***** ſae· |-،~--~∞.'，¿: ·№º-º-º--.* -->¿№ §§§）.…！， ：|- º º º ¿¿.*; º.ººº ！---- sº sº. ！！！ ！！ * *** ** ** -|- **** 8. º.，, - , :， ſºſ. 3 §: * * · * * * ·º ·-：ș， º *-****- ·， , ， …; ;|-…c.·.* * · · · * * *ſ.ſ. ， ， ， ， ， ， ; ≡ ≈ ≠ ≤ ≥ ≠ ≤ ≥ ±**：* * ·, ſº * * * * * · * ::::…， ¿（… $ $ $ $ · · · - ºf tº º :* { . . . . , gº º * * * * :）. ¿ $º &# § . …§§§）:- --§§¿-¿ ·¿--¿?¿ț¢+ -Ë 、。、、。、、。;&·§§§§¿ -§§ --§.- . -·-- -§§§§- ¿??¿·º'·'）;+?！?！?!?！?- ·±−.·-+>…-· ·¿ §§+§§§§§、· -、、、、、、、、、、、、、&#ffff;**£* ¿??¿¿¿、 §ſº， ºſ§§§·ţ§§§§→$ę%§§§。§§§·:iſ:№ºș&#ș;，&şçãº- -、、。、、。--、。-- - …$$$$·§§§§--:-’ -·-- "-* ¿***¿.*· -33， į、。· ·--***.*）..）， →- --· -.ſ ?-;~&Y’‘-;&§§§§§~~~~）*， *）， §. .>}·** ģĶț¢¿§§§:§§'ºſſº...，{{3}...}}<！*®.*\（.*?）（3）:šķ¿ 、- * -¿?- ·§§ - *¿?·-}; - -¿-+��§§§¿-&& &&ș; §§→*** ſ;، ، ، ، ، ، ، ،ș¿.*¿¿.*¿¿.*¿¿.*Ģºae&&&&&§§ .º.º.º. łºś - #&º 3. #3:1. º sº & 。 ¿ş%·ºx-ºſ:·§§ •¿žģ…- ș ș.ae· §§§ ? º º: §§ §§ § §§§ $ ĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪİ |- №g! № %• • • • =ļģījĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪțš iſſiſſiſſiſſiſſiſſiſi º “-º-º: | |U| º tºgº ¿№ſº！§ 17%ſaei ſſſſſſſſ Gº 9. % ſºſ IIITſūlīlīſ ！2 ķ% ĶŅZÂjſ } ĒĶĒĻ±%ğģįjį №ĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪffffffffÎÏÏĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪĪ T H E Alienist and Neurologist A oUARTERLY JOURNAL -OF- SCIENTIFIC, CLINICAL AND FCRENSIC |Psychiatry and Neurology. Intended especially to subserve the wants of the General Practitioner of JMedicine. ** Quantam ego quidem video motus morbosi fere omnes a motibus in systemate nervorum ita pendent, ut morbi fere omnes quodammodo Nervosi dici queant.”—Cullen's Nosology: Book II., p. 181—Edinburgh Ed. 1780. V O L U M E VI, –EDITED BY- C. H. H U G H E S, M. D., And an associate corps of collaborators. ST. LOUIS, MO.: - EV. E. CARRERAS, STEAM PRINTER, PUBLISHER AND BINDER, º 1885. F R. Ess D F Ev. E. Carreras, Stearn Printer, Publisher and Binder, ST. LDTTIS, MD. CONTRIBUTORS TO WOLUME WI. H. E. ALLISON, M. D., Willard, N. Y. GABRIELE BUCCOLA, M.D., Italy. G. C. CATLETT, M.D., St. Joseph, Mo. T. D. CROTHERS, M.D., .*- Hartford, Conn. JOHN CURWEN, M.D., Warren, Penn. W. W. GODDING, M. D., Washington, D.C. PROF. GOLGI, Pavia, Italy. J. L. HALLAM, M. D., - Centralia, Ill. HENRY HOWARD, M.D., Montreal, Canada. C. H. HUGHES, M.D., St. Louis, Mo. H. ILLOWAY, M. D. Cincinnati, O. JAS. G. KIERN AN, M. D., Chicago, Ill. S. B. LYON, M.D., Washington, D. C. PROF. LUCIANI, Italy. M. V. MAGNAN, M. D. France. EDWARD C. MANN, M.D., New York City. I. A. MERRIAM, M.D., Omaha, Neb. ANGELO PASSERINI, M.D., Italy. PROF. SALEMI PACE, Italy. GUISEPPE SEPPILLI, M.D., Imola, Italy. E. C. SPITZKA, M. D., New York City. W. E. SYLVESTER, M. D., Willard, N. Y. A. W. WILMARTH, M. D., Elwyn, Penn. T. L. WRIGHT, M.D., Bellefontaine, O. 233687 IV INDEX. INDEX TO WOLUME WI. Nerve centers post-mortem, how shall the student of psychiatry examine 547 Nervous and mental diseases, a year's Scientific progress in.............. º e e º 'º e 9 528 Notes on the pathology of idiocy...... 382 Paretic dementia............................. 65 Paretic dementia............................. 219 Physiological psychology in Italy..... 481 Possible origin of some delusions..... 243 Posterior Commissure of the brain... 225 Posterior spinal sclerosis, relations between the symptoms and the cord-lesions................................... 393 Post-neuralgic (encephalatrophic or cerebrasthenic) insanity, note on a form of.......................................... 566 Psycho-sensory (affective or moral) insanity, a case of.......................... 229 Responsibility as affected by alco- holic anaesthesia........................... 37 State provision for the insane........... 192 Study of the minute anatomy of the central organs of the nervous sys- tem, continuation of..................... 307 Trial of Dr. L. U. Beach, of Pennsyl- vania; with his psychological and ORIGINAL CONTRIBUTIONS. Asylum construction, recognition of classes of the insane..................... 360 Asylum treatment of the insane, re- port On......................................... 411 Asylum treatment of the insane, re- port on (concluded)....................... 535 Borderland psychiatric records......... 84 Care of the insane................. tº e º e º e º e º a 210 Case of Lucille Yseult Dudley, psy- chological aspect of.................... 373 Cerebral lesions in the chronic in- 8&ne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Clinical lectures on dipsomania (lec. ii.)................................................ 180 Cortical epilepsy.............................. l Demonomania with periodic hystero- epileptic accesses, case of.............. 167 Fools and their folly........................ 248 Forensic psychiatry, a case record in........ º º sº e º 'º e º ºs e º e º e º 'º e º e s & © & © tº e º 'º & e º e º e º 'º º º e º e 87 Functions of the cerebellum ........... 339 Hygiene of the nervous system and mind............ ................................ 44 Incipient stages of inebriety, some clinical studies of........................... 199 Insane population of the United States....... ....... ........................... 32 Localization of the psycho-visive centre, clinical and anatomico- pathological contribution to........ 234 pathological history............. ...... 325 Vindication of history..................... 67 What shall be done with the ine- briate 7........ ................................. 369 INDEX. V SELECTIONS. Page. Page CLINICAL NEUROLOGY..— NEUROPATHOLOGY—Continued. Absent tendon reflex in diabetes, Aphasia, a case of............................. 613 prognostic value of....................... 145 Basal pathology of chorea............... 427 Clitoridean crisis before the pains of Chronic epilepsy after scarlet fever 271 progressive locomotor ataxia........ 438 Coca-.............................. ................. 271 General paralysis, statistics on......... 274 Corpora quadrigemina, tumor of...... (309 Gray degeneration of the optic nerve Diabetes insipidus........................... 606 with abnormal patella-tendon re- Diabetic Coma..................... * e a tº e s a e s e s s 606 flex............................................... 6||7 Diabetic neuralgia........................... 606 Inability to walk backward easily a Disease of Auerbach's and Meissner's new symptom of locomotor ataxy 145 plexuses ............................... ...... 608 Jacksonian epilepsy caused by a Cer- Epilepsy caused by the sight of a ebral tumor of the motor area of COTDSé . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 431 the Cortex...... • e e s e e s p e º e s e e s tº e º e º t e º e º e º e º 9 º' 273 Experimental chorea....................... 429 Low temperature in diseases involv- Harvey’s forcast of coming events... 143 ing the nervous System................. 276 Intestinal neuroses “...................;... 607 Monoplegia due to tubercular menin- Mechanism of epilepsy........ * * * * * * * * * * * * 146 gitis over the motor area............... 439 Microcephali.................................... 430 Paralysis of the lower extremities Morbid anatomy of diabetes............ 605 with hypertrophy of the skin, sub- cutaneous and muscular tissues, a Psychical disturbances in the pre- ataxic stage of tabes of syphilitic Origin............................................ 275 Raynaud's disease .................... ..... 616 Relation of the hemicrania to tabes dorsalis. ...................................... 276 Secondary neurotrophic phobias, a case illustrating........................... 144 Skin diseases of reflex nervous CauS- ation..................................... ....... 616 Static reflex Spasm, a case Of..........., 27] Typhoid fever, an epidemic of, in the insane asylum of Osnabrueck, Germany....................................... 275 CLINICAL PSYCHIATRY. — Moral insanity................................. 276 FORENSIC PSYCHIATRY.- Legal value of the testimony of the insane........................................... 277 NEUROPATHOLOGY..— Amaurosis due to bromide of potas- Sillſ/l. . . . . ...---------------------------. . . . . . . . . . 613 CEdema from vaso-motor paralysis... 609 Pathology of Cheyne-Stokes breath- Ing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Progressive muscular atrophy......... 270 Progressive spinal amyatrophies...... 268 Spinal ataxy, contribution to the doctrine of.................................... 269 Thomsen's disease........................... 265 NEUROTHERAPY.— Action of hypnotics on the cerebral circulation.................................... 146 Atropine in epilépsy........................ 264 Atropine in mania........................... 265 Bilateral blepharospasm and tic con- Vulsif................................. * * e º 'º e º ſº e º º 264 Blisters Over the fourth and fifth dorsal vertebrae, value of............... 43] Chloride of ammonia...................... 263 Electricity in mental disease............ 202 Ergotin in the treatment of Landry's paralysis....................................... 613 Hygrine of cocaine........................... 614 Intermittent fever, treatment of, by the intermittent current........ ..... 264 Mechanical nervous irritation, thera- peutic Value of.............................. 262 VI INDEX. SELECTIONS. Page. Page. NEUROTHERAPY-Continued. PSYCHIATRY—Continued. New anti-epileptic and nervine........ 614 Recent experiments on the severed Ozonized air on the brain, effect heads of Criminals....................... 437 Of............................ ................... . 265 Partheneia as an anti-neuralgic....... 433 PROCEEDINGS.— * Roumanian clippings....................... 433 American Neurologieal Association 440 Stretching the facial nerve................ 263 Thirty-eighth annual meeting of the Sulphuric ether, injection of..... ..... 433 ASSociation of Superintendents of Syncope from the use of cocaine...... 434 American Institutions for the In- Same-... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tº º e º ºs e º º e 99 PSYCHIATRY.- Case of George Wood, the vitrol thrower, tried in Philadelphia for Thirty-ninth annual meeting of the Association of Medical Superin- tendents of American Institutions Vitrol throwing................ ............ 434 for the Insane.............................. 571 EDITORIAL. Page. Page ALIENIST AND NEUROLOGIST in New Dangerous physicians.................... 456 York............... ................ ............ 454 Development of language in in- . Anaesthetic and hypnotic properties fants.................................... 9 se e e s e s a 152 of Cocaine....... . ........................... 156 Edinburgh Medical Journal.............. 633 Another asylum for the insane Errata ............... ........... ................. 633 burned.......................................... 463 Exchanges will please take notice.... 465 Apomorphine in nervous affections 157 Ferran and his inoculations.............. 458 Apropos of the threatened invasion Gaillard's Medical Journal............... 292 of cholera..................................... 455 General Grant................................. 452 Arthropathia progeSSiva.................. 157 Honors to Dr. Workman.................. 153 A suggestion....................... ............ 630 Immediate restoration of function in Bell’s law discovered by Magendie 151 the divided nerves........ ...... ....... 154 Brain nomenclature......................... 462 Insanity and divorce...... ................. 278 Bromides and iodide of potassium, Insanity, causes of........................... 632 large doses of......................... ...... 149 Insecurity of hospitals for the insane Change in name of the Association against fire................. ................. 28S of Superintendents of American Intra-cranial cerebral tumor, case Institutions for the Insane............ 454 of........................... .......... ‘.......... . 156 Change of address........................... 157 It is not electricity which cures but Chorea and leucorrhoea................... 465 electrizations .......... ..................... 153 Cocaine for meconism and alcoholism 285 Jaborandi in obstinate hiccough...... 292 Cocaine, stronger Solutions of........... 632 Judicial murder of lunatics advo- Contagious diseases, theory of im- cated............................................ 291 munity from Secondary attacks of 150 Massage, the abuse of........ * B & e º e º e º e º 'º ºp e º 627 INDEX. VII Safety in lunatic asylums, ceaseless vigilance the price of, and the only guarantee of Security against cas- ualties................................... '... . . . . . . 622 Simaba cedron as a remedy for hy- drophobia....... ............................. 292 Sober second thought in gynecol- O£y . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------------------- 155 Solar heat intolerance, a sign of the cerebral arteriole hyperaemia of cerebral vaso-motor nerve atonicity 148 State of the cordical motor Centers in epilepsy....................... ............ 447 Strychnia, conditions under which large doses of, may be given......... 626 SWeating to death........................... 154 Texan’s eulogium on cocaine........... 463 The rectum...................................... 624 The Third Annual Meeting of the American Rhinological Associa- tion............................. .... ............ 632 Transitory mania................ ............ 620 Treatment of Cholera....................... 461 Vivisection ........ ............................. 290 What then?....... ........................... . 464 Who owns the physician’s perscrip- tions?........................................... 630 Would-be suicide, sudden revulsion of feeling in a............................... 618 NOTES. Page. Dr. J. H. McBride, Wisconsin.......... 292 Dr. R. M. Wigginston, Wisconsin.... 158 Impending fatal chloroform anaes- EDITORIAL. Page. Page. Melancholic attempts to Commit Sui- Sensational bonfires of restraint ap- cide while under the influence of paratus.................... .................... 151 cocaine......................... tº º tº º ºr e º s e e s e s e is 460 Mind cure, new and old.................... 287 Monument to Dr. Benjamin Rush..... 464 Mr. Clark Bell................................ 289 Mysomania...................................... 286 Neural pathology, the reign of the................................................ 631 Neuropathic conditions of cancerous degeneration; electricity and neu- rotherapy in its prophylaxis and possible cure................ ................ 2S1 New York Medico-Legal Society...... 285 Non-restraint Sermon....................... 464 Philanthropy in the right direc- tion.......................................... .... 152 Physicians’ prescriptions................ 451 Premeditation, knowledge of right and wrong and absence of heredity in a presumptive lunatic............... 290 Presidency of the Missouri State Medical ASSOciation........... ...... .. 454 Proceedings of the Fourth Con- gress of the Italian Phreniatic So- Ciety ............................................ 455 Prof. Berger.................................... 633 Repeated self-inflicted injuries to the head..................... * tº ſº º º º e º is tº º ſº e º e s e º e < * * ~ * 620 Rumford Chemical Works, Provi- dence, R. I.................................... 632 HOSPITAL Pege. Dr. Edward N. Brush, of Buffalo...... 158 Dr. Buttolph. New Jersey............... 158 Dr. Edward Cowles.......................... 471 Dr. Floyd S. Crego........................... 635 Dr. Fisher....................................... 634 Dr. C. C. Forbes. ............................. 635 Dr. P. O. Hooper.................... ......... 635 thesia......................... ........... ..... 15S Ohio................................................ 469 Tennessee......................... .............. 469 VIII IWDEX REVIEWS. Page. Page. Archives of Medicine....................... 164 Manual of medical jurisprudence ; Biennial message of John M. Hamil- with Special reference to diseases ton, Governor of Illinois............... 301 and injuries of the nervous sys- Brain and the nerves ........... ........... 162 tem.…. 475 Brain and the nerves, their ailments Manual of nervous diseases and an and their exhaustion .................... 293 introduction to medical electricity 302 Brain exhaustion............................. 639 Medical rhymes............................... 163 Buntling Ball............ • * * * * * * g e º 'º e º º ºs e º a s - º º 300 Mumps as a cause of sudden deafness 164 Clinical observations on the blood of Mynert's treatise on psychiatry........ 163 the insane............................... • - © - - - 296 Nervous diseases, a treatise On......... 642 Club foot: Is excision of the tarsus New Book ...................................... 475 necessary in children?.................. 164 New method of recording the mo- Cocaine and its use in ophthalmic tions of the soft palate...... e tº e s tº º 'º & © tº º 302 and general Surgery..................... 303 Notes on the treatment of trachoma Comparative physiology and psy- by jequirity........ .......................... 164 chology.............. • - - - - - - - - - - - - - - - - - - - - - - - - - - 162 November Century..................... * @ 9 tº º o 638 Cure of Writer’s Cramp..... ............... 303 Observations on the crania from the De L’Aphasie et de Ses diverses stone graves in Tennessee............ 295 formes.......... dº e - e < e < e < e < e < * * * * * * * * * * * * * * * * * * * 302 Organic diseases of the brain........... 303 De L’Aphasie et de Ses diverses People's Health Journal of Chicago 479 formes par le Dr. Bernard......... 472 Physician himself............................. 302 Diseases of the brain, lectures on..... 640 Prospectus of Mind and Nature........ 298 Draft of a proposed law for the in- Real and imaginary intemperance.... 159 Sane of Illinois ....... ......... ........... 301 Report On tinnitus aurium.............. . 303 Hydrobromate of hyoscine............... 641 Searcy on nerve functions......... • tº e º e º 'º - 299 Idiotic and feeble-minded children... 297 Il Manicomio Giornale de Psichiatria. Organo del Manicomio Interpro- viciale, V. E. II. ....... .................. 476 Index-catalogue of library of Sur- geon-General’s office, United States Seventh annual report of the State Board of Health of Connecticut.... 478 Some interesting facts concerning the proportions of nervous to other diseases........................................ 304 Studies from the biological labora- Army............................................ 163 tory of Johns Hopkins Univer- Index medicus........................ ........ 303 sity........... ................................... 47S Insanity as a plea for divorce or Third edition of the Official Register nullity............................. ............ (536 of Physicians and Midwives in the Inebriism........ • * * g e e º 'º - G - e º e s is • * * * * e º e º a e º e - a 643 State of Illinois............................. 163 La Salute Revista di Medicini.......... 303 Treatment of the Insane............... .. 303 OBITUARIES. Dr. Gabriele Buccola........................ 466 Dr C. C. Graham.................... ....... 2S5 Dr. Edward J. B. Dumesnil.............. 156 Dr. Joseph A. Reed.......................... 154 THE ALIENIST # NEUROLOGIST. TV Ol. VI. JANUARY, 1885. NO. 1. ORIGINA / CONTRIBUTIONS. CORTICAL EPILEPSY.* EXPERIMENTAL RESEARCHES-SPANTHETIC RE VIE W. By GIUSEPPE SEPPILLI, M. D., Imola, Italy. MONG the more important results obtained in late years, from the experimental explorations of the brain, is that of having established the fact that epilepsy may be produced artificially by irritation of the cerebral cortex. The first knowledge of this fact dates from the time of the well-known experiments of Hitzig and Fritsch (1870), which have signalized the commencement of an era, the most fruitful and the most memorable in the physiology of the brain. In the work published by these two observers on the electric excitability of the brain, we find it stated that in dogs electric excitation of the cortex gave place to well-characterized epileptic attacks, which, beginning in contractions of the muscles corresponding to the cortical motor centre stimulated, extended first on the same side of the body, and afterwards on the other side. Some years afterwards Hitzig tried to establish, in a more precise manner, the relation between cortical exci- tation and the genesis of epilepsy by effecting on dogs lesions limited to the motor zone, and he observed that * Translated by JoSEPH WORKMAN, M. D., Toronto, Canada, from the Rivista . Sperimentale, 1884. 2 Giuseppe Seppil/i. in some of those which survived the operation, true epiletic attacks were developed. The Opinion of Hughlings Jackson, based on clinical Observation, that in men also certain convulsive forms have their origin in the cerebral cortex, led Ferrier to make a series of experiments, from which he concluded that the excitation of the cortical motor centres provokes epilepsy. In Italy, the subject of cortical epilepsy has been pro- foundly studied by Albertoni, who has sought to deter- mine the conditions and the genesis of the epileptic attacks; and by Luciani, whose theory of the seat and Origin of epileptic convulsions has been accepted by many able physiologists, and has found several applica- tions in the clinical field. Among those who have specially engaged in the study of cortical epilepsy, and who have sought, whilst taking departure from different points of view, to determine the part taken by the cerebral cortex in the genesis of the epileptic attack, we must mention Bubnoff, Heidenhain, Franck, Pitres, Unverricht, Rovighi, Santini, Danillo and Rosenbach, whose labors have cast a clear light on the mode in which we should interpret the mechanism of epilepsy of cortical origin, whilst, taken in their entirety, they give us an exact and complete idea of the phe- nomena that characterize an epileptic attack, experimentally provoked, and of the mode in which it begins, extends and runs through, as well as the varieties which, accord- ing to circumstances, it presents. Cortical epilepsy is a subject of great interest, not so much because of the physiological questions which it raises, as of the immediate applications which it may present to the physician at the bedside of his patient. We shall, therefore, fully discuss it in this work, in which we purpose, first, to examine the conditions requisite for the production of artificial cortical epilepsy in animals, and the mode of provoking it; we shall then analyze the access of cortical epilepsy and the causes which modify Cortical Epilepsy. 3 it; lastly, from the basis of the facts, we shall see what is the functional significance of cortical epilepsy. FIRST. The disposition to cortical epilepsy varies much in different classes of animals; it is absent in the batrachia, in reptiles and birds, but it is present in the mammifera. By exciting, with a very strong Faradic current, the cerebral hemispheres of frogs, toads, chickens or pigeons, we do not succeed in provoking any epileptic access. Only some of the mammifera are predisposed to present cortical epilepsy. Albertoni observed that the sheep, the goat, the ass and the horse are not susceptible of having partial epilepsy; whilst in cats, dogs and monkeys it is very easily provoked. But even animals of the same species do not present an equal predisposition to cortical epilepsy. Experiments have shown that in some dogs, even when not narcotized, it is impossible to provoke an epileptic attack, whilst in others, on the contrary, very slight excitations are fol- lowed by convulsive attacks, and again, in some others, strong and prolonged excitations are required to pro- duce epilepsy. Again, certain monkeys are more predis- posed than others to artificially provoked epilepsy. It is further to be observed that the same experimental condi- tions being given in many animals of the same species, or of different species, epileptic convulsions with the same characters are not always obtained. In some animals they continue localized, whilst in others they have a tendency to become diffused. It is, therefore, proper to note that the predisposition to the diverse forms of epi- lepsy (peripheral, toxic, cortical) is variable in animals; in the guinea-pig, for example, it is very easy to provoke peripheral epilepsy, but not the cortical; in the dog, which is much predisposed to cortical epilepsy, it is very difficult to produce the peripheral. The degree of the excitability of the cerebral centers has a great influence in the production of epilepsy. It is very variable in the dog, and it may be diminished or abolished, or notably exaggerated under the action of 4. Giuseppe Seppilli. various causes. The facility of provoking epileptic attacks stands in relation to the state of excitability of the brain that is subjected to the stimulus. We shall now proceed to enumerate the principal causes which tend, more or less, to modify the cortical excitability: (a.) The age.—From the researches of Soltmann and Tarchanoff it is known that the brain of dogs, cats and rabbits, newly born, is altogether inexcitable. Albertoni could not, in a dog thirteen days old, provoke either movements or epileptic convulsions by Faradization of the brain, whilst in another, twenty-two days old, excita- tion on the right hemisphere brought on a complete epileptic attack. It is held by some observers that it is easier to provoke epilepsy in young than in adult animals. (%.) Andesthetics.-The state of narcosis, to which the animals are usually subjected by means of chloroform, ether or morphia, has great influence in diminishing the state of excitability of the cerebral cortex. If the chloro- form narcosis is very profound, the cortical excitation may be rendered absolutely ineffective. Having been present at the numerous researches of Luciani and Tamburini, in the asylum of Reggio, on the brain, I often had occa- sion to observe this fact, and to see afterwards that in proportion as the narcosis went on decreasing the excit- ability of the cortex of the brain returned. Hitzig observed that with strong doses of ether, he was able to obtain cessation of the movements which had been pro- voked by galvanizing the excitable zone of the brain. Morphine, also, when administered in a rather full dose, produced the same effect. But when these substances are cautiously given so as not to induce in the animal to be operated on a profound degree of narcosis, their paralyz- ing action on the cortical excitability, if indeed it appears at all, is only transient. (c.) Bromide of Potassium.—Albertoni instituted a series of researches most interesting in the study of the action of divers medicinal substances on the excitability of the cerebral cortex. Having laid bare the motor zone in the Cortical Epilepsy. 5 dog and in monkeys, he fixed on the lowest degree of current necessary to provoke an epileptic attack. He then administered the medicament, and as soon as signs of its action began to appear, he examined anew, in the same way, the excitability of the brain by laying bare the other motor zone. In this way Albertoni discovered that the bromide of potassium is capable of considerably diminishing the electric excitability of the brain, and of withdrawing the possibility of production of epileptic attacks by means of excitation of the cortex. Rosenbach has recently confirmed these facts. (d) Perfrigeration.—The epileptogenous faculty of the cerebral cortex may be diminished or altogether abol- ished by the local application of some substances which produce a great and rapid lowering of the temperature “Of the brain. Franck and Pitres found that whenever the cerebral cortex was cooled down by means of etheriza- tion, prolonged for some minutes, the excitation of the cortex no longer provoked convulsive attacks. They assured themselves that the ether does not act by chem- ically altering the cerebral substance, as they obtained the same effect when they protected the cerebral cortex from contact with the ether, by means of a thin fold of caoutchouc. On the contrary, however, Marcacci states that local anaesthesia of the exposed cortical centres, obtained by the pulverization (spray ?) of ether, does not modify the cortical excitability. We know not how to explain this difference in the experimental results of the authors cited, unless by admitting that in the experiments of Marcacci, the perfri- geration of the cortex was not pushed to so intense a degree as in those of Franck and Pitres; or by supposing that the cerebral cortex does not in all animals equally feel the local anaesthetic action of cold. This would seem to find confirmation in the observation of Unverricht, who, in making his experiments on dogs, found that in some of them, despite an enormous lowering of the tempera- ture, the excitability of the brain persisted to such an 6 Giuseppe Seppilli. extent that he was able to provoke a true epileptic state, whilst in the majority of them the cooling of the cere- bral cortex rendered it altogether inexcitable. (e.) Anaemia.-In animals which, during the operation, have lost a considerable quantity of blood, the electric excitability of the brain usually descends to a very low degree, or it is completely abolished, so that we do not Succeed in provoking epileptic attacks. Sometimes, how- ever, the cortical excitability does not undergo any diminution. The ligaturing of all the arteries which go to the brain does not, in some, in the least modify the electic excitability of the cortex, but in others it dimin- ishes it—[Minkowsky.] Orschansky studied how the electric excitability of the cerebral cortex behaved in dogs, in which abstrac- tion of blood was made from the femoral artery. When the quantity of blood abstracted was about one-seventh of the whole mass, the cortical excitability was not modi- fied. The withdrawal of about one-fifth of the mass caused augmentation of the excitability. If the loss of blood is still greater, the excitability of the cortex dimin- ishes. When the quantity lost is about three-fifths or two- thirds of the mass, the excitability disappears entirely in a few minutes. Slow abstractions produce slight modifica- tions of excitability, but rapid abstractions modify it con- siderably. (f) Asphyxia.—Arrest or momentary suspension of respiration rapidly produces inexcitability of the cerebral cortex. It is easy to verify this fact in an animal that has undergone tracheotomy and breathes through a tracheal canula. As long as the respiration is free, it is easy to provoke convulsive attacks by exciting the cortex, but this part does not respond to the stronger stimuli, when the animal is hindered from breathing by closing the mouth of the canula—[Hitzig.] (g.) Alcohol.—Danillo is the only one who has studied the influence of this substance on the function of the motor zone of the brain, and over the attacks of corti- Cortical Epilepsy. 7 cal epilepsy. His experiments were made on dogs in which he injected into the blood of the saphena vein a strong dose of alcohol, at forty-five degrees (from forty to sixty grammes for each animal). He found that alco- hol thus administered diminished rapidly the excitability of the motor region of the brain, even to its complete abolition. The action of alcohol on the motor functions of the brain would therefore seem to be analogous to that of anaesthetic agents. (h.) The Essence of Absinthe.—This substance also has been experimented with on a large scale, in dogs, by Dan- illo, who found that by administering it in repeated small doses, by various injections, the excitability of the cere- bral cortex was so much increased that a trivial excita- tion of the motor zone sufficed to provoke a very strong convulsive attack. The essence of absinthe has, there- fore, close analogy to strychnia, which also possesses the power of considerably exaggerating the excitability of the brain, and consequently of rendering more facile the pro- duction of epileptiform accesses, and their symptomatic manifestations more violent. (i.) Atropine, Cinchonidine, Picrotorine.—According to the researches of Albertoni, atropine augments the excita- bility of the cerebral cortex, and the continued use of it does not take away or diminish the possibility of pro- ducing epileptic attacks by cortical excitation. Chirone and Curci explain the epileptogenous effect of cinchoni- dine as an action by this substance on the cortical cen- tres. Rovighi and Santini have arrived at the same conclusion, from their experiments with cinchonidine, made under the direction of Prof. Luciani, and they believe that the epileptogenous action of picrotoxine should be explained in the same manner. (l.) Encephalitis.-Phlogosis of the cerebral cortex is a condition very favorable to the exaggeration of its excitability, provided, however, that it is not of such a degree as profoundly to disorganize the tissues in which case the excitability is wanting. Cortical excitability, 8 Giuseppe Seppilli. consequent on an inflammatory state, may be so much increased that, as Franck and Pitres have observed, even mechanical stimuli, such as simple contact, stroking, or the pressure of a sponge, suffices to provoke an epileptic a CCCSS. SECOND. The most efficient and certain means for stimulating the cerebral cortex, in order to provoke an epileptic access, is electrization. We may employ either the continuous electric current or the induced, of variable in- tensity, according to the degree of excitability shown by the animal, and also according, as we shall see further on, to the point of the cortex where the electric stimulus is applied. Mechanical and chemical excitations applied on the cerebral cortex do not usually provoke any immediate effect; we may cut, Squeeze, strongly stroke with sponges, or profoundly cauterize the cortical substance without provoking thus either a partial or general epileptic access. In some cases it has, however, been observed that me- chanical excitation of the cortex may give place to epilepsy. Franck and Pitres relate the following experi- ment: On a large dog they laid bare, by trephining, the left motor zone, and they placed over this part a bit of tinder (lighted P). A few seconds after, with out any provocation, the animal was seized with a most intense general convulsive attack. The convulsions succeeded each other at short intervals, and a true epileptic state was produced, under which the animal died. Whilst it is a rare or exceptional fact that mechanical stimuli applied over the cerebral cortex, immediately produce epileptic convulsions, it is on the other hand observed rather frequently, that epilepsy at some later time follows brain injuries. When the motor zone of a dog is laid bare on one hemisphere, and the animal is allowed to survive, it readily becomes subject to spon- taneous epileptic attacks, after complete cicatrizing of the wound. Hitzig and Luciani specially availed themselves of this very method for the study of epilepsy of cortical origin. Cortical Epilepsy. 9 The dog, the monkey and the cat are animals in which cerebral injuries readily produce an epileptogenous action; it is not the same with rabbits and guinea-pigs, in which Franck and Pitres never saw epilepsy supervene, even for several months after they had made on them partial lesions of the cortex. THIRD. A very important question presented to us in the study of cortical epilepsy, is that of learning whether the cerebral cortex is capable of developing a partial or general attack of epilepsy, whatever may be the point at which it is excited. Albertoni, as is known, assigned an epileptogenous property exclusively to that part of the cerebral cortex which corresponds to the postcruciate con- volution, where the motor centres of the limbs of one side exist. Only these points of the cortex would there- fore, have the property of provoking epilepsy when they are stimulated. Luciani and Tamburini modified the idea of Albertoni by demonstrating that the whole of the motor zone, in which the centres for the limbs, for the face, the trunk and the neck are comprised, is an epileptogenous zone, for by electrically exciting single centres, epileptic ac- cesses, more or less diffiused, can be produced. But this epileptogenous property is not equal at all points of the motor zone. According to Luciani and Tamburini it is found in the dog more developed in the centres for the movements of the upper jaw and the face, than in the centres for the motions of the limbs. The cerebral cortex of the motor zone is not the sole region in which epileptic accesses may be provoked. Luciani and Tamburini saw developed, several times, con- vulsions in dogs by means of intense and prolonged Faradization of the convolutions of the sensitive zone. Rosenbach, Franck and Pitres have observed the same. This, however, does not prove that all the parts of the cortex have the property of provoking convulsions when they are stimulated. Several experimental researches clearly show that the epileptogenous property resides IO Giuseppe Seppälä. exclusively in the motor zone, and that if other parts of the cortex when stimulated provoke epilepsy, this hap- pens because the excitement is propagated to the motor zone. The facts on which we rest for admitting with Luciani and Tamburini that the epileptogenous function of the cerebral cortex pertains exclusively to the motor zone are the following: First.—After the destruction of the psycho-motor centres, excitation of the intact occipital convolutions cannot pro- voke any attack—[Franck, Pitres and Rosenbach]. The same result is obtained if, instead of destroying the motor zone, we separate it from the posterior parts of the cere- brum by removing an intermediate zone of the cortex.— [Danillo.] Second.—If the posterior convolutions are removed, and the intact motor regions are excited, convulsions are readily produced, just as though the hemisphere had not been touched—[Franck and Pitres.] Third.—A weak electric current, which being applied to the motor zone gives place to an epileptic attack, is quite unfelt on the cortex of the occipital lobes. In order to pro- voke, from this region, an epileptic convulsion, an electric current much more intense and prolonged is required than for obtaining a convulsion by excitation of the motor zone. Physiologists have devoted much attention to the in- quiry whether the epileptogenous property of the motor zone pertains exclusively to the cortical substance, or is participated in by the medullary substance. Franck and Pitres, from a great number of experiments, found that direct excitation of the white fibres of the centrum ovale, corresponding to the motor zone, is incapable of provok- ing convulsive access, though it may give place to simple movements analogous to those produced by excitement of the motor cortical centres. Here we are not to believe in a state of exhaustion of the animal, consequent on the operation from which the white substance is rendered in- excitable, since it is observed in the same animal, that whilst stimulation of the white substance of the centrum Cortical Epilepsy. I If ovale is incapable of provoking convulsions, excitation of the conserved grey substance, whether upon the same hemisphere or the opposite one, readily determines; epileptiform convulsive attacks. r But in order that excitation of the medullary substance" shall not appear to provoke epilepsy, it is necessary that the cortical substance of the motor zone be completely" destroyed; if any points of this zone remain intact, the current, by diffusion from the medullary substance on which it has been applied to the cortical substance, readily produces epilepsy. Rosenbach has observed that an intense and prolonged excitation of the medullary substance develops an epileptic attack, when the destruction of the cortex of the motor zone is not considerable ; but on the contrary,. if the destruction of the psycho-motor zone is complete, then the excitation of the medullary fibres, thus stripped, does not give place to any epileptic convulsion. The results of the researches of Bubnoff, Heidenhain and Albertoni do not accord with those above cited from Franck and Pitres, as they show that excitation of the white substance, after removal of the cortex, may give place to epilepsy. This difference in the effects of excitation of the medullary substance leads us to suppose that the experimental conditions have not been identical ; it is probable that in the experiments of Albertoni, Bubnoff and Heidenhain, the destruction of the cerebral cortex was not so profound as in the researches executed by the two French physiologists, so that irritation of the remaining portions of the cortex, by diffusion of the current, could not be avoided. Nor can we suppose that the effects obtained by the former from exciting the medullary substance should be attributed to the greater intensity of the electric current, since Franck and Pitres. assert that they always found that even the strongest electric excitation of the sub-cortical white substance did not produce convulsive attacks, when the corresponding: grey substance had been destroyed. I 2 Giuseppe Seppälli. Partial destructive lesions of the grey substance of the motor zone provoke, in the neighboring parts of the cortex remaining intact, an irritative state, by which their excitability is so exaggerated, that intense convul- sions are produced by the very slightest stimuli. From the researches of Franck and Pitres it becomes evident that the hyper-excitability of the cortical motor centres, which accompanies light phlogoses of the con- volutions, is not in relation with the concomitant hyperaemia, but rather with the nutritive disorders of the nervous elements, as they observed that active hyperaemias of the brain, experimentally provoked by section of the cervical sympathetic, or by removal of the superior cervical ganglion of one side, and also passive con- gestion obtained by ligation of the great veins of the neck, did not produce appreciable modifications of the cortical excitability. FourTH. Hitherto we have been occupied with the principal conditions that modify in animals the predisposi- tion to provoked cortical epilepsy, as well as with the stimuli adapted to cause development of the access, and the differ- ing epileptogenous faculty inherent in the various cortical regions. We shall now proceed to study in what manner the access of cortical epilepsy presents itself, how it is initiated and becomes generalized, and by what phenomena it is principally characterized. We may hold it, as a general law, that the access of cortical epilepsy is always initiated in the muscular group which corresponds to the excited cortical motor centres. This is a part to which Luciani and Tamburini have called special attention, on which all observers are now found in accord, and whose importance is considerable in view of the clinical applications it may have. The form of an epileptic access of cortical origin is vari- able. The convulsion at one time remains limited to one group of muscles (monospasm), at another it is diffused through the muscles of a single circle of the body (hemi- spasm), or to the muscles of both sides (general epilepsy). Cortical Epilepsy. I3 The different mode taken by the convulsive access in extending itself, depends chiefly on the intensity and duration of the stimulus. The more prolonged and energetic is the electric excitation, the more readily does the epileptic convulsion become general; on the contrary, by very slight excitations the convulsion may be limited to those muscles whose centre has been stimulated. The epileptic access follows, in becoming diffused, an order almost always corresponding to the anatomical disposition in which the motor centres are found in the cerebral cortex. To become convinced of this fact, which is of the highest importance with regard to the functional significance of cortical epilepsy, it is sufficient to read attentively the experiments of the authors, who have occupied themselves with artificial epilepsy. An attack of hemiplegia which had been provoked in a dog by exciting, on the left, the cortical centre for the closing of the palpebrae, was first manifested in clonic contrac- tions of the right orbicular muscle, and the elevator muscles of the angle of the mouth on this side; then the convulsion gradually extended to the right ear, and to the muscles of the ocular bulks (nystagmus, mydriasis), to the muscles of the jaw, which was closed with great force, and to the muscles of the tongue; the head was forcibly drawn to the right, and bent towards the shoulder; the convulsive movements spread afterward to the fore leg, and to the hind leg of the right, and here it stopped. During the access, saliva ran very abundantly from the mouth, and the close of the fit was signified by discharge of faeces and urine. If the reader will take a look at the figure of a cere- bral hemisphere, on which the excitable areas of the cerebral cortex are shown, it will not be difficult for him to become pursuaded that the mode of diffusion of the attack, in the case we have given, corresponds with the topographic distribution of the motor centres. The convulsive access is propagated, as if the excitement, setting out from the motor centre of the orbicularis, is ; I4. Giuseppe Seppälli. carried in a direction toward the centres for the muscles of the jaw and of the limbs, and in the other direction to the motor centres of the ear and the eye. The same , consideration may be held of all convulsive accesses, what- ever may be the muscular groups in which they are initiated. Therefore, we may conclude with Unverricht (who is in this imperfect accord with what had first been established by Luciani), that there enter into convulsion, one after the other, only those muscles whose centres are neighboring in the cerebral cortex. “Never,” he observes, “is it seen, for example, that the convulsive motions of an extremity succeed to those of the ear, without the orbic- ular muscles participating in the convulsion—the centre for the latter being found between the auricular centre and the centre for the limbs.” Sometimes the excitement of a cortical centre is more promptly diffused in one direction than in another, e. g., excitement of the centre of the orbicularis is diffused to the muscles of the upper limbs before the muscles of the tongue and the jaw. But much more important, than , the course taken by the convulsions on one side of the body, is the mode of propagation of the epileptic attack from one-half of the body to the other. Unverricht is the person who has made the most numerous and accurate researches in this relation, and he has arrived at the following conclusions: The attack of epilepsy always invades the other half of the body in a strictly regular and typical order, what- ever may have been , its point of departure on the side first affected. The convulsion commences on one side in the inferior extremity or in the orbicularis, and it passes into one side of the tongue or into the muscles of the jaw. It is always propagated first into all the muscles of the corresponding half of the body, and afterwards it , extends into the other side following an ascending direc- tion, because of which the lower extremity is first struck by it, and then gradually the other groups of muscles situate in the Superior. regions. If, for example, the centre Cortical Epilepsy. I5 for the right lower extremity is excited, the trunk and the neck are seen to be first curved in an arc turned to the left; next convulsions in the upper extremity are shown, and in the muscles of the jaw, the face and the tongue on the right. The muscles of the left side of the body enter into convulsion in the same order as those on the right, excepting that the diffusion is much more rapid, and the convulsions are more tonic. If, however, instead of the motor centre for the inferior extremity, in the left cerebral hermisphere, we excite the region in which the bilateral movements of the ocular bulbs have their origin, it will then be seen that the con- vulsion in the right side is propagated in a descending direction from above downward, but on the left side it extends, as in the preceding case, from below upwards, making a sort of circuit of the body. In short, whatever may be the course, ascending or descending, followed by the convulsive access in propagating itself in the side oppo- site to the motor centre excited, the direction taken by the convulsion in its diffusion on the other side, that is the one corresponding to the stimulated cerebral hemisphere, is always ascending. Franck and Pitres wished to apply the graphic method in the study of the mode of extension of convulsions of cortical origin. They laid bare in dogs the motor zone of one side, and then placed in relation with a graphic apparatus each tendon of the extensor muscles of the two fore paws and the two tendons of Achilles. In this way they were enabled to discover that by strongly exciting the centre for the right front limb, the convulsive attack succeeding, extended in the following order: Ist, In the right fore leg. 2d, The right hind leg. 3d, The left hind leg. 4th, The left fore leg. In this experiment we have a confirmation of what we said regarding the rule which the epileptic attack observes in passing from one side of the body to the other, and thus becoming general. The duration of each epileptic access varies from some seconds to two minutes; the access which follows a single I6 Giuseppe Seppilli. cortical access is almost always unique, and in order to re- produce it, the excitation has to be repeated. If the cerebral cortex of an animal is several times in succession repeated, the accesses succeed each other with an always greater intensity, and in more rapid course. But some- times the convulsions are spontaneously repeated at short intervals, without the requirement of repeating the excita- tion of the cortex. The animal falls into a true epileptic state, under which it most usually becomes exhausted and dies. In the first periods of the epileptic state, Unverricht made the interesting observance that the convulsion, in repeating itself, sometimes commences on that side of the body in which it had terminated. If, for example, an epileptic access, which having set out from the right orbic- ularis, has made the round of the body, having gradually descended in the right side and ascended through the left, it is frequently seen that it revives in the muscles last engaged in convulsion, that is to say, in the orbicularis and the muscles of the ear of the left side, and then is diffused in inverse direction, descending on the left side, and ascending on the right, where it terminates in the orbicularis and the ears. In addition to this form of the epileptic state pointed out by Unverricht, he has described another, which is ob- served in the first periods of the epileptic state, and is called by him relapsing. When the first access has terminated, a second, a third, a fourth, are seen to arise, the point of departure of which is always the one and same muscular group, and then the convulsion becomes general. This fact shows that there exists in the cerebral cortex a determined point, under a state of chronic excite- ment, from which the fresh accesses always set out, whilst in the oscillating form there is present a diffused disturb- ance of the equilibrium of the gangliar cells, which have been altered by simple functional excitement of neighboring groups. & It is interesting to note that, as well in single epileptic Cortical Epilepsy. I7 accesses as in the epileptic state, all the muscular groups do not always participate with equal intensity in the con- vulsion, but rather, in certain cases, some muscles remain quite unaffected. Thus, under an epileptic access which includes the face and the limbs of one side, it is frequently observed that the muscles of the jaw take no part, or only a trifling part, in the convulsive cramp of the other muscles. In some of these cases, by exciting electrically the cortical point corresponding, we discover their slight excitability. [Unverricht.] This part is very important, as it shows that the cerebral cortex of the motor zone may undergo, only partially, a modification of excitability; it accords with what we have said respecting the variable excitability of the motor points of the cortex, by reason of which a strong excitation of a given centre does not provoke any epileptic access, whilst even a slight one of another centre brings on a convulsion. By the aid of the graphic method, Franck and Pitres analyzed the muscular phenomena of the epileptic access of cortical origin. They observed that the complete access consists of two successive phases: one tonic or tetanic, and the other clonic or spasmodic. Sometimes the myo- graphic characters of the access are incomplete and abnormal. The tonic phase may thus be wanting, and, therefore, the epileptic attack is manifested in clonic con- vulsions only. Instead of gradually increasing in force, as is most commonly observed, the convulsive movements may present with oscillations of much amplitude immedi- ately after the tetanic phase. For an exact description of these and other modifications of the epileptiform muscular phenomena, we refer the reader to the work of Franck and Pitres, in which there are given some graphic figures that show them very clearly. According to the researches of Unverricht, the tempera- ture of the body, in isolated epileptic accesses of cortical origin, is raised I* to 2° centigrade. In the epileptic state he observed it up to 44.5° (I 12° F.), and this went yet a few tenths higher, after which death took place. I8 Giuseppe Seppälli. The phenomena presented by animals at the close of epileptiform accesses are deserving of special interest. Sometimes they pass into a state of violent agitation, they run impetuously as if impelled by some irresistible force, dashing against objects, and they appear to be hallucinated. In a dog, operated upon by Luciani and Tamburini, the epileptic accesses were followed twice by a state of fury. In another they saw the access followed by a sort of maniacal state, in which the animal ran furiously hither and thither through the room, knocking his head now on one side and then on the other. A cat operated on by Luciani was seized at the close of the epileptic convulsion with a sort of impulsive mania, which caused her to run as if insensate, without looking what direction she took. Being one day seized with a maniacal access, she jumped into a tub of water, and on another occasion she leaped into an oven that was still hot. In some cases the animal, after the convulsion ceases, falls into a state of exhaustion, is broken down and reacts feebly to stimuli, it stands with difficulty on the feet, for in the muscles of the limbs there succeeds to the spasmodic state, a paresis which is shown more intensely on the side of the body opposite to the cerebral hemisphere operated on. It is very easy to verify the exhaustion of the excitability of the cortical centres, im- mediately after stimulation of them has provoked an access of epilepsy. This fact I have often observed in the animals on which Prof. Luciani and Tamburini pro- voked epilepsy by exciting the cortex. Franck and Pitres after provoking in a dog four epileptic accesses by excit- ing the right motor zone, failed to produce any muscular reaction, even by stimulating the sigmoid gyrus with an electric current that was painful to their fingers; the motor region had become completely inexcitable. Ordi- narily the loss of excitability following accesses of epilepsy, is not complete; it, however, reaches a degree sufficiently observable, but if the animal is allowed to repose, it passes off in the course of an hour or an hour and a half. Cortical Epilepsy. 