and more adequately compensated walks of private professional practice. "1 need scarcely say that this step which terminates the pleasant official relations which I have been permitted to have with yourself, as well as with my associate com- missioners and the officers and employes generally of the department for the insane, is not taken without a feeling of sincere regret on my part. "In conclusion, 1 would take occasion to express my Editorial. 97 deep sense of personal obligation to you, as well as to your predecessors, Governors Hill and Flower, for the confidence, encouragement and support which you and they have at all times extended to me in the discharge of the arduous and oftentime trying duties of my office, and especially for sustain- ing the Commission in its endeavor to maintain the depart- ment of the State government over which it presides on a non-partisan basis." Of the value and extent of the service rendered by Dr. MacDonald to the people of this State in the seven years of his membership of the Commission, few persons not directly and intimately connected with the general administration of lunacy affairs can have any adequate idea. To him more than to any other one person may be assigned the chief meed of praise for the final establishment of the policy of State care on a stable and durable basis, as an effective, economical and practical measure of dealing with the largest and most costly of the State's charities. In securing the adoption by the Legislature of this policy, and in the subsequent improvement, enlargement and extension of the work, his services have been of the first importance. Indeed, the commanding value of his connec- tion with the Commission and the loss it will sustain ifl the severance of his relations to it would be difficult to over-estimate. Dr. MacDonald's entire professional life has been spent in the special field of psychiatry, and he has attained the highest honors in the gift of the State in his department of medicine. How his retirement is viewed by those best qualified to judge, viz.: the State hospital superintendents, appears from the following, adopted at a meeting of representatives of the ten State hospitals: WHEREAS, The superintendents and representatives of the State hospitals of New York, in conference assembled, have learned with deep regret of the contemplated retire- ment of Dr. Carlos F. MacDonald from the presidency of the State Commission in Lunacy; therefore, Resolved, That as representatives of the State hospitals for the insane, we deem it appropriate and fitting to make public acknowledgment of our appreciation of the important service rendered by Dr. MacDonald on behalf of the estab- lishment, upon a permanent basis, of the policy of State care for the insane, and of carrying out that policy into practical operation in an efficient and economical manner. We also record our regret that Dr. MacDonald has found it necessary to withdraw from the service of the State in that 98 Editorial. capacity; and we tender him the assurance of our confidence in the administration of lunacy affairs by himself and his associates. Our thanks are due to him for his efforts to promote the welfare of the insane and the successful con- duct of the State hospitals, and for his future prosperity and success he has our heartiest wishes. A copy of these resolutions, handsomely engrossed on parchment, was presented to Dr. MacDonald, together with an elaborate and costly solid silver punch bowl. Dr. Wise, the new president of the Commission has given a quarter century to service of the State and the care of dependent insane. In 1873 he was appointed assist- ant physician and in 1884 he was promoted to the medical superintendence of the Willard asylum. In 1889 he accepted the medical superintendency of the new St. Lawrence State hospital at Ogdensburg. The latter institution was con- ceived in a most enlightened spirit of progress, and was intended to be an exponent of the latest and most approved plans of hospital construction and administration. In the seven years of Dr. Wise's incumbency, the policy of the hospital and basis of its organization has been completed. It is recognized throughout the scientific medical world as a model of convenience and adaptability for its purpose, and has already attained a high reputation as a curative insti- tution. Dr. Wise thus brings to his new position a mature experience gained in long and active duty in the great department of which he is now the head. Dr. Wise was highly commended by Dr. MacDonald as his successor and the Governor's action in appointing him is most commend- able.—New York Mail and Express, October 3rd, 1896. A Physician in the Cabinet.—On this subject the editor of this journal desires to repeat, and will con- tinue to repeat it till the matter is accomplished, the view expressed by him as President of the American Medical Editors Association at their Banquet given at Washington in 1893, in honor of the Pan-American Medical Congress. The sentiment and the argument were then applauded by all the editors present. Let the medical press continue to enforce its claims and demand its and the people's rights in the premises, and the matter of justice to the profession and the people will soon be accomplished. "If you would make a people great and glorious in the arts, in sciences, in literature, in morals, in arms, in high- minded men that constitute the safest and best guardians of a State, give them good health, encourage their physi- cians to be great doctors, not mere nurses and apothecaries, Editorial. 99 and your medical journalists to be broad-minded, fearless men, in proclaiming the truths that constitute and contribute to the sanitary welfare of mankind, and make men great and women fair and good. "As a physician, a practitioner of the healing art, a teacher of medicine in school and with journal, 1 dare to proclaim that the wisest and best thing this Government can do, both for its present and future welfare, for its perpetuity and growth among the nations, the most power- ful, most beneficent and grandest of governments, would be to create a Bureau of Sanitation [Applause], not merely to keep out foreign epidemics of contagious diseases, tout a psychical and physical sanitation of the many forms of disease of body and mind known to science and modern medical progress, and recognize the profession of medicine as it does that of law, of agriculture and arms, by giving the most distinguished and capable of its votaries a proper and deserving place in the Cabinet of the Nation. [Applause.]" The Medico-Legal Journal continues to show its accustomed vitality and vigor in its special line. Its talented editor, Mr. Clark Bell, is to be congratulated on his con- tinuing energy, enthusiasm and ability in a cause so near to that of medicine. This able periodical has now reached No. 2 of its sixteenth volume. A glance at the table of contents of any number will disclose its value to the student of forensic medicine and especially to the alienist and neurologist. The following is the contents of the number for September, 1896: Group of Prominent Members of the Medico-Legal Congress; "Suicide (Continued)," by Dr. L. Forbes Winslow, of London; "The Case of Czynski," by Hon. Moritz Ellinger, of New York; "Commitment of the Insane in New York," by Albert Bach, Esq., of New York; "Commitment of the Insane," by Ralph L. Parsons, M. D.; "Credible Witnesses and Circumstantial Evidence," by Sophia McClelland, of New York; "The Future of Railway Surgery," by Clark Bell, Esq., of New York. Toxicological: "Inhibition of Strychnia Post-Mortem," by Geo. B. Miller, M. D., of Philadelphia; Arsenical Poisoning and Circumstantial Evidence. Psychological: Psychological Section Medico-Legal Society; Report of Woman's Committee in Case of Mrs. Maybrick, Caroline J. Taylor, Chairman; "Narcotic Inebriates," by J. B. Mattison, M. D. Criminal Anthropology: "Kleptomania," by Prof. Lacassagne; English Prisons and Irish Political Prisoners. Medico-Legal Surgery. Editorial: The Medical Agnos*ic.—Compulsory Vaccination. —Hospitals for Railways. —Railway Relief Cars. — Russian International Congress.—Physicians in Paris. — Italian Society of Freniatria.—Photography in Detecting Crime.— 100 Editorial. Medico-Legal Society of Belgium. Personal. Judge Calvin E. Pratt and Portrait. Recent Legal Decisions. Journals and Books. Magazines. Books. Journals and Pamphlets received. Dr. William F. Drewry who for several years past served as senior assistant physician to the Central Virginia Hospital for Colored Insane, has been promoted to the position of superintendent to fill the unexpired term of Dr. Barksdale who resigned on account of ill health. Dr. Frank Wilfred Page has been appointed sup- erintendent of the Vermont State Insane Asylum, to succeed Dr. Gidbings. The Value of a Knowledge of Neurology.— The Boston Medical and Surgical Journal of December 24, 1896, contains an editoral on the above subject which is pat and so in accord with neurological and clinical observa- tion, that we take pleasure in presenting it entire with our unqualified endorsement: The majority of medical students seem to regard the subject of neurology as something metaphysical and mysterious, a field apart from that of the rest of the science of medicine, and one which is only cultivated by persons of a peculiar squint-brained mould who devote themselves to it more to beguile the tedium of an elegant leisure than with any serious idea of benefiting humanity. They scoff, moreover, at the limited scope of its therapeutics, and attempt to stifle its raison d'etre with the sneering remark that "All you can do is to give iodide—and a bad prognosis;" and they even go so far as to glory in their profound ignorance of nervous disease, and studiously avoid the clinics. It should be impressed upon such men that in so thinking and doing they are thereby really throwing away the most splendid opportunity which is offered to them throughout their whole medical course, of training the twn faculties most essential to the suc:essful physician—the faculties of obser- vation and of logical induction. The trouble with most students who are placed before a clinical case is that in getting at historical data, they fail to eliminate the irrelevant, and mass the essential; and. secondly, that they are too prone to jump at con- clusions concerning a single organ without giving due consideration to the organism as a whole. To eradicate such defects falls peculiarly within the power of the neurological instructor: for the very nature of nervous cases, with their unlimited multiplicity of symptoms, is such as to educate his perceptive and reasoning faculties to the highest degree, and thus enable him to impart a clearer insight into the working of the human machine, energized and regu- late 1 as it is by the great cerebro-spinal apparatus, than is possible to the workei in any other field of the science- Editorial. 101 His distinctly neurological habit of careful and exhaustive examination, with its attendant systematic array of findings and logical inferences therefrom, cannot but have a profound influence in shaping the course of the future physician's work in a way which will at once distinguish it from the ordinary and sloven. Moreover, it cannot be argued that such a training will make a man see everything from a neurological point of view; it is too broad and thorough. On the contrary, it will enable the future surgeon to be some- thing more than a mere mechanical factor in operative cerebro-spinal dis- eases, a position which certain surgeons most conspicuously occupy at present. It will impart to the man of gynecological proclivities a more just appreciation of nervous phenomena which are only too frequently incorrectly attributed to uterine diseases, and enlarge his field of vision beyond a single organ and its adnexa; and, finally, it will rid the man who is to follow the path of general practice of that most senseless notion that the nervous system is a thing apart, and teach him to note the marks of its influence either as a valuable ally or as a treacherous antagonist in every case he meets. One of the most important reasons for the narrow scope of nervous therapy as regards organic diseases is that many such cases are, when in their curable stages, in the hands of a family physician, and the vague but unequivocal signs which they give are through his indifference—or ignor- ance—overlooked. This is especially true of that large class of nervous diseases which is the result of the virus of syphilis. As regards the cases which are really chronic from the start, a practical knowledge of neurology will enable the physician to alleviate suffering even if he cannot cure and, what is of chiefest importance, prevent him from exaggerating the disease by indulging in a wholesale and irrational exhibi- tion of strychnia, bromides and iodides. There is absolutely no reason why the sufferer from incurable nervous disease should not obtain at the hands of his medical attendant the same solicitude and studied attention to the alleviation of symptoms as does the victim of chronic heart, lung or kidney trouble, but that he generally fails to get either is a fact which obtains and will continue to do so until a broader and more rational knowledge of neurology is. by compulsion, if necessary,—incorporated into the general mass of medical information which is required of the men who leave our medical schools. Medico-Legal Society.—A regular meeting of the Psychological Section was held at the residence of Dr. Harriette C. Keatinge, New York Citv, October 26th, 1896, at 7:30 o'clock, P. M. Short papers were read by Prof. W. Xavier Suddiith, of Chicago, Chairman of the Section; Sidney Flower, Esq., of Chicago; Dr. U. O. B. Wingate, of Milwaukee; Jas. R. Cocke, M. D., of Boston; Thomson Jay Hudson, LL. D.; Clark Bell, Esq.; T. D. Crothers, M. D. 102 Editorial. The regular programme was suplemented by short talks an psychological subjects by invited guests. The American Electro-Therapeutic Associa- tion.—The Sixth Annual Meeting of this Association was held in Allston Hall, Boston, Mass., September 29th, 30th and October 1st, 1896. A full programme was presented. Southern Surgical and Gynecological Associa- tion.—The Ninth Annual Meeting of this Association was held in Nashville, Tenn., Nov. 10, 11 and 12th, 1896. Among the many interesting papers read, the following were of espe- cial interest to the alienist: "Acute Mania Following Surgical Operations," Joseph Price, M. D., Philadelphia, Pa.; "Mental Complications Following Surgical Operations," J. T. Wilson, M. D., Sherman, Texas. The next meeting of the Association will be held in St. Louis, in November, 1897. REVIEWS, BOOK NOTICES, ETC OVER THE HOOKAH; THE TALES OF A TALKATIVE DOCTOR, by G. Frank Lydston, M. D., Professor of Genito-Urinary Surgery in the Chicago College of Physicians and Surgeons; Professor of Criminal Anthropology in the Kent College of Law, etc. Sold by subscription only. Sent pre- paid on receipt of subscription price. Price in cloth, gilt top, $4.00. Price in morocco, full gilt, $5.00. Over 600 pages octavo, profusely illustrated from the author's designs, by C. Everett Johnson. The Fred Kline Publishing Co. Chicago. Among the subjects discussed therein in the author's own inimitable style are: "Several Kinds of Doctors;" "Apropos of Several Subjects;'' "How a Versatile Young Doctor Reported a Society Event;" "The Doctor Emulates Sandow;" "Seeing Things;" "The Rhodomontade of a Sociable Skull;" "A Martyr to his Passions;" "Old Abe" as a Musical Critic.— Negro Dialect;" "Poker Jim—Gentleman;" "Larry's Contribution to the History of Ireland—Irish Dialect;" "The Passing of Major Merri wether," and "Sprays of Original Verse." This is an excellent volume for diversion, relaxation and instruction. The melancholic doctor, the hypochondriacal doctor, the optimistic doctor, the pessimistic doctor—any kind of doctor, the scientist and the man of letters, the jurist, the prelate, the plain citizen, populist, popocrat, democrat, republican, silverite or gold bug—any sort of man or woman may find rest for his soul, and laughter for his bones in this humorous book. No book like it has ever before appeared. Its pathos and instructive features equal its humor. The two chapters devoted to the rhodomontade of a social skull are serious, serio-comic, scientific and imaginative, reminding the reader of some of the best work of Jules Verne. "Over the Hookah" lifts Lydston to a high literary plane among medical men, and will win him deserved rank and recognition among the medical literati of the world. THE NON-HEREDITY OF INEBRIETY, by Leslie E. Keeley, M. D., LL. D is an unsustained effort to controvert the prevailing medical opinion that an inherent instability of nerve elements makes one man constitutionally prone become an inebriate under alcoholic potations, whereas another may go on for a life-time an habitual drinker and though his system will be undoubt- edly damaged by aicohol, he will not become either dipsomaniac or a common drunkard. So many have the inherent neuropathic tendency to instability of nerve element by reason of the bibulous habits of our ancestors, that most [103] 104 Reviews, Booh Notices, Etc. men under the use of aicoholic liquors as a daily beverage do finally be- come drunkards, that the inaccurate observer is apt to conclude that aicohol or its compounds makes the disease inebriety sttigeneris, and that it is not due to neuropathic diathesis, but is usually developed. The tables of Morel and the records of Belman and others, and the teachings of Rush, and the testimony of Alienism appear to have made no impression on the mind of the author before us. It has been 84 years since Benjamin Rush taught that inebriety was a disease and advised its treatment in hospitals, yet we do not note any reference to this distinguished American author's contributions to the subject. Nevertheless the book is adroitly written and refreshingly novel. The author's discussion of what he calls "the management of the ativism of the cell", is a proof of the heredity of inebriety, and a refutation of his position. Scott, Foresman & Co., Chicago, Successors to S. C. Griggs & Co., are the publishers. ARCHITECTURE OF THE BRAIN. ILLUSTRATED. By Wm. Fuller, M.D., Grand Rapids, Mich., formerly Demonstrator of Anatomy, McGill College, Montreal, Canada, and Professor of Anatomy, Bishop's College. This is an excellent work by a master in demonstrative anatomy. It is an advisable and almost indispensable accompaniment of the author's far- famed anatomical casts of the brain, with which we have long been acquainted, using them to accompany and elucidate cerebral demonstrations, and make plain localities in discussing before the class focal lesions of the brain and its meninges. We consider it decidedly the best descriptive text and series of plates of the encephalon extant. With this book and its accompanying plates brain anatomy is decidedly easy, and with the addition of the author's sectional casts so true to nature, the study of the brain becomes little more than child's play. DAS CONTRARE GESCHLECHTSGEFUHL (SEXUAL INVERSION). Von Havelock Ellis und J. A. Symonds. Georg H. Wigand, Publisher, 2 Lindenstras, Leipzig, also published in English. Our readers are already quite familiar with the ability of Dr. Ellis on the subject of sexual inversion through his able contributions to the ALIENIST AND NEUROLOGIST. He therefore needs no further introduction. The book will interest and instruct all clinical psychiaters and all physicians of extensive observation and practice. The medico-legal student, the lawyer, the psychologist and jurist will likewise find instruction in this work. It presents singular phazes in the morbid sexual life of the genus homo. GENIUS AND DEGENERATION, a psychological study by Dr. William Hirsch, translated from 'the Second Edition of the German work' is a fit companion to "Degeneration." by Max Nordau. It is somewhat corrective and psychically antidotal In its teachings to some of the most vicious doc- trines of Nordau, and is withal far more scientific. Reviews, Book Notices, Etc. 105 D. Appleton & Co., New York, are the publishers. The book is very appropriately dedicated to Dr. E. Mendel, of Berlin, Professor of Neurology in the Royal University. A PRACTICAL TREATISE ON MEDICAL DIAGNOSIS. For the Use of Students and Practitioners. By John H. Musser, M.D., Assistant Professor of Clinical Medicine, University of Pennsylvania, Philadelphia. New (2d) edition, thoroughly revised. In one octavo volume of 925 pages, with 177 engravings and 11 full-page colored plates. Cloth, 85.00; leather, $6.00. Lea Brothers & Co., Publishers, Philadelphia and New York. Professor Musser's work has achieved the foremost place as a full and systematic treatise on Diagnosis. In this new issue will be found a full account of all trustworthy advances that have been made in its department, one of the most progressive in medicine. The work has been enlarged not only in text, but also in illustration,numerous handsome engravings in black and many full-page plates in colors having been added. A TREATISE ON APPENDICITIS. By John B. Deaver.M.D. Itsclearand thorough teaching, its terse and forcible style and the wealth of experience which it represents, are not excelled in any similar work. Its illustrations, editorials and literary make-up also commend it. Price 83.50. P. Blakiston, Son & Co., Publishers, 1012 Walnut Street, Philadelphia. PHYSICIAN'S VISITING LIST for 1897. P. Blakiston, Son & Co., 1012 Walnut Street. Philadelphia. The improvements made in this List for 18% seems to have met with very general approbation, and Blakiston, Son & Co. report an increase of sales of more than ten per cent. over those of 1895. Can Physicians Honorably Accept Commissions from Orthopedic Instru- ment Makers? Commissions to Physicians upon the Sale of Orthopedic Apparatus from the Manufacturer's Standpoint. By H. Augustus Wilson. A. M., M. D., Clinical Professor of Orthopedic Surgery in the Jefferson Medical College of Philadelphia, etc., Philadelphia, Pa. Ueber syphilitische desseminirte, cerebrospinale Sklerose nebst Bemer- kungen uber die secundare Degeneration der Fasern des vorderen Kleinhirn- schenkels, des centralen Haubenbundels und der Schleifenschicht. Von Prof. W. v. Bechterew, St. Petersburg. On the Mode of Procedure under the New Lunacy Law of the state of New York, with Suggestions of Methods under which its Provisions can most easily be carried into Effect, and also of Improvements in the Law Itself. By Ralph Lyman Parsons. A.M., M.D. The Microscopical Proof of a Curative Process in Tuberculosis; or the Reaction to Tuberculin Evidenced by Blood Changes Hitherto Unrecognized. By Charles Denison, A.M., M.D., ex-President of the American Climatolog- ical Association, etc., Denver, Colo. 106 Reviews, Book Notices, Etc. Some Observations on the Effect of Thyroid Feeding on the Insane. B>' Charles G. Hill, A. M.. M. D., Physician-in-Chief to Mt. Hope Retreat; Professor of Nervous and Mental Diseases, Baltimore Medical College, etc. , Baltimore, Md. Gonorrhceal Iritis and Non-Suppurative Gonorrhceal Conjunctivitis and their Pathology. By William Cheatham, M.D., Professor of Ophthalmology. Otology, and Laryngology in the Louisville Medical College, etc., Louisville, Kentucky. Presidential Address before the American Medico-Psychological Associa- tion, 1896. Our Association and our Associates. Some Relations Affecting Medical Officers of Hospitals for the Insane. By Richard Dewey, M.D, Chicago. Clinical and Pathological Report of a Case of Cerebral Syphilis. By George Emerson Brewer. M.D., Attending Physician. City Hospital, and Pearce Bailey, M.D., Assistant in Neurology, Vanderbilt, Clinic, New York. Report of Two Fatal Cases of Hematuria, one in Male, from Spinal Injury, Traumatic; one in Female, from Primary Epithelioma of Trigone of Female Bladder, Pathological. By Thomas H. Manley, M. D., New York. The Etiology and Prophylaxis of Functional Nervous Diseases. By John Punton, M. D., Professer of Nervous and Mental Diseases, University Medical College and Woman's Medical College, etc., Kansas City, Mo. Pediatrics; Past, Present and Prospective. By S. W. Kelley, M. D., Professor of Diseases of Children in the Cleveland College of Physicians and Surgeons (Med. Dept. Ohio Wesleyan Univ.), etc., Cleveland, O. A Series of Articles of Speech-Defects as Localizing Symptoms, from a Study of Six Cases of Aphasia. By J. T. Eskridge, M. D., Neurologist to the Arapahoe County and St. Luke's Hospitals, Denver, Col. On the Treatment of Fractured Shafts of Bone in Children; Simple, Complicated and Compound. By Thomas H. Manley, M. D., Professor of Surgery, New York Clinical School of MeJicine, New York. Report of Thirteen Cases of Multiple Neuritis Occurring among Insane Patients. By E. D. Bondurant, M.D., Assistant Superintendent of the Ala- bama Bryce Insane Hospital at Tuskaloosa. Diagnosis of Chronic Abscess of the Brain. By J. T. Eskridge, M.D., Professor of Nervous and Mental Diseases in the Medical Department of the University of Colorado, Denver, Colo. The Symptomatology and Pathology of Exophthalmic Goitre. By William C. Krauss, M. D., Professor of Nervous Diseases, Medical Department of Niagara University, Buffalo, New York. The Solvent Properties of the Buffalo Lithia Waters of Virginia. By George Halsted Boyland, M. A., M. D., Formerly Professor of the Baltimore Medical College, etc., Paris, France. Reviews, book Notices, Etc. 107 Some Studies of the Blood in the Thyroid Feeding in Insanity. By Mlddleton L. Perry, M. D., Assistant physician at the New Jersey State Hospital, Morris Plains, N. J. The Relation of the Physician to Social,Educational and Moral Questions. By E. Stuver, M.Sc., M.D., Ph.D., Member American Medical Association, etc., Rawlins, Wyoming. Ueber das Kniescheibenphanomen als diagnostisches Kennzeichen von Nervenleiden und uber andera verwandte Erscheinungen. Von Prof. W. v. Bechterew, St. Petersburg. A Case of Hysteria with Ataxia Confined to One Leg. By Charles W. Burr, M. D , Clinical Professor of Nervous Diseases in the Medico-Chirur- gical College, Philadelphia. Animal Therapy. By Thomas Osmond Summers, M.A., M.D., F.S.S.C., London, etc., Professor of Anatomy and Histology, College of Physicians and Surgeons, St. Louis. < A Report of the Surgical Clinic at the University of Vermont in the Mary Fletcher Hospital. By Dr. Noyes, House Surgeon, and Dr. A. M. Phelps, Professor of Surgery. Transactions of the Forty-third Annual Meeting of the Medical Society of the State of North Carolina, held at Winston-Salem, N. C, May 12th, 13th and 14th, 1896. Acute Rheumatic Iritis; With Cases. By A. Britton Deynard, M. D., Instructor in Refraction of the Eye, New York Post-Graduate Medical School, etc., New York City. The Effects of Emancipation Upon the Mental and Physical Health of the Negro of the South. By J. F. Miller, M.D., Superintendent Eastern Hospi- tal, Goldsboro, N.C. The Effects of Early Optic Atrophy upon the Course of Locomotor Ataxia. By Pearce Bailey, M. D., Assistant in Neurology, Columbia College, etc., New York City. Prevention of Tuberculosis. By E. B. Borland, M.D., Clinical Lecturer Disease of the Chest, Medical Department of the Western University of Pennsylvania. The Relation of Noises to Public Health. By William C. Krauss, M. D., Professor of Nervous Diseases, Medical Department of Niagara University, Buffalo, N. Y. Diphtheria. By C. T. Hood, M. D., Professor Mental and Nervous Diseases, the Chicago Homoeopathic Post-Graduate Medical School, etc. Chicago. Das Kontrare Geschlechtsgefuhl. Von Havelock Eliis und J. A. Symonds, Deutsche Original-Ausgabe besorgt unter mitwirkung von Dr. Hans Kurella, Leipsig. 108 Reviews, Book Notices, Etc. On Movements of the Eyelids Associated with the Movements of the Jaws and with Lateral Movements of the Eyeballs. By Harry Friedenwald, A. B., M. D. An Exact Method for Determining the Capacity of the Stomach and the Amount of Residual Contents. By J. H. Kellogg, M.D., Battle Creek, Mich. Arterio-Sclerosis Among the Insane. By E. D. Bondurant, M.D., Assistant Superintendent of the Alabama Bryce Insane Hospital at Tuskaloosa. Feigned Insanity. Report of Three Cases. By William Francis Drewry, M.D., First Assistant Physician, Central Insane Hospital, Petersburg, Va. The Bload in Chorea. By Charles W. Burr. M.D., Professor of Dis- eases of the Mind and Nervous System in the Philadelphia Polyclinic, etc. On the Course and Destination of Gower's Tract. By Hugh T. Patrick, M. D., Professor of Neurology in the Chicago Polyclinic, etc., Chicago. A Case of Symphysiotomy. By H. S. Chrossen, M.D., Superintendent and Surgeon-in-Charge of the St. Louis Female Hospital, St. Louis. Intrabronchial Medication. By Joseph Muir, M.D., Physician to the Lung Department of the New York Throat and Nose Hospital. The Physiology of Decussation of Nerves; a One-Sided Body Means a One-Sided Brain. By Geo. M. Kellogg, M. D., Chicago, 111, Eine seltene Form lokalisirten klonischen Krampfes. Simulation Unfall- neurose oder hysterische Schreckneurose? Von A. Eulenburg. The Early Stage of Paretic Dementia. By Frank C. Hoyt, M. D., Sup- erintendent Iowa Hospital for the Insane at Clarinda, la. The Commitment of the Insane and the "Insanity Law" of the State of New York. By George|William Jacoby, M.D., New York. A Case of Tumor of the Thalamus, with Remarks on the Mental Symp- toms. By Walter Channing, M. D., Brookline, Mass. Procto-Colonoscopy and its Possibilities; By a New Method. By Thomas Charles Martin, M. D., Cleveland, Ohio. On Imperative Ideas; Being a Discussion on Dr. Hack Tuke's Paper in Brain, 1894. By Dr. J. Milne Bramwell Two Years' Clinical Experience with Gold Solutions. By Eustathius Chancellor, M.D., St. Louis, Mo. Hypnotism; Clinical Lecture Delivered at the Chicago Polyclinic. By Hugh T. Patrick, M. D., Chicago. The Ultimate Physiological Units of the Organism. By M. P. Over- holser, M. D., Harrisonville, Mo. The Practical Uses of Suggestive Therapeutics. By William Lee Howard, M. D., Baltimore, Md. Reviews, Book Notices, Etc. 109 Insanity in the South. By J. T. Searcy. M.D.. Superintendent Insane Hospital at Tuscaloosa, Ala. Remarks on the Causes of Glaucoma. By Leartus Connor. A.M., M.D.. Detroit, Mich. Gontagiousness of Consumption. By J. G. Hopkins. M.D., of Thom- asville, Ga. Notes on Inguino-Scrotal Cysts. By Thomas H. Manley, M. D.. of New York. Diagnosis of Hystero-Epilepsy. By Hugh T. Patrick, M. D., Chicago. The Diagnosis of Hysteria. By Huge T. Patrick, M. D., Chicago. Hypnotism in Every-Day Life. ByC. T. Hood, M. D., Chicago. Chorea. By Henry Hatch, M. D., Quincy, 111. THE Alienist and Neurologist. PSYCHICAL HERMAPHRODITISM. A Few Notes on Sexual Perversion, with Two Clinical Cases of Sexual Inversion. By WILLIAM LEE HOWARD, M. D.. Baltimore, Md. HE poet says that some truths had better be kept be- ■ hind the screen. This statement may be applicable to the writings of the poet, but the scientist wants the verity of life. The truth is, the evils are, with scarcely an exception, old. That which is new is the intelligence which discerns and the humanity which renders them. Sexual per- version has always played an important role in human life. Nor is it confined to the modern life alone. Few general practitioners realize the prevalence of distorted genesic in- stincts to day, or the important bearing it had on the life of the ancients. When this psychical condition is studied by the light of history we can congratulate ourselves that this vice, and often disease, is no longer a factor that can VOL. XVIII. ST. LOUIS, APRIL. 1897. No. 2. ORIGINAL CONTRIBUTIONS. [Ill] 112 William Lee Howard. be insiduously admitted as part of a nation's foibles or prac- tices, or that it has any role in the life of the normal human being. The ancient history of vice and disease is as inter- esting to the scholar as its aetiology and pathology are to modern medical men. The history of sexual perversion will be a source of pleasure to the optimist and instructing to the pessimist. Before coming to the clinical study of sexual perversion as we see it to-day let us take a cursory glance of the sub- ject from an historical point of view. Von Krafft-Ebing* has ably shown the influence that sexual life exercises on religion, art and poetry. According to his statements there does not exist a real work of art without a sexual basis, and he has properly called attention to the fact that great poets and great artists, and I might add, great writers, are mostly of a sensual nature, and I will further indite, often this sensuality partakes of a perverted feeling. There are a large number of men that feel themselves attracted to other men and boys. This attraction for individuals of the same sex is designated under the name of homo-sexuality, in distinction to the term hetero-sexuality, which designates the normal attraction. The name Lesbian designates the love of woman for woman, and was used in this sense by Sappho. Westphal t employs the expression sexual per- version (Contrare Sexualemjindung) which allows of a great- er latitude in dealing with the subject. Westphal's idea is that it is not always a question of deviation from the in- stinct itself, but of the sensations that make many an in- dividual feel that his personality is entirely estranged from the sex to which he belongs. We will see this fact clearly demonstrated later on in one of my cases. This writer is also of the opinion that sexual perversion embraces also those cases in which, the sexual instinct remaining normal, the individual presents certain tendencies belonging to the opposite sex. It is well here to have a clear understanding between perversion and perversity. There is an incised and rigorous distinction, and as laid down by Krafft-Ebing it is as follows: "We speak of perversion when the sex- ual instinct is a perverted instinct, while we speak of per- * Psvchopathia Sexualis. t Arch, fur Psychlatre. II. page 74. Psychical Hermaphroditism. 113 versity when it is a question of a perverse action, without taking into account the motive that has determined that ac- tion, whether it be a perverse inclination or any other mo- tive, a criminal action for example." Perversion is an in- clination independent of the will, and for which no one can be held responsible, at least in the eyes of an impartial judge; on the contrary, perversity, which is manifested in the action, must often be placed to the account of the in- dividual. Pederasty is often used by modern writers when speak- ing of homo-sexual love, but this is incorrect so far as it only relates to the act which involves imissio penis in anum. Pederasty comes from pa^^s erastes, "lover of boys;" and it is by this term that the ancient Greeks designated, in a general way, whether the sexual act was involved or not, lovers of boys and young men. Sexual perversion exists to-day to a much greater ex- tent than the general practitioner realizes. A proper under- standing of this abnormal condition is of great scientific im- portance and medico-legal interest. The medical man who has a clear understanding and conception of the psycholog- ical conditions governing the mental and physical attitudes of these perverts and inverts, who is known to understand their morbid desires, and appreciates their moral palsy, will, be astonished at the number which will seek him for relief. 1 do not refe/ to the vicious, to the morally depraved, to the male prostitute, to that class which comes under police notice, or to the degenerate whose actions are decidedly anti-social. Space prevents me from showing where the rigorous line should be drawn between these banal and vicious classes and the unfortunate psychical pervert. It is certain that in sexual perversion we have to deal with well- defined pathological phenomena occurring under conditions that vary only in circumstances and environments, which have always existed at all periods and in all countries. Natural laws govern all the phenomena from the first appear- ance of sexual life, through its various phases to decadence. A close study of the history of cases will show analogies which will convince the most skeptical. The invert and the 114 William Lee Howard. pervert is to be found among the aesthetic class. A marked feature of this anomaly is the precocity of the sexual instinct. Ninety per cent, of these abnormal individuals are engaged in artistic pursuits. They are found among the painters, musicians, poets, and the writers of erotic fulmination. Among Havelock Ellis' thirty-three cases, two were physicians. Female perverts depart to a greater degree from the normal than do the male. There are more female preverts than inverts in my experience. These cases of true sexual perversion, can seldom, if ever, be seen in hospitals and dispensaries. (1 use tl word per- vert to cover all abnormal sexual desires, while invert is strictly applied to designate the love of one sex for an individual of the same sex. In speaking in a general way of the subject, perversion covers all cases). The practi- tioner, while he may have them in his office to be treated for some extraneous trouble, will not often be made the confident of the pervert. These individuals are secretive, reserved and obmutescent. As they recognize the fact that unless understood they will be avoided, shunned with dis- ^c^'-*" gust, and finally met with social d#gf+Hgalaile, it is not strange that their abnormality is seldom recognized except by those of similar psychical desires, and to the specialist, with whom they are pitiably frank, honest and hopefully confident. The genital organs of the pervert are almost without an exception normal in appearance «and function. The condition of these individuals is a decided psychical morbid entity. Some of them do not realize that their passions, desires and thoughts are abnormal. It is not easy to appreciate the role that external impressions and acci- dental environments have played in the individual develop- ment of these cases. 1 do not believe that true inversion is ever an acquired condition; it is congenital. I will not here go into this interesting branch of the subject, but will give fully the history of two cases in which I have been able to get at definiie basis of facts as regards heredity. The first case 1 requested to write out for me, in his own words, his history, physical condition, and mental attitude Psychical Hermaphroditism. 115 and desires. This will better enable us to understand the moral status of these unfortunates. CASE I.—H. W. F., 1 am thirty years old. Ever since I was a small boy of eight or nine I have practised the habit of self-abuse. For many years 1 had no idea that it was wrong or injurious; when my eyes were opened 1 loathed myself, and have had no self-respect. 1 have hon- estly resolved time and again to break this habit. One summer, four or five years ago, 1 remember how earnestly I tried to refrain, and was most miserable. I had nocturnal emissions, which proved far more weakening than the indul- gence; had a cough, was melancholy and despondent. 1 never had advice, 1 have simply drawn my own inferences; my experience taught me that 1 could not overcome the habit unaided. I could not then, and doubt if 1 could now, go to my doctor and tell him what 1 write for you. To-day I transgress more than ever; the result: I have never weighed as much; eat well. 1 sleep about nine hours nightly, and have very few spells of that awful despon- dency. I believe that 1 have a goodly amouut of conscien- tiousness. 1 loath the practice, but somehow there seems to be a hungering, burning desire, crying for appeasement so loudly that the voice of reason is drowned. It seems almost as if 1 had two beings. When 1 am my rational self 1 .say to myself "the right is well-defined; the proper course is simple," but when the fit is upon me, there seems to be only one word, MUST. It must be gratified regard- less of consequences. The object of my imagination is man. 1 suppose that men who practice this habit have as the idol of their imagination woman. But it is not so with me. I think that 1 have the same regard for men as a healthy man has for woman. 1 have loved men passion- ately. I idolize them. Any licentious thought in regard to such I regard as a sacrilege. That love is just as real to me as the love of a young man for a woman, though my better s• If would tell me how preposterious it was; yet I seem incapable of any other. I can define my disposition no better than to say that I seem to be a female in a per- fectly formed male body, for, so far as I know, I am a well-formed man, capable of performing all of man's func- tions sexually. Yet as far back as I can remembei, sureb/ as young as five years, I seemed to have the strongest pos- sible desire to be a girl, and used to wonder if by some peculiar magic I might not be transformed. I played with dolls; girls were my companions; their tastes were my tastes; music, flowers and millinery interested me and do 116 William Lee Howard. to this day. I have had little sympathy with boys or men. It has always been a topic for thought and speculation, the abnormal development of man. Any such thought or con- versation kindles the fire of passion in my brain. My love for a woman is the same that 1 have for a work of art; for a statue. 