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Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajoutdes lors d'une restauration apparaissent dans le texte, mais, lorsque cela dtait possible, ces pages n'ont pas 6t6 filmdes. Additional comments:/ Commentaires suppldmentaires; D D Coloured pages/ Pages de couleur Pages damaged/ Pages endommagdes Pages restored and/or laminated/ Pages restaur^es et/ou pellicul^es Pages discoloured, stained or foxed/ Pages d6color6es, tachet6es ou piqu^es Pages detached/ Pages d^tach^es Showthrough/ Transparence Quality of print varies/ Quality in^gale de i'impression Includes supplementary material/ Comprend du materiel supplementaire Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to enutions to medical literature have justly made them famous. At the same time, it was my duty to o])ey your behest to the best of my ability. My co-members were consulted and asked to contribute even a mite to luy collection, but my effort was " love's labor lost." My genial and well qualified friend from the sunny south, has ])een otiierwise engaged and ])rayed i^ be excused. My other talented su})porter in tin. tripartite committee from the gi'eat north-west, did not answer my appeal, but as at that time the thermometer was dancimj about in the neighborhood of forty degrees below zero in his locality, I am convinced he must have been in a partial condition of congelation, and incapacitated by the withering bi'eath of old Boreas from responding to my entreaty for needed aid. I am pleased to see a thaw has taken place, and that it is not yet too late for *Kca(l at the Annual Meeting of the Association of Superintendents of American Institutions for the Insane, held at Newport. R. I., June 20, 1888. •( fe, i< i 1i • ^ hira to conti'ilnite his exporionce to tlio common fund. Those are two valid reasons out of a i)os!sil)le three for my short-corn ini!;s in tliis ej)itome. It would he impossible in a sliort ])a])er to present mon^ than a condensed view of a few of the many lields of ol)servation, whicli are continually (»peiiinii; up in our chosen ti-act of exploration. These will he given in as few words as is ])ossihle. The advancement of |)rac'tical medical knowledi^e may not he very striking from year to year, yet, exjierience teaches that ai)|)arently insignificant facts may he followed hy momentous results. The ol)serva- tions and exj)eriments of (ralen over seventeen cen- turies atco, on the recurrent lai'vuireal nerves and on the functions of arteries, led to the great discoveries of nerve function and blood circulation. The investiira- tions in respect to the woi-k of the lymj)hatics made in the seventeenth century, led to our ]>resent knowledge of their im])ortant place in the anin)al economy. Bell's researches into nerve structui'e and function, made nearly eighty years ago, were a gi-eat stride forward towards the better understanding of the workinirs of the cerehro-spinal economy. Mairendie used Bell's data, and by adding them to his own ohservations, hased on experi/nent, he came a step farther into the light of truth. Little did Tyndall dream that when he was experimenting with a sun- heam which straggled into his study, he was gathering material to prove the germ theory, and in LL^feriinn revolutionized the practice of sui'gery. Thus it always has heen and alwavs will he — one lays the foundation and another huilds on it. One isolated fact may he a key to open a door into a veiitable chamber of wondei's. It is never to he forgotten that theoi-y is always to be received with caution, hut exj)erimental las ch( pal in 8 knowledge oairicH itn own cnldence witli it. In this lies the great udvantuge of ])athoh)gioal' research. Diseased organs witli the signs and Hynii)t()nis oonse- ([uent thereon, have been studied dosely during the last ([uarter of a century, witli all the assistance chemistry and the microscope could give to the pathologist, nor have the o])servers lalmred in vain in this marvelous field of iniiuiry. Let me give a few facts of recent date on this subject, in relation to cerebro-spinal pathology. Of course, they can only be a few out of the many daily coming into observation. In 1840, Nasse discovered that aftiir the division of a nt.'rve, not only was the cicatrix after healing a different texture from that of the nei've divided, but that all tlie nerve from the cut ])art to its utmost extremity had changed in charactei'. Atrophy, de- generated