19 FIFTH. The animal, on which success has been attained in provoking epileptic accesses by irritation of the cere- bral cortex, are subjects of research very favorable for the study of the different factors which have more or less influence in modifying the course of convulsions already in progress, in the way of diminishing their in- tensity or of arresting them. It has been observed that anaemia has no influence on the evolution of the convulsive attack, when once it has commenced. If the carotids of an animal in an epi- leptic state are cut to let blood flow, the clonic cramp of the muscles does not cease. Ligation of the two carotids and the two jugulars does not arrest the epilep- tic attack. The mass of arterial blood in the brain may be reduced to a minimum quantity, without impeding the manifestation of epileptic phenomena. Accumulation of carbonic acid in the blood diminishes the intensity of cortical epilepsy. By compressing the trachea of an animal under an epileptic state, the clonic contractions of the muscles in convulsion continue for a short time, but afterwards they cease by little and little, whilst dyspnoeic phenomena enter on the scene, and are followed by death. If the compression of the trachea be” withdrawn, and, in case of its need, artificial respiration be employed before death happens, the animal may revive, but it very soon falls into the convulsive state. Unverricht observed that accumulation of oxygen in the blood does not moderate the epileptic state; in many cases, indeed, a continuous succession of the accesses was observed, that is, an absolute absence of intervals between the convulsions. Inhalation of irritating vapors (ammonia, acetic acid), irritation or cutting of the cervical sympathetic, the application of strong cutaneous excitements, as punctures, cauterization, and the cold douche, according to Franck and Pitres, do not arrest an already commenced attack in its course, nor do they sensibly modify it in its evolu- tion. 2O Giuseppe Seppälli. The principal means which have the property of diminishing the duration and intensity of the attacks are morphia, chloral and ether. Morphia administered by venous injection acts only in very large doses, and it is generally fatal. Ether, given by inhalation, completely arrests the convulsive state. Chloral has the same action, even in small doses; O.2O injected into the femoral vein of a dog that was in the epileptic state arrested totally the convulsions—[Unverricht.] Atropine, the utility of which in the case of epilepsy has been so much vaunted, possesses, on the contrary, according to the experiments made with it on animals rendered artificially epileptic, no antispasmodic virtue. Indeed, from the researches of Albertoni, it is shown that it favors the development of the epileptic attacks, because it augments the excitability of the cerebral cor- tex. In some dogs, Unverricht, after the administration of atropine, provoked convulsions by cortical electric excitation, though previously it had failed to produce them. As to the application of the Faradic or galvanic cur- rents on the brain, during the presence of the attack, it has been found that the convulsions become so much the more intense, the more energetic has been the cur- rent employed. The course of convulsive attacks, consequent on exci- tation of the cortical motor zone of the brain, like the attacks caused by the action of absinthe, is arrested by the intravenous injection of alcohol—[Danillo.] SixTH. After having examined, hitherto, the conditions necessary for the development of epilepsy by excitation of the cerebral cortex, by what stimuli the convulsions are provoked, what course the epileptic attack holds in its in- ception and extension, and the means by which it may be modified, we have now reached the moment when we should take into consideration the pathogenesis of epilepsy, of cortical origin, and its localization. The numerous experimental researches which have been Cortical Epilepsy. 2 I instituted, with regard to cortical epilepsy, have brought into relief several facts which concur in demonstrating that the point of departure, the central organ, the anatomical seat of the epileptic convulsions, is represented by the motor centres of the cerebral cortex. This doctrine, warmly contended for by Luciani, on the basis of experimentation, is now shared in by almost all the authors who have been occupied with the study of cortical epilepsy, among whom it may suffice to name Heidenhain, Munk, Wernicke, Rovighi, Santini, Unverricht, Rosenbach and Danillo. The principal arguments favorable to the admission of a cortical genesis of the epileptic attack, whether partial or general, are:— (a.) The epileptic unilateral convulsions provoked by irritation of the cortex, share on the side of the body in which they are developed, those muscular groups whose cortical motor centres have been destroyed. In the work of Luciani we find recorded two experiments which we are pleased here to relate in a few words. A dog, the whole of whose motor zone on the left hemisphere had been des- troyed, with exception of that part which contains the centres for the muscles of the tongue, the face, and the mouth, became subject to repeated epileptic accesses, limited exclusively to these muscles, and of such intensity as to cause his death. Another dog, operated on in the left motor zone, whose cortical centres for the limbs were destroyed, was seized with convulsions of the jaw, with movements of the head, and now and then of the muscles of the right half of the face. Luciani cites, besides, an experiment by Franck and Pitres, which relates to a dog that, after removal of the centre for the left fore leg, pre- sented an access of partial epilepsy, characterised by con- vulsive shakings in the left hind leg and in the left side of the face, whilst the fore leg remained flaccid and immova- ble throughout the entire duration of the access. (b.) After the destruction of the whole motor zone of one side, excitation of the medullary substance lying directly towards the base of the brain and the bulbo-spinal 22 Giuseppe Seppälli. centres, is not capable of provoking convulsion on the opposite side. (c.) After extirpation of the cortical zone of both sides, excitation of the white substance does not provoke the epileptic attack. This fact, which was first demonstrated by Bubnoff and Heidenhain, meets, to a hair, the just re- mark made by Morselli, in the Phreniatric Congress at Reggio, to Luciani, to whom he observed, that in order to give a decisive proof of his theory, it was necessary to show that an animal totally deprived of the motor centres on both sides, no longer falls into an epileptic access, whatever may be the excitations brought to bear on it. But there is more yet. Unverricht made the very important observation that in some dogs, on which the cortical ex- citement produced a complete epileptic attack, extending to both sides of the body, by removing the whole motor zone of one side, e. g., the left, with exception of the centre for the orbicularis, and then exciting this centre, a convul- sive attack was obtained, which was limited to the right orbicularis, without participation in it by the muscles of this side, but the access was afterwards diffused into the whole of the left side of the body, where it commenced in the hind leg, and ended in the muscles of the tongue and the face. (d.) In the initial phase of the epileptic attack of cor- tical origin, extirpation of the motor centres which have been previously excited can arrest the access. Heidenhain, in certain cases, succeeded by the prompt extirpation of the whole motor zone of one side, in arresting the convul- sion on the opposite side of the body. Munk obtained the same result by cutting away the excited cortical centre. (e.) The convulsive access provoked by epileptogenous substances, such as picrotoxine and cinchonidine, is modified in animals whose cortical motor centres are mutilated on only one side of the brain. From several experiments made on dogs by Rovighi and Santini, under the direction of Luciani, it was found that the isolate contractions in the muscles of the face, the trunk and the limbs, which precede Cortical Epilepsy. 23 the general epileptic attack, either from picrotoxine or cin- chonidine, are not manifested in an equal and symmetrical manner on the two sides, but very weakly on the side op- posite to the destroyed cortical zone. Now, as the two above-named authors justly remark, if the initial convulsing effects, determined by the picrotoxine and the cinchoni- dine, are less manifest on the side of the body opposite to that of the destroyed zone, this signifies that in this zone are contained the motor centres, which are the first to feel the convulsing effects of these two poisons. All these facts are of themselves so eloquent as to in- duce, even in the most incredulous, the persuasion that there exists an intimate, immediate relation between the cortical motor zone and the epileptic access produced by excitation of the cerebral cortex, and that the motor zone is indispensable for the generating of the convulsive access. Several objections have been made to the doctrine which places the seat of epilepsy in the motor-zone of the cerebral cortex. In a lively discussion which was set on foot respecting this subject in the Phreniatric Congress at Reggio-Emilia, the distinguished Prof. Vizioli remarked, that the fact observed by Luciani, that dogs operated on, not in the motor zone, but in the sensitive zone, also pre- sented epileptic convulsions, is in contradiction to the cortical theory of epilepsy. Since, he added, it is no longer a motor centre irritated that avails to pcoduce the epileptic attack, but it can be provoked also by a part exclusively sensitive. Very well, this fact, as Luciani him- self well observed, is not in the least opposed to the doc- trine of epilepsy maintained by him. The excitation may set out from any point of the cortex, distant from the motor zone, and it is by its diffusion to the cortical motor centres that the epileptic access is developed. In order to combat the cortical genesis of epilepsy, we should be able to demonstrate that animals, in which the epileptic access is provoked by exciting a cortical point situate behind the motor zone, also fall equally under the access after destruc- tion of the motor zone. Instead of this, the experiments of 24 Giuseppe Seppälli. Rosenbach and Danillo show that the very opposite is verified. If on a dog the whole of the motor zone of one side is destroyed, or if a strip of the cortex between the motor region and the posterior region of a cerebral hemi- sphere, be taken away, and the occipital lobe be then ex- cited by an electric current, no epileptic access is provoked. On the other hand, if the cortical region situate behind the motor zone be destroyed, leaving this zone intact, excitation applied on its motor points determines the development of epilepsy. Further, extirpation of the posterior part of the cerebral cortex, effected when the convulsive attack has already commenced, does not interrupt it, but this happens if at Opportune time the motor region is destroyed. One of the strongest arguments that have been ad- vanced by the opponents of the cortical doctrine of epilepsy as it has been conceived by Luciani was, that in order to place it beyond contradiction it must be demonstrated that, not only in the inception but also in the diffusion of the epileptic attack, the cerebral cortex has an essential part. As it is admitted that direct excitation of the motor centres of one side provokes convulsion in the opposite side of the body, it must also, by consequence, be admitted, that when this convulsion invades the other side also, the direct ex- citation is diffused from the motor zone primarily stimu- lated, to that of the opposite side. But from the experi- ments of Albertoni and those of Franck and Pitres, it results that the extension of the epileptiform convulsions does not stand in necessary relation with the conservation of the cortical centres; for complete, bilateral, epileptic accesses may be provoked by exciting the motor zone of one side, after having previously destroyed the motor zone of the other side. We have, however, reason to hold, that these experiments do not absolutely exclude the idea that the diffusion of the epileptic attack depends on the excita- tion of the cortical motor centres of one side passing to those of the other side, for the whole of the motor zone of one side had not been destroyed, but only a part of it. Besides we have the experiments of Heidenhain, showing Cortical Epilepsy. 25 that after bilateral destruction of the motor-zone, epilepsy is no longer provoked, whilst by exciting the medullary substance of a hemisphere from which the motor zone has been previously removed, convulsion is provoked on the same side with the stimulus, because the excitation is, as Heidenhain admits, carried over into the intact motor zone. These experiments would therefore demonstrate that the cerebral cortex is indispensable alike for the development and the diffusion of the epileptic attack. # Unverricht, who has very profoundly studied the phe- nomena of the epileptic attack of cortical origin, concludes from his researches that the intactness of the cortical motor region is a necessary condition for the development of a complete epileptic attack, and he calls attention to a fact, which at first view might induce some doubts as to the participation, by the cerebral cortex, in the mechanism of the convulsion. He observed in certain cases in which the convulsion was limited to one side of the body, e. g., the left, that the limbs of the right either remained tonically extended, or participated, with the same rhythm, but in a feebler degree, with the movements of the limbs on the left. That in these cases we have an accidental phenom- enon, and not a true convulsive attack, laying hold of muscular groups on both sides of the body, seems to be shown by this fact, that the typical progression of the epileptic convulsion is not altered. In fact, in proportion as the convulsion is diffused cotemporaneously to the limbs of the side opposite to the excited motor zone, it is seen that the limbs of the other side also become subjected to slight muscular movements; the convulsive attack extends on this side also, commencing in the inferior (hind) limb, and in the meantime secondary muscular contraction may be observed on the other half of the body, which had been previously more forcibly struck by the convulsive attack. These secondary contractions are not at all modified by the extirpation of the cortex, and they continue even after hemi-section of the spinal marrow, consequently it is to be admitted that they are produced by a diffusion of the 26 Giuseppe Seppilli. excitement into the inferior gangliar groups. They cannot be placed on a par with the epileptic convulsions, because, in order to be consistent, the centre of epilepsy should then be sought in the medulla spinalis also. “The essential part of the epileptic attack,” says Unverricht, “ consists in the primary muscular contractions, which have a typical course round the body, and to their production the cerebral cortex is indispensable.” But even admitting that in epileptic convulsions of cortical origin, the excitement is diffused from the cortex into the inferior nervous centres, not the less on this ac- count is the importance of the cerebral cortex in the genesis of the convulsions. If, in a dog poisoned by picro- toxine, the motor zone of one side be removed, the con- vulsions which are produced, conserve, in the muscles corresponding on the sound side, the character of epilepsy proceeding from excitement of the cortex, that is, in being prevalently clonic, whilst in the muscles that depend on the mutilated cerebral hemisphere, they have a tonic form, as is observed to result from a bulbo-spinal excitation, and they are besides less intense. Furthermore, that the cerebral cortex is an essential element not only in the initial movements of epilepsy, but also in those succeeding in the attack, is demonstrated by the fact that extirpation of the cortical motor centres causes cessation of the convul- Sion in the corresponding muscular groups. Thus, oppor- tune experimental conditions being had, it is easy to pro- voke an almost general attack, in which, by previously extirpating their corresponding centres, the muscles of a region of the body, e. g., the face, the jaw, or a limb, will remain unaffected. We should therefore hold, that in both the genesis and the subsequent generalization of the epileptic access, the cerebral cortex has an essential, we would not say an ex- clusive participation, because we have not sufficient proofs that the subcortical centres do not also take part in the access. As an argument against the doctrine that the bilaterality of the epileptic access, produced by unilateral Cortical Epilepsy. 27 excitation of the cortex, depends on the passage of the excitement to the cortex of the other hemisphere, it has been stated that section of the corpus callosum does not prevent the generalization of the access. Franck and Pitres made, on a cat, a complete longitudinal section of the corpus callosum, and then by the motor convolutions of the right hemisphere they provoked an immediate, general and violent convulsive attack. It seems to me that such experiments do not suffice to invalidate the theory of the cortical genesis of epi- lepsy, since they presuppose an anatomical fact that has not yet been demonstrated, that is, that the commisural fibres of the corpus callosum are uniquely and exclusively the parts of communication between the cortical centres of the two cerebral hemispheres in animals. Besides, when section of the corpus callosum is made on an animal, the experiment becomes too complex, nor can it be excluded that the general convulsive accesses, which may be pro- voked immediately in it, by stimulating the motor centres of one side instead of depending on this excitation, are the direct consequences of the extravasation of blood into the lateral ventricles, consequent on the cutting of the parts, since we know that ventricular hemorrhages very readily follow general convulsive phenomena. The doctrine of Luciani on the pathogenesis of epi- lepsy has been combated by Franck and Pitres in their latest work. These two authors believe that Luciani has fallen into a double error in holding that epilepsy, what- ever may be its origin (toxic, cortical or peripheral), results always from an abnormal excitation of the cerebral cortex, and in concluding that the cortex is the central organ of the convulsions, resting on the simple fact that the con- vulsions succeed to the cortical excitation. As regards the first of these objections, urged by the two French observers, against Luciani, it does not really appear that they are of much importance. From the moment that Luciani posited the assemblage of the cortical motor centres as a sine qua non condition in the development 28 Giuseppe Seppilli. of epilepsy, it was very natural that he should admit an identical pathogenesis for epileptic convulsions produced by diverse causes. It would, indeed, be in open contra- diction of his theory to have admitted the contrary. The fact of epileptic convulsions being variable in form, accord- ing to their determining causes, does not exclude the idea that they depend chiefly on abnormal excitation of the cortex. The greater or less extension of this excitation in the cortical centers, its variable intensity in individual centers, the different mode in which it is diffused, and the different excitability of cortical points, may give us a reason for the various forms presented by the epileptic access. Pitres and Franck have reproved Luciani for not having taken into account of the experiments which show. that animals deprived of their cerebral hemispheres may still be subjects for convulsive attacks. It appears that the discussion which took place at the Phreniatric Congress, at Reggio, respecting the pathogenesis of epilepsy, was not known to them. In this discussion Luciani replied with precision to this objection, which was then made by Albertoni, Silvestrini and Chirone. Luciani asks: “With what propriety can we baptize as epilepsy convulsions that follow excitations of the bulb, after removal of the cerebral hemispheres, when they have not the most im- portant character of epilepsy, to-wit: the complete or almost complete suspension of consciousness, which can depend only on functional disturbance of the cortex, and the other character also of the epileptic access is want- ing, that is of convulsions at the first localized in certain groups of muscles, and afterwards becoming general (?) Indeed, in his memoir on the pathogenesis of epilepsy he cites the accurate researches of Cwsjanikow, by which this Russian physiologist has demonstrated that there exists in the bulb a centre of reflex general cramps, from which it is not surprising that there may be obtained general convulsions, uniquely dependent on reflexes aroused by excitation of the bulb, but which have not, however, any analogy to convulsions of epileptic character. Cortical Epilepsy. 29 As regards next the other assertion made by Franck and Pitres, that Luciani had based the cortical patho- genesis of epilepsy solely on verification of the fact that the convulsions succeed to the cortical excitation, we must declare it incorrect. Luciani only availed of this argument in a secondary way, and instead of founding his doctrine specially on the fact diligently observed and described by him, that in sequence to partial destruction of the motor zone epileptic convulsions may be devel- oped, which prevent this characteristic, that is, of being limited only to groups of muscles whose cortical centres have been spared in the operative act. The facts we have related, and particularly those of Unverricht and Heidenhain, regarding the mode of origin- ation and extension of the epileptic access, seem to us to be very valuable, as warranting the acceptance, in the present state of our knowledge of the doctrine of Luciani on the genesis of the epileptic attack. We must merely at the present say, that it seems to us a little too exclusive, as we shall show in a future work by us, on cortical epilepsy, studied clinically, limiting ourselves in the meantime to a brief record of a case of much interest, and which is perhaps unique in the literature we have had the opportunity of perusing. It is that of a woman of thirty years, who became epileptic at the age of twelve, after, as appeared, a cerebral disease. She presented left bodily hemiatrophy, very con- spicuous in the upper limb, and she had convulsive attacks, sometimes general, at other times partial, which had the characteristic of being initiated in the left arm, and becom- ing then diffused over all the same side. The left arm was affected with incomplete paralysis and contracture, the lower limb of the same side was paretic. She remained several months under our observation, and she died of diffuse miliary tuberculosis. In the autopsy I found complete des- truction of the so-called motor zone of the right cerebral hemisphere. The two ascending convolutions, the feet of the three frontal, and those of the two parietal, and the paracentral lobule were totally destroyed, and in place of 3O Giuseppe Seppil/i. them there existed a fibrous tissue, resistent and of spongy aspect, with small cavities full of serum and of a substance having a mucous appearance, which being examined in very thin cuttings under the microscope, presented no cellular element, but many sclerosed vessels, masses of pigment, fatty granulations and many amylaceous corpuscles. The medullary substance also, corresponding to the convolutions mentioned, was transformed, in its whole thickness, almost as far in as the ependyma of the ventricles, into a compact fibrous tissue. I further observed descending degeneration of the whole of the left pyramid. It is unnecessary to spend many words in demonstrating that this case cannot be reconciled with the cortical theory of epilepsy. We had met with a left hemiplegia, which had led us to suppose that the right motor zone was conserved in part, at least; but on the contrary we found it, on section, totally destroyed throughout. This case leads us to the hypothesis which is logically linked with the doctrine of the functional compensations of the brain. Luciani and Tamburini, in their researches on the motor centres, have admitted, in explanation of the dis- appearance of paralytic phenomena, after extirpation of the cortical centres, that the basilar ganglia may have a psycho- motor function, differing only in degree from that of the cor- tex, but in the absence of the latter, it is developed and aug- mented, and thus favors the improvement of paralytic states. Now, as epilepsy may be considered as the effect of a functional exaggeration of the motor apparatus of the brain, it is, in our belief, legitimate to suppose that basilar motor centres, when they supply the function of the destroyed cortical motor centres, may acquire, as these, the epilepto- genous property, by exaggerating their proper function in such a manner that in the case of absolute want of the motor zone, they may become points of origin and of diffu- sion of an epileptic attack limited to the opposite side of the body. We would thus explain, in the case cited, the existence of a partial epilepsy, with the complete want of the motor zone. Cortical Epilepsy. 3 I BIBLIOGRAPHY. HITZIG, “Untersuchungen über das Gehirn.” Berlin, 1873. FERRIER, “Experimental Researches on the Physiology and Path- ology of the Brain.” Paris, 1874. ALBERTONI, “Influence of the Brain in the Production of Epilepsy.” Milan, 1876. LUCIANI AND TAMBURINI, “On the Cortical Psycho-motor Centres.” Rivista Sperimentale di Freniatria, 1878. LUCLANI, “On the Pathogenesis of Epilepsy,” Rivista Sperimentale di Freniatria, 1878. - LUCIANI AND TAMBURINI, “On the Cortical Psycho-motor Centres.” Ibidem, 1879. CHIRONE AND CURCI, “On the Biological Action of Cinchonidine.” International Journal of the Medical Sciences. 1880. LUCIANI, “On Epilepsy Provoked by Wounds of the Head.” Report of the Phreniatric Congress of Reggio-Emilia, 1881. ALBERTONI, “The Action of Medicinal Substances on the Excitability of the Brain, and a Contribution to the Therapeutics of Epilepsy.” Rivista Sperimentale di Freniatria, 1881. BUBNoFF AND HEIDENHAIN, “Ueber Erregung und Hemmungsvor- gänge innerhalb der Motorischen Hirncentren.” Pfluger's Archiv. Bd. 26, 1881. MINKowsky, “Ueber die Aenderungen der elektrischen Erregbarkeit des Gehirns.” Inaug. Dissert. Königsberg, 1881. RovigHI AND SANTINI, “On Epileptic Convulsions from Poisons.” Florence, 1882. DANILLO, “Contributions to the Pathological Physiology of the Cor- tical Region of the Brain, and the Medulla in Poisoning by Ethylic Alcohol and the Essence of Absinthe.” 1882. ORSCHANSKY, “Ueber den Einfluss der Anämie auf die elektrische Erregbarkeit des Grosshirns.” 1883. DANILLO, “Ueber die Reaction der Hinteren Abschmitte der Hirnrinde auf elektrische Reizung.” 1883. FRANCK AND PITREs, “Experimental Researches on Convulsions of Cortical Origin.” 1883. UNverRICHT, “Experimentelle und Klinische Untersuchungen über die Epilepsie. 1883. RosFNBACH, “Zur Frage tiber die Pathogenese der Epilepsie.” 1883. The Insane Population of the United States. By W. E. SylvestER, M. D., Willard, N. Y. No. unfrequently an asylum officer is asked his opinion regarding the increase of insanity in this country; and, though sad may be the fact, he can only admit that the number is rapidly growing larger. For various reasons it is impossible to ascertain the exact number of our insane population; but from informa- tion furnished by the United States census office and asylum superintendents and that gathered from other sources, we shall be able to obtain a general idea of the prevalence of insanity in our midst at the present time. We must accept all estimates of the number of insane as merely approximate, but it is probable that this portion of our population will number one hundred thousand persons. The census shows that twenty years ago the number was only 24,042. In 1870 it had reached 37,432, and in 188o we are called upon to provide humane treatment for 91,959 lunatics. From 1870 to 1880 the increase of insanity was over IOO per cent., while that of the total population was about 26. These figures do not represent an actual increase, but during this period a large number of insane persons, previously concealed, were brought to public notice by more thorough investigations. The proportion of insanity is greatest in New England; while the increase has been most rapid in the Western States. In this country, aside from several large county asylums, there are eighty State and forty private institutions for the care of the insane, with a capacity for about 40,000, but accommodating 53, 192; thus leaving probably 45,000 to be cared for elsewhere. In looking over the reports from asylums, one finds an almost universal cry for more room. [32] Insanity in the United States. 33 We will give briefly, as far as we have been able to learn, the present distribution of our insane population. In New England we find Maine with about I,542 lunatics, of whom 1,000 are crowded into the single asylum that was originally intended for only 500. However, the building of a new hospital for the insane is under advise- ment by the legislature. New Hampshire has 1,056 insane, and cares for 312 of them in the State asylum, which can accommodate 325. Vermont has 1,015. In the one asylum there are 369 patients, which number can be increased to 400 without overcrowding. In Massachusetts we find the number of insane to be 5,700. Of these, 3,657 are in the fourteen asylums scattered over the State. Rhode Island, with one State and one private asylum, has about 700; of which 525 are in institutions. Of I,723 in Connecticut, about 1,000 are cared for in hospitals for the insane. The State asylum is somewhat overcrowded. New York shows the enormous insane population of I5,OOO. In this State we find thirty-five institutions for the care of these unfortunate people, accommodating II,343 patients; while it is claimed that there are 4,OOO provided for at home. sº The insane cared for in institutions are divided as follows:— State Asylums, - - - - - - - - 3,647 City Asylums, - - - - - - - - 5,016 County Almshouses, - - - - - - 1,869 Private Asylums, - - - - - - - 558 State Asylum for insane criminals, - - I44. State Asylum for insane emigrants, - IO9 The counties of Kings and New York contemplate build- ing additional asylums for their chronic insane. The returns from New Jersey give the number in that State as 2,405. The two State asylums contain about 34 W. E. Sylvester. 1,400; the five county institutions care for 7 Io, and the re- mainder are with friends and in the almshouses. The lunatics in Pennsylvania number 8,304. In the eight asylums, with a capacity for 4,OOO, there are 4,739 patients. º Delaware has about 200, and the majority are provided for at home. Maryland claims about 1,900, and has 915 of them in the various asylums and retreats, 200 in almshouses, and 731 at home. The District of Columbia has 938 insane people. Of this number 860 are in the Government Hospital for the Insane. The census of this institution, which is I, I55, also includes the insane of the United States army and navy, and of the Marine Hospital service. Virginia comes next on our list with 2,4II; and provides for I,098 in asylums, IO2 in almshouses, and the remainder at home. West Virginia has about 985 lunacy cases. For want of accommodation the asylum is obliged to refuse many appli- cations for admission. These applications are filed away and taken up for consideration as vacancies occur. The number in North Carolina, as given by the last census, is 2,028. Here there are three asylums with 640 patients. - Out of I, II2 in South Carolina, 425 are cared for in two asylums. In Georgia we have about 1,800 of these dependent persons; 1,218 of whom are in the only asylum. This asylum has under progress of construction a detached block to accommodate 250 more. Florida, with an insane population of about 253, has 167 in the asylum. The Alabama Insane Hospital, having a capacity for 750, has 613 cases out of 1,521 in the State. Mississippi has 1,147. The present asylum is full, and another, soon to be finished, will have accommodations for 25O. Insanity in the United States. 35 About one-half of the I,002 insane in Louisiana are in the various asylums. The census returns give the number in Tennessee as 2,404. This State has one asylum in operation, and another in course of erection. Kentucky adds 3,000 to the number. Of these I,800 are in asylums, and the remainder at home and in alms- houses and jails. Next we have Ohio with 7,286, and about 3,500 in hospitals for the insane. Indiana follows with 4,OOO, and the present asylum capacity is about 1,400. The three asylums now being built, when completed, will accommodate 2, IOO patients Illinois has 5,500, and complains that the asylums are overcrowded. Michigan, with her 3,000 insane, makes the same com- plaint. Here we find two State asylums in operation, and two more in process of erection. Wisconsin's 2,800 cause the cry of overcrowding to be still heard. Minnesota probably has 2,OOO, and accommodates I, IOO of them in the two asylums. In Iowa we find an addition of 3,000 to this portion of our population. The capacity of the present asylums is being increased to give room for 3OO more patients, and a new hospital is about to be built. The number in Missouri is 3,310, and the great majority are cared for at home. Arkansas has one asylum, accommodating at present 250 patients; but the exact number of insane in the State is not definitely known. * Of the 1,564 suffering from some form of mental disease in Texas, 550 are in the asylum. Another asylum, with room for 350 patients, will soon be completed. Kansas provides, in two asylums, for 690 out of a total of I,297. Nebraska has 450 lunatics, and the asylum shelters 330 of them. - 36 W. E. Sylvester. The capacity of the Colorado Insane Asylum is for 225. We find I 17 cases there, which probably is nearly all of this class in the State. Nevada's insane number about 160, and are all in the asylum. In California it is impossible to give a reliable estimate of the number of insane in the State outside of asylums. In the State asylums there are 2,650 patients, being many more than they were intended to accommodate. Last of the States comes Oregon with about 378, and nearly all of them are in the asylum, which has room for 412. As near as we have been able to ascertain the number of insane in the various Territories are as follows: Arizona, - - - - - 2 I | New Mexico, - - - I53 Dakota, - - - - - 75 || Utah, - - - - - I 5 I Idaho, - - - - - - 16 || Washington, - - - - I4O Montana, - - - - - 59 Wyoming, - - - - 4. In many of the Southern and Western States politics enter largely into the management of all institutions, and such a system of frequent changes cannot be productive of the best administration; particularly in asylum service where a special course of experience and study is required. From the South, where many of the insane are kept in jails and poorhouses, we hear pitiable stories of their treat- ment. It is a great satisfaction to see that the public is begin- ning to regard an insane person as one suffering from a disease, and to view asylums as hospitals for the alleviation or cure of such ailment; instead of considering the lunatic as a convict fit for the ball and chain, or a gloomy cell in the dark attic of some private dwelling; and the asylum as a place worse than the Prison of Chillon. - With the advancement of scientific knowledge, let us hope that the people will appreciate the real condition of this unfortunate portion of our population, and see to it, that they are given the benefit of the most approved methods of treatment. Responsibility as Affected by Alcoholic Anaesthesia. INTELLECTUAL AND MORAL FA CULTIES WEAKENED AND BENUMBED, INABILITY TO DISCRIMINATE BETWEEN RIGHT AND WRONG – DISGUISED BY A UTOMATISM.3% By T. L. WRIGHT, M. D., Bellefontaine, O. HEN the material instruments of the mental and moral powers are, for a protracted season, inhibited in function by the anaesthetic or paralyzing property of alcohol, great and fundamental disturbances must ensue in the manifestation of mind and morals. Clearly pronounced anaesthesia withdraws the nervous centres from independent and spontaneous activity, and compels the mind to assume, in all its essential functions, that inferior plane of exhibi- tion, which is simply routine, imitative, habitual, automa- tic. It is impossible for a mind in which the feeling of the ego is weak, and the sense of personality is wavering or destroyed, to so establish its own relations with morality, as to be capable of distinguishing accurately between right and wrong. To perceive what is right requires alert- ness, and the power of ready and clear discrimination in the mental operations. To recognize wrong, not only re- quires the same mental properties, but also a sensitiveness of the moral faculties, which is wholly inconsistent with the obscurity and sluggish movements imposed by alcoholic anaesthesia. & The stereotyped questions propounded in courts of law, respecting the moral capacity of criminals, are as follows: “Could the prisoner distinguish between right and wrong? Did he know when he committed the act that he was * This is one of three chapters “On Alcoholic Responsibility,” in a manu- script dissertation on inebriety. y [37] 38 T. L. Wright. doing wrong?” The importance of a familiarity with all the terms employed in these questions, when applied to ascertained facts in criminal cases, is apparent when it is remembered that they embody what the courts in England and America insist shall be considered as the only test of legal responsibility. But the power of discriminating between the finer shades of the moral qualities must be weakened when consciousness is defective ; and it is always defective to some degree, in every grade of anaesthesia. When it is considered that habitual anaesthesia may become, to a cer- tain extent, constitutional and hereditary, we are compelled to admit that the transmission of an alcoholic neurosis may eventuate in the establishment of a mental condition which is incompetent to determine the distinctive qualities of the moral attributes. That is, it may eventuate in the founding of a criminal constitution, through the laws of heredity. I believe that normal consciousness, and a clear sense of personality, or egoism, are nearly convertible ex- pressions; and I repeat in effect, though in somewhat different language, what I have already said: unless the feeling of personal identity is clear, it is difficult to bring self into satisfactory relationship with the delicate and re- fined principles of the higher morality. I make a distinction, however, between the purely ra- tional process of discriminating as to the nature of moral qualities, and the living and appreciative feeling of the same qualities. When the distinguishing characteristics of right or of wrong are assimilated in the sound mind, they be- come motives to conduct; and this is very different from the cold and automatic admission of their existence, without their warming and moving impulses. The knowledge of right, abstractly or automatically, and through reason only, and the knowledge of wrong abstract- ly and by habit or rote may be present, and yet the power of discriminating between the two, the power of using the reason and the sensibilities together, in a comparison or analysis of the elements of right as relates to the elements Responsibility as Affected by Alcoholic Andesthesia. 39 of wrong, may be wholly absent. It is possible to have an idea of right without feeling it, for knowledge and sensi- bility are not always conjoined; and so also there may be a rational idea of wrong, without a living appreciation of its qualities and possibilities. There may exist, indeed, an utter incapacity to enter into such a process of comparison between the two attributes, as to apply the results, to a determination of the character of conduct. Relevant to this subject are the words of Seppilli: “We must remember that cerebral activity is manifested under two different aspects—that of the conscient and of the in- conscient. The conscient activity or consciousness is con- stituted of knowledge possessed by the ego of its own acts —that which happens within itself, which happens in its relations with the external world. On the contrary, in the inconscient activity of the brain, denominated also auto- matism, all those actions enter in which the ego takes no part or is aware of any; but these latter are combined and directed so as to resemble those which the ego perceives, wills and directs.” Here is explained the difference between responsible and automatic life. Not only is the fact recognized that normal life must be founded upon a conscious ego, but the fact is also recognized that a life founded upon an inconscient ego may resemble the former. The first is dominated by an ego which perceives, wills and directs; while the other is an exhibition of habit, imitation, custom, in brief, automatism. Human conduct directed by a con- scious ego comes of a capacity to discriminate between right and wrong; and it is therefore amenable to the re- quirements of responsibility. But conduct resting upon automatism, into which the conscious ego does not enter, and which is incompetent to discriminate between right and wrong, cannot be esteemed as a proper subject for ordinary responsibility. Yet the obvious features of these two lines of mental existence resemble each other; or, rather, the automatic life imitates and resembles the truly rational life. 4O T. L. Wright. The conclusion now forces itself upon the attention, that it is exceedingly difficult, very frequently, for a wit- ness to answer the usual questions proposed by lawyers, respecting the ability of a criminal to discriminate between right and wrong. The imperfections in sensation, and the inhibition on the moral faculties imposed by alcoholic anaesthesia, so depress the mental powers as to compel them to assume the characteristics of automatism ; but the semblances of automatism are so similar to conscious rationality, that they disguise the actual incompetency of the moral powers. The beholder very often cannot say with absolute certainty, from the ordinary life of the criminal, whether or not he can discriminate between right and wrong. That automatic life is merely imitative, and is not something independent and individualized, is shown by the fact that, in any country, the automatic exhibition follows the pattern of the rational operations peculiar to the same country. The automatism of the Hindoo re- produces the manners and customs of the Hindoo religion and civilization. The automatic existence of the barbarian is a reflection of the actual life and habits of savagery. The “right and wrong” test of responsibility, although of undoubted value, is too frequently lamentably deficient. . It has wrought the greatest hardship and injustice to multitudes of persons accused of crime, and has spread desolation and woe into hearts that were worthy of sym- pathy and pity. As a test of responsibility, it should stand subject to explanation and impeachment; it should be examined by the light of circumstances, and become the object of severe inquisition and of undoubted pre- ponderance of proof. It should never be admitted un- supported by collateral evidence--by evidence converging from other lines of inquiry; and especially, it should never be invested with the force of demonstration, as though it were impregnable and beyond the reach of question. Independent of the habit of automatism, incident to the depravation of the intellectual and moral powers by Responsibility as Affected by Alcoholic Anaesthesia. 