1 believe that Venus herself would not excite a bit of emotion in me. Yet a handsome man throws me into a passionate and emotional fit. In the romances that 1 draw for myself I always picture myself as a beautiful girl. This is not a forced imagination; such dreams and fancies come uncalled for in my mind. My childhood was loveless, and I often used to reason that 1 longed for love and sympathy. When 1 first heard that twins were born 1 wondered if I had not lost my mate, such was that ever present longing. In my mother's family there were four girls and one boy. He was connected with many women; having three wives, all living. He was very erratic. Of the four girls, two never had children, though married young. The husband of one of them told me that his wife could never have children. I have two sisters and one brother; both sisters married over twenty years and childless. Their doctor told me that neither of them could have children. My mother died when 1 was six years old. My father was addicted to the morphine habit, and wished to be left alone. Yes; I love man in the sexual sense; unsatisfac- torily? not wholly so; but the voice that haunts, the fire that burns, are stilled and quenched for the time, but only for a time. Men who have known men thus extraordinarily favored are common. * * * When I see some men my face flushes; I tremble; my voice seems unsteady and harsh; the nerve strain is acute; only by a mighty effort do 1 keep a semblance of coolness. * * * Should I meet a man who said that he was the favored one 1 would throw discretion to the winds; I'll follow impulse regard- less of consequences, though I should lose my position and be forever disgraced. Indulgence will restore me quickly to my mental equilibrum. I desire to have the penis placed where the female organ would be if it existed. * * * 1 wanted to be an artist but the opposition was greater than the determination. I now paint and design during my leisure moments. The quality of my voice has been so frequently remarked as to annoy me. 1 have quite a stong falsetto voice of considerable compass. I once knew a man who would entice boys to his room and expose him- self and fondle them. I have no desire that way. I desire only handsome and robust men. 1 do not think that I Psychical Hermaphroditism. 117 look twice at a man wholly shaven. I do not always entertain lascivious thoughts toward them, 1 feel if 1 could only caress, kiss and "love" them it would be the acme of happiness. We see in this case a peculiar congenital condition, which differs from the generally conceived idea of a sexual pervert, in the fact that the idea of sodomy (immissio penis in anum) is repulsive. This condition was first pointed out by Casper in the Vierteljahrschrift in 1852. We also have in F's statement the idea and suggestion of a female soul in a male body. This phantasy (anima muliebris in copore virili inclusa) is an old one, first expressed by Carl Hein- rich Ulrich, but is an original conception with F; of this 1 am reasonably certain. Such a specious explanation, while it satisfies the psychical longings of the pervert, has no scientific psychological basis. CASE II.—Mr. W.: age 38 years; occupation, artist; referred to me by Dr. C. G. Chaddock, of St. Louis, Mo. His father was a prominent physician who died when W. was about twenty years of age. He had been a hard drink- er; and during the latter part of his life was addicted to taking large doses of chloral, and died in an insane asylum. W.'s mother died of paresis when W. was an infant. A brother is a steady drinker, and another died insane. He has rea- sons to believe that one of his sisters is a victim of sexual disturbances. In fact we have a history of a family en- dowed with superior mental capacity yet exhibiting lycan- thropic stigmata throughout its whole existence and person- nel. When W. was about eight years of age the question of sex differentiation arose in his mind, and he questioned his father regarding the subject. He was erroneously in- formed that there was no difference, and from this mislead- ing and injudicious instruction W. dates back the psychical twist in his sexual character. At school he practiced mut- ual masturbation, but went no further in physical contact with his schoolmates. He has never had any normal inter- course with, or mental pictures of women or girls. So for- eign to him is the ordinary attraction of women to men that he expresses no desire to be placed in such a mental con- dition as to realize this attraction. He wishes to be relieved from a very depressing and annoying nervous irritation which inevitably culminates in excessive masturbation, and is accompanied by salacious thoughts regarding those of his 118 William Lee Howard. own sex. These attacks occur at intervals of about four weeks, an interesting pathological fact, and immediately cease after he has manually relieved himself. For several days preceding this psychical explosion he is a different person; irritable, unable to rest or sleep, and oblivious to his other personality. We have here a disordinated condition of the mind, or what Prof. Newbold calls an "amorphous mind," the dis- ordination producing an imperative and uncontrollable desire to masturbate; the impulse to act being forcibly accentuat- ed by hallucinations regarding the male genital organs. During these periods he has no clear consciousness of the existence of his normal body, or rather no lucid conscious- ness belonging to that body. When he is W. he realizes that he is a man, and has all the habits and instincts of a man aside from sexual desires, which are then negative. When in this condition, if he has any sexual suggestions, auto or otherwise, he is transformed psychically into the opposite sex. This derangement of personality, with sexual inversion as its motif, I do not remember having ever met with before. It offers a new field for studies which involve the most perplexing of psychological and physiological problems. Treatment.—There is but little to be said regarding the treatment of the true sexual pervert. As I have stated the condition is a congenital one. In the two cases given above, and in several others, I have been able to abolish the habit of masturbation, subdue the intense despondency, and suppress hysterical tendencies, by the use of hypnotic suggestion. This mode of treatment has brought about a better physical and mental condition, and aside from the inverted sensibility, but which now partakes more of the social and sentimental aspect, the patients are well and re- signedly contented. Drug medication in these cases is ab- solutely useless. Suggestion, avoidance of surroundings which are apt to produce emotional feelings; such as music, art galleries or the theatre, and substantial but nourishing diet is all that can be done; and this only with the idea of keeping them free from vicious habits and placing them in a condition of mental equilibrium, although they still re- main psychically inverted. Preputial Reflex Epileptiform Convul- sions, with Report of a Case. By ALEX. L. HODGDON, M. D., Dispensary Physician to Department of Nervous Diseases, College of Physicians and Surgeons. Baltimore, Md. r)HIMOSIS, of course, is only one of the many sources * of reflex epileptiform convulsions. A tooth forcing its way through the gums, causing pressure on the sensi- tive nerve filaments; a splinter imbedded in the finger exerting deleterious nerve irritation, or an unaccomodated eye with its resultant irritant action, might all produce these reflex, epileptiform convulsions, or shall 1 not say the beginning of true epilepsy? And it seems doubtful if all epilepsies are not in a way reflex, from the irritable gas- tric nerves, constituting gastric epilepsy, to the tumor, caus- ing irritation by pressure on some one or several of the functioning centers of the brain, and by the resulting symptoms indicating their locality. Gray very aptly, and 1 believe truly, says that Epilepsy is only a symptom.* "Our conception of epilepsy will be altered, if at the out- set we recognize the indubitable fact that epilepsy is but a symptom, just as is a cough or fever, so that epilepsies may be divided into those that are due to recognizable organic disease, those that are reflex and those that we may call idiopathic." If due to some irritant which may be removed, why not very carefully try to prevent further convulsions in the teething infant, and circumcise the epileptic infant with phimosis, for there must be a beginning to everything finite, and by removing sources of irritation you may prevent the formation of a permanent "Nervous and Mental Diseases." Gray. [119] 120 Alex. L. Hodgdon. lesion, or an intangible condition, such as habit epilepsy, both of which may in the end terminate the life of the epileptic, lapse into epileptic mania, and may finally follow the subject to his grave. We have somewhat of an illustration of this habit epilepsy in the rigor of malaria, those paroxysms which continue after the miasm has been removed from the system, which are dispelled, in some instances, by a mental impression, such as turning back the hands of the clock, till after the usual time for the chill; only the malarial paroxysms do not seem to produce a permanent change in the function of the nerve tissue, which may occur in epilepsy. May we not possibly by administering proper doses of bromide of soda to the teeth- ing infant, and by circumcising the child with phimosis, prevent a life-time of misery? These matters should be attended to, and it would be well if all male infants were circumcised within the first month after birth, taking care to cut off all the skin that covers the head of the penis, so as to leave it completely uncovered, and so that no part of the head can be made to remain covered. If this were done it would prevent the occurrence of phimosis in the future, even if not present at that time. About the only objections that have been urged against cutting off the foreskin, is that it leaves the sensitive head of the penis constantly exposed to friction against the clothing and other rough articles, and another objection made is that the exposure to friction decreases to a certain extent the sensibility of this very sensitive head. It does come in con- tact with the clothing, after circumcision has been performed, but after some time, the mucous membrane of the glans penis becomes toughened and thicker, and so far as the decrease in sensibility is concerned, this is an advantage, as the act of coitus is prolonged, the glands of Tyson situated near the corona dry up, so that the glans penis of the circumcised individual remains dry and clean. I have performed the operation of circumcision many times, and have seen cases which have been operated upon by some inexperienced operators, which were about as badly off after the operation as before, on account of not having Preputial Reflex Epileptiform Convulsions. 121 removed enough skin. One should not operate on persons afflicted with haemophilia, unless the risk incurred from not operating, were greater than that from an operation. Kobelt has said that the glans penis is not exceeded in richness of nerves by any other part of the economy not excepting the organs of sense, and if so, is it any wonder if reflex epileptic convulsions occur in the case of the infant or adult afflicted with phimosis, with a quantity of smegma imbedded under the foreskin, on the delicate surface of the glans, which cannot be wiped off because the foreskin cannot be retracted, and is it not a wonder that trouble does not ensue in more cases? The case which 1 will report is that of W. T., aged, nearly four months, who had suffered since one month of age from epilepsy, having had a convulsion nearly every day, and has also exhibited a great deal of irritability, which he manifested by frequent attacks of crying. -Upon inquiry I found that his urine had always passed away in drops, and dribbled away very slowly, also that he was passing considerable mucous by the anus. When 1 examined him, 1 found a very small preputial orifice, and was led to conclude that the convul- sions from which he had suffered, were probably reflex. As he had suffered from about three or four convulsions on the day when I first saw him, 1 resolved not to delay operating till the following day, but circumcised him that night. Since the operation of circumcision was performed he has passed his water without difficulty, and his feces appealed more natural. I circumcised him Saturday night, and he had no convulsions on Sunday, but Monday after- noon he had three or four convulsions and a temperature of about 102^2° Fah. 1 gave a little Bromide of Soda and Ace- tanilide, also small doses of Quinine Sulphate. On Tuesday the temperature was about 101°, and on Wednesday his temperature was normal. He has not had a convulsion since Monday, and seems to be very quiet and good-natured. It has been a long time since he was operated upon, and I have not heard of his having a convulsion since two days after he was circumcised. On Intemperance, Consanguine Marriages and Educational Overpressure, as Factors in the Genesis of Nerve Disease and Degeneration of the Race.* By SIR FREDERIC BATEMAN, M. D., LL. D., F. R. C. P. Consulting Physician to the Norfolk and Norwich Hospital: Corresponding Member Medico- Legal Society of N. Y.; Laureate of the Academy of Medicine of France. THERE are few subjects that for some years past have so much engrossed the public mind, as those included in the title of this communication. 1 propose considering how far degeneration of the nervous system may be caused, directly or indirectly (that is in the individual himself or in his offspring, but especially in the latter) by Intemper- ance, Consanguine Marriages and Overpressure in Education. Let me say, in limine, that the effects of each of these causes have, in my opinion, been greatly exaggerated, and it is with the view or arriving at a correct estimate of the effects of each of the above causes of degeneration of nerve tissue, that I desire to bring my views before the New York Medico-Legal Society, feeling that there is no better arena for arriving at a satisfactory conclusion upon a sub- ject alike interesting to the legal and medical profession. It is essentially a practical subject, and the practical experience of the members of the Medico-Legal Society will be extremely useful in aiding a settlement of the much vexed question as to how far the above-mentioned causes *Read before the Psychological Section. Medico-Legal Society. Oct. 8th. 1896. Read before the Medico-Legal Society. Dec. 16th, 1896. Note.—Published by courtesy of the Author and the Medico-Legal Journal, [122] Intemperance and Degeneration. 123 are responsible for the widely spread neurotic degeneration characterizing the close of the nineteenth century. Let me begin with Intemperance, ^which was said, I believe, by the late chairman of the Ervglish Board of Lunacy, Lord Shaftesbury, to be the cause of fifty per cent, of all cases of insanity. I need .not say that this statement is not endorsed by those most competent to form an opinion on the subject. The part which alcohol plays in the production of insanity, has for some time occupied the attention of the alienist physicians, and has frequently been the subject of discussion at various scientific associations, the result of which is that Lord Shaftesbury's fifty per cent, has been reduced to fourteen per cent., and by some , observers to even a lower figure. Doubtless many cases are stated as due to the abuse of alcoholic stimulants, where some other distinct influence co-existed. In France, M. Lunier, Inspector of Asylums, has shown that the departments in which the consumption of alcohol had increased most, were those in which there had been a corresponding increase of insanity, and this was shown most strikingly in regard to women, at the period when the natural wines of the country gave way to the consumption of spirits. In Sweden, Dr. Westfelt has lately made a communi- cation to the Stockholm Medical Society, containing the statistics of alcoholic abuse and its results in Sweden. He calculates that at least from seven to twelve or thirteen per cent, among males, and from one to two per cent, among females, of all cases of acquired insanity, are due to the abuse of alcohol; and in reference to its influence on progeny and race, he shows that a steady diminution of the population was coincident with a period when drunken- ness was at its greatest height. I now arrive at the consideration of how far intemper- ance in parents may cause nerve degeneration in their off- spring, and this is a question upon which, perhaps, more definite and reliable conclusions can be formed. The sub- ject as to how far intemperance in parents injuriously effect their progeny was prominently "brought before the 124 Frederic Bateman. British Medical Association a few years ago, by Dr. Fletcher Beach, and there is a general consensus of opinion that the abuse of alcoholic stimulants—mark, I do not say the proper use of alcoholic stimulants—tends to bring families into a low and feeble condition, which thus becomes a prolific cause of idiocy in their children. From a report on idiocy, by Dr. Howe and other Commissioners appointed by the Governor, of Massachusetts to ascertain the causes of this calamity in that State, it is stated that "out of 359 idiots, the condition of whose progenitors was ascertained, ninety-nine were the children of inveterate drunkards"; and the report goes on to say-forther, that when the parents were not actually habitual drunkards, yet amongst the idiots of the lower class, not one quarter of the parents could be con- sidered as temperate persons. From the table drawn up by the late Dr. Kerlin,- an American physician, in which the causes of the infirmity are given in 100 cases of idiotic children, I observe that in thirty-eight of the number, intem- perance on the part of the parents is traced as an acces- sory, main, direct, or indirect cause. At the annual meeting of the British Medical Associa- tion, held at Cambridge, Dr. Fletcher Beach read a paper on the "Intemperance of Parents as a Predisposing Cause of Idiocy in Children." In 430 patients, he was enabled to trace a history of parental intemperance in 138 cases, or 31.6 per cent.; of this number seventy-two were males and sixty-six females." Other observers lay less stress upon parental intem- perance as a cause of idiocy. Dr. Wilbur found that out of 365 cases in the State of Illinois, only eight cases were assigned to the abuse of drink in the parents; and Dr. Shuttleworth could trace this cause in only 16.38 per cent, of the cases observed by himself and by Dr. Fletcher Beach;* the same writer under the head of toxic idiocy, mentions the case of an idiot boy, who was said to have been brought up on porter instead of milk. It will there- fore be. seen that there exists a great difference of opinion * "Mentally-deficient Chiidren, their Treatment and Training" By Ci. E. Shuttle- worth. M. D. Page 36. Intemperance and Degeneration. 125 about the influence of intemperance of the parents in the causation of idiocy; but although statistics may vary upon this point, there cannot be a doubt that the children of drunken parents inherit an unhealthy system, which in many cases culminates in idiocy. Idiocy is especially prevalent in Norway, and Ludwig Dahl, a Norwegian writer, says that to the abuse of brandy, especially in the fathers, but also in the mothers during pregnancy, may be assigned an important, perhaps the most important, influence in the production of the large number of idiots in that country. In considering this question, we must bear in mind that intemperance is only a relative term; for in the early part of the century we read of our ancestors indulging in a bottle of port wine to each individual, without, it seems, incurring the charge of drunkenness. There cannot be a doubt, however, that the habitual use of alcohol, without being carried to the extent of actual intoxication, is cal- culated to cause a low and feeble condition of the body, and thus conduce to the production of idiocy in the off- spring; for we may fairly assume that what too severely tries the nervous system in one generation will appear in their descendants.* Without, therefore, exaggerating the influence of alcohol on the genesis of idiocy, I think 1 shall not be deviating from the path of strict scientific accuracy, if 1 say that over indulgence in alcoholic beverages is calculated to produce a low state of vitality, and a degen- eration of nerve tissue which may culminate in the develop- ment of idiocy in subsequent generations. Just now that the attention of the Legislature is being -prominently called to the treatment of habitual drunkards, it cannot be too widely known that their innocent offspring are but too frequently the victims of the brutish excesses of their parents, who, a few years ago, were well described by the then Secretary of State for the Home Department, *Toussenel. a French writer says. "La plupart des Idiots sont des enfants procreea dans I'lvresse bacchique. On salt que les enfants se ressentant generalement de I'influence passlonelle qui a preside a leur conception." At a discussion at the Obstetrical Society, Dr. Langdon Down is reported to have entertained similar views. 126 Frederic Bat eman. when receiving a deputation on the subject, as not quite criminals nor quite lunatics, although nearly approaching both classes in many cases. The above statistics fully corroborate the pertinency of Lord Cross' remarks. I do not allude to these facts with the view of casting any reflection upon the poor, honest, and temperate laborer, who may be afflicted with the calamity of having an idiot child; but I merely mention them in order that they may serve as an additional caution against habits of intemper- ance, and may strengthen the hands of that noble band of philanthropists who are endeavoring to check the torrents of this hideous vice so prevalent in the present day. 1 would refer those who may wish to pursue the inquiry as to the baneful influence of alcohol on the human frame, to the celebrated Cantor Lectures on Alcohol, by my friend Sir B. W. Richardson, in which he introduces the physio- logical argument into the temperance cause, asserting that alcohol cannot be classified as a food; that degeneration of tissues is produced, that it neither supplies matter for con- struction nor production of heat, but, on the contrary, militates against both. Consanguine Marriages.—There is no point connected with the causation of degeneration of the nervous system that has given rise to so much controversy as the marriage of near relations; formerly one of the most popular notions was that consanguineous marriages were among the most common causes of idiocy, whereas the researches of later observers have tended to modify, to a considerable extent, this sweeping assertion. Different observers have furnished different results, as to the proportion of idiots found to be the offspring of con- sanguine marriages; thus Dr. Grabham's statistics give the proportion as about two per cent., Dr. Langdon Down's rather more than five per cent., and Dr. Shuttleworth's less than five per cent. The statistics of the Eastern Counties' Asylum, kindly supplied to me by Mr. Turner, the Resident Superintendent, show that about 6.5 per cent, were the offspring of cousins. Of 359 cases observed by Dr. Howe, seventeen were Intemperance and Degeneration. 127 known to be the children of parents nearly related in blood. The history of these seventeen families, the heads of which being blood relatives intermarried, showed that there were other causes to increase the chances of an infirm offspring, besides that of intermarriages, as most of the parents were intemperate or scrofulous; some were both the one and the other. There were born unto them ninety-five children, of whom forty-four wore idiotic, twelve others were scrofulous and puny, one was deaf, and one was a dwarf! In one family of eight children, five were idiotic* That eminent clinical observer, the late Professor Trous- seau, + in treating of the influence of consanguine marriages, gives the history of a Neapolitan family, in which an uncle married his niece. There had previously been no hereditary disease in the family; of the four children, the issue of this marriage, the eldest daughter was very eccentric; tlie second child, a boy, was epileptic; the third child very intelligent; and the fourth was an idiot and epileptic. Dr. Ireland, who has investigated this point with great minuteness, pertinently remarks that it has been the cus- tom to collect instances of cousins who have married, and have had unhealthy children, as if this never happened to anyone else; and he adds that "the proper way to examine the question clearly is to find what is the proportion of marriages of blood relations in a given population, and then to inquire if there be in the- issue of such marriages a larger percentage of insane, idiotic, or otherwise unhealthy children."]: There cannot be a doubt that consanguinity has hitherto been considered too great a factor in the production of idiocy, ami that in weighing the evidence, we must not lose sight of the fact that in many cases recorded, other factors besides intermarriage of relatives have contributed concurrently to the development of the mental detect. Educational Overpressure.—I now proceed to consider a * "On the Cames of Idiocy.'' liv S. G. Howe, M. D. iJaue .,5. t Cliiilou. Mtlicale Jc 1'H'itel-DUu Jc Paris. X "On lalucy and Imbecility.'' By W. W. Ireland. M. P, r'ai.-'-' v>- 128 'Frederic Bat eman. cause of social degeneration, which is attracting much notice at the present day, especially amongst English-speak- ing people, which has been pointed out by Dr. Seguin, and which he says is due to the unsatisfactory social conditions under which women of the present day exist. "'As soon," he says, "as women assumed the anxieties pertaining to both sexes, they gave birth to children whose like had hardly been met with thirty years ago.* Great prominence has lately been given to this subject by an oration on "Sex in Education," by Sir James Crich- ton Browne, at the Medical Society of London, in which he called attention to the "growing tendency to ignore intel- lectual distinction between the sexes, to assimilate the education of girls to that of boys, and to throw men and women into industrial competition in every walk of life." Elsewhere, he adds, that "to throw women into competi- tion with men is to insure to them a largely increased liability to organic nervous disease Woe betide the generation that springs from mothers amongst whom gross nervous degenerations abound." Sir J. C. Browne supports his views by showing that there are organic cerebral differences between men and women, and that therefore they must be educated in different ways, being destined to play different parts in the stage of human life. Sir J. C. Browne, in speaking of the brain of men and women, says there can be no question of inferiority or superiority between them any more than there can be between a telescope and a microscope; but they are differ- entiated from each other in structure and function, and fitted to do different kinds of work in the world. He maintains that the weight of the brain is less in women than in men, that the specific gravity of the gray matter is less, that the distribution of the blood varies in the two sexes to a considerable extent, and that the blood going to the female brain is somewhat poorer in quality than that going to the male brain, and contains four millions and a half * "New Facts anJ Remarks Concerning Idiocy," by E. Seguin, M. D. Page 28. New York, 1*70. page 19. • Intemperance and Degeneration. 129 corpuscles to the cubic millimetre, instead of five millions in the case of the male. The above views of Sir J. C. Browne have not remained unchallenged, and -the eminent psychologist has found uncompromising opponents in Mrs. Garrett Anderson and others, who stoutly refuse to recognize the position of the "Tacens et placens uxor" of old-time dreams. Mrs. Ander- son, who, I need scarcely add, writes most temperately upon this matter, in alluding to Sir J. C. Browne's assump- tion of the intellectual difference between men and women, remarks: "All 1 would venture to say is that, if it could be proved that an average man differs from an average woman as much as Newton differed from a cretin, it would still be well to give the cretin all the training which he was capable of receiving When we hear it said that women will cease to be womanly if they enter professions or occasionally vote in parliamentary elections, we think that those who conjure up these terrors should try to understand women better, and should rid themselves of the habit of being frightened about nothing." It seems that one of her own sex is of a different opinion to Mrs. Anderson, as in a series of articles in the "Nineteenth Century" for 1891 and 1892, Mrs. Lynn Linton strongly deprecates any departure from the comparatively restricted area of usefulness hitherto open to women, and she even boldly states that it is for maternity that women primarily exist! She also adds, "be it pleasant or unpleasant, it is none the less an absolute truth—the raison d'etre of a woman is maternity .... the cradle lies across the door of the polling booth and bars the way to the senate." The controversy is continued in the same serial by Mrs. Mona Caird, who in a powerful article, entitled "Defense of the So-called Wild Women," severely criticises Mrs. Lynn Linton's views as to the restrictions she would impose upon the freedom of women to choose their own career. The limits of this essay will not permit me to dwell at any great length on the important question under con- sideration. There cannot be a doubt that the tendency of 130 Frederic Bateman. the present age is to encourage women to choose careers and to accept burdens unfitted for them. In thus expressing myself, 1 distinctly deprecate any hostility to the woman's movement at the present day, which rests on the claim for women for an open career; and 1 should be glad to see our universities ignore the ancient and exploded prejudices, which led to long subjection of women to hardship and inequality. They ask for the same facilities «s are enjoyed by men, and they have amply shown that they can com- pete with men in intellectual pursuits, and all they ask is to be allowed to compete on equal terms. 1 therefore cordially welcome the gradual emancipation of women from comparative subjection to comparative freedom; but the multifarious fields of energy and usefulness open to modern women, have brought with them disadvantages as well as gains. Whilst, therefore, unreservedly admitting the claim of the fin de siicle woman to freedom of action and to intel- lectual equality, I must think there are certain branches of study, described by a modern writer as belonging to the "gynagogue" class, which are less suited to women than some others; and amongst these, I would name the abstruse study of mathematics, for although success in this branch of knowledge may lead to a brilliant career as a high wrangler, I think that a female mathematical athlete is not suited for the duties and responsibilities of maternity, and that the mental endowments of her children are likely to be below the average. I am quite aware that 1 am treading on dangerous and delicate ground, but although I would not discourage the highest aspirations of women, whether of an intellectual, social, or aesthetic character, 1 must think- that a word of caution is necessary against the overpressure of the present day in the direction above indicated. With every desire to treat this question from a most liberal point of view, 1 desire to emphasize the fact that men and women have different parts to play on the stage of life, and should be trained differently; but provided mental overpressure is guarded against, 1 have no fear of women engaging in cer- Intemperance and Degeneration. 131 tain occupations which custom has not hitherto recognised as feminine, and experience has shown us that they may be safely left to follow the promptings of their own powers and instincts. Although the injurious effects of overpressure in educa- tion have been principally referred to in the education of girls, the same pernicious results may accrue in the case of boys. Dr. Wynn Westcott,* in his work on "Suicide," states that during the last few years there have been several English cases of children killing themselves because unable to perform school tasks. He also says that child suicide is increasing in England and in almost all Continental states, and that the cause in many cases is due to overpressure in education. Dr. Strahan.t writing upon the same subject, in his treatise on "Suicide and Insanity," corroborates Dr. Westcott's views, and remarks that fifty years ago, child- suicide was comparatively rare; but that during the last quarter of a century it has steadily increased in all Euro- pean states, and that the high-pressure system of education is generally considered the cause of it. If any apology be needed for dwelling at such length on the evils of the educational overpressure so prevalent in our days, 1 would observe that it has an indirect bearing upon the causation of idiocy; for although the sinister results recorded by Drs. Westcott and Strahan may be comparatively rare, still consequences of a more remote character may ensue, for the injury done to the nervous system is cumulative and transmissible from generation to generation, and a neurotic tendency may be engendered in the offspring of those who have been exposed to this evil, which may manifest itself in the appearance of idiocy or some lesser form of mental defect. * "Suicide. its History, Literature. Jurisprudence, etc" By W. Wynn Westcott. M. D. t "S^uiciJe and Insanity, a Physiological and Sociological Study." by S. A. K. Strahan. M. D.. Barrister at Law. WHAT IS MENINGITIS? By W. S. CHRISTOPHER, M. L>., Chicago, 111. Fellow of the Chicago Academy of Medicl»e; Professor of Diseases of Chiidren, Chicago Polyclinic. THE object of this paper is to call in question certain theories regarding meningitis which are very generally accepted. These theories are, that symptoms found during life in meningitis, result from lesions present in the men- inges. Very naturally the definition of meningitis must be called in question, and it becomes necessary to ask what is meningitis? The question has occurred to me almost entirely from a clinical stand-point as will be seen by the following cases: In children a vast number of so-called brain symptoms occur in a host of cases of great variety. Nearly all febrile diseases present more or less brain symptoms, but the classical picture of meningitis, that is to say, cases in which there occur coma, eye symp- toms and symptoms involving various other muscles than those of the eye, vomiting, then convulsions, are the ones I shall discuss in considering meningitis. Meningitis varies materially in the semeiology which it presents. Sometimes with the simplest symptoms, fatal meningitis will ensue, and sometimes with the most severe symptoms, recovery will occur. Some six years ago last month 1 saw a child fourteen months of age, which presented this group of symptoms. For four weeks it had diarrhoea of a putrid type. It took four weeks to cure the gastro-intestinal derangement at which time there was left an emaciated little baby with marked enlargement of the mesenteric glands that could be * Chicago Academy of Medicine Transactions. [132] What is Meningitis? 133 readily seen through the thin, lax abdominal wall. Dr. Henrotin asserts that the child undoubtedly had tuberculosis. A few days later the child had returned to its febrile con- dition and there was presented a picture of photophobia, strabismus, irregularity and sluggish reaction of the pupils, irregular respiration, irregular pulse, and the most marked type of hydrocephalic cry to which 1 have ever listened. These symptoms lasted for a week ultimately terminating in recovery. One would say of course there-was a basilar meningi- tis presumably presenting all the ^etiological factors of a tubercular type. Five years have elapsed and the child is practically well. I saw her recently and found a tendency to stumble. I could never make out any paralysis or any particular weakness of the muscles, and this tendency to stumble may have been a clumsy habit. 1 mention this case for what it is worth. The child is absolutely free from gland enlargement, and from any evidence of tuber- culosis, so that if she had tubercular meningitis, she made a complete recovery. That she had a basilar meningitis seems certain. 1 shall next cite a case of the very opposite type. A child born in December, 1894, was taken sick in July of 1895, with slight fever, the nature of which was never discovered. It was presumed to be "la grippe." This fever lasted a few days, but the child never seemed exactly the same. In August it was found that the mother's milk was insufficient and it was suggested to wean the child. Before the mother had made up her mind to do so the child refused to take the breast. It was then put on ster- ilized milk and refused to take this. 1 saw the child Mime time later and all I could find wrong with it was persistent refusal to take food. It would sit up with a most stern and determined expression, upon its face, the little lips were tightly closed, absolutely refusing to allow anything except water to pass the lips. There was- no evidence of nausea and no vomiting. It was suggested, however, that meningi- tis might occur. The child went on in this way for three weeks during which time it received not over a pint of 134 W. S. Christopher. sterilized milk by the mouth. Latterly it was fed by mouth with peptonized and sterilized milk and within twenty-four hours thereafter it presented a picture of meningitis. "The symptoms consisted of strabismus, photophobia, general convulsions and retracted abdomen. In short there was a typical classical picture and so-called symptomatic meningi- tis. The milk was perfectly sterilized, the mother and her family were absolutely free from tuberculosis as was also the father of the child. Not a servant with a suspicion of tuberculosis had lived in the house. It is interesting to compare two such cases as these: One presenting for a period of three or four weeks simply a symptom of refusal to take food and terminating after twenty-four hours with a complete picture of meningitis; the other presenting a classical picture of the disease and terminating favorably. It has been my experience that the cases presenting classical pictures of meningitis do not termi- nate favorably. Very few of them recover so that when the classical picture of meningitis is present it is an extremely unfavorable prognostic sign. The disease is dan- gerous to life, and life is usually sacrificed with the pres- ence of such symptoms. Another case occurred in my practice January, 1895, in the child of a physician. It was about fourteen months old. The child had been bottle fed, but been fed very carefully. Its nutrition seemed perfect. The character of its food had been such as to secure for it good nutrition. No defects of any kind could be seen in its nutrition, no evidence of a rachitic condition, no evidence of scorbutic starvation, no evidence of failure of nutrition. About Christmas time in consequence of a little indiscretion in feeding the child, there developed putrid diarrhoea, which later improved, but finally became worse until about the middle of January. At that time 1 saw the child. Its tem- perature was 103". It was somewhat stupid but manifested no sign of meningitis, other than stupor which I did not look upon as meningeal in the absence of other symptoms. There was a rose rash over the abdomen, but not of a type to indicate typhoid. Without the slightest hesitation typhoid What is Meningitis? 135 fever was excluded. At first it was concluded that there- was simply a condition of fermentation in the bowel, a gastro-enteric intoxication, and in all probability the matter could be straightened out by proper attention to the bowel. However this proved erroneous. The bowel was cleaned out, the feces rendered relatively aseptic and still the fever continued. While it was doubtless true that this child had originally had an infection of the bowel contents.it was unques- tionably true now that it had general infection of the blood, which infection probably had found its way into the circulation through the medium of the bowel. The febrile symptoms continued and gradually there developed evidences of men- ingeal trouble. The stuporous condition continued until the 1st of January, at which time the child became somewhat brighter and more irritable. The nutrition continued good. About 21st, sleep was broken and the hydrocephalic cry occurred. The child was given one-fourth grain Dover's powder to control the pain in the head. There was stupor following this dose, but it was thought at the time that it was due to other things than opium. On the morning of the 24th, there was a stuporous condition. The abdomen was somewhat distended, and enemata were given to relieve the bowel distention and to flush the kidneys. The case ran along in this way until about January 30th, when the stools were of a dark greenish color like chopped spinach. For four or five days there was no diarrhoea. Urination copious enough; hydrocephalic cry; the child was under the influence of opiate. Appaiently some photophobia, con- vergent strabismus for several days preceding d,eath, ina- bility to bring the left arm across the body, although it could reach back of the head to seize the ice bag.and pull it away. There were evidences of paralysis of the left side of the body, the left leg absolutely motionless while the right was kept in constant motion. The left arm it never attempted to pull across the body but could rajse to the head. The character of the movements of tire left arm indicated some form of paralysis. Expressions of pain were developed on lifting the lower part of the trunk with the hands under the head. There was a hyperaesthetic condi- 136 W. S. Christopher. tion of the left leg and some rigidity of the spine. This disappeared somewhat when the strychnia which was given was discontinued. The child was kept on strychnine ila grain every three or four hours, but the condition did not entirely disappear. The temperature reached normal a few days preceding death. Sponging was sufficient to reduce the temperature, no other anti-pyretic being given. The pulse throughout illness remained strong. January 30th there was considerable distention of the abdomen with ineffectual strain which was relieved by massage. The temperature then was 103°, when sponging reduced it to 100°. The child sank into quiet slumber about 3 o'clock in the morning, when it was found to be in a dying con- dition. The child died, but before death there was ameliora- tion of the meningeal symptoms. 