myeline, fibres changed in ojiacity and outline were always found to be the result of division in all the cut-off nerve. Ten years later. Waller not only corroborated this, but took a stej) farther and showed by actual experiment that not only did this change take place, but that regentu-ation to the normal condition never supervened. This was a great stej> towards a proper study of nerve decay, and especially of insanity in relation to i)crninnent recuperation. A breach of continuity once effected in nerve tissue, either by disease or traumatic lesion, means irreparable loss of natural structure, and as a consequence loss in some degree of normal tone and function. We know that inflannnation never leaves a structure as it found it. The interosseous substance of a fracture is always different from the normal bone. A scar is a good example of change of structure, and which always remains in this condition. In the same way, so distinct '%i f-.l M* ; I is nerv'e change, tliat wo can trace its '.legcnemtive ravages tliroiigliout its most eccentric ramifications. Subsequent experiments during tlie ])ast year have not only eon'oborated these* facts, hut 1)} means of them the "centers of nutrition" liave, l)y ex[)eriinent, Iteen found to be h)cated in the spine and spinal ganglia. It ]»royed an extraordinary fact, viz., that if only a certain nerve were divided l)y the knife or aftV ;ted by disease, tlie degeneration oidy affected that nerve tract, however intimately tlie fibres might be bound up or interlace '.vith each other. This explains nuich that seemed erratic in tlie pathological condition of the cord and brain. Anatomy has shown lis little distinction in the composition of these two centers of nerve energy, but this cardinal fact shows us that even in ai)parently uniform nerve structures there do exist unknown differences in their ultimate elements. Turck, of Vienna, has shown cuses of brain disease in which certain definite tracks commenced at morbid centei's, and took their course with well defin3d boundaries downwards to the loAver end of tiie si)inal cord, the whole diseased tract havinix in a ijreater or less degree all the defjenerative characteristics of the central and initiatory morl/id change. In the most of cases recorded, this morbid change^-if in the brain — would spread from the brain lesion downwards through the crus cerelu'i, the pons and the anterior pyramid of the same side, then through the postei'ior section of one of the lateral columns. This corresponds to the anatomical continuity of fibres, as well as to the nutritive track. We often see this trail of disease with the naked eye, in cases of j^ost Qnortem, or those having had hemiplegia, sclerosis, or such like nerve disease. Charcot asserts, that the direction of disease in the posterior columns of the cord is upwards, and of course • lis. >t cm 'CIl ia. ii or lilt .1(1 in iiovor (lowinvanls. If tliut 1x3 so, then it is (ividcut (logeiicr.'itioii taken tlie diivctioii of the fmictioiial activity of iicrvi! fil)i'(;M. These grand faots, s])rini;iii<^ from tlie study of a nerve cieatrix to a nerve — then from a nerve to the spinal cord — then from the eord to the medulla oMongata and white brain substance, have given lis an insight into conditions the microseope could not divulge alone. These morbid changes show, on the one hand, the close intimacy of all nervo fibres; and on the other, the radical distinction of nerve tracts. Nerve fibres seem to lie aloui; side of one another like insulated electric wires, yet (juite distinct from one another in function, until some point of coimensus is reached in a nerve center. It will be seen then that a good deal of attention lias been given latcdy to the connection nerve influence has upon nutrition. It is asserted that certain i)arts of nerve centers hav^e more peculiai'ly the funetions of ennervating actions, which convey distinctive energies to focal points of assimilation. It is evident from recent examination that there exist these so-called "trophic centers." These spots of peculiar nerve movement and influence are ricli with the multipolar ganglionic cells. Onr anatomical knowledge teaches us that these rcgitms thus endowed are in the fourth layer of the cerebral cortex, in the anterior cornea and in the posterior columns of the spinal cord. Prolongations from these minute cells also affect nutrition. This great fact is strikingly illustrated in irritation of