41 alcoholism, there appear in the same train of mental dis- aster, certain other troublesome and unlooked-for phe- nomena. It is clear that the chronic inhibition or paralyza- tion of certain functional forms of mind and morals by the force of anaesthesia must end in the establishment of special habits of mind and morals, corresponding with the defects produced by the inhibitory power. The formation of habits, as well as their character for pertinacity, may thus be readily comprehended. When a habit becomes a part of the constitution, the phenomena of living are, with respect to that habit, automatic. But habit and autom- atism are not under the supervision of judgment or will, and consequently they have little or no place in the formation of comparisons, or the determinations of choice. They cannot, by any power of their own, act as arbiters in questions wherein the qualities of right and wrong are involved. * The tendency of defective mental function, to lead the mind into the ruts of automatism, will be appreciated upon a consideration of the ready disposition of the sound mind itself to follow the channels of habit. Common and healthy mental activity is largely automatic. Yet the peculiar sensitiveness of the moral nature, which is a lead- ing characteristic of humanity, renders the mind of man ex- ceedingly acute and inquisitive respecting points of moral- ity. And so it is, that although much of mental and motor function becomes a matter of routine and habit, the moral character of motive is, in ordinary circumstances, severely analyzed. Of course, when the co-ordinating centers are seriously repressed, as by alcoholism and its accompanying disabilities, the nature of morality, of motive, of right and wrong, is very imperfectly felt and comprehended. Habits of thought are acquired slowly and painfully. It is only necessary to advert to the difference between man and the lower animals. The former gains by long and laborious experiment a habit of mental activity fitted to his exalted sphere; while the latter are born with in- stincts sufficient for their lower place in life. The tedious 42 T. L. Wright. repetitions of sensations, perceptions, conceptions and the motor activities, becomes at last, to a great degree, a habit, which it is impossible to discard. Mental, and even motor life, are in time mere repetitions of long enacted powers, which are applied to the usual incidents of human existence. The power of walking erect is established with much balancing of the body and mental calculation. But at length the acts of walking, running and jumping are strictly automatic, requiring little if any exercise of the judgment or conscious will in their performance. Even the insane walk and run very well; but no one would claim, because an insane man can perform the act of walking with facility—an act, in its abstract nature de- manding judgment and nice calculation—he is therefore not insane, but is in possession of fine powers of reason and discrimination. There are many other courses of nervous function, of a purely mental or moral nature, which may become automatic. The mature mind often arrives at intellectual conclusions with wonderful directness and speed. What was once slow and anxious training, what was once pur- sued in regulated and prescribed steps, and over diffi- culties, is made by practice to be instinctive and auto- matic. The alphabetical order of reasoning no longer obtains. Small things are taken for granted. An immense number of positions are habitually assumed ; and in or- dinary life, the mental processes, like eagle-flights, are grand movements from point to point, from headland to headland of thought, not lingering to go through the tedious routine of detailed mental activity. And thus men not only sane, but men insane, live and think and act automatically in the common circumstances of daily existence. And it may be impossible to determine from the conduct of even an insane person, whether or not he can properly discriminate between the qualities of right and wrong; for, while automatism resembles rationality, it calls for no active process of discrimination. Many truly insane criminals are adjudged to be sane and responsible Responsibility as Affected by Alcoholic Anaesthesia. 43 because their automatic and common mode of life is like that of rational minds; while the cheat and pretender is acquitted upon the plea of insanity, because he shams under all circumstances and upon all subjects. It is not an impossibility that a mind may be imbued with an imitative and automatic capacity, which will direct the routine avocations belonging to its lines and asso- ciations, with a success above that of the average minds of its grade; and yet, this very success may disguise the real imperfection and emptiness of its powers. When the slow invasion of disease finally reaches such a point as to assume the domination of motive, and the control of con- duct, the ordinary appearances of automatism fail to illustrate and establish the character of the responsibility involved. The motives and the conduct originating from brain disease, or from toxic impressions, occupy a plane that is different from automatism; and one of these classes of mental and moral exhibition, cannot, by any process of reasoning, or any rule of justice, be brought forward to illustrate and interpret the other class. The “test,” of a sensitive knowledge of right and wrong, is fraught with difficulties, and it is sometimes liable to such interpreta- tions, as will confound the judgment respecting the mo- tive or incentive involved in a criminal act. When a concealed and carefully guarded delusion of insanity, or when the impulsion of alcoholic or other toxic agents circulating within the brain, suddenly and with irresistible violence, breaks forth into deeds of atrocity, the mind for the time being is operating independently of habit. Yet, while moving independently of automatism, it is directed by a power immeasurably greater—namely, the force of insane delusion, or the unbidden hallucinations born of noxious impressions. In such circumstances, it would not be correct to infer that a criminal, because his ordinary life resembles the common life of men in general, could discriminate correctly between right and wrong, or that he knew he was doing wrong when he committed the unlawful act. The Hygiene of the Nervous System and Mind.” THE RELATION OF THE NERVOUS SYSTEM TO CHOLERA AND ITS PROPHYLAXIS AND NEUROTHERAPY. THE CURE AND PREVENTION OF DYSPEPSIA AS A NERVO US DIS- EASE. THE NEUROPATHIC DIA THESIS ; ITS QUARANTINE AND TREATMENT. By C. H. Hugh Es, M. D., St. Louis. Lecturer on Psychiatry and Neurology, St. Louis Medical College; Honorary Mem- ber British Médico-Psychological Association; late Superintendent and Physiclan of the Missouri State Lumatic Asylum, etc. ACENTURY ago Cullen made the observation that from all that he could discern of the movements of the human body in disease they were all so intimately associated with and dependent upon the nervous system that they might in a manner be called nervous (“Quan- tam ego quide m video motus morbosi fere omnes a motibus in systemate nervorum ita pendent, ut morbi fere omnes quodammodo Nervosi dici queant.”—Cullen's Nos. b. II., p. 181, Edin. Ed., 1780.) This proposition has been sustained from that day to this by every step taken in the forward march of medicine, for, notwithstanding the significant and valuable discoveries of spores, fungi, microbes, bacilli and other microscopic revelations and their relation to morbid states of the blood and organism, it is not until the nervous system is morbidly touched and yields in disordered action (psychic, trophic, motor, vaso-motor or other parts of the sympathetic, es- pecially in its ganglia), that the characteristic phenomena of distinctive disease appear. The intangible virus of zy- motic fever, which “touches the life of all the blood cor- ruptibly” is first revealed in the malaise, cephalalgia, jactitation, insomnia or somnolencia and delirium of the *Read before St. Louis Medical Society, Sept., 1884. [44] Hygiene of the Nervous System and Mind. 45 higher psychical centers of the cerebrum. And so other fevers after the symptomatic revelations of a disturbed and struggling nervous system notify the physician that his aid is needed, the microscope, if he have time then to use it, may reveal the proximate cause of the morbid commotion to be, or have been micrococci or filiariae, but until the assaulted nervous system succumbs, we know nothing of the mischief brewing or the danger threatened, and the specific microbe sustains the same relation to the resultant phenomena that the draught of air or sudden exposure to change of temperature does to the vaso-motor paralysis and resultant mucous and vascular congestion phenomena of a common cold or its graver results in localized in- flammation. Bacilli are not disease, but only potent causes, just as stone in the bladder and sanguineous, fibrinous or serous exudates are consequences of morbid systematic action. º Malaria, of which we know so much and yet so little, reveals itself in chills and fever; both nervous phenomena, and in congestions and delirium and coma, which but for the yielding of the vaso-motor nervous system and dis- turbance of the psycho-motor area of the brain could not occur, and when the final ending of all physical function is foretold in the graver blood empoisonments of yellow and other fevers, the last expiring movement is in the nervous system, in those “idle comments of the brain which foretell the ending of mortality.” This is true of the rigor mortis of sudden death and the last comatose symptom of cholera collapse. We have seen, in the pro- gress of medical observation and research, many obscure diseases, as pathology has grown clearer, assigned to their proper place in the nervous system, from exophthalmic goitre to eczema and from cholera to dyspepsia, notwith- standing that in connection with the contagion and spread of cholera Asiatica, a contagium microbe, thanks to the labors and noble heroism of Koch, is proven in the comma bacillus as the essential causative or resultant excitant and propagative factor. Yet cholera is essentially a disease of 46 C. H. Hughes. the nervous system in its symptomatic display, especially beyond the bowels. The phenomena of this dread disease which demand our attention are essentially nervous ; the paralyzed vaso- motor control which admits of the fatal aqueous exuda- tions, which permit the exsanguined and shrunken features, and the fatal exhaustion, the sudden paralysis of appro- priating power of the centres presiding over nutrition, the complete exhaustion of the trophic nervous system which makes the administration of medicine in certain fatally predestined cases appear like a solemn mockery, the pinched, contracted visage, and the painful and finally painless cramps, and exhausted power of inhibition, which sooner or later appears, all tell us how essentially nervous are the phenomena of this pestilence, when once its hold is secure upon its victim, and suggest the importance of a well sustained, vigorous, tranquil and resisting nervous system in warding off its destructive attacks. Though this pestilence no longer walketh in darkness, and though it wasteth less at noonday than in the distant past, its sad work still goes on under the glare of the brightest light of science, but there are hygienic methods which to-day diminish susceptibility to contagion, by im- parting public confidence, reducing mental demoralization and panic, and maintaining the general health of com- munities up to a higher standard. Though by sight of science we have probably found the cholera bacillus (the bacillus of cholera Asiatica and of cholera nostras per- haps) we can not yet entirely by power of science keep this potent living infinitesimal from evil, yet we can resist and circumvent its power, not alone by clean streets and dwelling places, sunlight into the dark places and disin- fection and pure air where dirt and filth abound, but by clean and strong bodies and by well sustained, well rested, invigorated and tranquilized nervous systems, built up to the power of resistance to the very maximum of physio- logical strength, not stimulated spasmodically by sudden fright after the pestilence has come, but trained up in Hygiene of the Nervous System and Mind. 47 advance by adequate but temperate nourishment; by ample rest of brain for the fullest possible recuperation, each night, of the day's wasted power; by making cities profoundly quiet in time of the pestilence by interdicting the needless noises both day and night, which keep the cells of the brain and nervous system agitated and restless, when they might be restful and in condition of repair for more work; and by a trained abeyance of the passions, the abandonment of exhaustive vices which undermine the nervous system and fit it to succumb to light assaults of disease. To this end, in anticipation of an invasion of cholera here next year, the prudent will finish up, before the epidemic comes, present business enterprises which promise unusual mental strain, worry or other tax on their pow- ers, and permit a little of that reserve nerve force to ac- cumulate, which, hitherto, like an improvident man with his bank account, they have been in the habit of expend- ing as fast as it has accrued. Cholera is not in strictest sense a filth disease, at least in this country, though filth by contaminating the atmosphere and thus impoverishing the blood and impairing the nervous system, furnishes favorable conditions for its taking hold on the organism. On the contrary, putrefaction bacteria, as Koch asserts, destroy the comma bacilli or arrest their multiplication. Alcoholic stimulation, at least to dissipation so-called, must be abandoned; the physiological tone of the vaso- motor system maintained and the perfect stability of the higher cerebral centres—the psycho-motor and psychical— must be permitted to become re-established up to the point of their highest resisting power. Habitual alcohol- ization is a paralyzant of the vaso-motor nervous system as well as of the cortex of the brain, beyond all doubt, notwithstanding it acts as a temporary excitant, and mo- mentarily stimulates latent power into increased activity. The frequent habitual use of stimulants like alcohol ex- alts the heart's activity, exhausts the tonicity of the brain by causing it to expend its latent reserve power 48 C. H. Hughes. daily; and leaves its vessels dilated and its substance op- pressed; the cerebra-spinal fluid crowded out of the perivascular spaces and the brain is prepared then for apoplexia and coma. Tobacco, too, is a vaso-motor paralyzant and motor depressant and weakener of vital power in those in whom tolerance has not been well established, and had better be used with moderation or abstained from. To the end of proper prophylaxis in regard to the nervous system, the hours of rest and labor should be regulated by municipal authority, that over-taxed human beings, especially among the poor, should not be made ready subjects for attack and almost certain victims to the fatality of cholera. Night work should be discountenanced so far as practicable and prolonged work-hours without adequate rest following should, when practicable, be pro- hibited. * The schools should be looked after; tasks should be lightened and invigorating relaxation lengthened both for teacher and pupil, and more daylight and pure air let into the school room. Fewer hours of study should be required; overcrowded rooms should not be tolerated and basement lunch, or recitation rooms, abandoned. Those who hold people to service should see that they do not engage in dissipating and exhausting pleasures during hours which should be devoted to sleep, and should enjoin staying at home and resting instead of wasting their nervous powers by frolicking till midnight, and then retiring to be awakened unrefreshed for the morning's work. Cholera in the kitchen imperils the health of the parlor and the health of rooms upstairs is concerned in the welfare of the occupants of the laundry. Saloons should be closed at an early night season if not during the day, in times of epi- demic, and men before they get dead-drunk in them should be taken home and put to bed by the police. All causes, public or private, of depression of the nervous system should, in times of this epidemic be avoided; long and exhaustive funeral services, especially Hygiene of the Nervous System and Mind. 49 in crowded and illy ventilated rooms, tiresome and Osten- tatious funeral processions, cars and rooms vitiated by tobacco smoke and depressing human exhalations. Men may deny that nature's God commanded the Sabbath day for rest, but physicians know that imperious nature demands it, if longevity of human life would be reached. The law of Moses commanding a respite from customary labor one day in seven was founded in physio- logical wisdom, nature and nature's God inspired it. And for this reason physicians should demand that the sounds of busy industry should cease one day in seven, that the ceaseless bustle and din of business, which so tries the nervous system during the week, shall cease each seventh day, for one of recuperative rest to brain and mind; that all needless noises which harshly grate upon the ear and rob tired nature of needed repose should be suppressed, in order that enough of sleep, and rest, “sore labor's bath,” “tired nature's second course,” may come to the people of the heart of the city to “knit up the week's ravelled sleeve of care.” There is too much unnecessary noise even on ordinary business days, and too much noise allowed 1n the night time, and altogether too much on Sunday for the highest health of the people of our great American cities. The wealthy suburban resident does not suffer so much from this cause of nerve disturbance as the working man and subordinate business man who lives down town, but the needless wear and tear of brain and nerve from un- necessary and preventable city noises, if prevented, would add very materially to the healthful endurance of the people in time of cholera and at all times, prolonging life and averting insanity and premature failures of the nervous system in other directions. To be well repaired, man, like any other machine, must rest, and rest of brain and nerve is disturbed through the channels and centers of audition and sight, as well as through those of motion, etc. The prayer of conservative physiology is for rest, for the salvation of the resisting power of the nervous system to devastating pestilence, and the power of resisting and 5O C. H. Hughes. sustaining disease in general, is obtained by adequate rest of the organism, which is a condition of its repair and power. The cause of much of the premature decrepitude and nerve degeneracy, and breakdown of our day, is in the many inventions man has devised whereby he robs him- self of timely rest. The morning newspaper often read through before breakfast; the telephone in his house to call him at any and all times aside from his repose; the electric light to keep his brain unduly stimulated through the retinae; the railroad and the sleeping coach which may keep him constantly on the rail (if he chooses to so travel) for continuous weeks without rest from the noisy and exhaustive cerebro-spinal concussions of this mode of travel; hasty meals and telegrams, and business, and nightmare sleep, all commingled, wither and wreck lives innumerable, which, under wiser management might end differently, and the needless noises of the city, the bells and steam whistles, howling hucksters, noisy street cars, yelling hoodlums, that make night hideous with soul jarring sounds, hasten the premature endings of useful lives. And when, superadded to all this unphysiological strain, we have the assault of a pestilence that poisons, like cholera, how much exemption can such overwrought organisms expect? How much of resisting immunity can such overstrained and exhausted nerve force oppose to the invading foe P If the epidemic comes, as it almost surely will next summer or fall, there should be a common understanding among physicians to demand as much rest as practicable for the people, and, by comity among themselves, they should lighten each other's labors and no one should work continuously night and day. It is not long after an epidemic comes before the long watching nurses and the tired, over-taxed doctors become its victims. The lesson a pestilence teaches is not only cleanliness but temperance, and restful resisting vigor for the nervous system and the conservation of its powers, maintaining Hygiene of the Nervous System and Mind. 5 ſ the functions of the body in the presence of a blood de- stroying and vitality depressing enemy. With the human organization, in a long contest with disease, the blood is the life, but if the nervous system have secured to itself, by ample rest and frugality and economy of expenditure; and by freedom from overstrain and vicious indulgence, have es- tablished the habit of claiming and securing to recuperative use its own elements from the blood, it will be long in yielding and longer still in perishing under the assaults of disease. It is this trained resistance of the nervous system by which it is taught physiologically, pending a successfully resisted attack, to claim its own nutrition, even while the blood is depressed by the presence of a pestilential virus, which, in my opinion, constitutes immunity from recurring attacks; the comma bacillus is destructible too in strong healthy gastric juice as Koch and Klein have shown, and it is through a vigorous, well poised nervous system that we may be assured of the destructive potency of the gastric digestive secretion. The inferior animals too, whose nerv- ous systems are unshattered by the vices and overstrain of civilization, are more exempt than man from cholera. In time of epidemic visitation the illy-fed, unrested, pov- erty stricken or vice-broken succumb even more frequently than those whose ambition for wealth and schemes for success rob them of the full benefit of sleep and regular food and recuperating rest. Many a man well endowed and unweakened in his nerv- ous centers goes about unharmed with the same amount of malaria in his blood, probably, which causes another, less strongly fortified, to succumb to a fatal form of congestion. All other things being equal, the tranquil-minded and restful and daily and adequately recuperated nervous sys- tems of a community afford the best and longest immunity in time of pestilence. The unrested and unrestful, the weary and the heavy laden, the vice-broken and the unsteadily endowed nervous systems furnish the most numerous and earliest victims. 52 C. H. Hughes. Insomnia is a thief that robs the brain and nervous System of power and circumvents recuperation—a factor in nervous breakdown more potent than all others, yet it is preventable and curable by remediable measures, public and private. There is, therefore, without dwelling more in detail, an obvious and important sanitary hygiene for the nervous system in time of great epidemics, and the time for the beginning of preventive measures should be in advance of the actual presence of the morbid invader. That time is now, for when the pestilence shall have come and gone, those who are fittest in the tone and resisting power of their nervous systems to survive, will live out the scourge. The weak and organically unprepared will succumb. The practical deduction from the foregoing to avert cholera from the human system, in addition to such measures as quarantine it from the country or chemically destroy the bacillus and prevent it from coming into con- tact with the organism at all, is to eat only such slightly irritating substances as will promote the gastric secretion, without inducing catarrh of the stomach or bowels, and keep such a supply of healthy gastric juice in the stomach as will destroy such comma bacilli as may find lodgment there. Take the best possible care of the physiological vitality of the central nervous system by every known means of rest and repair, and by frequent moderate eating. Maintain by normal nutrition and electrizations the neces- sary tone of the solar plexus and the perfect physiological integrity of the cerebro-spinal axis; keep away from the cholera infected when the system is exhausted and the Sup- ply of gastric juice is likely to be scanty or weak in quality; cultivate and maintain a state of hopeful mental tranquility by avoiding every source of mental overtax and unrest. The successful prophylaxis of cholera consists of some- thing more than quarantine or chemical disinfection. The chemistry of the nervous system itself, if we but invoke it, may give us aid. The cultivation of resisting nerve force involved by healthy organisms is worthy of our Hygiene of the Nervous System and Mind. 53 consideration. A wise prophylaxis and therapeusis seems indicated in adequate rest of the nervous system, in gal- vanism, which maintains its tone and static electricity which promotes its vigor at the same time that it has the probable power to destroy bacilli and in hot water as near 150° F. as practicable, taken internally, which gives nerve tone and dissipates congestion through its influence on the vaso-motor system, and in chloral, which gives strength through restorative rest and which is also power- fully antiseptic. The following brief epitome of the anatomical and physiological data of the subject may serve to show still more plainly how essential is the integrity of the nervous system in its highest physiological power to the prophy- laxis and endurance of cholera. It is also a sufficient anatomical résumé for the subject that follows. The local innervation of the stoumach and intestines is carried on through interlacing of the nerve fibres and ganglion cells imbedded in the sub-mucous and muscular coats. Auerbach's plexus in the muscular and Meissner's in the sub-mucous tissue. Descending from the medulla are the pneumo-gastrics, and from the solar plexus of the sympathetic come gastric branches. The pneumogastrics and the gastric branches of the solar plexus may be said to encompass the stomach. Vaso-motor nerves branching through the splanchnics from the solar plexus accompany the gastric vessels. These nerves have connection with medullary centers and pass through the cerebral peduncles and thalami aptici to higher centers in the cerebrum. The salivary and gastric secretions, as well as the movements of the stomach and bowels, are dependent upon nerve influence and the regulation of inhibition and excitation. Gastric secretion is partly a local reflex act through peripheral stimulation from the interior of the stomach, through the nerve branches which go to Auer- bach’s plexus imbedded in the sub-mucous tissue, but the amount and quality of this secretion will depend largely 54 C. H. Hughes. upon the integrity of the general ganglionic and whole nervous system, especially upon the tone of the solar plexus and the brain. The gastric secretion may be inhibited or excited by a powerful mental impression; a painful emotion sup- pressing and an agreeable one, as of the remembrance of a delicious dish, exciting it and the salivary secretion also. A reflex from the gustatory nerves to the brain may pass to the stomach and excite it. Great fatigue as well as great pain suspend both gastric secretion and appetite. During the week of the great St. Louis fire in 1849, the ravages of cholera, which up to that event had reached a mortality of over two hundred a day out of a popula- tion of fifty thousand, almost entirely ceased, so stimulat- ing and invigorating was the excitement of that week to the brains and nervous systems of the people, the psychical exaltation inseparable from the sudden necessity thrown upon so many business men for repairing the sudden damage and re-establishing their abruptly interrupted busi- ness. Some of the germs, too, may have been destroyed by the great heat, but it was only the business part of the city that was destroyed, where but little cholera pre- vailed except on the steamers. The writer was in the city at the time and recollects this to have been the fact. And after a week had expired the pestilence raged as before in all its resistless and relentless virulence. The destructive power of fire suggests the value of crematories for destroying the cholera bascilli found in the clothing and dejecta of cholera patients. THE NECESSITY OF HYGIENIC MEASURES IN REGARD TO DYS- PEPSIA ARE BECOMING MORE AND MORE APPARENT EVERY YEAR. We have become a nation of dyspeptics, not because we eat too much but because we work too much with our heads and too inopportunely. Fret and worry and ambition to get rich keep the brains of Americans over active. The precarious results of business, the gambling ventures in stocks and sudden reversals of fortune and Hygiene of the Nervous System and Mind. 55 recurring threatenings of panics, and the feeling of in- security which periodically possesses the public mind, keeps the American brain constantly anxious and active to arrest impending failure or miscarriages of cherished enterprises, and the brain thus incessantly overworked and overworried, robs the ganglia of the sympathetic of their due innervation; the pneumogastrics too are impoverished and the innervation that belongs to the stomach through the solar plexus upon which a healthy quality and abundant quantity of gastric juice depends, is not received by it. The victim of dyspepsia is a victim of self-robbery. The overstrained brain surreptitiously takes from the stomach what it needs for healthy func- tion. It is not the bolting of food, so much talked of, that usually causes dyspepsia, but this voracious robbery of the brain, which takes all the nerve force of the body, which brings dyspepsia to the ceaselessly active brain worker and brain worrier. I have time and again seen men recover from dyspepsia. while under treatment for an overworked brain, without a single remedy addressed to the stomach, recover under rest and recuperation of mind and those agencies which induce them. DYSPEPSIA A DISEASE OF THE BRAIN AND NERVOUS SYSTEM. Forty years ago the distinguished Amariah Brigham observed that “in a majority of cases, especially among students, dyspepsia is primarily a disease of the brain and nervous system,” and before him the great Abercrombie wrote that “symptoms which really depend on disease of the brain are apt to be referred to the stomach.” The testimony of the thousands of watering place and mountain air resorts and sea voyage cures are wit- nesses of the fact that dyspepsia is largely a disease of the brain and nervous system. The changed home and scenery cure, where depressing cares are dropped and irritating environments are exchanged for agreeable mental surroundings and brain and nerve rest, is the surest 56 C. H. Hughes. therapeutics for the average dyspeptic, aside from a rational home treatment addressed to the rest and recuperation of the nervous system. If any one is dyspeptic let him relax his business and secure a rest for his brain, is a safe therapeutic axiom, and this suggests the hygienic procedures of preventive medicine. If the salvation of the people from gradual as well as sudden destruction be legitimate subjects of sanitation, then the investigation and removal, so far as practicable, of the causes of nervous dyspepsia are legitimate subjects for the efforts of physicians and sanitarians, and it should claim attention of one branch of civil service reform. In all departments of the public service hours of work ad- justed to the physiological endurance of the human nervous system and no more should be enjoined, and the time for rest demanded by the physiological necessity of the or— ganism should be secured to all government employees. The State could avert a good deal of nervous break-down and insanity in this way. The service of nervous dyspeptics, besides being a Crime against nature, in a government that develops it in its employes, is never the best service ; and in times of national trial or peril is not the kind of service to be relied on. All the causes, mental, moral and physical, of neuratrophia, or malnutrition of the nervous system are legitimate subjects of study for the sanitarian and physician, and the prevention of premature nervous exhaustion in the people of the country is the collective salvation of the nation. A sound nervous system develops and fosters a vigorous optimistic patriotism, confident of the future of the country and capable of putting forth the essential energies to prevent natural decay, while pessimists are bred by illy-nourished and unrested brains and nerves, and the conditions for the fulfillment of their sombre and fatal prophesies are in their nervous systems. Strong brains are the defensive and protective brawn of a people, whether in peace, war or pestilence, and a wise people \, Hygiene of the Wervous System and Mind. 57 will continually foster a judicious nerve sanitation. A well nourished nervous system is the foundation of personal courage and endurance, and in a whole people it is the best security for the prosperity of the state. The condi- tions and attendant vices of our present civilization tend to undermine nerve-stamina, and sanitation should address itself to arrest the individual and national nerve disin- tegration, which is in excess, in so many occupations, over recuperative conditions and physical regeneration. THE NEUROPATHIC DIATHESIS. There are too many insane, idiotic and feeble-minded people in this and other civilized countries. A proportion of one to every five hundred people annually falling mentally maimed in the battle of life is too large. The neuropathic diathesis and the insane tem- perament is becoming the fatal heritage of too many of our people; there are too many brain-weakened and nerve- degenerate victims strewing the pathway of our progress. Unstable nervous systems are everywhere, and they often wrongly influence public thought and state legisla- tion to the detriment of the race. Cranks and intellectual squints and obliquities, inheritors of neuropathic tenden- cies, from the vice, ambition, or misfortune-perverted brains of an overtaxed ancestry abound, instead of that nervous stability which, like righteousness, exalts a nation and without which a vigorously righteous people can not be made, but in lieu of which will exist a sickly moral sentimentality running after unfounded moralisms and pathies and driven by every wind of spurious doctrine. To be logical, brains must be strongly endowed. Cram- ming and straining of brains, especially such as are not uncommonly well endowed by nature, give activity but not power, and all systems of education which disregard individual capacities that come of unstable neurotic en- dowments are vicious; all plans which seek to draw out all the powers of a growing child, leaving no reserve force daily for building up the growing brain into its possible 58 C. H. Hughes. proportions of power and beauty, are wrong and must and do result in ruin. The wants of the evolution period of the nervous powers in the human economy can not be ignored, with- out arrested development and stunting of the mind and body, or more properly speaking the body; the mind is for all practical purposes, the body; its capabilities and powers being dependent upon the quality and tonicity of the brain texture. (Mens sana in corpore samo, and vice versa.) Education should repress tendencies as well as draw out powers, and to do this it is not moral platitudes that are demanded, but the training up of the organism in the way it should go, by the light of neurological and psycho- logical law; by regarding the physiological wants of the growing brain, letting it rest when it needs rest and feed- ing its powers during the process of evolution of the higher centers of the thought layers of the cerebral cortex, as well as of the basal ganglia, and by looking to the abundant nutrition, and daily repair of the ganglionic system which presides over the functions of organic life, and this part of education is not one of object lessons or of words, but of true physiological training by supplying the growing organism with the chemical elements of nerve repair richly and without stint. No Dotheby Hall plan of richness will suffice, but the true cream of nutrition for the brain and nerves as fast as they feel the famishing influence of disintegrating work. The proper building of a brain, with its wondrous powers and possibilities, is the grandest work that can engage the attention of educators, but the chief aim, or at least the principal effect of our present unphysiological system, is to exhaust it in many respects. Even the violinist will look well to the tone of his instrument, and to atmospherical conditions, before he attempts to use it, but the average educator treats the harp of a thousand strings regardless of the conditions of keeping it in tune, and as though, despite the worst ill usage, it would keep in tune forever. Aygiene of the Nervous System and Mind. 59 It is a long time since Grotius wrote “the care of the fluman mind is the noblest branch of medicine,” so long that, like all other medical facts long ago promulgated, it bas become common property, and the care of the mind should be the chief concern of the people. History shows us how nations have perished and been blotted out by reason of degeneracy of brain and nerve or- ganization, and how people, once masters in peaceful arts and war, have grown powerless or passed into third rate powers among the nations. “Greece, Rome, Carthage, where are they P" And why are they not as of yore? And Spain and Mexico how changed ' And other nations saved from absolute extinction by revolutions bred of unstable neurotic organizations, by which, in blood and carnage, hordes of neuropaths have been destroyed, and the neuro- pathic degeneration of the nation has been stayed through regenerating war permitting mainly the fittest to survive to propagate a fitter race to longer live. No regenerating revolutions have yet swept over our land, save the late unhappy war" with the South, itself born, in my humble opinion, of unstable passion, which, with better brains and steadier nerves, might have been averted, and we should have a care lest by carrying the forcing process of our public school and collegiate systems too far without due regard to the recuperation and growth in steady brain power of our children and youth, we fit the rising and coming generations for the repetition of £nsanguined history; for revolutions and wars must needs come, like pestilence and famine, to fit the survivors of a largely unfit people to live. As waste precedes repair and is a condition of it, in brain or muscle, and as it is the condition of the display of power in physics, so in the human economy the Ordinary waste may give place to extraordinary destruction, that that which is most physio- logical in a people should be separated from the patho- logical and it thus be made possible for a nation by the rejuvenation of revolution and war to live out an otherwise inglorious destiny. 6O C. H. Hughes. We see in our own day individuals stricken down in their prime, with preventable brain and nerve destruction, and it is fortunate for the welfare of the race that so many die prematurely without leaving behind greater multitudes than there are, dowered with the fatal tendency to break down early in life in brain and nerve. Yet too many, like Dean Swift, begin to perish at the top, even before middle life. Greeley, President Johnson, Vice- President Wilson, and hosts of others, whose names occur to you among the not remotely dead, tell how very prone the brains of our public men are to break down under the strain of life's demands. The hygiene of the mind and nervous system should be such as to make these too common occurrences ex- ceptional. Men should know that blood vessels kept over full by habitual and too prolonged mental excitation, aided by over stimulation of the heart by alcoholic indulgence, must sooner or later end in pathological dilatation of brain vessels, in serous exudation, or in arteriole rupture, or in heart failure or hypertrophy and their fatal conse- quences. There is a limit to the capacity of the brain or of any other organ of the body for labor, without ample rest and repair, even as there is a limit to the capacity of inanimate machinery less intricately and wonderfully wrought than the mind, to endlessly work on. Nations and states and communities have need of quarantine against the hordes of neuropaths that hover about, or fill high places or go about in public, ready, like dynamite bombs, to explode under slight, sudden pressure, and destroy. The Guiteaus and Boothes and Lawrences who shoot at Presidents, in times of public political excitement; the Passenantes and Hadfields who make Kings the mark of their unprovoked vengeance; the Freemans and Smiths who make tragedies of child- sacrifice to delusive inspiration, like the horrors of Pokas- sett and Westminster, and murder and arson and crimes. innumerable and nameless, are often only possible through predominance of insanity or the insane temperament, the Hygiene of the Mervous System and Mind. 6I spread of which is more to be dreaded in any community than the worst of physical pestilences, for its baneful work goes on from generation to generation ; through it the infant now just suckling at the breast is fatally predestined to slay her who gives it its first life sustenance; through it babes just born are strangled by mothers in the throes of puerperal mania; through it are fratricides, patricides and matricides otherwise impossible, and many of the most horrible and awful of crimes which in the public press daily keep our thoughts on blood. It is a great good for- tune for the perpetuation of the average stability of the race that so many who are possessed of the insane tempera- ment early commit suicide and that, possessed of feebler resisting power to morbid disintegrating forces, they die prematurely, or before propagating their species of inter- current diseases, and before others are made the victims of their fatally unstable heritage. When the neuropathic diathesis has developed into insanity, in its aggravated and dangerous forms, society is willing to house the lunatic and let him out again when he ceases to be harmful, but an insane man is never harmless to society if he be in the prime of life. If he be married, or likely to marry, the reason is obvious, and all the more harmful will he be if a victim of some doubtful undemonstrative form of insanity whose existence is so often denied, of insanity in psycho-sensory rather than in pronounced delusional form. Insanity and the insane temperament are therefore sub- jects of the greatest concern to any people, of the utmost importance to communities as well as to families. A matrimonial alliance once formed with an impending lunatic means the founding of a family with a tendency to brain degeneracy, and the likelihood of a progeny of cranks, or over active or feeble-minded and unstable eccentrics or positive lunatics, and the individual and the State must suffer. Our modern civilization does not justify the radical measures which would have occurred to Ly- curgus had he been confronted as we are, with the fatal 62 C. H. Hughes. ravages of the insane temperament; but law can and must, if the nation is saved, do something more than simply corral the physically dangerous lunatic in asylums, which is now the present tendency and only remedy employed. A certain degree of exemption should be proven, suffi- cient at least to give a reasonable chance of regeneration, before marriage contracts are sanctioned. Positive lunatics should of course be forbidden mar- riage, and marriage should be forbidden to confirmed drunkards, for drunkenness breeds hereditary epilepsy, dip- Somania, imbecility and insanity; and marriage should be forbidden to epileptics. The instructive typical family history given by Morel, of immorality, alcoholic excess and brutal degradation in the first generation, followed by a record of hereditary drunkenness, maniacal attacks and general paralysis in the second, hypochondria, lypemania, systematic mania and homicidal tendencies associated with sobriety in the third, with feeble intelligence, stupidity and mania in youth and transition to complete idiocy and extinction of the family in the fourth generation, is not more instructive than the history the writer has given of the O. Z. family, (Vide ALIENIST AND NEUROLOGIST,) where from the early intem- perance of the father (though reformation subsequently followed in the father) all of the immediate descendants are neuropathically endowed, one child having been first nymphomaniacal, then generally maniacal and demented, another maniacal, a third dipsomaniacal and morally de- ranged, a fourth epileptic, the fifth markedly hysterical and gangliopathic and the sixth, still a youth, markedly neuropathic. The peril of the race from the increase of the neuro- pathic diathesis should set us all to thinking, and those who have the authority, to acting in the direction of self- preservation and indirectly of the ultimate life of the nation. The multiplication of hospitals for the insane and of inebriate asylums and of schools for the feeble-minded, and improved methods of treating nervous diseases and Hygiene of the Wervous System and Mind. 63 of homes for impoverished neuropaths of every grade, from the hospital for nervous diseases proper to the almshouse where many of these wrecks are lodged, does not cure the evil, though they serve to hide it somewhat from public sight. We best provide against the spread of small- pox by general vaccination, not by numerous pest houses, so by general preventive sanitation can we avert the threatening spread of the now prevalent and growing dis- eases of the nervous system. The neuropathic diathesis, the insane constitution that breeds its like and burdens the State with hereditary im- becility, idiocy, insanity, deaf-mutism, and the lesser de- grees of mental defect, must be made the subject of statutory enactment and enforced law; sentimentality must yield to fact; the teachings of nature must be as decided and as sternly enforced as her own unerring edicts are. Why should the drunkard and epiletic be permitted to beget a race of imbeciles, epileptics, idiots or criminals? Why should the life-long criminal and the pauper be allowed to go on reproducing his defective kind, the lunatic like- wise, and all the mentally maimed of whatever degree, especially when by forfeiture of liberty they fall under proper custody of the law; and why should generation after generation of these miserables be allowed to be brought into being to become either burdens upon the state or victims of its misdirected vengeance, when prevention is possible, and better for the state, and only justice to the helpless and prematurely doomed to an unchosen ex- istence worse than death? If municipalities may lawfully quarantine yellow fever and cholera, why may not, and why ought not, this greater destructive agency than plague or pestilence, which never ceases its ravages—the hereditary descent of the organically vicious and defective —be stopped by law P No pestilence that ever walked in darkness or destruction that has wasted at noonday has done greater harm to mankind than the silent, ever active destructive power of hereditary degeneracy of brain and mind. Instead of visiting punishment on the heads of 64 C. H. Hughes. these weakened victims of entailed disease, let law go to the ſons et origo, and stop this vicious progeny from being thrown upon a world in which they are unfitted to live. More than a century ago Cabannis said: “As the liver secretes bile and the stomach gastric juice, so the brain secretes thought,” a proposition exact enough for comparison, and as a working basis for sanitary legisla- tion, for, though thought and mind are probably some- thing more than secretion of the brain, mind is dependent for its every normal movement upon the integrity of the brain, and wrong and misleading thought will be evolved if the physical subtratum of the mind—the human brain— gets out of order. The duty of our day is to see that, so far as practicable, we transmit to our descendents healthy brains and vigorous nervous systems, and to this end personal endeavor and municipal legislation should be in- voked. A true civilization should show development and not degeneracy of brain power, and the proudest monu- ment to our wisdom we might erect would be one of neu- rotic regeneracy, a richer legacy to the coming generations than railroads or telegraphs, phonographs or telephones, electric lights, or aerial navigation successfully accom- plished, for without neurotic regeneracy these blessings will prove curses and promoters of still further neuropathic decay, and final extinction of mind. To enjoy these, power of the nervous system and mind should be increased, not diminished; yet in them, and the press, injudiciously used, are the seeds and elements of destruction. Let the present generation, with all of its advance- ment and advantages, have a care for its strength of brain and nerve, and the brain and nerve strength of those who are to follow it. e PARETIC DEMENTIA.* IS IT A PSYCHOSIS, A NEURO-PSYCHOSIS OR A COMPLICATION OF THE PSYCHOSES 2 By JAS. G. KIERNAN, M. D., Chicago, Ills. Medical Superintendent of Cook County Hospital for the Insane. HE cases, herewith presented in tabular form, are for solution of the question such as came under my observation in the Cook County Hospital for the Insane, whose history could be obtained with sufficient accuracy to render them available raised in the preceding article: Name. § § 3 |Early Mental | State at Last Obser- Menstruation. §.