1 was satisfied toward the close of the child's illness that the bowels were clean and the administration of the milk did not seem to increase the trouble in any way. Furthermore diuretics were used very largely for the purpose of flushing the bowel artd of getting fluid into the general system as a means of general elimination. Fly blisters were applied to relieve the symptoms. Autopsy was made by Dr. Futterer. 1 told the father that the child had died of an auto-intoxication which produced marked brain symp- toms. Evidences of meningitis were shown by the ordinary lymph exudation thrown out upon the meninges. All the symptoms were not produced by the single cause. Some symptoms consisting of external manifestations were readily detected during life while others consisting of internal mani- festations were detected only by examinations of the body after death. I believe that the exudation upon the men- inges was a symptom produced by a certain form of poi- soning which was co-ordinated with stupor, convulsions, etc., not that the exudation upon the' meninges held to the external symptoms, the relation of" cause and effect. The object of the autopsy was not to overthrow or confirm diagnosis, but to find symptoms which did not exist before death. The autopsy showed the brain absolutely free from exudation. There was nothing in the shape of con- What is Meningitis? 137 gestion of the meninges or of the brain which could be called pathological. There was slight lesions of Peyer's patches and of the follicles of the large intestine. There was slight thickening of the small intestine but no ulcera- tion. The right kidney was in a state of acute congestion but there was no change in the left kidney structure. Dr. Futterer cited at the autopsy a certain paper read in Germany, entitled "Meningitis without Meningitis." In other words, an individual had died with the symptoms similar to those which I have described, but at autopsy no sign of structural lesion were found. 1 have not had the opportunity of looking up this paper. 1 asked Dr. Futterer if he had ever seen a case of anatomical meningitis with- out the symptoms of it during life. He said "no." 1 had the good fortune to see such a case within two week at the Maurice-Porter Hospital. A child 14 months of age had pneumonia, and I saw it at 6 o'clock in the after- noon. 1 had just left the death-bed of a child of the same age, who had died of pneumonia. For about a week and two days preceeding death it had distinct evidence of cere- brospinal meningitis. The child died about 3:30 o'clock in the afternoon. At 6 o'clock 1 saw the little one. Although there were no meningeal signs present, the general charac- ter of the pneumonic process reminded me so much of the case just lost. I asked the nurse to be careful to note any sign which could be referred to meningitis. I declined to put the child upon strychnine, which is the routine treat- ment in the hospital. The child was poorly nourished, very rachitic and in a bad condition generally. The prog- nosis was unfavorable. While it was stupid it was never- theless able to follow the finger with its eyes. There was no photophobia; normal reaction of the pupils; no opistho- tonos nor stiffness of any muscle of the body. In other words there was a complete absence of meningeal signs. When 1 reached the hospital the next morning the child was dead. In the meantime Dr. Quinlan had seen it, but found no evidence of meningitis. An autopsy was made and disseminated pneumonia found with exudated lymph covering practically the whole brain. The lymph covered 138 IV. S. Christopher. ttte meninges particularly in the region of the medulla. The cord was not opened. Although there was extensive exudation of lymph, yet there was not a single medullary sign present—no interference with respiration nor with the pulse that could be attributed to the exudation upon the medullary meninges. This case shows that the classical lesions of so-called meningitis can occur without the pro- duction of a single symptom referable to that condition. So far as I know there is no positive proof that an exudate upon the meninges can produce symptoms because of its location. The belief that such is the case is great because of the coincidence of the two conditions. Here is a single case where the exudate occurred without symptoms, which throws doubt upon the supposed causative relation between such an exudate and the symptoms which usually accompany it. In other words we have a case of meningitis so far as symptoms go, clinically speaking, which at the post-mortem table presents absolutely no evidence of the clinical and morphological lesions. This is something not uncommon. We have been told that when we do not find meningitis after death there has been a mistaken diagnosis. I believe that it is an incorrect position to assume that we should go into the body after death to find what other symptoms have been produced by the noxious causes at work besides those which we can detect by clinical means of investigation. It lays open the whole question of the sufficiency of morphological pathology. Take pneumonia for instance. It was defined when I was a student to consist of exudation of the lungs. It would be absurd to make such a definition now. Pneumonia is an infection produced by the pneumococcus and in the course of the life history of this germ there occur certain symptoms by the intoxica- tion which it produces. Among those symptoms are eleva- tion of temperature, sudden onset, hot skin, rapid respiration, interference with the action of the heart, dyspnoea and exudation into the lung tissue of a fibrinous substance. It is believed by some that it is the exudate into the lung tissue which produces the rapid respiration and dyspnoea in cases of fibrinous pneumonia. I do not believe it. Why? What is Meningitis? 139 Because in broncho-pneumonia where not a twenty-fifth part of the lung tissue is thrown out of active ope/ation dyspnoea is much greateY. Even when we cannot find the slightest trace or sign of a morphological lesion by physical examination in the broncho-pneumonia, the dyspnoea is severe. On the other hand 1 believe that we can have so-called lobar-pneumonia in a child without symptoms at all. Not a few cases of this type have come under my observation. A child nine years of age was found to be a little warm by his father who asked me to see it. The child had a little cough three or four times during the day, and it was believed that there was something wrong. I saw the child in the evening and made a careful examination of the throat, skin and pulse, etc., and found them normal. I also exam- ined the upper lobe of the right lung and found it solid. There was a slight elevation of the temperature but no acceleration of the pulse. The child was extremely angry, because during the next few days I compelled her to stay in the house. It was found that the child had fibrinous pneumonia which ran its course, resolved and was absorbed. I would therefore repeat that it cannot be the mechanical feature in the pneumonia which produces the dyspnoea but a toxic condition. We have been having quite a number of cases of cerebro-spinal meningitis, two cases of which disease occurred in my practice quite recently. A child two years of age was taken with tonsillytis, which on examination was found to be due to the pneumococcus. About the fourth day of the disease 1 had the opportunity of seeing the child when the irrfection of the throat had disappeared. But there was then present the signs of a fibrinous pneumonia. The entire posterior half of the left lung was absolutely solid. There was no question as to the exudate, and there were distinct evidences of cerebro-spinal meningitis. I saw the child a second time and found developing on one leg a bluish dis- coloration, which I learned subsequently terminated in dry gangrene. The child had a pneumococcus infection of the tonsil followed by secondary pneumococcus infection of the 140 IV. S. Christopher. lung and meninges and death. An autopsy was not made in this case, but the chances are that the symptoms of meningitis which consisted of an exudate of the meninges were present in that case. The other symptoms were pres- ent and death followed. If we look upon these cases as infection with the pneumococcus we can conceive that the intoxication might produce gangrene of the extremity. Another case, five months old, was taken sick with what was supposed to be rheumatism. A diagnosis of cerebro-spinal meningitis was made. The condition which made the diagnosis possible were, strabismus, opisthotonus, inability to move the right leg, which was accompanied by slight swelling of the thigh, simulating osteomyelitis with pus outside of the bone. The child died two days ago. Dr. Fenger who saw the case before death was of the opinion that the cerebro-spinal symptoms were reflex. This child had besides osteomyelitis, cerebro-spinal meningitis. In trie discussion Dr. Gustave Futterer remarked: "In reference to the case Dr. Christopher mentioned in which 1 autopsied, the anatomical findings were follicular enteritis, swelling of the patches, with acute swelling of the mesen- teric glands. To the naked eye the pia mater was per- fectly intact, glassy, no milky appearance and no exudation anywhere. From an anatomical standpoint we had to con- clude that there was no meningitis. My opinion was that there was septic enteritis, and that from it the meningeal symptoms had resulted. The paper to which Dr. Christo- pher refers was read by Hoffman, of Heidelberg, at the International Medical Congress in 1885 entitled, 'Meningitis without Meningitis.' He related some cases in which men- ingeal symptoms had existed wherein the typical exudation was found and only a milky appearance of the pia mater. In one statement I must correct Dr. Christopher. When he asked me whether I had ever seen a similar case or not, 1 replied 'yes.' l referred to an interesting case in differential diagnosis mentioned by an assistant of Olivar. The patient seemed to have typhoid fever, bat a diagnosis of meningitis was made. At the autopsy which was made by myself no exudation was found, but the pia mater had a milky appearance. I recalled the case of Hoffman, took particular pains to examine them and found extensive cellu- lar infiltration. In a general way in reference to the menin- geal symptoms we know that other symptoms can exist except What is Meningitis? 141 those which produce either a meningeal exudate otherwise and they may baffle the most expert clinicians, making it exceedingly difficult for him to say whether there is anatom- ical meningitis or not. I refer here to tetanus, uraemia, septic conditions and rheumatism. In tetanus for instance, we have trismus, and of course that aids us in making a differential diagnosis, but aside from that the symptoms can be exactly the same as those which we encounter in a case of meningitis. In tetanus we are reasonably certain that it is only an intoxication. Probably the same condi- tion obtains in other diseases. I agree with Dr. Christopher that it is not necessary to have meningeal exudate to explain the clinical symptoms. The more cases of meningi- tis we observe the more difficult it is to make a correct diagnosis." In reference to localizing the lesions in most cases this is quite impossible. In a very few instances of men- ingeal tuberculosis it is possible to make a correct localiza- tion. If we have paresis of the facial nerve, if we have symptoms in the lower extremities or if we have a lesion of the central frontal convolution we may be able to localize it, while in most other cases we cannot do this. Dr. Ludwig Hektoen said: "Dr. Christopher's remarks dealing more particularly with the clinical phenomena of meningitis made it rather difficult for me to discuss the subject very extensively. I think that we must grant Dr. Christopher's first proposi- tion, namely; that the meningeal symptoms can exist in a number of cases of infections and in cases without any meningeal lesion. Concerning his second proposition I do not think that everything he claimed can be readily granted. Before referring more directly to the point, I wish briefly to go over the cases the doctor mentioned and to call atten- tion to the most particular points with reference to those cases. The first case might be one of meningeal tuberculosis that had recovered. The proposition is somewhat startling, but one instance of meningeal tuberculosis with recovery has been described by Dr. Futterer. Another instance of chronic meningeal tuberculosis occurred in which the symp- toms existed for many weeks, finally terminating in death. The lesions in this case were retrogressing at the time of death, though recovery from the anatomical changes was taking plnce. In the second case, meningeal tuberculosis cannot be excluded even though there is no history of 142 W. S. Christopher. heredity and even though the manner of feeding the child would exclude tubercular infection by way of the food. We cannot exclude tubercular infection from inhalation in that case, and then subsequent infection of the meninges either directly from the lung or bronchial glands; neither can we exclude tubercular infection from the meninges through the nose. In the third case the meningeal symptoms present must be regarded as due to some general infection or intoxi- cation, but just what sort of general infection or intoxication is present we cannot say because no bacteriological exami- nation was made. In the fourth case we have pneumonia complicated by a sero-fibrinous leptomeningitis. This meningitis gives rise to no symptoms. Leptomeningitis occurring in the course of lobar pneumonia due to pneumococcus infection is of rather frequent occurrence. It is my impression that some of the cases of meningitis occurring in the course of pneu- monia are atypical so far as the clinical manifestations are concerned. In the fifth case, as near as I understood it, we have reason to believe there was pneumococcus infection. A dry gangrene of the extremity occurred, and the logical way of explaining that gangrene would be that there existed some endocardial inflammation due to the pneumococus, and that from the endocardial inflammation emboli were detached and lodged in the arteries of the lower extremity in that way producing dry gangrene. In the sixth case there is osteomyelitis, and of course, that points to invasion of the blood by micro-organisms, and in the course of this genera! infection meningeal symp- toms might really have been developed, inasmuch as Dr. Futterer dealt with this point. In many cases of meningi- tis, the fnicroscopic ones may be marked, and of these lesions particularly in tubercular meningitis the intravascular changes may be the most pronounced of all. There may be endarteritis with a tendency toward extension in men- ingeal tuberculosis. Recently I have observed some intra- vascular proliferation in cases of pneumococcus meningitis." Dr. Henry B. Favill: "I was particularly interested in the maintenance of certain facts offered by Dr. Futterer and Hektoen; yet neither of these somewhat opposing contentions seemed to represent the final conclusion of Dr. Christopher. There can be no question that at this day the clinical picture of What is Meningitis? 143 meningitis must be regarded as essentially an intoxication. The question is as to what may properly be called men- ingitis. The majority of meningites which have come to autopsy have been associated more or less with lymph exudation upon the meninges; but the very contention of Dr. Hektoen and Dr. Futterer is qualified by stating that with the extreme microscopic perfection there may be pro- nounced microscopic changes. They simply call attention to the common method of observation hitherto recorded. As clinicians we must agree that intoxication is fundament- ally responsible for the symptom group presented by an infectious disease. There must be some determining ana- tomical factor, and it may be anything from a mere vascu- lar disease, as pointed out by Dr. Hektoen, to an intense disease manifested upon the meninges. This is not only truj with regard to meningitis, but equally true of typhoid fever and pneumonia. Are we prepared to say, as 1 heard Dr. Fenger fifteen years ago say in making a post-mortem examination, 'No lesion of Peyer's patches, consequently no typhoid fever'? If we say that of typhoid fever, we may logically say the same with reference to meningeal tuber- culosis. It is not to my mind a satisfactory position, because 1 consider the lesion of Peyer's patches like the exudate upon the meninges as too gross to permit of exclusive reli- ance upon it as a means of diagnosis. Our attention is called to the distinct difference which exists between an intoxication leading to meningeal symptoms of sufficient definiteness to warrant the diagnosis of meningitis, and on the other hand to infection of the meninges, two pro- nouncedly different conditions. From the standpoint of a clinician 1 must entirely corroborate the observation of Dr. Christopher. The feature of intoxication in infectious dis- ease is of the greatest importance, and that the anatomical lesion must be regarded as, on the whole, due to a certain process occurring with variations and possibly of a nature at this moment quite beyond our knowledge." Dr. Jas. G. Kiernan: "One most important question propounded by Or. Christopher is this: 'Do certain clinical symptoms depend on the seat of the lesions rather than the character.' In psychiatry this position of Dr. Christopher has long been established. There are an immense number of cases, some of which reach insane hospitals, some of which die outside, belonging to this class which there is a growing tendency among alienists to designate as primary confusional insanity which are diagnosed meningitis, They have many of 144 IV. S. Christopher. the symptoms which are supposed to be characteristic of meningitis, yet on autopsy, microscopic and macroscopic appearances are absolutely nil. The same thing is true of acute mania even with the cardiac complications which occasionally occur, pointing to complications resulting from the medulla. In the vast majority of cases where lesions occur these are the secondary results of a biochemical change consequent on the psychosis rather than the reverse. This is still more true of acute melancholia. It is excep- tionally true of more definite psychoses, like paretic demen- tia which may occur without demonstrable lesions. Even of the degenerative types, paranoia for example, this is true. Cases of paranoia with a well-defined history, with constitutional stigmata occur where there is no cerebral teratological change, no microscopic or macroscopic change. All these things can be explained from a biochemical stand- point since in the function of the neurons certain changes occur during life, which are not the result of a direct patho- logical change in the sense of demonstrable conditions after death, but are merely biochemical changes which may lead to these. Dr. Christopher has raised the question of the curability of meningeal tuberculosis. At one time (my mind is now in statu quo) 1 did believe that a large number of cases of meningeal tuberculosis were recoverable. This was twenty years ago, before bacteriologic diagnosis was in existence. In a number of cases of katatonia or, if you will, cases presenting a symptom complex, which is regarded by a large number of alienists as katatonia, whatever may be the nosological position, meningeal tuberculosis was found in a large number of instances which had passed into cal- careous changes. In a paper 1 read on Katatonia,' two decades ago,* I narrated a number of these conditions. At the time both Meynert and Kahlbaum had found a number of similar cases.t A certain number of cases of hydroceph- alus undoubtedly do recover. So-called macrocephalic indi- viduals are cases in which an increase of the barren formation has taken place. One of the most notorious of these was Cuvier, whose recovery accounted for his large brain. Another case which came under my observation (carefully examined by Dr. Spitzka and myself) twenty- one years ago, was an idiot, whose brain weighed five ounces more than that of Cuvier. The barren tissue com- pensated for the old hydrocephalic change. Dr. Christopher has done excellent service in calling our attention to the * American Journal of Insanity, 1877-'78. + Alienist and Neurologist, 1882. What is Meningitis} 145 multitudinous absurdities diagnosed under the term meningi- tis. There are a hundred and one conditions, meningeal, neurotic, hysteric and otherwise, put in this omni gatherum. Under the term meningism, the condition described by Dr. Christopher was characterized at the 1896 meeting of the French Neurological Society. Dr. Futterer's 'acute delirium' case was one of typhomania—a psychosis marked by cere- bral change." Dr. Sanger Brown: "The position which we will reach in our own minds regarding this question depends very largely upon the theories of cerebration, of the modes of action of the cortex of the brain, which we have accepted as most reasonable to us. It appears that we have all agreed that acute men- ingitis is an infection disease, and further that the essen- tial feature so far as the clinical symptoms are concerned is the action of some morbific influence upon the cortex of the brain, which evidently gives rise to the essential and distinctive features. As has been previously remarked there are various toxaemias which have an influence on the cor- tex of the brain. Tetanus, for instance, has some influence on the nervous syste.n and on the cortex of the brain. Scarlet fever or certain forms of it, produce profound impres- sions, stupor, while tetanus produces spasm. But these have symptoms quite distinct from those observed in meningitis. We are accustomed to believe that when the meninges are involved in addition to the other symptoms, there is pain, photophobia, etc. I have not heard enough yet to convince me that I have to abandon the idea that the distinctive symptoms of meningitis are due in most cases and mainly to the action of a toxin both upon the cortex of the brain and upon the meninges. While 1 do not think it can be demonstrated, it looks reasonable to me to suppose that the presence of these toxins alone would be sufficient to cause the symptoms but not the exudation. In one case particu- larly reported by Dr. Christopher there were no symptoms during life, yet there was found an exudation of lymph after death. It is possible under such circumstances that this child was stuporous for some hours before death, and is not possible that this exudate found at the autopsy might have been thrown out during these hours of stupor. It is believed that cases of undoubted meningitis with the symptoms of involvement of the cranial nerves get well. I think there are facts in pathology and in clinical experience which are similar to that." Dr. Hugh T. Patrick: 146 W. S. Christopher. "We must all concede that there are a number of diseases distinctly classified in our nosology that gives rise to so-called meningeal symptoms. It must be the experi- ence of every man who sees cases in general medicine or nervous disease in consultation that not infrequently vari- ous infectious diseases have been diagnosed as probable meningitis, particularly those cases in which the practi- tioner is unable to make an accurate diagnosis. Pronounced meningeal symptoms occur in many diseases. Furthermore the best diagnosticians make a diagnosis of meningitis and do not find post-mortem evidence of the disease. We must concede that there are cases of severe meningitis, not in anatomical sense of the word in which death does not ensue. Death may ultimately ensue, but patients with a profound meningitis may live for a long time, in other words, one case may live with a meningitis ten times as pronounced as another patient who dies. When I was an interne we had a child in the service not without cerebral symptoms, but no one made a diagnosis of meningitis. We found hydrocephalus which was nothing but meningitis with an exudate one-fourth of an inch thick covering the entire brain. 1 have seen syphilitic meningitis extending to the convexity, at the base also one-fourth of an inch in thickness. The patient died with it, but had lived with it a short time before death. This class of cases includes tubercular meningitis, chronic syphilitic meningitis of the brain and cord, diffuse sarcomatosis also occasionally cases of syringomyelia extending up to the pons so nearly like sarcomatosis, that they can scarcely be distinguished. In all such cases the anatomical condition is that of meningi- tis. This condition may be extremely pronounced before a patient dies. "Along with that class of cases I would like to say that I saw two cases come to autopsy in the service of Erb of Heidelberg than whom there is no better diagnostician. I do not remember the diagnosis which was made, but the post-mortem in both cases showed cerebro-spinal meningitis. Notwithstanding these facts which go to support the hypo- thesis of Dr. Christopher 1 think we can only call it an hypothesis. What is needed in this class of case is inves- tigation. The meningitis can produce no cerebral symptoms aside from the cortex. Pain, delirium, coma, stupor, refrac- tion, must come from the involvement of nerve tissue. How may the nerve tissue be involved in meningitis? It may be involved by direct intoxication by circulatory disturbances and that is about the end of the string. It is here that investigation is needed. Dr. Hektoen's investigation per- What is Meningitis? 147 tains particularly to vascular disturbances which is a great step in advance. A great deal has been done in the inves- tigation of the effect of toxaemias on nerve tissue and it is here later investigations must come, as well as investigation of the vascular structures." Dr. Gustav Futterer: "Some years ago 1 dissected a brain in a case of delirium acutum and on examining the cortex 1 found opaque triangular spots in the brain. After the post-mortem I could not see them because after the cortex is laid bare in five or ten minutes it is much more difficult to see the spots. 1 furnished microscopic proof that I had not been mistaken in observing these spots. 1 preserved the specimens in Mueller's fluid, cut them, and made specimens after Weigert. Each one of the spots showed itself clearly as it appeared in the brain itself. The nerve substance had disappeared which was the reason the spots were not dark. I conclude from my observation in this case that there was nothing specific about this condition of delirium action. I then ex- amined cases of meningeal tuberculosis in the same way and found at quite a distance from the tubercular lesions in the cortex such atrophic spots where the nerve substance had disappeared without any cellular infiltration or sign of inflammation being present." Dr. Sanger Brown: "I would ask Dr. Hektoen and Dr. Futterer in regard to investigations showing changes which occur in the neu- rons of the cortex whether or not they are familiar with any work on that subject more recent than the article of Dr. Berkeley,* which stated that alcohol was administered to rabbits for a number of months and then they died from the effects of it. The cortex was subsequently examined and very distinct changes were found to have taken place in the neurons. 1 would ask if such a system of experi- mental research is likely to throw light upon the results of the inflammation in meningitis." Dr. Ludwig Hektoen: "In answer to Dr. Brown's question I would say that I believe Dr. Berkeley's investigations will stand the test of criticism and he has shown by improved methods that changes do occur in the ganglion cells in the cortex of the *Johns Hopkins Hospital Report. 1896. 148 W. S. Christopher. brain as well as the condition referred to by Dr. Brown. Furthermore 1 believe similar processes will show marked changes in the cells in a large number of other pathological conditions." Dr. Brown: "As melancholia and dementia."1 Dr. Hektoen: "I am not able to speak particularly of those condi- tions, but of meningitis without meningitis, of conditions in which there are marked meningeal symptoms in general intoxication and infection." Dr. John Ridlon: "I have been very much interested in meningeal tuberculosis, and also in the statement of the cases that have recovered. 1 was taught that all such cases died. 1 thought they did until 1 encountered some cases that did not terminate fatally and then 1 wondered whether my diagnosis was correct. My position has been strengthened and 1 think now that my diagnoses were correct. More than half of my patients suffer from tubercular joint diseases and certainly three-fourths of all the cases die either of menin- geal tuberculosis or general tuberculosis. I have only seen three cases where a diagnosis of meningeal tuberculosis was made and the patients did not die. The first case was seen in St. Luke's Hospital, New York City, during my service as interne, the child suffering from tubercular spondylitis who developed the classical and typical symptoms of men- ingeal tuberculosis. A diagnosis of this disease was made by Dr. Newton M. Shaffer and Dr. Andrew H. Smith in consultation. A full dose of castor oil relieved the symp- toms of tubercular meningitis. I created a life long enemy by asking the next day had the child died, would it have died of tubercular meningitis? The second case I saw was a patient of Dr. Samuel Wood on Long Island, a very superior general practitioner. The case was seen many times in consultation by Dr. Wm. H. Draper of New York, Dr. Robert E. Weir and the late Dr. D- A. McBride. They all agreed that the case was one of tubercular meningitis, consequently an unfavorable prognosis was made. The patient is alive but is blind. The third case was a patient of Dr. O'Sullivan in Hyde Park, the child suffering with tubercular spondylitis. 1 saw the child two or three times during a year and it had What is Meningitis? 149 abscess in each buttock. In spite of my urgent request that the abscess be let alone, Dr. Sullivan could not withstand the temptation of thinking that the abscess must be opened. He opened the abscess «nd a week or ten days later the child developed the clinical symptoms of meningeal tuber- culosis. I saw the child three times during the following ten days and at my last visit made an unfavorable prog- nosis. 1 felt that the case would prove fatal from the beginning. The child however is alive to-day with no symptoms dependent upon any meningeal inflammation, and 1 have since wondered whether my diagnosis was right or wrong. I was very much pleased to hear the cases that have been cited and to hear it generally stated that men- ingeal tuberculosis may occur and the patient not die from it." Dr. Wm. F. Waugh: "It is a good rule not to look for an unusual or strange explanation of fact when a simple one will,answer. The condition Dr. Christopher speaks of may be defined as a toxaemia whose starting point was the intestinal canal and through failure of intestinal antisepsis the toxicogenetic centers develop in the mesenteric glands, and that such a condition results in the production of the phenomena ordin- arily attributed to meningitis as a clinical fact of consider- able value and it seems to me the value of it was a little obscured by Dr. Christopher's explanation as to the cura- bility of tubercular meningitis. Niemeyer records the case of a child who recovered from the primary attack but died subsequently about five years later and at the autopsy evidence of the first attack were found. Another physician reported seven cases that had recovered under the use of iodoform ointment to the scalp. I think it is begging the question to claim that cases which recover could not have , been meningeal tuberculosis. As regards the dependence of the phenomena on lesions demonstrated after death, it is not necessary that these phenomena should be attributed to those lesions." Dr. W. S. Christopher: "There are a few points I desire to touch upon closing. I would first like to ask pathologists present if it is not a fact that the symptoms found in meningitis have been gen- erally assumed to be due to lesions. Has pot .this idea been very prevalent?" Dr. Futterer: 150 W. S. Christopher. "Do you mean microscopic lesions or those visible to the naked eye?" Dr. Christopher: * "Not altogether." Dr. Futterer: "We admit that we may have a toxic meningitis with- out any visible lesion and I am not sure that we may have a toxic condition of the brain which may produce symptoms like those encountered in real meningitis." v Dr. Christopher: "I would like to ask Dr. Hektoen whether the anat- omical lesion are causative of symptoms of meningitis. 1 do not mean to-day, but was not this opinion held by prac- titioners some ten years ago?" Dr. Hektoen: "I believe at that time more stress was laid upon the effect of the anatomical lesions in acute infections diseases, than now. Now more stress is laid upon general infection and general intoxication." Dr. Christopher: "I do not think I am far from right although our path- ologists are beginning to hedge. The essential feature in disease years ago was the anatomical condition and out of it the so-called expectant school of treatment of internal medicine was evolved. I have not heard anyone assert that the exudate upon the meninges was the reason for the oc- curence of the symptoms. If they are not the cause of symp- toms which we see during life then we have no right to expect to diagnosticate that condition anatomically by the symptoms. Meningitis is a disease which has an extremely grave prognosis and that prognosis is grave irrespective of the lesion present. If the lesions produced no symptoms we may ignore them and when we find the symptoms of meningitis present, for it is only then that we can diagnos- ticate it, then we make a grave prognosis. The pathologist has nothing to do with prognosis. The question is settled at the time we get hold of the patient, when we make our prognosis upon the condition and symptoms which we find during life. When I find a child with photophobia, strabismus, coma, muscular contraction and with persistent vomiting I make a grave prognosis and it is quite imma- What is Meningitis? 151 terial whether the symptoms are produced by one form of intoxication or another unless we can diagnosticate the kind of intoxication and it be of a type which is remediable. If it be an intoxication from the bowel and we can remove the source of the poison, the prognosis is favorable. If it be a case of intoxication of the so-called rheumatic type and we can get the materies morbi through the kidneys the prog- nosis is fair. If we have an intoxication from some gen- eral infection in the blood which we cannot eradicate, the prognosis is grave irrespective of the lesions in the men- inges. The prognosis then of meningitis is entirely clinical. The second case which I recorded may have been tubercu- lar meningitis. I did not look into tho question because it brought up a very much disputed point as to whether cases of tubercular meningitis ever recover or not. I do not think we have any right to say that the case was or was not one of tubercular meningitis. We must simply say that the means of correct diagnosis is absent. We have at our dis- posal means of diagnosis during life by which we may be able to state with some degree of certainty that a certain case was tubercular meningitis and if it recovers we can say with some degree of certainty that the case has recov- ered. I refer to diagnosis by lumbar puncture. Lumbar puncture has been resorted to a number of times by introdu- cing the hypodermic needle between the second, third and fourth lumbar vertebrae with the child lying on one side and withdrawing some fluid or permitting it to run, determining the degree of pressure by the manometer and then exam- ining the fluid for the micro-organisms which it contains. In that way in some cases tubercule bacilli may be found in the fluid thus obtained. If tubercule bacilli are found we have excellent evidence that the disease is of a tuber- cular character. Until we have found the cause of tuber- cular meningitis by such means of finding the tubercular bacilli in the fluid as I have mentioned we have no right to say that a case of tubercular meningitis can recover. At the same time we have no right to say that a case of tubercular meningitis cannot recover. The question is beyond our knowledge to settle because of the absence of reliable data. I have had five deaths from meningitis within the past two weeks and of these two had pneumonia and two bowel trouble. One was a case of osteomyelitis of the femur which may or may not have had meningitis." Dr. Patrick: "How many autopsies?" Dr. Christopher: 152 W. S. Christopher. "Two. There seems need of some determining factor to justify a diagnosis of meningitis. It is, after all, a question of terms. 1 think we are all agreed that the occurrence of the lymph exudate upon the meninges is not enough to make out a disease which has the fatal prognosis that men- ingitis has. If meningitis is an anatomical condition we must admit that we cannot diagnosticate it during life with absolute certainty because the symptoms do not justify the exact anatomical condition present. We do find a certain number of things clinically which have an extremely bad prognosis and it is desirable to use the term meningitis to cover them. You may relegate the term meningitis to anatomical conditions that are found but if you do you must use a different word to describe the clinical conditions which are found. As remarked by Dr. Favill we must admit that there has been a general collapse of the anatomical condi- tion which constitutes meningitis. We no longer need to have pus or lymph, we may get along even with simply the changes which occur in the arteries or vessels themselves, and still have meningitis. The farther we get from the old gross lesion of meningitis the farther we are frem the caus- ative symptoms observed. THE CASE OF STURGEON YOUNG.* A Question of Hypnotic Injury and Death. Reported by CLARK BELL, Esq. Abstracted from Advance Sheets, Medico-Legal Journal, by C. H. Hughes. HE Coroner of Chautauqua County, A. H. Bowen, * M. D., Health Officer at Jamestown, New York, held an inquest as to the cause of death of Sturgeon Young, a colored lad, who recently died there in Janu- ary, 1897, under circumstances that led the authorities to regard it proper to investigate the cause of death, and how far it was traceable to his condition, as affected by the repeated placing of the lad in hypnotic state, by hypnotizers who were not skilled in the matter, and from which, it was thought, he had sustained physical injuries which might have incited the disease of which he died. I was called upon by the Coroner to aid him in this investigation, and 1 requested him to have a careful and complete autopsy made by competent medical men, and the inquest was adjourned to enable me to furnish him with * Read before the Psychological Section of the Medico-LeRal Society Feb. 10. 1897. Read before the Medico-Legal Society. Feb. 20, 1897. |153] 154 Clark Bell. expert and opinion evidence bearing upon the questions he regarded as important to the inquiry he was conducting. He furnished me with such of the facts as had trans- pired, a resume of which is given in my letter enclosed and with a Hypothetical question, which is subjoined. I sent a letter, of which the following is a copy, and the Hypothetical question to some of the more prominent experts who are members of the Psychological Section of the Medico-Legal Society: Dear Sir: — Will you please reply to the following hypothetical question? In case of a youth seventeen years of age, of good physical develop- ment and medical history, well nourished, weighing about 125 pounds, upon autopsy with no observable lesion, beyond slight cerebral softening, and trace of kidney deterioration, vital organs normal with cause of disease diagnosed as diabetes mellitus; and it appearing upon conceded evidence that the deceased had for approximately over six months been a chronic "sensitive subject" of extreme susceptibility to hypnotic or "mesmeric influence;" having been protractedly and repeatedly hypnotized many times by amateurs and irresponsible and reckless youthful operators and dabblers in hypnotism; and while under the influence or in a state of statuvolence having been sat or stood on, by men of average or heavy weight, while in a cataleptic state, with head and feet supported, so that he formed a bridge between such supports; and having been thrown into and left in hypnotic or trancoidal states with instructions to emerge therefrom at a given time, and upon emerging apparently from such trancoidal state complaining of nervous chill, physical prostration and malaise; in your view and opinion, accord- ing to the best of your professional knowledge and belief, according to the best authorities and latest research wherewith you are familiar, in physiology, pathology and psychology would physical injury or organic impairment particularly of the renal function, or symptoms of glycosuria, directly or Indirectly, follow from the psychic or emotional disturbance or derangement of nerve function, involved in or due to, the morbid innervation incident to such hypnotic practice or experimentation in "mesmerism" or alleged animal magnetism? The Case of Sturgeon Young. 