the fifth nerve. It is followed by skin eru])tion, ulceration of the cornea and inflammation of the eye. In paraplegia with wasting of muscles, we find its cause where the multi- polar cells most abound in the anterior cornea of the spinal cord. Progressive muscular atrophy has the same record, and ah analogous condition exists in y t' I ^ rfM V4; jM)steri<>r spinal sclerosis. Wc know how (licso states const'(|Ueii( on impaired niitiitioii hriiig about almonnal conditions of the joints — such as fVaetiires conscipient on want of appi'oj)riatioii of animal matter to j^ivo tho bones elasticity, and cvvn dislocations from want of tone in th(^ surround injii; tissues of the joints. Th.osc wlio liave ehnru:*' of th<' insane need not ho told how the least ])i'essure or blow will |)roduce ecchymosis, and a slight force will be followed l)y fracture of bone, in some brain diseases. Metastasis of so many aihnent.s is no doubt due to changes following nndiiutrition and the cause of these; (legeneratlons is in de})reciated iierv(! sMj»})ly from these great centers of intlucfnce. Tlie initiatory diseased imj)ulses are given from these centers, ])ut must however be alwavs distinguished from those ]>i<)duced by abnormal conditions at tlie j)eriph- ery of the nerve apparatus, and followed by vascular changes conseipicnt thereon. Such as the latter are brought about by vas\v iiid in s is tiid ted " It \H not cloarly dccidcMl where tlie tr<>|)l»i(' center?* ai'(! situated, Imt it is evident in all tonns of nntiitive deii^eneratioji, that desti'uetive chanj^'es take plaee in tin; multipolar cells, and often the axis cylinder is ehanj^ed into mei-ely shrunken tissue. This cell change and oltliteration are more; j>artieularly seen in the font layer of th(! brain cortex and in the anterior cornua of the ''ord. There are yet undiscovered tnndiic localities in the nerve masses, as there is no evidence that eitlnsr the motor or sensory nerves have the functions of trophic stimulation. Tiiis misdirected force hriiiirs about mal- niitrition in many forms. Atheromatous and calcareous degen(!i'ations, general as w(dl as local, give undoul)t(Ml evidence of its malirain al»scesses are formed the result is a temperature of several degrees below the normal, in th(! same region; the same is also true from end)olisni of cerei>ral vessels, followed by hemiplegia. This may be accounted for by the fact that tumors increase the blood supply in the part, but abscess or embolic conditions decrease it. In all, the heat is not normal, and more circumscribed in tumors than in the other two classes of diseases. If these clinical observations can be corrol)orated by a sufficientlv large number of cases to enable us to form- iilate a positive rule, there is a great step taken in differentiated diagnosis. It is not to be forgotten that thrombosis and abscess often co-exist, and that the former precedes the latter in the order of sequence, and also that congestions, of a temporary kind, of the coverings of the brain, will produce, for a time, an exaltation of temperature. The history of a case in res})ect to duration, extra-cranial symjjtoms, or non- local thermal conditions may go far to enable an acute observer to draw lines- of distinction in a majority of cases. A rich field of research, based upon blood circu- lation, and consequently upon local heat, in relation to intra-cranial disease is opening up to investigators. At the same time we ai'e not to be led away to believe too much in this direction, from the pretensions set up in aml)itious text-books on nervous diseases. Dr. H. Howard, of Montreal, in a somewhat dogmatic book on insanity, recently published by him, endeavors to show that we find a valuable diagnostic sign of insanity in a low condition of bodily heat, which is, he says, uniformly found. This is true in I'espect to many cases of melancholy and dementia, but it has no value as a general symptom of insanity in all its 'i! 11 Iiii-'li iro of -ion ; 'ssels, il for )ly ill se it. 