ºr. >k >k >k >k >k >k This story as related by Hoffmann is singularly con- nected and is told by him in such a plain, unvarnished manner, with such deep feeling that the listener is greatly moved thereby. It is the recital of a martyrdom. And still there is not an iota of truth in the whole story. Sworn testimony taken in New Orleans expressly contradicts his statement as to what occurred there. He never had a merchant tailoring establishment. The philan- thropic Frenchman like Manso, the guardian angel of Tasso, is only a creature of his imagination. He never had any wealth ; he never even had a large sum of money. The incidents said to have occurred in Cincinnati are equally imaginary. No such thing, as he relates, occurred in his house; this is testified to by his co-tenants, and the very persons to whom he himself refers. He was never infected with any venereal disease, so far as Dr. Fishburn can recollect. The Doctor is positive he never treated him for any such ailment; he is equally certain that he never treated Hoffmann for poisoning, and therefore did not say what is attributed to him by Hoffmann as men- tioned above. His wife is a very plain looking, hard-working woman, to whom this world has been a vale of tears. Her griefs nave left their indelible impress upon her countenance. Her character is the very best, as is testified to by peo- ple who have known her for years as co-tenants of the same house, neighbors and friends. She has worked hard, day and night, to raise her family, to clothe them, to feed A Case Record in Forensic Psychiatry. 93. them and to educate them. And she has raised them well ; they are praised as good children. She has paid all the expenses of the family, and owes no person any- thing; even when her husband left her and went away she paid his debts contracted to that day. The greatest burden she has had to bear have been the vagaries of her husband. As to him, Hoffmann, the testimony is rather conflict- ing. Some who knew him well describe him as a shift- less sort of a fellow addicted to drink, and using up all his earnings for this purpose. Others say quite dif- ferently. One witness in particular, a gentleman, an artist, informed me that he had frequently met Hoffmann pre- vious to the year 1876 in the evenings at some beer saloon ; that they conversed frequently upon many topics, and that he, Hoffmann, seemed to be a very well-informed person. In 1876 the artist went to Europe and was gone for some years. When he again saw Hoffmann he found him greatly changed; he was now shiftless, addicted to drink and rather irrational in his talk. At places where he worked as cutter he was regarded as “cranky.” Meeting accidently a gentleman in whose employ Hoffmann had been some years ago, I asked him, casually, whether he recollected ever having a man by the name of Hoffmann in his employ. “What!” he answered, “that crazy man P” And then related a rather peculiar act of his in connection with his employment. Various other queer doings of his, in different places where he worked, are related of him by fellow-workman. * >k >k >k >k >k >k >k From the foregoing it is clearly seen that the man labors under an hallucination—his wife's supposed infi- delity and her retention of his imaginary wealth. This hallucination has gradually grown upon him and waxed stronger. The enmity and bad feeling thereby engen- dered towards his wife would, in the natural course of events, extend to the children, or to any one particular child, if the child or children sided with the mother. In 94 Pł. Illoway. this particular case the son had always sided with the mother, and on one occasion ordered Hoffmann out of the house. The idea of his wealth was a fixed one with him. He abandoned his wife because she was unfaithful; but his money, his hard earned savings, which his dishonored wife carried around with her in her bosom, this he must have, and he made one last effort to obtain it peaceably. Shortly after his return from New Orleans he called upon Mr. H. Goebel, an attorney,” with whom he was well acquainted, and asked him to go to his (Hoffmann's) wife and demand of her, and make her surrender his money— seven thousand dollars. The lawyer paid no attention to the matter, knowing, as he says, that “Hoffmann never had any money.” Hoffmann called on the lawyer several times reiterating his request, but seeing that the latter would do nothing for him he ceased coming. Mr. Goebel also states that he intended to inform Mrs. Hoffmann to àe on her guard as Hoffmann had returned, but from some cause or other he neglected to do so. A few days thereafter the killing occurred. The culmination of all this imaginary suffering, these wrongs inflicted upon him, and lastly what perhaps had greatest weight with him and affected him mostly, the retention of his money which he had made a last effort to obtain peaceably, was a delirium, a delirium of perse- cution, and in the natural order of things there remained but two alternatives: suicide or murder. He committed the murder. In judging of a person's sanity or insanity, there is one point that is of the greatest importance and is of great aid in arriving at an opinion, and that is the family history. What is the family history of the prisoner P By authentic documentary evidence from the authorities of his native town, wherein his parents lived and where he was born, it is officially certified that his father was of * The present Republican Candidate for Probate Judge A Case Record in Forensic Psychiatry. 95 decidedly irritable temperament, flying into an uncontrol- lable passion on the slightest provocation. His brother's character was like that of his father. In the prisoner these characteristics were exaggerated to a high degree. Already in his early youth he was very nervous, very irritable, and over a trifle that displeased him he would go into such a rage and fury that, oblivious of his surroundings and of all consequences, he would do the utmost. Persons here who knew his parents well, state that the father and mother were both eccentrict and were known all around the district as the “crazy Hoffmanns.” One sister, as I have been informed by a responsible party, is completely demented, and has been confined in an asylum in this country for the last thirty years. Here we have clearly shown the seed that have borne such bitter fruit. The neurotic temperament in his family is demonstrated. His father, though not insane, was no doubt on the verge of it. Prof. Ball (the eminent French psychologist,) in a lecture on the “Frontiers of Folly,” calls eccentrics semi-alienated. In his sister the hereditary taint reached its climax in complete dementia. He, the prisoner, is hallucinated. Therefore, in this case, there can be no question of his insanity. He is a monomaniac. In the lecture above quoted, speaking of hallucinated persons, Prof. Ball says: Without doubt in the majority of cases the hallucinations are only a symptom of the mental malady that dominates the situation, but it happens sometimes, it happens frequently, that these sensorial troubles become the cardinal points of the insanity, the real source of the delirious conceptions. The patient thus becomes insane because he was subject to hallucinations. In the new hand-book of mental diseases by Dr. Bra,t in the chapter on hallucinations the author says: “The hallucinated form a class of very dangerous patients. Treat- ing of the duration of the malady, he says: “The duration * La Tribune Medicale (Paris), No. 755, 1883; “Les Frontieres de la Folie,” Cours de M. Ball. f Manuel des Maladies Mentales, par Dr. Marie Bra, Ancien Interne, St. Anne, Paris 1883. 96 H. Illoway. of hallucinatory troubles is, in the great majority of cases co-equal to the existence of the life of the individual— the prognosis is, therefore, certainly an unfavorably one.” Further on in the chapter on treatment it is stated: “It is of the greatest importance to surround the hallucinated patients with the most rigid surveillance so as to prevent any attempts at suicide or homicide. Generally the time comes when incarceration in an asylum becomes an absolute necessity.” >k >k >k >k >k >k >k In accordance with the results of my examination of the case and the argument thereto appended, I certified to the court. Meanwhile, a storm passed over our city, the court-house was burned and many things were changed. The lawyers who had been first appointed to the case went out of it and two others were appointed, and he was tried under the indictment for murder. For the reasons already given, which I believe are ample and sup- ported by good authority, I testified in court that John B. Hoffmann is insane. I believe he is incurably insane and should be placed in confinement for the period of his natural life. A P P E N D I X . After his trial and condemnation I visited him again, July 21st. His demeanor was more cheerful than on my first visit; a smile was on his face and he seemed in good humor and well satisfied with himself; he was being fed much better now, he said. He conversed cheerfully and intelligently on indiffer- ent topics, and displayed a good memory. I asked him in what year he left New Orleans ? He answered in 1863. “You must have been there in Butler's time P” “Oh yes,” he said. “We all had to take the oath again; though we Germans were always Union men and loyal, we still had to swear allegiance again to the United States.” I asked him whether any of his family came to see A Case Record in Forensic Psychiatry. . 97 him P He said no, he had not seen any of them since the trial ; he was very anxious to see the children. A little while before I came in, he had asked the jailer whether he could not take him home to see his family. Referring to his wife he said he did not want to see her any more—a woman who, for five long years, chloroformed her husband that she might carry on her nefarious prac- tice. She had made him miserable. She had executed her threat to be revenged on him for the death of Kirch- ner.” She had made him impotent. She had accom- plished this by making him drink of her menstrual fluid.i When he died he wanted the doctors to open him and examine him internally; he was positive they would find a terrible state of things. He requested me to see that this was done. Referring once more to the story of his hav- ing been poisoned, he said: “One evening I came home from work and, while eating my supper, my wife asks me how do you stand with your lodges P [ He, Hoffmann, belonged to several orders, seven or eight, paying life insurance.] I told her it was none of her business; what did she want to know for P ‘Oh,' she said, ‘I merely asked out of curiosity.' I told her I was in good standing in all of them. The next evening thereafter, she poisoned me, but Dr. Fishburn saved my life.” I asked him whether he still belonged to the lodges P. He said, “No, I do not; but I left them like a respectable, honest man. I paid up everything and then resigned.” .# Speaking of his lawyers, he said: “The last two are gentlemen, and did all they could for me; but the first two, especially Mr. [referring by name to one of them, a German] did not do right; but I know why; my wife bought them up. She has fifteen thousand dollars of my hard earned money, and she paid them well. Why did they not bring my witnesses P. They say they are dead; I can prove by letters, received from them, they are * This threat he mentioned above. + This must be some popular superstition. He asserts that many doctors told him that his impotency and ailments resulted from this. 98 H. Illoway. not dead; Dr. Hegewish is at Matamoras. But my wife paid them and they would not get them. “I hope I may get a new trial; but if I am to hang I should like to accomplish one thing first, I want to show up my wife's true character. It is true I killed that young man, but he was not my son, he was a bastard.” I asked him when it was he had attempted suicide P He smiled and said: “That is a foolish story. I read it in the papers at the time; it is not true; I am an honest upright man and it is against my principle to do any such thing. Why, if I wanted, I could hang myself here.” >k >k >k >k >}: >k >k It is unquestionable that we have here as well-defined a case of monomania as can be found in any of the records on that subject. PROC EED IN GS OF THE THIRTY-EIGHTH ANNUAL MEETING OF THE ASSOCIATION OF SUPERINTENDENTS OF AMERICAN INSTITUTIONS FOR THE INSANE. The Thirty-eighth Annual Meeting of the Association was called to order at IO o'clock A. M., Tuesday, May 13th, 1884, at the Continental Hotel, Philadelphia, Penn- sylvania, by the President, Dr. John P. Gray. Members present during the session: J. B. Andrews, M. D., Asylum for the Insane, Buffalo, New York. J. P. Bancroft, M. D., Asylum for the Insane, Concord, New H in pshire. W. J. Bland, M. D., Hospital for the Insane, Weston, West Virginia. J. P. Brown, M. D., Lunatic Hospital, Taunton, Massachusetts. W. T. Browne, M. D., Asylum for the Insane, Stockton, California. R. M. Bucke, M. D., Asylum for the Insane, London, Ontario. D. R. Burrell, M. D., Brigham Hall, Canandaigua, New York. John H. Callender, M. D., Hospital for the Insane, Nashville, Tennessee. H. F. Carriel, M. D., Hospital for the Insane, Jacksonville, Illinois. George C. Catlett, M. D., Lunatic Asylum, St. Joseph, Missouri. Walter Channing, M. D., Brookline, Massachusetts. John B. Chapin, M. D., Willard Asylum for the Insane, Willard, New York. R. H. Chase, M. D., State Hospital for the Insane, Norristown, Penn. Edward Cowles, M. D., McLean Asylum for the Insane, Somerville, Mass. John Curwen, M. D., State Hospital for the Insane, Warren, Penn. A. N. Denton, M. D., Asylum for the Insane, Austin, Texas. R. S. Dewey, M. D., Eastern Hospital for the Insane, Kankakee, Illinois. Pliny Earle, M. D., Lunatic Hospital, Northampton, Massachusetts. O. Everts, M. D., Cincinnati Sanitarium, College Hill, Ohio. Theo. W. Fisher, M. D., Lunatic Hospital, Boston, Massachusetts. T. M. Franklin, M. D., City Lunatic Asylum, Blackwell's Island, N. Y. J. Z. Gerhard, M. D., Pennsylvania State Lunatic Hospital, Harrisburg, Pennsylvania. g W. W. Godding, M. D., Government Hospital for the Insane, Washing- ton, D. C. { John P. Gray, M. D., State Lunatic Asylum, Utica, New York. Eugene Grissom, M. D., Insane Asylum, Raleigh, North Carolina. " John C. Hall, M. D., Friends’ Asylum for the Insane, Frankford, Philadel- phia, Pennsylvania. : © tº * : . : [99] IOO Proceedings. Charles J. Hill, M.D., Assistant Physician Mount Hope Retreat, Baltimore, Maryland. S. Preston Jones, M. D., Pennsylvania Hospital for the Insane, (Department for Males.) Philadelphia, Pennsylvania. Alfred S. Livingston, M. D., Wa-Wa, Delaware County, Pennsylvania. P. L. Murphy, M. D., Western North Carolina Insane Asylum, Morgan- ton, North Carolina. Charles H. Nichols, M. D., Bloomingdale Asylum, New York City, N. Y. George C. Palmer, M. D., Asylum for the Insane, Kalamazoo, Michigan. J. W. illoughby Phillips, M. D., Assistant Physician, Burn Brae, Kelley- Ville, Pennsylvania. T. O. Powell, M.D., Asylum for the Insane, Milledgeville, Georgia. A. B. Richardson, M. D., Asylum for the Insane, Athens, Ohio. D. D. Richardson, M. D., Department for the Insane, Almshouse, Philadel- phia, Pennsylvania. J. D. Roberts, M. D., Eastern North Carolina Insane Asylum, Goldsboro, North Carolina. Ira Russell, M. D., Highlands, Winchendon, Massachusetts. John W. Sawyer, M. D., Butler Hospital for the Insane, Providence, R. I. S. S. Schultz, M. D., State Hospital for the Insane, Danville, Pennsylvania. A. M. Shew, M. D., Hospital for the Insane, Middletown, Connecticut. George S. Sinclair, M.D., Assistant Physician, Hospital for the Insane, Halifax, Nova Scotia. E. E. Smith, M. D., Assistant Physician, Asylum for the Insane, Morris Plains, New Jersey. & Henry P. Stearns, M. D., Retreat for the Insane, Hartford, Connecticut. J. T. Steeves, M.D., Provincial Lunatic Asylum, St. John, New Brunswick. J. Strong, M. D., Asylum for the Insane, Cleveland, Ohio. H. A. Tobey, M. D., Asylum for the Insane, Dayton, Ohio. George B. Twitchell, M. D., Keene, New Hampshire. J. M. Wallace, M. D., Asylum for the Insane, Hamilton, Ontario. John W. Ward, M.D., State Lunatic Asylum, Trenton, New Jersey. The Secretary read the following letter from Dr. A. P. Tenney: ToPEKA, KANSAs, May 9th, 1884, Dr. JoHN CURWEN, Secretary, &c. DEAR SIR:—As I am unable to participate in the gathering of Super- intendents on the 13th, and as I understand Dr. Knapp will not be there, it seems to me that Kansas, now ranking among the first as an agricultural State, should be heard from as to the prosperity of her institutions for the insane. Our present population is not far from one million two hundred thousands. The growth of the State this year is estimated as likely to be one hundred and fifty thousands. The proportion of insane is about one to one thousand population, or not far from twelve hundred insane in the State. The asylum at Osawatomie, for some years and at present in charge of Dr. A. H. Knapp, has about four hundred and twenty patients. The Topeka institution has two hundred and fifty-nine. A building will be completed this year which will give room for two hundred and fifty more, which with the six hundred and seventy-nine now in the two asylums will Proceedings. t IOI by that time leave nearly four hundred outside of asylums. The State has, however, for some years, made appropriations for all who are refused ad- mission to the asylum for want of room, and has manifested a purpose to care for all of this class in the State. - Two hundred and ninety-nine applications for admission have been made since July 1st. One hundred and eleven have received letters of ad- mission to Osawatomie, one hundred and forty-three to the Topeka Asylum. Seventy-five have been discharged recovered from this institu- tion during the same ten months, and twelve only have died. I have not the figures of restoration and death for Osawatomie Asylum. The last Legislature appropriated about two hundred thousand dollars for additional room and other improvements. We have erected a new building for kitchen and bakery, boiler-house and laundry, which are now nearly ready for occupation. These take the place of temporary buildings erected five years ago, and are quite well suited to the needs of a large institution. The work of fitting up with new furniture and machinery keeps me closely at home and from meeting you at this time. My dear friend and earliest teacher in the care of the insane, Dr. C. A. Walker, will be missed by you all. You will remember of our riding to- gether at the St. Louis meeting eight years ago. Pardon me for writing so much. Wishing you all a profitable and cheering meeting, I am, Yours truly, A. P. TENNEY. A letter was also read from Dr. A. E. Macdonald assigning reasons why he could not attend this meeting. On motion of Dr. Chapin, Mr. D. A. Ogden, one of the Trustees of the Willard Asylum, was invited to take a seat with the Association. The same courtesy was extended, on motion of Dr. Palmer, to Dr. Foster Pratt, Trustee of the Insane Asylum at Kalamazoo, Michigan; on motion of Dr. D. D. Rich- ardson to Mr. P. C. Garrett and Dr. A. J. Ourt of the Committee on Lunacy of Pennsylvania; and on motion of Dr. Steeves to Dr. LeBaron Bottsford and Hon. A. G. Blair, Commissioners of the Asylum at St. John, New Brunswick. On motion of Dr. Curwen, it was Resolved, That the Committee on Lunacy of the State of Pennsylvania be invited to attend the sessions of the Association. & Dr. Curwen then offered the following resolution: Resolved, That in the death of our fellow-member, Dr. Thomas S. Rirkbride, this Association has lost one of its ablest associates, who, during the whole period of its existence had given to it most earnest and devoted I O2 Proceedings. thought and attention, and whose counsels were always wise, cautious and most enlightened. | A kind, warm-hearted and sympathizing friend, a faithful and prudent Counsellor, a genial and cheerful companion, and a most able, laborious and devoted physician and superintendent; no one who was privileged to know him in these relations can fail to feel the great blank which has been made by his removal. Privileged to continue in active, continuous service longer than any other member, his latest thoughts were given to the consideration of those things which would most benefit those for whom, for more than forty years, he had thought and labored. DR. CURWEN: I move, also, that the President appoint a committee to prepare a memorial of Dr. Kirkbride, to be preserved in the minutes of the Association. DR. GRAY : The resolution is before the Association. Dr. Nichols paid a brief but warm tribute to the high personal character and valuable labors of Dr. Kirkbride. DR. GRIssoM: Mr. President—In this connection I desire to lay before the Association a resolution adopted by the Board of Directors of the North Carolina Asylum at Raleigh. Dr. Kirkbride's reputation, fame and service, outside of the State of Pennsylvania, are, perhaps, nowhere better appre- ciated than in the State which I represent. During his career, he not only had a large number of patients from that State, but was always ready to aid by wise counsel in matters pertaining to the provision for and treat- ment of the insane. \ The resolutions were then read by the Secretary as follows: Whereas, The Board of Directors of the North Carolina Insane Asylum have heard with deep regret the announcement of the death of Dr. Kirk- bride, therefore, be it Resolved, That the Board desires to express and record its sense of appreciation of the eminent services rendered to humanity by Dr. Kirk. bride, during his half century of service as superintendent of asylums for the insane. That the unfortunate insane have been deprived of a great, kind and tireless friend, and the managers of asylums of a wise benefactor and teacher. That a copy of these resolutions be sent to the family of the deceased as a mark of condolence for their personal bereavement, to the authorities of the Institution over which he presided with such signal success, and to the Assembly of Superintendents soon to meet. NORTH CAROLINA INSANE ASYLUM, RALEIGH, N. C., May 5th, 1884. DR. GRISSOM: Mr. President and Gentlemen of this Association— When the garlands of remembrance are hung at the door of the tomb of such a man as Dr. Kirkbride, the State which I have the honor to repre- sent thinks it eminently proper that a spray of cypress should be offered Proceedings. IO3 from the South. It is good for us to pause and reflect upon the lesson which his example teaches, and to think of a life which for more than half a century was the sweet, Serene pathway of a good man, intent upon his duty, with a heart warm with love for his fellow-men, and a spirit as true to the demands of virtue and honor as the needle to the pole. It is almost an act of supererogation to speak in this or any other community of Dr. Kirkbride's fame. His name in medical annals and councils has long been honored as a household word; and his memory around thousands of fire- sides will be cherished with the veneration of a Roman’s reverence for his household god. This sun in the firmament of our specialty, whose bright and brilliant rays in the early morn of its career scattered wide and far the mists of mental gloom, and which shone with genial and gentle warmth through the long summer day, unobscured by a single cloud, has at last calmly and majestically set, leaving a surrounding afterglow, soft and beautiful, lingering upon the horizon of its career reluctant to vanish from the scene of its glory. Let us thank God that we have been permitted to witness this example of greatness and goodness, shining through such a 1ong life of usefulness and unselfishness. Let us honor the memory and practice the virtues of this sage, who moved among his followers like a genius, holding the volume of accumulated wisdom and dispensing with a modesty all his own, from the abundance of that knowledge which ex- perience collects and diligence preserves. We are wont to praise the gallant mariner who rescues a drowning man; Grace Darling will live forever in story and in song; but how can pen or tongue tell the tale of this gray- haired hero, whose career was one life-long struggle to save from despair those imprisoned spirits upon whom the world had already set the grave- Stone of oblivion ? “To dumb forgetfulness a prey.” Think how this man of delicate frame and soft and gentle speech stood for a lifetime on the ocean side of misfortune where the menta! wrecks of numerous victims were tossed by the waves, and with cool head and unshrinking nerve rescued from destruction their frail barks and wafted them once more with Reason at the helm and Hope at the prow, to seek yet again a prosperous voyage and a peaceful haven. Clothed and in their light minds, those to whom the precious jewels of man’s inheritance have been restored, bring to-day the brightest gems that sparkle in their mental crown, to adorn the shrine of Kirkbride's fame. His mission was at last ended. IIe died, but not unexpectedly. He kept his lamp trimmed and oil burning, for the coming of the bridegroom. He cherished a con- fitant remembrance of another life than this, another judge than man, another ordeal than human opinion. He did his duty at all times, in all places, to all men, and he enjoyed a wealth of noble thoughts, memories of noble actions and hopes of a noble felicity. We have on this occasion mingled emotions of sorrow and glad- ness. We mourn that Dr. Kirkbride is dead; we rejoice that Dr. Kirk- bride can never die. That omnipotent Providence which overrules our des- tinies has only removed from this to a higher state of existence a good man, a kind father, a loving husband, a faithful friend, a pure patriot, a distinguished philanthropist, an eminent physician, a sincere Christian. In IO4 Proceedings. this dispensation we lose a companion, his family a protector, the poor a benefactor, the afflicted a comforter, society an ornament, philanthrophy an instructor, the profession a votary, religion an exemplar. But Our tem- poral loss is his eternal triumph. So dear to him did the path of duty be- come, from long years of faithful habit, that as age gently withered his strength he tottered on toward honor and immortality. He went down to the grave calmly and without a fear. His example will teach on earth while his spirit rejoices with God. DR. EARLE: As I cannot trust my organs of speech upon such an occasion. I wish simply to say that I entirely and most cordially approve Of the resolution and the remarks that have been made. DR. GRAY : Gentlemen of the Association—Before putting this mo- tion I would like to add a few words to what has already been said in regard to Dr. Kirkbride. I first knew him more than thirty-five years ago, when I was a student in this city and was in a hospital here. I knew him then in association with other young men, as a friend of young men. With age, dignity and position, he was remarkably accessible to young men. It seemed to give him the greatest pleasure and satisfaction to advance them and encourage them. From that date to the time of his death I knew Dr. Kirkbride well as a friend, and the eloquent remarks of Dr. Grissom have appropriately portrayed the beautiful character of this distinguished phy- sician and superintendent. As Dr. Grissom has said, he was delicate in person, apparently frail in physical structure, but he possessed a large spirit. He was a man of great energy, great vigor of thought and action, though generally quiet in his movements. He seemed to be a natural leader in his profession. Men followed him, listened to him, recognized him as a man of thought and reflection with a power of formulating his ideas distinctly and clearly, and of presenting them so plainly that I hardly recall an instance where his propositions were not accepted, because they were completed in his own mind before he presented them,-like the sculptor who fashions and perfects the figure before he unveils it to the world, so that they who see it hear not the sound of the hammer or chisel, nor see the dust produced in its formation, so 1)r. Kirkbride wrought his work, fashioned in the mold of thought, and polished by experimental application, that it came perfect as from the hands of the workman. When we look back through his history we must estimate him, not as though we judged him to-day, as though he had arisen now or within the last quarter of a century. It must be borne in mind he came upon the stage at a time when there was little that could be said in regard to the treatment of the insane. As we look back now we see that little had been done. We must go back with him as a man who framed (for he was one of its framers) the constitution, so to speak, under which this Association lives and acts. He was connected conspicuously with all the operations in organizing the Association, and with all of its fundamental resolutions and its great work from that day to this; his hand touched everything. More than this, in the institution to which he was so early appointed, years be- fore the existence of this Association, he commenced the work of develop- ment of the structure of psychological medicine in this country, building from within and building from without, not alone a physical structure, Proceedings. IO5 but laying down principles for the guidance of those who might come after him. He was a progressive yet conservative man, with that self-poise which kept him from being carried away by seeming advances, and with that patience of judgment which led him to examine before approval or rejection, the ideas of others. He was among those who early recognized that the phenomena of disease were not made up from books, but only dis- closed to the patient, toiling observer, in the light of experience. He was himself a worker. The great utility of his life came from within; his aims were high and pure, and he urged his opinions with a simplicity and earnestness and unselfishness which made them not only unanswerable but irresistible. Any one reading the memorial of his life and work, traced by the hand and heart of his accomplished wife, through the long years of his usefulness, can not but be struck with the fact that he seems to have been associated with the origin and development of every advance made in the care of the insane. The narrative is, in fact, a com- pendium of the subject during the last half century, and Dr. Kirkbride stands as a foremost figure, especially in all that relates to the practical work accomplished in providing and organizing institutions of this class for our fellow-men. As Dr. Grissom has said, he was not a man of this State nor of this great and good city; he was a man of the world—whose name is written in every State and in every country in the characteristics which Dr. Grissom has so eloquently portrayed. A man of strong, firm character, of great decision of will, of sound judgment, of high purposes; he was withal, the gentlest of men. He had a sweetness of manner which was like that of a woman, a tenderness of spirit which reached every man he met, and I ven- ture to say there was no man with whom he came in contact that did not feel this. So he goes to rest! But, as Dr. Grissom has well said, “Dr. Kirkbride can never die.” His name will never perish from the earth while medical science and humanity have to consider the great questions which pertain to roan and his welfare in this world and which reaches on towards the world to come. DR. GRAY : Gentlemen, you have heard the resolution of Dr. Curwen. Those in favor of the resolution will so signify by rising. The resolution was unanimously adopted. On motion of Dr. Nichols, it was Resolved, That the Secretary be directed to forward to the Directors of the North Carolina Insane Asylum the appreciation by the Association of the spirit which dictated the resolution in regard to Dr. Kirkbride. On motion of Dr. Nichols, it was Resolved, That the Secretary be requested to communicate to Mrs. Kirkbride so much of the resolution just adopted by this body as relates to her late husband, with the expression of the sympathy with which this Association unites with his kindred in lamenting his death and honoring his memory. The President announced the regular Standing Com- mittees, as follows: IO6 Proceedings. ON NOMINATIONs: Drs. Chapin, Grissom and Palmer. ON TIME AND PLACE of NExT MEETING: Drs. Everts, Steeves and Powell. To AUDIT TREASURER's Account : Drs. Bucke, ‘W. T. Browne and Catlett. ON RESOLUTIONs: Drs. Callender, Stearns and Strong. On motion of Dr. Nichols, a recess was taken until 12 o'clock. On the re-assembling of the Association, Dr. Everts said: MR. PRESIDENT: During the proceedings of the morning in relation to Dr. Kirkbride, I presume many other members of the Association, like myself, felt that silence was a more satisfactory expression of their feelings than anything else, and the matter passed without such notice as, I think, becomes this Association. I therefore move that a committee of three be appointed to whom shall be referred everything, in memoriam, respecting Dr. Kirkbride, and I wish distinctly to decline any place on the com- mittee myself. The motion was seconded by Dr. Nichols and unani- mously agreed to. DR. GRAY : As Dr. Everts has distinctly declined to be a member of that committee, the chair would name Dr. Curwen, Dr. Nichols and Dr. Callender, as such committee. It is also understood, I believe, that Dr. Earle and others will communicate in writing to the committee what they desire to say in regard to Dr. Kirkbride. The Committee on Nominations reported that they would recommend for President, Dr. Pliny Earle of Massa- chusetts, and for Vice President, Dr. O. Everts of Ohio. On motion of Dr. Nichols, it was Resolved, That the report be accepted and that the acceptance carry with it the appointment of the officers of the Association. The President then delivered his address, at the con- clusion of which, he introduced to the Association his successor, Dr. Pliny Earle. Dr. Earle on taking the chair said : To all of us, gentlemen, this is an interesting occasion. The coming together at our annual meeting, the grasping the hands of friends, the mutual looking once more, eye to eye, upon familiar countenances, the re- newal of old friendships and the formation of new ones, and, above all, the hope that we may here gain something which shall assist us in our laborious duties at home, all these conspire to make this gathering abundantly in- Proceedings. Io/ teresting to every one of us. But you will pardon me if I claim that it is more overwhelmingly so to me than it can be to any other person now present. As I look around me I recognize the form and features of no one of my compeers, who, forty years ago, assembled in this city, upon this street, and but two or three squares below us, to form this Association. Many of you, gentlemen, were then in your cradles; several, perhaps, were in their first swaddling clothes, and some were but the dim shadows of the accidental or the incidental possibilities of the future. With me, and the companions offorty years ago, it is but the repetition of history or fiction, the history of the fiction of the old dinner party of thirteen men who met annually until at length the thirteenth one sat, sad and Solitary, at his anniversary meal. And this repeated story is now nearly told. Under these circumstances, to me sufficiently suggestive in themselves, gentlemen, you have come with an offering, the addition of which is, as a matter of sentiment, like the laying of the last sustainable straw upon the camel's back. Not longer to detain you, I simply and from the innermost recesses of my heart render to you my thanks. The Committee on Business made the following report, which was, on motion, adopted: The Committee on Business respectfully present to the Association the following report : Hold meeting for business on Tuesday, from 3 to 6 P. M. On Wednesday hold meeting for business from 10 A.M. to 1 P. M. At 4 P. M. visit the meeting of the Medical Society of the State of Pennsyl- vania. At 8 P. M., attend the reception of the President of the Medical Society of the State of Pennsylvania. On Thursday hold meeting for business from 10 A.M. to 1 P. M. At 2 P.M. leave for a visit to the Friends' Asylum at Frankford, returning at 6. On Friday hold a meeting for business from 10 A. M. to 1 P. M. At 2 P. M. visit the Department for Males of the Pennsylvania Hospital for the Insane, by invitation of the Board of Managers, returning at 6 P. M. At 8 P. M. hold a meeting for business. On motion, the Association adjourned to 3 P. M., when it was called to order by the President, Dr. Earle. The committee to audit the report of the Treasurer's account reported that they had examined the accounts, compared them with the vouchers and found them correct, and a balance on hand of six dollars and twenty-five cents; and they recommend an assessment of five dollars on each member to meet the expenses of the Association. The report was adopted. DR. EARLE: Before we proceed to business‘I wish to trouble you a moment with a small matter. From my first entrance into the specialty, IO8 Proceedings. forty-four years ago, I have kept what reports I could get, and since I went to Northampton have requested of superintendents to send me two reports, as I have sent them two reports each, yearly. One set of these reports, which I have kept since I went to Northampton, is for the hospital; the other is for myself. I have given my set from the beginning to the Ameri- can Antiquarian Society, whose large library is in Worcester, Massachu- setts. It is, I suppose, the most nearly complete collection of the reports of the institutions for the insane in this country, with, perhaps, a single exception. I am not certain that it is mot now the most complete. Ten years ago there was one collection which was larger. Those which I have already given to that institution are bound in over a hundred volumes, some of the volumes being pretty thick. They were given with the hope that they may be of use hereafter, to some one who may write the history of the progress in the treatment of the insane in this country. I have enough now to make nearly eight volumes more, so that in all, there will be about one hundred and twelve volumes. My object in calling your attention to this subject is, to say that I would like every superintendent to send me two copies this year; and I feel that I shall then have done my duty in that respect, and will not ask for two copies afterwards; but I should suppose that every superintendent would like to have his report preserved in such a collection, for the benefit of future researches. I believe the Antiquarian Society would like to re- ceive from every institution, annually, hereafter, a copy of its report. Quite a number of the superintendents have sent me two this year. Some —I think about twenty—have sent me only one, and some have not yet sent any. If there are any here who have sent me but one, I would thank each of them for another copy, and every superintendent can do what he thinks best in regard to the subject, in the future. We will now proceed to the business of the meeting, and you will please give your attention to Dr. Curwen's address on the history of the Associa- UlOI). Dr. Curwen then read the address prepared by him, and stated that he had also prepared a full account of the names, with date of appointment and resignation of each superintendent. After some discussion as to the manner of publishing the history, Dr. Everts offered the following resolution, which was, on motion, adopted : Resolved, That the Secretary of the Association be authorized to pub- lish five hundred copies of Dr. Curwen's Supplementary History of the Association, at the expense of the Association, provided that he shall send a written copy of all matters pertaining to each institution to the Super- intendent of such institution for correction, fifteen days before publication, with notice to return the same within that time; one copy of such publica- tion to be furnished gratuitously to each member of the Association. All copies required by superintendents or other persons in excess of the num- ber provided for, to be furnished at cost of publication by the Secretary. The copies to the members to be furnished unbound. Proceedings. IO9. The Secretary stated that the second address, on the “Causes of Insanity,” was assigned by the Committee to Dr. Earle, but his health not allowing him to undertake the labor requisite to prepare the address he declined, and the Committee and the Secretary took the liberty of asking Dr. Shurtleff to attempt it, but his health also failed and consequently no address had been prepared. Dr. Stearns then read his address on “Progress in the Treatment of the Insane.” Dr. Godding read his address on “Progress in Pro- vision for the Insane.” The Secretary read a letter from Dr. Clarke giving the reason why he could not prepare and read the ad- dress assigned him on “Progress in the Pathology of Insanity.” On motion of Dr. Curwen, it was Resolved, That the medical profession of Philadelphia and the members of the Medical Society of the State of Pennsylvania be invited to attend the sessions of the Association. The Secretary then read the minutes of the sessions of the day and, on motion, the Association adjourned to IO A. M. The Association was called to order at Io o'clock, A. M., on Wednesday, by the President. Letters were read by the Secretary from Drs. Hurd and Gundry, giving reasons why they could not attend this meeting. He also read the following communication from Dr. John S. Butler: MY DEAR DR. CURWEN : I am very sorry that it will not be in my power to attend this meeting of the Association. I regret it the more sincerely, as this is so near to the anniversary of our organization in Octo- ber, 1844. I naturally recall the events of that most important meeting—the dis- cussion of plans and principles since proved so sound—the natural doubts and fears of the future, giving way in the minds of all to high and confident hopes 1 All comes back so vividly to my mind, as if these events were not of forty, but only of a stngle year ago! In view of these most natural and kindly remembrances, I hope to be excused if I recall to the minds, especially of those members who have joined us in later years, simply the names of those pioneers whose self. I IO Proceedings. denial, hard and warm-hearted work accomplished so much for the insane and to whose good deeds I could here do little justice. They have de- parted, leaving to all of us their devoted and inspiriting examples. A better “Roll Call” than this was never read out after any hard- fought battle field ! Let their record answer to their names | Dr. Samuel B. Woodward, Worcester, Mass. Dr. F. T. Stribling, Staunton, Virginia. Dr. Samuel White, Hudson, New York. Dr. Isaac Ray, Augusta, Maine. Dr. Luther V. Bell, Somerville, Mass. Dr. Charles H. Stedman, Boston, Mass. Dr. Amariah Brigham, Utica, New York. Dr. William M. Awl, Columbus, Ohio. Dr. John M. Galt, Williamsburg, Virginia. Dr. Nehemiah Cutter, Pepperell, Mass. And last, but not least, in our respect and loving remembrances, Dr. Thomas S. Kirkbride, Philadelphia, Pa. These have ceased from their labors—but like the grand old architect of Christian Rome, “They had builded better than they knew.” Dr. Pliny Earle, of Northampton, Mass., alone remains in active duty, bringing to a higher excellency the good work he began in the hospital at Northampton. He will, I trust, be with you at this meeting, to do more and better honor to our departed associates. The good fortune of my connection with the Association from its inauguration and afterward the unmerited honor of being elected to pre- side over it, are among the richest rewards of my professional life. During the past forty years a great work has been done for the insane. As surely, a great work for the insane remains to be done. Advances are to be, and surely will be, made in the medical and moral treatment of in- sanity, and in the amelioration of the condition and surroundings of the lunatic. The greater work of all is to be done in the line of the Prevention of Insanity, Dr. Richardson, of London, says: “A change has come over the science of medicine; with true nobleness of purpose, true medicine has been the first to strip herself of all mere pretences to cure, and has stood boldly forward to declare, as a bigher philosophy, the prevention of dis- ease. The doctrine of absolute faith in the principle of prevention includes the existence of a higher order of thought, of broad views on life and health, on diseases and their external origin, of death and its correct place in nature. * * * * * The science of prevention becomes a political and a social as well as a medical study.” Dr. Henry J. Bowditch asserts, that “We stand now at the very dawn of the grandest epoch yet seen in the progress of medicine. While philo- sophically, accurately, and with the most minute skill studying by means of physiology, pathological anatomy, chemistry, the microscope, and above all, by careful clinical observation, the natural history of disease and the effects of remedies, our art at the present day looks still higher, viz., to the prevention of, as well as to the cure of disease.” Proceedings. III. These are, I believe, accepted as among our highest authorities. Here Advance and Prevention are synonymous terms. As such I com- mend them to the Association. Though I am so effectually on the “Veteran Retired List” that I can- not even “shoulder a crutch to show how fields were won,” still my heart warms to the good and progressive work of the Association. Remember me most cordially to “one and all ” of the members, but especially to those of that excellent “remainder ’’ of good fellowship with whom I have been, in olden times, so pleasantly associated. I remain, your attached friend, JOHN S. BUTLER. HARTFORD, CoNN., May 10th, 1884. On motion of Dr. Chapin, Mr. D. Willers, Trustee of the Willard Asylum, was invited to take a seat in the Association. On motion of L)r. Palmer, Mr. Levi S. Barbour, of the Board of Public Charities of Michigan, was also in- vited to take a seat in the Association. Invitations were read from the Managers of the House of Correction of Philadelphia to visit that institution, and from Dr. John V. Shoemaker to attend a reception at his house, which were accepted and referred to the Com- mittee on Business. The President then called for the reports of the Standing Committees. Dr. Theo. W. Fisher, from the Committee on Ne- crology, read a biographical sketch of Dr. R. H. Gale, prepared by Dr. C. C. Forbes of Arkansas: The subject of this writing was born in Owen County, Kentucky, on the 25th day of January, 1828. His life, though cut off a little past middle age, was singularly eventful. Graduating when quite young from Tran- sylvania University, at Lexington in his native State, he entered the office of his father, an eminent and popular physician as well as a wealthy and influential man; and after the usual term of pupilage under the care of so interested and capable a preceptor, he was enrolled in the classes of the Jefferson Medical College of 1847-48, graduating with excellent standing the latter year. * His first location in the pursuit of his profession was at Covington; Ky., where it is said his practice was signalized from the beginning by marked success. While in this field he became a staff officer of the Cin- cinnati Commercial Hospital. After very creditable public service and while possessed of a flattering and remunerative private clientage, he was induced by his family and their friends to change his location to the midst T I 2 Proceedings. of the community in which he had been reared; where his personal worth was appreciated, it might be said, to a degree of partiality and his profes- sional capability and skill were recognized at once. A man of lively sym- pathies and of a generous and genial nature, he could never feel indifferent as to whatever affected in any way those among whom he lived and moved. He was distinctly and distinctively one of the people. Influenced by their wishes, he was twice elected by their suffrages to the office of County and Probate Judge of Owen County. Subsequently he served his county one or more terms in the legislative councils of the State, assuming a prominent part in their proceedings and leaving a highly creditable and flattering record. + At the beginning of the war, impelled by his ardent sympathies with the South, he entered the service of the Confederate States in Col. D. How- ard Smith's regiment, which constituted a portion of Gen. John H. Mor- gan's famous command. His health failing from the energetic performance of his very arduous duties, he was obliged to resign his position and quit the service. After the war he settled in Louisville, where he immediately realized the eminence which he had already achieved. He very soon com- manded a lucrative practice and assumed a prominent place upon the staff of the City Hospital, where his tastes affecting surgery most, he took an enviable stand among the many powerful and eminent men then and still identified with the specialty in that institution. Besides devoting con- siderable time to clinical teaching in the hospital, he also gave lectures for several seasons in the Louisville Medical College. He was chosen about the same time Secretary—who was also ex-officio financial manager—of the Physicians’ Medical Aid Society. In 1873 he was appointed surgeon to the Louisville, Cincinnati and Lexington Railroad, and a year later by the Paducah road, to a similar position. In this capacity he served these roads till 1879, when he was appointed by Gov. Blackburn as Superintendent of the Central Kentucky Lunatic Asylum, in which position he continued till