155 Medico-Legal Society, OFFICE OF THE SECRETARY, No. 39 Broadway, NEW YORK, Feb. 1st, 1897. My Dear Sir and Colleague: —\ have received from the Coroner of Chautauqua County, a hypothetical question of which I enclose you a copy, to which he desires a reply from some of our medical experts familiar with the subject of hypnotic suggestion. Briefly, the case, aside from the state- ment made in the hypothetical question, is; that this Coroner is now con- ducting an inquest at Jamestown, N. Y., upon the body of a young negro named Spurgeon Young, which excites great public interest. Dr. C. J. Phillips and Dr. Wm. M. Bemus made the autopsy and subsequently testified substantially that, the treatment to which the deceased had been subjected while under hypnotic influence, had in their opinion, caused the disease, diabetes mellitiis which had caused death. The hypothetical question gives substantially the results of the autopsy, except that Dr. Phillips testified that he found no external bruises or internal lesions sufficient to cause death except as stated in the hypothetical question; that sugar was found in the urine, which he stated was the indication of diabetes, but that the tissues of the kidneys were not broken down. He further testified that diabetes was a kidney or nervous disease that may be caused by strong nervous excitement or non-assimilation; and that he believed that the tax upon the nervous system had a tendency to cause diabetes, and that acute and chronic diseases of the brain of a depressing character, such as might be caused by hypnotism might produce the disease. He further testified that hypnotism is sometimes used with beneficial effects in cases of hysteria and paralysis, but as it was commonly practiced it was extremely dangerous, and that it was a severe strain upon the subject's nervous system. He also testified that the first stage of hypnotism might be refreshing, but that the further stages might be dangerous. He was cross-examined as to whether a subject could be made to commit suicide or crime under sugges- tion, upon cases read from medical Journals; and answered that the cases were unusual, but that he had no doubt of their truth and was positive that hypnotism was a dangerous agency. It was claimed before the Coroner's jury by the District Attorney that hypnotism as practiced by amateurs was dangerous alike to morals and lives of the subjects in certain cases. I have beep appealed to by this public official to aid him as a public officer in the investigation of the subject by the opinion of scientific experts connected with this body in aid of the due administration of justice. The inquest is adjourned to to-morrow evening and will be further adjourned to hear my reply. I therefore ask that you forward to me at once your answer to the enclosed hypothetical question, taking into consideration also, as the basis of your decision, and opinion such facts as are contained herein, so that I may forward your reply to the Coroner. Yours hastily, CLARK BELL. 156 Clark Bell. Thomson Jay Hudson, Esq., LL. D., of Washington, D. C., replied as follows to the hypothetical question: In reply I have to say: — First, that I cannot be considered a meJical expert in the true sense of the term. I am a lawyer by profession and have given some attention in the course of my studies to the subject of Forensic Medicine: but not to the ex- tent to entitle me to assume the rank of an expert. I have however devoted' a large share of my time during the fifteen years past to the study of theoretical and experimental hypnotism and cognate psychical phenomena. My experience and observation in this line of inquiry enables me to say definitely and without reference to age, physical development, medical history or pathological condition that, given a case where "the deceaseJ had for ap- proximately over six months been a chronic sensitive subject of extreme susceptibility to hypnotic or mesmeric influence; having been protractedly and repeatedly hypnotized many times, by amateurs and irresponsible and reckless youthful operators, and dabblers In hypnotism; and while under the state of statuvolence having been sat or stood on, by a man of average or heavy weight, while in a cataleptic state, with head and feet supported, so that he formed a bridge between such supports; and having been thrown into and left in hypnotic or trancoidal states with instructions to emerge therefrom at a given time, and upon emerging therefrom such apparently trancoidal state complaining of nervous chills, physical prostration and malaise;" in my opinion there could be but one inevitable result, namely, a shattered nervous organism leading eventually, if life is prolonged, to im- becility or insanity. What physical ailments might result from an abnormal mental and ner- vous condition thus induced would depend largely upon the particular char- acter of the treatment to which the victim was subjected at the hands of his persecutors, and upon which the letter before me, throws no light. I do not however undertake to speak from experience or personal observation on this branch of the subject. It is the province of medical experts to determine what particular physical diseases may result from given nervous conditions. I may remark, however, that from a somewhat extended course of read- ing of the works of medical experts of recognized ability and standing in the profession, I have been led to believe that there are few bodily diseases that may not be produced by abnormal mental and nervous conditions. "Who." asks Dr. Tuke.' will pretend to assert that any tissue of the body is beyond the range of nervous influence?" The Case of Sturgeon Young. 157 I cannot within the limits of a letter give the rationale of my convictions relating to the disastrous effects upon the victims of unskilled and reckless hypnotic experiments. My views upon that subject may be found, however, in an article in the current number of the Hypnotic Magazine, Chicago, en- titled "The Danger Lines of Hypnotism." Prof. W. Xavier Sudduth, of Chicago, replied as follows: CLARK BELL, ESQ. , Dear Friend:—In answer to the hypothetical question in the case of the deceased negro. Spurgeon Young, would say that hypnotic suggestion or sug- gestion given in the hypnotic state is a positive force and its practice in the hands of "amateurs, irresponsible persons and reckless youthful operators and dabblers" is fraught with grave dangers. Cases are on record where subjects in such hands have suffered some nervous shock resulting in serious derangement of the nervous system even from one or a few experiments, not from or by reason of the hypnotization or the induction of the hypnotic state, but by reason of the emotional disturbance incident to such experimentation. A close distinction must be made between hypnosis, which is a restful state of somnolence, that can have no bad effects, in and of itself, and the vicious suggestions and practices made to and upon the subject while in the hyp- notic state. The bad effects of such suggestions are not alone confined to the hypnotic state, however, but are constantly being observed in the waking state in superstitious and susceptible individuals with equal or worse results than are ever to be observed in the hypnotic state, because with persons in the hypnotic state some degree of protection from shock is insured by reason of the general condition passively obtained during hypnosis where hypnosis (sleep) alone is indicated, and the patient left alone he quickly passes from the hypnotic sleep, into an ordinary sleep, to awaken sooner or later re- freshed by his experience. The nervous chills, physical prostration and malaise complained of in this case on awakening from the somnolent state were due not to the state but to the suggestions and practices indulged in by those who had him under control and for which they should be held crimin- ally liable. As to the possibility of inducing diabetes mellitus through emo- tional disturbance, 1 am not so clear, in fact, I am very doubtful whether such a condition could be thus brought about and should rather lean to the nega- tive side of the question. Disturbance of the renal function is constant in persons suffering from intense grief or melancholia. Many cases of so-called Bright's disease are the result of prolonged nervous strain and this may have been such a case, but on this point I would rather be excused from an- swering positively except on more information than is given in the question that is forwarded me for answer. If such were the case, however, I should not attribute it to hypnotism but to the vicious practices and suggestions in- dulged in while the subject was under hypnosis. In conclusion, I should like to say, that the practice of hypnosis by the laity is to be depreciated in all instances and that laws should be passed by the legislatures of the several states conferring its use, not to the physicians alone, but to those physicians 158 Clark Bell. who by study and scientific research have mastered the scientific application of this new old force. Irving C. Rosse, M.D., replied as follows: , In answer to the hypothetical question submitted, I should say that in my view and opinion the glycosuria is in no way related to the morbid innervation brought about by hypnotic practice. Glycosuria is extremely rare among negroes. Of many hundred I have examined for alleged kidney disease, sugar in the urine was found in but one instance, that of a messenger in the U. S. Treasury Department. Diabetes of traumatic origin and the association of this disease with nerve changes are familiar pathological facts. The neurosis known as major hypnotism is also a pathological state, since animals become demented after frequent subjection to hypnotic influence, and the best authorities are that vascular changes in the brain with breaking down of nerve tissue associate themselves with hypnotism. Moreover, hypnotized subjects are observed to show exaltation of the special senses; over excitability of the muscular system, and diminished reflexes. The injurious tendency of hypnotic practice to exhaust nervous force and weaken the will is spoken of by some authorities as a kind of moral masturbation that should be prohibited or restricted by legal enactment. The fact of the decedent having been a subject of extreme susceptibility to hypnotic influence affords sufficient ground for the inference that he was also neurotic, and his nervousism was aggravated and increased by the existing renal impairment or glycosuria, which was not due or incident to alleged hypnotic or mesmeric experiment. T. D. Crothers, M.D., of Hartford, says: The hypothetical question presented by Mr. Bowen, Coroner of Chau- tauqua County, N. Y., contains no facts from which any conclusions should be drawn that hypnotism was in any way an exciting or contributing cause of death. There are no authentic facts on record to support the assumption, that hypnotic conditions including catalepsy, trance and repeated hypnosis are followed by organic disease of any kind. Least of all organic impairment of the kidney or its glycosuric function. It is possible that certain degenera- tion of the nerve centers may be increased by repeated hypnosis, but at present there are no facts to prove this. In this hypothetical question there could be no connection between renal derangement and extreme sensitiveness to hypnotic suggestion. One could and would not follow the other. There Is no evidence so far, to prove hypnosis pathological. The symptoms of debility following such states are not the result to be attributed to it; the derangement of the kidneys is a chemical and organic one. in diabetes, and not from psychic influences from objective sources. The Case of Sturgeon Young. 159 This question offers no reliable suggestions along the line of observed facts up to the present; or indicates any reasonable possibility of the relation of cause and effect in this case. Henry Hulst, M.D., of Grand Rapids, Mich., writes: I received your letter with the hypothetical question, and will try to formulate my opinion at once. Given an extremely sensitive subject of extreme susceptibility to hypnotic or mesmeric influence, protractedly and repeatedly hypnotized by amateurs are irresponsible persons, being stood and sat upon, etc.. subse- quent malaise and physical protraction on the part of the subject is not to be wondered at, especially as such amateurs and irresponsible youthful operators can scarcely be expected to know enough to prevent or remove such disagreeable after-effects. As to whether symptoms of glycosuria directly or indirectly follow from psychic or emotional disturbance or derangement of nerve function involved in or due to the morbid innervation incident to such hypnotic practice or experimentation in "mesmerism" or alleged "animal magnetism," I must say that so far as I know no case of that kind occurs in literature. The etiology of Diabetes Mellitus is still very obscure. It is produced artifically in animals by irritating a particular spot in the medulla. Beyond that but Jittle is known positively. Osier says that "mental shock, severe nervous strain and worry precede many cases." He uses the word "pre- cede" not "cause." Our knowledge of the disease is too obscure to warrant us in concluding that any given antecedent severe nervous strain and worry is the cause in a given case. The question whether even the abuse of hypnotism can cause diabetes, it seems to me, ought to be answered in the light of the foregoing. To attribute the diabetes to the use or abuse of hypnotism in the case on hand, would be; therefore, a mere speculation, and not an opinion based upon scientific observation, cannot be determined from the facts set forth in the hypothetical question. Henry S. Drayton, M.D., of New York, says: My Dear Sir:— Your favor, with enclosed hypothetical question, is at hand this P. M. Just at this time I can but give my opinion briefly with regard to the interests involved. Assuming the premises as stated by Dr. Bowen, I have no doubt that hypnotic treatment so practiced by "amateurs and irresponsible and reckless youthful operators, dabblers in hypnotism" was perilous to such a "sensitive" in both physical and mental side. The very fact of a neurotic dyscrasia would itself render me exceedingly careful in employing the hypnotic method should a patient so constituted be brought to me for treatment. The old "mesmerists" were pronounced in opinion against the experiments of careless and ignorant persons deeming them of a dangerous nature, and the more experienced of modern hypnotists are quite 160 Clark Bell. In agreement that much injury may be done by unlearned and unskillful per- sons, who attempt experiments in hypnotic suggestion as tor those who perform in this wise in public for the sake of gain and notoriety there is little doubt that their extravagant and senseless operations may be produc- tive of much harm to the weaker subjects of their manipulation. Regretting lack of time for a better expression of my opinion, 1 am, etc. James R. Cocke, M.D., of Boston, Mass., replies: Dear Sir:—Concerning the coroner's questions, let me say briefly again, that I can readily understand how a person of exceedingly nervous, sensitive temperament could be so wrought upon as to induce an active hyperaemia in the medulla oblongata, where, as you know, in the floor of the fourth ventricle are centers which when disturbed unduly by chemical or other influences pro- duce a glycosuria which might become permanent if inflammation succeeded to the state of active hyperaemia. However, I have hypnotized thirteen diabetics. Besides diabetes mellitus these patients suffered from severe sec- ondary dermatoses, and in one case the patient suffered severely from der- mititis herpetiformis. In all these thirteen cases I succeeded in relieving the pain, dyspnoea, and to a certain extent the polydipsia and bulimia. The hyp- notism did not seem to exercise any inhibitory influence over the excessive glycogenic formation. However, of course, have never been and never will be subjected to those ridiculous and criminal performances which have rend- ered the name of hypnotism odious in so many places. I use hypnotism as a sedative and in these cases find that It makes no difference whatever in the amount of solids excreted by the kidneys. The revolving mirror and other exciting agencies of the kind will produce temp- orary albuminuria with subsequently a very fatal disease in the young. It is, of course, attributed, as you know, first, to disease of the medulla oblongata, secondly, to disease of the pancreas. The result of the post mortem sent by you is so incomplete as to make a decision of the individual case impossible. I believe, however, that the so-called hypnotic subject was an hysterical subject and that the excessive states of nervous excitation, could have been hastened, perhaps precipitated diabetes mellitus, granting that there was a peculiar vulnerability either of the centers of the medulla or of the tissue and other nervous mechanism of the pancreas. Diabetes mellitus in the young in my experience is an aggravated form of disease. The polydipsia and bulimia cause such intense suffering as to make it impossible for a subject to endure long the hypnotic experiments described. There is a form of intermittent glycosuria which has no etiological basis so far as we can discover. Diabetes mellitus is not necessarily attended with renal degeneration, al- though a secondary nephritis of the parenchymatous type is often seen in cases of long standing. In the young, renal degeneration is seldom exten- sive. These conclusions are the result of forty-one post mortems made by me and also based upon the authority of Keating's encyclopedia, "Diseases of Children." Prof. C. H. Hughes, of St. Louis, says: The Case of Sturgeon Young. 161 Dear Sir and Colleague:—Extensive observation of the hypnotic state and of the effect of repeated and long maintained hypnotism on the same subject, has convinced me of the deleterious effect of the often-repeated and long continued hypnotic state on the nervous systems of its subjects, es- pecially its damaging effect on the inhibitory centres of the brain which reg- ulate the normal volitions and the natural spontaneity of the mental operations of the individual. The repeatedly and continuously hypnotized subject becomes a more or less changed man as compared with his normal state and to this extent, is in an insane state of mind with this difference from the ordinarily insane person, that his change of mental character is chiefly subject to the directing influence of another person rather than to his own perverted and abnormal volition as is the case with the ordinary insane per- son. But he may become as insane and diseased in brain as an ordinary lunatic. In the case above submitted, I think it not at all improbable that the brain in the region of the fourth ventricle which contains the diabetic centre of the brain was damaged by the repeated hypnotisms, and that the diabetes itself resulted therefrom, as puncture of the floor of the fourth ventricle causes, in animals, the phenomenon of diabetes or glycosuria, and it is often also the result of psychic overstrain. Because of this experimental psycho- logical fact of a diabetic center in the brain, and the clinical evidence of psychical impressions as in diabetic melancholia, as it is called, but which is the diabetes of the nerve exhausted state of melancholia or melancholic diabetes, diabetes and vaso-motor effects and blood congestions are not unlikely to result from hypnotic experimentation too long maintained or too often made. Physical injuries also, doubtless, resulted to kidneys and abdominal vis- cera from the violent usage of the subject while in the hypnotic trance state, especially while in the condition of cataleptic rigidity, stretched from chair to chair, resting in opisthotonos attitude on head and feet, with persons walking on his abdomen or sitting or putting weights on him or pounding him. There are other causes of diabetes, however, such as excessive feeding, with sedentary habits and discontent, melancholia, etc , in plethoric, inac- tive persons. I could not answer this question definitely without knowing whether there pre-existed other probable causes of the slight brain softening and trace of kidney deterioration, but the result referred to in the interrogatory is not impossible after long, excessive and continuous hypnotic influence. Prof. Thos. Bassett Keyes, M. D., of Chicago, writes: Yours of February 1st, in regard to the hypothetical question, as to whether diabetes mellitus, as in the case referred to of Spurgeon Young, might result from improper handling, suggestions and impressions under hypnotism, is at hand and briefly considered. From what we know of the psychological action of suggestion, after hypnotism, it leads me to say that, since blisters have been drawn, ha;mor- 162 Clark Bell. rhages made to appear or stop, sores to heal, inflammation and swellings to disappear, glands and organs to become active or slow, according to the suggestions; since the tissues in every part of the body may be influenced, and from what we know of the etiology of diabetes mellitus; viz., that it is sometimes the result of irritation of the vaso-motor areas of the floor of the fourth ventrical, and since this irritation may*result from shock, mental labor, and strong excitement and emotion, it leads me to say that if improper suggestions were made to a hypnotized subject—such as suggest- ion to cause excessive fear or shock, or any but properly directed psycho- logical suggestions—they would have a deteriorating or abnormal stimulating influence upon the body and nervous system generally, and such shock, deterioration or abnormal stimulation might produce, it seems very probable, the disease—Diabttes Mellitus, or if the subject was improperly handled (the suggestions being also considered) a local or central hyperemia of the floor of the fourth ventricle might *be produced. "Mechanical irritation of this region produces glycosuria."—Loomis. .. Other questions might be considered, as the stimulation of certain ganglia so as to produce excessive activity and assimilativi processes. Dr. N. O. B.Wingate, of Milwaukee, Wis., says: Dear Sir and Colleague:—Yours of the 6th inst. received and contents noted. I enclose herewith a copy of the hypothetical question which you submit to me for reply, and will answer it as follows: I do not believe diabetes mellitus would follow in the treatment, but given a case where diabetes mellitus existed, I believe such hypnotic practice as related in the question would be decidedly injurious. Mr. Sydney Flower, of Chicago, replies: My Dear Colleague: —The Coroner's question may be condensed, may it not? into "Do hypnotic experiments, performed with a subject who is in the cataleptic state, produce physical injury or organic impairment in that subject?" I should think it most unlikely, and cite in defense of this posi- tion two significant facts, namely: 1st, That there are no instances on record of injury having resulted to anyone by such practice; and 2nd, That in the case of a greater weight being placed upon a cataleptic subject's body than he is able to support he will bend beneath it. In other words, cata- lepsy is a stiffening of the muscles of the body by voluntary effort under the suggestion of the operator; although, occasionally, the same state may be induced by the auto-suggestion of the subject. Only a certain small per- centage of hypnotic subjects become good cataleptics, and this important fact was emphasized by Dr. Parkyr, superintendent of the Chicago School of Psychology, when I submitted to him the Coroner's question. The point he makes in this connection is that few people have a natural aptitude for The Case of Sturgeon Young. 163 these experiments; and that though one subject may be, while under sug- gestion, capable of making his body rigid; another may fail utterly. Also that while one may stiffen certain muscles of his body, he may not be able to stiffen all, and lastly, that the boy who can, while in hypnosis, sustain a weight upon his stomach, when suspended between two chairs, can also perform the same feat while in the waking condition, and that the catalepsy is largely dependent upon his habit of life, muscular formation, and training or practice in these experiments. Seeing then that a subject who has not in himself the muscular power necessary to support a weight, will not do so, but will bend under it,and|that a cataleptic subject will come out of the cataleptic condition and his muscles naturally relax, when the limit of his endurance in this direction is reached, it becomes evident that a rigidity is by no means the formidable condition it is commonly represented to be. As I am not a doctor of medicine it would be presumptious in me to comment upon the finding that this boy, Sturgeon Young, died of diabetes supposed to be induced by his performances while in a hypnotic condition. But I wish to know if diabetes manifests itself with the rapidity here indicated; and if it has ever been shown that a pressure upon the abdomen results in a strain of the kidneys. As to the responsibility in the case, it seems to me that no authority upon hypnotism will deny that this boy was conscious of the fact that these experiments were to be tried upon him. He was not a persecuted infant, compelled by a stronger will than his own to perform muscular feats which were liable to injure him. He was in the position of an athlete who is willing for applause, or for gain, to test his strength in a certain manner. I do not think he injured himself by the performance of these feats, but admitting, for argument's sake, that he did, where lies the blame? He need not have consented to anything of the kind, but he voluntarily, and of his own free will, knowing well what he was expected to do, undertook to perform these experiments. 1 have always denounced somnambulistic per- formances which had no scientific aim, as foolish and dangerous. They are foolish, because when it is clearly understood that the subject is a con- scious agent, they can have no special interests as experiments, but de- pend for their attraction upon the mystery which is ignorantly impressed upon the spectators by the uninformed operator. They are dangerous only because of the want of knowledge of the operator in properly removing all suggested delusions—but even here, we can only assume a danger to exist. There have been no instances of evil effects resulting from even a careless use of hypnotism, and it is only by inferential reasoning that the best writers define the dangers of hypnotism. I think that both the experienced and the inexperienced operators are prone to magnify both the dangers and benefits of hypnotic suggestion. With reference finally to these experiments, I should place cataleptic exhibitions in the "foolish" class, and sense delusions in the "dangerous." Dr. Fred. Laidlaw, of New York, says: 164 Clark Bell. From the account of the autopsy given, it is my opinion that diabetes mellitus was the probable cause of death. It is my further opinion that the frequent practice of hypnotic experiments had no relation whatever to the diabetes. In my opinion, it is not possible to produce diabetes mellitus by the practice of hypnotism, nor, if the disease is already present, will it be aggravated by hypnotic experiments any further than is involved in the general proposition that, in any diseased condition, all exertions that exhaust the patient, render him more susceptible to the inroads of his disease. Dr. Jas. T. Searcy, of Tuscaloosa, Ala., writes: I think it a very plausible opinion that the disease of Diabetes Mellitus, of which, or with symptoms of which, the young man under consideration was said to have died, could have been occasioned, or could have been aggravated to a fatal termination, by the continued and excessive hypnotism to which he was subjected during the six months prior to his death. Hyp- notism is always a strain and often a serious danger to the brain, particu- larly if carried to excess or repeated for months in a case evidently of weak cerebral ability as this one seems to have been. In my opinion, sensitive- ness to hypnotic suggestion is always an indication of cerebral (cortical) weakness or abnormality. In that particular and in that way the person is weak. Diabetes is much more a disease of the brain or of high nerve structure than of either the liver, which produces the sugar, or of the kidneys, which eliminate it. The frequent and severe strains to which, not only the brain of the young man was subjected, but also his whole system could have occasioned a disease of brain structure, which was the first cause of the diabetes, or have very much aggravated it, if, by heredity, or by any other cause, it had already begun. This answer is given within the limits of the hypothetical question proposed by Dr. Bowen, and does not take into consideration other injuries to internal organs, which your letter refers to, and also supposes the cause of death to have been only the diabetes. The cerebral softening mentioned may be the pathological condition of which he died or may have been the pathological source of the diabetes. If the diabetes was of sufficient degree or of sufficiently long standing to have been the cause of death, you could, with great plausibility, advocate that it had been occasioned in a subject inclined to it, and had been aggra- vated, after it was begun, by the hypnotism he was subjected to, though there is no positive or direct proof, pathological or otherwise, connecting the hypnotism with the diabetes. The Case of Sturgeon Young. 165 Prof. A. A. D'Ancona, of San Francisco, replies as follows: Dear Sir:—Your favor requesting answer to hypothetical question asked by the Health Officer of Jamestown, N. Y., is at hand. lt seems to me that doctors who conducted the autopsy are under a misapprehension regarding the pathologyj>f diabetes. The kidneys are not the seat,of the trouble. They simply eliminate sugar fronTthe blood when it is inlquantity too great for the needs of the system,[or in a form not assim- ilable by the tissues. The doctors should have examined particularly the liver and pancreas. i. .itFurthermore, diabetes can not be predicated on account of the presence of one symptom, namely,"glycosuria. liThis^symptom often comes from mere excess of sugars and starches in.the.food.-^_So well recognized is this, that the large Life insurance companies],instruct^their examiners not to reject applicants on account of glycosuria, unless associated with the rational signs of diabetes. That it was not so associated, is^probable,/first, because the hypothetical question is silent upon the "subject of the rational signs; and, secondly, because one of the most marked symptoms of diabetes is progressive emaciation in spite of a voracious appetite and the subject in this case is described as "well nourished." Though the causation of diabetes is obscure, many cases have been considered to be due to nervous shock, emotion,,[anxiety; miny to injury and disease of the nervous system, to severe ^mental'and physical .strain, to blows upon the abdomen, etc., etc. It is certainly possible that the experiments outlined in the hypothetical question overtaxed the physical and mental powers of the subject. This com- bined with the supporting of heavy weights upon the abdominal walls may have produced profound functional changes in the abdominal viscera, diabetes being one of the affects. It is nevertheless true, that for the majority of cases of diabetes, no cause can be assigned. Owing to the uncertainty of |the etiology of the disease, to attribute [positively the cause of death to diabetes induced by functional nervous disturbance of the abdominal organs, the result of hypnotic experiments, however unskillful, seems to be unwarranted. Dr. J. D. Buck, of .Cincinnati,^replied as_follows: In my opinion grave physical injury would arise from the foregoing pro- cedure: first, impairment of the n'rvous system, and finally imbecility. See reports ol experiments of schools of Paris, Njrway and others. Cerebral softening and diabetes might result from repeated hypnosis. The practice is harmful under all circumstances except in ,the hands of_skillful physicians for the treatment of disease, and even then'in a narrow range of diseases and with doubtful results. In all other cases it is dangerous and should be suppressed by law and with severe penalties. This hypothetical question and my accompanying letter have been sent to other experts of position and prominence 166 Clark Bell. connected with the Medico-Legal Society and the Psycho- logical Section whose replies are not yet received. 1 have not formulated my own opinion upon the case, preferring to wait until I shall receive a more complete and detailed statement of the autopsy, which, in my opinion, should throw all necessary light upon the question pro- pounded by the Coroner. The case presents some interesting questions and will, 1 do not doubt, excite interest among students of the science on both sides of the Atlantic. I sent the question to Prof. R. Virchow, of Berlin, one of our honorary members and other eminent members abroad and the case will serve to call attention to a new field of inquiry upon this interesting subject. NOTE.—The following additional information was fur- nished by the Coroner after the verdict. The autopsy was as follows, though it was not furnished to any of the experts who replied to the hypothetical question: Examination of body of J. W. Sturgeon Young at the home of his father, 1033 North Main Street. Height, 5 feet 7 inches. Age, 17 years. Weight, (estimated) 125 lbs. Drs. W. M. Bemus, Phillips and Rice present, also Coroner Dr. Bowen. Drs. W. M. Bemus and Phillips operating. Rigor mortis well marked. Body fairly well nourished. 1. Examination of brain. Incision from ear to ear through scalp, and tissues dissected and scalp reflected forward and back. (4 oz. urine drawn by catheter) Coroner went away at 1 p. m. Cranium removed. Brain removed. Dura matter, normal. Pia matter and archnoid, normal; some small tubercules upon both sides of longitudinal fissure of cerebrum. Brain slightly softened on left side of cerebrum. White and gray matter, normal. Weight. 48 oz. 2. Chest opened. Lungs, normal. Oesophagus and trachea, normal. Pericardium, normal. Heart, normal. Weight 8 oz. Valves all normal. Diaphram, normal. Liver, weight 3% lbs., normal in appearance. Bowels contained scybala. Stomach, normal, but distended with gas. Pancreas small, but normal. Kidneys, left, hardened, small; right, hardened, small, with small tubercles in tubules of kidney. Spleen, small, dark, soft. Spine, normal; no evidence of external Injury. 3. Urine. Reaction, slightly acid. Sp. gr. 1.020. Phosphates pres- ent. No albumen. Sugar in large amount. WILLIAM M. BEMUS. C. J. PHILLIPS. A. B. RICE. The Case of Sturgeon Young. 167 The evidence of the attending physician, A. B. Rice, M. D., was: That he treated Young from January 14, 1897, to the time of his death; on the 20th of January, he was confined to his bed and passed very large quantities of urine, three or four gallons per day. On analysis the urine was found to contain large quantities of sugar. Dr. Rice diagnosed the disease as Diabetes Mellitus. Young complained of pain in his back, was very weak, had an inordinate thirst, voracious appe- tite, observed daily loss of strength, but kept his mental faculties, though at times he would lapse into a stupor. The verdict of the jury was as follows: We find that J. W. Sturgeon Young came to his death at 1033 North Main street in the city of Jamestown, in said county, on the 24th day of January, 1897, from diabetes and nervous exhaustion caused by hypnotic practices performed by the following persons as shown by the evidence: R. Louenstein, Daniel H. Grandin, Parke H. Davis, Charles Wood, Edward P. Dodge, Robert Bemus; and from the testimony produced before us upon the inquest it appears that the said J. W. Sturgeon Young for several months prior to his death had been habitually and continually hypnotized by the above-mentioned persons and that while under the hypnotic influence, his body was suspended between two chairs, the back of his head resting on one chair and his feet upon another without other support and that while so suspended a person weighing at least 180 pounds sat upon him; that he had also while under such hypnotic influence been carried through the various stages of intoxication and delirium tremens and other hypnotic feats. We would recommend that the state legislature pass a law prohibiting the practice of hypnotism. 1 was unable to give an opinion on the hypothetical question alone, and did not receive the autopsy or the statement of Dr. A. B. Rice, the attending physician, until after the verdict was rendered. NOTE.—Though this case is incomplete without a careful microscopical examination of the brain and a more thorough clinical record of Sturgeon Young, we give the record and opinions place in our pages because this is the first case of the kind in court annals of hypnotism Or sup- posed hypnotic influence in engendering disease in a hyp- notic subject.—C. H. H. ENCEPHALITIC AND LATE EPILEPSY By JAS. G. KIERNAN, M. D., Chicago. Foreign Associate Member French Medico-Psychological Association-, Fellow of the Chicago Academy of Medicine; Professor of Forensic Psychiatry Kent College of Law. EPILEPSY occurring after 25 and that due to encephalitis have points of special interest in common. Epilepsy following on the various forms of infantile encephalitis exhibits in my experience many peculiarities. It is more apt to be accompanied by trophic phenomena of the extrem- ities varying from the simple "dead fingers" to phenomena nearly approximating Raynaud's disease. It reacts badly to the bromides. Mental symptoms, fits of temper, of sullen - ness, of depression, or even destructiveness, replace under the bromides the convulsive attacks. The tendency to impairment of the circulatory innervation of the extremities is increased. The various bromic dermatoses appear with comparatively great frequency. In not a few instances, these eruptions have proven unduly severe and protracted. A nocturnal mental type takes the place often of the con- vulsion. It is attended by phenomena closely resembling those of somnambulism. In some few instances an intense pruritus results. While the dermic phenomena due to the bromides yield to arsenic, calcium sulphide, etc., still these ameliorations are very temporary and the original phenom- ena recur after a time. As Spitzka* has pointed out epilepsy is a diseased state of the encephalon without a palpable characteristic lesion, manifesting itself in explosive activity of an unduly irritable vaso-motor centre, leading to complete or partial loss of consciousness which may be preceded or followed by various *N. E. Medical Journal 1881. [168] Encephalitic and Late Epilepsy. 169 phenomena expressing the undue preponderance of some and the suspended inhibitory influence of other cerebral districts. The patho-anatomical changes found in patients suffering from this disease throw but little light on pathological phy- siology. Certain vascular phenomena accompany an epi- leptic attack so constantly that they have been considered the fundamental essential factor of epilepsy. Suddenly pro- duced anaemia of the higher nerve centers will, it is true, produce convulsions. But it does not follow that the arter- ial spasm is the direct cause of the epileptic fit. The convulsion while a phenomena of the fit, is neither an ini- tial nor is it as constant as it should be were the Kussmaul- Tenner theory correct. Nor does the discharging lesion theory of Hughlings- Jackson explain the phenomena of epilepsy. That an irri- tative lesion of different portions of the brain may result in epileptiform explosions is no proof that the idiopathic epi- leptic attack has a similar origin and is due to similarly located foci of impalpable disease. Take an inflammatory softening on or near the cortical area which stands in a relation to the muscle of the arm; epileptiform spasms may be a symptom of such a lesion and they may begin in the particular muscle whose "center" is affected, they may then extend to the other muscles of that half of the body or suddenly to the entire voluntary muscular system. Is that proof that the epileptic "discharge has extended through the cortex by irradiations?" It does not seem that this cpuld be maintained in cases where the transition from the localized or, as it were, "focal" spasm to the general convulsion was sudden. It seems more probable that the primary irritation had determined a secondary irritability of the great convul- sive center of the body, namely, the reticular gray matter of the brain isthmus particularly of the pons and medulla. Starting with the fact that all characteristic features of the full epileptic onset can be produced in animals deprived of their cerebral hemispheres working, a satisfactory hypothesis of the nature of epilepsy can be obtained. It needs but a 170 Jas. G. Kiernan. slight puncture with a thin needle to produce typical con- vulsions in the rabbit and some of the convulsive move- ments reported by Nothnagel have not only shown the true epileptic character but also that peculiar automatism noted in aberrant attacks. It is in this segment of the nervous system that |all the great nerve strands conveying motor impulses both of a voluntary and automatic and some of a reflex character, are found united in a relatively small area, and just here a relatively slight disturbance might produce functional disturbances involving the entire bodily periphery. The experiments of physiologists have shown that if a sensory irritation of a given spinal nucleus be kept up, after having produced a reflex movement in the same segment, if there is any reaction beyond the plane of that segment at all it is not in the next or succeeding planes but in the medulla oblongata. The motor reaction then manifests itself in laughing, crying or deglutitory spasms and, if the irritation be of the severest kind, epileptic or tetanic spasms in addition. Now the occurrence of laughing, crying or deglutitory spasms could be easily understood if the molec- ular oscillation induced by the irritation were to travel along the associating tracts from the given spinal segment to the nuclei of the medulla oblongata. For in the medulla there are found the nerve nuclei which preside over the facial, laryngeal and pharyngeal muscles. It is not easy at first to understand how tetanus and epilepsy, that is, spasms con- sisting in movements whose direct projection is not in the medulla- oblongata but in the cord, can be produced by irri- tation of the former. There are scattered groups of nerve cells in the medulla oblongata which have either no demonstrable connection with the nerve nuclei or are positively known to be con- nected with the longitudinal associating strands. These cells hence can safely be regarded as representing a presiding center over the entire spinal system. No spinal center exerts any influence even remotely as pronounced as that of the entire cord. This applies to man and other mam- mals. That the elaboration of the medullary ce"ntre was as gradual a process as that of other higher differentiations is Encephalitic and Late Epilepsy. 