'ibed If o phases, Ileic, in jiassino^, let nie say, that after a iiuinl)er of years of close ol>servation of the lieat of the Ixxly, and the (jiiality of the ])ulse in respect to diagnosis of diseases, especially insanity, 1 have been convinced of the iinrelial)ility of these two tests, if de])en(h>(l on alone. When we take into consideration the dirticnlty of finding the same heat twice, under ap])arently the same pathological conditions, in the same })atient ; also that scarcely any two thermometers indicate the same degree under exactly similar influ- ences of heat or cold, it is evident that as a diagnostic method it needs to su})|)ort it collateral confirmation from other quartern. Tiiis is more evident when we consider that alarming conclusions are drawn from only a few degrees above or below the normal standard. If a number of thermometers are j)ut in contact with the same axilla, or under the same tongue, it will be seen liow fickle they are, and that even if adjusted, no two of them exactly agree, as at present constructed. They can only approximate to the true condition. This un- trustworthiness is true of both temperature and pulse. A sudden bodily movement, a passing emotion, a transitory excitement, a sudden congestion of any of the organs of automatic life, or a shock of depression, may heighten or lower both without any apparent pathological change. To put the matter fairly to the test in insanity, I selected a number of cases belonging to distinct classes of disease, and took the temperature and pulse regularly, morning and evening, for several months at a time. No conchisions of a satisfactory character could be drawn from our trial. To speak generally, in dementia we found the heat and pulse below the standard of health, but in an erratic way, for several days at a time, they would take a leap up- wards. In cases where dementia and consumption I 4 10 were oombinod, both as a rule were found above nor- mal, but in this condition they were not continuous nor uniform. The nearest a])i)roach to stability was found in paresis and consumption combined. In this dual state both pulse and t(;mperature were generally abov'j normal. In paresift alone the same uncertainty prevailed — they rose and fell without any regularity, but oftener above than below the standard. The same was found true of mania and melancholia, even when cold and blue extremities indicated a languid circula- tion. Neither of them nor both combined showed positive indications of the genns or species of insanity. In this connection it may not be out of place to say that little has been done in the way of diagnosis based on the condition of the optic disc and its surroundings. The writer has seen, with the ophthalmoscope, so many normal conditions among the insane, and so many ab- normal among the sane, that his faith in reaching diag- nosis of brain troubles by this avenue, has been very much shaken. It is true, it has been very well estab- lished, that in traumatic lesion of the Ijrain, we often find papillary stasis and hypera3mia of the retina, and this without aifecting vision ; l)ut on the other hand sight is often impaired without any vascular disturb- ance, hence, no certain })athological condition of the retina has been fou'id upon which we can attach any diagnostic value. Cerel)rnl stasis — an undue increase of Huid surrounding the brain and the optic sheath, might produce, by compression, a decrease of arterial circulation, or an engorgement of the, veins in the optic region, or both, yet, this condition being only temporary, it can give no indications of any permanent brain trouble. The distance between the optic disc and I)rain proper, witli the })ossibility of a diseased condi- tion existing only in the course of the optic nerve, or in m:| of clJ tiJ Ei frl ai| vr ■T:t^J?, ■.i4 11 i\ in its envelops, after its emersion from the cerebral mass, will always leave in doubt tlie diagnostic value of any condition of the eye in its retinal expansion. Hyperfemia of the optic nerve, redness, swelling, or choking of disc may exist, but they give no indica- tion of brain condition, for they may be purely local. Each indivi'bial has a retina distinct in some particulars from any or every other, so no commcm standard of appearances can be given. We often see a state of vascularity in the retinal vessels, which looks like a congested oi* inflamed state, yet, it may be normal. We may find a pale, flaccid condition, which we might hastily attribute to disease, but it might only be consequent on languid circulation from cardiac defi- ciency or an anaemic condition, and yet not be a disease. It is true of this state, that if continued it may end in atrophy from impaired nutrition. At the same time, it is never to be forgotten, that the body is continually an organism of reflex movements and influences, and such being the case, optic abnormalities often