the day of his death, which occurred, as remarkable, on the day fixed for his resignation of the office to take effect. Lately, Dr. Gale had realized very sensibly and pain- fully the aptness of the pithy and pointed words of somebody, that “a superintendent of an asylum for the insane dwells ever upon a volcano liable at any moment to erupt a catastrophe.” He was both confiding and indulgent, and trusted his subordinates perhaps unduly. Unfortunate occurrences, concealed from him, led to charges which challenged investi- gation, and which eventuated in confirmation. Although the great mass of the testimony in the premises went very far to exculpate Dr. Gale him- self and to establish the goodness of his nature and efficiency of his man- agement, still the worry and anxiety incidental to the proceedings, so preyed upon his sensitive feelings and already failing health as, no doubt, to hasten his death. In 1846, when in his nineteenth year, Dr. Gale was married to Miss M. C. Green, a most charming and estimable lady, whose death in 1880 pre- ceded his own. As the fruit of this union, three children survive their parents, one son and two daughters, all married. Only a few weeks ago he was joined in a second marriage; this time to Mrs. Susan Bryant, an Proceedings. II 3 amiable and excellent lady, the daughter of Dr. Hughes, a gentleman of .fine fortune and great influence, residing near Springfield, Kentucky. In his personality Dr. Gale was a man, physically, of an exceptionally fine order; of commanding size, he was well-proportioned, gainly and graceful. Socially he was genial and unreserved, while he excelled as an agreeable and entertaining conversationalist. Although possessed of mental endowments and culture much above the ordinary plane, still his breeding and native modesty would never allow these qualities to even seem obtrusive. He died at the residence of his son-in-law, Mr. J. C. Reid, in Owen County, near the place of his birth, on the 22d day of April, ult, in the fifty-seventh year of his age. Dr. Dewey, from the Committee on Cerebro-Spinal Pathology, read a paper on the “Promotion of Mental Health by Care and Training of Children.” A motion to discuss the paper was made by Dr. Cur- wen, seconded by Dr. Fisher and agreed to. DR. FISHER: I seconded the motion, not that I had anything special to say upon the subject, but that members of the Association should have an opportunity to remark upon the paper, if they so desired. It is a step in the right direction, and if the Doctor would go through his entire hos- pital and gather the statistics he might present some valuable conclusions by another year. DR. GRAY : I hope that the Orator in the upper corner will give us something on the subject. DR. GRISSOM: “I am no orator as Brutus is.” DR. GRAY : I think with Dr. Fisher that the paper of Dr. Dewey is a step in the right direction. I think it is beginning at the right end of such cases. I presume that the difficulty he labored under is one that we have all appreciated—getting information imperfectly from the persons who bring patients to asylums. I thought I could see, in some of the cases of which he gave a brief analysis or synopsis, that he had labored under that difficulty. I have not a doubt in my mind that in the direction of true pro- gress in reference to the appreciation of causes and the proper classification and treatment of the insane, it is very important that we should have more information than we usually get or are able to get, to commence the care and direction and treatment of patients. Going back, as Dr. Dewey has suggested, to childhood, to see the influences that are brought about children from the hour of their birth to form their characters, to develop or suppress their passions, to guide them in all ways, either into usefulness and integrity and duty, or to let them drift to themselves, is of vital im- portance. Now it seems that several of these cases presented by Dr. Dewey, were children that could hardly be said to have been brought up ; they simply grew up as weeds grow in the streets, subject to the tramp of every foot or anything that might occur. Out of just such cases we have the institutions for the reformation of criminals very largely filled, and occasionally they II.4. Proceedings. drift to the asylums; but I perceive from the description of the cases given, that in the majority of these instances they have not simply been subjected to the exposure or drift of life, growing up on the street, homeless, finding there rest for the night and then pilfering or living as best they could through the day, without parents or friends or any one to guide them; but they have been given to those very excesses which in themselves, inde- pendent of such a vagabond life, are capable of producing most any disease. I notice that some of the young boys as a beginning have had syphilis. I think the earliest, the Doctor said, was at fifteen years of age. DR. DEWEY : Yes, sir. DR. GRAY : Now the lesson to all of us is—and I hope that Dr. Dewey will follow the subject up as he has opportunity, by taking a larger number of persons and giving us as accurate information as possible, and classifying them as he has here. The lesson that paper should teach is this: That we, as representatives of one of the departments of medicine and of a great department of hygiene, certainly of mental hygiene, should use our influ- ence, perhaps more than we do, with reference to the very point suggested in almost the first sentence of the paper of Dr. Dewey, that is, the care and guidance and bringing up of children. I think instead of standing at the other end of the line and inquiring what the diseases are we are to treat, we should do more towards going back to the beginning and impress upon the communities in which we live and act, and through the legislatures to which we constantly report, the infinite importance of such training. Certainly we represent these institutions and the interests of the public, and we should seek to impress upon the public authorities the greater im- portance of originating and using protective measures, so that in the train- ing of children from the very beginning, in our schools, and through humane societies that look after youth and children, the plain, simple facts in regard to vice, to training, to education, to diet, and all the elements that go to develop the physical, mental and moral life of youth. There is where I think we should begin if we wish to arrest the growing progress that there seems to be in diseases, insanity included. After this discussion, the paper was laid on the table. Dr. Catlett, from the Committee on Cerebro-Spinal Pathology, read a paper on “Tinnitus Aurium.” DR. CATLETT : Mr. President and Gentlemen—A report was not ex- pected from me, but the chairman of this committee recently notified me that he would not be present at this meeting nor would he be able to make a report. This paper is not intended as a report of the committee, only supplementary. It was written before I received notice from the chairman that he would not be able to make a report. Being exceedingly feeble from the effect of breathing sewer gas, which escaped into my room last night, I will ask the indulgence of the Association for the manner of pre- senting the paper. After the reading, the following discussion took place: DR. FISHER: In regard to the paper I have but a few words to say. I Proceedings. II 5 have been aware for a number of years, as probably all of you have, that auditory diseases: should be included in the symptoms to be observed among the insane. Deafness, or partial deafness, and hallucinations of hearing are very common in our insane hospitals, but the difficulties of in- vestigation are considerable. It is impossible to rely always upon the statements of our patients, and investigations must be limited to testing the hearing in many cases and making such superficial examinations as are possible. I had, not long since, a case of suicidal mania, in which I thought possibly some post-mortem evidence might be found of disease of the in- ternal ear. There was deafness in both ears which had heen gradually increasing for a number of years. There was also a decided tendency to rotary motion, from right to left, exhibited when the patient was walking by a series of cycloid motions across the floor, and when the patient was seemingly conscious of his actions. It was thought probable that some of the semi-circular canals might be found diseased. There was soon, unfor- tunately for the patient, an opportunity for the determination of his disease by an autopsy. On careful examination the semi-circular canals were found perfectly healthy in both ears; but evidences of disease were found in the cortex and in the membranes of the brain, such as are often found in cases of insanity of somewhat long standing. It was therefore supposed that the disease which affected the function of equilibrium was of centric, and not of eccentric origin. As it is often difficult to determine whether disease exists in the ear, we should carefully examine each case. Every patient coming into a hospital should be examined with reference to his hearing, as a matter of routine, as well as to the condition of the retina. The paper was then laid on the table. The next report was from the Committee on Thera- peutics and New Remedies, by Dr. J. B. Andrews. Dr. Andrews, before reading his paper said, in ex- planation : The paper I am about to read is illustrated by pulse tracings by the sphygmograph, used to show the action of drugs upon the circulation. The instrument employed is a modification of Pond's and is simple in con- struction and action, and gives very satisfactory tracings. I have prepared a few specimens which I will pass around, simply to show the work of the instrument. Thus far the sphygmograph has been but a plaything in the hands of many who have attempted to use it, and by few have its possi- bilities been developed. Those who have thoroughly tested the instrument and are therefore most competent to judge, claim for it a great value in the diagnosis of disease. A medical friend who has extensively used the sphygmograph, in an album of some two thousand tracings, presents many of great diagnostic value. That the instrument has not as yet assumed its proper place as an aid in diagnosis, is largely due to the want of sufficient skill in its use. To take a good characteristic tracing requires considerable experience and patient labor. Many of the tracings which would seem at first to be admirable because of their size, are really useless, as they show I IO e” Proceedings. only the systolic beat of the heart without the tension or dicrotism of the vessels. This instrument is very simple. It acts by transferring the arterial beat through a rubber diaphragm to the lever which gives motion to the needle. This motion is more direct and made with less friction than in other instruments. Another improvement is in the shape of the needle; the curve at the extremity prevents its plowing into the paper and gives greater sensitiveness to its motion. It is so arranged by a screw that the barrel of the instrument can be lengthened or shortened, and this raises the lever from, or causes it to approach the diaphragm, thus adapting it to different pulses. If the pulse lies very near the surface, less pressure will be required, and then by screwing up the barrel the end of the lever is brought nearer the diaphragm, which makes the sphygmograph more sensitive. If the pulse is more deeply seated, more pressure upon the artery must be used; then the lever is lifted from the diaphragm. The instrument is so arranged that the paper can be passed through at different rates of speed, to correspond with that of the pulse. The watch motion is very perfect and runs continuously for three minutes. I would like to call attention to two of the tracings presented. They are instances of very high tension, the highest I have had an opportunity to take. The pulsations were only 32 per minute, increased on exercise to 40. The papers are prepared for the tracings by being uniformly blackened. This is accomplished by passing them over a lighted lamp, and they are finished by being immersed in or painted over with a varnish made from the following recipe: Gum sandarach, half ounce; alcohol, half pint; castor oil, two drachms. Simple collodion will answer a very good purpose, but does not give the finish produced by the preparation given above. This is recommended by those engaged in the manufacture of sphygmographs, and does not originate with myself. You will notice in the tracings presented, that while there is very great variety there is a close resemblance in all of those taken from the same pulse. While there is as much diversity in the tracings of different il.di- viduals as in the appearance of their faces, a correct tracing is as charac- teristic as the photograph of the individual. With this introduction the Doctor read his paper upon “Paraldehyd, Nitro-Glycerine and Jamaica Dogwood.” This was profusely illustrated with sphygmographic trac- ings. In reply to a question by Dr. Grissom in regard to the action of nitro-glycerine in epilepsy, Dr. Andrews said: The patient who had been under observation for a year had never before had a series of convulsions, but after taking the medicine for Some six weeks he had a series of thirty-two seizures. The medicine was then dis- continued, and he has since had an occasional convulsion only. Glonoin has proved itself valuable in cases of feeble heart and of atheroma of the arteries, the tension of which it relieves in a marked degree, and also in *, Proceedings. I 17 cases of albuminuria; see statements of Dr. Bartholow in Philadelphia Medical Times of a few months ago. As the use of the drug in these diseases has been investigated and con- clusions favorable to its use presented, I have not enlarged upon this view of the subject. On motion of Dr. Curwen, Dr. I. N. Kerlin, of the Pennsylvania School for Feeble-Minded Children, was invited to take a seat with the Association. Dr. Curwen also stated that Dr. Kilbourne was con- fined to his room by an attack of rheumatism. The Secretary read an invitation to visit the School for Feeble-Minded Children, at Elwyn, also an invitation from the Secretary of the Medical Society of Pennsylvania, to an excursion to Cape May Point, on Saturday, and also to visit the Pennsylvania Hospital, Pine and 8th Sts. On motion, adjourned to 3 P. M. The Association was called to order at 3 P. M. by the President. The Secretary read an invitation from the Guardians of the Poor of Philadelphia, to visit the department for the insane under their care. The Secretary read the report of the Committee on Time and Place of Next Meeting recommending Saratoga, N. Y., as the place, and the third Tuesday of June, 1885, as the time, which was on motion, unanimously adopted. & The President appointed on the Committee of Arrange- ments, Drs. J. P. Gray, J. B. Chapin, J. B. Andrews, C. H. Nichols and John Curwen. On motion, the Association adjourned to Io A. M., Thursday. - After adjournment, the Association in a body visited the Medical Society of the State of Pennsylvania then in session, and remained until their hour of adjournment, and II 8 Proceedings. in the evening the members attended the reception of the President of the Medical Society of Pennsylvania. The Association was called to order on Thursday, at IO A. M., by the President. The minutes of the sessions of yesterday were read. The Secretary stated to the members the arrangement for going to Friends' Asylum that afternoon. He also stated that an invitation had been extended by the Pro- fessors of the Medical Department of the University of Pennsylvania to visit that institution that afternoon, at 5:30 P. M. On motion of Dr. Stearns, Dr. G. W. Russell, one of the Managers of the Retreat for the Insane at Hartford, was invited to take a seat in the Association, and on motion of Dr. Denton, the same courtesy was extended to Dr. White of Texas. Dr. Foster Pratt then arose to offer the following resolutions. DR. PRATT : Before introducing the resolutions I have to offer, I wish to remind the gentlemen present of the fact that last fall at Detroit, at the meeting of the American Public Health Association, I had the honor to read a paper which was in essence a careful study of the Tenth Census of the United States on what is termed the “Defective Classes” of population, including the insane. A copy of the paper was sent to every institution for the care of the insane, and also to every member of Congress and to State officials. The importance of the subject will commend itself, I think, to this body: Whereas, By a comparison of the statistics of the “defective ’’ classes of our population, as shown by the eighth, ninth and tenth census, it appears: 1st, That the proportion of insane to the total population of the United States is rapidly increasing ; and 2d, That a prominent factor in this increase is the large defective element found among the foreign born who have emigrated to us since 1847 and 1848, and who now constitute one-eighth of our total population; but who furnish approximately, one-third of our paupers, one-third of our criminals and one-third of our insane ; and, Whereas, While the cost of buildings to suitably keep and the annual tax to properly maintain these classes fall wholly and heavily on the several States and Territories, they are inhibited by Federal laws from enacting and enforcing effective measures to prevent or to mitigate these evils as far as they are caused by immigration; therefore, Resolved, That the Association of Medical Superintendents of American Institutions for the Insane respectfully urges the Congress of the United States to give early and earnest attention to this important subject, to the Proceedings. I IQ end that emigration laws may be enacted by it, which, while they do not unnecessarily obstruct the immigration of healthy and self-dependent per- sons, will effectively prevent the emigration and exportation to our ports of the so-called “Defective classes” of Europe and Asia. Resolved, That in furtherance of this object a copy of these resolutions and preamble be forwarded to the President of the United States, and to the President of the Senate and the Speaker of the House of Representa- tives at Washington, for consideratiºn by them and by Congress; also to the Governor and presiding officers of the [legislature of each State in the Union, and to each State Medical Society, that they and the people they severally represent, who are most affected by the pecuniary burdens and by the physical and moral evils caused by the unrestricted and unregulated immigration, may be moved to take such action as they deem best to secure early and efficient action by Congress (with whom alone is the power,) to abate the great and growing evils to which public attention is hereby called. While a study of the census of 1860, 1870 and 1880, as has been remarked in the preamble, demonstrates the increase of insanity, and that our foreign born population is one of its most important factors, we have in addition to the statistics a great many isolated and important facts, in late years, to substantiate the general charge. Among several leading editorials which the Chicago papers gave to their readers in comments upon my paper when first published, there was one very important editorial which con- tains the statement that the day previous, in Chicago, thirty persons had been adjudged insane by the courts, all foreigners and none of them more than six weeks in the United States. Entirely apropos, I find in the New York Herald of this morning the following editorial: “PAUPER IMMIGRATION.” “The action of foreign governments in exporting their paupers to this country is as ill-advised as it is impertinent. Hitherto, perfect freedom to admission to live and labor in the United States has characterized our sys- tem of economy, but this never contemplated the emptying upon our shores of the contents of British or other foreign workhouses. The arrival on the City of Rome of forty or more persons thus described, should arouse the vigilance of the authorities, and they should be at once returned whence they came. The fact, that in this instance, heads of families have been supplied by the British authorities with a little money, looks like an attempt to evade the strict definition of paupers while preserving the essential character. If there is probability of such persons being thrown upon our charities for their subsistence, they should be considered paupers and treated accordingly. The act of sending them bere is ill-advised, be- cause it is not unlikely to induce such legislation at Washington as will materially interfere with all foreign emigration to this country, a course of action not to be desired on any account.” It is but little over a month since two hundred and fifty were landed from one vessel at Boston, from Glasgow, I believe, but happily by a cable- gram from Glasgow they were detected and are reported to have been sent back. Now it is a significant fact, that, while those concerned in the manage- ment of immigrants claim, that as they arrive they are constantly sent back when found to be defective in any way, I have the statistics of the Commissioners of Emigration for the State of New York for the last ten years, and by their published statistics in those reports, year by year, they have failed uniformly to report the number sent back. I have also the reports of the Bureau of Statistics at Washington, a complete file from the I 20 Proceedings. organization of that department, or bureau, and while they enter into great minuteness of detail in the statistics of emigration, they, too, utterly fail to report these cases of pauper or defective persons sent back to the ports whence they came. By the request of the President, the resolutions were read a second time by Dr. Pratt. DR. PRATT: I will state by way of explanation on one point, that the Supreme Court of the United States in a series of cases, running for seventy years, has decided that the regulation of immigration is a regulation of commerce, and therefore, according to the Constitution of the United States, wholly within the control of Congress. The way they make com- merce of it is this: By the decision of the Supreme Court, in what is known as the “passenger cases,” it was decided that carrying passengers for hire was “commerce,” as much as carrying merchandise for hire. DR. EveRTs: I move the adoption of the resolutions. The motion was seconded by Dr. Catlett. DR. NICHOLS: I would like to have the preamble to this resolution slightly amended. Dr. Pratt says that one-eighth of the population of the United States is composed of the immigrants since 1847 or 1848, and their descendants. DR. PRATT: No, sir; I beg your pardon, they are the foreign-born, exclusively. DR, NICHOLS: Then I misunderstood or misrecollected the declaration in relation to this point, but the statement that it is conclusively demonstrated —l think that is the language—from an examination of the censuses of 1860, 1870 and 1880, that one-eighth of the inhabitants and one-third of the insane and other dependent classes are actual emigrants since 1847 or ’48, does not affect what I have in view. Now I have not the slightest reason to doubt the correctness of the deductions the Doctor makes from his examination of those censuses, but it might be that another examiner would draw a different conclusion. Besides, there may be errors in one or more of the censuses. If the language is made less positive by substituting the words it appears from, an eacamination, etc., in place of it is conclusively demonstrated, etc., I shall be willing to vote for the preamble and resolu- tions. Modified as proposed I think they will impress Congress more favorably than they will if we lay ourselves open to the liability of being thought too confident of our ground. DR. PRATT: I understand this is the difficulty, that Dr. Nichols and others have not investigated the subject. I have a table here, which was sent to every hospital for the insane in the land, and to several two or three copies. - I would like, now that I am upon my feet, to state some facts in regard to several States. To begin with New York, the native whites are 3,805,000; the foreign whites, 1,210,000. One-fourth of the entire population of the State of New York is foreign-born. Now, mark, of the native white 7,595 are insane, and of the foreign-born—only one-fourth of the population— Proceedings. I 2 I 6,321 are insane. Almost one-half of the insane of that State are furnished by one-fourth of the population. The same is true in Pennsylvania. Nearly the same is true in almost all the Northern States, except perhaps Maine, New Hampshire and Vermont. The same is true also, in almost all the Western States and Territories. Now, as I already remarked, (and gentlemen understand it, it is not necessary to elaborate the point or the argument,) these figures are official in all respects. If any gentleman wishes them for demonstration he may have them to study the subject. But I want to read a paragraph or two, which shows how this ratio of increase has been manifested. . Reckoning now from 1850 or 1860, as a basis to start with. During the ten years pre- ceding 1860, the increase of foreign population was 100 per cent... but the foreign born insane had increased 181 per cent. Secondly, while the total of this class had increased during the next decade 30 per cent., the insane of this class had increased nearly 100 per cent. Thirdly, in 1880, the foreign born had increased less than 20 per cent., but their insane had increased 150 per cent. These are the official figures. DR. FRANKLIN: I would add two or three items to the statements of Dr. Pratt. New York city, of course, suffers to a greater extent than any other place, from the very class of which Dr. Pratt speaks. Ireland furnishes to our institution at Blackwell's Island the greatest number of patients. Germany comes next. But I noticed, in 1881, in gathering matter for the annual report, looking up nationalities, etc., that one-half of the admissions for that year were people who had been subjects of Great Britain. Attracted by that fact, I looked the matter up again in 1882, and I found the number of those that had been subjects of Great Britain ex- ceeded by a little, 50 per cent. I have not made up the report for last year —have not followed the figures down each day so as to see if there is a gradual increase. Again, we get a great many from the Asylum for Insane Emigrants, at Ward's lsland, after they have completed that period during which the Emigrant Department is responsible for their care. Again, we get many whose recent arrival in the country we strongly suspect, but whose mental condition is such that we can learn nothing from them as to the dates of their arrival, and some of these not being visited by friends we fail to get information in that direction. We often get from patients facts sufficient to satisfy us that they are recently arrived emigrants; but the failure of recollection upon one or two important points make it impossible for us to prove to a certainty that which would send them to the Emigrant Asylum. These difficulties sometimes are done away with when the patient has nearly recovered; and at other times after, she has become incurable and acquired the rights of citizenship by residence in our institution. DR. CHANNING: I think there is one element that we have lost sight of in comparing the proportion of the insane in the foreign population and in our own, and that is the relative proportion of children. The nuumber of these in our immigrants is smaller comparatively than in our native population. Therefore, the inference we draw, without considering these circumstances, might be misleading. An investigation is now being made in the hospitals in Massachusetts, by taking the number of insane of foreign I 22 Proceedings. parentage and making a comparison in that way, and you [turning to President Earle] probably know the figures better than I do, but I think it is that three-fifths of our patients are of foreign parentage. THE PRESIDENT: I forget the proportion. DR. PRATT: Since I have had the matter under consideration, I have had some correspondence with Mr. Wines, specially in charge of this census work, in which I took upon myself to call attention to the fact that of the native born whites in the Northern States and Territories and the District of Columbia, the number of native born whites of foreign parentage out- numbers those born of native parentage by a million and a half. I know it is an astonishing statement, but the figures prove it conclusively. I will repeat it—that the native born children of foreigners of the Northern States, Territories and the District of Columbia—-the native born children of for- eigners exceed the children of native born parents by a million and a halſ; but the statistics of the census do not show when they come to classify the insane, anything about the parentage of those who are native born. While it is apparent from a study of the census that the proportion of insanity to population is increasing in the native white class very rapidly since 1850 Or 1860, yet the statistics have failed to show how much of this increase is due to the children of foreign parents and how much to the children of native born. While, of course, the children born here of foreign born parents are treated by the census as native born, it fails to give other im- portant data which should be given and without which we can never thoroughly study the subject; but Mr. Wines has promised in subsequent volumes of the census, if possible, to remedy this defect. * The gentleman from New York (Dr. Franklin) speaks of the State of New York as being exceptionally troubled. DR. FRANKLIN: The city. DR. PRATT: I have given the figures of the State. Of course the city is included in the State, in the statistical statement. Almost the same result found in New York is found in my own State. While the foreign born constitute one-fourth of the population, they furnish more than one-third of the insane. We have two ports, and a great many immigrants come to us from and through "Canada, and coming to Detroit and Port Huron, we are subject also to the same difficulty as the State or City of New York. DR. FRANKLIN: A great many come to us from Great Britain. DR. PRATT: I am perhaps in error in part of the statement that I made in regard to the arrival of two hundred and fifty from Glasgow in Boston some few weeks ago. A gentleman from there, sitting near me says they were not sent back, that a fine of five dollars was imposed and they were sent to the West. DR. FISHER: As I recollect, the immigrants were found to have about five dollars in money each, which had been furnished them at home, and for that reason they could not be considered paupers. Many of them represented that they had relatives to whom they were going and who would be responsible for their support. I think they were not sent back. I think I should have known it if they were. They were examined, and it Proceedings. I 23, . was contemplated to send such of them back as were not found to have sufficient means of support; but I think they were all sent West. DR. NICHOLS : In New York we should have voted them before we sent them West. That is all the difference I can think of between New York and Boston. DR. CHAPIN : I am not sure that I fully understand the import of this resolution, but think it is hardly wise for this Association to make any declaration about foreign born immigrants who are paupers or criminals, with which classes we have little to do. While, as Dr. Pratt has recited in his preamble, an unduly large proportion of the insane of the country are foreign born, or of foreign descent, it does not appear that these persons were insane or paupers before their arrival in the country. It is true that the foreigner on his arrival in a strange country is suddenly brought into contact with new conditions of living and environments. The change of food, the anxieties of a voyage, and residence among strangers, produce homesickness, and a strain which these persons are not prepared to endure. If they become incapacitated by insanity, or otherwise, they become a public charge at once and admission into a public asylum is an easier transition than for the native born. It is probable a few persons are sent over who are insane and paupers, but I believe if the facts could be reached the majority of the foreign born insane become so after their arrival in the country. As it has been the policy of the government to welcome and promote immigration, it would be very proper to inquire what causes so. much insanity among the foreign born as appears, and an extension of the inquiry whether there are existing conditions in our social organization that tend to develop both pauperism and crime, would not be out of the way. I am under an impression that a statute is now in existence to authorize the return of paupers and lunatics, and that it is enforced to a certain extent. DR. GRAY : You do not refer to the State of New York 2 DR. CHAPIN : I supposed the law was enacted by Congress. At least I understand from newspaper reports certain cases have been stopped and returned. DR. PRATT: The law is hardly directory. There is no penalty upon anybody who does not obey the law as directed. Now, in regard to the fact, it seems to be a very difficult matter to obtain statistics of the number who come here actually insane. But this body will readily understand that epileptics, and others who are periodically insane—who have lucid intervals—arriving here, or who become insane very soon after they come here, when they once arrive at an institution would remain there, especially if dangerous cases or cases of epileptic in- sanity. Once before on the floor I called attention to the situation in Chicago, that thirty persons were adjudged insane there in one day, every one a foreigner and none of them in the country six weeks. PRESIDENT EARLE : I would ask Dr. Pratt if we should infer from that the possibility of that number being adjudged insane every day, or whether in that city there are not certain days for trying the question of insanity, and those thirty patients, as we may call them, had accumulated there? I24 Proceedings. DR. PRATT : It is a daily business of certain courts in Chicago. But the important point is not whether courts act daily, weekly or monthly, but that thirty, all foreigners, and none of them more than six weeks in the country, by one court. DR. NICHOLs, [interposing.] They must have accumulated in six weeks. DR. PRATT : None of them more than six weeks in the country. Now the inference is irresistible that these persons, many of them if not all, had been insane before sent here—perhaps sent here during the lucid interval. I have personal knowledge, from my intercourse with the insane and their friends in my own State, that many have been sent to us who are period- ically insane. Many are among the class of recently termed “assisted emigrants.” They are sent over here on the ground, as is alleged, that they have friends to take care of them ; and when they get here, their friends prove to be the State. It is undeniable that various moral causes must produce, at least for a few years after their arrival, some degree of insanity among them, which may be properly chargeable to the simple fact of removal. Mr. Wines in his treatise on the subject, in the chapter on defective classes, calls atten- tion to this. In my correspondence with him I had occasion to speak ol the fact that in 1850 the proportion of insane to foreign born was scarcely, if any, larger than the proportion of insane to native born. It was a little larger, just about large enough to account for the effect of these moral and Other disturbing influences that I have spoken of. But as you come along down since 1850, that rate is increased in proportion. These foreign “de- fective ’’ come here from the poorhouses and the almshouses; and since we take them in, they have been acting upon it ever since. The statistics show, as I have already said, that a certain amount of this insanity in the foreign born is probably chargeable to disturbing influences resulting from a change of residence; but it is much more largely due to the fact that they bring with them their periodical insanity and an hereditary tendency to it, which develops here because of the moral disturbance which they encounter. Mr. Wines seeks to fortify his argument by showing that of the people from the Atlantic States going into the Western Territories, as into California for instance, a larger proportion become insane than they do at the East. I think that I succeeded in proving to the gentleman that he was mistaken in his estimate in that direction. The fact is, that in the Western Territories the proportion of foreign born which become insane, is much greater than that which develops in the American or native born. The total figures as shown by the census, in regard to paupers, I will read. I cannot turn to them just now very readily, but so far as the insane are concerned, the total number is 91,997, of which 26,259 are foreign white. I did not tabulate the details of the pauper element, because I was not so intent upon that as I was upon the matter of insanity. Total paupers, 88,665; foreign born, 22,961. DR. Sre ARNS: I would like to call attention to that portion of the preamble in which it stated that. “Whereas, one-third of the criminal class come from those who are foreign born,” etc. I do not know that we have anything specially to do with the criminal class as a body. It seems to me that it would be better to limit our language to the insane, or at most to Proceedings. I25 the pauper class, without including the criminal class. It would tend, I think, to prejudice any action in favor of the resolutions among those who are foreign born, and look as though we were stepping out of our sphere of action to include the criminal classes, if not the pauper class. DR. PRATT: In response to that remark I would simply say that every gentleman is fully aware of the extent to which these classes run together —how many insane come from the pauper class; how many insane come from the, criminal class—and it was simply because of their being to some extent connected together by being defective, that these two classes were considered in connection with the insane. Of course, we believe, as a general rule, that chronic paupers breed paupers, and criminals breed criminals, and we know that the criminal insane are largely found in those two classes. The gentleman is undoubtedly aware that a great many of the so-called political cranks of Germany and the social cranks become paupers and insane in the United States. It is with such a view only that these classes have been considered together, and are mentioned in the preamble ; but they are not alluded to in the resolutions. Mr. OGDEN: Is the gentleman sure that he is correct in saying that Congress alone has such power? DR. PRATT: Yes, sir. Congress alone has the power to apply the remedy, so far as these evils are caused by immigration. MR. OGDEN: It seems to me that is a mistake. DR. PRATT : No, sir. I can give you the references to the decisions from which it is clear that Congress is the only power that regulates immi- gration. MR. O.GDEN: My idea would be that diplomatic interference would be more effective than Congressional. DR. PRATT : Diplomatic action is based to some extent upon legisla- tion and also on treaty. The leading case in which the power of States in this matter was denied by the Supreme Court, is that of Gibbons v. Ogden, in 9 Wheaton. This has been followed by a line of decisions, the last being the People of New York v. The Company Generale Trans-Atlantic, pub- lished in the Albany Law Journal, April 7th, 1883. Still later, another case has been decided in the Circuit Court of California, in which these pre- cedents were faithfully followed. In these decisions—a line of decisions from the time of Chief Justice Marshall down—every attempt made by States to obviate or mitigate any of these evils has been decided null and void. The Immigration Commissioners of the State and City of New York were finally discontinued on that ground. Pardon me for a few further words. I think I know something of the sensibilities of foreign born people to any criticism upon them as a class. But if gentlemen will reflect a moment, this is not a criticism upon foreign born people as a class. I may state that the first audience of my paper, gathered together expressly for the purpose of estimating the effect the paper would have upon the foreign mind—the first audience of my paper, in my private office, was composed of two German Jews, two Englishmen, one Scotchman, three Irishmen and a couple of Scandinavians; all intelli- gent men. I read the whole paper to them as it is contained in this I26 Proceedings. pamphlet, and asked them if action by Congress, such as was asked for, would excite any unpleasant feelings among the foreign class. Somewhat to my surprise, and greatly to my gratification, they all, in the first place, confirmed the statements of the paper, saying that they knew personally that we were being imposed upon by the exportation of these classes to us to take care of, and that they, as foreigners, would rejoice to maintain any attempt to stop it. As taxpayers they feel the burden. I do not know but that the purpose of the paper can be accomplished by striking out in the preamble all allusions to the proportion which the foreign born population furnish to our pauper and criminal classes; but the foreign people themselves, I have the best reasons to know, are not at all sensitive on the subject, because they know better than we do that they as a class are not responsible; that it is really the mercenary, municipal officials who have charge of the poor in these foreign countries, who are making it convenient, and economical at the same time, to send them to America. So far as the accuracy of these statistics is concerned, of course the paper on which these resolutions are based professes to be nothing but a study of census statistics. The census chapter upon the defective classes explains with great detail the care taken in getting the statistics. The criminal list was obtained, not by any guess work, but from the dockets of the courts in the several States for a given twelvemonth. The pauper class was obtained in a similar way, by a careful compilation of official statistics; the insane were obtained partly by reports of asylums, alms- houses, prisons and jails, but mainly by a very careful analysis of all re- turns by the enumerators in their several districts, and with this remarkable assistance; 60,000 physicians, without fee or reward of any kind, except the consciousness of doing a work for humanity, made reports, each from their own immediate neighborhood, upon the report as made by the enumerator himself, as to the accuracy of the enumerator's report, by which some cases reported were stricken off and others were added, and in various ways the accuracy of the report was secured. Now, while I have studied statistics enough myself to know how unreliable they are, if defective, I have the greatest confidence in the general accuracy of the statistics of the defective classes, as furnished by the census of 1880. After this discussion the resolutions were unanimously adopted as amended. The report of the Committee on Bibliography of In- sanity, prepared by Dr. Hurd, was read by Dr. Palmer. Dr. Schultz, from the Committee on Asylum Location, Construction and Sanitation, read a report on that subject. DR. SCHULTz: Before being aware of my appointment on this com- mittee as chairman, I corresponded with other members in the desire and hope that a report might be made as the result of the labor and consultation. of all the members. The idea miscarried, so that the fragmentary remarks to which you have listened, I wish to say, cannot be charged upon any other members of the committee. Proceedings. 