171 illustrated by the case of the frog whose medulla has acquired the faculty of reproducing general spasms while the spinal cord itself retains this property also; hence here the predominance of the medulla is not so marked as in mam- mals. The reticular ganglion of the oblongata is not in the adult a part of the central tubular gray matter but has, through originally developing from it in the embryo, become ultimately isolated from its mother bed. It constitutes a second ganglionic category and the association fibers bring- ing it in functional union with the spinal gray (first cate- gory) in lower animals and shown to have assumed the position of projection fibers in the higher to constitute a second projection tract; both together are a second projec- tion system. The scattered gray matter of the medulla has an (inferentially) great importance. Anatomically it is (though its cells be scattered diffusely as a rule) a large ganglion with numerous multipolar cells of all sizes many of them of gigantic size sometimes exceeding the so-called motor cells (which they simulate in shape) of the lumbar enlargement in size. Scattered in the "reticular substance" of the medulla from the upper end of the fourth ventricle to the pyramidal decussation they merit the collective des- ignation of reticular ganglia. The cells of the reticular formation are known to be connected with the nerve nuclei on the one hand, and with "longitudinal fasciculi which since they run into cord, term- inate either in the gray matter (or the nerve roots directly) for nerve fibers do not terminate with, as it were, blind ends. Now in the mammalian brain the reticular ganglion lies scattered among fibres which come from the higher centers and the interpellation might be made whether after all, the reticular ganglion be not a mere intercalar station for fibres derived from a higher source. That originally the ganglion was an independent station there can be no reas- onable doubt for in reptiles this body of cells is too con- siderable to account for a termination in them of the few cerebral fibers possessed by these animals. And on the other hand the vertical strands are notably increased in 172 Jas. G. Kiernan. their passage through the field of the medulla oblongata. The medulla oblongata with its reticular ganglion seems to be the great rhythmical center. In fish, the movements of the operculum and mouth, in sharks those of the spir- aculum; in perenni-branchiate, amphibians the branchial tree, in the infant the suctorial muscles, in all vertebrates the movements of deglutition, of the heart and respiratory muscles, all movements presenting a more or less regular rhythm, are under the control of the medulla oblongata. The early differentiation of the part of the cerebro-spinal axis is without doubt related to the early manifestations of rhythmical movements in the embryo and their predominant importance in lower animals. The possibility should not be excluded that a rhythmic movement may be spinal, nay even controlled by peripheral ganglia (heart of embryo). A higher development however implies the concentration of rhythmic enervations at some point where that anatomical association may be effected, which is the expression of the mutual influence these movements exercise among them- selves. Two sets of phenomena need be borne in mind in studying, the physiological pathology of the epileptic attack. First, the condition of the epileptic in the interval. Second, the explosion itself. Too much attention is paid to the last, too little attention to the first. The constitutional epileptic is characterized by a general deficiency of tonus, associated with exaggerated reaction and irritability. Thus the pupils are at once widely dilated and unusually mobile. The muscular system though generally relaxed manifests exaggerated reflex excitability. The mental state is char- acterized at once by great indifference and undue irasci- bility. In the same way the vascular system is depressed in tone in the interval with rapid marked changes under excitation. The state of the nervous system as a whole Spitzka forcibly compares to that of an elastic band which being on the stretch continually, is apt to overshoot its mark when one end is let go. Under normal circumstances the band is less stretched and hence not as liable,to fly so far when the check is removed. Encephalitic and Late Epilepsy. 173 An irritation which, in health, produces restlessness of the muscular system, accelerated respiration and pulsation, and various mental phenomena within the normal limits, in the epileptic results in more intense phenomena in the same direction. The nervous irritability of the epileptic manifests itself in one direction especially. An important vaso-motor center for the brain vessels exists possibly diffused through an area somewhere between the thalamus and subthalamic region above and the pyramidal decussation below. The irritability of this center results in the sudden arterial spasm in the carotid distribution (so characteristic a feature of the fit onset); simultaneously with the contraction of the ves- sel, the pupil undergoes an initial contraction, and relaxa- tion instantly results in both cases. The sudden interference with the brain circulation produces unconsciousness, and destroys the checking influence of the higher centers on the reflexes in a manner analogous to any shock affecting the nerve centres. In the meantime while there has been a sudden deprivation of arterial blood and a sinking of intra- cranial pressure so far as the great cerebral masses are con- cerned there has been as sudden an influx of blood to the unaffected district of the vertebral arteries whose irrigation territory is now the seat of an arterial hyperaemia. The result of this is that the great convulsion centre the medulla being overnourished, functional excess, that is, convulsion occurs unchecked by the cerebral hemispheres which are disabled by their nutritive shock. The unconsciousness and coma of epilepsy more resemble shock than they do cere- bral anaemia or syncope. The impeded return circulation of venous blood now comes into play. The contraction of the neck muscles explains this obstruction and the accumu- lation of venous blood in the cerebral capillaries of the medulla especially. Meynert's opinion, that this venous blood by the formation of cyanide-like substance acts as a toxic agent and produces the severer symptoms noted dur- ing the post convulsive period, has been recently supported by the finding of convulsant urine toxins by Fere. In addition to those sustaining the "rubber band" analogy the following facts tend to demonstrate the view 174 Jas. G. Kiernan. just expressed. First (a) the contraction of the retinal artery (b) the initial and very brief contraction of the ordinarily dilated pupils; (c) the sudden pallor of the coun- tenance. Second (a) the secondary expansion of the retinal arteries; (b) the secondary dilation of the pupils; (c) the secondary flushing of the face. Third the post-mortem appearances found in those dying immediately after severe convulsive seizures. True epilepsy presents an enormous number of sub groups, exhibiting every variety of deviation from the ideal convulsive form, and the existence of these forms tends to demonstrate the views just expressed. In ordinary petit- ma! the initial arterial spasm has but to be confined to the surface of the hemispheres leaving the thalamus ganglia un- disturbed and it can readily be understood how the momen- tary unconsciousness or abolition of cortical function can occur without the patient falling, his automatic ganglia still carrying on their functions. At the same time with the lesser spasm there would be a less extensive sinking of intracranial pressure and less consecutive collateral hyper- aemia of the lower centres and therefore no convulsion. As Meynert has suggested, in certain cases the arterial spasm may fail to affect the entire cortical surface simul- taneously, some one trunk may be more pervious and as afflux of blood may occur in its special field where certain impressions and motor innervations are stored; the result will then be that the function of the relatively well nourished territory will be exalted. If it be a visual perception terri- tory, sights, colors or luminous spectra will be seen, if it be an olfactory territory, odors will be smelt, if a tectile center, crawling, tingling and cold sensation, if a speech center, cries, phrases and songs may ,be observed. This explains the manifold epileptic aura which is simply an isolated exag- gerated limited cortical function. The recurrence of the aura is readily explicable on the ground of the well known phy- siological law that any nervous process, morbid or normal, having run through certain paths, those paths will be the paths of least resistance for that process to follow in the future. To an extension of the same conditions are due the Encephalitic and Late Epilepsy. 175 peculiar convulsive equivalent and post-epileptic mental states. Encephalitic epilepsy while in many cases possibly Jacksonian at the outset but too often becomes an epileptic constitution with all the phenomena of idiopathic epilepsy underlaid by the pathology just enunciated. After the age of 25 and most frequently between 35 and 40 in persons with no very decided neurotic heredity and in most of whom lines can be excluded, occurs an epi- lepsy which resembles in many respects the epilepsy from encephalitis. As a rule in these cases, which I have found equally divided as to sex, there has been a precedent period of nervous exhaustion attended by vertiginous states as its later development. These vertiginous states are often preceded or followed by anomalous sensory disturbances frequently compared by the patient to "waves." They pass into states attended by loss of or dazed consciousness with or without motor explosions. Some of these vertiginous states even when with consciousness are attended by localized jerkings of groups of muscles. All these phenomena are clearly due to toxins resultant on nerve exhaustions which produce the effect that Meynert long ago showed was due to them in ordinary epilepsy. Under normal circumstances, the toxins and ptomaines which are produced in the organism are eliminated by various channels. Some of these products are transformed in the alimentary canal into innocuous substances; gases are elim- inated by the lungs, other compounds are intercepted and decomposed in the liver; lastly, certain effete products are eliminated by the kidneys and skin. When any of these emunctories is interfered with in the discharge of its func- tions the phenomena of auto-intoxication make their appear- ance. This is observed in certain affections of the alimentary system for example, which are attended by such symptoms as headache, pallor, hypochondriasis, etc. These manifestations which are the result of a chronic auto-intox- ication were not improperly attributed by the older writers 176 Jas. G. Kiernan. to disturbance of the hepatic functions. As Schopfer* has lately shown the liver, by its peculiar intrinsic action due to the specific activity of its cellules, can diminish the toxic power of the alkaloids with which it is brought into contact. Such action is manifested not only in the case of poisons introduced through various channels into the organism, but also in the case of poisons elaborated internally within the organism itself in consequence of putrefactions of the prod- ucts due to the activity of the tissues. He hence advises intestinal disinfections and special alimentation so as to obviate or to minimize "auto-intoxication in all maladies in which the liver does not perform its functions normally." One therapic great element in preventing the recurrence which constitutes the "epileptic habit" is hence diet. Asa rule the epileptic should be limited chiefly to a farinaceous diet. This should be varied in itself and by slight amounts of the more digestible meats, beef or mutton. Berries or small seed fruit, pine apples, bananas, parsnips and turnips should not be eaten and the amount of potatoes should be limited. Large quantities of water should be drunk. In this way the necessity for artificial intestinal antiseptics will be greatly limited. As Dr. J. M. Soniah remarks: "Recent biochemical researches by revealing the action of toxins, ptomaines, and leucomaines, have thrown much light on the action of a class of remedies which the older therapeutics called alter- atives which Headland however denominates catalytics. This class of remedies as Headland points out has the fol- lowing action. They act in the blood and their effect is permanent. Each of itself tends to work out a peculiar operation in the blood. The diseases in which they are used depend on certain morbid materials or actions in the blood. The result of the action of a catalytic medicine is in,some way to neutralize or counteract some one or more of these morbid processes. These medicines are all unnatural to the blood and must at length pass out of the system. These properties indicate their use in incipient sclerotic states. *American Medico-Surgical Bull 1894. Encephaliiic and Late Epilepsy. 177 The recent development of biochemistry and bacteriology demonstrates that organic compounds produced by bacteria and by metabolism are the origin of secondary pathological tissue change. Scleroses of all types may result from such action. Behind many forms of cirrhosis, renal, hepatic or gastric, is the ptomaine or syphilis. The foremost metallic alteratives are arsenic, gold and mercury. Gold is an old remedy but early in the seventies came into prominence because of its affinity for nerve tis- sue when used as a stain in preparation of microscopical sections. These remedies were found to act best in com- bination with chlorine, iodine and bromine while all of these last had an alterative action chlorine and iodine were long the chief favorites. Bromine widely used in neuroses attracted less attention as an alterative although when first discovered it was chiefly so used. Dr. Jas. S. Jewell* who incidentally noticed through its employment in neuroses that bromine seemed to have a specific action on the formation of connective tissue, remarks: "Some years ago I called attention to a class of cases in which there was chronic diarrhoea or a tendency toward looseness of the bowels, more or less gastric catarrh, sallow skin but clear conjunctiva, gastric uneasiness, habitual deficiency or absence of bile from the bowel discharges and clearly evident (from palpation and percussion) hepatic con- traction. In these cases there is actual hepatic atrophy. In them the persistent use of bromine internally has had good results. Its action is slow and it must be continued for months to be of permanent benefit. The bromine is given in distilled water ten drops of the liquid bromine to the ounce of water. Five drops of this solution should be given thrice daily to begin with. The dose should be increased one drop daily until it is plain the stomach will no longer tolerate a large dose. If the stomach become irritable as a result of the remedy it may be desirable to reduce the dose to one or two drops or even cease its use altogether for a time, to resume when the stomach will tol- *Chici2go Medical Review. Vol. 4. 178 Jas. G. Kiernan. erate it again. It should be given in a considerable quan- tity of water as it is likely to irritate the stomach otherwise. Under the use of bromine 1 have usually seen after a time less disturbances in the gastric zones, less diarrhoea, a reappearance of bile in the discharge from the bowels and a slow but decided improvement in the patient's general health. The alteratives are hence peculiarly suited for treat- ment of states due to toxins even antecedent to sclerosis. By destruction of the toxin through stimulus of hepatic action and elimination they tend to prevent its accum- ulation and the phenomena resultant on this. The alkaline bromides do not seem to exert this influence, hence in no small degree their untoward effects. Of late, metallic bromides have been (it is claimed) united in a compound the liquor arsen, auri, et hydrargyri of Barclay (arsenauro). This compound in the types of epilepsy to which allusion has been made, has given undeniably excellent results. Twenty drops in four doses daily are given gradually increased by two drops daily until slight sialorrhoea or loose- ness of the bowels occurs when the dose is reduced by two drops. None of the untoward effects of the bromides have beed observed and cases stupefied by them have reacted excellently. Like all beneficial affects of alteratives, improvement is at first slight but increases in geometrical progression. Of course certain symptoms require special treatment and an excellent adjuvant to dietetics and the alterative treatment is nitro-glycerin, which a little less than two decades ago, acting on basis of the morbid phenomena described, was introduced on therapeutical grounds without reference to bromide untoward effects. It was found by neurologists that it had neither the tendency to produce mental symptoms by suppression of the epileptic discharge nor yet the distressing dermic phenomena. Spitzka found it of especial value given at shorter intervals than the bromides in 1-50-grain doses. Trussewitch points out that it should be used when there is a defect in the equilibrium of the vascular tone and the blood is irregularly distributed. Encephalitic and Late Epilepsy. 179 It causes a rush of blood to the anaemic district or unloads the hyperaemic. He finds, as did Spitzka, that after a time there comes a toleration of the drug. It should then be dropped for one or two weeks when susceptibility will be regained. Osier finds that the physiological effects must be apparent before good results are obtainable. It controls, given on the principles indicated, the restlessness, the temper, as well as the motor phenomena of these epileptics. It is best given eight times daily in 1-250 grain doses. PSYCHOSES OF OLD AGE By HARRIET C. B. ALEXANDER, A. B., M. D., Chicago. HE psychology of normal old age, as Clouston remarks, ■ has yet to be written from the purely physiological and brain point of view. Poets, dramatists, and novelists have had much to say of it from their standpoint. King Lear is beyond a doubt a truthful delineation of senility partly normal and partly abnormal. By normal senility Clouston means "the purely physiological abatement and decay in the mental function running pari passu with the lessening of energy in all the other functions of the organ- ism at the jatter end of life. No doubt, in an organism with no special hereditary weaknesses, that had been sub- jected to no special strains, all functions except the repro- ductive should decline gradually and all together, and death would take place, not by disease in any proper sense, but through general physiological extinction. The great function of reproduction stands in a different position from all the other functions of the organism. It arises differently, it ceases differently and it is more affected in character accord- ing to the sex of the individual than any other function. It is, as a matter of fact, not entirely dependent on indi- vidual organs. It may exist as a desire and an instinct without sexual organs. It is probably an evolution from hunger. It is really an essential all-pervading quality of the whole organism, and to some extent of every individual organ, not one of which has entirely lost the primordial fissiparous tendency to multiply. But the Fellow of the Chicago Academy of Medicine. [ISO] Psychoses of Old Age. 181 physiological period of the climacteric has determined and ended it in its intensity and greater power, though many of its adjuncts remain; and in the male sex we have to reckon with it and its abnormal transformations to some extent even in the senile period of life. ,,Physiological senility typically means no reproductive power, greatly lessened affective faculty, diminished power of attention and memory, diminished desire and power to energize mentally and bodily, lowered imagination and enthu- siasm, lessened adaptability to change, greater slowness of mental action, slower and less vigorous speech as well as ideation, impaired muscularity and co-ordination, a changed tone of voice, fewer blood-corpuscles red and white, less- ened power of nutrition in all the tissues, a tendency to disease of the arteries, a lessening in bulk of the whole body, but notably of the brain, which alters structurally and chemically in its most essential elements, the cellular action and the nerve currents being slower, and there being more resistance along the conducting fibres." Dr. F. P. Norbury*, like Clouston, finds that the psy- chological study of old age is rendered difficult by the blend- ing of the normal and abnormal mental states. That it is easy to confound ordinary functional derangements with organic brain disease in its earlier manifestations, we are ofttimes forcibly reminded. This difficulty of diagnosis and classification must be experienced to be appreciated. He has been struck by the heterogeneous symptoms yet simi- larity of mental affections when modified by the influence of senility, in a study of 196 cases of insanity occurring in men of over 60 years of age. Senility seems to be more or less, a common mould in which the mental disorders of age are cast, for the mark of senile change is on them all. It is because of the modifying influence of senility that con- fusion arises as to differentiation. While it is true, senile dementia is the only characteristic alienation of mind which in its uncomplicated form, conforms more to a distinctive type than any one form of insanity at any age, yet other * Journal American Medical Association, 1897. 182 Harriet C. B. Alexander. types occur in the aged as much entitled to consideration both pathologically and symptomatologically as senile dementia. Chronic cerebral atrophy, often classed as senile dementia, is the most prominent type to be considered. It is seldom, if ever, given in hospital reports as a form of senile insanity having a distinct pathology and recognized symptoms. In fact it is most always classed as senile dementia. Chronic cerebral atrophy is not necessarily con- fined to what is ordinarily termed the senile period, for it has been observed before the age of thirty. It is however most frequently found beyond the age of fifty. The symp- toms are those of despondency with suicidal tendencies, maniacal outbreaks, inhibited intellection, transient paralytic affections of speech, of monoplegia, of vertigo, etc. These symptoms are not unlike those often encountered in paretic dementia or cerebral syphilis, but are distinguished from them by other associated symptoms especially of cardiac and renal origin. Vertigo is quite noticeable and is prob- ably due as Hirt says, "to the atheromatous condition of the arterial walls and the consequent irregularities of the blood supply to the brain substance. The melancholia is often a prominent symptom depend- ent alone on these circulatory changes. All have noticed in attacks of acute melancholia of the aged, where cardiac dis- ease was conspicuous, the dependence of mentality upon the stability and regularity of the heart's action. A series of such cases studied during past years has more than satis- fied Dr. Norbury of the dependence of melancholia on cir- culatory changes due to impoverished or inhibited circulation. The maniacal attacks of chronic cerebral atrophy with their explosiveness, incoherence and destructiveness may be of cardiac origin. Dr. Norbury repeatedly noticed especially in cases complicated with angina pectoris that the mania was very severe and distressing. The fear of impending death, to be noticed in individuals not insane, is in the insane, transposed into hallucinations and delusions destined to create sad havoc as demonstrated in the mental distur- bance of the individual. Psychoses of Old Age. 183 In the ordinary senile dementia, destructiveness, filthi- ness and incoherence occur; the physical and mental help- lessness being the outgrowth of the progressiveness of the disease. The decline is gradual; the slowness of the atrophic process, producing mental symptoms is at first regarded as the natural result of old age. The amnesia, the sudden changes of moods and emotions, and the appearance of delusions being the evolution of distinct senile dementia. The persistent wakefulness at night and the tendency to wander away from home are trying, to home friends, and lead to commitment of the patient to the hospital. Here in his career of helplessness he lingers along until death finally closes the scene. *Regis is. of the opinion that the insanity of old age, or senile insanity, is that which occurs from advance of years. It recognizes for its main predisposing cause heredity espec- ially cerebral heredity; and as its principal exciting causes, alcoholism, syphilis, great excesses, and misfortunes. Furst- ner, who has made a special study of the psychic disorder of old age classes them in three groups: (1) simple psy- choses; (2) senile psychoses with simple dementia; (3) senile psychoses with cerebral dementia. The simple senile psychoses are those in which the insanity is not accompanied by intellectual enfeeblement. It is then a more or less acute attack of mania, melancholia, or confusional insanity. The maniacal and confusional forms much the least frequent, are essentially curable. The mel- ancholic often due to a homologous and homochronous he- redity assumes by preference the anxious type, and almost invariably terminates in the chronic form. The senile psy- choses with simple dementia are those in which the insan- ity is associated with a condition of mental weakness without corresponding somatic lesions. It is a combination of an attack of mania or melancholia with simple dementia. It is generally met with as a sub-acute melancholia with ideas of persecution. These last are necessarily absurd and puerile from the co-existing dementia. The patients almost *Bannister's Translation. 184 Harriet C. B. Alexander. always think that some one has a design against them, but especially that they are to be robbed; this is their ruling idea. Under the influence of this fear they rise in the night hide everything they have in places which later they them- selves are unable to find, they barricade themselves in their homes and in their rooms, and go so far, so to speak, auto- matically, as to accumulate in their night vessels, their sheets, blankets and garments. There may be also hallucinations of sight or hearing, but confused and rudimentary as they always are in demented conditions. There is very little or no sleep; noc- turnal noisiness and excitement are nearly constant in these patients. Their actions bear the stamp of dementia. They are: absurd and infantile thefts, like those of paretic dementia but even more foolish; sudden and causeless fits of passion, ridiculous and heedless attempts at suicide; also libidinous actions, obscene exhibitions in public, attempts at rape, unnatural crimes, all resulting from lack of con- sciousness and absolute loss of the feeling of modesty. The senile psychoses with cerebral dementia are those in which the insanity is associated, not with simple mental enfeeblement but with the bodily and mental symptoms of loss of power due to a more or less diffuse lesion of the nerve centres, i. e., what is called organic or apoplectic dementia. In my own experience, aside from the other psychoses occurring in the old, the phenomena of senile insanity prop- erly so-called are of peculiar interest to the family physi- cian. Its miserliness, wandering tendencies, suspicional delusions and morbid tendencies to unfit marriages, consti- tute a symptom-complex, at once interesting and puzzling to the practitioner who is called on to advise an afflicted family. The question of senility is, like so many other ques- tions, a relative one. One patient is senile at sixty. Another reaches ninety without the appearance of senile change intellectually. Senile insanity usually begins with marked loss of memory respecting very recent events while events of the remote past are remembered with great min- Psychoses of Old Age. 185 uteness and are predominant. The patient is usually irrit- able in temper. If the mental change proceed no further the patient cannot be called insane. Later on however the emotional and motor faculties are affected. The patients are often greatly but sillily exalted in ideas, given to talk- ativeness and stupid jokes. Both sexes are often at this stage very erotic. The marriage of old gentlemen to dis- reputable women or vice versa, has often had its origin in this peculiarity. The patient shows a great tendency to wander about. An old patient may get up at midnight to search for the dead lovers of her youth. As Anstie has pointed out, there is often a phase of mental change in the aged which is inexpressibly trying to the patient, and still more to all brought into contact with him. It consists in a peculiar perversity, a tendency to offer vexatious and friv- olous delay and opposition to everything which is suggested by others, however important the occasion. They are just that sort of folk who insist on making perverse and unreas- onable alterations in wills when these have been settled long before in a just and convenient manner or who quar- rel in their last days upon some frivolous pretext with the friend of a life time. The first indication in treatment is to meet the waste which underlies the restlessness of senile insanity as it does the restlessness of mental conditions due to other exhaustional states. Frequent feeding at regular intervals of two hours per diem often exercises a decidedly beneficial effect on the restlessness and querulency. Sometimes milk and eggs will quiet when sedatives fail. Conium, sulphonal and cannabis indica act best as sedatives. The patient's tend- ency to insomnia of an intermittent type often yields to a warm mixture of milk and eggs followed in a couple of hours by conium and cannabis indica or sulphonal. In some cases salix nigra and camphor monobromate act excellently. Prognosis as regards perfect recovery is bad. The erethism may quiet down and the patient lead a relatively happy life in the insane hospital but such a seemingly recovered patient, "such a nice old lady," often renders home a perfect torment by unreasonable demands. Often 186 Harriet C. B. Alexander. this is due to the lack of regular feeding and sometimes to the patients relations from whom he will take less direction than from strangers. The delusions of being impoverished often aids insane hospital treatment. The patient who believes she is in a poor house takes food frequently because it costs her family nothing. As to frequency three per cent, of the patients admit- ted to the Cook County insane hospital were so demon- strably senile lunatics as to require hospital treatment. A larger percentage went to the poor house. For proper treat- ment at home, the ensurement of regular rest, frequent feeding and careful watchfulness against wandering tend- encies are absolutely requisite. If these cannot be secured the patient should be sent to an insane hospital. One such case will often wear out an entire family. The results of senile insanity in families have not escaped, as Clouston remarks, the attention of dramatists and novelists. A most interesting description of insanity in the senile period appears in "King Lear." Brigham* (one of the ablest American alienists) half a century ago, regarded Lear as a genuine case of insanity correctly reported. Still he apprehends that the plan or cause is generally misunderstood. The general belief is that the insanity of Lear originated solely from the ill treatment of his daughters while in truth he was insane before that from the beginning of the play when he gave his kingdom away and banished as it were Cordelia and Kent and abused his servants. The ill-usage of his daughters only aggravated his disease and drove him to raving madness. Had it been otherwise, the case as one of insanity would have been inconsistent and very unusual. Shakespeare and Walter Scott prepare those whom they represent to be insane by education and other circumstances of the disease. They predispose them for insanity and thus its outbreak is nat- ural. In the case of Lear insanity is so evident before he received any abuse from his daughters that professionally speaking a feeling of regret arises that he was not so con- * American Journal of Insanity Vol. II. Psychoses of Old Age. 187 sidered and so treated. He was unquestionably very trouble- some and by his "new pranks," as his daughter calls them, caused his children much trouble and introduced much dis- cord into their household. In fact a little feeling of com- miseration for his daughters at first arises in our mind from these circumstances though, to be sure, they furnish no excuse for their subsequent bad conduct. Let it be remem- bered they exhibited no marked disposition to ill-treat or neglect him until after the conduct of himself and his knights had become outrageous. Then they at first reproved him or rather asked him to change his course in mild man- ner. Thus Goneril says: "1 wouid you wouid make use of that good wisdom, Whereof I know you are fraught. and put away These dispositions, which of late transform you From what you are."' showing that previously he had been different. This how- ever caused an unnatural and violent outburst of rage but did not originate his insanity for he had already exhibited symptoms of it and it would have progressed naturally even if he had not been thus addressed. Lear is not after this represented as being constantly deranged. Like most per- sons affected by this kind of insanity he converses ration- ally. In the storm scene he became violently enraged exhibiting what may be seen daily in an insane hospital, a paroxysm of rage and violence. It is not until he has seen and conversed with Edgar, the philosopher and learned Theban, as he calls him, that he became a real maniac. After this aided by a proper course of treatment he falls asleep and sleep as in all similar cases partially restores him. But the violence of his disease and his sufferings are too great for his feeble system and he dies and dies deranged. The whole case is instructive not as an inter- esting story merely, but as a faithful history of a case of senile insanity. Bucknill* very lucidly points out about the period of improvement that: This is not mania but neither is it sound mind. It is the emotional excitability often seen in *Mad Folk of Shakespeare. 188 Harriet C. B. Alexander. extreme age as it is depicted in the earlier scenes of the drama, and it is precisely true to the probabilities of the mind's history that this should be the phase of infirmity displaying itself at this moment. Any other dramatist than Shakespeare would have represented the poor king quite restored to the balance and control of his faculties. The complete efficiency of filial love would have been made to triumph over the laws of mental function. But Shakespeare has represented the exact degree of improvement which was probable under the circumstances namely, restoration from the intellectual mania which resulted from the combined influ- ence of mental and physical shock, with persistence of the emotional excitement and disturbance which is incur- able and unalterable because of the malign influence of old age. Dr. Isaac Ray leans to the opinion that Lear is intend- ed to represent insanity in senescence rather than senile insanity. In Lear, Ray* remarks, Shakespeare has repre- sented the principal character as driven to madness by the unexpected ingratitude of his daughters; or more scien- tifically speaking, he has represented a strong predisposi- tion to the disease as being rapidly developed under the application of an adequate exciting cause. It is no part of his object to excite curiosity by a liberal display of wild- ness and fury nor to awaken our pity by the spectacle of a mind in ruins, and unconscious of its wretchedness. He aimed at dramatic effects by opening the fountain of sym- pathy for a being of noble nature and generous impulses cruelly despoiled of the highest endowment of man, but not so far as to lose all traces of his original qualities or cease for a moment to command our deepest respect. In Lear, we have a man of a hot and hasty temper, of strong and generous passions, of a credulous and confiding disposition, governed by impulses rather than deliberate judgement, rendered impatient of restraint or contradiction by the habit of command with a nervous temperament strongly suscept- ible to the vexations of life and, moreover, with all these moral infirmities aggravated by old age. With these simple *American Journal of Insanity, April 1847. Psychoses of Old Age. 189 elements of character is mingled and assimilated more or less of mental derangement, with equal regard to patholog- ical propriety and dramatic effects. And so nicely adjusted are the various elements of sanity and insanity and so admirably do they support and illustrate one another that we are not surprised in the progress of the action by vio- lent contrast; and we feel at last as if it were the most natural thing in the world that Lear should go mad, and precisely in the way represented by the poet. Mad as he becomes, the prominent attributes of his character are always to be seen. Through the whole play, he is the same generous, confiding, noble-hearted Lear. In short, assuming Lear to be an historical portrait instead of a poetical creation, we should say there existed in his case a strong predisposition to insanity, and that if it had not been developed by the approach of old age, or the conduct of his daughters, it probably would have been by something else. His inconsiderate rashness in distributing his kingdom among his children, his disinheriting the youngest for the fearless expression of her feelings and his banishment of Kent for endeavoring to recall him to a sense of his folly, all indicate an ill-balanced mind if not the actual invasion of disease. This view of the case is confirmed by the con- versation between the sisters immediately after the division of the kingdom. Goneril says: "You see how full of changes his age Is; the observation we have made of it hath not been little. He always loved our sister most: and with what poor judgement he hath now cast her off, appears too grossly.Tis the infirmity of his age," replies Regan, "yet he hath ever but slenderiy known himself." "The best and soundest of his time," continues Gon- eril, "hath been but rash, then must we look to receive from his age not alone the imperfection of long engrafted condition but there withal the unruly waywardness the infirm and choleric years bring with them." Regan then adds. "Such inconstant starts are we like to have from him as this of Kent's banishment." With a knowledge of insanity that could hardly have been expected from any but a professional observer, Shakespeare has here and elsewhere recognized the fact that very many of those who become insane are previously distinguished by some of those mental 190 Harriet C. B. Alexander. irregularities that pass under the name of oddity or eccen- tricity. The next thing we hear of Lear is his beating one of Goneril's gentlemen. His remarks on learning the fact show that his mental condition has not been improving since his abdication and prepare us for the mournful sequel. "By day and night he wrongs me: every hour He flashes into one gross crime or other That sets us ail at odds. I'll not endure it; His knights grow riotous, and himself upbraids us, On every trifle." The development of the early stage of Lear's insanity, or its incubation as it is technically called, is managed with masterly skill, the more surprising as it is that stage of the disease which attracts the least attention. And the reason is that the derangement is evinced not so much by delusions or gross improprieties of conduct, as by a mere exaggera- tion of natural peculiarities, by inconsistencies of behavior, by certain acts for which very plausible reasons are assigned though they would never have been performed in a perfectly sound state of mind by gusts of passion at every trifling provocation or by doing proper things at unreasonable times and occasions. With his own free will and accord he gives away his kingdom but finds it difficult to sink the monarch in the private citizen. He attaches to his person a band of riotous retainers whose loose and law- less behavior proves destructive to the peace and good order of his daughter's household. Goneril describes them as: "A hundred kniirhts and squires; Men so disordered, so debauched and boid, That this our court. infected with their manners, Shows like a riotous inn." Under such an infliction it is not strange that she should remonstrate and had not the divine light already begun to flicker he would • have acknowledged the justice of the reproof. As it is, however, instead of admitting some share of the fault, he attributes the whole of it to her, flies into a passion, pours upon her head the bitterest curses, upbraids her with the vilest ingratitude and forthwith proclaims his wrongs to the public ear. Like most cases in real life it would have to a stranger, the appearance of a family quar- Psychoses of Old Age. 191 rel springing from the ordinary motives of interest or pas- sion, but where really the ill-regulated conduct resulting from the first influence of disease provokes restrictions more or less necessary and appropriate, that become exciting causes of farther disorder. Another life-like touch is given to the picture, in Lear's attributing all his troubles to filial ingratitude, not