produce cerebral disturbance conducive to mental trouble. A small eccentric or distal cause may excite grave complications in the brain, especially if it should be ripe l)y predispositiou to manifest the insane diathesis. Nothing is more harmless and inert than gunpowder, if not ignited, but the explosive power is only latent, and a lighted match may l)e the occasion of its potency becoming manifest, so local disease of a[)parently small importance may in an analogous way be the occasion of exciting causes into manifest energy never dreamed of, until favorable conditions ])resented themselves. The statement of M. C. Dutuque, that in general paralysis we alwa;/s find irregularity of pupils, papillary con- gestion, varicose dilation of the arteries and veins of the r f^ m m I II I i^: ^j »^*t?. 12 retina, oUscurcd disc iiiMl ojUic ati'opliy, is a Hweoping generalization not warranted in a majority of easen of paresis. (Z' Enc('i>lmle^ January, 188;^). During tlie year a large number of cases have been collected to ])rove tlie doctrine of cross irritation and movenmnt, as between the motor centers and o|)]M)Hite layers of tlie body. Many experiments and diseased conditions no doubt prove this fact. At the same time, it is evident an intimate co-relation exists l)etween the ence[)haJon in its hemispheres and ])oth sides of the body. Diseased action in onedialf of the bi'ain often produces inijmired function simultaneously in both sides of the body, and often on the same side only as that ol he affected hemisph<'re instead of the opposite side, as asserted by some investigatois. (jleneral want of co-ordination and loss of function is almost uniformly true if the base oi'ijjans are affected. In nine cases out of ten this is true, if such im[)ortant organs as the pons varolii, medulla, anterior pyramids and cerebral pedun- cles are affected. It is true, a large numl^er of cases are recorded in which cross sym])toms only follow, but these are nearly all confined to results following the supei-ficial condition of the brain. The whole matter is so far in an unsettled state, but is being closely investigated as o[)portunities present themselves. It is now generally conceded that tendon — or rather muscular — reflexes are not always co-existent with Duchenne's disease. At one time, and up to a recent date, it was classed as absolutely j)athognomouic of locomotor ataxia, but recent researches show that in a lai'ge nundjer of cases this siixn is absent. It seems evident the absence is due to the condition of the spinal seat of nerve supply (Prevost and Tschii'evv). This location is that section of cord which supplies the three and four lumbar pairs. The presence or al e^ in tl o a 13 iH of absence of tills eoiiditioii is no doubt lai'goly diu; to the extent of nerve decay. In u medico ]ei:;al sense it is inilMU'tant to know with certainty that the absence of these retU^ves are not negative jM'oofs of non-existence of h)c()niotor ataxia. We are often asked in cases affecting the mental condition of a testator to diagnose this sj)inal disease — j)ure and simple — I'roni the shut- iling gait and prehensile unsteadiness of a case of paresis. The fulcrinn ])oint is, to desci'ibe a disease and its signs with initiatory mental alienation from one which, as a I'ule, terminates without brain disease and psychical dethronement, or, if so, only at the termina- tion of its course, At any rate, the tendon reflex must be ruled out as liaving absolutely no diagnostic value in determining this disease from others of a kindred nature. In this connection it may not be out of phice to state that much diagnostic value may be found in Zoo- chemistry. In locomotor ataxia, for exam|)le, amyloid degeneration in the diseased portions of the cord is very characteristic. It has been held by many patholo- gists to be either colloid or albuminous; this is not always correct, for the well-known chemical reaction of iodine and starch takes jdace, wath the addition of dilute sul])huric acid ; and in addition, the microscope clearly shows bluish starch granules. These starch-like bodies are easily seen in many brain affections, and often in paresis. The condition is evidently a retro- grade metamori)hosis of the nerve cells. When we think of onr chemistry, and rememl)er the definite changes in the alcoholic series of bodies from starch to sugar, alcohol, acetic acid and finally into carbonic acid and water, we . now that all only contain three ele- ments with different groupings and greatei' oxydation, and thus complexity of the analogous bodies increases. \ ! In 4'* '.