127 On motion, the Association adjourned to IO o'clock A. M. The members of the Association spent the afternoon in a visit to Friends' Asylum, at Frankford, under the care of Dr. Hall. The Association was called to order on Friday, at IO o'clock A. M., by the President. The discussion on Dr. Schultz's paper was postponed for the present. The next report was on the “Treatment of Insanity,” by Dr. Everts. DR. EvKRTs: Mr. President and Gentlemen of the Association—The task of preparing and reading a paper on so trite a subject—the treatment of insanity—to such a body as this, justifies me in stating that I shall not take it as disrespectful if any of the distinguished ex-Presidents of the Association shall go to sleep during the reading. The report was then read. On motion of Dr. Denton, Dr. Ghent, President of the Texas Medical Association, was invited to a seat in the Association. DR. GRAY : I suppose the general silence of the members would indi- cate what is in my own mind in regard to the paper that we have just heard read. Dr. Everts has so thoroughly exhausted the subject, and so clearly, intelligently and comprehensively, that it seems to me the only thing that remains is to practice its precepts. DR. GoDDING: Lest silence should be construed into dissent, I wish to rise to say amen to every word and every letter of the paper. DR. NICHOLS: I will only remark, Mr. President, that I am sure that none of the ex-Presidents, distinguished or otherwise, went to sleep during the reading of the paper; and that I am quite willing to unite in the gen- eral amen in respect to the substance of the paper, two dissenting thoughts occurred to me in respect to what mey be denominated non-substantive matters. The Doctor speaks of patients doing as well in institutions under homoeopathic as in those under allopathic treatment. For myself, I do not know that such is the case; nor do I know what therapeutic treatment is administered in homoeopathic institutions for the insane. Their annual reports that I have had do not go into much detail in respect to the medical treatment of their patients, but my knowledge of the views of eminent homoeopathists and of the practice of several of good standing, lead me to suppose that the medical men at the head of homoeopathic institutions I28 Proceedings. may give drugs of great power quite as freely as others do. It would not, therefore, be my inference that patients in homoeopathic institutions do well because they do not get medicine. I do not recollect that the Doctor drew that inference for me, but the inference appears to naturally grow out of the remarks. The other dissenting thought is this. In some works on insanity, in some annual reports and in the paper the use of “chemical restraint” is spoken of. The context in all cases has seemed to indicate that those words are used to describe the quieting and restraining excited and violent patient by administering drugs to them, and I have never been able to see any propriety in characterizing the quietude effected in that way by those terms. We have no evidence that opium or chloral act chemically in allay- ing excitement or producing sleep. Quietude or sleep produced by drugs should, it seems to me, be called therapeutic or medical restraint, if it be Called restraint at all. With the general views of the paper I fully sympathize and feel per- sonally obliged to the Doctor for presenting them—the more for the ad- mirable diction in which they are clothed. DR. GRAY: If no other member has any remarks to make upon the subject, I would suggest that Dr. Channing should now present whatever he has to say. DR. CHANNING: I have very little to say. It is indirectly in the line of the discussion of Dr. Schultz's paper in regard to cheap buildings for the insane. In Massachusetts, as the gentlemen here know, we have been going through the usual reaction in many of the other States in conse- quence of our past expensive buildings, and our insane have been collect- ing until now our institutions are practically all filled. The Danvers Hos- pital was opened six years ago, and since that time the insane have been increasing at about the rate of two hundred a year, and that is now about the rate of increase. At various times during the last three years we have considered—our and other interested legislatures have considered different plans for providing accommodation for the numbers of the insane which were gradually collecting; and one plan, especially, that has been thought about, has been in reference to provision for the criminal insane. We seem to have, in Massachusetts, an unusually large number of this class—that is, we have in the hospital at Worcester nearly seventy insane criminals. Many of them are cases of comparatively mild insanity, but the larger proportion of them are the insane convicts that have been transferred from the State Prison and other institutions during the last few years. Alto- gether there are considerably over a hundred insane criminals in all our different insane hospitals. The question of provision for this class of the insane was first presented in the form of a bill to the legislature and it died very shortly, and the matter was referred from one legislature to another. As the number of the insane was increasing so rapidly, last summer a joint legislative committee was appointed to consider the subject of the future provision necessary not only for insane criminals, but also for other classes of the insane. That committee sat during last summer. They de- cided that there was no need of a separate institution for insane criminals, although all the superintendents of hospitals that they saw very strongly Proceedings. I29. urged a separate institution. They thought that some separate treatment might be necessary in connection with the State Prison, or in connection with an insane hospital, but that is as far as they went. They found, how- ever, that there was need of increased accommodation for the general class of the insane, and among other plans that they recommended was that of a homoeopathic insane hospital, and the Committee on Public Charitable Institutions this winter has presented a majority report in favor of turning some of the existing buildings of the Westborough Reform School into a homoeopathic insane hospital, to accommodate about three hundred and twenty-five at a probable expense of $150,000. There were two minority reports, one that a portion of the buildings at Westborough should be adapted to the treatment of the insane and be under allopathic treatment, and the third one that supplementary buildings, such as those at Middle- town, or perhaps at Washington, or at Kankakee, should be erected upon the ground of some of the existing State hospitals; and those mentioned, if I am not mistaken, were Danvers and Worcester. The idea of the last minority report was that the building should be erected for a hundred persons, at an expense of $25,000, or at two hundred and fifty dollars a head, and Mr. Robert Treat Paine, Jr., of Boston, who organized our sys- tem of associated charities there and introduced this bill, was a member of the Committee on Public Charitable Institutions. He called a meeting at his house a week ago for the purpose of considering in what manner cheap buildings might best be erected to supply the present needs of our insane. A number of gentlemen were present, many of them legislators, and also architects, and two or three gentlemen interested in building and a few physicians. ge Hon. Edward Atkinson, of Boston, who is very well known I suppose throughout the country as a prominent Boston citizen, especially interested in insurance, and who is the president of a large insurance company which insures mills and factories, was asked to present a plan of a cheap building for the insane. This he consented to do and some of his plans and some rough sketches which he had made on a small scale, I have here in my hand. I think it may interest gentlemen here to see these plans. He ap- proaches the subject from a rather original point of view. Dr. Schultz spoke of so many of our hospitals being designed by architects who knew very little about the wants of the insane. Mr. Atkinson is not an architect but he understands thoroughly factory architecture, and it seemed to be Mr. Paine's idea to see if Mr. Atkinson, with his special knowledge of cheap, big buildings for manufacturing purposes, could not suggest some shape or form of building which would be cheap and in a certain measure would be appropriate for the insane. So he approached it from that unusual point of view. As he said, he knew very little about what the insane wanted, and the most he attempted to do was to give a plan of a mere shell of a cheap building which might be adapted to their use. He has, since given his plans on that evening, somewhat modified his views I am told. He discovered then that some things were necessary that he had not known of, in providing for the insane. Mr. Atkinson’s plans are a direct contrast to those of a hospital like Danvers, and furnish a good illustration of the extreme of reaction. He presents several of these plans. First he I 30 Proceedings. described a three-story building, and in illustration of it passed around the plan of a mill, showing the system of piping arranged for an automatic sprinkler. An inside view of this building gives an idea of an approved factory of three stories. Mr. Atkinson does not recommend a three-story building, but that section of the mill gives a good idea of the construction of the floors and of the supports of the three-story mill. [The plans were exhibited.] This plan, number two. is for a one-story building. This plan he especially recommended, although he modified his suggestions after learn- ing that a one-story building would not be as well adapted to the insane as a two-story building. His plan number two was a frame building, although he said it could be a building of brick at very nearly the same cost. He would build this one-story building with a unite of sixteen. That is, the separate rooms may be sixteen feet square; the hall sixteen feet wide; open dormitories sixteen feet wide; and the large rooms, three sections, each one sixteen feet square. The walls of brick or wood as I have said before. The roof of three.inch plank, covered with gravel or with duck properly prepared. It seems to me such a plan of roof would be a very good one for a lunatic asylum. It is simply nearly a flat roof, raised a little in the middle, of three-inch plank, covered with gravel or with duck, the duck saturated with pine tar or mineral paint. The partitions would be of two- inch plank, grooved and splined, plastered solid, either on wire or dove- tail lath nailed to the centre of the planks, so as not to be affected by their shrinkage. These one-story buildings could be set up in sections in one line, on the sides of a quadrangle, or in the shape of an H or Greek cross or star form, and each section could be separately constructed or extended. This special arrangement, of course, if it is in a Greek cross—and sections too near together are not to be recommended—but the general plan kept up in the sections and proper distances, is one that might be very readily available. Such a building as this could be constructed for about seventy cents, or between seventy and eighty cents a square foot, or without the various internal arrangements adapted especially for the treatment of the insane it would cost not over One hundred and fifty dollars a person. With the boilers and the Ordinary apparatus needed to carry on a hospital, it could be erected probably at two hundred dollars a head, on this plan. Here is a view of the one-story, not precisely like this that is mentioned on the other plan, but somewhat similar to it, showing, the size of the timbers needed for a one-story building, and somewhat the internal appearance. DR. EARLE: I would propose, as we have a great deal of business on hand and as our time is So short, that Dr. Channing let the plans lie on the table, where they may be examined at pleasure. As the Doctor well re- marked, they show the extreme reaction from what I was about to call the insane delusion which manifested itself in the erection of the Danvers Hospital. I wish at the present time to ask the assistance of the members of the Association. It is desirable that we should have, as I do not doubt that we shall have, an interesting meeting next year at Saratoga. Inasmuch Proceedings. I3 I as our closing session will be held this evening, it will become necessary to appoint, before that time, the members of the standing committees—the same committees a part of which have reported this year. I greatly desire that we shall so fill them that the right men will be in the right places. For myself, I am not sufficiently familiar with the special studies of the different superintendents to decide in all cases, who will be the best men to appoint as chairmen of those committees. I hope that if any member of the Association knows of another member who is especially qualified for either of the committees, he will mention the name of that gentleman to me; or, should there be any member who is pursuing studies in a special direction, I trust that he will not be so modest as to keep his name to him- self. I am very earnest in pressing this subject upon you and asking your assistance. The first standing committee is on the Annual Necrology of the Association; the second, on Cerebro-Spinal Physiology; third, on Cerebro-Spinal Pathology; fourth, on the Therapeutics of Insanity and New Remedies; fifth, on the Bibliography of Insanity; sixth, on the Re- lation of Eccentric Diseases to Insanity; seventh, on Asylum Location, Construction and Sanitation; eighth, on the Medico-Legal Relations of the Insane, and ninth, on the Treatment of Insanity. I desire, further, to seize the present moment to make a few remarks - on a subject which I think ought to be brought to the attention of the Association. Perhaps all of the superintendents of hospitals who are present, received, a few months ago, letters from New York asking for the number of patients admitted to their institutions the cause of whose in- sanity was alcohol. I declined to answer those which were addressed to me. Knowing that I could give no adequate idea of the actual number, or the proportionate number of my patients—whether those now present or all who have been inmates in past time whose insanity was caused by in- temperance; I believed that any attempt to answer the questions by statistics would do more harm than good. A few days ago the result of that inquiry was sent to me in the form of a pamphlet. Undoubtedly it was sent to other superintendents. I have not had time to read it, but have so far examined it as to learn that its author comes to the conclusion, derived from information of all sources, but chiefly from the superintendents of hospitals, that the percentage of insanity caused by intemperance is seven, or about seven. I leave it to you to form your own opinions whether that approximates in any very considerable degree of nearness of approach to the actual proportionate number. I still believe that those statistics will do much more harm than good. There was not, apparently, allow me to say, sufficient care on the part of the superintendents who answered the letter. As Dr. Chapin re- marked in essence yesterday, statistics are very delicate things and unless made with great care they may tell great falsehoods. At several of the hospitals, the figures in the column “Number of Patients Admitted” are not the numbers of patients admitted, but, appar- ently, the whole number in the house in the course of each consecutive year. Every patient received is consequently counted every year so long as he remains in the hospital. The effect of this repetition is greatly to increase the sum of what are called admissions, but are not what they I 32 Proceedings. profess to be. Thus, at one hospital, which according to its annual report, admitted, in the course of thirty years, 7,061 patients, the number of ad- missions is made by these New York statistics to be 20,658. The number of cases alleged to have been caused by intemperance was 1,141. The actual percentage so caused was 1141-7061, equal to 16.15, or nearly one- sixth of the whole. But the apparent percentage which is the result of the New York statistics, is only 1141-20658, equal to about 5.57, or but little more than one-twentieth of the whole. At another hospital the swollen numbers of the New York statistics make the admissions, in ten years, 6,187, whereas the true number, as shown by the annual report, was 2,451. The number of cases originating in intemperance was one hundred. The New York statistics make the percentage 100-6187, equal to 1.61, whereas the true percentage is 100-2451, Or 4.6l. - A very similar letter to the one just mentioned has since been received from Missouri. A committee of some association in that State requested the same or similar statistics in regard to intemperance as a cause of in- sanity. I answered that by first giving my correspondent the number of admissions from the opening of the Northampton Hospital to the present time, and then informing him that if he could sit down and make a shrewd Yankee guess he could obtain figures which would be of more actual value than ostensible facts which I could give him, especially if the com- mittee which used them would acknowledge that they were obtained by guess work. It is not necessary for me to point out the difficulties involved in this subject or to mention the impossibility of giving to outsiders, from the statistics which we have, an idea of the extent to which intenuperance is probably a factor in the production of mental disorders. DR. GRAY: Mr. President—I am glad that you have brought this matter before the Association, as I understand, formally. I have received, I suppose in common with other superintendents, on an average certainly of once a week, a claim or circular of some kind for information, upon which persons desire either to write a paper, or to write a book, or to appear be- fore some association, or execute some philanthropic purposes for the good of men. As a general rule I have put them in the waste basket. To me, a good many of them seem to be simply sponges, sucking up what they can get here and there and then appearing as authors. Occasionally, when I have complied, after a second or third letter telling me that I was either the only one, or nearly the only one in the State who declined to give the information, and furnished it, I have found that it was generally the case that the information was desired by the writers in order that they might appear as authors, either on opium or liquor, or statistical informa- tion, or in connection with the administration of various remedies. I have even been asked for detailed information as to the number of doses of various medicines given in the hospital; the persons calling for it wanting to write a paper, or appear before the public on chloral or bromides, etc., thus sponging all the information possible from persons of experience, they having little or none themselves, and then appearing as great authors on the therapeutics of these subjects. I doubt very much whether any of Proceedings. I 33 those circulars ought to be answered, except they come from some responsible body. I do not know exactly what association in New York the President referred to. I have received four or five pamphlets. DR. EARLE: It was a brewers’ association. DR. GRAY : I think I answered them after I had received additional letters from three or four prominent and responsible gentlemen, among them one or two lawyers, saying they thought a public officer ought to furn- ish the statistics upon any subject asked for by reputable men, or refer them to where the statistics could be found. Afterwards I furnished the sta- tistics as they appear in the reports made to the Legislature upon the sub- ject. I have not received any reply or any pamphlet, but I presume if the rest are in there that I appear with them. However, I have made up my mind to ignore those things as far as possible, because I do not think that that sort of pseudo-science, or whatever it may be called, should be in the least encouraged. I think spontaneous labor on the part of men who know about the subject they are writing upon, who give just what they know themselves and compare it with what they may get from others, or on general record, is the only way that authors should appear. I believe that these sponges should be dropped. DR. EARLE: I am very glad to have heard Dr. Gray’s remarks. The object in this case appears to have been, as I suspected from the beginning, to sustain a trade, the support of which is the support of the cause of in- temperance. The pamphlet shows that only seven per cent. of the cases of insanity are caused by intemperance, and then gives the National revenue from the production of alcoholic drinks in such a way as to lead to the inference that the nation gets abundantly paid, perhaps much overpaid for the little detriment of the seven per cent. of insanity which is caused by it. - DR. NICHOLS: The same application for information upon this subject came to me. It appeared to coune from an officer of a brewers’ society, and I supposed it was made entirely in the way of trade—that is, to make it appear that alcoholic, and particularly malt liquors, did not produce as much insanity as is generally supposed. I think I received as many as three applications for the same information from the same party. DR. EARLE: I had three or four. DR. NICHOLS: The second and third applications stated that an addi- tional number of superintendents had responded. I treated the applica- tions as Dr. Earle says he did. I didn’t furnish any information. While I am up I will take the liberty of saying that the subjects pre- sented by Dr. Channing appear to me to be of a great deal of moment in connection with the class of people in whose welfare this Association was organized and is met here to promote, and that I very much hope that Massachusetts will not be led into the concretion, so to speak, of the ex- treme reaction of sentiment which has taken place in that State in relation to the cost of its institutions for the insane. Nobody will deny that one, perhaps both, of the institutions last erected in that State, including the arge sums expended in preparing the sites for building, cost a very un- necessarily large sum, but the money can not in any way be called back I34 Proceedings. into the public treasury and its expenditure has not impowerished the State. It is still perfectly able to provide for the increase of insanity within its borders, and I cannot think that it will be led into putting up card-board shanties that will be neither comfortable, healthy and safe as respects patients taken care of in them, nor reputable to that great com- monwealth. From the outset of the consideration of the subject of making proper provision for the criminal insane my judgment had in certain cases favored the erection of buildings or quite separate wards in connection with our State institutions for the treatment of this class of patients. We all agree that the criminal insane should not be placed in the same wards with inno- Cent, reputable people and that they should not be confined to the cells of a prison. Now, the rational course, it seems to me, is to adopt some Scheme of separating them that is feasible and practicable. New York has a sufficient number of the criminal insane to justify it in providing and maintaining a separate asylum for them. Other States have a sufficient number of this class to justify the same procedure, but I believe New York is the only State that has such an institution, though the separation of the Criminal insane from other classes has been strongly advocated by this Association of Superintendents in their annual reports for at least twenty- five years. Massachusetts might have an entirely separate institution for the criminal insane, but I cannot think that altogether desirable under the circumstances. DR. EARLE: Not in Massachusetts. DR. NICHOLS: But there are States beside New York that probably have a sufficient number of criminal insane to justify an altogether separate provision for them. The plan that is suggested by Dr. Channing, or that it is now proposed to carry into effect in Massachusetts, is such a one that the small States can carry into effect; and whether a State has six or sixty criminal insane, it can in that way give them the most enlightened and humane care at a moderate expense; and I believe it can be done without encroaching upon the welfare of the ordinary insane in public institutions. DR. GRAY: I was not present when the matter came up, but I think I ought to say something in connection with the remarks of Dr. Nichols. I have had some experience in having criminal insane, both convicts and what are ordinarily called criminal insane, in a State institution. I am utterly opposed, looking through my experience, to any such plan as a ward, connected with a State institution or any other institution, for the care of criminal insane. In the first place, the proximity of that class—for they are a class that should be kept away from the ordinary insane—is unpleasant, and it is difficult to have them properly cared for without, on the one hand, too much isolation; and, on the other hand, if they are mingled with the ordinary classes in their exercising grounds, in the work upon the farm, or walks to anywhere in the vicinity, that immediately breaks up any separate management. Besides that it would be unjust to the criminal insane themselves to house them together in a Ward, the quiet and orderly with the noisy, disturbed or dangerous. It throws aside at the very beginning all the ideas of classification, by placing an injurious attrition upon each other. The very purpose, therefore, of making them Proceedings. I35 feel agreeable and comfortable, and putting them under enlightened super- vision, is thwarted. Such a ward would become merely an almshouse ward. I have been in an almshouse where they took care of the chronic insane with all classes in one ward. There were the nolsy, maimed and epileptic patients; the violent, the quiet, the demented classes. This would be the same thing. The State of New York projected this institution a great many years ago, that now has its existence there, and is highly successful. At that time I visited, at the request of the Governor, all the prisons of the State; examined all the convicts and made a report to him as to the num- ber and character of the prisoners there who were actually insane, or who were so insane as to disturb the discipline and order of the prisoners. The institution was erected, organized and then a law passed subsequently authorizing the transfer from the State asylums of such criminal insane as were recommended to be transferred by the superintendents, after exam- ination into each case by a Justice of the Supreme Court, he having the final responsibility. I am glad to say that this last winter, as one of the results of the legislative investigation that was had, was the passage of a more comprehensive law, similar to the provisions (or in essence) that exist in England; that is, instead of restricting the cases of transfer simply to murder or attempted murder, and arson and highway robbery, there is no designation of crime but embraces all persons who have committed crimes, leaving it open then to transfer all criminals who are dangerous or injurious to the welfare of the ordinary insane in the hospitals, following the course in England of transfers from other county asylums of persons of the same class to Broadmoor. Now the system has certainly acted well there, and I think—I speak in the absence of Dr. McDonald, who is Super- intendent of the Criminal Asylum in our State—it is conceded by those who have had opportunity to look into the matter, our State officers and the Legislature, that that institution is a success; I know that it is an infinite relief to the State Lunatic Asylum at Utica, and I should be very sorry to see any movement which would tend to place the criminal insane in isolated confinement in connection with any State institution. Of course, if the States are too small, as some of the New England States are said to be, I can see no objection to the erection of some central hospital, where One State could secure an opportunity of transferring its criminals to the care of that institution. I do not know how the matter would work, but if there are from seventy to one hundred or more in the State of Massa- chusetts, that would be half as large an institution as some of the members of the Association believe ought ever to be erected. But any institution that Covers over fifty persons, could very easily arrange a proper classifica- tion, so that these people would not be brought together in a confused, heterogeneous mass of mania and melancholy, dementia and general paresis, and the filthy, the orderly and the quiet and neat all put into one Ward. I think nothing could be worse than that. If I had a friend or acquaintance so unfortunate as to be a criminal, I should pray that he be left in prison, than that he should be changed under such a system as that. DR. CHANNING: I do not think that Massachusetts will put up such buildings as Mr. Atkinson has drawn here. I simply brought them here as Suggestive of what were better than card houses, warm and well venti- 136 Proceedings. lated, etc., and thought they might be interesting to the Association to look at. The chances seem to be now that we shall have a homoeopathic hospital there — that the building of the Westboro Reform School will be adapted to the use of three hundred and twenty-five insane persons, under homoeopathic treatment. In other ways we have, perhaps, retrograded somewhat in Massachusetts in regard to provision for the insane. A bill was passed last winter, that cities of over 50,000 inhabitants may erect an institution for the care of their insane. Just now we have only two or three cities of more than 50,000, so there will not be very many of them at any rate. But our State Board of Health, Lunacy and Charity, has recom- mended the transfer of the insane from the cities and towns back again to the almshouses, especially if they have an insane department. In conse- Quence, at the present time, we have quite a large number of persons under lay management. For instance, in Lowell the insane department has now, I believe, fifty or sixty insane persons, and they are visited by a doctor from the city once or twice a week. There are also insane departments at Salem and Lawrence. When I spoke of the proposed plan, I did so for the purpose of showing how a number of insane persons might be kept cheaply, but not to recommend it. DR. NICHOLS: Are there not quite a number of insane kept at Salem? DR. CHANNING: I do not think a very large number, probably fifteen or twenty. DR. NICHOLS: Not as large as they have had 2 DR. CHANNING: I think they were sent to State hospitals, and not sent back for want of proper accommodations. In regard to an institution for insane criminals, having been connected with the Auburn Hospital for some time, I got some knowledge of insane criminals; and having also examined insane convicts in the State prisons and reformatories of Massachusetts, I have a little idea of the treatment of insane criminals both in special institutions and in general insane hospitals. Insane convicts, where they are treated with the other insane in a general hospital or in a separate ward, from what I have seen myself, are a source of great embarrassment. At Worcester, where the number is very large, wards were supposed to have been built especially for that class. They cannot all be treated satisfactorily together in one ward, there are so many varieties of insanity among such a large number of insane convicts. I think it is the testimony of Massachusetts' Superintendents, that it is a source of great difficulty with them. But the State of Massachusetts re- tains insane convicts in the prisons, because of no other place to send them. We do not ſeel like obliging the superintendents of hospitals to take them, as they are often disturbing and dangerous men. I do not feel like recom- mending such a transfer, although l know it is the quickest way to get such accommodations as we ought to have. The Warden has to keep them closely confined, and they do not receive the medical treatment that they need ; and yet, if they go to the insane hospital they make so much trouble that it seems only right to keep them confined in a close room as in a prison. The picture is very different as seen at Auburn, where the insane criminal is very much like any other insane man; except that he is confined Proceedings. I37 more closely within four walls. He has more privileges, a greater amount of freedom and much better treatment in every way than it is possible to to give many of the insane convicts in a lunatic hospital. Men who are disposed to be vicious, cannot be allowed to associate with other patients without the greatest injustice; and where one has seen both sides of the picture as much as I have—having always been interested in the subject and seeing a number of insane criminals every year—one is much im- pressed with the advantages of a separate institution for insane criminals. DR. EARLE: Dr. Nichols suggested, as a palliative, at least, of the mistake made by Massachusetts in the erection of so expensive a hospital as that at Danvers, that Massachusetts was not impoverished by it. Of course she was not. If she had expended ten millions upon it she would not have been. But that does not relieve the taxpayers of the State from the effect of the burden of to-day, which is, that they are paying ninety thousand dollars interest, annually, on the cost of that establishment. Aside, therefore, from the actual necessary current cost of support of its inmates, there is this additional ninety thousand dollars a year to be con- sidered as a part of the expense to the State. The hospital was intended for four hundred and fifty patients. The commissioners and the physician who advised them, always maintained that it never ought to contain more than that number. Provided, therefore, that the number of patients had been limited to four hundred and fifty, the actual cost to the taxpayers of Massachusetts, of the insane paupers—and I suppose considerably over three-fourths of the inmates of Danvers are paupers—are they not, Dr. Channing? DR, CHANNING: I should think so. DR EARLE: The actual cost, then, would be about eight dollars each, per week. Instead of having four hundred and fifty patients it has almost seven hundred and fifty. When I last heard, it had seven hundred and thirty. The hospital never paid its running expenses until the last official year, when the average number of inmates was nearly seven hundred. In regard to the plans which have been shown by Dr. Channing, and the remarks upon them by Dr. Nichols, I may say that the gentlemen may rest assured that Massachusetts is not going to commit itself to any unwise experiment. That State will never, unless a great change takes place, house its insane in buildings where their physical comforts will not be sufficiently administered to. As an evidence, take our asylum for the chronic insane, at Worcester. A member of the State Board of Health, Lunacy and Charity, within the last year has said to me, “It is the best hospital in the State’—meaning, as I inferred from the previous conversa- tion, the most comfortable and home-like. DR. NICHOLs: Better than Northampton? DR. EARLE, [hesitating.] I quote from a member of the Board of Health, Lunacy and Charity: The whole subject is in the hands of a body of men who will never see their fellow men improperly treated—a body of men and women, for women are beginning to form an important factor in the administration of the charities of Massachusetts. 138 Proceedings. DR. SCHULTz: Mr. President—With reference to the remarks of Dr. Nichols I wish to say something. He did not elaborate his remarks and I do not know fully what his ideas are in regard to the association of these two classes of people, the ordinary insane and the insane convicts; whether he believed they ought to be in the same building, or in the same town, or on the same farm. We have two hundred and sixty acres at Danville and have only four hundred patients, and yet cannot find room enough for suitable exercising grounds, for they are mostly unskilled laborers and they require plenty of elbow room. On that account we go out for exer- cise into the lanes and roads of the neighborhood and the consequence is that we are blamed for trespassing, justly, perhaps. Now, if we had insane convicts, classified and known as such, we should be restricted still further, as they could not come in contact with each other out of the buildings and away from them, any more than in the halls or amusement room or chapel. When the Danville Hospital was being erected the attempt was made to have a part of the building appropriated for the insane convicts of the State, but while deliberations on the matter were in progress an article appeared in one of the medical journals of this city, by one whose ability to speak with authority none of us would for a moment question. He maintained with much emphasis and philosophy, I think, that it required one kind of mental organization, habit of thought and moral disposition to take care of the criminal class, and a totally different one to take care suc- cessfully of the ordinary insane, and that the two classes could not be suitably cared for under one management. When, some years later the buildings had to be in part re-erected, the same question arose once more. After a somewhat full conference at the hospital, by a Legislative Committee, the Board of State Charities and the Trustees and Officers of the Hospital, the conclusion was arrived at and acted upon that it was inexpedient to take care of the insane convicts in the building. I hardly know whether I am more surprised or more pained to hear a statement made in this meeting, that these two classes of patients should be taken care of together. I think the position of this Association ought to be decidedly, that it is utterly wrong to treat them together, and it is to be tolerated only as the lesser of two evils. Dr. NICHOLS: Dr. Channing and Dr. Schultz appear to come to a common ground on this question. No man can be more deeply impressed with the importance of separat- ing the criminal from the reputable insane than I am. When I was an assistant at Utica a considerable number of criminal insane were treated in that institution, and at Washington a very few such patients were treated at different times, and I am unable to express my sense of the injustice to the reputable insane of treating the two classes together. And if they are treated under the same economical and medical organization as the ordinary insane, I have not the slightest idea of having the two classes come in con- tact with each other, and cannot see that such contact would be necessary. A State institution should have as much as two hundred and sixty acres of land—some have a much larger area—and I cannot see why fifty or sixty acres of it cannot be walked in, buildings be erected in such enclosed Proceedings. I39 grounds, and the criminal insane of an asylum district be treated there just as well as they are treated at Auburn. Perhaps I was unfortunate in using the word ward, though I think I did use the word building. I cannot think that any one here really supposes that I have for a moment entertained the idea of putting all the criminal insane of one sex in one ward—much less that I have entertained the idea of putting both sexes in one ward—which language used in this discussion might be thought to imply. If a separate building in a separate enclosure provided for three (3) classes of each sex, the classification would be more liberal than has always been provided for the reputable insane in State institutions; and in that proportion of the almshouses of the country in which from ten (10) to a hundred (100) or more insane persons are taken care of, are there six (6) distinct wards, three (3) for each sex? Probably in no more than one (1) out of ten (10.) It is from my sense of the crying evil of associating the ordinary and the criminal insane, and of the urgent necessity of everywhere disassociating them that I am in favor of a plan or scheme that the State legislatures are like to authorize and make the necessary preparations for. I am not in favor of a retrograde movement in this or any other matter, unless it may be, to depart from a single line of endeavor that has long been pursued without desired results, except in one instance as far as I now recollect. DR. CHANNING: I understood Dr. Nichols to say a ward. DR. NICHOLs: If I used the word ward alone, I was in error. I should have used the word building. DR. CHANNING: Could not a building be put up on the grounds of an existing hospital? On the score of expediency it might be the best plan; but I think the best or ideal plan is an institution for the criminal insane, that is wholly, and absolutely separate, where there is no possibility of association or of demoralization in the environment or in the proximity of that class. I think the insane criminals, themselves, could have more liberty and more treatment, if they required treatment, by themselves, on a good-sized farm, which they could perfectly, work and carry on, than in proximity to another institution. I think with a tenement, one would have an opportunity of curtailing the whole. That would be the only practical advantage. DR. NICHOLS: The erection of a building on the grounds of an exist- ing hospital—on a part of the farm set apart for the treatment of criminal insane—is just what I advocate where it is not practicable to have a separate asylum for that class of patients. You would consider it neces- sary to have that part of the farm walled in 2 DR. CHANNING: Not unless there was an institution nearby. DR. NICHOLS: I think it should be walled in in every case, in order that the patients might have an easy liberty of personal movement, without the liability to the escape of persons very dangerous to be at large. It has been proposed that two or more States should unite in the estab- lishment of an institution for the criminal insane for their common benefit. All that can be said of that scheme is that it has not yet been carried into I4O Proceedings. effect though proposed many years ago, and that there are many reasons Why it is not likely to be. * DR. CHANNING: There is a certain number that will escape, and I think provision should be made in insane hospitals for that class. They should not be allowed the same privileges, should be guarded very closely, placed in particularly strongly constructed rooms, and also more closely watched when they go out doors. You know Dr. McDonald allowed quite a large number to go out into the neighborhood for farm work, and into the fields around. Even in criminal institutions a large number can go out under the care of attendants, without the walls. It would be very expen- sive to put up walls around a large farm. DR. GRAY: Wouldn't an institution on a farm, or anywhere else, have to have a medical officer detailed for service there ? DR. CHANNING: Certainly. In regard to card-board houses, or cheaper buildings, Dr. Palmer told me to-day that at his hospital, near Kalamazoo, they have what I think he calls “sheds,” where, if I am not mistaken, he has forty patients, at a total cost of fifteen hundred dollars; they are there in the winter as in the summer, and he said they are very comfortable. T)R. EARLE: It is necessary, in justice to myself, that I should make an explanation in regard to the subject which has been under discussion. While Dr. Gray had the floor, I expressed the opinion that it is not desirable, in Massachusetts, to have a separate criminal asylum. It is not because I do not think that such separate treatment is best. My remark was based upon the fact that the number of patients in Massachusetts who, in my Opinion, Ought to be dormiciled in such an institution, is too small, at present, to justify the construction of an independent establishment for their ac- commodation. Could such a thing be effected, I would hail the day upon which it might be decided that the States of New England should unite in the erection of a joint asylum for the criminal insane. Dr. Gray alluded to the number of the criminal insane in Massachusetts. Three quarters of them, roughly speaking, are criminal only in the very lowest degree, and no worse than many of the patients by whom they are surrounded in the present hospitals. An insane man, happening to get drunk, is taken up in the streets, sent to the Jail and thence to the PHouse of Correction. He is 'brought from that institution to ours or one of the other State hospitals, and in two or three months the term of his sentence expires. Shall all these cases be confined in a separate institution with other convicts 2 If those, why not a large proportion of other pauper insane in the institutions who are really as objectionable as these petty criminals themselves 2 I do not wish to prolong the discussion, but I thought it right to prevent myself from being misunderstood. DR. GRAY: I would say at this point that those persons are not recog- nized in our State as criminals. They are simply persons who have not been tried by courts or by juries for crimes, but are found to be dangerous to be at large, and are not subject to transfer to Auburn. DR. EARLE: In our State they are called criminal insane, and the fact that so large a proportion of them were arrested for merely petty offences is perhaps one of the chief reasons why Massachusetts has not done some- Proceedings. I4 I thing toward making separate provision for them. The numbers of the really criminal insane, that is, those convicted of felony and those who have committed homicide or other capital crimes, but have not been put on trial, are very few. Dr. Fisher then read a paper containing a history of a case of tumor of the brain. Dr. Chapin read a paper on “Mental Capacity in Typhoid Fever.” On motion of Dr. Gray, it was Resolved, That if any member of the Association wishes to attend the International Medical Congress, he shall be furnished by the Secretary with a certificate as delegate. On motion, the Association adjourned to 8 o’clock P. M. The Association spent the afternoon in visiting the Department for Males of the Pennsylvania Hospital for the Insane, under the conduct of Dr. S. Preston Jones. The Association was called to order at 8 P. M., by the President. Dr. Chapin offered the following resolution: Resolved, That Assistant Physicians of State and Incorporated Hospitals and Asylums for the Insane, who have been continuously on service for a period of years, are hereby constituted members of this Association during their official connection with their respective institutions. On motion of Dr. Chapin, the resolution was referred to a committee consisting of the President, Vice President and Secretary, to report at the meeting in 1885. The Secretary read the list of the Standing Committees for the year 1885. \ [The list of Committees is here omitted, the same having been published in the July (1884) Number of this Journal.] Dr. Callender, from the Committee on Resolutions, reported the following: The Association of Medical Superintendents of American Institutions for the Insane, about to terminate its meeting in this city, in which it was Organized forty years ago, and in which it has held seven of its annual meetings, in the customary resolutions on the occasion is inspired by I42 Proceedings. mixed emotions. The selection of Philadelphia for this meeting was mainly induced by the hope of the presence at its deliberations of one of its venerable and eminent founders, whose weight of years and declining strength was known to the membership —the late Thomas S. Kirkbride, M. D. The inscrutable wisdom of Providence has frustrated that hope. His face was not among us, but the memory of his abilities and his rare virtues was left to us to honor, and will be green as long as the Association shall survive. This meeting has been graced, however, by the presence of an- other of the links yet connecting the body to the day of foundation, in the person of our distinguished President, his contemporary and colleague, and the Association congratulates itself upon the fact and cordially Wishes him length of years and usefulness. * The Association records with pleasure, that the authorities of public institutions of this city with which our work is affiliated, and the resident members of the medical profession have greeted it with their accustomed liberal hospitality, and the observation of our visit is that Philadelphia, the pioneer in this country of humane endeavor in behalf of the insane, is yet abreast of the current of progress in general philanthropy guided by medical science. To the Board of Managers of the Pennsylvania Hospital for the Insane, and to Dr. S. Preston Jones, for many years in immediate superintendency of the Male Department of that renowned institution, we are indebted for the privilege of visiting the wards of that department and for their court- eous attention. To Dr. John C. Hall, the Superintendent, and the Managers of the Friends’ Asylum at Frankford, we are also indebted for an agreeable afer- noon in the inspection of the appointments of that institution—a model of neatness and comfort, and an honor to the specialty. The Association expresses its high appreciation of the invitation to visit the Medical Society of the State of Pennsylvania in its annual session, and the opportunity afforded to mingle with its members and of attending the reception held by its eminent President, Henry H. Smith, M. D., of this city, in the rooms of the Philadelphia Academy of Fine Arts. The thanks of the Association are returned to the Guardians of the Poor, of the city of Philadelphia, for an invitation to visit the Insane De- partment of the Almshouse; to the Managers of the House of Correction, to visit that institution, and also to the Directors of the School for Imbecile Children at Elwyn, Pennsylvania, and its regrets expressed that the limited period of the session and the immediate business of the body rendered it impossible to avail itself of their kindness. The reporters of the city press, in attendance upon the sessions of the Association, have laid it under obligations for their full and accurate minutes of its proceedings; and Messrs. Kingsley & Co., of the Continental Hotel, have its thanks for the quiet and commodious parlor furnished for its use, and for their attention and courtesy to its members as their guests. On motion of Dr. Curwen, the Association adjourned to meet in Saratoga, N. Y., on the third Tuesday of June, 1885. John CURWEN, Secretary. SELECTIONS. HARVEY's FoRCAST OF CoMING EVENTS.—We note the following from Dr. J. Russell Reynolds’ “Harvein Orations,” published in the British Medical Journal, October 25, 1884: “We find him saying, “In general, the first processes of nature lie hid, as it were, in the depth of night, and, by reason of their subtlety, escape the keenest reasons no less than the most piercing eye' (Anatomical Exercises on the Generation of Animals, p. 225). In another paper, “All living things . . . . derived their origin from a certain primary something or primordium, which contains within itself both the “matter' and the “efficient cause,’ and so is, in fact, the matter out of which, and that by which, whatsoever is produced is made '' (Thesis on the Uterine Membranes and Humors, p. 554). Again, “It appears advis- able to me to look back from the perfect animal, and to inquire by what process it has arisen and grown to matu- rity, to retrace our steps from the goal to the starting place; . . . so that we shall perceive from what primary matter and from what efficient principles, and in what way from these, this plastic form proceeds . . . . . . y 3 (Introduction to Exercises on the Generation of Animals, p. 163). Further on, in the same paper, we find him saying, “Man comes into the world naked and unarmed, . . . . as if nature had desired that he should be guided by reason rather than be driven by force ; therefore she did endow him with understanding, and furnish him with hands, that he might himself construct what was necessary to his clothing and protection. To those animals to which nature has given vast strength, she has also presented weapons in harmony with their powers; to those that are not thus vigorous she has given ingenuity, cunning and singular dexterity in avoiding injury.” (Ibid., p. 425.) In connec- tion with this, he proceeds to mention the “ornaments *...* offence weapons, teeth, horns, spurs, and other imple- ments employed in combats . . . . the subject of dispute being no empty or vain-glorious matter, but the perpetu- ation of the stock in this line or that ; as if nature intended that he who could best defend himself and his should be preferred to others for the continuance of the kind.” (Ibid., p. 425). [143] I44 Selections. In the passages just read, we have, as it appears to me, very much the same ideas as are now conveyed by the term “protoplasm; ” “the relation of man and animals to their environments; ” and the doctrine of “the survival of the fittest.” With reference to the significance of the primordium, the protoplasm, as seen by Harvey, let me read another passage from his writings. Speaking of the lowest forms of life known to him, he says: “These have no heart, as not requiring any impeller of nourishment into the extreme parts; for they have bodies which are connate and hom- ogeneous, and without limbs; so that, by contraction and relaxation of the whole body, they assume and expel, move and remove the ailment . . . . The whole is used as a heart, or the whole animal is a heart.” (An Anato- mical Disquisition on the Motion of the Heart and Blood, p. 76.) Further on, “All local motion proceeds from, and has its original, in the contraction of some part.” (Ibid., p. 81.) Here we have, as it seems to me, an account of the simplest form of life; his counterpart of the “amoeba,” as we may find it described in the most modern and, to my mind, one of the most able text-books of physiology of our days. (Introduction to Michael Foster's Text-book.) —Philadelphia Med. and Surg. Rept. A CASE ILLUSTRATING SEconDARY NEURATROPIC PHO- BIAs.