being aware of course that he was on the high road to insanity long before he had any reason to doubt their kindness. In fact nothing is more common than for the patient when telling his story, to fix upon some event and especially some act of his friends, as the cause of his troubles, which occurred long subsequently to the real origin of his disorder, and might have had but an accidental connection with it. The conduct of his daughters faithfully exhibits strong tendencies of human nature. No doubt their patience was severely tried—such a trial as only the mildest temper joined with the firmest principle could enable them to stand successfully. Wanting these how- ever, his irregularities are met with reproaches and stric- tions instead of kind and conciliating measures, an explosion follows and in mutual hate and anger they separate. To their heartless natures such conduct may not have appeared like unmitigated ingratitude toward a father who had loved and cherished them as the very idols of his heart, but to be founded on provocation that seemed to justify their behavior. Such is the ingratitude of the world ever coupled with some shallow pretense of wrong or indignity sustained and often presenting the fair outside show of a worthier feeling in the daughter's treatment of her father. Shake- speare strips off the thin disguise of conventional morality and lays bare that heartless selfishness which is ever ready to sacrifice to momentary ease and gratification the tender- est sympathy of our nature. It is fearful to think how often the case of Lear and his daughters is paralleled in actual life and it is the very commonness of the fact that prevents us from regarding it as a curious monstrosity, fitted to excite but a momentary horror, and which imparts a deep moral interest to the representation of the poet. When the astounding fact of Goneril's baseness is fin- 192 Harriet C. B. Alexander. ally made so plain to Lear that he can no longer doubt, his senses appear to reel under the shock, and for a mom- ent he questions his own identity. "Does any here know me? Why this is not Lear! Does Lear walk thus, speak thus? Where are his eyes? Either his notion weakens or his discernings are lethargied. Sleeping or waking? Ha, sure 'tis not so. Who is it that can tell me who 1 am?" The continued objurgations of Goneril and her bare- faced impudence in proposing a diminution of his train soon produced a reaction in his mind and Lear gives vent to his feelings in that blasting curse whose bitterest ingredient was the wish that she might feel: "How sharper than a serpent's tooth it is To have a thankiess chiid." Then bursting into tears of which his noble nature is ashamed he quits the presence of a child upon whose affection he had reckoned for the support of his declining years, and resolves to go to his other daughter who had shared his bounties, certain that he would receive from her the hearty welcome and tender regards that he had been scornfully refused by her sister. While pondering upon past scenes he is conscious that his mind has sustained a fear- ful shock and as is often the case in such circumstances he has a vague presentment of the fatal result. "O, let me not be mad. not mad. sweet Heaven! Keep me in temper: I wouid not be mad!" On arriving at Regan's residence he finds that she refuses to see him, and that his faithful follower has been placed in the stocks. These things excite his suspicion that all is not right and renew the agitation that had been moment- arily quieted. Still he is slow to believe what is evident enough to everybody else and fondly hugs the delusion in which his only hope of happiness rests. But when the conviction is forced upon him that Regan even goes beyond her sister in ingratitude, he utters a wail of heartful wretchedness and lofty indignation, ending with another foreboding of the impending calamity. "O fool, I shall go mad." Driven with contumely and scorn from that shelter in the affections of his child which he had fondly expected to find, he goes forth at night and braves the pelting of the Psychoses of Old Age. 193 pitiless storm. The howling of the wind, the roar of thunder and the flash of lightning are welcome, for at least they lack the sting of filial ingratitude and are in mournful accordance with the tumult in his own crushed and bleed- ing bosom. One dark overshadowing, all engrossing idea, the cruelty of his daughters is suggested by every object, gives a tone to all his reflections and like the worm that never dies, is gnawing perpetually at his heart. Well might he invoke the fury of the element upon his head for the worst they could do would be mercy compared with the torments his own flesh and blood had inflicted. "The tempest in my mind Doth from my senses take all feeling else Save what beats there." There is now obviously a degree of incoherence and absurdity in the thoughts that race through his mind though they are never destitute of that grandeur and boldness of expression indicative of his lofty and noble nature. But the idea of the thunder cracking nature's moulds and destroying the germs of the race contained in his invocation to the elements, is a little too fanciful for even a figure of poetry. In a simi- lar strain he charges the elements with conspiring with his daughters against his old white head, and soon after imag- ines that the Gods have raised the storm for the purpose of finding out their enemies. This is crazy enough no doubt; but his apostrophe to sinners of various kinds that immediately follows, is both correctly and beautifully expressed. He seems to be fully aware that his thoughts are deviating from the right track and exclaims that his "wits begin to turn." The predominant idea follows him in the next scene, and ever and anon intrudes upon his reflections though he always recoils from it with a kind of horror, as if conscious it had the power to deprive him of his reason. "O that way madness lies." Unable as the insane are to perceive their own insanity yet this appre- hension of its approach so frequently repeated by Lear usually occurs during incubation. While still able to con- trol his mental manifestations the patient is tortured with anticipations of insanity; but when he actually becomes so insane that the most careless observer perceives the fact, 194 Harriet C. B. Alexander. he entertains the most complacent opinion of his intellectual vigor and soundness. And yet this is one of the nicer traits of insanity which the ordinary observer would hardly be supposed to notice. But Shakespeare was no ordinary observer; and this explains the cause of his preeminence in certain parts of his art. The appearance of Edgar who is feigning madness in order to avoid his enemies, again excites Lear's predomin- ant idea and fixes it permanently in his mind. The form- er's ragged, wretched, degraded condition, he can attribute to nothing but filial ingratitude and he pours out curses on Edgar's unnatural daughters. He is no longer able to cor- rect the errors of his own judgement; reason exercises but a feeble control over his conclusions and scarcely a gleam of light struggles through the darkness which envelopes his soul. The predominant idea however has not yet relin- quished its hold and it still gives direction to his thoughts. The very images of his daughters appear before him in vis- ible forms glowering upon him with looks of scorn and hate. The idea of placing them on trial enters his mind and he proceeds to the business with all due forms and solemnities. Edgar the fool, and Kent are appointed to the bench, his daughters in the shape of joint tools are arraigned before the court; and Lear appears as witness against them. Then, after a brief interval, during which it would seem as if he imagined them to have been convicted and sentenced, he exclaims with touching pathos: "Let them anatomize Reran, see what breeds about her heart. Is there anv cause in nature that makes these harJ hearts?" The scene on the hearth between Lear, Edgar and the fool, has not its like, in the whole range of dramatic liter- ature. No less a genius than Shakespeare would have ventured to bring together face to face three such difficult characters, one actually mad, one falsely pretending to be so and the third a fool. And yet in the successful manage- ment of such discordant and intractable materials, he has given a fresh instance of his wonderful skill. Nothing could have seemed more likely to disappoint and displease than to bring the noble-hearted Lear, staggering under the shock Psychoses of Old Age. 195 of his daughter's ingratitude with blasted heart, bewildered reason, into such strange companionship, and yet who can finish this scene without feeling that he has read a new chapter in the history of mental disease of most solemn and startling import. The sight of another in rags and wretch- edness reveals to Lear a deeper depth of agony in his own soul. He sees in the stranger only another victim of filial ingratitude, the counterpart of his own case, and Edgar's weak and blighted condition forewarns him of his own approaching fate. Its first effects is to produce a shower of curses on Edgar's unnatural daughters and the next to draw him toward his fellow sufferer by that kind of sympathy which, irrespective of social conditions, is awakened by mutual affliction. In this play of wild and discordant fancies, the fool mingles his humors which fall on the ear like sounds of jollity and mirth ascending from a house of mourning. The successful management of such deep masses of. light and shade whether in poetry or painting requires the master hand of Shakespeare or a Rembrandt. Thus far the progress of Lear's insanity is represented with the closest fidelity to nature. It is not more different from the disease as daily observed, than Lear's normal and intellectual constitution, when in health, is different from that of ordinary men. At every interview reason seems to have lost somewhat of its control. The mental excitement has been steadily increasing until now having reached its height, he goes about singing, dancing and capering through the field, fantastically decorated with weeds and flowers looking, acting and talking like a madman. His perceptive 'organs are deceived by hallucinations and his discourse though tinctured with his natural shrewdness and vigor of thought is full of incoherence and incongruity. In short he is now what is called raving. In the representation of his condition we have another instance of Shakespeare's unrivalled powers of observation. To ordinary apprehension the raving of a maniac is but an arbitrary jumble of words and phases between which no connecting threads can be discerned. But in fact discordant and heterogeneous as they may appear, they are nevertheless subjected to a certain 1% Harriet C. B. Alexander. law of association difficult as it may be frequently to dis- cover it. The phenomenon may thus be physiologically explained. In consequence of the cerebral excitement, impressions long since made, so long perhaps as to have been forgotten previous to the attack are so vividly and distinctly recalled that they appear to be outward qualities. So long as the intellect retains its integrity it is able to recognize the true nature of the phenomenon; but when touched by disease it ceases to correct the error of percep- tion. The impressions are actually considered to be what they appear and the patient thinks and discourses about them as such. In his mind's eye he sees sights and in his mind's ear he hears sounds, imperceptible to others and this is the source of much of our difficulty in discovering the object and relevancy of his remarks. Another source of our difficulty in discovering the filia- tion of the maniac's thoughts has been generally overlooked and the fact strongly shows with how little sagacity the operations of the insane mind have been studied. The maniac being restrained by no sense of the propriety or fitness of things, expresses every thought that enters his mind or, at any rate, is governed by no principle of selec- tion. In the sound mind on the contrary a considerable portion of the thoughts never find utterance in words, being suppressed from their want of the connection with one another, or their irrelevancy to the subject in hand. Every one must be aware how often in the course of ordinary con- versation, thoughts start up having the remotest possible connection with anything already said. So remote indeed, as to defy any one but himself to discover it. Any person who should utter every thought that arose in his mind in the freest possible conversation would most certainly be taken for a fool or a maniac. The mental defect is far from being confined to the state of raving. In a greater or less degree it occurs in almost every form of insanity. Even those whose delusions are very circumscribed, who conduct for the most part with great propriety and to common observers betray no indication of unsoundness in their conversation, will usually evince it when very talkative and Psychoses of Old Age. 197 encouraged to talk without interruption. Their remarks may he correct and even shrewd, not a single word may be uttered "sounding to folly" while there is a certain peculiarity in the association of their ideas never witnessed in the sound mind. Though not easily described it is read- ily recognized by those who are conversant with the insane and to them it is a conclusive proof of mental disease, though they may be incapable of making the grounds of their conclusion intelligible to others. Courts and juries are not always disposed to make sufficient allowance for the fact and regard with suspicion the embarrassment of the medical jurist, who sees that what is to him the strongest proof of insanity is to others no proof at all. Bearing in mind these facts we readily see how there may always be some method in madness, however wild and furious it may be, some traces of the delicate thread which, though broken in numerous points, still forms the connecting link between many groups and patches of thought. It is in consequence of Shakespeare's knowledge of this psychological law that in all his representations of madness even though character- ized by wildness and irregularity, we are never at a loss to perceive that the disease is real and not assumed. Not so however with most writers even of distinguished name who have undertaken to represent the workings of a diseased mind. Unaware of the law in question and governed by the popular notions on the subject they seem to have aimed only at [unlimited extravagance and incoherence. Otway, for instance, in "Venice Preserved" represents Belvidera in that state of mental disturbance which results from wounds of the softer affection of the heart. A speech full of those strong and vehement expressions characteristic of deep felt emotion but presenting no trace of delusion finishes with the following jargon, which no insane persons would have uttered in such a connection, though it might very likely proceed from one simulating the disease. "Murmuring streams, soft shades, and springing flowers, Lutes, laurels seas of milk, and ships of amber." In the first scene in which Lear makes appearance after becoming stark mad, his mind is solely occupied with images 198 Harriet C. B. Alexander. formed under the influence of the intense excitement of the internal perceptive organs. He at first fancies himself in a battle and then as engaged in the sports of archery and falconry. Something reminds him of Goneril and then suc- ceeds to one another by a natural association, the ideas of a white beard, of the flattery of his courtiers of the detec- tion of their deception. When Gloster hears his voice and asks if it be not the king's, Lear replies, "Aye, every inch a king." Visions of his royal state then pass before his eyes and he is reminded of the criminals he pardoned and the crimes they committed, and thence, by a natural trans- ition he is led to some caustic reflection on the frailties of women. Another remark of Gloster turns his mind to the examples of self righteousness and self deception, servility and time-serving with which the world abounds and in a strain of bold indignant sarcasm he lashes the vice to which poor human nature is especially prone. All this is exceed- ingly natural. It is not uncommon to meet with madmen of the most wild and turbulent description mixing up their utterances with the shrewdest remarks upon men and things, and the keenest and coolest invective against those who have incurred their displeasure. The poet perhaps has used the utmost license of his art in the present instance, but if few madmen have exhibited so much matter mingled with their impertinency as Lear it may be replied in justi- fication that few men are endowed like Lear with such a union of strong passions and natural shrewdness of under standing. Here endeth the madness of Lear. By his youngest daughter he is placed in the charge of a physician whose medicines throw him into a deep sltep from which and his madness together he awakes as from a dream. The man- ner of his recovery displays the poet's consummate skill that could delineate the most touching and beautiful traits while observing the strictest regard to facts. Lear at first knows not where he is nor where he has been. He scarcely recognizes his own friends and almost doubts his own identity: Psychoses of OU Age. 199 "Pray do not mock me, I am a foolish, fond oid man, Fourscore and upwards; and to deal plainly I fear I am not in my perfect mind. Methinks I shouid know you, and know this man, Yet I am doubtful; for I am mainly lgnorant What place this is: and all the skill I have Remembers not these garments; nor I know not Where I did lodge last nlght." A faint idea of recent events now occurs to him and he says to Cordelia: "Your sisters Have, as I do remember, done.me wrong." A more faithful picture of the mind at the moment when it has emerged from the darkness of disease into the clear atmosphere of health restored was never executed than this of Lear's recovery. Generally recovery from acute mania is gradual, one delusion after another giving way until after a series of struggles which may occupy weeks or months, between the convictions of reason and the suggestion of disease the patient comes out a sound, rational man. In a small proportion of cases however this change takes place very rapidly. Within the space of a few hours or a day he recognizes his true condition, abandons his delusions, and contemplates all his relations in an entirely different light. The management of Edgar's simulation strikingly evinces the accuracy and extent of Shakespeare's knowledge of mental pathology. In placing the real and the simulated affection side by side he has shown a confidence in his own skill which the result has perfectly justified. In no other way could the fidelity of his delineations have been sub- jected to so severe an ordeal. We are left in no doubt as to the views of what is and what is not genuine insanity, and by holding before us an elaborate picture of each, he enables us to compare them together and to judge of his success for ourselves. In these pictures he has availed himself of no equivocal traits; the touches of his pencil are of that strong and decided character that admits but a single meaning. Not more true to nature is the represen- tation of Lear writhing under the stroke of real insanity than is that of Edgar playing upon the popular curiosity with such shams and artifices as would most effectually 200 Harriet C. B. Alexander. answer the simulator's purpose. The one is an exhibition of character as genuine and marked by as distinctive traits as the other; and Shakespeare would have been as unlikely to confound them and mistake the one for the other as to fail to recognize the commonest forms of nature around him. Edgar's first design is to personate a Tom O'Bedlam beggar, one of a class of lunatics who were discharged from Bethlehem Hospital when restored in some measure, that they might subsist upon the charity of the community. Accordingly he provides himself with their usual dress and appurtenances, repeats their phrases and imitates their practices for exciting the compassion of the charitable. In his anxiety to produce an impression, he falls into the common mistake of simulators who overact their part and thus betray their true character to the practiced observer. We could not commit a greater error than to regard this fact as a fault of the poet who displays in it a power of philosophical discrimination which, when strongly marked, is indicative of the highest order of genius. The subject of the past is to deceive multitudes, not the professional student, and for this purpose nothing could be better calcu- lated than the gibberish which he utters in his double character of a lunatic beggar and a victim of demoniac possession. Had it been Shakespeare's design to represent a case of real demonomania or of chronic mania, we should unquestionably have had something very different from the part of Edgar. If the former, we should not have found the patient talking so clearly about his own case, while indulging in unlimited incoherence and rambling about everything else; and, if the latter, we should not have seen a strain of acute moralizing succeeded more than once by a trait of mental imbecillity. Poetically considered, the. feigned madness of Edgar is well calculated by force of contrast to deepen the impression made by real madness of Lear. The abject condition of the former excites our pity as an object of physical distress which we would endeavor to relieve. In the case of Lear, however, all the finer emotions of the soul are aroused by the sight of a noble Psychoses of Old Age. 201 nature, crushed to the earth by sufferings which touch the inmost springs of humanity. We cannot dismiss this play without a passing notice of the fool in whose character Shakespeare has shown that his observation of mental impairment was not confined to one of a few of its forms. He is used like the same char- acter in other plays, his quips and cranks serving as a foil to the humor of his stronger minded companions. They who .find fault with the poet for infusing too much wisdom into the folly of his fools may well take a lesson from him in certain branches of psychological study. In the present instance, he knew what is not generally known even now, as we often have painful reason to remark that a very obvious degree of intellectual deficiency is sometimes accompanied by a little shrewdness of observation and practical sagacity. They, who are much conversant with this form of mental impairment, have no difficulty in believ- ing that the very person who is unable to rise to the sim- plest abstract truth may occasionally utter a shrewd remark and succeed as well as wiser men in "shooting folly as it flies." It was this class of subjects that furnished the domestic fools and court jesters of the olden times. With no sufficient understanding or character to awaken the jeal- ousy of their patrons or exercise any restraint upon their manners they had the sense to discern the foibles and fol- lies of their superiors and ready wit enough to extract from them food for amusement and mirth. The biting jest and timely reproof were good-naturedly received since their acknowledged imbecility rendered them for the most part, quite irresponsible for their sayings and doings. With such characters royalty could unbend without loss of dignity and enjoy a jest even at its own expense. Dickens in "Old Curiosity Shop" has depicted an even more pathetic instance of a senile lunatic, more demented than King Lear who displays the wandering tend- ency of old age and its suspicional delusions. These serve as a beautiful foil to the devotion of "Little Nell." From a forensic standpoint, unjust wills, false accusa- 202 Harriet C. B. Alexander. tions of cruelty against children and relatives, indecent exposure, criminal assaults especially on children of both sexes, illegal and improper marriages and other contracts, and theft are to be expected from senile lunatics. THE AUTO-TOXIC ORIGIN OF EPILEPSY.* By J. NELSON TEETER, M. D., ASSISTANT PHYSICIAN UTICA STATE HOSPITAL. E do not see epilepsy at birth, and not for years ™ * afterward may it show itself. It is the predispo- sition which is transmitted, and not then until some excit- ing cause presents itself to act upon the susceptible nerve cells do we have the manifestation of faulty inhibition, development, nutrition or whatever the condition may be. The child of epileptic parentage may have an attack of intestinal trouble (perhaps putrefactive, therefore toxic) fol- lowed by a convulsion. The nervous centers have shown themselves susceptible to the intestinal irritant and it is reasonable to suppose that upon a subsequent and similar irritation another convulsion will occur. The predisposition, which might be called the epileptic habit, becomes con- firmed when the inhibiting influence governing the action of nerve cells is lost, this inhibiting influence being paralyzed by the intoxicating agent. Gowers says: "Epilepsy is a disease because the tendency to what we call 'discharge' is increased each time the tendency has its effect." Thus the epileptic habit is established. J. S. Bristowe reports cases of epileptiform convulsions apparently produced by extreme slowness of the pulse. In his cases the pulse during the intervals between the attacks was as slow as 20 to 30 beats per minute, and after the attacks reached 70 to 120 beats to the minute. It would seem to me that in these cases the extreme slowness of *Selected and abstracted (rom Stole Hospital Bulletin, Vol. 1, No. 4. [203] 204 J. Nelson Teeter. the heart, with the consequent retarded circulation in the veins and lymphatics, allowed the accumulation of toxic principles in the brain, giving rise to an irritation which resulted in convulsive manifestations. Dr. T. Oliver, in reporting a case of "Epilepsy in a Puerpera with Hyper- pyrexia," speaks of the imperfect renal action allowing the retention of animal poisons in the blood, "there being no reason why the disordered blood of pregnancy, with its altered arterial tension and plethora should not so influence the cerebral centers as to lead to the nervous explosion upon which the fit depends." In this patient no convul- sions occurred until pregnancy was established, and the author excluded kidney disease or any reflex difficulty. It has been shown in extended observations by Herter and Smith that intestinal putrefactive processes are dis- tinctly related to the epileptic paroxysm. They have demonstrated that intestinal putrefaction is indicated by the amount of sulphuric acid in ethereal combination found in the urine. The degree of intestinal putrefaction appeared to influence the seizures in part of the cases cited, being less during the intervals and increasing up to and after the attacks. Haig .claims a relation between uric acid and epilepsy, namely, that grand mal is caused by an excess of uric acid in the blood, while there is a decrease in the amount found in the urine before, and an excess at the time of the paroxysm. It thus appears that the subject of auto-intoxication in epilepsy as a factor in its etiology has occupied the minds of many acute observers and is the path in which we should direct our work until the subject is at least exhaus- ted. The excretory products found in the urine and faeces have received most attention and been thoroughly investi- gated, except the substances found in the urine by Bouch- ard and which he designates "extractive matters," one of which upon injection into animals produces convulsions, another lowers the temperature, and, lastly, one contracts the pupil. To quote from Bouchard: "One kilogramme of man eliminating in twenty-four hours a quantity of urine capable of killing 461 grammes of animal, the proportional The Auto-Toxic Origin of Epilepsy. 205 part of the mineral matter in this toxicity may be indicated as follows: potass, kills 217 grammes; soda, 30 grammes; calcium, 10 grammes; magnesia, 7 grammes. The whole of the mineral matter kills 264 grammes. On the other side, urea kills 63 grammes. There remains to be destroyed 134 grammes." "We may say that one kilogramme of man eliminates in 24 hours organic matter, capable of being fixed by char- coal, which is able to destroy at least 134 grammes of ani- mal. These substances (coloring, extractives or alkaloids) represent 30 per cent, of the total toxicity. It is to these substances, still undetermined, that hereafter the effort of chemistry should be directed." The writer has formulated the following schedule of work directed toward the solution of the problem of auto- intoxication in epilepsy, which will, as far as possible, be carried out in our laboratory: I. Urine. C Intervals. II. Blood. J Before paroxysm. III. Cerebro-spinal fluid. After paroxysm. ( a. Inorganic principles. for J b. Toxicity as shown by injecting animals. I <. Organic principles. { matters of Boucllard. On account of the many changes to which the urine is subjected after expulsion from the body, it occurred to him that an examination of the blood itself would present a more direct and definite evidence of toxic principles existing in the body. This is the work at present being carried out, and this report will be confined to the amount of urea found in the blood serum. Considerable difficulty was experienced in ascertaining a good method by which the urea could be separated from the blood, but the following description of Haycraft's method from the works of Professor Gamgee appears the most simple. Twenty c. c. of blood is defibrinated and placed upon a parchment paper dialyzer and spread over it so as to form a thin layer. Float in a vessel containing 50 c. c. of absolute alcohol. From time to time add a very little 206 /. Nelson Teeter. distilled water to keep the mass on the dialyzer moist— continue the process for twelve hours. Treat the diffusate with an equal bulk of concentrated solution of oxalic acid and evaporate to dryness. To the residue add some petroleum naphtha to remove fatty matters. Dissolve the residue in a little water and add barium car- bonate. Evaporate. Treat the residue with boiling alcohol and filter. Concentrate the filtrate, from which, on cooling, urea will crystallize out. The advantage of this method is that the urea is obtained pure and can be subjected to test. The amount of urea in healthy blood has been variously estimated at from 25 to 35 milligrammes per 100 grammes of blood. The small superficial veins of the forearm should be selected, as, in case obliteration of the vein occurs subse- quent to the operation, collateral circulation is readily estab- lished. A bandage should be tied tightly above the elbow, as in the ordinary process of bleeding, and after the arm has been made thoroughly clean with soap and water fol- lowed by carbolic acid, alcohol and ether, a small incision is made over the distended vein and parallel to it. When the superficial fascia is exposed, the skin should be drawn to one side so that it is possible to cut along side the vein rather than directly over it. If the vein is not completely bared, the hemorrhage will diffuse beneath the fascia and by pressure cause the flow of blood to cease. A small cut is made in the exposed vein and the fine stream of blood is allowed to flow into a glass graduated in cubic centimetres held by an assistant. 1 have found it better to take 40 c. c. of blood as the specific gravity can be more readily secured. When the quantity of blood desired is obtained, the bandage should be removed at once and a compress dressing applied to the wound. 1 have experienced no unpleasant after effects from successive bleedings. This should be attended to by an assistant, as the blood requires immediate attention. After defibrination, which may be done with a glass or wire brush, the specific gravity should be taken. It is then placed upon the dialyzer and the process continued as before mentioned. Care should be The Auto-Toxic Origin of Epilepsy. 207 taken to have the parchment fit very tightly to the glass so as to prevent the possibility of the alcohol leaking directly into the dialyzer, which event would render the operation worthless, as no osmosis would occur. The urea, being a crystalloid, separates from the mass on the dialyzer and is taken up by the alcohol which, when treated by the oxalic acid, results in the oxalate of urea. The barium car- bonate combines with the oxalate of urea, forming the oxalate of barium, separating carbonic acid and urea. After the final filtration and concentration the liquid is left to cool and urea crystallizes out in rhombic prisms, which may readily be seen under the microscope. CASE NO. 1.—Male, age 54, single, farmer. Admitted September 12, 1895, suffering from a maniacal condition following several epileptic attacks. His history shows that he had been suffering from grand mal since twelve years of age, the attacks occurring about once a month, and that now he is a confirmed epileptic. Only one examination of the blood could be obtained as patient refused to allow further bleeding. CASE NO. II.—Male, age 30, single, book-keeper. Admitted December 9, 1892, also suffering from a maniacal condition superimposed upon epilepsy. He had suffered from attacks occurring about once a month of the grand mal form since childhood. Only three examinations were obtained in this case. CASE NO. 11I.—Male, age 37, single, waiter. Admitted August 17, 1893. He has suffered from grand mal for six- teen years, and occasionally from psychical attacks. Since admission to the hospital his attacks have continued with undiminished severity. Four examinations of the blood were procured in this case. CASE NO. IV.—Male, age 32, single, no occupation. Admitted June 4, 1895, with a diagnosis of epileptic dementia. He has suffered since childhood with attack's of the grand mal form which occurred about twice a week. Since admission the attacks have continued with the usual severity and frequency. Eight examinations were made in this case. For one month previous to the commencement of the blood examination all treatment was stopped and the patient allowed the routine hospital diet. In cases' III. and IV. all the urine was collected and examined for the tota( 208 J. Nelson Teeter. amount of urea excreted by the kidneys in twenty-four hours, and attention paid to the variation in the amount before and after convulsions. A convalescent patient was used as a "control" case in the blood examinations. In the following table is a record of the quantity of blood drawn, its specific gravity, the amount of urea found, and the relation of the examination to an epileptic paroxysm is given: BLOOD EXAMINATION. 1 Specific Gravity. M e 1 Quantity in c. c. Quantity in grammes. Time of exam- ination. li Percent urea per 100 Grammes of blood Date. Case. *' 42.24 1056 .03 June I 40 .072 July 9 II 40 42.32 1058 .005 .01165 11 '* 20 21.12 1056 .021 13, .098 ii . 16 1 1 40 42.32 1058 Ten minutes after fit. .032 .0755 11 2 20 21.121056 .02 1 t III i 1 40 42.16 1054 .015 .094 7 .0345 " 9 " 40 42.16 1054 Three tits from 6:30 to 1 . 7:30; blood after 1st .01 .024 Aug. 17 20 21.12 1056 Just after fit. [fit. .015 .0709 June 24! IV 20 21.12 1056 .032 .150 30 " 20 21.12 1056 .02 .094 July 2 11 40 42.24 1056 Fit, 11 P. M., blood, 11:10 P. M .118 2654 11 71 1 1 20 21.08 1054 Fit, 9 A. M., blood, 4 1 P. M. .01 .046 13 1 1 40 42.24 1056,Just after fit. .012 .028 1 t 20 1 1 40 42.00 1050 Just after tit. .02 .047 Aug. 16 1 1 20 21.20 1060Ten minutes after tit. .02 .0942 Sept. 12 11 40 42.16 1054 Six hours after tit.| .021 .0497 12 | j June Control case 20 21.12 1056 .005 .025 Aug. M, 20 2C.90 1045 .003 .0143 In case No. 1 the amount of urea obtained in the single examination exceeded the normal of .025 to .035 grammes per 100 grammes of blood—averaging about double this estimate. There was no convulsion in proximity to the examination. In case No. II. the first examination presented a decrease from the normal; the second a considerable increase, being .098 grammes per 100 grammes of blood. There was no convulsion before these examinations. The The Auto-Toxic Origin of Epilepsy. 209 thi-rd examination was made ten minutes after an attack of grand mal, presenting an increase above the normal to .0755 grammes. This is lower than the result obtained on July 13th, but it may be noted that the fit followed three days later. It will be seen in the examination of July 7th of case IV., that the amount of urea found apparently decreases the longer the interval up to a limited point between the fit and the examination. We find in this case an average for the three examinations of .0617 grammes per 100 grammes of blood, or, in other words, about twice the amount of urea found in normal blood. Passing on to case No. Ill: On July 1st patient had a number of severe epileptic attacks of the grand mal form. The examination of the blood on the day following showed .094 percentage of urea. No convulsions occurred before the examination of the 7th, and the percentage of urea fell to .0345 grammes. On the 9th patient had three fits and the blood drawn between the attacks showed in this instance only the normal average, the percentage being .024 gram- mes. On the 17th the blood taken directly after the fit showed .0709 grammes of urea per 100 grammes of blood. The average amount of urea found in 100 grammes of blood for the four examinations we therefore find to be .055 grammes, which will be seen to exceed the normal. In case No. IV., the first examination gave a result of less than normal, the second a considerable increase, and the third, which was performed ten minutes after the con- vulsion occurred, reached the remarkable average of .2654 grammes in percentage amount. These three examinations showed a continued increase up to and just following an epileptic paroxysm. The next examination, made five days later, and seven hours after a convulsion, showed .046 grammes of urea, a marked decrease over the previous result. An examination on the 13th, and after a fit, showed a still further decrease, when the amount again began to rise, and on August 16th reached .0942 grammes in per- centage amount following a fit. In this case it will readily be seen how greatly the amount of urea varies and how inconstant are the results as compared with the epileptic 210 J. Nelson Teeter. paroxysm. In the control case it will be noted that the urea held to or was below the normal average. The average amount of urea passed by the urine in case No. III. during the months of July and August was 9.45 grammes per 24 hours; less than one-third the normal amount. An increase in the amount of urea per cubic cen- timetre before the convulsions occurred was noted and cor- roborated the results recorded in the writer's previous paper spoken of in the first part of this article. In case IV. the average amount of urea excreted by the kidneys was 11.64 grammes per 24 hours—about one-third the normal amount of 33.19 grammes. A similar increase in amount of urea per cubic centimetre before the fit occurred was noted in this case. Conclusions: As before quoted, Bouchard states that of the 461 grammes of animal killed by the amount of urine excreted by one kilogramme of man in 24 hours, urea killed only 63 grammes, from which we must infer that urea rep- resents only a small part of the total toxicity of the urine. My results, though meagre, would seem to corroborate this view, for the variability of the amounts of urea found, even when examinations were made under apparently similar physical conditions, would seem to prevent the possibility of placing much importance upon this excretory product as a cause of epileptic convulsions. 1 do not mean to eliminate it entirely from the list of toxic causes, for it is probable that auto-intoxication is not due to any one toxic principle alone, but to the action of a combination of all the poisons. We can only conclude that, firstly, there is an average increase in the amount of urea found in the blood serum of cases of idiopathic epilepsy above that of normal man; secondly, there seems to be but little relation between the amount of urea found and the epileptic paroxysm, as in some cases we find an increase directly after a fit, in oth- ers a diminution. The increase of urea found in the urine after a convulsion must be accounted for in other ways, possibly by the great muscular exertion during the fit, or by the diuretic action of the urea itself as it accumulates in the blood. This would seem to be proven by the blood The Auto-Toxic Origin of Epilepsy. 211 examination, as the amount of urea found was seen to gradually decrease for some time after the epileptic par- oxysm occurred. Probably a more fruitful field of research in this direction will be an examination of the toxicity of the blood serum before, after, and during the intervals of epileptic convulsions, as shown by injection into the lower animals. BIBLIOGRAPHY. Ch. Bouchard: "Lectures on Auto-Intoxication in Disease," 1894. Herter and Smith: ''yttiology of Idiopathic Epilepsy," N. Y. Medical Journal, '92. pp. 208, 234 and 260. W. R. Gowers: "The Dynamics of Life in Relation to the Nature of Epilepsy," The Lancet, 1894, pp. 1015 and 1080. Victor Horsley: "The Origin and Seat of Epileptic Disturbance," British Medical Journal, 1892, pp. 693 and 696. T. Oliver: "Epilepsy in a'Puerpera with Hyperpyrexia," The Lancet, Vol. 1, p. 1295, 1894. Rubert Boyce: "The Seat of Origin and Paths of Conduction of the Fits in Absinthe Epilepsy," British Medical Journal, 1893, pp. 1097. E. T. Wynne: "The Morbid Anatomy of Epilepsy," The Lancet, 1893, p. 433. J. S. Bristowe: "The Influence of Extreme Slowness of Pulse in the Caus- ation of Epileptiform Convulsions," The'Lancet, 1894, pp. 671. Charles Mercier: "The Origin and Seat of Epileptic Disturbances," British Medical Journal, 1892, pp. 809. A Haig: "Uric Acid as a Factor in Causation of Disease." J. N. Teeter: "On the Relation of Urea to Epilepsy," American Journal of Insanity, January, 1895. SELECTIONS. NEUROTHERAPY. EFFECT OF THE X-RAY ON THE CENTRAL NER- VOUS SYSTEM.