>,i :li I A hi 14 Cerehriii is a norve snl)stancp containiiijjj tliC'S(! radical elements, f()nil)iiie(l with nitrogen and j)li()sj)]i()riis. In a degenerative and descending scale, deoxydation would bring about a more primitive grouping of tliis and analogous substimces, and as a result a starch-like body would be generat(Ml ; in other words, it miglit be a sugar ])i'o(luct. The (h'oxychition may ])e caused from deprivation of ])roperly oxygenated Idood in nerve tissue, or i'rom an undue; formation of deb.'terious acids in wasting tissues, or from a lood supply and p/itlioloi^ical conditions to establish this fact, and to account for so litt'e functional and mental disturbance in numberh^ss cases of cortical lesions, and even in their destiuction. This view is beginning to attract attention among those better qualified to })rove its worth, than the writer can possibly be, because of his comparative v.ant of o])portunity. Couty says, in the light of recent exi)eiiments, "The effects of cortical lesions as irritations are always indirect and due to intermediated discnxlers of the ap})aratus, comprised between the bi'ain and the l)eripheral organs — to wit — the bulb and the medulla vertebralis. Disorders of co-ordinations of vari.)us forms, can be explained only by supposing a pathological modification of the apparatus of the medulla to wdiich they belono;. He concludes that there is no necessary relation between the nature and seat of a lesion, and the i-esulting nature and seat of the motor disorders. Dr. M. Couty gives us the result of seventy-six experiments made on brains of nogs and monkeys, in the la1)oratory of the museum of liio Janeiro, and as a result of these trials he holds that it is not necessary to discard the old views, as to the excital)ility of grey substance. It has never yet been invariably demon- strated that there is a constant and invariable relation between the seat of lesion and the character of the trouble produced. The lesion of the brain produces remote disturbances whose character tepends on the extent and in no respect on the location of the lesion, by acting by inhibition or exaltation upon remote parts of the nei'vous system (lievue Scientifque). Golz's experiments have all been in favor of central focal points of energy. They are interesting from a pathological point of view. He not only watched the f Y !i \ ■•■h I 4 l\ mi mil 16 imiii(>(H;it(! oflV'cts of (lostnu'tion of Lraiii sul)stnnc'o, ])ut wan also jihU' to kccf) alive the animals ojuTated upon for as long as eight months in severe cases, after the lesion occurred. In this way he could watch secondary effects. The latter condition was more analogous to spontaneous disease in its insidious invasion, than could he the shock of traumatic lesion. Dr. Exner, of Vienna, has collected one hundred and sixty-eight cases of simple lesion of the cortex cerebri, in which were good histories of the ])atients and of the j)Ofit mortems. lie divided the cerehral surface into three hundred and eighty arbitrary s(juares, and then compared the functional disturbance with the parts diseased. It is evident such divisions could not he satisfactory unless each sfjuare represented a dis- tinct oj'gan, so his conclusions must l)e reservably received with due allowance for his increnious device. He found, however, that the cortex had dilt'erent degrees of excitability, and that small lesions were not to be depended on in studying functions arising tliere- from. Luys, in his recent woik on "The Brain and its Functions," holds to a localization theory somewhat different from Charcot, Richet, Ferrier and their school of thinkers. He lias proved satisfactorily to himself, that the psycho-intellectual activities are in the cerebral cortex and that the central ganglia focalize these, in being the points for the reception of sensory imj)res- sions on the one hand, and of outgoing impulses whether physical or mental on the other. The optic thalamus is the terminal center for sensation, and the coi'pus striatum is a corresponding center from which radiates voluntaiy motor excitations. He claims to be the discoverer of this fact, and founds it principally on the morphological analogies found in the structure and rell m<| tul II is' stj to wm 17 l>iit the ilaiy s to Iiaii and 'li. >'y relation of the vnn(!