--Dr. C. H. Hughes (St. Louis Med. and Surg, Jour, Oct., 1884) reports the following case: John C., aet. 52, of spare build, height five feet eleven inches, weight one hundred and forty pounds, blue eyes dark (now gray) hair, of Irish birth and by occupation, most of his life, a hotel porter, is married and the father of three children. He has never been sick so as to be confined to bed. Has had spermatorrhoea, and been treated for it in vari- ous ways without material benefit. He is a man of medi- ocre intelligence, steady in his habits, and never used whiskey or tobacco. He has now cutaneous anaesthesia in face, arms, thighs and hands and intense burning sensations in feet. Eats sparingly and sleeps badly. He has been employed in one of the principal hotels of this city for many years and by frugal economy has accumulated considerable means for one of his station in life. He confides in me, but is suspicious of others. His speech and manner betray timidity of mind and lack of resolution. He has anthro- pophobia, being afraid to meet any one about the house, Selections. I45 as he says, and polyphoöia, “afraid of everything, some- times,” to use his own language. He has also phoöopho- bia being “afraid something is going to happen to frighten him.” & His failure of memory is quite marked. So much so, that the ordinary orders in regard to trunks, to which he has been accustomed, he is obliged to note down at once, or he would forget the order and the number of the room in the house before reaching the latter, yet this failure of memory is secondary to his fear of forgetting and the indirect product of it, his mind being preoccu- pied with the fear of forgetting, so that the impression of office instructions are evenescent and indistinct by reason of this preoccupancy, for he bears in mind instruc- tions concerning his medicine and hygienic advice and carries them out precisely. His volition is impaired and quite abeyant to one who gets his confidence, so that, not- withstanding his suspiciousness, he can be unduly influ- enced. He has improved some under systemic electricity, induced sleep, peptones, and reconstructives, but will likely pass into the insanity of premature senility, the conse- quence, in part at least, of over sexual strain. There is atheromatous degeneracy of the radials, an anaemic cardiac bruit, he has few remaining teeth and his skin is dry, harsh and shriveled. This is not a case of neurasthenia pure and simple. It is a condition of greater gravity. Yet the morbid fears of neuratrophia are marked and prominent. It is the neuratrophia of atheromatous degeneration of the cere- bral vessels. INABILITY TO WALK BACKWARD EASILY, A NEw SYMP- ToM OF LocoMOTOR ATAXY.—The British Medical Journal directs attention to the fact that ataxic patients ex- perience difficulty in walking backward at a time when they may have no trouble in walking forward. Their heels catch the ground. If they walk backward, it is in a halting, odd, and timorous fashion, which at once attracts attention, if they are capable of thus walking at all. THE PROGNOSTIC VALUE OF ABSENT TENDON REFLEX IN DIABETEs.-Professor Bouchard (L’Union Médicale) on the prognosis of saccharine diabetes says, in forty- seven cases of diabetes in which the tendon reflex persisted, there were only two deaths, or one in twenty- 146 Selections. three ; in nineteen cases with absence of the reflex there were six deaths, or one in three. ON THE MECHANISM OF EPILEPsy.—Lecture at the Hotel Dieu, by Prof. Germain See, reported in the Med. and Surg. Rept. Ist. Over-excitation of the reflex function in general, especially that of the bulb, through the instrumentality of the different parts of the nervous system, “excito-motor epilepsy.” 2nd. Augmentation of the excitability of the vaso-motor center, located in the bulb, “vascular epilepsy.” 3d. Excitation of the cortex cerebri, “cortico-cerebral epilepsy.” “When the cerebral system comes under the persistent influence of a lesion of the spinal cord, of certain nerves, or of the enceph- alon, the medulla oblongata becomes the seat of a func- tional modification, that is to say, an aggravation of its reflex power, which makes the organ a prey to the least excitations; the bulb can itself engender convulsive attacks without the least exterior determining cause. Here we have the first theory. The acquired property of the bulb extends naturally to the vaso-motor center in the bulb ; the excitation of the vaso-constrictor, then of the vaso- dilator nerves, determines anaemia, then hyperaemia of the encephalon, and we have the grand mal attack with loss of consciousness; the vaso-motor theory is only applicable to the grand mal— this is bulbar epilepsy or bulbo-vas- cular epilepsy.” The theory of excitation of the pyscho-motor centers explains all the other cases, “all the forms of petit mal, i. e., vertiguies, absences, ‘petit mal auto-motor,’ which is a psychical trouble with unconcious movements.” The phenomena will vary according to the region of the cortex excited. If the frontal are excited, intellectual troubles result ; if the fronto-parietal convolutions, the ascending parietal convolutions or the paracentral lobule, troubles of motility; if further back, the parietal lobes, the angular gyrus, the occipital lobes or the temporo-sphenoidal con- volutions, to hallucinations of taste, of hearing, of sight, of smell, or to troubles of general sensibility, “which con- stitute in the majority of cases the auras of common sen- sation or of special sense, which one may consider rather as the first manifestations of the grand or petit mal than as prodromes capable of being arrested. THE ACTION OF HYPNOTICs on THE CEREBRAL CIRCU- LATION.—Drs. Bergesio and Mosso (London Medical Record, Selections. - I47 October 15, 1884,) having a patient who had lost a portion of the calvarium, were enabled to make observations on the circulation in the brain. They confirmed the view that the brain is anaemic during sleep. Paraldehyde gave the same result as natural sleep. Morphia and alcohol caused endocranial congestion. The authors remark that the hypnotic effects of these drugs do not depend upon the change in the blood-pressure, but upon some more inti- mate modification, perhaps of a chemical nature, of the cerbral cortex. EDITORIAL. [The Editor is Responsible for all Unsigned Editorial Matter.] Solar Heat Intolerance, a Sign of Cerebral Arteriole Hyperaemia of Cerebral Vaso-motor Nerve Atonicity.—Note on its Frequent Occurrence and Significance in Certain Cases.—The frequency with which this associated symptom has presented itself to the writer's notice during the past several years, in the practice of neurology and psychiatry, has estab- lished the conviction that it is a sign of no mean sig- nificance worthy to be classed with the sense of enceph- alic pressure, insomnia, etc., of exaggerated cerebral arteriole distension or dilatability, under slight provocative cause. In the writer's view, the true disease is not the hyperaemia of the brain, but the hyperexcitability of certain areas of the cerebro-spinal substance implicating directly or indirectly the cerebral vaso-motor center in the cord and medulla, which constitutes the essential pathological condition which we recognize in the arteriole symptoma- tic expression of hyperaemia. The brain of a cerebral hyperaemic need not be constantly hyperaemic, and the degree of arteriole distension varies under varying sur- roundings. Hyperaemic states of the brain are induced by over excitation of the brain cells through psychical as well as physical impressions, or of certain purely psychi- cal stimuli to ideation, and through optical, auditory, gustatory, general, or special, tactile or olfactory impres- sions, etc., and vice versa. A brain flushed with blood evolves ideation different in degree from the thought products of normal blood supply. But whether this view of the pathological condition of the brain state called cere- bral hyperaemia be accepted or not, there is no doubt about the vascular condition, and we never fail to find augmented heat areas, more or less extensive, in this con- dition, and this increased internal heat and its probable cause in lowered vaso-motor tonicity and exalted im- pressibility to paralyzing influences partly, if not wholly, explains the heat intolerance of these patients. There is doubtless also a changed condition of the whole nervous system, especially the central. We often see marked, light and especially sound intolerance in these cases. But the fact of heat intolerance has been so uniformly found [148] Editorial. I49 in our observation, that we here make record of the fact for the consideration of others in the profession, occupied, like ourself, with the study of morbid neural phenomena. The citation of cases would be needless, for we have never failed to find it among our patients when we have inquired about it, and this latitude is peculiarly depressing to such persons in the months of June, July and August and some- times in September. Large Doses of Bromides and Iodide of Potassium,_Séguin (Archives of Medicine) has called attention to the fact that the use of large doses of iodide of potassium originated in New York, but large doses of most all drugs, much larger, generally, than those of Our European confrères is characteristic of American therapeu- tics. Séguin himself has called attention to the value of larger doses of the bromides in children than is commonly given them, and the editor of this Journal has, on many occasions, found it desirable and decidely beneficial to give, largely diluted, in aggravated hyperatemic conditions, one-hundred-grain doses of the bromides every four hours during the first twelve hours. But these large doses can not be given, without harm, for any great length of time, seldom beyond the first day. Under them patients undergo a state of dementia and ataxia of speech and gait, more or less pro- longed and serious, and necessitating decisive, counteracting and recuperative measures. The same results we have seen to follow the long continued employment of drachm doses of iodide of potassium even in syphilitic nervous lesions, as well as in other forms of profound central nerve trouble. We have seen dementia induced by large doses of iodide recovered from in one instance during the past year, and ameliorated in another, by suspending the iodide alto- gether. The long continued use of iodide of potassium in one-ounce doses daily, or in two-drachm doses daily when there are grave head symptoms, either specific or not specific, is hazardous, and in administering them, when necessity seems to justify their use, they should be cau- tiously given largely diluted, and at lengthened intervals of not less that six hours, when the stomach is empty of food and gastric juice, and with due regard to the quality of the patient's blood and the assimilability of an abundant reconstructive haematic nutrition. As far back as 1867 the writer employed, with success, two-drachm dose ter in dež for a while, in the successful treatment of mania caused by syphilis, but not continuously. It is as important I5O Editorial. to know when to discontinue as it is to know when to give large doses of either the iodide or the bromide of potash. When nutrition weakens and psycho-motor ataxia appears, resentful nature has thrown out the signal for suspension of our vigorous assaults upon the disease, and we should call a halt lest we fatally invade non-combatant territory of the tissues of the body and destroy the physician's most friendly ally, in every contest with disease, the vis medicatrix ma- tura. There are untowered sequellae to injudicious over- dosing as well as to over-timed underdosing with both the iodide and bromides of potash, which should always be borne in mind when we employ them. The Theory of Immunity from Second Attacks of Contagious Diseases, attributed lately to Tyndall, was promulgated by Dr. M. L. Linton, Prof. of the Prin- ciples of Medicine, in St. Louis Medical College, as far back as 1858, to our certain knowledge. He used to say that certain elements upon which the contagion fed disap- peared to return but tardily or never, and conjectured also that the thymus gland, etc., that existed in infancy, but disappears with advancing years, explained the immunity of age to certain contagious diseases from which early life was not exempt. The real cause of immunity from certain contagious diseases, after successfully combatting a first attack, is probably due to an educated resistance in the nerve centers of organic life; in the same way as immunity to the congestion of taking a cold is brought about by the hardening process of repeated exposure. Acclimatization, to either a hot or a cold country, is brought about by cautious, repeated exposures and long residence; and the individual who has had yellow fever, or cholera, and passed triumphantly through the ordeal, emerges stronger in re- sisting power to that particular kind of assault upon his organism. Instead of something being lost, we think some- thing has been added to the power of the central nervous system by which it is enabled better to resist than before. In the case of microbe diseases it is less vulnerable to their assaults, and does not a second time so readily respond to their presence in the organism, in morbid commotion. It is the same principle of organized tolerance under repeated, but not overpowering strain, which we invoke to explain the acquired immunity from the toxic effects of certain narcotics, like tobacco, opium, etc. Linton, likewise, more than a quarter of a century ago, controverted the cell Editoria/. I5 I doctrine in his lectures, and denied the then strenuously asserted existence of a specific cancer cell, maintaining the precedence of a primordial plasma. Sensational Bonfires of Restraint Apparatus for the insane, and calling upon the public to indulge in jubilee over the abolition of all restraint, is not the way to do the greatest good to the insane. The best way is to dispense with all needless restraint and supplement restraint, So far as practicable, with unirritating surroundings, thus reducing the necessity of restraint to the very lowest possi- ble minimum compatible with the individual and collective welfare of an asylum, by judicious study of the subject, and them to make the fact known for the benefit of those super- intendents of asylums who wish to learn how to be as humane as possible. The Chiaruges, the Pinels, and the Conollys have shown how greatly restraint may be minim- ized, let those who seek fame in the same direction show the people and legislatures how a liberal, and not parsi- monious, provision for these unfortunates, by providing for them congenial surroundings, may lighten the weight of such remaining restraint as must needs still be employed. It is a tragic thing to make a public bonfire of all restraint apparatus, but it becomes a farcical performance when fol- lowed by preventable homicides. It would be still more sensational to burn up the building, but not more farcical than to burn up all and every form of restraint appliance, though it were better to burn them than to allow ignorant and brutal attendants to abuse them. But a well conducted asylum, with a disciplinarian at its head, will use without abusing needful restraint, prescribing a camisole or a safety bed as he would a medicinal potion and never allow their use otherwise, and the same psychiatric skill is often as essential to determine when to employ a restraint appliance, as is demanded to properly determine when and how to set a limb in a plastic splint. Bell’s Law Discovered by Magendie.—Professor Chapman says the credit of demonstrating the functions of the anterior and posterior roots of the spinal nerves belongs to Magendie, and not to Sir Charles Bell. When Magendie, in 182 I, published the correct idea, Bell collected and destroyed, as he thought, the whole edition of his own pamphlet printed in 18 II, which advanced the idea that the posterior roots are trophic only, and quickly published another containing the true idea. Professor Chapman has I52 Editorial. seen a copy of Bell's treatise of 18 II which escaped destruc- tion, and is now owned by the celebrated Richard Owen. Development of Language in Infants. – Sikorsky, in an interesting communication on this subject in the Archives de Neurologie, No. 13 (November, 1883), presents some observations of value germane to our cap- tion, but which we have neither time nor space to epi- tomize. The contributions also of Segismund, Darwin, Vierodts, Preger, Kussmaul, Tami, Lobish, Schultz, Simo- novich, are referred to Sikorsky, and with these very complete references and the observations of Sikorsky him- self, the reader explores this field so far as it has been traversed, and still, at the end of his explorations, he will be enabled to conclude with the opening sentence of Sikorsky's entertaining paper, viz., Le mode de developpement du language chea les infants est encore très peu commu. In confirmation of this observation we here record, without comment, the record made by us of the vocabulary evo- lution period of our own child; Ray Hughes. They are the first words he learned to speak, at about the age of two years (the child is now six years old), and were so different from the usual monosyllabic abbreviations of this period of life, that they attracted general attention, our own, especially, and were made a matter of record at the time. The child soon learned to speak correctly, and effaced all peculiarities of utterance. The following is the list:—Hobbaloo (Sarah, his aunt), Rusu (sugar), Tippity (gravy), Haha tippity (sausage gravy), Tata (sister), Hammie (Henry), Nammie (Clarence), Lala (Charlie), Mamie (Catie), Mamma-la (mamma), Papa-la (papa), Wasra (syrup), Bulla (water), Ninnie (the breast), Ninnin (dinner, supper, breakfast), Niminé (chamber vessel, afterwards Pepe), Muk (milk). The most remarkable word is the first one, which was one of his earliest attempts, and the thirteenth, which is the same expression as that used by his father at about the same age and with the same meaning. Truly, “the mode of development of lan- guage in infants is as yet very little understood.” Philanthropy in the Right Direction.—Mr. Vanderbilt's munificent donation to the College of Phy- sicians and Surgeons, of New York, is a lift to the cause of higher medical education that will not be lightly esteemed by the fortunate recipients, or by the profes- sion of the United States. The College of Physicians and Editorial. I53 Surgeons will now hold higher still its exalted standard, and those whose eyes are longing to see high grade medical education popular throughout this mediocrity cursed counting may soon gain new hope by looking towards New York. John P. Morton, the well-known Louisville publisher, has presented a splendid building, suitably finished, to the Episcopal denomination of Louis- wille, to be used as a “Church Home and Infirmary for the Sick of all Denominations.” These donations go together. The first goes to improve facilities for imparting skilled treatment, the last goes towards proper care; good gifts both of them, in the right direction, and there remains ample room for the repetition of the example of Vanderbilt and Morton in each of the great cities of the Union, save perhaps, the city of Baltimore, for which the late Johns Hopkins so liberally provided in the university which bears his great and good name. It is not Electricity which Cures, but Elec- trizations, a process requiring far more technical skill than the uninitiated generally believe, truthfully says DeWatteville in his “Practical Remarks on the Use of Electricity in Mental Disease,” in the January number of the Journal of Mental Science. If this truth were fully appre- ciated, how many blunders now being made might be escaped, and how much more real therapeutic progress might be accomplished by this subtile and potent agency. To possess a battery does not make an electrician any more than the possessing of a set of tools makes a surgeon. DeWatteville who has studied deeply into this subject, believes that the galvanic current can be made to per- meate the brain, while a recent medical author on elec- tricity in this country is skeptical on the subject, yet nothing is more easily demonstrable then this fact of practical observation and personal proof. Honors to Dr. Workman.—Dr. Joseph Workman was made an honorary member of the Phreneatric Soci- ety in Italy, in September, 1883, also an honorary mem- ber of the British Medico-Psychological Association in July, 1884. Dr. Workman is one of the recognized alienists of North America, and will honor any society that honors him with such distinction. We heartily join our Canadian confrères in congratulating our distinguished collaborator and the distinguished societies, upon the reception and bestowal of so worthy a laurel. I54. Editorial. Sweating to Death.--Dr. Myrtle in a recent paper cites the case of a healthy, active man, who, after suf- fering for three weeks from pains of a rheumatic char- acter, relieved by sodium salicylate, was seized with profuse sweats of offensive character, lasting often for ten hours. He improved for a time, but he died from exhaustion I21 days after the first symptom. There was no post-mortem. Dr. Myrtle regarded the case as one of paresis of nerves supplying the sweat-ducts, caused by frequent exposure to cold during his employment. Dr. Jacob thought the intermittency of the attacks pre- cluded a peripheral paresis, and pointed rather to the sweat-centers being affected.— Vide Proceedings West Rid- ing Medico-Chirurgical Society, in London Lancet, Nov. 1st. Immediate Restoration of Function in Di- vided Nerves. – Dr. James P. Bramwell (London Lancet, Nov. I 5th, 1884), referring to two cases, one of a few months, and the other of fourteen years, cured by Villeaux, sensibility returning in both cases within forty- eight hours after the reunion, cites an instance in his own experience, and published ten years ago in the Edinburgh Medical Journal, where the ulner nerve having been re- united immediately after accidental division, neither sensa- tion nor motion in the parts supplied by the divided nerve were supplied. Ten years ago he also made the statement that if the ends of a divided nerve were brought into im- mediate apposition, there conductivity would be retained without organic reunion, just as a severed telegraph wire, if the divided ends are brought into immediate and perfect contact, would at once continue to conduct the electric current without soldering. The Death of Dr. Joseph A. Reed, superintend- ent of the Dixmont Insane Asylum. Next to Dr. Curwen and the late Dr. Kirkbride, Dr. Reed was the most prom- inent and widely known superintendent of the insane in the state, having devoted himself exclusively to his work for a period of nearly thirty years. Born in Washington, Pa., in 1823, he graduated from Washington College at the age of nineteen, completing his medical education at the University of Pennsylvania and Jefferson Medical College of Philadelphia, from the lat- ter of which institutions he received his degree of M. D., in 1847. He spent ten years in the practice of medicine in Alleghany City. Editorial. I55 In 1857 he was appointed medical superintendent of the Western Pennsylvania Hospital for the Insane, located at Pittsburgh. He succeeded in enlisting the Legislature in his scheme to build a great hospital for the insane on an improved modern basis, and in 1862 opened the commodious and now widely known institution at Dixmont. Under his efficient management it soon became one of the most successful institutions of the kind in the United States, and his annual reports, for upwards of twenty years, are justly regarded as a valuable addition to the practical literature pertaining to the care of the insane. Reports derogatory to the management of the hospital have led to two or three Legislative investigations, which, however, failed to develop any serious abuses. The few irregularities discovered being traced to worthless employees who had imposed themselves upon the man- agers. Dr. Reed has been a trusted adviser in matters pertaining to the erection of the various State Asylums, having been a member of the commission appointed by the Legislature to erect the Danville Asylum. In the death of Dr. Reed, Dixmont has lost a strong pillar of popular confidence, the State of Pennsylvania a practical and prominent alienist, and the country a noble man, a kind, competent and true physician. This Journ AL too, in his demise, has lost one of its staunchest and earliest friends. By a life of honest, earnest and fruitful labor he has well earned the right to an eternity of rest. His memory will live long in the hearts of the afflicted ones of Dixmont, and in the kindly affectionate recol- lection of his confrères in the field of practical psychiatry. The Sober Second Thought in Gynecology.— Under the caption of “Nerve Counterfeits of Uterine Diseases,” Dr. Wm. Goodell, of the University of Penn- sylvania, says: “The crying medical error of the day is the mistaking of nerve disease for womb disease. From this widespread delusion it has come to pass that no organ in the human body is so overtreated, and conse- quently so maltreated as the womb.” He demonstrates with clinical proofs, a fact long known to neurologists, that many cases which have been regarded as serious uterine disease, in fact, are cases of nerve exhaustion or malnutrition of nerve centers. Prof. L. Chas. Boisliniere, of this city, has antedated Dr. Goodell in this line of obser- vation, and with the growing tendency to repeat and 156 Editorial. confirm similar utterances, the recent strictness of Dr. Clifford Allbutt in “Visceral Neuroses,” promise to be not long appliable to this valuable department of medical research and work. The Case of Intra-cranial Cerebral Tumor, recently so skillfully diagnosticated on by Hughes Bennett and operated upon by Surgeon Godlee, is reported as mak- ing satisfactory progress towards recovery. The chief symp- toms which led Dr. Hughes Bennett to diagnose the extent and locality of the tumor were paroxysmal twitchings of the left side of the face, alternating with twitchings of the arm on the same side, followed by slowly progressive paralysis of the hand and later on by twitchings of the eyelids and leg without paralysis. These symptoms were accompanied by double optic neuritis and violent head- ache. The conclusion arrived at was that there was a tumor, probably not larger than a walnut, situated at the upper third of the fissure of Rolando. The skull was tre- phined by Mr. Godlee over the corresponding spot under which the convolutions appeared to be healthy. An incision was then made in the ascending frontal convolu- tion, and a quarter of an inch below the surface a tumor of the size suspected was discovered and removed. The Anaesthetic and Hypnotic Properties of Cocaine are among the most recent therapeutic novelties. Since the Vienna student, Zoller, announced its local anaesthetic power, the journals have teemed with confirmatory records of clinical experience with this agent on the eye, the nose, the fauces, the gums and OS uteri. Experiments with it in forms of neuralgia due to central nerve lesion have been less satisfactory. In the British Medical Journal, for December 20th, Dr. J. Swain records some successful experience with it, hypodermically, and with the valoid internally for sleeplessness. Contrary to statements made by others as to the toxic effect of cocaine, Swain saw no bad results from one-fourth grain doses, hypodermically, or from the valoid in five drachm doses. Dr. Edward J. B. Dumesnil, for many years one of the editors of the Annales Médico-Psychologiques, and ..one of the oldest and ablest alienists of France, is dead. Dr. Dumesnil was born at Constance, in December, 1812. In 1847 he was made Medical Superintendent of St. Dizier's Asylum. In 1852 he was assigned to Dijon, and in 1858 Editorial. I57 he became Superintendent of the Quatres Mares Asylum, Rouen. Dr. Dumesnil was a thorough scholar in all that pertained to the department which he cultivated, and his executive capabilities were adequate to all the important trusts confided to him. His death was caused by embolism. Apomorphine in Nervous Affections.—Dr. Weill (Lyon Medical Journal) says: “The hydrochlorate given, hypodermically, in does of from one-thirtieth to one-tenth of a grain has a favorable action in obstinate hiccough, epi- lepsy and chorea. By using the drug carefully, sedative effects may be produced without nausea.” Arthropathia Progressiva is described with plau- sible claims as a new disease of nervous origin by Dr. A. McLane Hamilton (New Yoré Medical Journal, Jan- uary 24th, 1885). The author does not think the symp- toms can be confounded with those of any other disease. Please Note the Change of Address, of this JoURNAL, to 30OO Chestnut Street. HOSPITAL NOTES. DR. EDWARD N. BRUSH, of Buffalo, and late first assist- ant physician at the New York State Lunatic Asylum, at Utica, has been appointed physician to the male depart- ment of the Pennsylvania Hospital for the Insane at Phila- delphia. Dr. Brush is a native of Buffalo, where he graduated in medicine and engaged in practice for some years thereafter. He was formerly one of the visiting physicians to the Buffalo General Hospital, one of the editors of the Buffalo Medical Journal, and a lecturer in the Buffalo Medical College. He is a physician of varied and rare accomplishments, and he will carry to his new field a large experience in the care and management of the insane. NEw JERSEY.—Dr. Buttolph, late of the Morris Plains Asylum, has removed to Short Hill, near Milburn, New Jersey. The career of Dr. Buttolph was a long and successful one, and we wish him, in his retirement, that restful happiness which he has so richly earned by a life of diligent and profitable endeavor in behalf of the insane of his State. IMPENDING FATAL CHLOROFORM ANAESTHESIA can be arrested, according to Dr. L. M. Yale's observation, by rubbing the patient on the left side. The suggestion is worth a trial in every case where alarming symp- toms appear. Dr. Yale's conclusion is drawn from data furnished by seven thousand cases in the London Hos- pitals.-Vide Medical Mews. WisconsiN.—Dr. R. M. Wigginston has been in charge of the Northern Hospital for the Insane, in Winnebago, since July Ist, 1884, but we have only lately been advised of the fact. Dr. Walter Kempter, the former superintendent, having gone into private practice. L158] REVIEWS, BOOK NOTICES, ETC, REAL AND IMAGINARY INTEMPERANCE. By G. Thomann, Secretary United States Brewers’ Association. The apparent purpose of this pamphlet is to show that fermented liquors are harmless and even healthful drinks. We suspect, however, that the discerning reader will conclude that the writer's logic is faulty, and that even his statistics, in So far as they are of any value, tip the balance against his theory. Mr. Thomann deserves credit for his candor, which is everywhere apparent, and which is as rare as it is refreshing in the discussion of this subject. The admissions, however, which his sense of fairness leads him to make, very seriously weaken the force of his argument. It would appear to be the opinion of Mr. Thomann, though he does not distinctly say so, that distilled liquors are very liable to abuse, and he would have the world drink fermented liquors in their stead. He has much to say of the “proper use ’’ and the “abuse” of intoxicating liquors, although his statements of what their proper use consists in are certainly hazy, obscure and unsatisfactory. While he mildly and in an indirect and circuitous way suggests that fermented liquors are less injurious, or, perhaps, less abused than distilled, yet he evidently understands that the distinction needs not be wide, else it would suggest to the reader what is really the fact that in their ultimate effects upon the tissues of the body, fermented and distilled liquors differ mainly in degree. Mr. Thomann concedes that a proportion of insanity is due to intem- perance, and much of his effort is directed to showing how small this pro- . is and the trifling cost it occasions taxpayers in comparison to the vast revenues derived from the liquor traffic. His statement of the cost of maintaining the insane is quite incorrect, the cost being very much greater than is stated by him. He neglects also to consider that greater cost which is occasioned to the community by the loss through insanity of valuable working members, and the loss through the impoverishment and pauper- izing of families where the head becomes insane. This is a loss which statistics can not show, yet it is very great and probably affects society more seriously than the additional, taxation due to the maintenance of the insane. • Mr. Thomann’s habit of barricading himself with qualifications and reservations is shown in the following from page 6: * With certain reservations as to the kind of drink used, the climate, the temperament and habits of the drinkers, as well as their social condition, it may readily be conceded that an increase of inebriety implies a propor- tionate increase of insanity; but it is not, therefore, by any means fair to infer an increase of inebriety from an alleged increase of insanity. On page 21 he says: Such evidence could easily be made interminately cumulative. Enough [159] I6O Reviews, Book Motices, &c. has been said, however, it is hoped, to show that a decrease in the con- sumption of distilled spirits, attended by an increase in the use of fermented beverages, in countries where the vine is indigenous, must necessarily diminish that form of intemperance, from which, when persisted in to excess, alcoholism and insanity are apt to result. The assumption that fermented liquors are harmless is the chief aim of his entire essay, and this quotation may be considered a fair summary of his opinion. That this is an error is sufficiently apparent from the investigations of Dr. Sunier, published in 1872. He found that distilled liquors produced a much larger proportion of insanity than fermented, but he also concluded that fermented liquors produced a proportion of mental disorders. His conclusions were “that the pernicious influence of intoxi- cating drinks, as regards insanity, is in the following order: Alcohol from cider, alcohol from beet-root and grain, cider, wine, beer; the white wines being much more injurious than the red.” If “intoxicants civilize nations,” as Mr. Thomann asserts, then such civilization is attained at a fearful cost as is implied by the following on page 48, the reader bearing in mind that pauperism is but one of the evils that result from the intemperate use of alcoholic liquors: The proportion of pauperism caused by intemperance is 10.74 per cent. Among the female paupers there are very few intemperates; but in the female department and nursery of every poorhouse there are, of course, a number of inmates whose indigence was caused by the intemperance of husband or father, and in estimating the number of persons made dependent upon public charity by drink, this fact must be taken into consideration. As it is extremely difficult, not to say impossible, to obtain correct data on this point from the institution here referred to, the compiler adopted the proportion which appears from the Danish statistics of pauperism, adding 5 per cent. for females and 8.03 for children, so that the total proportion of pauperism caused by intemperance is raised from 10.74 per cent. to 23-74 per cent. Hence we have four intemperate paupers to every ten thousand of the entire population. The opinion expressed concerning the relation of intemperance to crime is apparently correct. It is a common belief, but a mistaken, one, that crime is usually the result of intemperate habits. The shrewder class of criminals do not drink to excess. The criminals who drink are the petty offenders and they do not go to penitentiaries, but are sentenced to local jails and workhouses and houses of correction for short terms. The difficulty with the problem which Mr. Thomann has attempted to solve is, that it is a problem which statistics will not solve. It is an attempt to measure that which is immeasurable. The harm of the exces- sive use of alcoholic liquors is in a proportion of cases conspicuous, so that he who runs may read the story of degradation that results; but these effects are but a part of the total evils that flow from such excesses. There is certainly great demoralization in the children of a family in which a parent is intemperate. The scenes they witness blunt and wound and harrow their sensitive feelings, they are experiences which leave scars upon the minds of children, experiences which degrade because they familiarize the young with vice, and the mental organization, and perhaps the physical, of children reared under such conditions, must be more or less awry. Thus the inheritance of disease or the tendency to mental and physical degeneracy is great in the children of those who drink to excess. Reviews, Book Notices, &c. 161 Intemperance brands with degeneracy the offspring of those who are its victims, and if in the histories of those who are idiotic or insane we could trace these states along their various lines of causation, a much larger pro- portion than now appears would be found directly or indirectly due to intemperance. The difficulty of tracing the history of an individual in a case of mental disease is very great, so great that it is a rare achievment to obtain a reliable history in a case of insanity. This difficulty is increased a thousand ſold when we attempt to reach the lives of parents and bring to light vices which would produce weak and degenerate offspring and get vices the existence of which the descendants would prefer to conceal. The writer hereof can recall many cases of insanity in which the cause of the disorder was quite beyond solution until the ancestral history being revealed by some family acquaintance, it became clear that the principal cause was in the unstable and defective organization which had resulted from parental vice. Statistics will not solve the question, and though it is an important in- quiry how large a proportion of insanity is due to intemperance, it is yet well to bear in mind that the showing must be incomplete and is at least but a fragment of the truth. The conclusions to which Mr. Thomann's investigations would lead were doubtless foreseen by the superintendents who furnished him statistics, for they knew that statistics do not, and never will, show the proper share which intemperance has in the causation of insanity. In many cases where intemperance is the direct cause it will be denied or concealed, in others where it has been less excessive the physician may not consider it the cause, though it may have been the straw that . broke the camel's back of mental health; in another, the insanity is the bad fruit of ancestral indulgence, and here again the physician may fail to reach the fact. The preponderance of medical opinion of the present time is in favor of the view that alcoholic liquors of all kinds when habitually used are injurious. Distilled liquors are probably more injurious than fermented, but the difference is one mainly of degree. This is simply the statement of a scientific fact, and we who indulge in our social glass occasionally should not delude ourselves with the belief that we are in any way the better for it, but let us drink it if we will with the clear understanding that without it we would be as happy, as healthy and clearer-headed. Science is the only proper temperance lecturer, for she appeals to human reason and without prejudice, and every day she speaks to a larger audience and more and more effectively. Men indulge to excess because they are weak, and as the better intellect illustrates the height of human progress, so the wrecks and the degradation we see in the world illustrate the further extreme of human frailty and imperfection. To that silent and ceaseless progress in which we all take some share humanity is steadily gaining in self-control, in the power of self-denial, and every day the race is lopping off something of its weakness and its grossness. This growth of self-restraint will ultimately enforce a universal temperance, and the indulgences which now degrade and kill will be thrown aside, their victims falling by the wayside as the dead leaves fall from the living branches. M. I62 Reviews, Book Notices, &c. OOMPARATIVE PHYSIOLOGY AND PSYCHOLOGY: A Discussion of the Evolu- tion and Relations of the Mind and Body of Man and Animals. By S. W. Clevenger, M.D., Chicago: Jensen, McClurg & Co. 1885. The object of this work is the discussion of psychology from a monistic stand point. Dr. Clevenger seems to be a follower of Condillac for he claims that: “The mind consists of sensations and therevivability of sensations. All psychic phenomena have these as there basis, feelings, cognitions, reason and volitions, etc., being mere modes of working of sen- sation and memory.” In the present volume Dr. Clevenger discusses: the evolution of emotions and their differentiation from fundamental pecu- liarities of the amoeboid cell, such as hunger and the enemy-escaping reflexes, which crop out in insanity in bulimia and delusions of persecution. The relations of Darwin's serviceable associated habit to the integration of emotion and their development of centers and peripheries for their expres- sion. Analysis of cognitions as being modes of sensation, and their reviv- ability depending upon memory registrations. Feelings as depending wholly upon superimposed, feebly-registered past Sansations, Reason as involving fully evolved reflex systems. Instinct as being the outcome of reason, and depending upon an acquired or inherited stability of reflex systems (Spencer's idea). “The will of the individual being the co-ordi- nated wills of the component cells” (Foster). Consciousness as being the result of sensation summation, past and present, on the plane peculiar to the individual. It is exclusively connected with the functional disintegra- tion of the central nervous elements; its intensity is in direct porportion to this disintegration, and simultaneously, in inverse proportion to the facil ity with which each of these elements transmits to others its functional vibrations, and with which it relapses into repose, into integration. . . . Its intensity is in an inverse ratio to the facility and rapidity of central trans- mission. Pleasures and pains as being comparable to Euler's consonance and dissonance. The simpler the terms in which the order expresses itself, the greater is our delight. Hence the superiority of the simpler ratios in music over the more complex ones. The style of the author is marked by extreme conciseness and his theories are extremely suggestive. As a statement of the problems by life and mind from the sensational and monis- tic stand point, the work deserves perusal. It is well issued. J. G. KIERNAN. THE BRAIN AND THE NERVES. By Thomas Stretch Dowse. Second Edition from the Press of Putnam's Sons, 27 and 29 W. 23rd St., New York. This book is reserved for further notice. A worthy review of the book has been expected from other than editorial Sources, as the time of the editor is now too much engrossed to Write Out in eastenso and place, in proper light, before the readers of the ALIENIST AND NEUROLOGIST, its distinctive features and merits. It is, however, a very satisfactory treatise on an interesting and still neglected subject in medicine. Neurasthenia, or better, neuratrophia, a term which we have already offered to the pro- fession as preferable, is deserving of as much thought and research as the now popular themes baccilli and bacteria are. Neuratrophia and neurasthenia are at the foundation of a World of psy- chical and physical misery in the human organism, and every ray of Reviews, Book AVotices, &c. 163 light thrown upon these subjects must illumine the whole field of path- Ology. "the author especially deserves the thanks of all Americans for the tribute he pays to the work and memory of the late and largely lamented Dr Beard, whose labors shed much light on this subject. Dr. Dowse, however, appears not to have learned of the contribution to this subject by Van Deusen, another American physician who preceded Dr. Beard. The contributions of Flint and Weir Mitchell are also acknowledged. We cordially commend the book, confident that a perusal of its pages will repay the reader, and with the regret, in conclusion, that we are com- pelled thus cursorily to notice it. MEDICAL RHYMEs. Published by J. H. Chambers & Co., St. Louis. An attractive book consisting of a collection of poems, grave, senti- mental and humorous, relating to medical subjects. Several of the choicest of Dr. Holmes' poems have a place with selections from a great many other medical poetical writers. There are poems on anatomical lore—on Medicine, Surgery and Obstetrics, and on a great many miscellaneous subjects. The whole is arranged by DR. HUGO ERICHSoN, Professor in the Quincy School of Medicine, with an introduction by Prof. Willis King, Kansas City Medical College, and Ex-President Missouri State Medical Society Melancholy moods are, in this book, dissipated by light laughter over medical melodies. Trials and tribulations, toothache and tape worms are treated in most amusing verse-touching medicine, surgery and obstet- rics. The music of the mother, with a thrilling tale of a Blue Glass Baby, together with other kinds of Doctor's ditties, from the earliest times to the present, find place in this volume. THE THIRD EDITION OF THE OFFICIAL REGISTER OF PHYSICIANS AND MID- WIVES IN THE STATE OF ILLINois. It shows that during the last four years there has been a slight reduc- tion of the number of physicians in the state notwithstanding the increase of population. The actual number now in Illinois in practice is given as 5,885, whereas in 1880 it was 5,979. Of the various graduating institutions represented there are in all 198. In the United States 138, Canada 10, Great Britain 14, Continental Europe 34, Africa. 1, and South America. 1. The Secretary invites corrections from all interested in the accuracy of details of the report. INDEx-CATALOGUE OF LIBRARY OF SURGEON-GENERAL's OFFICE UNITED STATES ARMY, Vol.V., Flaccus-Hearth: Washington Government Print- ing Office. This extensive volume is but one of a series of which the reader may form some estimate by observing that it embraces only those subjects in alphabetical order between the words Flaccus and Hearth. The labor in preparing this index must be something enormous, but when completed it will be the most extensive work of the kind in the world. MYNERT's TREATISE ON PsyCHIATRY. Translated by Barrey Sachs, M.D., Illustrated. New York: G. P. Putnam's Sons, This publication is soon to be offered to the medical profession. The first part of the work, devoted to anatomy and physiology of the brain, is ow ready. The work is fully illustrated. I64 Reviews, Book Notices, &c. NOTES ON THE TREATMENT OF TRACHOMA BY JEQUIRITY. By Leartus, Connor, A. M., M.D., Ophthalmic Surgeon to Harper Hospital, Detroit, Mich. Reprint. 1884. * This is a brief, critical review of the literature of the subject up to this time. “It is in substance and in diction characteristic of its learned and talented author.” CLUB Foot: Is Excision OF THE TARSUs NECESSARY IN CHILDREN ? By DeForest Willard, M. D., Lecturer, Orthopedic Surgery, University of Pennsylvania, etc. From Transactions of the Medical Society of the State of Pennsylvania. g MUMPS As A CAUSE OF SUDDEN DEAFNESS.—Also by Same author. THE ARCHIVES OF MEDICINE.—We regret to note, has suspended pub- lication. While it lived it made a lasting record. Care of the Chronic Insane. A paper read before the Tenth Annual Conference of Charities and Corrections, held at Louisville, Ky., Septem- ber 24–30, 1883. By H. Wardner, M. D., Superintendent of the Southern Illinois Hospital for the Insane. [Reprint.] The Obligation of Civilized Society to Idiotic and Feeble-Minded Children. By Hon. H. M. Greene, Lawrence, Kas. A paper read at the Eleventh National Conference of Charities and Correction, St. Louis, Oct. 16, 1884. [Reprint.] The Fillmore Will Case. By Landon Carter Gray, M. D., Professor of Mental and Nervous Diseases, New York Polyclinic; Physician-in-chief to Department of Mental and Nervous Disease, St. Mary's Hospital. [Reprint.] Permanganate of Potassium : Its Action and Uses. By Robert Bartholow, M. D., L.L. D., Professor of Materia Medica, General Therapeu- tics, and Hygiene, in the Jefferson Medical College of Philadelphia, etc. [Reprint.] º Provision for Idiotic and Feeble-Minded Children. By Isaac N. Kerlin, M. D., Elwyn, Pa. A paper read at the Eleventh Conference of Charities and Correction, St. Louis, Oct. 16, 1884. [Beprint.] The American Method of Giving Potassium Iodide in Very Large Dose, for the Later Lesions of Syphilis; More Especially Syphilis of the Nervous System. By E. C Seguin, M. D. [Reprint.] Therapeutische Notizen der Deutschen Medizinal-Zeitung. 