—Some interesting experiments are reported from Russia (St. Petersb. Med. Woch., No. 1, 1897), that tend to show that the X-ray has a quieting effect on the central nervous system. A frog was placed in a small wooden box on which the ray was directed, while the con- trol frog, in a similar box, was protected from the ray by a sheet of lead laid on top of the box. It even counteracted the effects of strychnine, as no traces of intoxication were noticed in the frog after the administration of 0.04 milli- grams, and exposure to the ray, while the control frog was found in tetanic convulsions. Half an hour's exposure before administering the strychnine rendered it possible to increase the dose, without intoxication.—Journal American Medical Association. THE TREATMENT OF ATONY OF THE SMALL INTES- TINE IN NEURASTHENICS.—Dr. Chalmet (Journal des Prat- iciens), believing that whether the nervous system presiding over the epithelial (secretion and absorption) and muscular functions may or may not play the principal part in this condition, the best method of improving the tone of the nerve is to nourish it better. To improve nutrition he administers during the early hours of intestinal digestion, a salt water enema of a concentration above that of blood serum—e. g.; 1-2 per cent, of salt—in order that he may produce in the large intestine an osmotic current which shall act at a distance upon the small intestine, retarding absorp- [212] Selections. 213 tion and permitting the transformation of food-stuffs to go on for a longer period before absorption of the liquor con- taining these substances in solution.—Modem Medicine. CONSCIOUSNESS IN EPILEPSY.—The following are the conclusions of a paper by Prof. E. Siemerling on "The Transitory Disturbances of Consciousness in Epileptics in their Forensic Relations," Berliner Klin Wochenschr:, Nos. 42 and 43, 1895: 1. In the epileptic psychoses a dream-like, altered condition of consciousness is probable, and not by any means a total or partial amnesia. 2. The most various transition forms occur between the different forms of so-called acute and chronic epileptic psychoses. Epileptic or epileptoid conditions and psychoses must alike be reckoned as symptoms of cerebral disease. 3. The transitory, dreamy states are characterized by the rapidly recurring, apparently orderly, indifferent, and inconspicuous manifestations, and by unusual, unexpected, often, violent acts. 4. There is no epileptic psychosis without epileptic or epileptoid antecedents. Epileptoid conditions are more fre- quent than is commonly supposed, especially vertiginous attacks. 5. With the lack of epileptic or epileptoid manifesta- tions, all other symptoms, such as amnesia, similarity of the attacks, peculiarities of actions, sensory hallucinations, will serve to make the diagnosis of epilepsy most probable. —Canada Lancet. INTESTINAL ANTISEPTICS IN INSANITY.—The use of drugs intended to prevent or check fermentation and pu- trefactive changes in the intestinal tract has found extensive application in the treatment of acute insanity. Our usual procedure is to give a laxative or free purge, then some one or a combination of several intestinal antiseptics—B. napthol, napthalin, boric acid, bismuth, carbolic acid, calo- mel, thymol and chlorine solution (yeo). Many cases of melancholia in particular are benefitted. In epilepsy the use of B. napthol especially has been attended by good 214 Selections. results in improvement in general health and dimunition in number of convulsions.—Bryce Hospital Report. NEUROPATHIC HEART—C. H. Brockway, M. D., of Worcester, Mass., has found Cactina Pillets useful in func- tional disorders of the heart. INJECTIONS OF OSMIC ACID FOR NEURALGIA.—Dr. Erwin Franck (Fortscluitte Jer MeJicin) reviews the literature from 1882 and recommends ostnic acid, 1; distilled water, 6; glycerin, 4; (Schapiro) to be kept in a closed bottle. Of this one-sixth of a grain of the drug is used, although in one instance the dose was four times this amount. Three cases are reported—right facial neuralgia, sciatica, and tabes in ataxic stage. In the first, cure resulted; in the second, disappearance of the pain for eight weeks, recurrence, which the treatment failed to relieve; in the third, relief of the hyperaesthesia and neuralgia of the ulnar nerve, cessation of the pain during time of observation (one month). The needle is inserted perpendicularly and deep into the muscles or to the bone as near as possible to the most painful point, the overflow on the skin being prevented by a bit of cotton. When injections are made into the face, a smaller quantity should be used to avoid induration, which may be of a dark color. Saline subcutaneous transfusion in the INSANE.—Dr. James T. Searcy, superintendent and phy- sician-in-chief of the Bryce Insane Hospital at Tuscaloosa, Alabama, gives the following record of his work in this direction: In some cases of acute mental disease, cases showing auto-infection symptoms, and in cases refusing food, excel- lent results have followed the employment by hypodermic transfusion of large quantities (one litre) of 0 75 per cent. blood-warm sterilized solution of sodium chloride. The injection is made into the loose areolar tissue of the abdominal wall or gluteal region. The improvement in cir- culatory activity and arterial tone, increase in urinary secretion, relief of dryness of lips and tongue, clearing of mental faculties, etc., are often quite pronounced, and perma- Selections. 215 nent improvement is sometimes obtained. The injections have not been used oftener than once daily; are sometimes used from one to three times only—sometimes continued for weeks. To the simple saline solution other salts may be added, as magnesium sulphate for its laxative effect, or the fluid may be made nutritive by addition of egg albumin. The introduction of the needle and fluid is only slightly painful, and under antiseptic precautions no ill result will follow. This treatment has been used in about thirty cases. THERAPEUTIC VALUE OF MERCURY AND ARSENIC— Probably, says The Times and Register, no practitioner is doubtful as to the therapeutic value of mercury and arsenic. Probably every physician has encountered grave difficulty in administering these agents for a sufficient length of time or in proper quantities to produce their full therapeutic effect. Before their remedial properties have had opportunity to exert themselves some form of stomachic disturbance or an exhausting diarrhoea accompanied by profound mental depres- sion,- have indicated their discontinuance for sufficient time to permit the patient to re-establish such tone as would enable him to again "stand the treatment." This is espe- cially true in its application to mercury, and equally true, though in a lesser degree, with reference to arsenic. That these metals have been rendered more easy of assimilation and their therapeutic value distinctly enhanced by skillful manipulation and combination, recent medical literature leaves little doubt. In the preparation known as Arsenauro we have in solution a combination of the bromides of arsenic and gold, which is certainly an advance in pharmacy. Mercauro, which is one of the same class, has in addi- tion to gold and arsenic the bromide of mercury in solution. According to Drs. Stucky, Lydston, Wight, Dumesnil, lngersoll, Wade, Kennedy and others, these solutions are blood-builders and blood-makers, valuable nerve tonics and vaso-motor stimulants, and in the experience of several, 216 Selections. Mercauro has earned first place in the treatment of the later stages of syphilis, with its accompanying nerve tissue degeneration. A CASE OF CEREBROSPINAL MENINGITIS COMPLI- CATING GONORRHOEA TREATED BY ANTIKAMNIA.—The concluding remarks from the above article, by G. S. Leggatt, M.R.C.S., England, L.S.A., taken from the Lancet (London) are interesting from both therapeutic and physiological stand- points. Remarks. 1. "This is a rare complication of gonorrhoea, and, as far as 1 can find, is not mentioned in any of the books which refer to the subject; but bearing in mind the similitude of structure between the meninges and the joints there seems no reason why they should not be occasionally attacked in a manner similar to the latter. 2. "Antikamnia is a remedy said to possess analgesic, antipyretic and anodyne properties. Its dose is three to ten grains, and it will be observed that the doses I gave were large ones; but the symptoms were extremely urgent, and it is interesting to note that there was no depression. During its exhibition the pulse improved in force, and the administration of the drug reduced the temperature to nor- mal, and seemed in this respect to be greatly superior to that of phenacetin. 3. "As to the diagnosis it is difficult to know how the symptoms, which were of a most pronounced kind, could be accounted for on any other supposition than involvement of the fibrous textures of the spine and cranium. That the disease did not more definitely and more permanently attack the pia mater and arachnoid is probably due to the prompt administration of the antikamnia and salicylate combined, which seemed to me to prevent the optic neuritis and other more obvious and serious consequences of an established meningitis." PSYCHIATRY. NEUROPATHIC HEREDITY AND ALCOHOLISM, AND VICE VERSA.—Sollier, who wrote the recent Aubenal prize essay on alcoholism, commended and prefaced by Bourne- Selections. 217 ville, gives some clinical records which clinch the proofs beyond all controversy, as to both the neuropathic and the alcoholo-neuropathic heredity of the drink crave, the drink habit and the drink vice, and vice versa. 1. Ben—4 yrs. Congenital idiocy. Grandfather and great grandfather inebriates. 2. Maisohn—14 years. Epilepsy and hemiplegia. Father and paternal grandfather inebriates. 3. Deloim—11 years. Idiopathic epilepsy. Father and paternal grandfather inebriates. 4. March—8 years. Complete symptomatic idiocy. Father and paternal grandfather inebriates. 5. Dumas—10 years. Imbecility. Hemiplegia of left side. Father and paternal grandfather inebriates. 6. Assass—6 years. Complete idiot. Father and paternal grandfather inebriates. Paternal grandmother hem- iplegic. 7. Lefes—21 years. Idiopathic epilepsy. Maternal grandmother and maternal cousin (german) inebriates. 8. Fan—5 years. Complete epileptic idiot. Maternal grandfather inebriate and idiot, and nephew of grandfather inebriate. 9. Abbad—10 years. Epileptic idiocy. Maternal uncle and grandfather inebriates. Maternal great grandfather nervous affections. 10. Marni—8 years. Cerebral atrophy and imbecility. Father inebriate, and paternal grandfather inebriate and suicide. 11. Porcher—6 years. Epilepsy. Father and paternal grandfather inebriates. 12. Peck—8 years. Slight idiocy. Father and pater- nal grandfather inebriates. 13. Que—7 years. Complete idiocy. Father and paternal grandfather inebriates. 14. Amb—10 years. Epilepsy and mental debility. Father and paternal grandfather inebriates. 218 Selections. 15. (Same Subject.) Mother and maternal grand- father inebriates. 16. Dur—7 years. Mental instability. Father and maternal grandfather inebriates. 17. Dethan—11 years. Idiocy. Father and paternal great-uncle inebriates. 18. Tanp—8 years. Slight idiocy. Father and pater- nal grandfather inebriates. 19. Noisen—19 years. Congenital idiocy. Father and paternal grandfather inebriates and apoplectics. Paternal uncle suicide. Paternal grand-uncle, apoplectic, and pater- nal great-grandmother senile dementia. 20. Ada—14 years. Pronounced imbecility. Father and paternal grandfather inebriates. Paternal grandmother paralyzed. 21. Berg—16 years. Epilepsy. Father and paternal great-uncle inebriates. 22. Bourarl—14 years. Epilepsy. Father and paternal grandfather inebriates. 23. Charpeut—11 years. Idiocy and deafness. Father and paternal grandfather inebriates. 24. Thierr—12 years. Hysteria and epilepsy, homi- cide. Paternal grandfather inebriate. 25. Comms—17 years. Imbecility. Father inebriate, and paternal grandmother inebriate and idiot. 26. Farg—13 years. Cerebral atrophy and hemi- plegy of left side. Father and paternal grandfather ine- briates and venereal. 27. Hunsick—16 years. Epilepsy. Mother and mater- nal grandmother inebriates. 28. Laugl—17 years. Mental instability and epilepsy. Father and paternal grandfather inebriates. 29. Rioch—13 years. Imbecility. Father's uncle and paternal grandfather inebriates. 30. Rami—16 years. Epilepsy. Father and paternal grandfather inebriates. Selections. 219 31. Co—6 years. Epilepsy and mental debility. Father and paternal grandfather inebriates. 32. Bourd—13 years. Symtomatic epilepsy. Uncle and paternal grandfather inebriates, and paternal grand- mother died of an affection of the marrow. 33. Ducr—5 years. Mental instability. Sister and father inebriates, and mother insane. 34. Poup—8 years. Cerebral sclerosis. Father and paternal grandfather inebriates. 35. Cane—17 years. Epileptic hysteria. Father and paternal grandfather inebriates. 36. Dufa—10 years. Idiopathic epilepsy. Father,uncle and paternal grandfather inebriates, and two paternal aunts inebriates. 37. Stem—10 years. Imbecility. Paternal grandfather and paternal great-grandmother inebriates. 38. Hel—18 years. Epilepsy and hemiplegia. Father and paternal grandfather inebriates. Paternal grandmother paralyzed. 39. Parment—16 years. Idiopathic epilepsy. Father and paternal grandfather inebriates. 40. Pen—16 years. Idiopathic epilepsy. Father and paternal grandfather inebriates. 41. Quen—9 years. Idiocy. Father and paternal grandfather inebriates. Paternal uncle suicide by hanging. 42. Riedling—14 years. Hysteria and imbecility. Father and paternal grandfather inebriates. 43. Remeli—14 years. Epilepsy and alcoholism. Father and paternal grandfather inebriates. 44. Rua—42 years. Alcoholic and epileptic. Father alcoholic and apoplectic, brother apoplectic, and cousin feeble. 45. Thei—19 years. Epilepsy. Father and paternal grandfather inebriates. 46. Bont—15 years. Idiopathic epilepsy. Father and paternal grandmother inebriates. 47. Guid—16 years. Epilepsia and dementia. Father ataxic, paternal uncle inebriate, paternal grandfather delir- 220 Selections. ium-tremens, and paternal great-grandfather inebriate. 48. Chambel—13 years. Complete idiocy. Uncle and maternal grandfather inebriates. 49. Min—7 years. Idiot. Father and paternal great - uncle inebriates. 50. Cher—59 years. Epileptic and alcoholic. Father and brother inebriates. 51. Car—34 years. Alcoholic and epileptic. Father alcoholic. 52. Mor—3 years. Epileptic idiot. Mother alcoholic and debauched. Maternal grandmother the same. 53. Led—14 years. Pronounced imbecility and epi- lepsy. Paternal grandfather inebriate, and two paternal cousins (german) epileptics and inebriates. 54. Lefer—27 years. Epilepsy, athetosis, and hemi- plegia. Father and paternal grandfather inebriates, and paternal cousin (german) inebriate. 55. Coq—16 years. Epilepsy. Father and paternal grandfather inebriates. 56. Bar—18 years. Mental debility. Father and pater- nal grandfather inebriates. 57. Desant—45 years. Inebriate and epileptic. Father alcoholic, debauched and paralyzed, and paternal grandfather paralyzed. 58. Fourn—10 years. Epilepsy, idiocy and hemiplegia. Father and paternal grandfather inebriates. 59. Hug—15 years. Cerebral atrophy and epilepsy. Father and paternal grandfather inebriates. 60. Leqr—16 years. Idiopathic epilepsy. Father and paternal grandfather inebriates. 61. Lamruch—18 years. Idiopathic epilepsy. Pater- nal great-uncle alcoholic and suicide. Paternal great-grand- father alcoholic and suicide. 62. Lei—14 years. Imbecility. Mother and maternal grandfather inebriates. 63. Ney—37 years. Idiopathic epilepsy. Father and paternal grandmother inebriates and cousin (german) of father insane. Selections. 221 64. Delac—5 years. Idiot. Father and grandfather alcoholic. 65. Coeur—10 years. Idiot and hydrocephalus. Father and paternal grandfather inebriates. 66. Leclu—33 years. Epileptic hysteria. Father alco- holic, and paternal grandfather alcoholic and drowned. 67. Doucer—14 years. Epilepsy and infantile hemi- plegia. Father and paternal grandmother inebriates 68. (Same subject)—Uncle and maternal grandfather inebriates. 69. Boyan—6 years. Epilepsy. Father, uncle and paternal grandfather inebriates. 70. Fair—9 years. Halfwitted in childhood and men- tal debility. Father and maternal grandfather inebriates. 71. Pica—16 years. Epilepsy. Brother, father, uncle and grandfather inebriates. Paternal grand-uncle alcoholic and suicide. Mother alcoholic. Maternal grandfather ine- briate and hung. Maternal grandmother alcoholic and para- lyzed. Maternal uncle and maternal great-grandmother ine- briates. 72. Hub—19 years. Epilepsy. Father and paternal grandfather inebriates. 73. (Same subject)—Maternal grandmother and great- grandmother inebriates. 74. Hir—18 years. Hysteria and epilepsy. Maternal grandfather, and maternal great grandfather inebriates. 75. Hani—18 years. Epilepsy and mental debility. Father, uncle and paternal grandfather inebriates. 76. Alrat—17 years. Mental instability. Father ine- briate, suicide, and paternal uncle and grandmother ine- briates. 77. Hall—17 years. Epilepsy. Father, two uncles and paternal grandfather inebriates, sister nervous, and a grand aunt (on the mother's side) insane and maternal grandfather paralyzed. 78. Margal—13 years. Epilepsy. Brother and father inebriates, and paternal grand-uncle and grandfather the same. 79. Mige—13 years. Epilepsy and hemiplegia of left 222 Selections. * side. Paternal cousin (german) inebriate. Father, uncle and paternal aunt inebriates, paternal grandfather and great- grandmother inebriates, and paternal grandmother insane. 80. Pius—17 years. Cerebral atrophy and hemiplegia of left side. Father, uncle, and paternal grandfather ine- briates, hysterical aunt, melancholic great-aunt, and paternal grandmother nervous attacks. 81. Pig—11 years. Convulsions, vertigo, imbecility. Father and paternal grandfather inebriates, and paternal great-grandfather insane. 82. Pil—14 years. Imbecility and hydrocephalus. Father, grandfather, and grandmother inebriates. 83. Sauln—10 years. Imbecility and strabismus. Father, grandfather, and grandmother inebriates, great- grandfather and grandmother (parents of grandmother), ine- briates. 84. Brouck—16 years. Idiot and epileptic. Father, paternal uncle and grandfather, inebriates, and paternal great-aunt insane. 85. Chas—4 years. Deaf Idiot. Father and paternal grandfather and grand-uncle inebriates. 86. Etien—11 years. Inebriate. Maternal grandfather inebriate, and maternal great-grandmother, paralyzed. Insane cousin. 87. Toff—9 years. Imbecility and epilepsy. Father, paternal uncle and grandfather inebriates. 88. Taut—14 years. Complete idiot. Father and paternal grandfather inebriates. 89. Laumail—9 years. Imbecility and symptomatic epilepsy. Father and paternal grandfather inebriates. 90. Jon—5 years. Congenital idiocy. Brother, father, paternal grandfather, and maternal grandmother inebriates. 91. Lepi—12 years. Imbecility and cerebral sclerosis. Maternal uncle and grandfather inebriates. 92. Clong—3 years. Complete idiot. Mother, grand- father and grandmother, inebriates. Maternal great-grand- mother inebriate. 93. Terr—10 years. Imbecility and infantile paralysis. Selections. 223 Paternal grandfather alcoholic and apoplectic. Great grand- father inebriate and great grandmother apoplectic. 94. Mong—50 years. Alcoholic and epileptic. Father alcoholic. 95. Fevrier—20 years. Imbecility. Father inebriate. Paternal grandmother inebriate and insane. Paternal grand- father paralyzed. Paternal great grandmother demented. Paternal uncle insane, and paternal aunt demented. 96. Sorg—20 years. Idiot. Father and paternal grand- mother inebriates. 97. Muls—18 years. Alcoholic and epileptic. Mother inebriate. 98. Widm—20 years. Hysteria, epilepsia. Two uncles and maternal grandfather inebriates. 99. Mor—14 years. Alcoholism, epilepsia. Father and maternal grandfather inebriates. 100. Songe—24 years. Alcoholic and epileptic. Pater- nal grandfather alcoholic. Paternal uncle insane. Paternal cousin-german hysteria. 101. Monneh—15 years. Imbecility and epilepsy. Mother and maternal grandfather, inebriates. Maternal great-aunt and grandmother suicides. 102. Alep—8 years. Alcoholic and epileptic. Father and paternal giandfather inebriates. 103. Bule—14 years. Idiot. Father, paternal grand- father and grandmother inebriates. Paternal cousin-german inebriate, and paternal grandfather hung. 104. Lob—1 year. Hydrocephalus. Father and pater- nal grandfather and grandmother inebriates. 105 (Same Subject)—Maternal grandfather and great- grandfather inebriates. 106. Caldair—12 years. Epilepsy. Brother, father and paternal grandfather inebriates. 107. Tot—55 years. Epilepsy. Father inebriate, and paternal grandfather paralyzed. 108. Rob—6 years. Symptomatic idiocy. Maternal grandmother alcoholic and debauched. Maternal great grand aunt insane. Maternal great aunt drowned. 109. Gonell—15 years. Epilepsy and hemiplegy of 224 Selections. left side. Maternal grandfather inebriate. Maternal great- grandmother paralyzed. 110. Dop—14 years. Symptomatic epilepsy. Father absinthic. Paternal aunt drunkard, and paternal grand- mother apoplectic. 111. Siv—23 years. Idiopathic epilepsy. Father alco- holic, dying of cerebral apoplexy. Paternal grandfather paralyzed. Paternal great-uncle suicide. Paternal uncle epileptic and insane. 112. Bert—3 years. Idiot. Maternal uncle inebriate. Maternal great-uncle spendthrift. Maternal grandfather ine- briate. 113. Mehn—17 years. Epilepsy, athetosis and hemi- plegy. Father alcoholic and paternal grandfather paralyzed. 114. Masser—6 years. Pronounced imbecility. Father inebriate and paternal grandfather apoplectic. 115. Bruc—13 years. Imbecility. Father inebriate and paternal grandmother senile dementia. 116. Chaut—6 years. Symptomatic imbecility. Pater- nal grandfather inebriate. Paternal great-grandfather insane. 117. Doist—12 years. Epilepsy. Father alcoholic and paternal grandfather insane. 118. Rochet—12 years. Imbecility. Father inebriate and paternal great-uncle insane. 119. Poins—18 years. Idiot. Maternal grandfather inebriate and maternal great-grandmother paralyzed. 120. Boutr—8 years. Epilepsy and mental debility. Father inebriate and paternal grandfather insane. 121. Drug—16 years. Idiopathic epilepsy. Father alcoholic. Paternal grandmother paralytic. 122. Guinn—5 years. Imbecility (pronounced). Pater- nal uncle inebriate. Paternal grandfather suicide and asth- matic. 123. Georg—4 years. Symptomatic idiocy. Mother ine- briate and maternal great-uncle insane. 124. Buff—16 years. Idiot. Maternal grandfather alcoholic. Maternal great-grandmother paralyzed. 125. Nom—7 years. Idiot. Father alcoholic and hys- teric and paternal grandfather paralyzed. Selections. 225 126. Franc—13 years. Idiopathic epilepsy. Father alcoholic and paternal aunt insane. Paternal grandmother childish. 127. Stof—6 years. Complete idiot. Father inebriate. Paternal grandfather suicide (original). 128. Dupu—-11 years. Congenital imbecility. Father inebriate and suicide. Paternal uncle inebriate and pater- nal great-grandfather suicide. 129. Hue—4 years. Alcoholism and imbecility. Father and uncle inebriates. Paternal grandmother cerebral rheu- matism. 130. Heur—10 years. Complete idiot. Grand-uncle inebriate. Grandmother exalted. Great-grandmother insane. 131. Spor—14 years. Imbecility. Father alcoholic. Paternal grandfather cerebral apoplexy. 132. Cres—18 years. Epilepsy, loss of intellect. Father alcoholic with general paralysis. Paternal grand- father mysterious. Paternal grand-uncle suicide, persecuted, and insane. 133. Bri—16 years. Hereditary epilepsy. Father and uncle alcoholic and paternal grandmother epileptic. 134. Despaig—15 years. Epilepsy. Father alcoholic and epileptic. Paternal grandmother hysteric and debauched. Paternal grand-aunt insane, and two paternal great-uncles suicides. 135. Mor—11 years. Imbecility,. epilepsy and deaf- ness. Father inebriate and paternal grandmother demented. 136. Sim—16 years. Mental instability and alcoholic. Paternal grandfather apoplectic and a suicide. Mother ner- vous, maternal grandfather apoplectic. 137. Mor—16 years. Alcoholic and epileptic. Father apoplectic. Mother nervous and irritable. Maternal aunt and great-aunt insane. 138. Estes—7 years. Symptomatic idiocy. Father alcoholic, and paternal grandfather paralyzed, and paternal uncle insane. 139. Loi—6 years! Alcoholic and epileptic. Mother nervous and epileptic. 226 Selections. 140. Mott—59 years. Epileptic and absinthic. Father died at 81. Mother senile dementia. 141. Hers—17 years. Pronounced imbecility. Father, excessive alcoholic and venereal, grandfather the same. Grandmother epileptic and insane. Uncle inebriate, aunt epileptic. Cousin-german epileptic. PREVENTION OF INSANITY.—THE DUTY OF PSY- CHIATRY AND THE STATE.—The German publicist, Dr. William Hirsch, has observed: "It becomes the task of modern Psychiatry not only to treat individual patients but also to observe society, and especially to guard against that phenomenon which ought to be termed Secular Hysteria, the peculiarity of which is that it attacks not isolated indi- viduals but epidemically entire communities, and in that way influences the development and metaphysical concep- tions of whole nations." Is there not a corresponding duty on the part of the State to deliberately mould its policy so as to render the community less and less susceptible to such attacks, an obligation which, when once recognized, would be fulfilled from considerations of public economy? Such policy of pre- vention would extend to isolated cases. In our last Annual Report we ventured to refer to the importance of restrictions upon parentage. When congratulated upon the birth of his son, it is related that the father of Nero bitterly exclaimed: "The offspring of me and of Aggrippina can only be a monster who will scourge the world." It is a startling thought that society is still content to breed under the laws of Roman degeneracy. According to the modern doctrine of heredity it does not appear that it is a disease which is inherited, "but a diathesis, a predisposition, a want of resistance to all bale- ful influences of the direct, exciting causes of disease." This lack of resistance must be overcome by education. We have heretofore urged the extension of free instruction to the adult population by means of the school, the library, the lecture, the training in manual arts. It has been a theory of public instruction that the natural bent or incli- nation of the pupil should be watched for and developed. Selections. 227 Is it not evident that the theory is erroneous? We respect- fully invite the attention of your Honorable Board to the suggestion that the mental point of least resistance is the point of danger, and that our system of public instruction should be so directed as to bring up the laggard faculties of the pupil and set them into harmonious co-operation.— From Trustees Report, Pennsylvania Hospital for Insane. PSYCHOTHERAPY. DANGER OF HOME ATTENTION OF THE INSANE.— In my report of 1894,1 urged upon the citizens of Delaware the necessity of familiarizing themselves with the methods in vogue in caring for the insane and stated that a goodly number of cases were detained at their homes until they became dangerous to themselves and others, and then and then only they consented to allow them to be removed to a hos- pital. 1 cannot do better to instil this into the minds of the citi- zens of this State than to quote from the admirable work of M. Regis on Mental Medicine: "The fundamental prin- ciples of the treatment of the insane is isolation. This consists in separating the patient from his habitual sur- roundings from contact with persons and things familiar to him, amongst whom he lives, and where its disorder had its birth and development. Nothing is worse than the detention of the patient in his own dwelling, and the con- tinuation of his stay amidst his family. There is, in such cases, the influences of the family on the one hand, an influence that is injurious and prevents or delays the cure; and on the other hand the influence of the patient upon his family, which is not less hurtful, and sometimes, where there are children, actually dangerous. Moreover we must take into account the danger from an insane person, either to himself or to society, against which his situation with his family affords only very insufficient guarantees. Isola- tion is, therefore, a measure of security and a powerful therapeutic agency"—Dr. Wm. H. Hancker, Med. Supt., Delaware State Hospital for Insane. 228 Selections. CLINICAL NEUROLOGY. HYSTERIA.—A FAVORABLE PROGNOSIS NOT AL- WAYS SAFE.—That a favorable prognosis is not always safe in hysteria, has been shown by Fournier and Sollier (Jour, de Med.). In some cases expectant treatment will not answer. Death may occur from spasm of the glottis. Fournier had a case with severe asphyxia in a young woman of twenty that was saved by faradism, but who afterwards had another attach, in which she died. Where there are laryngeal manifestations in hysteria it is not safe to leave the patient to herself. Potain had a case of hysterical angina pectoris that died, and the post-mortem revealed nothing to account for the fatal result. In hysterical an- orexia, death also has been known to occur, even where artificial feeding has been resorted to. The system in such cases seems to have no power of absorption. Vaginal hys- terectomy is particularly dangerous in such cases.—Periscope, Medical and Surgical Reporter, February 6, 1897. KEROSENE IN ALCOHOLISM.—The most recent remedy for alcoholism in Russia is petroleum or paraffin oil, to which the notice of the St. Petersburg medical authorities was called by accident. It appears that a laboring man who had been drinking heavily for four days and nights entered, in a complete state of intoxication, a grocer's shop. Un- noticed by the shop keeper, he staggered up to an open cask of petroleum and began drinking from it. It is related that the petroleum cured him of all the effects of over- drinking; the nausea, unsteadiness of gait and headache disappeared as if by magic.—N. Y. Med. Times. NEURIATRY. THE TRAUMATIC NEUROSES IN THEIR MEDICO- LEGAL RELATIONS.—Dr. A. L. Hall, in a paper on this sub- ject, concludes as follows: I. The surgeon should be an equal authority with the neurologist in determining the sequences of trauma upon the nervous system. Selections. 229 2. Neurasthenia is the usual form under which traumatic neurosis expresses itself, and its symptoms are indistinguish- able from neurasthenia arising from other than traumatic influences. 3. The actual condition of the patient previous to the accident must be known in order to reach a correct estimate of the damage from injury sustained by the nervous system. 4. The type of symptoms manifested by the neurosis, whether neurasthenical or hysterical, is oftentimes a question of vital importance in the adjudication of a claim for damages. 5. Traumatic neurosis occurs oftenest at the centres of population, but it is by no means a rare affection in the country districts. 6. It is probable that traumatic neurosis is dependent upon some definite—yet unknown—change in the arrange- ment and structure of the cellular elements of the nervous system, which gives rise to stable rather'* than unstable symptoms. 7. A stable, well-organized symptom complex indicates damage to the nervous structures; while instability of symp- toms and want of orderly arrangement denote trivial injury, —and, if long continued, simulation is rendered probable. 8. The so-called "objective symptoms" depend upon the psychical rather than the physical state of the subject, and are unreliable guides to diagnosis. 9. A correct diagnosis is best obtained from a reliable account of the accident, the history of the previous state of the patient, the presence of surgical troubles, and the ex- istence of a stable, well-defined, organized symptom complex. 10. The term "traumatic neurosis" is an expression for an indefinite condition, and a simplification of the subject is desirable from a clinical stand-point.—Medical Record. THE PUPIL IN PARESIS.—Simerling (Berl. klin. IVoch.) refers to the Argyll-Robertson phenomenon in the insane. In 3,000 cases of general paralysis (various observers) reac- tion to light was lost or diminished in 65 per cent. The symptom is an early one and of importance in the diagno- sis of general paralysis. Referring to the Argyll-Robertson phenomenon along with the lost knee jerks, he remarks: "the 230 Selections. more advanced the disease the more these symptoms are found together. Permanent one-sided loss of light reflex is rare. The irregularity in the pupil in general paralysis is well recognized. Diminished reaction to light first occurs, then total loss, then paralysis to accommodation". In a few cases of general paralysis without tabes, Simerling has noted the phenomenon recorded by Gowers, namely, the pupil first of all reacts to light, then dilates and ceases to respond. The inequality of the pupils shows considerable variability of the pupils on different days. The pupils are usually stable in general paralysis. The phenomenon was also observed in 19 cases of senile dementia and even in old people of sound body and mind. It was present in 9 cases of syphilis of the central nervous system, but was rare in chronic alcoholism. The loss of this reflex is an extremely important symptom, and even when it does not cause ser- ious misgivings'as to the presence of general paralysis, etc., it points to a disturbance in the central nervous system. General paralysis may supervene many years after the loss of the light reflex. The loss of this reflex undoubtedly con- stitutes one of the chief distinguishing features between epilepsia and hysteria. If the reaction is sometimes pres- ent in epilepsia, then, in the author's opinion, there is hystero-epilepsy. NERVOUS FUNCTIONS OF THE SUPRARENAL CAP- SULES.—Dominicis has already published various studies of the functions of the suprarenal capsules, and a recent article by]him in the Gazetta d.Osp. e d Clin, of November 22, 1896, throws new light upon their connection with the nervous system. The experiments he describes on dogs and rabbits consisted in the transplantation of one capsule, after ligat- ing its pedicle, to the internal and anterior surface of the kidney, leaving its point of attachment intact. The animal remained in the same health as before. Ten to fourteen days later, he removed the other capsule, and in every case the animal died in three hours with the same symptoms as when both capsules are removed at once. The transplanted capsule showed no traces of degeneration, anatomically nor histologically, and seemed to be perfectly normal. Its func- Selections. 231 tion, however, was evidently suspended, and it was unable to take the place of the other capsule when it was removed, as occurs in the case of glandular organs with an internal secretion, when they are transplanted or ingrafted, the thyroid gland for instance. He adds his experience that section of the spinal cord below the level of the capsules invariably retards death for eighteen to twenty-six hours . when both capsules are removed at once. These facts demonstrate that we must look elsewhere than to an exclusively glandular function in ascribing a role to the suprarenal capsules.—Journal of A. M. A. [NEUROPATHOLOGY. NEURASTHENIA AS A TOXIC NEUROSIS.—Experiments have shown that the sense of fatigue is due to poisoning of the cerebrum by the products of retrograde meta- morphosis. "The blood of a tired animal is poison, and when injected into another animal causes the phenomena of fatigue." Vigoreaux, in a monograph upon this subject, claims also that all neurasthenics are arthritics, basing this upon the analysis of the urine in one hundred and fifty cases. The urine was invariably found to be highly acid. Bouchard believes that it is due to gastro-intestinal auto- intoxication. Neurasthenia is sometimes a sequel of an acute infectious disease, as influenza or typhoid fever. In the first place, then, neurasthenia is due to a tox- aemia; due not to one, but to a variety of poisons. These are sometimes bacterial in origin, as in cases following influenza or gastra-intestinal fermentations; sometimes the poison is uric acid, but most often the nervous system is poisoned by its own excreta—Dr. John Ford Barbour in American Practitioner and News. [But in the neurasthenic constitution it is the neuras- thenia that permits the toxaemia to take place and persist. —Ed.] EDITORIAL. [All Unsigned Editorials are Written by the Editor]. Higher Medical Education is being continually sung in our ears by little men in the profession who happen to get onto State Boards of Health and wish to appear great by talking "large" on this subject, as if medical education had not steadily advanced most marvellously during the last few decades and as if the equipment of the leading medical schools were not constantly adding to their teaching facilities since the day when Benj. Rush founded the first medical college in this country, patterned after the best schools of Great Britain, and as if medical men in this country who teach in the best chartered colleges were all incompetent. It is a strange spectacle to see this everlasting notoriety seeking by medical men "clothed with a little brief author- ity," assaulting colleges ten fold better than those they graduated in, with facilities twice as great and far better qualified, equipments far more complete and terms of study lengthened to twice the time they spent as students. The little fellows of some State Boards are the most clamorous for higher medical education, restrictive legisla- tion and discrimination against the diplomas of the best chartered colleges. The medical profession can not be trusted to exercise chartered rights, like other instructors, when instructors secure charters to teach, but must be subjected to additional espionage by state medical detectors called examining boards, and last comes a new proposition to examine the professors, as if faculties of honorable medical men and boards of trustees controlling our medical colleges required this spying system more than the literary and scientific universities of the land. But if the faculties are to be examined by a board of examiners, who will examine the examiners and attest their qualifications? Now we are opposed to this whole system of discrim- [232] Editorial. 233 inating espionage reflecting on the integrity and qualifications of the teaching element of the United States and it is a shame that it should come only from medical men, too, who are usually of exceedingly slender qualifications them- selves and who wish to appear great in their littleness by defaming American medical education, which, considering that it gets no aid from the state or people, and is in no sense a paying business to those engaged in it, is the best in the world and is making more strides to-day in the direction of the very zenith of "practical utility than that of any other country. And what country has such institutions of medical teaching as the United States as sole result of personal professional effort, zeal and financial support with- out state aid? Rush and Jefferson, the universities of Pennsylvania, Virginia, Minnesota, Michigan, Bellevue, Barnes, Baltimore, California, Tulane and in nearly every city and state are monuments of indefatigable medical devotion and largely disinterested sacrifice of medical time, talent and means, to advance medical education. Every large city on this continent has schools of which Americans may be justly proud, notwithstanding the notes of defamation and puerile cries of suspicion directed from various unhallowed motives against them. Defamation of American medical colleges by little med- iocrities in medicine has about reached the limit of tolera- tion by the friends of medical education in the profession. The question how to improve and advance is always in order, but late methods of public defamation of American schools is dispicable and disastrous to the welfare of the whole medical profession and should be discountenanced and discontinued. State boards and schools should arbitrate differences and not antagonize. Program of the Section on Neurology and Medical Jurisprudence of the American Medical Association.—Tuesday, June 1st.—Chairman's Address, Dr. W. J. Herdman, Ann Arbor, Mich.; History of the Section on Neurology and Medical Jurisprudence, Dr. J. G. Kiernan, Chicago; History of American Neurology, Dr. C. H. Hughes, St. Louis; On the Pathogenesis of Locomotor Ataxia, Dr. L. Harrison Mettler, Chicago; Trunk Anaesthe- sia in Locomotor Ataxia, Dr. Charles W. Burr, Philadelphia; The Paralyses, by One of the Many Paralytics, Dr. Samuel Knox Crawford, Chicago; Internal Cerebral Meningitis Chronica, Dr. E. S. Pettijohn, Alma, Mich.; The Differ- 234 Editorial. ential Diagnosis between Cerebral Syphilis and General Paresis, Dr. Hugh T. Patrick, Chicago; Hereditary Lateral Sclerosis, Dr. Augustus A. Eshner, Philadelphia: A Case of Thomsen's Disease Complicated by Multiple Neuritis, Dr. M. Nelson Voldeng, Des Moines, Iowa; Pain Traumat- isms, Dr. Thomas H. Manley, New York City; Melancholia and its Treatment, Dr. W. S. Watson, Fishkill-on-Hudson, N. Y. Wednesday, June 2nd.—Aphasia, Dr. Charles K. Mills, Philadelphia; Discussion, Drs. F. X. Dercum, Hugh T. Patrick, William G. Spiller, Barney Sachs, J. J. Putnam, C. W. Burr and W. J. Herdman; French and Motor Aphasia in a Polyglot, Dr. Frederick Peterson, New York City. The Subconscious Mind, Clark Bell, Esq., New York City; Some States of Disturbed Consciousness, Dr. J. T. Eskridge, Denver, Colo.; Expertism, Dr. S. V. Clevenger, Chicago; A Synopsis of the Duestrow Case, Dr. L. Bremer, St. Louis; The Medico-Legal Aspect of Choreic Insanities, Dr. C. C. Hersman, Pittsburg, Pa.; Insanity and Pulmonary Consumption Among the Negro Population of the South Since the War, Dr. Thomas J. Mays, Philadelphia; Remarks on the Curability of Insanity, Dr. John Punton, Kansas City, Mo.; (a) Alcohol as a Causative Factor in Disease of the Central Nervous Sys- tem, (b) Inebriety and Tuberculosis as Allied Diseases, Dr. T. D. Crothers, Hartford, Conn.; The Status of the Present Treatment of Alcoholism, Dr. J. K. Bauduy, St. Louis; Stigmata in Young American Degenerates, Dr. Eugene S. Talbot, Chicago; Some Affections of the Sym- pathetic Nervous System, Dr. Jas. Hendrie Lloyd, Phila- delphia; Subject un-announced, Dr. Henry W. Coe, Port- land, Oregon. Thursday, June 3rd.