1880—1883. Herausgeber Dr. Julius Grosser. An excellent ready therapeutic reference for German reading physicians. [Reprint.] Progress in Provision for the Insane, 1844–1884. By W. W. Godding, M. D., Superintendent of the Government Hospital for the Insane, Wash- ington, D. C. [Reprint.] Explanation of the Pathology and Therapeutics of the Diseases of the Nerve Centres, Especially Epilepsy. By J. McF. Gaston, M. D., Atlanta, Ga. [Reprint, Hair: Microscopically Examined and Medico-Legally Considered. By William J. Lewis, A. M., M. D., F. R. M. S., Hartford Conn. [Reprint.] Rezniezws, Book Motices, &c. I65 Epileptic Insanity. A paper read before the Academy of Medicine. February, 4th, 1884. By Philip Zenner, A. M., M. D., Cincinnati, O. [Reprint.] Notes on the Treatment of Trachoma by Jequirity. By Leartus Connor, A. M., M. D., Ophthalmic Surgeon to Harper Hospital. [Reprint.] One Aspect of the Subject of Medical Examination, as set fourth in the work of the North Carolina Board of Medical Examiners. [Reprint.] Illustrations of the Anomalous Course of Posterior Spinal Sclerosis. By E. C. Seguin, M. D. [Reprint.] One Hundred Years of Publishing—1785–1885. Philadelphia: Lea Brothers & Co. 1885. The Treatment of Epilepsy. By Landon Carter Gray, M. D. [Reprint.] ALIENIST a NEUROLOGIST. VOL. VI. ST. LOUIS, APRIL, 1885. | No. 2. OR/G/WAL COAVTRIBUTIONS. A Case of Demonomania with Periodic Hystero-Epileptic Accesses.” By DR. ANGELO PASSERINI. I. HE case which I purpose to describe appears to me of some importance, not only because demonomania has, in our days, become, as Dagonat writes, “a very exceptional affection,” but also because it furnishes an- other proof of the very great influence which delirious ideas may exercise over the various nervous functions. In the patient whose history I am about to relate, the demoniacal delirious ideas, under certain circumstances, reached such an intensity as evidently to become, in a predisposed subject, determining causes of violent hystero- epileptic accesses. In this respect my case presents the usual analogies to all those which authors have described under the name of melancholia demonomaniaca, or damono- Matria, in which, according to Krafft-Ebing, neuralgias, paralgias and convulsions of undoubtable hysteric origin are very frequent, and the accesses of true raptus but reiterate the ecstasies of all delirious religious fanaticisms. But in this case the intensity of the hysterical phenomena attained the degree of the grand hysteria, the hysteria major of Charcot. , * Translated by JosłPH WorkMAN, M.D., Toronto, Canada, from the Archivio Italiano, July, 1883. Milan. [167] 168 Angelo Passerini. My case presents not a little interest also in the fact that the delirious ideas alluded to became exalted at a fixed time; and at a time which might be said to be fixed with scrupulous regularity, the convulsive accesses deter- mined by these ideas burst forth. II. There resides in Settala, a little village in the neigh- borhood of Milan, a young woman a little over 20 years old, who has been regarded by most of her fellow residents as possessed by a devil. Her name is Henrietta. Ga ; she belongs to a family in rather good circum- stances, but of trivial intelligence. A maternal aunt, who died a few years ago, suffered under nervous troubles; a paternal uncle was, and her father now is, addicted to the pleasures of Venus and Bacchus. The mother is rather a robust woman, and appears not to have suffered any dis- ease of importance. When, however, she was pregnant with Henrietta she experienced sufferings new to her, which in subsequent pregnancies were not felt by her ; digestion was slow and difficult, she had vomiting which no medicine suppressed, obstinate constipation and great debility. Having very little milk for the infant, it was given to a nurse, who became enceinte in a few months, but from greed for the wages she held on to her nursling. Henrietta was vaccinated twice unsuccessfully. She did not take either measles or scarlatina. Dentition proceeded regularly ; and she commenced to walk at the usual period. From her earliest years it was evident that her intellect was below mediocrity, and that it would hardly attain to normal development. She was late in commencing to speak and slow in showing that she understood anything spoken to her by her relatives or neighbors. Having been sent to school, she was always among the lowest in her class, or indeed, the very lowest herself. Under the belief that this was in part owing to the numerous causes of distraction presented in her home and around it, she was Demonomania. I69 placed in a college in Milan, and kept there for two years; but the result was far from equaling the expectations of her parents. During her absence from the family, she gave no indication of affection for any of them ; she never wrote unless in reply to letters received by her, and her answers were always very short, and always devoid of expressions of affection. It cannot, however, be said that her heart was entirely closed against every altruistic and benevolent sentiment; she greatly loved one of her college companions, who was very unlike herself in physical con- stitution, and in aspect, and much superior to her as to her intellectual faculties. This affection ultimately reached such a degree that Henrietta could not absent herself from her friend for an instant, and having become jealous, she hated and ill- treated those companions who appeared to her desirous of supplanting her in the position she held, or believed that she held in the heart of the one for whom alone she was, perhaps, capable of having any affection. Separation from this companion must certainly have contributed very much to throw Henrietta into that state of melancholy in which she was found after her parents decided on taking her home. The little or no affection shown by her for the family, her gloomy and taciturn character, and her indisposition to employment in domestic engagements, very often provoked reproofs from her mother, who, possessed of very little intelligence and not much tenderness of heart, exacted from her daughter far more than she was able to accomplish, and she ascribed to laziness her mental dull- ness and her disinclination to do what any other girl who had never been at college could do very well. She often, in presence of her daughter, lamented with friends for having spent money on her education in vain, and she often threatened to drive her into a convent, or into some far distant place, in order to relieve herself of the presence of so senseless and annoying a being. One fine day, for what reason is unknown, the mother shut Henrietta up in a small and dark apartment, and I7o Angelo Passerint. went out of the house. The poor prisoner first tried to break the lock, to smash the door, to wrench off the window fastening, but after fruitless efforts, finding that every effort to escape was useless, she began to weep, to Scream, to call loudly for aid, and to rage madly. Night came, and the darkness augmented her terror and des- peration; the end was, according to her own statement and the testimony of many neighbors who heard her say So, that she invoked the assistance of the devil, promising to him both her soul and body, if he would free her from that place of imprisonment. In the subsequent days the girl's melancholy showed a notable augmentation; she spoke only in monosyllables, and then only when questioned; she took very little food, and she wept every now and then. The end of April, I88O, came round; on the morning of Ist of May, she went from home, in company with her mother, to attend church and hear mass. The poor girl, as she herself afterwards related, tor- mented with melancholy thoughts, and full of remorse for having sold herself to the devil, had not closed an eye the preceding night, until near morning, at which time she had a dream of terrific nature, or, to use her own words, “a frightful vision.” She said the devil, in person, pre- sented himself red, frightful, sullen, with very long legs which were shriveled and distorted, with coiled up tail and long hooked claws; and having threatened her in thunder tones, and with a terrifying glance, he forbade her, in a hollow voice and with a savage and terrifying frown, ever to set her foot in a church, for she already was his property, and if she disobeyed his orders he would drag her, the very first time, down to hell. As Henrietta gradually approached the church, her breathing became short, frequent and oppressed, and just as she was about to set foot on the steps that led up to the door, she uttered a piercing cry and fell to the earth senseless. She remained for a short time motionless and stiff, then she began to tremble all over, and became livid Demonomania. 171 in the face, she ground her teeth, and foamed at the mouth, and finally she shook, and was furiously convulsed; she rolled her eyes and stared, tossed her limbs, elevated the pelvis, and every now and again carried her hands to the epigastrium and the throat, alternately. Having been carried home, she continued this, with short pauses of remittance, for an hour; she then began to weep and to try to escape, and she shrieked and groaned; finally she fell into a profound sleep which lasted as long as, or perhaps longer than her period of agitation. On the following morning, feeling pretty well, she wished to renew the attempt to go to church, and behold ! another access of grand hysteria, more violent and longer than the first. At 2 o’clock P. M. there was a third access, which lasted till 4 o'clock. In the succeeding days an access, similar to those preceding, took place daily and invariably about 2 P. M., and ending about 4. The poor girl, at the close of these accesses, usually cried out that she had seen the devil, and that he abused her; she tried to leap from her bed, to dash through the window, to knock her head against the furniture and the wall of her chamber. After this she thrust her hands into her hair and rapidly tore it out, and she tore her clothing into rags. Two pretty strong persons were at times unable to restrain her. In the intervals Henrietta was pretty well, and some- times she conversed with her young neighbors, telling them of her misfortune and lamenting the unpardonableness of her sin, for now her soul and body belonged to the devil, to whom she had devoted herself, and he had come to her to remind her of her promise. She said that she, a pupil of nuns, and both by education and tradition, once the friend of priests, was now, through her diabolical work, con- strained to feel repugnance towards both, and was unable to look on them without feeling a crushing at her heart and a sort of nauseous shuddering. She said that from . midday till towards 2 P. M., her anguish sometimes in- creased up to sheer desperation; that the idea of being 172 Angelo Passerini. damned, beyond all pardon, at such times caused her un- speakable anguish; that her convulsive accesses were very often pre-announced to her by a sort of shivering, which radiated with the rapidity of lightning from her right little finger up to the throat, and there choked her, and ascended to the head so as to blind her and deprive her of feeling. According to her statement the devil often presented him- self, both in the daytime and the night, to remind her of her promise, under the form of a cat, a dog, or some other animal, and she knew quite well how to interpret, in their real signification, the mewings, the barkings and the menacing howlings of these nasty beasts. Her relatives never thought of placing her under the care of a physician; but, being convinced that the case was one of demoniac possession, they had masses and ceremonies celebrated to drive out of the body of the girl the malignant spirit that possessed her. A priest ad- vised them to send her, on the 26th of May, to the Sanctuario di Caravaggio, where the apparition of the Blessed Virgin had many and many a time worked the miracle of curing those possessed of devils. For the readers who do not know it, we may say that Caravaggio is a little village of Cremasee, a few miles from Trevoglio, rather famous in the surrounding region, and for a good distance beyond, for a grand and hand- some church, which was erected on a spot where, accord- ing to the legend, the Madonna appeared and worked many miracles. Every year, on the 26th of May (the day of the apparition of the B. V.), a great festival is held there, and the people run to the place in crowds, partly for devotion, partly through curiosity, and partly for other purposes. It is related that several women on the coming round of this festival, have shown themselves to have been freed from (at least for a few days) hemicranias, constrictions of the throat and stomach, neuralgias and similar nervous disturbances by which they had previously been tormented. For those, therefore, who believed themselves invaded by Demonomania. I73 the devil, to whose baleful operations they ascribed their maladies—like the ancient Babylonians who believed that every disease was produced by an invisible being, the enemy of man—there is, attached to the church, an ap- propriate small chamber, under the care of guards, in which, separated from all other persons, they take part in the religious functions, and are able to see, through the gratings, the great altar and the priests there officiat- ing. On the approach of evening, just a little before 5 o'clock, the hour at which it has been related that the Madonna appeared for the first time, at the moment when the chief priest is elevating the consecrated host and when all the faithful reverently cast their eyes down, as un- worthy to look upon the body of the Lord, the apparition of the Blessed Virgin takes place. At that instant the bells sound all over, the clergy chant almost cracking their throats, trumpets and drums resound, fire-crackers are let off, and instantly there, in that special chamber, the poor possessed ones are contorted, they roll their eyes around, they make wry faces, they hammer their breasts and heads, they sob, weep, howl and scream with des– peration. The devil, forced by the great power of the Madonna to give up his prey, at least for a time (for the most of them in the next year return to the same exploit) is the cause of all this rumpus. Our young lady, therefore, on the 26th of May, 1880, early in the morning, along with a crowd of the people of the country, proceeded to the Sanctuary of Caravaggio. She had been greatly agitated on the preceding day. The usual access of grand hysteria had commenced at noon, instead of two hours later, and it lasted until 3 o'clock, and was followed by several minor accesses. During the journey to church she was much preoccupied, and she wept from time to time. The moment she came in sight of the sacred temple she burst into loud weeping, into groans and piercing shrieks. She could not enter the church, being held back as if by an invisible iron hand, and she stood with her relatives on the area at the foot I74 Angelo Passerini. of a tree, to wait for the benediction. Towards the middle of this, that is to say exactly at the instant of the eleva- tion of the host, she acted just as her companions in mis- fortune who were shut within the chamber, but far worse, as she had within her a demon much stronger and more malignant than any of them carried about. From that day onward, throughout that year, she had no more exaltations or accesses, excepting on Christmas Eve and the two holidays of the Nativity; then there was another pause until the two days of Easter, 1881. These having passed over, she remained tranquil until the last day of April, from which until the 26th of May succeed- ing, when she again betook herself to the miraculous Sanctuary, she had daily an access of grand hysteria, similar to those of the year before, coming on at the same hour, and preceded and followed by an exaltation of the demoniacal ideas and more or less severe agitation. In the past year and the current one, there have been the same phenomena, with the same law and scrupulous regularity, so that we have the following characteristic periods, and therefore, coincident with with the grand mystico-religious epochs of the year: 1880—All the month of May. 1880—The festals of the Nativity. I881—The festals of Easter. 1881—All the month of May. 1881—The festals of the Nativity. I882—The festals of Easter. 1882—All the month of May. 1882—The festals of the Nativity. 1883—The festals of Easter. 1883—All the month of May. In the intervals of the accesses she was pretty well, excepting a little "melancholy and sometimes ill-humor. She often spoke of the devil, to whom she was given over, and by little and little she reached the point of becoming rather sympathetic with him. She invoked his aid every time she got into any trouble, and she said that through Demonomania. I75 his intervention she succeeded in the end with whatever she wished to accomplish. One time a priest, who was consulted by her parents, advised them to put her into the hands of an exorcist, and they probably would have done so, had she not vehemently opposed them, protesting that she much preferred to remain as she was. [As more comfortable 2–TRANS.] Henrietta had menstruated for the first time at thirteen years of age, but she was always more or less dysmen- orrhoeal. Her appetite was always very variable, without, however, ever reaching the extreme degree of sitophobia or bulimia; she had for several years been troubled with constipation. Excepting some fevers of malarial origin, it does not appear that she ever suffered from any diseases of importance. Henrietta is tall and of well-formed person; she has black hair, dark chestnut eyes, and a pale countenance. Her physiognomy, usually devoid of expression and deeply serious, becomes at times suddenly animated and full of life, and at such times her cheeks become bright red, and her eyes sparkle with unwonted brightness. Her muscu- lature is sufficiently developed, the subcutaneous fat is rather scarce, the mammae are of moderate volume. The size of the cranium is a little below the medium; it is brachicephalic; the face is oval and regularly developed. The pupils are equal and slightly dilated; they react promptly and actively to light; she shows a hardly sensi- ble degree of myopia; there is great facility in the spasm of accommodation. Hearing is normal. Her general sensibility is very exquisite, and her sense of place is well developed. I did not succeed in finding any hystero-genic zone. She has a decided predilection for acidulous sub- stances and for roasted meats, but boiled meat nauseates her; she does not care for fruits unless they are sour. Sometimes she eats with real voracity, and again she will pass a whole day without touching food. Digestion is effected slowly and gives place to the formation of much gas, so that the bowels very often rumble- and become 176 Angelo Passerini. notably puffed. Usually she is rather constipated. She is very subject to palpitation, and sometimes to abortive accesses of angina pectoris. The other organic functions are accomplished with all regularity, excepting menstru- ation, which is scarce and painful. She complains much of frequent ovarian troubles, especially on the right side, where pressure a little strong gives pain; she also com- plains of the hysteric constriction and the feeling of the Oesophageal ball. Henrietta usually sleeps but little, and her sleep is frequently disturbed with dreams which are mostly of a terrifying nature. As regards the psychic functions, I may, from my inquiries, state as follows: Her ideas are puerile and extremely limited, not clear, and often dis- connected; her language is very often improper, vague and confused. She speaks rather well her local dialect, but the Italian very badly; of the French idiom, although she had studied it in the college for two years, and for some time afterwards, she remembers, only with great difficulty, a few scattered words and some half phrases, which she at times horribly distorts. She hardly ever speaks unless when questioned. If by chance she enters on a chat of more than half a dozen words, she has much difficulty in keeping to the thread of her discourse. She rambles from one thing to another with perfect nonchal- ence and facility. Having at her disposal only a very limited vocabulary, she makes free use and abuse of general expressions and paraphrases. She recollects only with difficulty, and with much uncertainty and confusion, principally names and dates, and the occurrences of her own life, and these not very remote. Of her beloved college companion she no longer preserves more than a vague remembrance; she has but little affection for her mother. She spends hours and hours at her looking glass, in adorning herself; she studies with close diligence the ad- justment of her hair, she paints her face with white lead and rouge, she perfumes and powders herself all over. Demonomania. 177 If any one asks her why she bestows so much study in adorning herself, in a country in which luxury and fashion have not yet taken their abode, she replies with a smile : “My devil-Áin so wishes it.” It now seems that for some time past, instead of being distressed for having commerce with the devil, she has concluded by entering into friendly relations with him ; and at the present time, far from feel- ing afraid of him, she entertains a certain affection for him. She invokes his assistance in every trifle; for ex- ample, in searching for a pin, lost by her, in threading her needle when the light is bad, in making any decision whatever, and so on. [Note.—Being asked how it ever could happen that she, now so closely intimate with the devil, was in such desperation and distraction last May, and at other times, because of being possessed by him, she merely replied: “In that time I was mad.” It is almost totally useless to interrogate her as to the manner in which she communi- cates with the devil, or upon the particulars of such com- merce. We obtain only laconic and vague replies, such as the following: “He appears to me in the night, in my dreams. I hear his voice in the night time, and some- times I see and also feel him. . He takes the form of a dog, a cat, etc., and he talks to me in dog barés, cat mewings, howlings, which only myself can interpret in their true signification, etc.”] This fact (of invoking the aid of the devil) is explicable by her systemized delirium and the gradual shrinkage of her ideative field. The demoniac ideas which once caused ner anguish have become powerless to move her, being now habitual. Her intellective perception is tardy, and reflection most feeble. She hardly ever succeeds in mentally accomplish- ing an arithmetical process, however simple and short. . It is superfluous to say that she is quite incapable of in- tense and prolonged attention. As in the past her humor is usually sad and gloomy, rather than melancholic. She is very capricious, and when 178 Angelo Passerini. she is bent on doing a thing, she must be allowed to do it, at whatever cost. The ideas of justice, propriety, good morals, duty, etc., are dead letters with Henrietta. The feeling of modesty is very poorly developed, so that she hesitates not to denude herself even totally. She is insusceptible of com- passion; rather indeed she sometimes delights herself in stupidly tormenting, in various ways, animals that come within her reach, and not seldom even the children of her neighbors, whose crying and screaming make her merry and happy. She seems to be altogether dead to family affection and to friendship. Some months ago a sister died of pneumonia; they say she did not shed a tear. It is now three years since she came from college, to reside continuously in the country, and she has never sought for friendship with anyone. As to the passion of love, in the strict sense of the term, it seems that she never has felt it, and that she is insusceptible of it. III. In summation of the case we may say that Henrietta Ga is a girl imbecile, hystero-pathic, in whom there has been developed a religious melancholy with demoniacal ideas, in which the demonopathic accesses provoked by recurrence of the religious epochs of the year, are always associated with the convulsions of the grand hysteria. Now, the association of imbecility with religious delirium, and of the latter with hystero-epilepsy, as also the influence exercised on the delirium by religious festals, all seem to me to be important facts which merit notice. Besides, the dependence, so manifest in our patient, of hystero- epilepsy on religious ideas, reminds us of the fact that very often it is, that the grand hysteric access commences with delirium, and not less frequently, with delirium it closes. This sporadic case of demonomania with accesses of grand hysteria, may also explain the fact of the constant association of religious deliriums with hysteric neurosis in * Demonomania. I79 the great demonopathic epidemics, which afflicted many countries in the middle ages, and which, even in the present century, have repeated themselves, though in less grave proportions, as at Morgines, Verzegnis and Genzano, and at Alia in Sicily; it may also serve to throw light on the genesis of many of the cases of the so-called “malady of the mystics,” of which in our own time Luigia, Latteau and other celebrated stygmatists have been stupendous examples. SETTALA, June, 1883. Clinical Lectures on Dipsomania.” D E L T V E R E D A T THE A S P L U M OF ST. A N N E . By M. LE DR. M. V. MAGNAN. J.ECTURE //–SyMPTOMS. SUMMARY.-Dipsomania; impulsive paroxysm. Prodromata:—Depression, precordial anxiety, anguish, irresistible craving and struggle to resist. After the attack:—Sobriety; no inclination to drink. CASE II.—At 20 years of age, melancholia; at 24, first attack of dipsomania during pregnancy. The attacks continue after confinement. Suicidal impulses. CASE III.-(M. Trélat)—Prodromata:— Self-reproach. Ineffectual attempts to resist the inclination. Uncontrollable desire for drink. CASE IV.-Malaise, the forerunner of the attack. Ineffectual resistance. Impulsive paroxysms. Desperate craving for drink. Attempts at suicide. Restraint. Dipsomaniacs do not choose particular liquors—frequent exceptions. During his paroxysms M. R. would take ether with sugar, his mother also taking it in enemata. ENTLEMEN:—The alcoholic excitement with which an attack of dipsomania terminates when the latter lasts long enough or is repeated with sufficient frequency to cause the toxic symptoms due to the cumulative action of the alcohol, this excitement I say should not be con- founded with the dipsomania itself as it is a complication only, not a symptom of it. Trélat,f in his work on “Lucid Insanity,” lays great stress upon the distinction between these two conditions. “Drunk- ards,” he says, “are a class of people who become in- toxicated whenever the opportunity offers. Dipsomaniacs are patients who do so whenever their attack comes on.” The chief and characteristic feature of dipsomania is its * Translated by Henry R. Stedman, M. D., Boston, Mass. # Trélat, “ Folie Lucide” Paris, 1861, p. 151. [180] Clinical Lectures on Dipsomania. - I8 I tendency to manifest itself in attacks which are essentially intermittent and paroxysmal, and leave behind them a certain cerebral discomfort which gradually diminishes, the patient resuming in the interval his wonted sobriety, regretting his excesses and being left free for the time being. The attack is preceded by symptoms which are usually identical. At first a vague feeling of sadness arises which no occupation or diversion can dispel, and the patient depressed and discouraged, finding it impossible to apply himself, stops working. He soon falls a victim to gloomy thoughts, believing that everything about him has changed and that speedy disaster awaits him. He also becomes more irritable, his feelings change and his dearest friends are objects of indifference. To these symptoms of the intellectual and moral order are soon added physical symptoms. At first, anorexia, with precordial anxiety and a sense of constriction of the epigastrium and throat ap- pear, and then loathing of solid food. Finally, disturb- ances of the general sensibility supervene ; the patients complain of a burning sensation in the stomach and heat in the throat. They have a most intense thirst, not one which any sort of a draught will quench, but a special kind of thirst with craving, an irresistible longing to drink something stimulating. From this time nothing can dissuade them. They must have some alcoholic drink at any cost. When they have no money with which to procure it, they leave no stone unturned, even using the basest means to accomplish their desire. Theft, prostitution, and even crime they will not stickle at to procure an exciting drink. It is in these cases that the father of a family is seen taking the last piece of household property to the dram-shop, deaf to every en- treaty of the mother who points to her starving children; or else it is the mother, who, forgetful of her duty, throws aside all shame and makes a prostitute of herself for a few glasses of brandy, or sells her daughter as related in a newspaper account of a case in England. I82 M. V. Magnan. Here is a patient who will tell us her experience. Her History is as follows: Louise B , 33 years of age, is hereditarily pre- disposed to insanity. She is the daughter of a drunkard whose father committed suicide. Her mother appears to have been a woman of ordinary intelligence, but the patient's brother died of hydrocephalus, at the age of five. Lastly, one of her cousins is insane. At the age of eight, Louise had an attack of typhoid fever which left its mark in permanent mental enfeeblement, attended by so great failure of memory that she forgot all that she had known before, and was obliged to begin again to learn to read and write. After that was accom- plished she had no further difficulty. Towards the age of twenty she had intervals of sadness and discouragement. She experienced pains and dragging sensations in the stomach, and complained of a feeling of weight in the hypogastrium. These phenomena were worse at the menstrual periods and were not replaced by any other manifestation. She noticed even at that time that a little sweetened wine would entirely relieve the hypogastric distress. Louise married in 1873, when 24 years old. Her hus- band, who had known her for several years previously, was very fond of her and she, in return, was devoted to him. The first indications of pregnancy, which appeared not long afterwards, bound them closer to each other, and it seemed as though nothing could disturb their domestic tranquility. In the third month of her pregnancy, how- ever, she began to grow sad from no apparent cause. Social pleasures, diversion of any sort, annoyed her; the most trifling daily duties were a burden; she sought the solitude of her room only to be haunted by the same feeling of ennui and lassitude. At the same time she developed a loathing for Solid food and began to ex- perience, on the other hand, an incessant thirst which nothing could allay and a dryness of the throat. At first she took peppermint water and, finally, wine to quench Clinical Lectures on Dipsomania. 183 it, but her desire for drink was unassuaged. She then decided to try brandy. The immediate relief which began to follow its use impelled her to drink more. The first exhilaration of drunkenness dispelled ‘her discomfort and she continued to drink until, after consuming half a bottle- ful of alcohol in a short time, she became profoundly intoxicated. After five days of sobriety and regularity of life her sadness returned, when she completely abandoned herself to her longing for drink, with the same result as before. Her husband and her family attributed this fancy to her pregnancy, and used every means—censure, advice and surveillance, to induce her to correct her vitiated appetite. She promised to reform and kept her word for a month, but the depression and craving for brandy again set in. She was haunted by a craving from which there was no escape. Realizing, after a determined struggle, that she must soon give up to it, and being anxious to .escape the inevitable reproaches of her family she left home, taking some clothing with her which she sold for a song at the first offer. With the proceeds she bought some brandy and, shutting herself up in a hotel chamber, drank until she fell to the floor insensible. The next day she was found by her husband, who had searched for her all night, in a stupid and dirty condition. He took her home and redoubled his vigilance, but with no better re- sults. She relapsed again and again, into her old habit, until her confinement took place at term without accident. She had scarcely left her bed before her old feelings of sadness and discouragement returned accompanied, as usual, by malaise, a sense of constriction at the epigas- trium and dryness of the throat, which culminated in the Overmastering desire for drink. She, at first, fought against it, knowing that once the descent was begun she could not stop short of the lowest depth of degradation. Every precaution was again taken and yet she yielded to the impulse, directing all her energies toward gratifying her irresistible desire. From that time her attacks increased in frequency, occurring at irregular intervals, but perhaps I84 M. V. Magnan. more particularly at the menstrual period. Later she took to the use, or rather abuse, of absinthe as well as brandy, and its effect soon showed itself in muscular twitchings and attacks of vertigo. Her afflicted family are at a loss to account for the patient's condition. This woman, chaste and reserved in her intervals of sobriety, no sooner begins to drink than she loses all modesty and discretion. For a glass of spirits she abandons herself to the first comer. Her resorts are drinking places of the lowest kind, and she gives herself up to the most disgraceful debaucheries. with prostitutes in the worst quarters of the city. Some- times, for want of money, she is forced to leave her gar- ments in payment of her debts, and she is then found by the police lying on the sidewalk nearly naked. The crisis passed she becomes herself again and mani- fests the utmost remorse and grief for what she has done and promises not to allow herself to be again led astray. Her resolutions are sincere and she willingly seconds every attempt to turn her from her propensity. She was, at one time, given a position in a business house with the hope that by keeping her constantly under a friendly oversight it would be less easy for her to obtain liquor, and it was thought probable that she would return every evening in a calm frame of mind to her home where her husband and her child awaited her, but all these pre- cautions were of no avail. When the impulse comes on she contrives a thousand ways for obtaining drink and begins another debauch. After the first glass her firmest resolutions vanish, to be replaced by ravenous indulgence of her appetite. After a time her relatives decided to place her in charge of an uncle in the country who was a physician. She readily agreed and counted on securing complete protection by this arrangement. While she was there, every means were employed to prevent a relapse; per- suasion, threats, and even restraint, but to no purpose. As soon as the attack seized her she would steal off and begin anew her old practices. At one time, however, she Clinical Lectures on Dipsomania. I85 appeared to reform and had a respite of three months. Her husband, believing her cured, took her back to Paris where she received the congratulations of all her friends. But on the very first day she began to feel sad and un- comfortable, took no interest in household matters, and passed a sleepless night. On the following day her hus- band, on returning from his business, found her stretched upon the floor, soiled by her evacuations and profoundly intoxicated. She was again put under her uncle's care for some time, but little benefit resulted. Returning to Paris she again took up her double existence, so to speak, at times conducting herself as a worthy and estimable wife, showing the utmost affection for her husband and child, at other times, falling, inevitably, back into her old indulgence in debauches of the most revolting character. In January, I877, she left the house one morning with the apparent intention of going to work, and took her way to her place of business. On the way the impulse to drink seized her, and having no money with her she pawned a ring, went to the dram-shops and there re- mained for two days. She was arrested and slept at the police station, where she was found by her husband, on the second night, in a half-naked condition, all her jewels and most of her clothing being in the hands of the pawn- brokers. In the following May the same thing was repeated, except that on this occasion she remained away from home four days, during which time she was under the influence of absinthe and took no nourishment, but hung about the drinking places until they were closed for the night. Then, being turned out into the street, she wandered about waiting for some shop to open where she could obtain her favorite drink and satisfy the burning thirst which was consuming her. The scandal her conduct created led to her arrest. When her husband found her at the Prefecture of Police she was again nearly naked. Even her corsets had gone, she knew not where, to pay for drink. Her cloak had also been pledged early in the morning for two glasses of absinthe. On another occasion, I86 M. V. Magnan. towards the last of July, feeling herself sad and thinking that a walk in the Square would cheer her, she went out taking with her her little child as a safeguard against temptation, but in spite of her precautions she drank, on the way, several glasses of wine, and when she reached the garden was somewhat overcome by it. Here she entrusted her child to a drunkard whom she met. Her husband not finding her at home went out to look for her, and, at about eleven o'clock at night, met her returning in the company of a laborer as intoxicated as herself, who was forcing her to walk along. She was afraid that on her return home she would be taken to task and had induced the laborer to take her to his house. On the next day she was placed with some friends who felt sure they could watch her closely, but her attack returning, she made her escape to a distant quarter of the city, where she was twice arrested in two days for being intoxicated. To-day her appearance shows the ravages her excesses have made. She drinks until she falls insensible and motionless. She remains prostrated for several hours and for five or six days is in a stupid condition which in- capacitates her for work. This was her condition when she was brought to St. Anne. A week after admission she had become calm and rational, and gave a most accurate history of her case, You can see how she deplores her unfortunate pro- pensity for drink. She knows that she could be very happy in her home and that, instead, her dissolute life has brought only desolation and misery upon it, as her husband has not been able to provide the household neces- sities and to meet, at the same time, the increased expense her excesses have entailed. She states with distinctness the premonitory stages of her impulses, and insists that she is powerless to resist them. With her child in her arms, she could not prevent herself from entering the wine- shop. Occasionally she has thought to commit suicide by throwing herself in the Seine. She even drank to give herself courage so to do, but the brandy only had the Clinical Lectures on Dipsomania. 187 effect of depriving her of all energy, and instead of con- tenting herself with the small amount necessary to produce a little excitement, she would drink until she became brutishly intoxicated. In all dipsomaniacs the impulse is preceded by the same prodromata, and manifests itself in the same manner with the single difference that the various features of the disease are appreciated in proportion to the education and intelligence of the patient. Moreover, some of them quickly develop an aptitude at concealing the habit from others. The struggles which some of these unfortunates make before yielding to their disastrous propensity, indi- cates in the clearest manner possible how much they differ from natural drunkards. The latter seek every opportunity to drink, while the dipsomaniac, on the con- trary, begins by avoiding it. He reproaches himself. He enumerates, perhaps, in a loud voice, the different torments that await him. He endeavors in a thousand ways to make himself disgusted with liquor, even contaminating his drink in hope of keeping himself from yielding to the tempta- tion. The ordinary drunkard does not behave in this way. Trélat has reported a very interesting case bearing upon this point. Madam W was an earnest and energetic woman. She had started several enterprises which had always failed for the same reason. As a rule, she was regular, circumspect and economical in her habits, but from time to time she would be seized with attacks of the drinking monomania which made her forget every- thing, business interests, obligations of all kinds and her family, until, at last, she brought upon herself complete ruin. It was impossible to hear her describe the efforts she had made to cure herself of the propensity which was ruining her. When she felt her attack coming on she would put substances into her wine which were most calculated to excite disgust, but to no purpose. She would even mix it with excrement, telling herself at the time of the harm which would come of it. “Drink that,” she I88 M. V. Magnan. would say, “Wretched creature drink, you sot, drink miserable woman, forget every duty, and bring disgrace on your family.” But her craving was stronger than all reproaches and any amount of disgust she could feel. When the dipsomaniac finally succumbs he behaves altogether differently from the drunkard. He conceals and secludes himself after secretly purchasing his liquor, and then steals away with it utterly ashamed of himself. The habitual drunkard, on the contrary, is demonstrative and noisy, and asks his friends to join him in drinking. He displays the bottles he has emptied and is proud of telling his exploits. One is insane before drinking, the other only becomes so because he has drunk too much. The accounts given by dipsomaniacs of their struggles to resist the impulse is even more, instructive. They drink the first glass to give them strength and assistance in carrying on their struggle against temptation and promise to go no farther, or else they do so in order to dispel a feeling of heat in the throat. But from that moment the power of resistance wanes, as they experience a slight exhilaration or a sense of well-being, of satisfaction or a kind of relief from their trouble. Then nothing can stop them and they are impelled to hasten their libations. They must have at any cost their favorite drink, and nothing short of confinement can keep them from it. We have a patient in this service an examination of whom will show, better than any description, the moral condition usual with dipsomaniacs, the period of sadness which preceds each of their attacks, their resistance be- fore succumbing, the means they use to gratify their passion and, finally, what is most marked, the remorse which torments them after each new relapse. Her history is as follows: Marie T , a seamstress, aged 5 I years; has been several times admitted to St. Anne. Her maternal grand- father committed suicide. Her mother, at 40 years of age, had an attack of melancholia. The patient contracted drinking habits in a regiment in which she was vivandiére Clinical Lectures on Dipsomania. I89 and where she occasionally drank a little brandy. “It was a part of the business,” and, at that time, she drank without any craving for liquor, and solely so as not to offend by refusing when it was offered to her. It is im- portant to emphasize this point. At the age of 34 years she complained of cramps in the index finger and thumb of the right hand, in which she also noticed a diminution of sensibility. This obliged her to learn to sew with the other hand. Galvanization was tried without suc- cess. Two years later she had, from no assignable cause, her first attack of depression. This she thought she could drive off by taking the lees of brandy, but this only caused her to lose sleep. She had, thus far, not had a genuine attack of dipsomania, but not long afterward she had a second attack of melancholy. She felt unfit for anything, and wept and mourned for two days as though she felt some calamity impending. Distension of the stomach caused pains and for the first time she felt a desire to drink, which not being immediately gratified became irresistable. She left her home in order not to be seen intoxicated in that neighborhood, and ran off to the dram-shops, but was greatly ashamed of this freak and determined not to repeat it. Up to that time she had been comparatively sober as a rule, but since then she has had, at irregular intervals, periods of melancholy marked by a feeling of powerlessness—“like cutting off her arms and legs”—which renders her incapable of doing any work. Her stomach also seems to burn and she feels as though she had a heavy weight on her chest which was stifling her. These phenomena are immediately fol- lowed by a desire to drink. The impulse quickly drives her to drink to excess which she is generally sorry for afterwards, but cannot resist repeating whenever the attack recurs. Finally, alcoholic complications brought her to La Pitié, where she developed suicidal desires and endeavored to leave her bed in order to throw herself into the bear's pit in the Jardins-des-Plantes. On one occasion she succeeded I90 M. V. Magnan. in eluding her watchers, and leaping over the stair-rail threw herself down from the second floor. As she received no injury to speak of and heard a voice calling her to make another attempt higher up, she went to the third floor and made ready to throw herself down again, when she was secured. The next night she attempted to strangle herself with one of her garments. She was brought to St. Anne on the following day for the first time, suffering from horrible hallucinations. She saw serpents, birds, white cats coming to devour her and soldiers who wished to kill her. She was abused and everyone was in league against her, etc., etc. At St. Anne the undercurrent of melancholy has re- mained unchanged for eighteen months. She has not com- mitted any excess thus far, although given charge of the distribution of the allowances of wine at meals. Never- theless, on several occasions she had felt impelled to drink the contents of the glasses placed in her care, but being under close observation she did not succeed in her attempts. She said, moreover, that she would be disgraced by suc- cumbing, as an inward voice which urged her to resist said, “You will be pursued and punished if you drink.” We have seen what weight a similar suggestion had with her. A phenomenon also manifested itself in spite of the patient's sobriety, which we shall have occasion to refer to again. The physiological equilibrium finding itself dis- turbed during this preliminary period of the attack of dipsomania, Marie was seized in the middle of the night with an attack of alcoholic delirium. She saw grimacing faces, shadows of Chinese figures dancing on the wall, and flames and sparks. She also smelled offensive odors. To- day you see her in her usual state. She hears voices within her “not sounding in her ears,” but saying to her mentally, “You have done finely, you will end by killing yourself; you wretch! You have begun badly and you will end badly.” Lastly, this woman presented a final peculiarity which is striking. When walking with another patient she is always careful to keep her on the right side, as she cannot Clinical Lectures on Dipsomania. I9F possibly feel anyone on her left. If she fixes her left eye on a light, it seems as though it would fall upon her head. Everything she looks at with this eye alone seems to dance about. Her arteries are atheromatous, and sensibility of all kinds is weakened on the left side. What liquors do dipsomaniacs prefer P Every kind of alcoholic drink is acceptable. One patient drank Eau de Cologne; the first woman I called to your notice took vulneraire.” You remember the other who drank essence of peppermint and afterwards absinthe, and we shall see a fourth who prefers wine. An insane person well known in the medical world, Comte de R——, resorts to ether taken with sugar, and his mother, who also seems to have been a dipsomaniac, is in the habit of inhaling it and sometimes even goes so far as to use it in enemata. Many dipsomaniacs invariably take the first liquor which comes to hand. It is not only during their impulsive phases that dipso- maniacs differ from habitual drunkards. The toxic de- lirium also which follows their drinking spells is not the same. While the drunkard calls incessantly for wine, brandy, champagne, etc., and takes what is administered, if it is given the name of the drink he clamors for, the dipsomaniac, on the other hand, when his impulsive craving is gratified, is disgusted at the mere mention of alcoholic drinks of any kind as they inspire the greatest repugnance. Our first patient could not bear the odor of vulneraire between his attacks, although he drank glassfuls of it at other times. Of the two other dipsomaniacs now in this service one usually takes nothing but water, milk, soup and a very little wine, and the others will not take any liquid for several days after an attack. * Also known as arquebusade water. A lotion used for wounds.—TRANs. State Provision for the Insane.* By C. H. Hugh Es, M. D. E live in an age when every uttered sentiment of charity toward the insane is applauded to its remotest echo; an age in which the chains and locks and bars and dismal dungeon cells and flagellations and manifold tortures of the less humane and less enlightened past, are justly abhorrent; an age which measures its magnificent philanthropy by munificent millions, bestowed without stint upon monumental mansions for the indwelling of the most pitiable and afflicted of the children of men, safe from the pitiless storms of adverse environment without which are so narshly violent to the morbidly sensitive and unstable insane mind; an age in which he who strikes a needless shackle from human form or heart, or removes a cause of human torture, psychical or physical, is regarded as a greater moral hero than he who, by storm or strategy of war, taketh a resisting fortress; an age when the Chiarugi's and Pinel's, the York's and Tuke's of not remotely past history, and the Florence Nightingale's and Dorothea Dix's of our own time, are enshrined in the hearts of a philanthropic world with greater than monumental memory. Noble, Christlike sentiment of human charity | Let it be cherished and fostered still, toward the least of the children of affliction and misfortune, as man in his im- mortal aspirations moves nearer and nearer to the loving charitable heart of God, imaging in his work the example of the divinely incarnate Master. But let us always couple this exalted sentimentality with the stern logic of fact and never misdirect or misapply it in any of our charitable work. Imperfect knowledge perverts the noblest sentiments; widened and perfected * Remarks following ‘‘Definition of Insanity,” published in the October number of THE ALIENIsT AND NEUROLogist, and read before the Association of Charities and Corrections, at St. Louis, Oct. 15th, 1884. - [192] State Provision for the Insane. I93 1