—Neurasthenia Essentialis and Neurasthenia Symptomatica, Dr. F. X. Dercum. Philadel- phia; A Study of the Symptomatology of Neurasthenia in Women, Dr. Louis F. Bishop, New York City; Clin- ical Evidences of Neurasthenia as an Abdominal Neuro- sis, Dr. G. Betton Massey, Philadelphia; Function of the Nerve Cell, Dr. Win. B. Hall, Jr., Sewanee, Tenn.; The Causative Factors in Disease of the Central Nervous Sys- tem, Dr. Geo. H. Rohe, Sykesville, Md.; The Use and Abuse of Electricity in the Treatment of the so-called Neu- roses, Dr. L. Harrison Mettler, Chicago; The Rest Cure, Dr. Landon Carter Gray, New York Citv; Discussion: Drs. Chas. K. Mills, E. S. Pettyjohn and C. H. Hughes; Rest and Northern Lake Air for Neurotics, Dr. E. S. Pet- Editorial. 235 tyjohn, Alma, Mich.; Treatment of Graves' Disease, Dr. Herold N. Mover, Chicago; Discussion: Drs. A. A. Esh- ner, and C. H. Hughes; Habit Spasms of Children, Dr. Samuel J. Fort, Ellicott City, Md.; A Study of the Develop- ment of Some Common Psychoses of Childhood into Perman- ent Criminal Tendencies, Dr. J. Francis Calif, Middletown, Conn.; Subject Unannounced, Dr. H. O. B. Wingate, Milwaukee, Wis. Friday, June 4th.—*Tumor of the Spinal Meninges, Drs. Charles K. Mills and Aloysius O. J. Kelly; *(a) Fibroma of the Dura, (b) Syphiloma of the Dura, (c) Glioma of the Thalamus, Drs. Chas. W. Burr and Aloysius O. J. Kelly; ;iTumors of the Cerebellum with the Report of a Case, Dr. Aloysius O. J. Kelly; *A Clinical and Pathological Report of a Case of Chronic Progressive Non-Specific Dementia with Arterio-Sclerosis, Drs. Charles K. Mills and Mary Alice Schively; *A Case of Paretic Dementia with Autopsy, Dr. Charles W. Burr and John H. W. Rhein; *Tumor of the Basal Ganglia, Drs. Charles W. Burr and Carl Ohnesorg; *Tumor of the Spinal Meninges, Drs. Samuel W. Morton and A. Ferree Witmer; Bilateral Psycho- motor Myo-Synchrony, Dr. C. H. Hughes, St. Louis; Men- ingo-myelitis with Special Reference to the Tubucular Form, Dr. William G. Spiller, Philadelphia; (a) A Contribution to the Pathology of Myelitis, Acute and Chronic, (b) Lesions of the Spinal Cord Due to Tubercular Disease of Column, With Microscopic Specimens, Drs. John K. Mitchell and Jonn H. W. Rhein, Philadelphia; Rumination in Man, Dr. Wharten Sinkler, Philadelphia; Tremor in Chorea, Dr. John H. W. Rhein, Philadelphia; Hypnotism in the Treatment of Disease, Dr. U. O. B. Wingate, Milwaukee. Typhoidous States.—After Woodward receded from his attitude on typho-malarial fever and Da Costa objected to the term typhoid-pneumonia, etc., American medical teachers and authorities began to drop the use of the term. We think this was a mistake. There are states of nervous exhaustion like those which accompany typhoid fever, with- out the coexistence of this fever with its characteristic enteric feature, for which we need a descriptive term. These are real typhoidous states without the implication of Peyer's patches. They are nervous typhoid conditions minus involve- *From the Second Report of the Neurological Laboratory of the Philadelphia Polyclinic which is established in connection with the Department for Diseases of ttie Mind and Nervous System, and in charge of Professors Charies K. Mills and Charies W. Burr. Members of the Section are invited to visit the Laboratory. 236 Editorial. ment of the elliptical plates. They are true typhoidous states, as much entitled to be so regarded because of the exhaustion resemblance to the typoid fever accompaniment, as true typhoid is to the typhus, after which it is named because of its symptomatic resemblance, and from which it is differ- entiated because of its distinctive intestinal pathological contrast. Then let us have a typhoidous pneumonia, a typhoidous malarial fever, and a typhoidous nervous exhaus- tion or a typhoidous malarial neurasthenia, with the under- standing that the true typhoid sign is not a factor in the cases. We need such a term for descriptive papers, because such states are clinical facts. Kleptomania and the Case of Mrs. Castle.— The Humanitarian comments with some justice on this case, though we by no means go to the extent of considering crime as "generally a form of insanity." "The case of Mrs. Castle is one of those which illus- trates every now and then the crying need of reform in our criminal law. Her case was one for the psychol- ogist rather than the bribed juryman; for the doctor rather than the judge. The Home Secretary recognized this, by promptly commuting her sentence, which was tantamount to a confession that she never ought to have been sent to prison at all. The whole question of crime and criminal tendencies needs overhauling from a scientific point of view. To treat it merely from the Old Bailey aspect is 'brutal, ignorant and ineffective. Half the unhappy beings who are hauled before our Police Courts should be dealt with by scientists rather than by lawyers. Crime is generally a form of insanity. And this is especially true of kleptomania, which is far more widespread than most people imagine. There is no need to mention names, but it would be easy to call to mind many eminent personages who have been afflicted with this disease, which numbers its victims largely among women." In this case the inconsistency appears of a bail fixed at 40,000 pounds as an equivalent for three months' depriv- ation of liberty. The Medico-Legal Journal of New York has an interest- ing abstract on this subject from Prof. Lacassagues before the Congress of Criminal Anthropology in whose views however we do not fully concur. There is a definite line between normal theft and abnormal stealing or kleptomania, and that is in the voli- tionally regulated promptings of healthy but wrong motive and the resistless impulsions of disease. The disease is often Editorial. 237 inferable in the character and motive of the thefts and almost always provable in the physio-mental disease of the victims of kleptomania. Lacassagues makes a move in the right direction in his resolution recommending that the large stores exert greater surveillance and place less temptation in the way of those mentally and neurotically weak creatures who under great temptation may develop into either thieves or kleptomaniacs, for there are both, and both may be found among the rich and the poor. The National Medical Review very justly expressed its surprise that some of its exchanges have inclined toward London Truth in its discussion of the sad case of Mrs. Castle. It says: "A* our readers know, this London journal took the position that it was only the rich who were ever afflicted with kleptomania, while the poor were always regarded as thieves. Both Truth and some American journals appear to forget that one of the strongest evidences is that the party committing the theft has no need of the things stolen. If the person who takes the goods is poor this would not be the case, for even if the goods could not be used they could be readily disposed of at a good figure. So strong are the temptations con- nected with poverty that it would be difficult to imagine that a person in need would store away in her room a large number of goods which could be readily sold or pawned and the proceeds devoted to satisfy comfort and hunger. We do not remember ever having heard of an instance where a person in need of food and clothing stored away quantities of goods in this way. On the other hand, we have one who is supplied with every need, and is surrounded by everything which money could purchase in order to make life happy and pleasant. Such a person has no possible use for a large number of articles of one kind. Well fed, richly clad, surrounded with luxury, there can be no temp- tation to take articles of small value, either for use or in order that they may be sold. We think there is every good reason to believe that kleptomania is a disease which affects the rich more than the poor." Tri-State Medical Society of Iowa, Illinois and Missouri, held a well attended and successful meeting at St. Louis, on the 6th, 7th and 8th of the present month. The following officers were elected: Dr. Emory Lan- phear, President; Dr. C. E. Ruth, of Keokuk, Iowa, First Vice-President; Dr. E. Wyllis Anderson, Chicago, Second Vice-President; Dr. J. W. Fowler, Dubuque, Secretary; 238 Editorial. Dr. C. S. Chase, Waterloo, Iowa, Treasurer. Dubuque was selected for the next place of meeting. New Pathological Department.—The Indiana Hos- pital for the Insane announces, with ground plan and eleva- tion, the finishing of its elegant and complete pathological department, whereon the superintendent, Dr. Geo. F. Eden- harter, justly remarks: "It is a great credit not only to the State, but reflects the greatest wisdom on the part of the Board of Control. The benefits to the people will be very great." This is not only a great credit to the State but a great credit to science and the welfare of the insane, promising more light on the dark processes of cerebro-rhental disease and opening the way further for the lifting of the cloud that hangs over mental aberration. National Confederation of State Medical Examining and Licensing Boards.—The seventh annual meeting of this Confederation will be held in the small banquet hall of the Hotel Walton, at Philadelphia, Monday, May 31, 1897, at 10 o'clock, A. M. The object of the confederation is to consider questions pertaining to state control in medicine and to compare meth- ods in vogue in the several' states; the collection and dis- semination of information relating to medical education, and to consider propositions that have for their purpose advance- ment of the standards in the United States. A cordial invi- tation is extended to all members and ex-members of state medical examining boards, and to physicians, sanitarians and educators who are friendly to the objects named, to attend the meeting and participate in its proceedings. Officers: President, Wm. W. Potter, Buffalo. N. Y.; Vice-Presidents, Chas. A. L. Reed, Ohio, J. N. McCormack, Kentucky; Secretary and Treasurer, A. Walter Suiter, Her- kimer, N. Y. Hobart A. Hare.—Messrs. Parke, Davis & Co. announce the complete equipment of a Pharmacological and Bacteriological Laboratory for the careful testing of all their drugs and antitoxic serums, and that they have retained the services of Dr. Hobart A. Hare, Professor of Therapeutics and Materia Medica in the Jefferson Medical College, Phila- delphia, as Consulting Therapeutist for their house. Dr. Hare will undoubtedly prove an invaluable acquisition, as this firm believes, to its Medical Staff as all questions relat- ing to the practical value of new and old remedies, and to the relative merit of various preparations, will be referred Editorial. 239 to him for an opinion. The profession may congratulate itself that its interests will be well looked after with Messrs. Parke, Davis & Co. The gentlemen in charge of their Biological Department are Dr. Charles T. McClintock and Dr. E. M. Houghton, formerly of the University of Michi- gan. They will continue to supervise the manufacture of their bacteriological agents, test their pharmaceutical prod- ucts, and investigate the physiological action of new reme- dies. Though the laboratory worker is not in position to speak the last word on the remedial value of therapeutic agents, such researches, supplemented at the bedside and in the hospital by searching study of the clinical behavior of drugs and the indications for their use, is what the profes- sion requires from its therapeutic caterers. Parke, Davis & Co. are keenly mindful of this vital connection between scientific research and actual bed- side results, and appear to profit by every resource which may contribute to the potency, the uniformity and the reli- ability of their products. The Profession will recognize the earnest progressive spirit of this great northern firm. Aphasia Medico-he gaily Considered.—The Medi- cal Press remarks that, "it is quite possible that in due course of time the question of whether aphasia constitutes a legal disability in the case of a patient making a will, will be brought forward for decision. Dr. Mantle, of Halifax, has just recorded a case in which an aphasic patient of his made a last will and testament under certainly unusual circum- stances. The patient formed the outline of the letters on the bed-sheet with his finger, and then explained to his solicitor and wife that when they meant "yes" they were to squeeze his hand, and when they meant "no" to tap it. In this manner the testator was able to have his wishes incorporated in a will, which he subsequently signed with his left hand. Of course the point upon which the legality of the document will depend is, whether there is sufficient evidence to show that the mental condition of the patient was satisfactory at the time that the will was drawn up and signed. As such point has never been raised before, the matter is one of no little interest." A similar point has been raised before and affirmatively settled in the courts of St. Louis in the case of Wm. T. Bevan, reported by the editor of this journal, which we reproduce, wherein the writer, with other physicians, main- tained the affirmative of the proposition and they were sustained by evidences before the jury and the jury's 240 Editorial. decision. The subject of aphasia was then comparatively new, and its literature far less than at present, while the knowl- edge of this subject was less extensive, definite and elabor- ate than now appears from the later researches of Bartholow, Mills, Eskridge and others in this country, to say nothing of European contributors, which, however, have not equalled those of American writers, if we except the physiological experimentations of Heitzig, Ferrier and others. Change of Address.—The Columbus Medical Journal has removed from 150 E. Broad Street to its new quarters, 58 Buttles Avenue, Columbus, Ohio. A Study in Morbid Egoism.—Under an entirely different caption and not for a purpose wholly different from this editorial, our esteemed seaboard contemporary, the Boston Medical and Surgical Journal, thus discourses: "From time to time the enraged practitioner, or the sta- tistically inclined editor of a medical journal, raises his voice in melancholy plaint and inveighs against the dread evil of Hospital and Dispensary into whose hungry maws, ever insatiable for material, he sees disappearing day by day the last remnants of the 'general practitioner's' clientele. To him no words are strong enough to express his condem- nation of 'misguided charities'; and in the blindness of his rage he totally overlooks a far more formidable antago- nist, who stands between the public and himself and takes more dollars from his pockets than any hospital clinic that ever existed. We refer to the wily patent-medicine man. Backed by the testimonials of a host of so-called 'cures,' both male and female, selected from the most prominent walks of life, he probably accumulates more money in a month than the average medical practitioner does in a year, for at no time within our memory has the craze for exhib- iting their photographs with a neatly-worded and convincing testimonial appended as the virtues of this, that or the other quack nostrum, been so rife among people whose names are household words all over the country and whose influence among the masses is widespread. The unblushing manner in which women disclose to the general mass of readers of the daily papers the pathological workings of their genito-urinary apparatus and the marvelous relief which they obtain—as evidenced by the redundancy of mammary tissue exposed in the accompanying wood-cut—by merely purchasing a bottle of Mrs. Allslop's Ovarian Stimulator, after they have been for months exposed to the ruthless fingers of all the best-known gynecologists, is enough to bring a Editorial. 241 flush to the cheek of a pernicious anemic—but it doesn't, it simply sends hundreds of other suffering females in search of this wonderful remedy for their self-diagnosticated com- plaints. "Not a day passes but the lay press contains a villainous reproduction of the face of some well-known divine, accom- panied by a testimonial overflowing with exuberant grati- tude for the remarkable manner in which Dr. Charcoal's Tablets have enabled him to overcome the ravages of a deadly disease whose nature was so obscure that it defied the skill of the most renowned specialists even to determine. Cheek by jowl with him will be imprinted the philanthropic features of some famous temperance advocate who testifies in language whose sincerity is beyond a doubt, that it is only through the constant use of Brown's Nervine lnvigor- ator (mainly proof-spirit with a dash of gentian and nux) that he is able to withstand the strain upon his nervous system incident to his vigorous onslaughts upon the demon Rum. "Next to the pulpit, the stage furnishes the greatest number of promising wrecks who have been snatched from an untimely grave—or from the lunatic asylum, more's the pity!—solely by the use of Someone's Malt or So-and-So's Wine, the secret of whose virtue is beyond the chemist's art to discover, but which probably owe their wonderful therapeutic value to the fact that they are a little more stimulating than beer and a trifle less paralyzing than absinthe. It will not be overstepping the narrow bounds of truth to say that there is hardly an actor or actress, singer or songstress of any repute to-day, for whose power to entertain we are not indebted to the magic influence of some patent nervine or reconstructive*. "Even the legal profession is not loth to lift its voice to swell the chorus of praise for services rendered by the various prominently advertised nerve-foods and panaceas: and not a few eminent law-makers unconsciously—but clearly—explain, in the exhaustive symptomatology which they detail of their sufferings previous to their use of one of these panaceas, that peculiar flavor of general paresis so characteristic of certain statutes governing the practice of medicine. "Now that athletics stand so conspicuously before the public, we are everywhere confronted by the beautifully portrayed musculatures of crack athletes who owe their wonderful powers of endurance to an occasional nibble at Blank's Comatogenous Biscuits washed down by two or 242 Editorial. three drops of Somebody's Kola Preparation to whose su- periority as a preventive of undue tissue waste, the lavish supply of muscles in which the athlete rejoices abundantly attests. One cannot sit down in an electric car without being confronted by a galaxy of lithographic beauties singing the praises, in rubricated rhyme, of coal-tar products or cold cream; and beside them one beholds the smiling and scorbutic countenance of a banker's or a merchant's child —money no object—whose once feeble frame was coaxed into vigorous activity by some patent food, after it had nearly succumbed to the misdirected onslaught of the best- known pediatrists. "The effect of all this upon the general public can be easily imagined. If the Rev. Dr. This or the Hon. That has been cured by somebody's nostrum, or if their babies are able to thrive vigorously on a patent food, why shouldn't the humblest of these gentlemen's admirers and their babies do the same? They try one bottle—and keep on buying just as they keep on buying lottery tickets, until their money is exhausted, and then—too poor to employ even the general practitioner, they turn in desperation to the dispen- sary and hospital clinics where they faintly hope that they may come in contact with some specialist who will, by mere bull-luck, be able to stumble upon a remedy for their complaint. Let the general practitioner be content!" With the addition of certain obscure proprietary medi- cine enthusiasts who tell the most wonderful and unguarded stories of remarkable success with impossible clienteles and often impossible dosages compatable with continuing lives to imaginary patients, the above picture of notoriety egotism (to use no harsher term), is'complete. The egotism that prompts many of the improbable statements attending the (unpossessed) powers of some of the numerous ines, etc., on the medical market, when not positively venal and mer- cenary, is often absolutely morbid, and a prelude in some cases to mental doom, as the certificates themselves are prima facie evidence of that mental weakness which is precursory of cerebral softening. The Rights of the Insane in State Hospitals. —Since the foundation of this Government, when the divine prerogative of kings to oppress their people was denied and it was declared that all Governments among men derive their just powers from the consent of the governed, declar- ations in state bills of rights have been made and statutes have been framed for the protection of the governed against Editorial. 243 the executive and other official oppression. State after state, our own Missouri among them, has reiterated the affirmation of the fathers of the Declaration and the Con- stitution, until now the rights of sane people are pretty well secured, except the steady encroachment on individual rights to liberty of business by combined capital, which, like the usurers among the money-changers of old, should be and will be similarly restrained and regulated by law. We have, in the main, as a people, made good the declar- ation of our fathers, that men have precious rights, and Governments and Governors are created among men to protect and defend these rights. So much for the rights of the rational. But how about the rights of the insane? When a citi- zen, who in his best estate, has helped to sustain the elee- mosynary institutions of his commonwealth by faithful exer- cise of his franchise and the payment of his taxes, falls mentally maimed in the battle of life, is carried to the rear and is placed in the hospital for the insane, he has helped to provide; if he belongs to that large army of men, who, for himself and his household, employs one or more of the 5,000 regular physicians of the state to minister to his health, when he or his wife or child, or other kindred, becomes insane, must he have forced upon him medical ser- vice which, in his sane estate, neither he nor his family would have approved? Has he lost his rights with his rea- son? The state stands in his stead as though he were sane, and has no more right to force upon him obnoxious medical service than to force food upon him which he could not tolerate when rational. The state and the law should guard his rights to life and happiness according to his sane ideas. The curator or guardian of an insane man, who accepts for his insane ward the medical attention of the votary of sectarian medicine, homoeopathist, eclectic, Thompsonian, vitapathist, osteopathist, mind or spirit healer, which his ward would not have accepted for himself if sane to choose, violates the right of that man, even though he be now insane. It is not necessary to quarrel over the claimed merits of the isms and pathies in medicine. The question of sectarian medical aid to non-sectarian insane people is not a question to ,be entertained in the premises. Another right belonging to the insane is the right to receive at the hands of the state every aid promotive of the speediest possible recovery of this mind. To this end the statutes of many states now provide that the physician 244 Editorial. whom the Governor may select as medical chief of state asylums shall not be a tyro or a novice in psychiatry. The rights of the insane require, and in the name of those helpless wards of the state who by grave affliction are incapacitated from maintaining their rights, a Nineteenth Century humanitarianism demands, as their friend, that their rights in this regard be respected by their guardians, the state and its executive. It is a crime against their rights in the premises to place them under the medical care of men without adequate special experience in this most intricate branch of medical practice. These rights of the insane the state should be bound to respect, and it seems to me that the courts could enforce them. The superin- tendent of a hospital for the insane should be a man who has lived among them and learned well how to treat them. "The treatment of insanity," says a great authority, "is now so much confined to the heads of extensive estab- lishments in which its subjects are congregated, that oppor- tunities for studying it are comparatively limited in ordinary practice, so that a physician may be justly celebrated in the knowledge and treatment of other diseases, and at the same time be poorly qualified in matters pertaining to insanity." Again he says: "Physicians are frequently unwilling to believe it" (as we see every day by the way they rush into court with these crude unsustainable theories) "and are disposed to act on the popular notion that all medical sub- jects are equally familiar to them." These rights of the insane are but the golden rule applied, and if you but reflect upon them, most excellent Governor, your heart will approve them. If you wish to understand this question look into your own heart and you will see that justice demands the recognition of these rights. Your official oath demands of you to guard, and not to vio- late, to protect, and not to invade, them." The statutes of Missouri say "the superintendent shall be a physician of knowledge, skill and ability in his pro- fession and of special skill and experience in the care and management of the insane." This article is inspired by an attempt on the part of the Governor of Missouri to turn over an old institution under regular management to the homoeopath ists. It con- cedes all it asks, namely, the political right of people of the homoeopathic faith having a separate hospital if any considerable number of that faith ask for such an institution. Editorial. 245 The Semi-centennial Meeting of the American Medical Association, which will be held in Philadelphia on the 1st, 2nd, 3rd and 4th of June, 1897, bids fair to surpass in the character of the entertainment, the scientific papers and the number in attendance, any meeting which has hereto- fore been held. The Committee in charge has been able to obtain large and roomy places of meeting for the general meetings and the section meetings, all within a single block, and within very short walking distances or immediately adjacent to the largest and most comfortable of the Phila- delphia hotels. For the week preceding and following the meeting the Committee of Arrangements have also arranged for clinical courses which will be open without charge to all physicians who may visit the city at that time. These courses cover every branch in Medicine and its specialties and will afford visitors the opportunity of seeing the active clinical work of all the great teachers of Philadelphia, which is now, as it has been for so many years in the past, in every respect the medical centre of the United States. Poetic Therapy.—It is seldom we find poetry and physic blended. Dr. Frederick B. Sutton has "set on" Frank Ruf's Antikamnia in the following poetic fashion: A-ll the nerves gone on a bender, N-ot an organ is exempt, T-eeth and scalp and muscles tender, l-cy chills, the bones pre-empt; K-aleidoscopic are the symptoms legion, A-s they over-run the system, M-aking life a weary region, N-o one able to resist them. 1-s there nothing that will cure? A-ntikamnia will, I'm sure! Bi-Lateral Psychomotor Myosynchrony.—A case of this kind atavically descended from a grandfather has fallen under our observation in the person of a girl about sixteen years who cannot move the fingers of one side without the corresponding fingers of the other being sim- ilarly moved, and who could not learn to play the piano in consequence. We think Erb has somewhere described a case or cases of this kind, but do not know when or where, or what he called them. For want of a better name, we designate this condition bilateral psycho-motor myosynchrony, the muscles moving in synchronous manner when a psycho-motor impulse 246 Editorial. is directed to but one side. The patient is not ambidex- trous. American Public Health Association, compris- ing the United States of America, the Dominion of Canada, and the Republic of Mexico, will hold its twenty-fifth annual meeting at Philadelphia, Pa., October 26th, 27th, 28th and 29th, 1897. Medico-Psychological Association of Great Britain and Ireland.—The next annual meeting of this association will be held in Newcastle, at the College of Medicine, in the latter part of July. Notice of the dates and other particulars will be issued in due course. A considerable part of the time, of the meeting will be devoted to discussions, papers, and demonstrations, on sub- jects connected with insanity and the structure and func- tions of the brain and nervous system. The president, T. W. McDowall, M. D., Northumberland County Asylum, Morpeth, and Hon. R. Percy Smith, M. D., Gen. Secretary, 11 Chandos Street. Cavendish Square, London, W., will be glad to receive at an early date the title of the paper which any member proposes to read at the meeting, or sub- ject he designs to bring before it. Gayety and Gloom.—A visitor to a lunatic asylum, seeing therein a former friend and noted wit, expressed his surprise that one formerly so jovial should now appear so depressed, for his friend was a victim of profound melan- choly. Thereupon the victim of melancholy replied: "It was then my business to make people laugh. My business exhausted me and I am tired of it and of life." The daily press has not failed to note that excessive wit making may exhaust the brain, as well as excesses of other sorts. The people of the gay French Capitol have lately noted the fact, and their newspapers ask: "Where are the leading French humorists of the last twenty years? Gil- Perez, an eccentric comedian on and off the stage, died mad; Andre Gill, a caricaturist of undoubted genius, went the same road, as did also Charles Desteuque, one of the liveliest spirits of the boulevards. Rhoul Foche, who delighted Paris with his comic dramatic criticism, committed suicide, and the same fate cut short the famous practical jokes in society of Lemice Terrieux." The Globe-Democrat, of St. Louis, commenting on this, thinks absinthe has something to do with this dire result, but the brains of men break under the excessive strain of Editorial. 247 wit as well as wisdom, of worry and wrong, without remis- sion, as well as vice. Respite and rest betimes, constitute one of the laws, at least, of physiological integrity. Meeting of American Medical Publishers' Association.—The Fourth Annual Meeting of the Ameri- can Medical Publishers' Association will be held in Phila- delphia, on Monday, May 31st, 1897. Tennessee Centennial and International Expo- sition, Nashville, Tenn.—The Centennial and Inter- national Exposition to celebrate the one hundredth year of statehood by the citizens of Tennessee is now open. A separate and special building for medical and surgical appli- ances and hygiene has been provided, for everything per- taining to these sciences and arts. This building will be specially attractive to the many medical men who will be in attendance from all parts of the world at some time during the season. A dozen or more prominent medical organizations have signified their intention of meeting in Nashville during the Centennial, as well as many doctors who are in affiliation with other orders, societies and organizations that will meet here. DEERING J. ROBERTS, Chairman. The Medical Staff of the Illinois Eastern Hospital' for Insane has given a course of instruction to the Training School for Nurses throughout the winter months, with an intermission of two weeks for Christmas holidays. Charles VI., of France, was afflicted with melancholia and was, in fact, almost incurably insane. To interest and amuse him, the game of cards was introduced at court in 1392. Illinois Eastern Hospital for Insane.—During the winter, W. O. Krohn, Ph. D., Professor of Psychology, University of Illinois, Champaign, lectured once a week to the Medical Staff of this institution on Physiological Psy- chology, illustrating his lectures with laboratory experiments. Physical Rest Versus Gymnastics after Study. —Baum in a recent number of the Therapeut. Woch. main- tains that mental fatigue is increased by muscular exertion and that such fatigue is best dissipated by both physical and mental rest, and we are in full accord with him in his assault on muscular gymnastics of school children now so much in vogue in our public schools immediately after books 248 Editorial. are laid aside, and maintain on principles of cerebro-therapy after mental strain, that the practice is bad hygiene. Brain fatigue is best dissipated by giving the psycho-motor cen- ters, as well as other portions of the cerebral cortex, a proper period of rest immediately after great mental labor. The Physician as a Citizen.—There is no doubt that medicine requires not only close and constant devotion to study, but that the physician shall be within ready call of those to whom he has undertaken to minister. It is quite evident, therefore, that close and continuous devotion and engrossment in public matters and the undertaking of a large share of the direction of political movements is incom- patible with the active practice of the profession. So much being granted, however, it is also quite evident that a phy- sician may, without detriment to his professional studies, and without neglect of his patients, give a portion of his time and thought and action to the public welfare; how much and how applied, circumstances and individual dis- cretion must determine.—Philadelphia Polyclinic. Meeting of the Missouri State Medical Asso- ciation.—Present prospects are that the meeting of the Missouri State Association this year will prove very satis- factory. The committees have all gotten to work early which is a good indication. The committee on scientific communications is already in receipt of titles in numbers and character sufficient to insure the programme scientific- ally attractive. The executive committee is enabled to announce the following programme, the details of which only remain to be completed. The association will meet in St. Louis May 18th, 19th and 20th. All the first, the sec- ond and the third day until noon will be devoted to the scientific programme. On the evening of the first day the association will as a body attend a session of the Illinois Society in East St. Louis. On the evening of the second day the Illinois Society will attend as a body a session of the Missouri Association, after which there will be a ban- quet and reception. On the third day both bodies will adjourn and join a steamboat excursion on the river. Toxic Neuriatry promises to become an interesting and fruitful source of light in neuropathic states and symp- tomatic expressions of nervous disease. The microbean view of tetanus and some forms of the neuritides, alcoholic poly- neuritis and insanity, the paralysis of saturnism, the ve- nereal, rheumatic and gouty neuroses, and the ancient atra- Editorial. 249 biliary theory of melancholia, have paved the way for the later theories of autotoxine epilepsy, melancholia, insanity, etc. Dr. Von Geisen, in the State Hospitals Bulletin of New York, has taken up this subject and is now investigating the toxic condition of the cerebral cells in insanity, the cytoly- sis or disintegration of the cell. Clytothesis, or the rebuild- ing of the cell for the cure of neuropathic states, is what, in conditions of auto-toxicity, bacterio-toxicity and extrin- sic poisonings of the nerve centers, Dr. Van Giesen pro- poses in the therapy of insanity and other psycho-neuroses and in the neuropathies in general and in all such condi- tions so fast as they may be found out. "So say we all of us." Female Escort for Insane Women.—Since August, 1895, the law of Connecticut has required that in every committal of an insane female beneficiary to the Connecti- cut Hospital, the probate court "shall, unless such female is to be accompanied by a member of her own family, direct that at least one adult female shall accompany her." This is an excellent legal safe-guard and should be the law of every state. University of the State of Missouri.—A bill has been introduced into the House and Senate giving the Uni- versity at Columbia an additional endowment of two mil- lions of dollars bearing interest at five per cent, a year. The general revenue fund is now not large enough to pro- vide for all the public institutions of the state. Hence, at the suggestion of Governor Stone, seconded by Governor Stephens, and endorsed by all the officers of state at Jef- ferson City, a bill has been introduced providing for the needs of the University by adding to its endowment two millions of dollars. The interest will be paid out of the interest fund, which is amply able to bear the expense, and not out of the general revenue fund, which is not now sufficient for the institutions of the state. We are in favor of the above but not the rate of interest. Long time bonds bearing 2Vi to 3%, say fifty year bonds, could be placed and would be as desirable as British consols, for dependent and helpless and untrustworthy beings, etc. This Journal will favor no 5% interest in the future for state indebtedness. The times have changed. Association of Assistant Physicians of Hospi- tals for the Insane.—The fourth meeting of this asso- ciation was held December 3d and 4th, 1896, at the Eastern Michigan Asylum, Pontiac. The following papers were read: Five Cases of Hys- 250 Editorial. terectomy in the Insane, Dr. Isabel M. Davenport; Static Electricity in the Treatment of Nervous and Mental Diseases, Dr. H. R. Niles; Delirium Grave, Drs. A. S. Rowley and Robert Howell; Bone Marrow in Anaemia, Dr. William C. Mann; A Series of Cases of Erysipelas in Insanity, Dr. George Boody; A Classification and Table for Practical Use, Dr. R. M. Phelps; The Examination of the Insane, Dr. William G. Stearns; Pubescent and Adolescent Insanity, Dr. Jason Morse; Paranoia, Dr. J. H.Gahagan; Some Modern Agents in the Treatment of Insanity, Dr. Irwin H. Neff. International Medical Congress.—Section on Nervous and Mental Diseases.—Presidents, Profs. A. J. Kojewnikow, S. S. Korsakow, W. K. Roth, Moscou. Members of Committee, Prof. J. A. Amfimow, Kharkow; Prof. B. M. Bekhterew, St. Petersburg; Prof. L. O. Dark- chevitch, Kazan; Prof. P. J. Kovalevsky, rector Varsovie University; J. P. Merjeevsky, academician, St. Petersburg; Prof. O. O. Motchoutkovsky, St. Petersburg; Prof. J. G. Orchansky, Kharkow; Prof. M. N. Popow, Tomsk; Prof. N. M. Popow, Kazan; Prof. Runeberg, Helsingfors; Prof. J. A. Sikorsky, Kiew; Prof. Soelan, Helsingfors; Prof. W. F. Tchige, louriew; Prof. A. E. Stcherbak, Varsovie. Secretaries, L. S. Minor, agrege, Moscou; W. P. Serbsky, agrege, chief of the clinic of mental diseases, Moscou. Atropine Versus Quinine Tinnitus.—A writer, M. Aubert, in the Lyon Medicale, January ultimo, relates three cases of neuralgia in which he attenuated and even suppressed this disagreeable symptom by adding a small dose of atropine sulphate. From five to seven grains of quinine were given at a dose and to each the author added 0.007 of a grain of atropine sulphate. In one case this prevented and in the two others greatly moderated this dis- agreeable symptom. The pains were allayed and no atro- pinism followed. A favorite formula in sciatica and facial neuralgia of suspected malarial origin with us for the past twenty-five years has been as follows: IJl Quiniae Bisulph 5 ')• Ext. Belladona, gr. iij. Ext. Nucis Vom gr. jss. Liq. Potass. Arsen., 3 j- Ext. Tarax. et Olei Menth. Pip., q. s., ft. mass. Ft. Cap., No. XXIV. Sig.:—Two capsules after each meal. P. S.—Latterly we have added twelve grains taka-diastase or scale pepsine to the above; sometimes both and a duodenal digestive. Editorial. 251 We think susceptible patients tolerate the quinine better perhaps with the atropia, but we have not discovered that the idiosyncracy against quinine in some persons has been truly overcome or that the tinnitus of the drug is entirely destroyed by the atropine. Hydrobromic acid or sodium bromide act better in this direction. American Medico-Psychological Association. —Preliminary programme of the fifty-third annual meeting of the American Medico-Psychological Association, to be held at the hall of the Medical and Chirurgical Faculty, 847 N. Eutaw Street, Baltimore, on May 11, 12, 13 and 14, 1897, at 10 a. m.:— The President's Address, Theophilus O. Powell, Milledge- ville; Annual Address, The Relations of Neurology to Psy- chiatry, B. Sachs, New York; The Medical and Material Aspects of Industrial Employments for the Insane, G. Alder Blumer, Utica; The Constructive Forces, Ralph L. Parsons, Greenmont; Insanity Following Surgical Operations, Richard Dewey, Chicago; General Questions of Auto-Infection, Charles K. Clarke, Kingston; The Historical Development of the Conception of Auto-Intoxication, August Hoch, Wav- erly; The role of Auto-Infection in Melancholia and Epilepsy, Charles G. Hill, Baltimore; Clinical Aspects of Auto-Intox- ication, Arthur W. Hurd, Buffalo; Another Chapter in the History of the Jurisprudence of Insanity, Dailiel Clark, Toronto; Nursing in State Hospitals and Training of Nurses, Peter M. Wise, Albany; The Development of the Higher Brain Centers, Stewart Paton, Baltimore; The Private Hospital for the Insane, Carlos F. MacDonald, Pleasantville; An Unusual Case of Meningitis, C. B. Burr, Flint; Com- mitment of the Insane, Edward N. Brush, Towson; Sporadic Cretinism in the Negro, Henry J. Berkley, Baltimore; Hospital Records, R. L. Parsons, Greenmont. Congres International de Medecine Moscou, 7 (19)—14 (26) Aout 1897. Section des maladies Nerveuses et Mentales. COMITE D'ORGANISATION:—Les gerants: Prof. A. Kojevnikoff, Prof. S. Korsakoff, Prof. W. Roth (Moscou). Membres: Prof. J. Anfimow (Kharkow), Prof. W. Bech- terew (St. Petersbourg), Prof. L. Darkschewitz (Kazan), Prof. P. Kowalewski (Varsovie), Academicien J. Mierzeiewsl